Edinburgh and Madrid have very little in common. One sits on a northern Atlantic coast, shaped by industrial heritage and a National Health Service; the other lies on the high Castilian plateau, Mediterranean in character, with a different welfare tradition and a healthcare system excellent at acute care but historically less focused on prevention.
Yet both cities show the same thing when cardiovascular mortality is mapped against socioeconomic geography: a gradient so sharp and consistent that it is difficult to explain as anything other than a structural feature of urban inequality.
What the Two Cities Have in Common
The HHH Project was explicitly designed to compare cardiovascular health inequalities across both cities, using parallel methodologies to allow meaningful comparison despite differences in data availability and administrative structures.
The findings converged on several consistent patterns. Neighbourhood deprivation was strongly associated with cardiovascular mortality, independent of individual risk factors. The relationship between tobacco retail density and cardiovascular risk was present in both cities. Green space access was lower in deprived neighbourhoods in both Madrid and Edinburgh. Community health infrastructure was sparser in the areas of highest cardiovascular need in both cities.
These convergent findings matter because Edinburgh and Madrid differ on many variables that might otherwise explain cardiovascular inequality: diet, welfare systems, climate, drinking culture. The fact that the same gradient appears in both suggests it is driven not by local cultural factors but by the structural relationship between urban socioeconomic deprivation and cardiovascular risk — a relationship that appears remarkably consistent across European contexts.
Where the Cities Differ
The differences are instructive. Scotland’s NHS provides universal coverage with no point-of-care costs, while Spain’s Sistema Nacional de Salud also provides universal coverage but with greater variation in service quality between regions. Despite universal coverage in both cases, cardiovascular inequalities persist in both cities — suggesting that healthcare access alone is insufficient to close the gap.
Edinburgh’s deprivation geography is largely a legacy of industrial deindustrialisation. Former working-class communities built around mining, shipbuilding, and manufacturing have experienced prolonged socioeconomic decline. Madrid’s geography of deprivation reflects a different history — rapid migration from rural Spain in the 1960s and 1970s, fast housing construction in peripheral districts with minimal infrastructure investment, and the concentration of lower-wage employment in service and logistics sectors.
Smoking rates have declined faster in Edinburgh than in Madrid — Spain retains higher smoking prevalence than the UK, a pattern connected to the geographic concentration of tobacco retail in deprived Madrid neighbourhoods — and this contributes to the absolute level of cardiovascular mortality. But the socioeconomic gradient within each city is similar in shape, which suggests the gradient is driven by relative deprivation and neighbourhood environment rather than by absolute smoking rates.
What Each City Can Learn
Scotland has been more aggressive in tobacco policy. Smoke-free legislation in Scotland predated Spain’s by several years, and Scotland’s minimum unit pricing for alcohol — implemented in 2018 — has no Spanish equivalent. These policies have demonstrable effects on health outcomes that are not purely explained by individual behaviour; they change the environment in which decisions are made.
Spain, and Madrid specifically, has invested more heavily in certain forms of community health infrastructure. The red de centros de salud comunitaria in Madrid — of which the CMSc Villaverde is an example — represents a model of neighbourhood-level health investment that the Scottish system has not fully replicated, despite the strong evidence base for community health centre effectiveness.
The lesson from comparing the two cities is not that one system is simply better. It is that different elements of the policy toolkit have been deployed more effectively in different contexts, and that both cities have things to learn from the other. The cardiovascular inequality problem in both Edinburgh and Madrid is solvable — as the evidence on social determinants and upstream policy consistently shows. What is lacking is not knowledge but political commitment.
