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Health as if everybody counted blog

Ted Schrecker

Ted Schrecker

Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institute, a partnership between Bruyère Continuing Care and the University of Ottawa, and a member scientist of the Population Health Improvement Research Network (PHIRN). A political scientist by background and an activist by inclination, Ted has a special interest in globalization, political economy, and issues (such as health and human rights) at the interface of science, ethics, law and public policy. From 2005-2007, he coordinated the Globalization Knowledge Network of the WHO Commission on Social Determinants of Health, and subsequently was one of the lead authors of a report to WHO that examined the implications of the Commission’s findings for future research priorities. He is currently editing the Ashgate Research Companion to the Globalization of Health; a four-volume collection of major works in global health (http://www.uk.sagepub.com/books/Book235377) that he co-edited with colleagues Ron Labonté, K.S. Mohindra and Kirsten Stoebenau has just been published in the Sage Library of Health and Social Welfare.

Photo courtesy of Ron Garnett, AirScapes.ca

Food security: Canada gets a warning

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Thursday, 17 May 2012
in CHNET-Works!

Olivier De Schutter, the second United Nations Special Rapporteur on the Right to Food, is one of the most thoughtful thematic mandate holders, as they are called in UN-speak. (There are currently 36 such mandates.) His reports and commentaries provide articulate critiques not only of the policies of specific national governments, but also of an international agri-food system that is conspicuously failing to protect and fulfil the right of all to an adequate diet – one of the most basic social determinants of health.

The preliminary report of Prof. De Schutter's mission to Canada, which wound up on May 16, is sobering reading for a country that is often prone to self-congratulation on its human rights record. He points out that according to the 2004 Canadian Community Health Survey, 7.7 percent of Canadian households reported moderate or severe food insecurity – this before the financial crisis of 2008 and subsequent recession – and "was disconcerted by the deep and severe food insecurity" faced by aboriginal people, the legacy in part of a "long history of political and economic marginalization."

de-schutter-pic-1UN Photo/Jean-Marc Ferre.
Reproduced under Creative Commons Licence 2.0.
His report directly links food insecurity and increasing reliance on food banks to low incomes and the high cost of housing – a link that has been referred to in earlier postings. "In the view of the Special Rapporteur, social assistance levels need to be increased immediately to correspond to the costs of basic necessities," and minimum wages should be set at a living wage level as required by the International Covenant on Economic, Social and Cultural Rights, to which Canada is a state party.

Population health researchers have effectively documented the extent of food insecurity in Canada; the work of the University of Toronto's Valerie Tarasuk is especially powerful in this respect, as are the reports of the Toronto Department of Public Health. We have perhaps not taken advantage of opportunities to frame food security as a human rights issue, a matter of priorities. Maybe food security for all is just more important than freeway widenings or fighter aircraft ... or maybe we don't even need to make those choices. Prof. DeSchutter pointed out that: "The tax-to-GDP ratio of Canada ... is now in the lowest third of OECD countries. Consequently, Canada has the fiscal space to address the basic human needs of its most marginalized and disempowered." I've made a similar observation in a previous posting.

Predictably, the official response was less than cordial. Cabinet minister Jason Kenney, at roughly zero risk of food insecurity, referred to "lectures to wealthy and developed countries" as "a discredit to the United Nations." He might want to have a talk with Department of Justice lawyers about the nature of obligations under human rights treaties, but that's a topic for another day. Clearly, Prof. De Schutter's intervention gives a boost to those who would address the politics and priorities that deprive people in such a "wealthy and developed country" of food security.

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The diabetes crisis: health care not doing its part? *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 11 May 2012
in CHNET-Works!

I do not ordinarily write about the health care industry (and it is an industry). I decided to break this rule after reading a recent report in the Ottawa Citizen on a decision by the Champlain Local Health Integration Network (or LHIN, Ontario's version of a regional health authority) to hire two chiropodists to provide free foot care to diabetics – a service otherwise not covered by provincial health insurance, and therefore unaffordable for many. Lack of appropriate foot care was cited as one of the reasons for the region's high rate of hospitalization for diabetic foot infections, which sometimes lead to amputations.

