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Governance for Health Special Issue Paper

Health inequalities e why so little progress? H. Burns* University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK

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Article history:

Studies of the health of the population of Scotland over many years have provided new

Received 16 February 2015

insights to the basis of inequalities in life expectancy across the Scottish population.

Received in revised form

Conventional descriptions of health inequalities as being due predominantly to smoking,

21 March 2015

obesity and alcohol do not fully account for the situation in Scotland. The deeper insights

Accepted 27 March 2015

obtained from comprehensive analysis have prompted new approaches to narrowing the

Available online 29 May 2015

gap. Opportunities for well-being are created within the complex system of a well functioning society and novel methods are required if the outcomes of such a complex system

Keywords: Health inequalities

are to improve. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Salutogenesis Improvement science

Introduction In many countries, there is a marked and growing gap in life expectancy between the poorest and most affluent members of society.1 Differences in risk of premature death associated with wealth have been known about for many years. One of the first statistically important studies of wealth and mortality is to be found in the city records of Glasgow for 1861. John Strang, the City Chamberlain, an officer of the city who was responsible for collecting taxes, calculated the ratio of domestic servants to total population in each electoral district of the city as a proxy for economic status. He showed that in the most affluent area, where there was one domestic servant for every 2.8 residents, infant mortality was 17.8 deaths/1000 live births in the first year of life. However, in the poorest district, with one servant for every 67.8 residents, 260 of every 1000 babies born alive died in their first year of life. Many studies since then have confirmed a striking relationship between poverty, poor health and premature mortality. In the UK, the Report on Inequalities produced by Sir

Douglas Black2 showed that, in the 1970s, unskilled workers were 2.5 times more likely to die before the age of 65 years than professional classes. More recently, figures based on mortality data from 2010 to 2012 show that male life expectancy at birth in the city of Glasgow is 72 years,3 15 years lower than in the most affluent areas of England. This gap is also seen within the localities of west central Scotland. Glasgow Centre for Population Health4 reports a 15 year gap in male life expectancy at birth across neighbourhoods in the Greater Glasgow area and an equivalent 11 year gap in female life expectancy in the period 2008e12.4 Initially, attempts to explain these differences focused on a behavioural model.5 The commonly held view, perhaps encouraged by a UK Government report of 19766 was that individuals were responsible for their own health, implying that those with poorer health at the lower end of the social scale were more likely to indulge in unhealthy behaviours and less likely to access health care. Inequalities were seen as the consequence of choices made by the poor and the remedy was to provide them with better information to make it clear that they were making the wrong choices.

* Tel.: þ44 (0) 141 548 5948. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.puhe.2015.03.026 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.


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Those who recognized the poor as victims of circumstance questioned this approach. Attempts to explain inequalities as being due to decisions made by individuals have, rightly, been dismissed as ‘victim blaming.’ In 1980, The Black Report suggested the idea that the material circumstances in which poor people lived were the principal cause of inequality.2 Poverty exposes people to health hazards, the report argued, because it made them more likely to live in poorly built houses which were cold and damp and often in areas affected by air pollution. While there is some evidence to support this argument in part, it is clear that it fails to explain much of the inequality in health and it does little to explain many of the other inequalities encountered in poor areas. Yes, unhealthy habits were commoner in deprived areas and these areas may have poorer environments which might contribute to inequality in health status but, as Sir Michael Marmot has often stated ‘We need to look behind the obvious explanations. We need to understand ‘the causes of the causes’ if we are to improve the situation’.7

Inequality in Scotland e an alternative analysis For many years, the explanation for the gap in mortality in Scotland, as in other countries, was assumed to be due largely to health related behaviours. The affluent were more likely to eat well, take exercise, be non-smokers and drink alcohol more sensibly than the poor. There remains, in Scotland, as in other societies, a clear association between higher levels of healthy behaviour and relative affluence. However, association tells us little about causation. In the last few decades, dissatisfaction with behavioural causes of inequality in life expectancy prompted public health practitioners to dig more deeply in to the problem and seek ‘the causes of the causes’. They have produced extensive and insightful studies of the causal mechanisms for the link.

