Joyce McMillan: Health problem rooted in lost world

THURSDAY MORNING; and over a moderately healthy breakfast, I am taking a close look at the maps that accompany The Scotsman’s story about this week’s Audit Scotland report on the nation’s health gap. Scots living in areas of high social deprivation, it seems, can expect to die up to 18 years earlier than those living in more upmarket neighbourhoods; and the maps show exactly where those deprived areas lie, snaking along the Clyde from North Lanarkshire to Greenock, and – on a much smaller scale – around parts of Dundee.

Money has been thrown at this health gap problem, we are told; £1.7 billion a year is being spent on schemes like the current Scottish Government’s Equally Well programme, which seeks to tackle the underlying causes of poor health in deprived areas, including unemployment, poor physical and social environments, and the breakdown of families under pressure.

Just to list those underlying factors, though, is to offer a glimpse of the daunting scale of the task, and of the reasons why – as Audit Scotland points out – well-intentioned spending in this area has often had so little effect. For as the maps reveal, this is not, except in the most superficial sense, a “health care” problem.

It is, rather, a slow-motion human disaster, driven by economic and historic factors far beyond the reach of any health system; the story of a city that was largely made by the Industrial Revolution, and which became, for a while, the heavy industrial workshop of the world, but has now lost the raison d’etre that drew most of its people to it, in a population explosion that saw it grow tenfold in the century between 1800 and 1900.

In the years of industrial decline since the 1960s, most of the city’s people have managed to move on, into new sectors around education, tourism, retail and finance. It is hardly surprising, though, given the key role of those lost heavy industries in shaping a whole world of social connection and meaning, that some have failed to make the leap.

Instead, they have internalised the political narrative which dismissed them and their communities as worthless and out of time, and are now suffering from what the healthcare specialists call “low self esteem”, which apparently leads, in many cases, to poor diet, obesity, excessive smoking and drinking, and the abuse of drugs.

It’s therefore worth noting that the Audit Scotland Report, for all its thoroughness, contains a strange internal contradiction. On one hand, it acknowledges that much of the preventive health spending in these areas has been ineffective in narrowing the health gap, and yet on the other hand, it advocates a massive transfer of health resources from middle-class Scotland to those areas.

Yet it seems to me that what the people of – say– the East End of Glasgow need most is not more healthcare, but more of a future. They need work; and if government wants to spend money there, then it could and should start by paying people there a living wage to do everything that so obviously needs to be done in their own community, from cultivating barren ground to grow vegetables, to looking after the local elderly and infirm, and keeping them out of hugely expensive hospital beds.

Behind this whole debate, though, there lies an ever-more insistent, budget-driven suggestion that people are responsible for their own health, and should somehow be punished for their failure to choose healthy lifestyles; perhaps, most seriously, by being deprived of treatment, if they fail to lose weight, or give up smoking.

Yet this mean-minded and authoritarian way of thinking about the human body both betrays the basic principles of human compassion and solidarity, and ignores some of the deepest existential questions about the meaning of human life.

For if many of the assumptions made about “punishing” people for unhealthy lifestyles are riddled with class prejudice – it’s always about Buckfast drinkers and junk food addicts, never about ski-ing injuries, or gouty old chaps who have been toping Burgundy since their teens – the people who talk this kind of talk are also in denial about the risks we human beings must take every day, if we are to have lives that are worth living.

From getting entangled in destructive relationships to taking up dangerous sports, we often do foolish things, not because we are stupid, but because we sometimes need to live in the moment, rather than according to the dictates of some fatuous 50-year life-plan; and a nation that would instruct its medical system to withdraw care from us, when we come to self-inflicted grief, would effectively be telling doctors to turn away half of their patients, or more.

So what I would like to hear, from people in charge of healthcare in Scotland, is a little less condescension towards the folk of Easterhouse or the Gallowgate, and a little more understanding of the choices they may make. The last time I was in the East End of Glasgow – visiting, needless to stay, a new artist studio complex in the Barras – I passed a grim-looking pub with wire netting over the windows; outside sat a line of mobility scooters, parked with a certain determined look.

At one level, it was a demonstration of all that drives social policy makers to despair. Yet on the other hand – well, why not? If your horizons are necessarily short, if you may not have many days of life left, if there is nothing big left to hope for – then why not spend the time you have in small pleasures, in good company, drinking the odd pint before you die? As for the cost of it all – well, I think someone once called it a “price worth paying”, for the modernisation of the British economy.

And we can be sure that that price will keep rising, until we finally sort out our mixed messages; and stop telling people that they are worthless losers on one hand, while on the other suggesting that they should adopt the egotistical world-view of the more fortunate, should “choose life” as defined by mainstream society, and should strive for eternal youth and health, whether they have anything to live for or not.