Residential segregation and health in Northern Ireland
Introduction
Over the 30 years of the ‘Troubles’ in Northern Ireland (NI), nearly 3700 people were killed (Fay et al., 1999) and over 50,000 injured with the intensity of the violence being particularly severe in the early years. Many more were traumatised by grief, imprisonment and witnessing violent events often with a delayed onset of symptoms and often with enduring effects (McDermott and Fitzgerald, 2004; Luce et al., 2002; Curran et al., 1990). Despite the cessation of militarised violence in NI following the 1998 Good Friday Agreement, tensions between the Protestant and Catholic communities have persisted. Sectarian violence remains a problem for many at home and in the workplace, taking the form of attacks on people and property (Jarman, 2005). Less violent forms of aggression such as verbal abuse, harassment, visual displays and graffiti also continue to be significant (Bryan and Stevenson, 2006; Bryan et al., 2008; OFMDFM, 2007, OFMDFM, 2008).
Residential segregation has been a feature of NI since the nineteenth century increasing during the twentieth century, particularly in working class areas (Boal, 1982; Poole, 1982; Shirlow and Murtagh, 2006).2 Segregation intensified during the early years of the Troubles with the ‘largest forced population movements in Western Europe since the aftermath of World War II’ up to that point and in Belfast, nearly one quarter of all households moved house between 1969 and 1974 (O’Duffy and O’Leary, 1990; Deloitte, 2007). From this point of view the physical separation of the warring communities would have been expected to ease tensions. However, those living at interfaces still had cause to worry about their security.
Shirlow and Murtagh (2006) observe that a third of the victims of politically motivated violence in Belfast were murdered within 250 m of an interface. Much of the violence associated with the ‘Troubles’ historically occurred at interface areas. Such areas continue to experience high levels of tension reflected in the construction of the peace lines between religiously defined areas. Segregation means that many can live with little interaction with the other community but the possibility and the fear of violence remain (Jarman, 2005). The lack of inter-group contact then in turn helps to perpetuate hostilities (Niens et al., 2003; Darby, 1986). Summarising studies on the association between segregation and violence, Poole (1995) states “earlier research on the geography of political violence has demonstrated the latter to have a strong correlation with the social composition of local and subregional environments, especially with the intensity of ethnic residential segregation “the stability of this pattern is consistent with the hypothesis of environmental influence upon violence”.
This paper investigates the possibility that inter-community tensions are damaging to the physical and mental health of the people of NI. The evidence in the literature for effects of the social environment on health is reviewed next.
While the causes of ill health are undoubtedly complex, many contributory factors are well established in the literature. Poor health can be caused by individual circumstances (e.g. income) and individual choices (affected by education) as well as the physical environment (e.g. housing, leisure facilities). There is also a growing body of evidence linking the social environment to health. Measures of social capital have been shown to be related to mortality, health-related behaviour, mental health and homicide over and above individual socio-economic characteristics (Stafford and McCarthy, 2006). Feelings of social isolation, job strain and depression at the time of the collapse of the Soviet system helped explain differences in coronary heart disease incidence between Lithuania and Sweden (Kristenson et al., 1998, Kristenson et al., 1997) while Marmot et al., 1991, Marmot et al., 1984 in their classic studies of Whitehall civil servants found those at the bottom of the hierarchy suffered low control, lack of variety at work, lack of social contact, distressing life events, difficulty paying bills and hostility with associated increased incidence of the risk factors for premature heart disease. Brunner and Marmot (2006) conclude that the physical effects of prolonged stress are depression, increased susceptibility to infection, diabetes, high blood pressure and the accumulation of cholesterol in blood vessel walls leading to heart attack and stroke. Of more relevance within the context of the Northern Irish ‘Troubles’ are studies showing racial discrimination causing anxiety and depression (Noh et al., 1999; Ren et al., 1999) with associated physical symptoms (Karlsen and Nazroo, 2002; de Castro et al., 2008). Paradies (2006) in a review of this literature concluded that the most consistent result was an association between self-reported racism and negative mental health outcomes with a weaker association with physical health outcomes. Ongoing community tensions at interface areas would then be expected to be injurious to the health of people living in those areas.