Inequality is widest in younger people An important study was that carried out by Leyland and colleagues.8 They examined in detail the underlying pattern of inequality across the life span of the Scottish population. Many studies simply look at overall life expectancy without giving enough consideration to the underlying patterns of death. Their work showed that the widening gap in life expectancy in Scotland is partly due to the fact that ischaemic heart disease mortality has fallen faster in wealthier areas than amongst the poor and perhaps this is a reflection of the ability of the better educated and more affluent to adopt healthier life-styles and behaviours. However, the latter decades of the 20th century saw a rise in the number of deaths in the younger working age population due to negative lifestyles. Inequality in incidence of deaths due to alcohol, drugs and assault increased significantly over this period and inequality in mortality is greatest amongst those aged between 30 and 49 years. These are not in the age groups most affected by heart disease and cancer. The assumption that the common causes of death are driving inequality misses the fact that other, less common causes of death in a much younger population have emerged

in recent decades. This emergent pattern of premature mortality is due to causes which are strongly associated with adverse social conditions. It is difficult to avoid the conclusion that much of the increase in inequality may have been precipitated by changes that took place in social structures in Scotland in the latter half of the 20th century.

Social turbulence in the latter decades of the 20th century The widest inequalities in life expectancy in Scotland are to be found in the cities of Glasgow and Dundee. In the 1970s, both these cites experienced major loss of employment in traditional industries.9 In Glasgow, jobs in shipbuilding and heavy engineering were lost as competition from Far Eastern countries became more intense. At the same time, the production of jute based products which, at its height, had provided employment in 130 mills in Dundee declined precipitously. The loss of employment in traditional industries in Glasgow was accompanied by major changes in housing which compromised social cohesion in many communities.10 A post war plan to demolish overcrowded and insanitary inner city housing led to almost one third of the population being moved from their homes. Extensive motorway and commercial property building led to whole districts being demolished and the people living in them spread across new developments, often with few facilities. The resulting dislocation of communities, at a time when worklessness was increasing dramatically led to severe social problems in the 1960s when gang violence attracted national attention. A credible hypothesis suggests that widening inequality in health and an increase in socially determined causes of death in the most economically deprived individuals was a consequence of large scale social turbulence. Unemployment, social dislocation due to the break up of communities and the poverty and hopelessness associated with such chaos produced psychological and social stresses. An individual who feels he has no future is less likely to worry about his health. As a clinician in Glasgow in the 1980s, I would often encounter patients whose smoking and drinking habits had caused serious surgical illness. Cessation advice would often be met with a response which indicated a lack of concern about risk. ‘Why should I worry? What have I got to live for?’ The increased incidence of health damaging behaviours in people living in poverty and who have little hope that their circumstances might improve is easily understood. Yet conventional risk factors, as argued above, do not account for the pattern of premature death which has emerged in this post industrial society. This observation prompted us to ask what was driving this increase in mortality in young, working age people due to drugs, alcohol, and violence?

Salutogenesis rather than pathogenesis Clues as to the drivers of inequality and possible remedies are to be found in the idea of salutogenesis. This is a term introduced by the American sociologist, Aaron Antonovsky who

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developed an approach to health promotion that focused on those factors that support human health and well-being, rather than on factors that cause disease. More specifically, the ‘salutogenic model’ is concerned with the relationship between health, stress, and coping. The medical, or pathogenic paradigm, on the contrary, is concerned with the causes of disease rather than the causes of well-being.11 Antonovsky argued that individuals who lacked the ability to see the world about them as structured and meaningful and who felt unable to manage their lives, would lack a sense of control over events affecting them. They would, he argued, experience a state of chronic stress. His analysis suggests that it is not enough simply to improve material well-being in order to improve inequalities in health.12 Well-being is created through building those psychological resources that allow people to establish secure relationships and participate in supportive social networks. In addition, society needs to provide opportunities for people to feel their lives have meaning and purpose. Without such internal capacity and support, attempts to narrow health inequalities simply by improving external social circumstances are unlikely to be effective.

