Sunday, 31 December 2017

Thank you, Scotland's NHS

Half a dozen years ago, while living in Uganda, I went down with a serious disease - not life-threatening, but extremely unpleasant. And, in fact, nothing to do with being in Uganda. Indeed, I received excellent healthcare at my GPs' surgery and, later, the International Hospital in Kampala, little different from the care I would have had in Britain. The only reason I returned to Britain for a while, was for investigations, not available in Uganda, into the causes and control of residual pain. In the end, I came back to Uganda and my husband and I finished off our contracts, Stuart having carried out both our jobs while I was away.

Despite my satisfactory healthcare in Uganda, there was one key difference, however, between the two countries: in Uganda we (actually the insurance company used by our sponsoring agency) had to pay for this care, and not at overcrowded public clinics but at good private institutions. Not that we don't pay for public healthcare in Britain, of course, but it is free at the point of use and the comfortably off pay more through their taxes than the relatively poorer. You can argue that resources in the UK are still not enough, of course, but that is not the main point of this post.

The point of this post is that if I had been an ordinary Ugandan woman living in a village, working perhaps in subsistence agriculture and bringing up a large family, not only would I not have received such good quality care, but, worse, my health could have been irreparably damaged. Specifically, I could have lost the sight in one eye. Not only did I need to take expensive drugs for the underlying medical condition, but the doctor had to train me to look after my eye to avoid infection. I had to make regular purchases of dressings, eye patches, strips to make the eyelid close on the paralysed side of my face and eye drops. And a Ugandan woman would have had to travel some distance to the clinic, if lucky in the back of a pickup, if not on foot. All this is in a hot climate, with flies and copious amounts of red dust.

Graca Machel recently wrote that access to health is a human right. She quoted the following statement from the Constitution of the World Health Organisation: "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being". In Africa, millions, however, are faced with the choice between medical care and providing food for their families. Mme Machel is campaigning for universal access to affordable and accessible healthcare, of good quality.

In Kenya, 83% of people lack financial protection from health care costs, a similar proportion as in South Africa. Malawi does not charge fees in public health facilities (though they are very overstretched). As a result Machel writes, Malawi has a child mortality rate of 64 deaths per 1,000 compared with 109 in Nigeria. In Scotland, infant deaths have fallen to an all-time low of 3.7 per 1,000. Health is about money. Life is about money.

The recent publication of Tracking Universal Health Coverage: 2017 Global Monitoring Report states that 800 million people spend at least 10% of their household budgets on health expenses for a sick family member. 100 million of these people will be forced into extreme poverty as a result, forcing them to survive on just $1.90 or less a day. Nevertheless, over the last few years, overall health has improved through access to antiretroviral treatments for HIV/AIDS, immunisation, family planning, and treated bed nets to protect against malaria. It does not take much, however, for economic or political problems in individual countries to threaten the scope and effectiveness of such programmes, as the WHO has just reported about immunisation in Kenya, which has dropped from 85% coverage to 68%.

Across the world, there are significant differences in health service coverage between the wealthiest and the poorest, even within individual countries. The World Bank reported that only 17% of mothers and children in the poorest fifth of households in low and lower middle income countries received at least six of seven basic health interventions compared to 74% of the wealthiest fifth. Without adequate healthcare, children will not reach their potential nor countries achieve their aspirations. Health affects education, family life, employment, food security and trade.

Such discrepancies in the health of different communities within the same country do not just occur in the developing world, of course, though the causes and relative impact of such discrepancies may be more notable. In Scotland, as in sub-Saharan Africa,  access to healthcare may be influenced by a number of factors.

Geography may be one factor. For example in Scotland, it is more difficult to access health services in rural areas and on the islands compared with the Central Belt. The current appeal for a cancer charity notes that it costs some patients £150 per month in travelling expenses alone to attend the necessary clinics.

Social factors are also significant. The Herald recently reported on the impact on Scots of benefit cuts, which have resulted in widening health gaps between richest and poorest, with the most deprived significantly more likely to die from alcohol abuse, coronary heart disease and cancer. In Scotland, it is not so much provision of health care that differs across the country as uptake of screening services such as those for bowel and breast cancer.

Social and economic factors influence health-related behaviour. More affluent people may check on symptoms sooner than the more deprived. And you can see why. They have better access to transport and more money to pay for it. They may find it easier to miss work to attend an appointment. It is difficult to attend clinics when on zero hours contracts or doing two or more jobs to make ends meet. The pay the more prosperous may lose as a result may not have as much significance for their budgets or for their continuing employment as it does for the poorer, particularly if repeat visits are necessary. Wealthier people are more likely to be able to afford childcare and may find it more straightforward to organise. Above all, as we know, some households are under severe stress. They may be headed by parents whose personal lives and family organisation may be affected by mental health problems which make it difficult for them to take on yet another challenge. 

The Herald reports that more than 21,000 people in Scotland died before the age of 75 in 2016, but the rate was 3.7 times higher among the poorest Scots compared to the most affluent - up from 2.7 in 1997. The differences are particularly noticeable in communities and families under stress. Deaths from overdoses, suicides and assaults are over six times higher among the poor as among the prosperous. The article lists some shocking data, many associated with the impact of smoking, obesity and alcohol consumption. These factors not only have a significant impact on health differences within Scotland, but also, as most of us are aware, in Scotland compared with the rest of the UK.

