1. Scottish mortality diverged from other high-income nations in the mid-20th century likely due to industrial dependence, poverty, and cultural factors exacerbated by deindustrialization. 2. In the 1980s, a "Scottish Effect" emerged where Scottish mortality further diverged and could not be fully explained by deprivation alone, possibly due to a "political attack" increasing stress, violence, and substance abuse. 3. No single cause explains the mortality phenomena and recent divergence is likely influenced by politics in the 1980s and resulting cultures while downstream factors like behaviors are necessary but not sufficient explanations.

1. Accounting for
Scotland’s excess
mortality: towards
a synthesis
Gerry McCartney
Chik Collins
G. David Batty
David Walsh

2. Male life expectancy in available high income nations
90
80
70
Life expectancy (years)
60
50
40
30
20
10
0
1751 1801 1851 1901 1951 2001
Year
Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Canada, Chile, Denmark, England & Wales, Finland,
France, Germany, Ireland, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Portugal,
Scotland, Spain, Sweden, Switzerland, Taiwan & USA.

3. Higher overall mortality than comparable nations
85
Life expectancy at birth (years)
80
75
70
65
60
1971 1976 1981 1986 1991 1996 2001 2006
Year
Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Canada, Chile, Denmark, England & Wales,
Finland, France, Germany, Ireland, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland,
Norway, Portugal, Spain, Sweden, Switzerland, Taiwan & West Germany.

4. Higher overall mortality than comparable nations
85
Life expectancy at birth (years)
80 Scotland
75
70
65
60
1971 1976 1981 1986 1991 1996 2001 2006
Year
Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Canada, Chile, Denmark, England & Wales,
Finland, France, Germany, Ireland, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland,
Norway, Portugal, Scotland, Spain, Sweden, Switzerland, Taiwan & West Germany.

5. Higher overall mortality than comparable nations
85
Life expectancy at birth (years)
USA
80 Scotland
75
70
65
60
1971 1976 1981 1986 1991 1996 2001 2006
Year
Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Canada, Chile, Denmark, England & Wales,
Finland, France, Germany, Ireland, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland,
Norway, Portugal, Scotland, Spain, Sweden, Switzerland, Taiwan, West Germany & USA.

6. Emergence of the ‘Scottish Effect’
Scotland SMR (age & sex)
Scotland SMR (age, sex & Carstairs)
47% explained by
43% explained by deprivation
118 62% explained by
deprivation deprivation
115
Directly standardised mortality
115 114
(England & Wales = 100)
112
112
109 108 108
106 105
103
100
1981 1991 2001
Year
Source: Hanlon P, Lawder RS, Buchanan D, et al. Why is mortality higher in Scotland than in England and Wales? Decreasing
influence of socioeconomic deprivation between 1981 and 2001 supports the existence of a 'Scottish Effect'. Journal of Public
Health. 2005; 27:199-204.

7. nd
t la
o
Sc
Source: Mackenbach 2008 and Popham 2010

8. nd
t la
o
Sc
Source: Mackenbach 2008 and Popham 2010

9. Summary: the Scottish mortality phenomena
1. Scottish mortality is around European median until 1950
then diverges
2. Scottish mortality pattern changes and diverges again
around 1980
3. Deprivation explains less of the higher mortality in Scotland
and Glasgow from 1981 onwards (the Scottish/Glasgow
Effect)
4. Scottish health inequalities are wider than the rest of
western Europe

10. Aims
• Identify the various hypotheses for mortality phenomena
• Evaluate each hypothesis using Bradford-Hill criteria
• Begin to synthesise the valid aspects of the hypotheses

11. Methods
• Systematic search for hypotheses in health literature
combined with outputs of dissemination seminars
• Application of Bradford-Hill criteria
– Strength of association*
– Consistency
– Specificity**
– Temporality*
– Biological gradient
– Plausibility*
– Coherence
– Experiment
– Analogy
• Synthesis drawing on Hegelian approach
* Criteria given most weight by the Academy of Medical Sciences:
Identifying the environmental causes of disease: how should we decide what to believe and when to take action? . London:
Academy of Medical Sciences; 2007.
** Criteria given more weight by other authors (e.g. Weiss NS. Can the "specificity" of an association be rehabilitated as a basis for
supporting a causal hypothesis? Epidemiology 2001;13:6-8).