at school and are more likely to be unemployed on leaving.17 While poverty is often seen as a cause of adversity in early life, it is also likely to be a consequence of failed childhood. An intergenerational cycle of alienation from mainstream society is perpetuated as young people who have not experienced a nurturing childhood become, in their turn, dysfunctional parents. They are less likely to be able to support the growth and development of their own children. Inequality in any society is primarily a consequence of inequality in the distribution of those resources that give children the opportunity to flourish in a safe and supportive environment. Nurturing environments for children and the social, and economic resources that allow parents to create safe and stable environments for their families to grow and develop are essential if we are to narrow the gap in health, in educational attainment and in offending behaviour. By providing such opportunities early in life, inequalities across many aspects of society are likely to be improved. Fundamentally, we need to ensure that everyone has an equal opportunity to develop his or her capacity to contribute to and be part of a well performing society.

The biology of social chaos

Breaking the cycle

The evidence linking adverse and chaotic social circumstances to elevated stress levels is extensive and compelling. A clear relationship between adversity and stress exists across all ages. Children living with depressed parents show elevations in cortisol levels from an early age. Hertzman and Boyce13 have reviewed such observations and concluded that adverse experiences in early life become ‘embedded’ in ways that affect health across the life course. The physical consequences of these adverse experiences are now well understood. Neurobiologists have shown that adversity in early life affects brain development in ways that impair learning ability and ability to respond appropriately to external events. These changes also affect emotional control, making the individual more likely to be anxious, fearful or aggressive in new social situations.14 The Canadian researcher, Michael Meaney has examined how maternal care can affect the cognitive and psychological development of offspring. His work has shown that the quality of the motherechild relationship influences the expression of genes responsible for behavioural and neuroendocrine responses to stress, as well as the development of connections within key areas of the brain.15 Social conditions which compromise the care and attention babies receive from parents lead to significant and measureable alteration in physiological and psychological responses to the external world in children. The science of early child development has been extensively described by the Harvard Center on the Developing Child. Its Director, Jack Shonkoff, has written extensively on the health, social and economic consequences of adversity in early life.16

The statement that ‘insanity is continuing to do what you've always done and expecting different results’ is often attributed to Einstein. Our analysis of the drivers of inequality in Scotland convinced us that the complexity of the problem could not be overcome through conventional policy approaches. Such approaches usually involve convening a group of experts who will meet regularly over several months. The end product of such a process is normally a policy recommendation to a minister based on consideration of available evidence. If the minister agrees with the recommendation, a policy document with recommendations for action is then issued to a public service. There are two problems with this approach. The first is that ministers and their officials often operate in silos and we have already agreed that tackling inequality requires action across all sectors of society not just those that are the responsibility of individual ministers. The WHO concept of ‘health in all policies’ is an attempt to overcome this difficulty. This approach is a reasonable idea but it encounters the second difficulty, which is that you cannot expect people to be committed to a policy which they have had no involvement in shaping. Our analysis tells us that the basis of inequality lies in failure of individuals to develop the capacity for positive interaction with society and its behavioural norms. It is difficult to imagine any government policy which will easily facilitate empathy, for example. The change requires people on the front line to do things differently. It needs change at scale and it requires real time data to confirm that the change is happening. Too often, governments rely on the ‘three year project’ approach. They fund a project in a discrete area. After three years, they commission an academic evaluation of its effectiveness. Usually, the conclusion is that the project has not achieved its objectives. This conclusion is often erroneous because not enough people have experienced the

The cycle of alienation Children who experience adversity are more likely to have mental health problems in early life, are less likely to succeed


