Solving a 165 year-old problem

Culture, climate, and childhood development. Demographics, deprivation, and deindustrialisation. Genetics and migration. Piqued your curiosity yet? 

Social capital. Healthcare and health behaviours. Water hardness. Public spending and pollution. Perhaps a little more intrigued?

Statistical artefact, occupational hazards, income inequality. Politics. Further mystified or has it all become clear? 

The link between these disparate items may not immediately be transparent – yet there is one. They have all been put forward as drivers of the ‘North-South health divide’ in England. Dating back to at least the 1860s, people in the North consistently have had higher mortality rates than those in the South. This is the case across all socio-economic groups, all ages and amongst both men and women. Such is the extent of the gap that since 1965 over 1.5 million northerners have died before their time.

Perhaps surprisingly in light of these statistics and its broader cultural relevance (Elizabeth Gaskell, anyone?) the health divide has been the subject of relatively little academic attention. Until recently, that is. In 2020, a team from Newcastle University, led by Professor Clare Bambra, Inequalities Lead for the NIHR ARC North East and North Cumbria, was awarded a five-year grant from the Wellcome Trust to investigate the divide’s history, causes and the way it has been popularly represented. 

Thanks to a supervisory connection and funding from the ACRC Academy internship scheme, I was fortunate enough to join this team for a four month period. Guided by Professor Bambra and others, I carried out a review of the many hypothesised drivers of the disparity between North and South. As the above list indicates, these are very varied in their scope. Consequently, some of the interdisciplinary skills developed within my role as an ACRC PhD student have been particularly handy.

So what is the cause of the disparity then? As anyone with a background in public health will suspect, much of it is down to deprivation. The North is poorer than the South, and since lesser wealth has via a range of causal mechanisms long been linked to worser health, this accounts for a comfortable majority of the gap.

Two issues remain, however. The first is that not all of the divide can be accounted for by deprivation. Regardless of the way in which deprivation is measured, some ‘excess’ mortality remains. A substantial amount of research has been carried out into a similar phenomenon in Scotland and Glasgow – what were previously called the Scottish and Glasgow ‘effects’ – and we drew on some of the lessons from this work to try and understand what could be responsible for it in the North.

The second issue is that saying that the North suffers worse health outcomes because it is poorer is a bit of a cop out. It raises a further question: why is the North more deprived in the first place? The answer lies in economics and politics – in more ‘upstream’ factors such as deindustrialisation and the planning and implementation of regional policy by Westminster. To address this issue, we integrated many of the other hypotheses into an overarching synthesis that was better able to account for these more fundamental drivers.

Untangling the various hypotheses has been hard work; the divide is both a bleak and tricky topic. Nonetheless, it has also been one of the most interesting things I have worked on and my thanks go to Professor Bambra and Dr Vic McGowan for supervising me during the internship and the ACRC for funding it. 

We are aiming to submit our findings for publication in the coming months, but for anyone interested in any of the work mentioned in the meantime, please see the links below:

https://jech.bmj.com/content/71/9/928

https://arc-nenc.nihr.ac.uk/projects/north-and-south-regional-health-inequalities-in-england/

https://www.gcph.co.uk/latest/publications/310-history-politics-and-vulnerability-explaining-excess-mortality

https://policy.bristoluniversitypress.co.uk/trade/health-divides