06 March, 2007

Glasgow's health priorities – where now?

Glasgow’s health priorities – where now?
A summary of the meeting - by Dr Duncan MacIntyre

Dr Burns, once consultant surgeon and Director of Public Health in Glasgow, now Chief Medical Officer at the Scottish Office was introduced by the President, Mr David Ritchie. He started by looking at life expectancy changes over the 20th century in Western Europe – rapid and then slower improvement but with Scotland being overtaken in that process. In 1900 it had better than average life expectancy. The problems in the west of Scotland and in particular in deprived areas of Glasgow are well documented. Standardised mortality rate for Glasgow are approximately twice the English average and significantly worse than other "post industrial" UK cities. There is a fourteen year difference in life expectancy between deprived and affluent areas of the west of Scotland. The traditional killers such as coronary disease and cancer are diminishing in importance with increased death rates from violence, drugs and alcohol effects. Once again the new killers are most obvious in those population groups with a highest depcat scores.

The challenge is to understand the underlying reasons and intervene appropriately. There are obvious major social issues. In a general sense the fabric of Glasgow remained poor while other cities were improving. However, relying on change in social environment to produce health returns is a long term and uncertain policy. Similarly changing personal habits is slow. The Health Service can have a more immediate role in ensuring access to currently available care.

Dr Burns then developed his thesis that deprivation itself contributes to poor health outcomes. Analysis of traditional risk factors and intervention approaches shows that they do not provide all the answers. The increasing health risk of smoking is uniform in most studies but the risk is multiplied for each level of tobacco consumption in the west of Scotland. Dietary interventions in Finland correlated with changes in coronary heart disease but these changes were mirrored in Scotland where there were no such interventions. The initial clue to other factors came from detailed investigation in Finland at the time of these interventions. It was found that psychological profiling or the feeling of hopelessness correlated with mortality risks and interestingly with more aggressive carotid atheroma (Doppler assessment). The conclusion was that a chronic low grade stress might contribute to physical illness. There is good evidence that stress hormone levels are increased with deprivation. From the WOSCOPS study came data correlating CRP with deprivation and showing that both smoking and obesity further increased CRP levels. CRP in turn correlates with risk of myocardial infarction and of development of diabetes. Interestingly the statins have an anti inflammatory effect – perhaps a mechanism of disease reduction. Another interesting recent observation looking at telomere levels as a correlate of DNA repair activity indicates that this marker of stress at the molecular biology level also reflects measures of individual stress – findings replicated in twin studies. This gives rise to the concept of molecular biological age as opposed to chronological age.

What can we do about all this? Dr Burns used the example of Dr Tudor-Hart in Wales and his groundbreaking work in general practice in taking care to individuals in activities such as blood pressure control. This produced locally improved life expectancy and has been an example of how the application of proven medical interventions can be effective. Such an approach is effectively applying the founding principles of the NHS and filled Harry Burns with enthusiasm that Scotland could address its medical problems.

There followed half an hour of stimulating debate around the reasons for the west of Scotland’s problem, what possible interventions could be considered, and how these might be achieved. Dr Keith Beard who had been a medical and rugby playing colleague of Dr Burns at university expressed the audience's considerable thanks for a fascinating evening.