Under attack? Public accounts of health inequalities and the social determinants of health in Scotland

Abstract

Scotland experiences higher mortality rates and larger health inequalities than other high-income countries, including the wider UK. The predominantly epidemiological evidence-base identifies deprivation, inequalities in wealth, deindustrialization, health behaviours and housing as important factors, while excess mortality has been attributed to a ‘political attack’ on the Scottish population in the late twentieth century. This paper synthesises 48 studies offering lay perspectives on the factors shaping health in Scotland, identified via systematic searches. The findings demonstrate that people with lived experience of disadvantage have a good understanding of the social determinants of health inequalities. We also identify five ways in which Scotland’s disadvantaged communities experience a sense of ‘attack’: the structural violence of poverty; disadvantageous national policies; ‘street level bureaucrats’ gatekeeping welfare support; local profiteers (e.g., unresponsive landlords); and interpersonal violence. We argue that these findings provide support for the ‘political attack’ hypothesis and that they suggest research and policy needs to better grapple with the depth of poverty, the intersectional nature of inequalities and the roles that history, narratives, crime, violence and policy implementation each play in shaping Scotland’s health outcomes. We call for research and policy responses that ground both diagnosis and future prescriptions in the experiential knowledge of those most negatively impacted.