In the latest of our series of blogs on place-based inequality, Dr Jon Minton discusses evidence from a recent study of risk and vulnerability to death in Scotland. The evidence shows that within the most disadvantaged neighbourhoods men are more vulnerable to death by alcohol, suicide or drugs. For those who began working life after the late 1980s, known as Generation X, the hazard of drug-related and suicidal death increased and has been sustained throughout the life course. Jon describes and explains the data for ‘despair-related’ death and argues that we need deeper insights into the human stories that lie behind the data.

T2, the sequel to the film Trainspotting, depicts a middle-aged group of former intravenous drug users from Edinburgh trying desperately to piece together lives that fell apart two decades earlier, with only limited success. The stories of these ageing and unlikely posterboys – now nostalgic and mawkish survivors – of ’90s Cool Britannia match the data from a recent study on drug related deaths in Scotland. 

In the pulp fiction of the 1950s and 1960s, the same story was recycled.  Whether the setting was a small town, a desert, or a space ship, the story was the same. In social and health research, there is a place for pulp non-fiction too. Working with the same colleagues in NHS Scotland, using the same methods and approaches, I explored data on three separate causes of death in Scotland: alcohol-related deaths (ARD), suicide, and other drug-related deaths (DRD). These data were made available separately by age, by level of area deprivation, by gender, and by year, with records stretching back to the late 1970s.

The stories of the data are contained in these maps. But unlike in pulp fiction, the story is real, a hidden story with thousands of characters, stretching over generations…

Within three sets of maps, from three sets of data, I saw two tropes with much overlap. For all three forms of death (suicide, alcohol and drugs),the story is of risk and disadvantage, vulnerability and resilience. The main disadvantage by area, with much higher risk of dying of any of these causes in the poorest fifth of Scottish neighbourhoods than elsewhere; and the main vulnerability by gender, with men having a much higher risk of dying of any of these causes than women from the same neighbourhoods. Men living in the poorest neighbourhoods carried with them up to a ten-fold increased risk of dying of these causes, as they aged, compared with women.

The stories differed, however, in terms of the age and period. For alcohol-related deaths the story was of persistent disadvantage – people dying a decade or two before their time in their fifties and sixties rather than seventies and eighties – followed by a worsening in risk over the mid-1990s, peaking in the mid-2000s. For suicide and drug-related deaths it was a story of inter-generational inequality, of those who began working life after the late 1980s carrying with them much increased hazard of dying early from drugs as previous generations at the same stage in life.  This generation, Generation X, was the vanguard of higher drug-related and suicidal hazard throughout the life course, and later generations unfortunately seem to have followed their lead in worsening trends in these forms of despair-related death. Within Generation X, trends in suicide worsened slightly earlier than trends in drug deaths, suggesting that the conditions which led to increasing hazard of the former may have also exacerbated demand for illicit drugs use which led to the latter. Put more simply, supply followed demand: a market for chemical escapism must be preceded by a potential customer base experiencing conditions they wish to escape from.

“a market for chemical escapism must be preceded by a potential customer base experiencing conditions they wish to escape from”

This latter story also appears to be one of resilience and self-worth becoming worn down, systematically, with prolonged exposure to the social, cultural and economic conditions of adulthood in deprived neighbourhoods. Deaths from suicides and overdoses are not accumulative, but sudden, all-or-none events which stop decades or potential life being lived. Actuaries have long noticed what they term an ‘accident hump’ of additional deaths in early adulthood, of mortality risk jumping up in young adulthood, above the level expected from biological ageing (‘senescence’) alone, and for this ‘hump’ to be much more pronounced for males than females. But within this early adulthood mortality hump are a number of distinct sub-humps, related to different causes. The first large hump to clear occurs around the age of 17, and is due to dying in cars and other vehicles. Both the humps in drug-related death and suicide, however, occur around eight years later, peaking around the age of 25 years, when the vehicle-related hazard has largely passed. If death by vehicle is caused by too little experience combined with too much confidence, death by needle appears caused by the exact opposite. After almost a decade’s experience of precarious economic and social conditions, there is a wearing out of self-regard and confidence. Once this reservoir of self-worth has depleted, the hazard of both suicide and drug-related deaths then appears to remain with people as they age.

“ Once …self-worth has depleted, the hazard of both suicide and drug-related deaths then appears to remain with people as they age.”

Though looking at data can say something about the stories of reality, and the stories within the stories. Only more grounded and personal research can untangle the stories behind the stories: the reasons why particular individuals, living in particular areas, turned to drugs. The reasons why deaths from these causes are so much higher in poor than rich areas, for greater male vulnerability, and what can and has been done to address the causes of these deaths. Solutions and effective interventions are needed at multiple levels, from the individual, to the community, to the economy and society. Along with looking down at maps of data showing how thousands of stories have ended, there is also need to look across to, the individuals whose stories are not yet finished, and do what we can to make them longer and happier.