History, politics and vulnerability: explaining excess mortality in a post-industrial Scottish city

Background
High levels of excess mortality (i.e. that not explained by deprivation) have been observed for Glasgow (Scotland) in comparison with similar post-industrial cities such as Liverpool and Manchester (England). Many potential explanations have been suggested. Based on an assessment of these, the aim was to develop an understanding of the most likely underlying causes.

Methods
40 hypotheses were examined. The relevance of each was assessed by means of Bradford Hill’s criteria for causality. Where gaps in the evidence base were identified, new research was undertaken. Causal chains of relevant hypotheses were created, each tested in terms of their ability to explain the excess. The models were further tested with key informants from public health and other disciplines.

Results
Glasgow was made more vulnerable to important socioeconomic (deprivation, deindustrialisation) and political (detrimental economic policies) exposures, resulting in worse outcomes. This vulnerability was generated by a series of
historical factors: the lagged effects of historical overcrowding; post-war regional policy including the socially-selective relocation of population to outside the city; more detrimental processes of urban change which impacted on living conditions; and differences in local government responses to UK
economic policy in the 1980s. Protective factors were identified e.g. greater social capital in Liverpool. Other contributory factors include the inadequate measurement of deprivation.

Conclusions
The work has helped to further understanding of the underlying causes of Glasgow’s excess mortality. The implications for policy include the need to address three issues simultaneously: to protect against key exposures (e.g. poverty) which impact detrimentally across all UK cities; to address the
existing consequences of Glasgow’s vulnerability; and to mitigate against the effects of future vulnerabilities which are likely to emerge from UK Government ‘welfare reform’ policies.

Key messages:
Politics matters for population health
Glasgow’s excess mortality is best explained by a greater vulnerability to detrimental exposures, created in large part by historical political factors