Improving the health of the citizens of Glasgow.
The World Health Organisation (WHO) defines:
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition is unchanged since 1948.
Demography of Glasgow
According to the 2002 census, Glasgow has a population of nearly 580,000. This is more than 10% of the total population of Scotland that is just over 5 million. The metropolitan area of Glasgow houses about 1.7 million people. It is the largest city in Scotland and 4th largest in the UK. Slightly fewer than 24% of the population of Glasgow are below the age of 20 and slightly more than 15% are aged over 65 with about 7% over 75. This is similar to the rest of Scotland.
The ethnic mix is: 96.5% white, 2.5% Asian, 1% Black, Chinese and other ethnic groups.
Indices of deprivation were updated in 2007 for England but slightly different indices are used for the four home nations of the UK. The Scottish index was produced in 2006. Although there are slight differences in the criteria, eastern Glasgow has the most deprived areas in the whole of the UK. However, Glasgow is a mixed conurbation with many affluent areas too.
The NHS was supposed to remove health inequalities but has failed to do so. The Black Report, commissioned in 1977 and published in 1980 found that little had changed in terms of health inequalities. Sir Donald Acheson’s Report of November 1998 found little evidence of improvement. A seminal paper by Dr Julian Tudor Hart in 1971 coined the inverse care law. “In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support and inherit more clinically ineffective traditions of consultation than in the healthiest areas; and hospital doctors shoulder heavier case-loads with less staff and equipment, more obsolete buildings and suffer recurrent crises in the availability of beds and replacement staff. These trends can be summed up as the inverse care law: that the availability of good medical care tends to vary inversely with the need of the population served.”
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Tackling health inequalities is a major component of the Government’s health policy. There are plenty of publications but little evidence of change. Health and life expectancy have improved through all strata of society but the gradient down the social classes remains or has expanded. Some argue that this is a disgrace whilst others say that provided that there is improvement in all sections that this is an achievement.
The WHO Commission on the Social Determinants of Health was chaired by Sir Michael Marmot and looked at health inequalities not only in poor nations but also in the rich. It found that children born in the Calton area of Glasgow will live, on average, 28 years less than a person living eight miles awayinLenzie, East Dumbartonshire. There the life expectancy is 82 years compared with 79 for the whole of the UK. A Calton resident has a life expectancy of 54 years. The report said adult death rates were generally 2½ times higher in the most deprived parts of the UK than in the most affluent. Throughout the country and through all social classes, women live, on average, five years longer than men.
Mortality rates are high in Scotland, higher in Clydeside and even higher in Glasgow. They are especially high in areas of deprivation. Decreases in deaths from coronary heart disease (CHD) have been offset by increases in deaths from liver disease and suicide.
Glasgow is probably the most challenging city in the UK to improve health, if not the most challenging in the European Union (EU). The incidence of CHD and stroke is the highest in Western Europe and most of this is attributable to modifiable risk factors. Rates of cancer are also high. The incidence of lung cancer is 77 per 100,000 in Western Scotland compared with 49 per 100,000 in the rest of the UK and most of this is accounted for by smoking habits. Glasgow has been called “the UK’s fattest city” Obesity is well known as a risk factor for CHD and diabetes but it also contributes to the risk of many cancers. The WHO says that obesity is second only to smoking as a cause of cancer.
If improvement in the health of Glasgow was aimed purely at reducing smoking and obesity it could have a major impact on health. Other areas where there may be significant benefit are a reduction in drug and alcohol abuse and safe sexual practices. Substance abuse and sex are related. Most prostitutes work to fund a drug habit and much injudicious sex occurs when intoxicated by drugs or alcohol. Intravenous drug use and promiscuity spread hepatitis B and HIV. Hepatitis C is very common with intravenous drug use but is less commonly sexually transmitted. Accidents and much violence result from intoxication, especially with alcohol. Between 1960 and 2002, the death rate from cirrhosis in men rose by 69% in England and Wales and 106% in Scotland. Amongst women it rose by nearly half. Improving mental health is also extremely important. It is often linked to substance abuse but it is difficult to decide if mental illness is caused by drug or alcohol abuse or a result of it.
People often have more than one risk factor. This is why doctors use tables that examine several parameters to assess an individual’s risk. Those in lower social classes are more likely to have multiple risk factors. For males, 30% in social class V have at least two or three high risk behaviours compared to fewer than 10% in social class I. For females, the figures are 20% and fewer than 5% respectively.