Diabetes is not an equal-opportunity disabler. As noted in an earlier posting, a pronounced socioeconomic gradient exists in the prevalence of Type 2 diabetes, and limited incomes seriously compromise patients' ability to manage the disease effectively. This helps to explain why diabetes mortality has declined faster among higher-income patients in Ontario. But even aside from these important issues, which suggest at the very least a need to broaden insurance coverage, Ontario's health care system seems not to be doing its part. Province-wide, according to health ministry figures, as of late 2010 fewer than two out of five Ontarians with diabetes had received all three of the tests recommended for diabetes management – blood glucose every six months, cholesterol (LDL) every year, and retinal eye examination every two years – in the appropriate period. (Nationally, a clear socioeconomic gradient exists for receipt of these tests; it would be interesting to know whether the same is true in Ontario.) And a recent article by Tara Kiran and colleagues at the University of Toronto, based on Ontario Health Insurance Plan records, points out that the 2002 introduction of a new billing code specifically to reimburse physicians for diabetes management tasks had, by the end of 2008, led to only modest increases in monitoring.

This is part of a more general, Canada-wide picture. Jeffrey Turnbull, past president of the Canadian Medical Association, has pointed out that in one of the OECD's more expensive health care systems (although it's not one of the more expensive when only public spending is considered) chronic disease management is "woefully inadequate" and "Canada now ranks below Slovenia in terms of effectiveness and last or second last in terms of money spent" on health care. With specific reference to diabetes care, 2008 figures from the Commonwealth Fund show that Canada ranked far behind the Netherlands, New Zealand and the United Kingdom in the percentage of adults with diabetes who received appropriate monitoring.

Now, I am an outsider to most of the quotidian operations of health care institutions; I don't have ready answers. Health system managers seem to be proliferating, yet few signs can be found of the "new management systems and new accountabilities" that Dr. Turnbull called for. Surely it's not unreasonable to ask that health ministries and regional health authorities have routines in place to benchmark diabetes management, and myriad other health care processes, against the world's best and transform the way they do things to match the leaders' performance.

* Tara Kiran provided valuable help with research for this posting. All views expressed are exclusively my own.

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Small steps toward walkability

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Thursday, 26 April 2012
in CHNET-Works!

Toronto’s Department of Public Health, a leader in such areas as publicizing the conflict between eating a healthy diet and keeping a roof over your head when living on a low income, has issued a new report with important recommendations for improving health by promoting walking and cycling.

Among the recommendations: reducing speed limits to 30 km/h on residential streets and 40 km/h on most others, and installing “leading pedestrian signals” at major intersections.  (These are signals that give pedestrians a walk signal a few seconds before the light turns green for vehicle traffic, improving drivers’ ability to seen them.)  The report also notes the need for more investments in pedestrian and cycling infrastructure, and for working with Metrolinx (the regional public transportation authority, now facing drastic funding shortfalls as a consequence of provincial austerity measures) to promote active transportation.

The report is based on a longer study that undertook an extensive review of the evidence on active transportation and health, emphasizing the equity dimension.  It noted, in particular, that “low-income families often live in high-rise neighbourhoods in Toronto’s suburbs,” which are hostile to pedestrians and cyclists.  Roads are wide; marked pedestrian crossings few and far between; pedestrian collisions are more frequent even though pedestrian volumes are lower; and three-quarters of parents do not feel comfortable letting their children walk unaccompanied in their neghbourhoods.

creative-commons-licencePhoto: Richard Drdul,
reproduced under a Creative Commons licence
The longer study also argued for traffic calming strategies: engineering measures to slow down traffic, like speed bumps and curb extensions, which have resulted in major reductions in injuries and fatalities when implemented in Europe.  A more extensive review of traffic calming and health was published late last year by Canada’s National Collaborating Centre for Healthy Public Policy, and will be the topic of a CHNET-Works Fireside Chat on May 10.
 
Predictably, the Toronto Public Health recommendations were greeted with howls of outrage from some of Toronto’s more retrograde politicians, but as readers of a previous posting (and the longer Toronto study) will know, such measures are either already in place or under serious consideration in many European cities.  This is, literally, an issue of street-level politics: will the “right to the city,” in Henri Lefebvre’s frequently cited phrase, favour pedestrians and cyclists or people protected by two tons of steel and airbags?  In many other Canadian cities, we’re still waiting for Toronto-style public health leadership.