After adjustment for differences in deprivation, premature mortality (<65 years) in Scotland is 20% higher than in England & Wales (10% higher for deaths at all ages); similarly, the excess for Glasgow compared with Liverpool, Manchester and Belfast has been shown to be approximately 30% for premature mortality, and around 15% for deaths at all ages. 

The City of Glasgow and nearby council areas have some of the highest levels of premature death in the country. With a population of 1.2 million, life expectancy at birth in greater Glasgow is 71.6 years for men, nearly seven years below the national average of 78.2 years. It is 78 years for women, over four years below the national average of 82.3. In 2008, according to the World Health Organization, life expectancy for men in the Calton area of Glasgow was 54 years, attributed to alcohol and drug abuse, and a violent gang culture, exactly the same life expectancy as in Uganda at the time.

These areas in the west of Scotland are also those where deindustrialisation has had the greatest impact, where poverty is at its highest and recent and ongoing benefit cuts are having the greatest effects. Not that there is no poverty elsewhere in Scotland, of course, for example in the rural areas of the Highlands and Islands and in other cities like Dundee and Edinburgh. Even prosperous Aberdeen has areas of acute deprivation. But not as high or as intractable, perhaps, as in the west.

Indeed, inequalities in health are becoming increasingly evident across the UK. A study just published by the Nuffield Trust has shown the 'devastating impact' of deprivation on child health. The UK's poorest teenagers were 70% more likely than their peers to appear in Accident and Emergency services. School aged-children from the poorest areas are two and a half times as likely to be admitted to hospital in an emergency for asthma as those in the richest areas. Anecdotal evidence from doctors points to the return of rickets and other diseases more often associated with nineteenth century slums and poverty stricken villages in the developing world. The increasing numbers of children brought up in temporary accommodation - 3,000 such children in London alone, an increase of 52% over the last five years - are reflected in increasingly negative health statistics. The Joseph Rowntree Foundation has found that almost 400,000 more children in the UK lived in poverty last year than in 2012-2013.  And it is not going to get better. The Institute for Fiscal Studies has predicted that the number of children living in poverty is likely to rise to 5.2 million over the next five years. Increased poverty means increased ill health.

In 2016, the Office for National Statistics reported huge disparities in health and longevity between different areas of the UK. Women in prosperous Richmond-on-Thames live 15 years longer than those in deprived Tower Hamlets. Scotland has the worst longevity rates, but also some areas where people may live the longest in good health during retirement, for example on the Orkney Islands where rates are similar to Richmond. Orcadians on average live 12.5 years longer than people in Glasgow.

Nevertheless, while our health services in Scotland and the UK as a whole are demonstrably overstretched, though not as much as those in sub-Saharan Africa, few of us in Scotland doubt that our local and national governments on the whole aim to ensure that all Scots have the access they need. The pressures come from increasing demands on the system. How this compares with the situation in the USA before the Affordable Care Act, and what is happening now, as Trump attempts remove the little support there is!

It is true that in Scotland, the prosperous and very rich may use private health care provision; however, most people use the National Health Service, confident that it will serve them well. In sub-Saharan Africa, on the other hand, governments pay millions of dollars providing expensive private healthcare in foreign hospitals for their politicians and civil servants, and, including their families, dollars provided by ordinary taxpayers. The daughters of Uganda's President Museveni gave birth abroad to save themselves and their babies from the risks their fellow Ugandans face in the country's maternity units.

Now, I would be the first to accept that Scotland experiences a different sort of poverty from that in the developing world. Indeed, people in Uganda and Malawi might have a wry smile when reading some of the Scottish data. Dying before the age of 75, as reported in The Herald? In Uganda, Stuart and I used to play the game 'spot the old person' when driving along the road, there were so few of them compared with the increasing proportion of older people in our own country - around 40%. At the time we lived in Uganda, only between 2 and 4% of the population was aged 60 or above, the result of decades of conflict and the impact of HIV/AIDS, malaria and other diseases. On the whole, Ugandans do not die of obesity, though the children of the more prosperous are now being fattened up on burgers, pizzas and 'sodas'. While junk food and fizzy drinks are frowned on among the middle classes in the UK these days, in sub-Saharan Africa they are signs of prosperity and even relatively poor families may occasionally buy them as a treat for their children. When the organisations I work with hold community meetings, it is de rigeur to provide 'sodas', and people feel cheated if they don't get them. So, as extreme poverty falls in the developing world, the health problems of the west may begin to creep in. While the west may have the facilities, though not necessarily the will, to deal with such lifestyle problems, the developing world almost certainly does not. In Malawi, most ex-pats fly home or to South Africa for treatment.

Nevertheless, as the Gates Foundation Report has recently pointed out, health statistics in the developing world are generally improving. There is hope. Effective action can be taken. In all countries improvement 'just' takes the will of local and national government and the willingness of taxpayers to influence this will through voting for political parties prepared to take radical action. And, we might add, through avoiding the twin temptations of corruption and tax evasion. 

