The vital clues to Scotland’s wretched health


By Kenneth Roy

Scotland’s shocking catalogue of poor health is widely lamented, though – as we pointed out in the first instalment of this piece (15 September) – our position internationally is less generally understood. The amount of literature on the subject is inadequate to say the least – but from the little we do know, it is clear that Scotland has much to learn from other countries. There are vital clues out there. We continue to overlook them at the expense of our health.

Finland is a country with which Scotland is often compared. It was only recently that the Finnish life expectancy overtook our own, and it is certainly worth examining the possible reasons. At the beginning of the 20th century, life expectancy in Scotland was 50.1 for men compared with 45.4 in Finland. By the end of the century, the average Finn was living to the age of 72.9, the average Scotsman eight months less. The mystery is why Scotland’s comparative position has declined so sharply. What is it the Scots are doing wrong? Or, to put it more positively, what are the Finns doing right?

Thirty years ago, in the relatively poor eastern province of North Karelia, local communities began to tackle the health inequalities on their own doorstep. The core message was broadly the same as it is in Scottish public health policy today: it was about lifestyle choices. It took three decades of sustained and patient commitment to bring about a significant change for the better. In North Karelia, it has finally been achieved.

A benevolent interventionist state at work? Not quite. The initiative came from within; it was triggered by the people of North Karelia themselves. They networked, they lobbied, they prodded their government into action. In Scotland, in contrast, health improvement is driven from the top rather than inspired from the roots.

Scotland’s chief medical officer, Sir Harry Burns, is sensitive to the importance of such organic projects as North Karelia, and their potential for Scotland. He wrote recently that ‘inadvertently, in seeking to improve the lot of the most disadvantaged members of our society, we may have made them more, rather than less alienated, by doing things to them rather than with them’. Sir Harry recognises that this approach ‘reinforces dependency and encourages passivity’, and so he is keen to encourage self-help wherever it is to be found – in the healthy living centres springing up in some of our poorest communities and in the pioneering work of such enterprises as Glasgow’s Theatre Nemo.

The example of Theatre Nemo deserves to be celebrated and emulated. It was set up by Isabel McCue as a creative response to the mental disintegration and suicide of her son; the company actively encourages people with mental health problems, and their carers, to use drama as a means of self-expression. Harry Burns rightly quotes it as an illustration of what needs to be done in Scotland.

it is not simply that Scotland is falling behind the rest of western Europe.  The disturbing fact is that we are starting to do rather worse than eastern European countries, too.

But there may be a still deeper dimension to our malaise. It is informed by the valuable research of the Glasgow Centre for Population Health in the Polish region of Katowice, which shares with urban Scotland many of the effects of post-industrialisation on the health of the people.

If present trends are maintained, male life expectancy in Katowice will soon exceed that of Scotland. Women there are already living longer than their counterparts here, although as recently as the 1980s Scottish women enjoyed a comfortable advantage. So it is not simply that Scotland is falling behind the rest of western Europe. The disturbing fact is that we are starting to do rather worse than eastern European countries too.

Why? More than one survey has revealed a pattern of accelerating improvement in the health of societies in which democracy has recently emerged. It seems that, when the socio-political culture changes for the better, people quite literally start to feel better. In theory, then, the coming of devolution to Scotland 12 years ago should have started to produce a healthier population. Is it happening? The evidence is not terribly encouraging.

If it isn’t happening, we are left with two possibilities. Either devolution hasn’t gone far enough to make us healthier; or Scotland is so sunk in alienation and apathy that we are capable of bucking any trend. But we do have a chief medical officer who is prepared to think deeply about these issues; and, for me, that is a reason to hope.


Courtesy of Kenneth Roy – read Kenneth Roy in the Scottish Review