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Fostering blissful ignorance about poverty?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 23 April 2012
in CHNET-Works!

Many readers of the federal budget will have missed the decision to shut down the National Council of Welfare, a small and independent-minded unit of the Government of Canada that since 1962 has been a source of information about the extent and depth of poverty and inadequate social provision in Canada. With its demise, a resource for advocacy on social determinants of health has been lost. It is still possible to use the Council's site to access an interactive map showing that (for example) inflation-adjusted social assistance incomes in Ontario are no higher than they were in 1986. And the ground-breaking 2011 study on The Dollars and Sense of Solving Poverty is still available. To quote just one provocative finding from its summary: "The poverty gap in Canada in 2007—the money it would have taken to bring everyone just over the poverty line—was $12.3 billion. The total cost of poverty that year was double or more using the most cautious estimates," although these are admittedly incomplete and fragmentary. The public health community would be well advised to act fast and download the Council's publications before they are consigned to the memory hole.

Another disturbing set of findings about economic insecurity comes from the latest annual survey of Canadian family finances (families of two or more people) from the Vanier Institute of the Family. Some of the study's findings will be familiar: for instance, after-tax income of the poorest 20 percent of Canadian families (two or more people) rose by just 19 percent between 1990 and 2009; the incomes of the richest 20 percent rose by 35 percent. We know from other studies that the trend toward increasing inequality is even more extreme when we look only at the top one percent of the Canadian income distribution: 246,000 people with an average income in 2007 of $404,000 who accounted for 32 percent of all the growth in incomes between 1997 and 2007.

blissful-pic-1Source: Department of Finance Canada.
This illustration is taken from an official Government of Canada publication;
it is used here without Government of Canada endorsement.

Other Vanier findings are less familiar, and more disturbing. For instance, Canada's official unemployment rate in early 2012 would have been 9 percent, rather than 7.6 percent, if the participation rate had been as high as before the recession; 'discouraged workers' who have given up the search for work are not counted as unemployed. And although the overall insolvency rate (bankruptcies and proposals to creditors per 100,000 population) dropped slightly in 2010 and 2011, insolvencies among people aged 55-64 increased by almost 600 percent between 1990 and 2010. Among people over 65 they rose by 1747 percent. This suggests that one of the signal accomplishments of postwar Canadian social policy, cutting the percentage of poor seniors to one of the lowest in the OECD, may be in danger.

As noted in an earlier posting, addressing the possible consequences for population health of such trends unavoidably raises questions of public health ethics. One approach would be to set up an elegant prospective epidemiological study, wait 10 or 15 years, and hope that the casualties, their survivors, or someone are still interested in the answers. Another approach, adopted by the Commission on Social Determinants of Health, is to act on what we now know or can presume with a high degree of confidence, drawing on various sources of evidence and research traditions. So far, our political leaders – and, it must be said, a few of our public health colleagues – seem more interested in punishing the poor and economically insecure, or just ignoring them, than in equalizing opportunities to lead healthy lives. Inequality trends are important for many reasons, but one is that they give the lie to claims that such equalization is unaffordable.

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“A social movement, based on evidence”? *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 21 March 2012
in CHNET-Works!

Sir Michael Marmot, who chaired the Commission on Social Determinants of Health and later led a review of influences on health inequalities in England, has called for "a social movement, based on evidence, to reduce inequalities in health" (1) and even claims to identify the beginnings of such a movement. Has such a movement begun to coalesce, and what are the prospects for its success?