12. Identified hypotheses – artefactual and
‘downstream’
1. Poverty and material deprivation*
2. Genetic vulnerability
3. Health behaviours
* Only artefactual in relation to the Scottish/Glasgow Effect

13. Identified hypotheses – ‘midstream’
1. Migration
2. Different culture of substance misuse
3. Different individual values (time, aspiration)
4. Family, gender or parenting differences
5. Health service supply or demand
6. Greater inequalities
7. Greater concentration of deprivation
8. Deindustrialisation
9. Sectarianism
10. Different culture (boundlessness, alienation)
11. Lower social capital

14. Identified hypotheses – ‘upstream’
• Culture of limited social mobility (Craig)
• Political attack
• Climate (sunlight, cold weather)

15. Number of Bradford-Hill criteria met by each hypothesis for the divergence
of Scottish mortality in the mid-20th Century
Health behaviours
Hypothesis in relation to the divergence of Scottish
Greater inequalities
mortality pattern from elsewhere in Europe
Deindustrialisation
Deprivation concentration
Different individual values (time, aspiration)
Lower social capital
Political attack
Sectarianism
M igration
Family and gender differences
Deprivation and poverty
Genetic differences
Climatic differences
Different culture of substance misuse Meets criteria
Different culture (boundlessness, alienation) Does not meet criteria
Culture of limited social mobility
Health service supply and demand
0 1 2 3 4 5 6 7 8 9
Number of Bradford-Hill criteria

16. Number of Bradford-Hill criteria met by each hypothesis for the later
divergence and Scottish/Glasgow Effect
Political attack
Health behaviours
Hypothesis in relation to the emergence of a
Greater inequalities
Artefact
Scottish Effect or Glasgow Effect
Lower social capital
Deindustrialisation
Deprivation concentration
Different individual values (time, aspiration)
Sectarianism
Migration
Family and gender differences Meets criteria
Genetic differences
Does not meet criteria
Different culture of substance misuse
Different culture (boundlessness, alienation)
Climatic differences
Culture of limited social mobility
Health service supply and demand
0 1 2 3 4 5 6 7 8 9
Number of Bradford-Hill criteria

17. Political attack
• Was the UK exposed to a form of neoliberalism not seen
elsewhere; and was Scotland more vulnerable to it, targeted
or have a particular reaction?
• Deindustrialisation managed and mitigated in other countries
• Parallels with transitions in Eastern Europe and USA
• Accommodation in Scotland not seen in England
• Linked to alienation, disempowerment and democratic deficit
• Timing and plausibility rate highly
Sources:
Collins C, McCartney G. Is a ‘political attack’ an explanation for the ‘Scottish Effect’ in health outcomes? . International Journal of
Health Services (in press).
Stuckler D, King L, McKee M. Mass privatisation and the post-communist mortality crisis: a cross-national analysis. Lancet
2009;373:399-407.
Boyle M, McWilliams C, Rice G. The spatialities of actually existing neoliberalism in Glasgow, 1977 to present. Geografiska Annaler;
series B, Human Geography 2008;90:313-25.
Phillips J. The industrial politics of devolution: Scotland in the 1960s and 1970s. Manchester: Manchester University Press; 2008.

18. • “The passage of 30 years does not alter the fact that a
great many people were hurt, and hurt very badly,
because of Margaret Thatcher. … she willed an
economic catastrophe. A large part of a generation
never recovered. Some sickened; some died too soon.
It's true” (Ian Bell, Herald)
• “A war without bullets” (Cathy McCormack)

19. Synthesis for the divergence of Scottish mortality from mid-20th
Century
Possible mechanisms and key factors Outcomes
Development of new
Poverty and Industrial peripheral housing
inequality dependence estates
Cardiovascular
Instability of industrial Gender disease
Scottish culture
employment disharmony
Respiratory
Substance disease
misuse
Migration patterns
Insecurity of Stroke
Increased
stress employment
Cancer
Overcrowded city
centre housing Sectarian divide
Rise in inequality
and poverty

