Can we afford to turn our backs on the poverty which is killing

Dr Harry Burns was driving from his office in the centre of Glasgow to a meeting at Stobhill Hospital in the north of the city. It was a cold winter day and sleet was falling as Burns sat at the lights at Saracen Cross in Possilpark, one of the city's most deprived neighbourhoods. In the doorway of a grey tenement the doctor in charge of the city's public health spotted a young boy wearing no more than a dirty T-shirt and jeans sitting shivering while inhaling glue from a plastic bag.

"This was his escape. Where is the aspiration for this child? When adverts for holidays appear on the television, what will they mean to him? Where is the aspiration for him to be able to achieve the nice things in life?" Burns asked.

This image lingers in the doctor's mind as he goes about his job, trying to make the health of Glaswegians improve at the same rate as the rest of Scotland and the UK. The poverty in Glasgow is legendary and the link between deprivation and ill-health universally acknowledged, but experts now believe that unless inequalities in Scotland are tackled the health and wealth of the whole nation will suffer.

Two new studies carried out by Greater Glasgow NHS Board show that levels of premature death due to poverty are failing to drop at the same rate as other post-industrial cities. And a new analysis of the relationship between poverty and ill-health shows that 1600 deaths a year in Glasgow can be attributed to deprivation.

The first piece of research compared the death rates for men and women aged between 15 and 64 in industrial cities across the UK. It found that unlike Leeds, Sheffield, Birmingham, Newcastle and Liverpool the death rate in Glasgow is not falling significantly. The only other city where the death rate remains stubbornly high is Manchester but even there the numbers involved are much lower than in Glasgow.

From 1989 to 1999 the standardised mortality ratio (death rate) for Leeds decreased from 119 to 93. In Sheffield it dropped from 113 to 93. In Birmingham it fell from 126 to 107. Newcastle experienced a plunge from 141 to 113. Liverpool's rate reduced from 153 to 137. The Manchester rate has risen from 153 to 162 while Glasgow has shifted slightly from 194 to 187, significantly higher than all other cities. In comparison, Edinburgh has fallen from 123 to 109.

"There is nowhere else in Scotland quite like Glasgow, a large, post-industrial city with large areas of unemployment. We wanted to see if other cities like Newcastle and Sheffield had the same experience as us. This shows that we are starting off from a poorer base and don't seem to be catching up. Glasgow's parlous state is compromising any leap forward that Scotland might make," Burns said.

The second piece of research examined how much of the disease in the Greater Glasgow NHS Board area is attributable to poverty. Burns estimates that 1600 deaths a year in Glasgow are caused by poverty- related illness. He split the population into seven categories and calculated how many people would have developed cancer if everyone shared the same level of affluence as the top category. He calculated that 22% of the cancer cases in Glasgow from 1986 to 1995 would not have occurred if the whole city was as well off as the most affluent group. This was a drop from 27% in the previous 10 years from 1976 to 1985, but Dr Burns does not think the gap is narrowing as much as in other areas of Scotland and the UK.

"We wanted to see if we could measure across the whole population the risk of ill health attributable to social economic status. This gives an estimate of the deaths from cancer that we might avoid if we lessen the impact of poverty."

Another new analysis, carried out by Glasgow City Council, shows that Glaswegians are trapped in a dependency culture. The study found that 31% of the working age population in Glasgow are on benefits, compared to 14% of the working age population in Edinburgh. Of those on benefits, 10% of Glasgow's working age population are on incapacity benefit compared to 4% in Edinburgh.

This week, at a conference entitled "State of the City Economy" held by Scottish Enterprise Glasgow, delegates will discuss the fact that although more jobs are being created in Glasgow they are not going to the city's unemployed, who have given up hope of working again and are stuck in a dependency trap.

Earlier this year a report published by the influential think- tank the Scottish Council Foundation (SCF) showed that there are only 61% of working-age adults in work in Glasgow, around 15% below the UK average. The figure for Edinburgh was 84%, regarded as full employment.

Jim McCormick, research director with SCF, warns that the health of the whole country could suffer as a result of these inequalities. "I don't think there is much evidence internationally that says if you run these kind of inequalities you can thrive economically and gain health improvement across the nation as a whole.

"We want to recognise that some indicators for health in Glasgow have been improving, but the problem is that they are improving so slowly and the rest of Scotland is driving ahead so quickly that the gap is growing. Inevitably that causes inequalities, especially between two adjacent cities. It impacts on population growth.

"If you ask the government this question they will fairly say that they are starting to address the issue of preventing people coming into the system ending up on long-term sickness benefit. There is more active support to help people get back into work at an earlier stage. Where we have been less effective is in helping the long-term claimants to be active again. Moving a 55-year-old ex-welder back into work after five years on incapacity benefit is more difficult."

The SCF recommended that GPs prescribe voluntary work for those who have been on long-term sickness benefit as a stepping stone to getting them back into employment.

"The ill-health burden is to do with the loss of contribution to society and loss of identity. There is clinical evidence that if people are encouraged to volunteer in their local area and their contribution is valued then that has an impact on blood pressure, mental health and coping capacity, so that when they face difficulties their resilience is improved."

Professor Phil Hanlon, director of the new Public Health Institute of Scotland, believes that many Scots' health has improved while others are stuck in unhealthy, deprived lifestyles. He says people will only get healthier when they feel in control of their lives - he calls this "authorship".

"The key question might be to ask, 'What would it take to give a much larger portion of people in Scotland a sense of authorship over their own lives?'"

To Dr Burns this control or authorship is the same as aspiration. "We need aspiration and ambition in the east end of Glasgow," he said.

Earlier this year Cardinal Winning's successor, Archbishop Mario Conti, like Dr Burns, was appalled by the levels of poverty he saw in Glasgow. He was so stunned by the extent of deprivation he encountered that he criticised politicians for not concentrating on relieving the impact of poverty in Scotland's biggest city.

He said: "It is when you confront this reality [of poverty] that you really begin to question whether some of our national politicians are living in ivory towers when they suggest that the matters which concern and excite public opinion are the hunting of foxes or the outlawing of the smacking of children."

In Cafe Lido on Saracen Street, a few yards from where Dr Burns set eyes on the half-dressed child shivering and glue sniffing in a doorway, shop assistants from the local Co-op sit chatting over a coffee. One of them, a young grandmother, has angina but feels unable to buy into the healthy-living culture.

"Healthy food is too expensive for us to be able to afford," she said. "Take Benecol for example, it is meant to reduce your cholesterol, but you almost have a heart attack when you get to the check-out and see how much it costs."

Glasgow holds the record for the highest premature death rate in the whole of the UK. New research shows that while premature death rates in most post-industrial cities are falling, the toll in Glasgow remains stubbornly high. Health experts warn that the gap between Scotland's rich and poor is threatening the health of the whole nation.

www.hebs.scot.nhs.uk www.phis.org.uk

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