"Scotland's most distinguished political commentator" - Roy Greenslade.
Wednesday, February 24, 2010
Heart disease: even fit people like me get it.
I'm going into the Edinburgh Royal Infirmary for a heart bypass operation today. May not be around for a while. Here is an account - rather long - of how I discovered that Scotland's number one preventable health problem isn't really preventable.
It began with what I thought was a chest infection that wouldn’t shift - my lungs started burning whenever I exerted myself. I ignored it. Men do. Then one day I was cycling uphill from the Scottish parliament and I collapsed in the gutter with a crushing weight on my chest that stopped me breathing. Even then I didn’t think it was heart trouble. I thought I had immunised myself against ‘Scotland’s disease’ - our number one killer. I’m fitter than I was twenty years ago. I eat broccoli for heaven’s sake. Even as they trundled me into the cardiac ward I was remonstrating that it must be some kind of mistake. Really, don’t waste your time. But it wasn’t.
Back in the 1980s, when I worked for BBC Scotland, I remember being told that the reason the BBC pension scheme was so generous was because the average life expectancy of BBC employees after retirement was a year and a half. It was probably apocryphal, but it rang true. In those days, far too many journalists never reached retirement. Hacks were notoriously self-destructive - smokers, drinkers, deadline junkies. Typical angry Scots who don’t look after themselves and don’t do emotion.
But I was determined not to become just another statistic. So, after one too many funerals, I started to organise my life around not dying. Proper diet, no smoking, exercise, moderate drinking. By the time I reached my fifties, I was pretty pleased with myself. Low blood pressure, low cholesterol, the ideal weight for my height. I knew I was fitter than I had been twenty years previously because I go up Curved Ridge and the Aonach Aegach in Glencoe three or four times a year. That was, until I discovered that Scotland’s number one preventable disease, isn’t.
An angiogram showed that key blood vessels were blocked nearly 90% with cholesterol and plaque - a kind of hard connective tissue that forms in diseased arteries around the heart. There was no doubt about it - my health-conscious lifestyle had in no way immunised me from the Scottish disease. I had the heart of a 55 year old overweight smoker who’d been living on pies all his adult life and spent his leisure time in the pub. In Springburn. Naturally, I felt just a little cheated. What was the point of all that good living if you still end up like this? I’d ticked all the boxes, only the ticker somehow hadn’t noticed.
I remonstrated unreasonably with the various doctors who had the misfortune to treat me. They all said the same thing: “Look, you’re a male Scot. There’s really nothing you can do about it. Scottish men just get heart disease.” Now, I could initially accept this as a statistical generalisation, but the more I heard it the grumpier I became. What are they saying? Is it something in the Scottish genes? Is there something in the water? Is it some kind of weird collective suicide trip, like those gypsies who‘re supposed to die if they aren’t allowed to travel?
The genetic inheritance argument certainly didn’t stand up in my case. My father lived until he was 90 and never had any problems with his heart, and nor did his father who lived until he was 84. My mother lived until she was 89, similarly untroubled by heart disease, and her father lived until he was 92. He was a shipyard worker at Weirs on the Clyde who lived a hard life. I used to remember my grandfather on visits, coming back from work with his hat sparkling with metal splinters and always smoking. Both he and my father smoked Senior Service full strength cigarettes, untipped, all their working lives. My dad used to let me puff them sitting on his knee.
I was a natural smoker in my teens, but before I left university I’d already resolved to give up the weed - and I more or less did. But you never entirely escaped from cigarettes, of course, because when I started working, everyone still smoked in offices. Smokers in the eighties still regarded it as their constitutional right to pollute the atmosphere, and the rest of us just put up with it, sometimes tapping them for the odd fag out of nostalgia. I suppose passive smoking could have laid the ground for my own heart condition, but that didn’t really make a lot of sense either. Seven years after giving up smoking your lungs are supposed to revert to normal. Everyone says that exercise and good diet can prevent and even reverse blocked arteries. I don’t even eat most dairy products and I was one of those boring people who really did eat five portions of fruit a day.
Was it perhaps the other scourge of the modern age, stress? It is widely believed that stress causes heart disease, but the actual evidence for this is pretty thin. The American Heart Association has long said that there is very little direct evidence that psychological stress as such has any connection with heart disease. There was a huge longitudinal study in Finland by the University of Helsinki which found that stressed workers were more likely to die than those who didn’t - but that was looking at real stress caused by living at the bottom of society’s heap. People doing menial jobs with bad housing, poor wages and little control over their lives. The truth about stress is that it is a poor person’s disease; the stress experienced by television presenters and newspaper columnists doesn’t really count. In all countries, the unemployed are the group most likely to get heart disease, and Scotland is no exception.
There’s some evidence that so-called “Type A” hard driving personalities are more prone to heart disease, though this whole area is controversial. I do get very frustrated and angry - mostly with computers. I’m a very poor timekeeper, and habitually late for things - and I always seem to be bumping up against the next deadline. But for an incorrigible procrastinator like me, deadlines are a kind of liberation - I’d never get anything done if I didn’t have them. They provide a structure for life - a peg on which to hang some kind of achievement. And when it comes down to it, is this any worse than teaching thirty offensive teenagers? or a postman having to do a round at a minimum of four miles and hour and taking home £13, 000 a year? Probably not.