In a recent book on women's resistance to workplace sexual harassment in the United States, Carrie Baker defines social movements as "a mixture of informal networks and formal organizations outside of conventional politics that make clear demands for fundamental social, political, or economic change and utilize unconventional or protest tactics" (p. 4) and argues that the resistance she studied fits that definition, even though much of the action took place in courtrooms, administrative hearings, and Congressional committees. Crucially, the coalitions that formed to fight sexual harassment connected women who were not otherwise similarly situated in socioeconomic terms. Restaurant workers, middle managers in banks and federal agencies, and lawyers trying to make partner in their firms were united - sometimes temporarily and precariously – by lack of legal protection from sexual harassment by male colleagues and superiors.

social-movement-pic-1ACT UP demonstration, St. Patrick's Cathedral, New York City, December 10, 1989. Photo: Richard B. Levine

A parallel can be drawn with what is almost certainly the most successful contemporary health-related social movement, that involving treatment and prevention of HIV/AIDS. At the forefront of that movement was the AIDS Coalition to Unleash Power (ACT UP), co-founded in New York City in 1987 by playwright Larry Kramer, who was to become identified as the public face of the movement. ACT-UP quickly adopted the tactic of mounting high-profile demonstrations in places including Wall Street, the US Food and Drug Administration in Washington, DC, and St. Patrick's Cathedral (to protest against Catholic opposition to AIDS education and condom distribution). Some of ACT UP's approaches were controversial, but it "added enterprise and erudition" to confrontation, and the organization and its tactics quickly spread nationally, and even internationally.

In the early years of the epidemic, AIDS was an equal opportunity killer. This is less true today, yet the solidarity forged in the formative years of AIDS activism survives and crosses both class and national boundaries, as seen for example in the transnational support that South Africa's Treatment Action Campaign (TAC) has mobilized. That support was critical in convincing pharmaceutical companies to abandon legal efforts to prevent South Africa's government from buying lower-cost generic antiretrovirals, and TAC continues to appeal to a global audience for maintaining access to AIDS treatment.

social-movement-pic-2ACT UP demonstration, Paris, 2005. Photo: Kenji-Baptiste Oikawa, reproduced under a Creative Commons Licence.

Here's the rub.

Effective social movements are not based on evidence. Social movements can use evidence in various creative ways, but they are based on rage, hopelessness, desperation, hope, or combinations of these. That's where their energy comes from. Normally, as shown by the examples of ACT UP and resistance to sexual harassment, their protagonists share a particular vulnerability even though they may otherwise have little in common. If we go farther back in history, the movement for female suffrage and the trade union movement are useful case studies; movements to abolish slavery, in which some protagonists had no personal stake yet were willing to place themselves at considerable risk, provides a partial counterexample.

What shared passions or vulnerabilities (and effective social movements require at least one of these, and often both) will provide the basis for reducing health inequity by way of action on social determinants of health in Canada? What more needs to be known about social movements in order to create an effective one around this agenda? The answers are far from clear, which may be why the agenda is making slow progress.

social-movement-pic-3Launch of Poverty Free Ontario Campaign, Sudbury, September 2011. Photo: Cait Mitchell (used with permission).

Public health researchers and practitioners, whatever their level of commitment (which varies greatly), are at minimal risk from many of the conditions of life and work that are most destructive of health: inadequate incomes, precarious employment, hazardous exposures on the job, and the physiologically corrosive levels of stress that go along with all of those. Perhaps that is why the enterprise of health promotion still focuses far too much attention on health literacy, "choosing your sandwich with care," and similar constructs that ignore the quotidian challenges of too little money, too many demands in the workplace (including, for women in particular, the domestic workplace), and too few hours in the day. Prof. Marmot's 2004 book The Status Syndrome is eloquent on the topic of these challenges. Further, few efforts appear to have been made to make common cause and build working relationships with anti-poverty organizations or the trade union movement. (I would love to hear from readers about exceptions to this generalization, in Canada or elsewhere, for future postings.)

Gratifyingly, some health professionals now understand the importance of such alliances. For example, in a special section on advocacy in the March 2012 issue of Canadian Nurse, Joyce Douglas of the Canadian Nurses' Association writes: "Front-line nurses can speak from experience and work with organizations, associations and movements that advocate for wages that people can live on, affordable housing, healthy environments and social inclusion." As Ontario and many other provinces face hard choices about how to reduce their post-recession deficits, let's hope health professionals of all kinds understand the issues and the stakes.

* A conversation with Kumanan Rasanathan helped to clarify some of the ideas presented here, but all blame rests with me.

(1) The hyperlink is to a video interview with Prof. Marmot; the phrase is also the title of his response to a series of commentaries on his two reports that appeared in Social Science & Medicine.

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