Some benefit may be obtained from improved medical services. Governments may help with alleviating poverty and economic regeneration but most intervention will be aimed at getting the individual to take responsibility for his own health. He has to understand the problem. He must want to change. He must be empowered for his own good. There is a vast amount of health promotion material that is readily available.
A single agency is limited in what can be achieved. It is important that many agencies and all levels of society should feel part of this great challenge to change the ways and the attitudes of the people of Glasgow.
Improving medical services to cope with those who suffer from the important diseases should improve outcome but disease prevention offers hope of a much greater improvement. Most of the risk factors for illness and premature death are modifiable and amenable to change by the individual.
Legislation may come from the EU, UK or Scottish Government. It may change behaviour as in banning smoking in public places or it may address poverty and bad housing. Poverty is bad for health but poverty applies only to the lowest in the social scale whilst there is a gradient of health and life expectancy right across the social classes. The benefit of giving money to poor families is unclear.
Laws may aim to curb tobacco or alcohol use. Raising taxation reduces tobacco consumption and there are a number of ways of other ways of reducing alcohol consumption too. Subsidy as well as taxation may make healthy food more attractive and unhealthy food less so.
Governments must assure funding for health promotion campaigns and may help with coordination across various departments. The NHS is an obvious department to be involved in both health promotion and provision of medical services. Education may be important in trying to change both knowledge and attitudes amongst young people. It can help to develop an interest and knowledge in healthy eating and cooking. It can aim to change attitudes to tobacco, alcohol and drugs and encourage an ethos of exercise. The Department of Trade and Industry may be involved in economic regeneration. Both the police and courts may be able to direct people with problems related to drug or alcohol abuse towards care rather than just a punitive system.
The process of change
Health promotion aims to get individuals to change to a healthier lifestyle. This is not easy to achieve. Change is rarely easy. It involves the individual going through several steps on the way to achieve a lasting change in habit and attitude.
Health promotion initiatives
The mechanism for health promotion is usually mass media campaigns. They seem to work for smoking cessation and even in changing sexual behaviour in young people. However, there is very little evidence about long term effects.
Campaigns may be aimed at one facet or multiple risks. For example, diet, weight and exercise are intimately entwined. This may spill over into smoking, alcohol and drug abuse. Health promotion may be at a national, community or individual level. The individual level is usually when a patient is seen in a medical setting, especially general practice.
Simply exhorting people to change is not enough. It must be facilitated. Most general practices have antismoking clinics where support, advice and even prescriptions to help withdrawal may be had. The subject has been extensively reviewed by both CKS and NICE. People must be helped to appreciate what is healthy food and that it is not more expensive than their traditional diet. Fun runs are of limited value as they are an isolated event. Changes in diet and exercise must be for life. The individual must find a form of exercise that he can manage and he likes or he will not persevere. Counselling and support for substance abusers must be available. Methadone can give stability to the life of a heroin user and acamprosate can reduce the craving for alcohol but counselling must not be ignored.
Long term change
In Europe it is usually suggested that inequalities in health are the result of inequalities in income. In the USA they focus on health literacy and suggest that it is inequality in education that is responsible. As income and education tend to be related it is possible that one is a surrogate for the other. Health is worse in those of lower intelligence but this does not account for all the discrepancy..
People from poorer backgrounds are more likely to smoke. Smoking is the main cause of differences in death rates in middle age across socio-economic groups. In men between 35 and 69 years, it accounts for 59% of social class differences in death rates. They are more likely to be obese and this may be linked to the higher incidence of diabetes. Abuse of alcohol is more prevalent as is drug abuse. They are more likely to experience teenage pregnancy and to be involved in accidents. Accidents are a major cause of death and disability in those under 45. They are more common in lower social classes and in males more than females. This is not just due to high risk jobs as both poverty and lower social class are risk factors for children too. There is also a relationship between poverty and poor mental health. However, as poor mental health causes social decline the question of cause and effect arises.
Perhaps the most important aspect of long term health improvement is improvement in general education. Health literacy is closely related to general literacy. People of poor health literacy have poor lifestyles, they present late with disease and are poor in compliance with management. Those with poor educational achievement have a dead end job or no job. They have low self esteem and are more likely to abuse drugs and alcohol, to smoke and have a poor diet. Teenage pregnancy is more common in low achievers. Improved education, improved job prospects and improved standard of living are the key to improving health.
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