Letter from Glasgow

Drug Deaths In Scotland

‘I’d rather be a picket than a scab.'

—Picket line slogan, UK miner's strike 1984-851

For me, the 1980s in the UK was about working as a doctor in a political environment dominated by the right-wing policies of the Conservative government, led by Margaret Thatcher. Those policies led to large parts of the country becoming de-industrialized, with whole communities left without jobs, and hope. Mining was one of the affected industries and the National Union of Mineworkers (NUM), led by Arthur Scargill, went on strike to protect their livelihoods. Ultimately the miners failed but the human cost was felt by everyone including doctors.

I remember as a trainee general practitioner seeing a young man with jaundice. It turned out he was a miner who was on strike against the National Coal Board's (NCB) decision to close pits. The NCB were pursuing this with the full blessing of the UK Conservative government to help bring the miners into line. He turned out to have hepatitis B as a result of injecting drugs— heroin. Even today, I’m not quite sure why this young man turned to inj ecting drugs but as a young doctor in Edinburgh in the 1980s, I was aware that drug misuse was a huge problem particularly among young men and, to a lesser extent, young women. Edinburgh, famous as a tourist centre, managed to gloss over for outsiders the serious drug problem that existed in its deprived communities, often hidden far from the tourist crowds. In this aspect, Edinburgh was no different from Scotland as a whole, and the drug problem in numerous cities and towns. Edinburgh came to the fore with its epidemic of AIDS-related deaths linked to drug injecting. Thus, simultaneously, Edinburgh achieved notoriety for HIV among drug injectors but also as a centre for investigating the causes of the epidemic and helping to understand the new disease.

Looking back at that time, we were aware that drug misuse affected deprived communities and individuals disproportionately and they bore the brunt of the havoc caused by drug misuse. It affected society as a whole but for most people and the politicians in power it was easier to ignore the reasons why drug misuse was prevalent, and its consequences.

Those events of over 30 years have continued to reverberate through Scotland, with its impact on the health of the population. Over the decades, health researchers have found that Scotland's health has been improving but at a much slower rate compared to other European countries.2·3 Some years ago, I even commented on the ' Scottish effect’ in a Letter from Glasgow.^[4] As a consequence of Scotland's health improving more slowly than other countries, these countries in Europe have accelerated past Scotland over the past 50 years in terms of their health profile.

Part of the health research in Scotland has looked at mortality and drug misuse and the reasons why the epidemic unfolded as it did. Among other hypotheses, the issue of economic and social upheaval caused by the political decisions of the Conservative government in the 1980s have been considered. As indicated above, there was an impact on health due to the social and economic policy of de-industrialization pursued by the Conservative government (including the denuding of the mining industry). This affected young people in particular resulting in unemployment, more poverty, and importantly, little hope. For young men it also resulted in a dislocation of the hitherto accepted norms of identity, and working to provide for the family.

Now Parkinson and her colleagues explore this further with an analysis of drug-related deaths (DRD) in Scotland and its relation to the political context from the 1980s onwards.^[5] They found the peak for DRD was 1990, especially for males aged 18 to 45 years and there was a cohort effect, particularly among males living in the most deprived areas. They state ‘the age-standardized rates for DRD among young adults rose during the 1990s in Scotland due to an increased risk of DRD for the cohort born between 1960 and 1980, especially for males living in the most deprived areas. This cohort effect is consistent with the hypothesis that exposure to the changing social, economic and political contexts of the 1980s created a delayed negative health impact’. So the evidence of Thatcherism worsened the health of young people, particularly men, grows. To public health physicians who have lived through the past four decades, this is unsurprising.

Much has changed in Scotland since the 1980s, including the setting up of the Scottish Parliament in 1999. This devolution of powers allows for distinctive Scottish policies and solutions to problems and appropriate public health responses.^[6] While it will not be straightforward, further changes in politics and devolution will happen in the UK as the UK leaves the European Union (‘Brexit’). However, that will throw up challenges of its own in addition to the challenges Scotland faces in improving the health of its population. Given this, perhaps we need to be more innovative and imaginative of how we tackle them. In many respects a political rebuttal of the policies of the 1980s is simple, but taking public health forward needs to tackle the problems of today and those that will be faced by our children and grandchildren. This includes taking into account global warming and the ecological imprint of humans on the earth.^[7] Perhaps we need to be even more radical so that we have healthier and more equitable societies within, and between, countries. Ultimately, this requires action to share resources and opportunities more equitably at a global and local level—not an easy task with politicians hooked on power, the quick fix, and, in democracies, their own re-election. Analysing the effects of political decisions on public health is a start, but meeting the challenges for public health for the future is a difficult task but a prize worth fighting for.