20. Synthesis for the divergence of Scottish mortality from mid-20th
Century
Possible mechanisms and key factors Outcomes
Development of new
Poverty and Industrial peripheral housing
inequality dependence estates
Cardiovascular
Instability of industrial Gender disease
Scottish culture
employment disharmony
Respiratory
Substance disease
misuse
Migration patterns
Insecurity of Stroke
Increased
stress employment
Cancer
Overcrowded city
centre housing Sectarian divide
Rise in inequality
and poverty

21. Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow
Effect’
Vulnerability Trigger Mechanisms Outcomes
Drugs-related
Individuation and Breakdown in confidence of
competition working class communities
Alcohol-related
Greater poverty Reduced self-esteem &
1976 financial crisis Suicide
and inequality self-efficacy
and subsequent
Decreased Substance Road-traffic
Scottish culture 'political attack' by
well-being misuse accidents
Thatcher government
Industrial on numerous elements
Increased Family
dependence of the organised Cardiovascular
stress breakdown
working class disease
Sectarian divide Disempowerment Increased
Respiratory
and hopelessness violence
disease
Genetic factors Rise in Stroke
Reduced community
inequality and
Scottish climate cohesion
poverty Cancer
Deindustrialisation

22. Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow
Effect’
Vulnerability Trigger Mechanisms Outcomes
Drugs-related
Individuation and Breakdown in confidence of
competition working class communities
Alcohol-related
Greater poverty Reduced self-esteem &
1976 financial crisis Suicide
and inequality self-efficacy
and subsequent
Decreased Substance Road-traffic
Scottish culture 'political attack' by
well-being misuse accidents
Thatcher government
Industrial on numerous elements
Increased Family
dependence of the organised Cardiovascular
stress breakdown
working class disease
Sectarian divide Disempowerment Increased
Respiratory
and hopelessness violence
disease
Genetic factors Rise in Stroke
Reduced community
inequality and
Scottish climate cohesion
poverty Cancer
Deindustrialisation

23. Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow
Effect’
Vulnerability Trigger Mechanisms Outcomes
Drugs-related
Individuation and Breakdown in confidence of
competition working class communities
Alcohol-related
Greater poverty Reduced self-esteem &
1976 financial crisis Suicide
and inequality self-efficacy
and subsequent
Decreased Substance Road-traffic
Scottish culture 'political attack' by
Political attack by the well-being misuse accidents
Thatcher government
Thatcher government
Industrial on numerous elements
post 1979 Increased Family
dependence of the organised Cardiovascular
stress breakdown
working class disease
Sectarian divide Disempowerment Increased
Respiratory
and hopelessness violence
disease
Genetic factors Rise in Stroke
Reduced community
inequality and
Scottish climate cohesion
poverty Cancer
Deindustrialisation

24. Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow
Effect’
Vulnerability Trigger Mechanisms Outcomes
Drugs-related
Individuation and Breakdown in confidence of
competition working class communities
Alcohol-related
Greater poverty Reduced self-esteem &
1976 financial crisis Suicide
and inequality self-efficacy
and subsequent
Decreased Substance Road-traffic
Scottish culture 'political attack' by
Political attack by the well-being misuse accidents
Thatcher government
Thatcher government
Industrial on numerous elements
post 1979 Increased Family
dependence of the organised Cardiovascular
stress breakdown
working class disease
Sectarian divide Disempowerment Increased
Respiratory
and hopelessness violence
disease
Genetic factors Rise in Stroke
Reduced community
inequality and
Scottish climate cohesion
poverty Cancer
Deindustrialisation

25. Conclusions
• No single ‘cause’ is likely to explain the mortality
phenomena
• There is a greater degree of uncertainty about the
divergence of mortality from the mid-20th Century
• ‘Downstream’ causes are necessary but insufficient to
explain the Scottish Effect and Glasgow Effect
• Politics of the 1980s and the cultures arising from this
are likely to be important in explaining the recent
divergence

26. Acknowledgements
• Co-authors: Chik Collins, G. David Batty & David Walsh
• Glasgow Centre for Population Health for supporting the
work
Contact: Gerry McCartney (gmccartney@nhs.net)