In addition, it could be supposed that areas currently experiencing community tension would also have higher health care needs due to traumatising incidents that took place there during the Troubles. These could take the form of physical injuries requiring ongoing treatment or ailments induced by grief or trauma experienced during those times. However, violence did not occur only in areas of high segregation. Fay et al. (1999) saw the NI Troubles as a complex overlapping mix of conflicts: (i) a republican war against the state taking the form of a bombing campaign against ‘economic targets’ and anti-security force rioting in the cities with high civilian casualties whereas in contrast the rural war was fought more directly between the protagonists, (ii) intra-community struggles from paramilitary feuding or punishment-type activities in addition to (iii) the inter-communal conflict in contiguous areas already considered (Fay et al., 1999). In order to make the association between historically violent areas and current health needs, geographical data on the intensity of the Troubles could be used to analyse variations in the current utilisation of health services. Of course the flaw in this type of analysis would be that it presupposes that those affected have remained living in the same area. We would also argue that as the memory of the Troubles recedes it is more pertinent to analyse the health effects of ongoing tensions between the communities in a way that is updateable albeit at decennial intervals. We concede that any significant effects on health now observed in highly segregated areas may be due to events occurring in the past but it is beyond the scope of this paper to disentangle current from historical causes.
There is some evidence that the Troubles affected both physical and mental health in NI. The Cost of the Troubles study (1999) found that a greater proportion of those in areas with a high intensity of Troubles-related violence indicated that Troubles-related factors caused changes in their health than in areas less affected. GPs reported that patients affected by the Troubles display a range of physical and psychological problems, including injury from punishment beatings and shootings, arthritis, diabetes, psoriasis, stress, depression and anxiety (Hamilton et al., 2003). It would appear however that the more enduring effects have been mental rather than physical. At the start of the civil unrest, higher prescribing rates for tranquilisers were noted in areas affected by riots (Fraser, 1971). In a survey conducted some time after the most intense conflict, feelings of rage, helplessness and stress were recorded in connection with the Troubles; yet few respondents felt the Troubles had affected their physical health (Smyth et al., 2001). Empirical evidence of the effect of the Troubles on mental health was found by O’Reilly and Stevenson (2003), who reported that the likelihood of psychological morbidity increased the greater the extent to which the Troubles affected a person's area or life. More recent evidence would indicate that the conflict is now of less direct relevance to current physical and mental ailments. Preliminary figures from the 2007 Northern Ireland Survey of Activity Limitation and Disability found that only 1% of people with a physical or mental disability stated ‘the Troubles’ as the cause. However, in the light of the literature reviewed above on social determinants of health, it may be difficult for survey respondents to directly attribute the cause of their ill health to something as diffuse as past civil unrest.
In summary, the historical conflict and enduring animosity between the two communities in NI at interface areas may have consequences for the physical and particularly the mental health of residents of those areas. To identify segregated areas, measures of residential segregation will be used and various measures of segregation are discussed in the next section. The effect of segregation on costed utilisation of services will be estimated while controlling for socio-economic factors. The long-term health of those living in many other areas may also have been affected by the Troubles but these considerations are left to further research.
Section snippets
Methodology
The literature suggests a number of different approaches to modelling segregation that are highly dependent on the purpose of such an indicator. In their classic study, Massey and Denton (1988) highlighted five dimensions of segregation:
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evenness involves the differential distribution of the subject population,
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exposure measures potential contact,
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concentration refers to the relative amount of physical space occupied,
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centralization indicates the degree to which a group is located near the centre
Data
Three different datasets were used in this analysis based on (i) acute hospital activity, (ii) hospital, community and social services for the elderly and (iii) the costs of prescribing for anxiety and depression medication. The acute activity was further spilt into non-elective and elective, where an elective admission is pre-planned in contrast to a non-elective admission, where the patient is admitted in an emergency. The acute and elderly activity occurred in 2003–2004 and was costed and
Results
The segregation indices were first computed for each SOA and descriptive statistics on these variables are provided in Table 4. Potentially all indices could run from 0 to 1 depending on patterns of segregation. The dissimilarity index, D, shows the greatest variation of the segregation measures almost covering the full mathematically possible range. In contrast, the weighted average of the two S indices, S(wtd), varies the least with a range approximately half as large, which may limit its use
Conclusion
Smyth et al. (2001) conclude that ‘communities in which violence was historically concentrated…are more residentially segregated’ and ‘experiences and impacts have been cumulative and are relevant to today's policy maker’. Patterns of residential segregation in NI reflect historic sectarian conflict as well as current animosities and the disentangling of these effects on current health status has not been attempted here. In this study, variations in costed utilisation were related to measures
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This work was undertaken by the Centre of Excellence for Public Health (Northern Ireland), a UKCRC Public Health Research Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, Research and Development Office for the Northern Ireland Health and Social Services and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration is gratefully acknowledged.