‘Hiding in Plain Sight, Exploring Scotland’s Ill Health,’ by Carol Craig

Scottish Review
February 2018

The title on the cover of this book is simply ‘Hiding in Plain Sight’ – which singularly provides the reader with no indication of what it’s about. The title page, however, with the subtitle ‘Exploring Scotland’s Ill Health,’ does point us in the right direction, even if it does nothing to prepare us for the shocking impact of what is to follow.

CCWB stands for the Centre for Confidence and Well-being which Carol Craig set up after the positive reception to her first book, ‘The Scots’ Crisis of Confidence,’ published in 2003. Located in Paisley, the centre organises public events and conferences, and a series of publications called ‘Postcards from Scotland,’ which includes this book, while in an earlier work, ‘The Tears that Made the Clyde,’ Craig had already explored the ill-health of the city of Glasgow.

Now all of Scotland is in the author’s sights, and the result is a book that is deeply disturbing and depressing. In fact I’d go as far as to say that I do not recall reading a book that depressed me more. Carol Craig, however, will be disappointed by such a reaction. In her book’s short final chapter, she points to recent developments which provide some ‘grounds for optimism’ over the issue of Scottish ill-health. They include a handful of grass-roots movements like her own Centre for Confidence and Well-being, the research and campaigns led by several active and iconic women who are committed to transforming Scotland’s approach to the upbringing of children (arguing, for example, that formal schooling for our children should not begin before the age of seven).

That Nicola Sturgeon turns out to be a strong supporter of Carol Craig and her work – and that she and her government agree that there is at least an issue over childhood in Scotland – is indicated by their commitment, however controversial, to the ‘named person’ scheme monitoring the welfare of all Scottish children from birth to the age of 18. However, in its previous eight chapters, this book paints so bleak a picture that I find it hard to believe that such proposals for change will be able to transform, even in the longest of terms, the reality of Scottish ill-health.

So what is it that is hiding in plain sight which is notionally the explanation of Scotland’s health problems? (The evidence indicating how serious these problems are will emerge shortly.) The answer is Adverse Childhood Experiences (ACEs). I have to admit that I – like I suspect many of you – was unaware of this condition. Yet Carol Craig’s book shows that in recent years the reality of ACEs, and their significance, have gained considerable currency in studies in the field of social work and social problems.

Originally identified in the USA, but now widely recognised in the UK, ACEs are the subject of books and over 70 research papers published in academic periodicals since the 1990s. A lay person like myself can hardly dispute their findings.

How was the existence of the condition established? The original survey in the US involved 17,000 patients who were asked to respond to 10 questions about their life experience prior to the age of 18. The questions concerned how they were treated by their parents both physically and emotionally. Were their parents separated or divorced? Was there a problem in the family with drink or drug-taking? Was physical violence experienced or witnessed? A positive answer to any question scored 1. So each respondent ended up with a score between 0 – meaning that an individual had no ACE – and a worst case 10.

The next stage in the research was an investigation into the medical histories of the respondents. The result was clear-cut. A link between ACEs and a range of physical and mental health outcomes was overt. Having ACEs apparently increased the risk of adult heart disease, chest and lung disease, liver disease, depression, suicide attempts, HIV and sexually-transmitted diseases, and other leading causes of death. For example, 50% of respondents scoring 4 or more suffered chronic depression. Only 1% of those scoring 0 attempt suicide, whereas an individual with a score of 4 or more is 1,220 times more likely to have done so. And so the statistics go on and on.

What is the relevance to the state of Scotland’s health of this research into ACEs? To recognise that, one has first to accept that Scotland is far from being a healthy country – and that basic point is driven home again and again in Carol Craig’s book. ‘Scotland has the worst health for men and women in western Europe,’ she writes. Our poor health is evidenced by low life expectancy rates, and by the age at which we become affected by long-term medical conditions. The health of the poor in Scotland is particularly dismaying. And the overall picture gets progressively darker.

Over and over again the statistics show that Scotland’s health is markedly worse than that of England and Wales. Defining premature mortality as death before the age of 75, Scotland has the highest premature mortality rate in the UK, and the worst in western Europe. A major study compared the health of Glasgow, Liverpool, and Manchester, cities remarkably similar in terms of poverty and inequality. But Glasgow’s premature mortality rate is 31% higher than that of the
English cities. And morbidity is not confined to poor Glasgwegians – members of the middle class do not survive as long as their peers in Liverpool and Manchester. Meanwhile Scotland has the highest number of drug deaths per head of population in Europe – and its figure is twice that of England and Wales. Similarly, Scotland’s death rate from alcohol abuse is 50% higher than that in England and Wales.

Explanations for dire statistics of this kind have traditionally focused on the impact of a rapid process of industrialisation on Scottish society in the 19th century, leading to massive overcrowding and poor housing conditions in Scotland’s cities. More recently the problem has been the impact of equally rapid deindustrialisation with all that has meant in terms of unemployment, poverty, and inequality. Add in Scotland’s addiction to excessive drinking, drug-taking, and a related pattern of violent behaviour, and Scotland’s ill-health is accounted for.

Carol Craig does not deny that such factors are relevant, but argues that they do not tell the whole story. Her own experience of growing up in Milngavie – admittedly in one of its less fashionable areas – confirms that premature death is equally a feature of middle-class Glasgwegian life. Thus the traditional explanations of Scotland’s ill-health fail to convince. What does is the explanation hiding in plain sight – adverse childhood experience. As we have noted, research shows that those who suffer ACEs are highly vulnerable to ill-health later in life. Scotland’s problem then crucially arises from its attitude towards children and their upbringing. This is the central point Craig’s book makes.

In a series of chapters covering such topics as Scotland’s drink and drug culture, family conflict, punishment and violence (particularly within the school system), and a tradition of negative and abusive humour, she argues that forms of adverse childhood experience have become almost normative in our society. As she puts it, ‘nurturing children has never been one of Scotland’s strengths.’

The case the book makes is a strong one, and the author bolsters it by pointing to the ubiquity in Scottish culture – fiction, memoirs, films – of dark and disturbing accounts of failed relationships between fathers and sons, and other forms of childhood trauma. And the summary of Scottish history, and religious history in particular, she provides does seem to suggest that the upbringing of children in Scottish society has always been problematic.

So perhaps it is true that ‘Adverse Childhood Experiences’ have always been detrimental to our society and its overall health. Yet some problems remain with the notion of ACEs. Reading this book I kept remembering the last book I reviewed here: Kay Carmichael’s ‘It Takes a Lifetime to Become Yourself.’ The account Kay provides of her childhood years makes it clear that her adverse childhood experiences were off the scale of 1 to 10. Yet as an adult she became a model caring social activist.

Now Carol Craig is perfectly aware that there are lots of children who experience some form of childhood trauma yet who, as adults, neither fall ill nor die prematurely. How is this to be accounted for? Well, the explanation that Craig offers is remarkably similar to Kay Carmichael’s personal suggestion. Kay writes that she, ‘like all children, needed love, needed comfort, needed the warm feeling of being valued.’ And her grandmother in Shettleston provided her with that support. Carol Craig tells us that research shows that ‘the people who are the most resilient in the face of childhood adversities are those who early in life had a significant, reliable adult to turn to and who could give them support.’ Her mother played that role in her own life. The parallel here is so close that one wonders whether the authors had met at some point and discussed precisely this issue.

To my mind more research is needed into why some individuals survive the adverse childhood experiences that eventually prove fatal for others. In any event, all those professionally committed to the caring for children in Scotland need to pay attention to this challenging book.