Accounting for Scotland's Excess Mortality: Towards a Synthesis

Scotland, because of the higher mortality of its population, has been dubbed ‘the sick man of Europe’. This higher mortality is most apparent in the west of Scotland and in the city of Glasgow in particular.Yet Scottish mortality was not always higher: it was only after 1950 that the rates improved more slowly than elsewhere in Europe. As late as 1981, most of the excess in Scotland ascompared to England & Wales could be explained by deprivation. Over the next 20 years this excess increased, and the scope to account for it by reference to deprivation declined, raising the question of how to account for the balance.The immediate causes are known: high rates of alcohol and drug-related deaths, suicide, violence, cardiovascular disease, stroke and cancer. But what are the underlying causes? There are multiple candidate hypotheses regarding both the divergence of the Scottish mortality pattern from the rest of Europe from around 1950, and also the rise in excess mortality unexplained by deprivation from 1980 in Scotland (and Glasgow) as against the rest of the UK.This report uses the criteria developed by Bradford-Hill for causation in observational epidemiology to evaluate each of these candidate hypotheses. As none of the hypotheses seems likely to provide for a ‘total’ explanation, a synthesis is attempted. Finally ecommendations are made for future research.