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intervention, it has not been in place long enough to see a change in the outcome being measured or the appropriate data have not been collected. Funding is withdrawn and the project deemed a failure. Accordingly, we decided to try an approach which would involve front line workers in shaping the interventions through a continuous cycle of testing to find what actions are most likely to achieve the desired outcomes. Our analysis of the science underlying poor outcomes in deprived communities suggested the most important first step in breaking the cycle of alienation would be to transform childhood. We adopted a complexity based approach and set up a change programme based on the Institute for Healthcare Improvement's ‘Breakthrough Series Collaborative’ model.18 Voluntary sector workers, the police and government officials joined teams of leaders and front line workers from every local council and health authority in Scotland. Over a two year period, aims were agreed, drivers of change that would produce the desired change were identified and interventions that might influence the drivers were tested. Around 800 people met regularly to share their successes and failures. At the initial meeting, an overall statement of ambition for the collaborative was agreed. This was: ‘to make Scotland the best place in the world to grow up in by improving outcomes, and reducing inequalities, for all babies, children, mothers, fathers and families across Scotland to ensure that all children have the best start in life and are ready to succeed.’ Collaboratives are driven by data and a key principle is to identify what system changes will be achieved and to state by how much and by when the objectives will be achieved. The aims are: 1. To ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidenced by a reduction of 15% in the rates of stillbirths (from 4.9 per 1000 births in 2010 to 4.3 per 1000 births in 2015) and infant mortality (from 3.7 per 1000 live births in 2010 to 3.1 per 1000 live births in 2015); 2. To ensure that 85% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time of the child's 27e30 month child health review, by end-2016; 3. To ensure that 90% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time the child starts primary school, by end-2017. Since the first meeting in January, 2013, teams from across Scotland have been testing changes which they think will deliver these aims. Using plan, do, study, act cycles, measureable change is being achieved across the whole system and there is optimism that the first aim will, indeed be delivered. The Early Years Collaborative has energized the system of child and family support in Scotland and convinced frontline workers that their actions and experiences are central to improving childhood. The change we are seeking will be produced by changes designed and delivered by front line staff acting in concert rather than through direction from managers.

The EYC aims to change life in Scotland for children before birth to the age of eight years. We now have a Raising Attainment for All Collaborative.19 The vision for RAFA is that ‘Scotland should be the best place to go to school. We want each child to enjoy an education that encourages them to be the most successful they can be and provides them with a full passport to future opportunity’. Front line workers from 150 schools are now breaking down this vision into aims with measureable and time related outcomes and working to find successful drivers of change. The method adopted to improve childhood and educational attainment is being used in other settings. We see it in action in encounters with offenders, substance misusers, and people who are simply lonely and isolated. It appears to have empowered people to go out to the community and make connections which, for many, can be transformative. By breaking down bureaucratic barriers, it seems to have legitimized caring and compassion. In the foreword to his 2010 report, Fair Society e Healthy Lives, Michael Marmot wrote ‘the more favoured people are, socially and economically, the better their health’.20 If health inequalities are to be overcome, the social and psychological isolation which has its roots in early life and which is exacerbated by economic failure in adulthood needs to be addressed. In Scotland, we seem to have identified an approach which allows public servants to engage with their fellow citizens on a very human and caring level.

Author statements Ethical approval None sought.

Funding None declared.

Competing interests None declared.


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7. Marmot Michael. Achieving health equity: from root causes to fair outcomes. Lancet 2007;370(9593):1153e63. 8. Leyland A, Dundas R, MacLoone P, Boddy. Cause-specific inequalities in mortality in Scotland: two decades of change. A population-based study. Available from: http://www. biomedcentral.com/1471-2458/7/172. 9. Phillips Jim. The moral economy of deindustrialization in post-1945 Scotland. Available from: www.ehs.org.uk/dotAsset/55d36e845e9c-4596-b42d-a0ad0c1ea69c.pdf; 2013. 10. Crawford F, Beck S, Hanlon P. Will Glasgow flourish? regeneration and health in Glasgow: learning from the past, analysing the present and planning for the future. Glasgow: Glasgow Centre for Population Health; 2007. 11. Antonovsky Aaron. The salutogenic model as a theory to guide health promotion. Health Promot Int 1996;11(1):11e8. http://dx.doi.org/10.1093/heapro/11.1.11. 12. Antonovsky A. Health, stress and coping. San Francisco: JoseyBass; 1979. 13. Hertzman C, Boyce T. How experience gets under the skin to create gradients in developmental health. Annu Rev Public Health 2010;31:329e47. 14. McEwen BS. Understanding the potency of stressful early life experiences on brain and body function. Metab Clin Exp



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Health inequalities - why so little progress?

Studies of the health of the population of Scotland over many years have provided new insights to the basis of inequalities in life expectancy across ...
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