Could there be more profound existential factors at work? undressed emotional conflicts, neurotic anxieties, corrosive resentments and other New Age afflictions of the heart? Until relatively recently, it used to be commonplace to say that people “died of a broken heart”, and even though this makes little physiological sense, some still hold to the diagnosis. A friend of mine, Jo Clifford, the transgender playwright, had heart disease and puts it down, literally, to a broken heart after his partner, Suzy, died six years ago. Since then ‘he’ has given up being a man. “You have to listen to what your heart is telling you” she says. “My heart told me I had to stop - just stop. My life, my work, was killing me”. No, Jo doesn’t advocate sex change as a preventative measure. But intuitively, you feel she must be right about intense emotion playing some kind of role. I went through a hellish divorce around the same time and I remember feeling my heart ache, quite literally, in the early mornings after waking up too early, or thinking about the children. But medical science doesn’t recognise any such condition as a broken heart. Cardiologists are a hardhearted lot and as far as they are concerned, lifestyle factors aside, heart disease is essentially a lottery. When your number is up...
Only it seems that Scots men are particularly adept at winning. Which brings me back to this refrain that “Scottish men just get heart disease”. I’ve decided that there’s a degree of inverted sexism in this. I was taken aback recently by a close female friend who, on hearing about my condition, gave me a sharp dressing down about how “Scottish men just don’t look after themselves”, which in my case was laughably inappropriate. The judgemental attitude has become quite commonplace recently following all the health education campaigns that suggest heart disease is avoidable if you live right. It’s easier to live with the prevalence of this killer if you think that, through their anger and loathing and unhealthy lifestyle, Scotttish men are morally responsible for their own misfortune.
Men are certainly very poor at politicising their ailments, compared with women who have made turned conditions like breast cancer into moral crusades. Every year, 21,000 Scots die prematurely from cardio vascular disease against only 1,000 who die from breast cancer. Coronary heart disease is the number cause of premature death , and men, historically, are twice as likely as women to go pop. Men tend to die quietly, no fuss - or at least they used to.
But why Scottish men? And why only in Scotland? It’s been well established by studies of emigrants to Canada and Australia that Scots acquire the mortality rate of the host nation within two generations. This is too short a time for any genetic adaptation to occur, which suggest that there is no genetic, or racial factor in heart disease. Or rather - it’s not enough just to be Scottish - you have to live here for it to be fatal. Some say it is lack of sunshine and vitamin D in the dark winters. Some public health researchers in Scotland believe is some kind of social or cultural pathology at work.
There’s evidence that Scotland’s cardiac health is deteriorating relative to comparable regions in Europe. In fact, in ten years time, according to a recent study by the Glasgow Centre for Population Health, the West of Scotland will have the lowest life expectancy in Europe. In places like Silesia in Poland, mortality is falling faster, even though the region is far poorer than the west of Scotland and has worse unemployment and housing and has far less spent on preventive health. It’s led people like Professor Phil Hanlon of Glasgow University, co-author of the report, to conclude that there might be a Scottish ‘x-factor’. Something about the way Scots relate to each other that explains why we do so much worse than anywhere else in Europe. “This is a real challenge to us as a nation”, he says. “In Mediterranean countries, the extended family unit and a young man’s role in it seems to have remained stronger and it may have protected them from some of these effects”. In Scotland half of all children are now born out of wedlock.
This is echoed by writers like Dr Carol Craig of the Centre for Confidence and Wellbeing who has long argued that Scots’ low life expectancy may have something to do with the negativity, lack of confidence and low self-esteem that seem to define Scottish male culture. But this is fiercely contested by the Chief Medical Officer for Scotland, Harry Burns. He insists that there is no mystery about Scotland’s poor health, and that it can be explained simply by unemployment and deprivation in West Central Scotland. “There’s actually no evidence”, he told me, “that Scottish males’ health risk factors are any worse than anywhere else in Europe.” In fact, take the West Central Scotland out of the equation, and Scotland’s mortality from heart disease is the same as the rest of Europe.
Burns sounds a note of optimism. He says that Scots are making the right changes - like giving up smoking taking exercise. Better treatment and earlier detection has halved mortality rates from heart attacks in the last decade, though there is an increase in the numbers of men seeking treatment for angina, the pain associated with coronary heart disease. You’ll never stop people getting against the trend and it’s wrong to suggest that my experience in any way diminishes the value of a healthy lifestyle.
Plus the good news is that the NHS in Scotland is now very good at dealing with heart disease, and truly amazing things can be done now with minimal surgery. I’ve had stents - little lattice tubes - inserted into my arteries to unblock them. Witnessing surgeons conduct this procedure live on large TV monitors was one of the most curiously moving experiences of my life. Medical advances like these and better drugs like statins have saved thousands of men from having to go through open-heart surgery. But it isn’t infallible, and it doesn’t stop you having symptoms. I look pretty normal, but I still have angina which comes on when my heart beat rises above 120, which is depressing because it means not being able to go out in the hills. The worst thing is the drugs, four in the morning, three at night, which leave you feeling as if your head is on the wrong way.
Almost everything changes when you have heart disease, and yet nothing does. The condition of your heart becomes the prime focus of existence, but ordinary life goes on and you just have to manage it. Emails still pile up, bills go unpaid, contacts get huffy that you haven’t called. But this is just how life is for the 620,000 Scots - an astonishing number - who currently suffer from heart and circulatory disease. And be in no doubt: one day it could be you - no matter how many Glasgow marathons you’ve run.
Iain Macwhirter is the award-winning political columnist for the Herald and Sunday Herald. He has been a political broadcaster for over 20 years, in Westminster and Holyrood, and is former Rector of Edinburgh University.