Now, what has brought these health issues to my mind just now? It is Christmas, after all, not necessarily the most appropriate season for solemn comparisons of national health systems.

All of us who have made frequent visits to the developing world are well aware of the fortunate lives we lead here in the west, lives which even the professional colleagues we work with might find it difficult to imagine. Six years ago, in Uganda, I was able to keep the sight in my left eye because I was European. I was able to learn how to live with chronic pain because I had available to me the medical resources of one of the richest countries in the world. I was able to receive ongoing medication by means of free prescriptions which meant it was less likely that the condition would recur. And I didn't have to undergo my treatment while producing the only food my family was likely to eat, through subsistence farming on exhausted or poorly-irrigated land. I didn't have to use my children's or grandchildren's school fees to pay for my healthcare, nor was I tempted to forgo treatment in order to keep them in school. Our National Health Service saved me from these painful choices.

This year, in between my usual trips to Malawi, a routine mammogram in Edinburgh homed in on a tiny lump in my breast. Without this routine screening, available to all women my age in Scotland, neither I nor clinical staff would have been able to find the troublesome cells by touch for they were buried too deep. By the time this lump had become obvious, it would probably already have shed malignant cells leading to secondary tumours elsewhere in my body. As it was, I climbed on board a conveyor belt of diagnosis and treatment employing the most up-to-date procedures and medication. Oncology services at the Western General Hospital in Edinburgh are among the most advanced in the UK. The hospital's staff must surely be among the most humane and caring.

So, here I am now, at the end of December, surgery successful and chemotherapy underway. It will be quite a long haul. By the time the chemo is over, there will be radiotherapy and medical procedures to deal with the impact of these therapies on my bones. Active treatment should be over by the end of May but Scotland's NHS will monitor my progress and continue to deal with any after effects for some years. And as long as our country remains reasonably stable in economic terms, I have no reason to doubt that the NHS will continue to provide this oversight and care. Only a looming Brexit and consequent withdrawal from Euratom, the source of the medical radioisotopes necessary for such treatment, are making me uneasy.

Even within Scotland, I am very fortunate. I don't have to travel for two hours from the Borders to receive my treatment, nor do I have to rely on ferries and tiny planes to transport me from the Western or Northern Isles. My husband and I can well afford the necessary transport arrangements and the little luxuries that make the treatment liveable with.  I am also mindful that mine is one of the more straightforward cancers to treat; other people, even in Scotland, are nowhere near so lucky.

If transport is difficult to organise, I can, if necessary, call on an ambulance. I don't have to balance on the back of a push bike or pickup like a Malawian. All my treatment so far has been in outpatient clinics, but if I ever needed to be treated on an inpatient ward, I know that the NHS would provide me with food and bedding, which they will even launder for me. I won't have to sleep on a mattress on the floor, nor will I need to keep a grandchild off school in order to cook my meals and provide my nursing care. I know that the hospital has a supply of safe water and electricity and is unlikely to be affected by power cuts. I will have the use of regularly cleaned flush toilets, rather than a pit latrine in the hospital compound.

But then, if I were Malawian, the treatment I am in the middle of just wouldn't be provided in the first place.

The impact of budget cuts on national health services in all the constituent countries of the UK has been significant. Inequalities in the state of people's health in different geographical areas, and in access if not provision, are unacceptable. It is morally wrong that the poor die 12 years earlier than the comfortably off.

However, I also cannot forget how fortunate I am that this prosperous European country of Scotland can provide me with some of the best treatment in the world. Because I live in Scotland, I am going to live.....

Malawi registers success in child healthcare services - Muluzi, 5 December 2017, Nyasa Times
Concern as Baby Immunisation Coverage Stalls, 28 December 2017, The Nation
Africa's Health Challenge is a Human Rights Issue, by Graca Machel, AllAfrica, 18 December 2017
Half the World lacks access to Essential Health Services, World Bank  and the World Health Organisation, 14 December 2017
Health inequalities widening in Scotland with the poorest nine times more likely to die from alcohol harm, Helen McArdle, The Herald, 20 December 2017
Excess mortality in Scotland and Glasgow, The Scottish Public Health Observatory, 2017
Mystery of Glasgow's Health Problems, Ali Muriel, The Guardian, 6 November 2012.
Glasgow has the lowest life expectancy in the UK, BBC News, 19 October 2011
Excess mortality in the Glasgow conurbation: exploring the Glasgow effect, James Reid, PhD thesis, University of Glasgow Faculty of Medicine, September 2008
Behind the Glasgow effect, Michael Reid, Bulletin of the World Health Organisation, October 2011
Health of Scotland's Population: Mortality rates, Scottish Government
National Register of Scotland, Age-standardised death rates
The Affirm Study, University of Edinburgh
Scotland's Stillbirth rate reaches a record low, The Scotsman, 25 March 2014
Huge health gap revealed between UK's rich and poor, The Observer, 24 December 2017
Figures reveal huge inequalities in health and longevity across the UK, The Guardian, 11 October 2016
Does it matter if the UK leaves Euratom?, 12 July 2017, BBC News