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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

Environmental justice: revived and revisited

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 31 January 2012
in CHNET-Works!

With a few exceptions, such as a short 2008 report from the Canadian Policy Research Networks, socioeconomic inequalities in exposure to environmental hazards have not been a central concern of Canadian population health research or public health practice. In the United States, on the other hand, the highly visible and persistent reality of racial segregation has generated a substantial stream of research and activism on environmental justice, including the establishment of units like the Environmental Justice Resource Centre in Atlanta. In 1994, an executive order issued by then-President Clinton required all federal agencies to consider environmental justice in their programs. Official interested waned (to put it politely) under subsequent Republican administrations, but the issues are now being revisited.

The December 2011 issue of the American Journal of Public Health – fortunately, available on an open-access basis – is based on a symposium on Strengthening Environmental Justice Research and Decision Making organized by the US Environmental Protection Agency in March 2010. The articles are a valuable resource for exploring both the strengths and the limitations of current US approaches to the issues, and amply support an editorial conclusion that the EPA's current approach "is not sufficient to end make progress toward ending environmental health disparities and environmental injustices," given its heavy reliance on toxicology and engineering.

env-justice-picture-1-1Reproduced with permission of the US Environmental Protection Agency

Among the many important points raised in the collected articles:

  •  An overview of methodologies points out that most existing studies of the spatial distribution of environmental health hazards rely on census data, so effectively track only nighttime exposure. People's daytime locations and exposures are harder to track, and it's certainly plausible that people living in locations where their exposure to environmental hazards is high are also more likely than others to be working in similar environments.
  •  In assessing the overall distribution of inequalities in the chance to lead a health life, it is essential to consider the combined health effects of chemical exposures and stressors of other kinds, including psychological and social stressors. A companion article by Bruce McEwen, one of the world's leading researchers on the biology of stress, elaborates on the physiological pathways that are likely to be relevant. Since population health researchers often ignore the massive accumulation of human and non-human evidence on this topic, its recognition is especially important.
  • Paula Braveman and colleagues elaborate on a now familiar definition of health equity by dealing explicitly with the issue of strength of evidence and standards of proof, arguing: "It must be plausible, but not necessarily proven, that policies could reduce [health] disparities, including not only policies affecting medical care but also social policies addressing important non-medical determinants of health and health disparities ..."

env-justice-picture-2-1Living near pollution from heavily travelled roads is one of many environmental hazards that are unequally distributed. Photo: Atwater Village Newbie

The symposium also (not always intentionally) underscores the limitations of the US approach. For a variety of reasons, many of which have to do with industry's use of the courts to resist environmental regulation, quantitative risk assessment is "the central paradigm of the Environmental Protection Agency". Especially in the case of cancer risk, it can be difficult to establish links with the spatial distribution of hazards: because of long induction and latency periods, "studies would need to include residential histories for as many as 15 to 30 years before a cancer diagnosis to capture pertinent environmental exposures," even before dealing with the problem of exposures when people are not at home – on the job, for instance. The effect is to build in a bias against regulation that requires "requires positive evidence of 'dead bodies' before acting," in the words of a classic 1978 article by environmental economist Talbot Page, unfortunately not available for open access. More generally, the emphasis on quantitative risk assessment focuses attention and resources on refining measurement techniques and building ever more elaborate models of causal pathways. An alternative, explicitly precautionary approach to environmental justice would focus instead on eliminating hazards once a much lower standard of proof is met. This tension is hardly unique to environmental justice; indeed, as Page pointed out, it is pervasive in the regulation of many kinds of health hazards.

As mentioned, environmental justice issues have had a relatively low profile in Canada. Three Canadian researchers recently argued (I think quite correctly) that institutional health promotion here has simply failed to address environmental health inequalities. Here's one of many areas related to social determinants of health in which even a modest commitment of additional research dollars is likely to generate valuable, if politically awkward, findings.

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Understanding social determinants of health: A good-news story

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 20 January 2012
in CHNET-Works!

In an earlier posting, I commented on how difficult it is to get many colleagues to understand that conditions of daily life like not getting enough to eat, or having to spend four hours a day commuting to work while dropping off and picking up the kids at school and daycare, might not be good for your health. When you have that kind of day, some of life's less healthy diet choices look awfully attractive. 

ncd-good-news-1
On a tight schedule and a tight budget,
healthy eating options are not always feasible.

The bad news is that it's still difficult. The good news, showing that an increasing number of people are beginning to 'get it,' comes from two medical journal articles that appeared around the time of the UN High-level Meeting on Non-communicable diseases in September, 2011. That's the meeting where, as reported in the Canadian Medical Association Journal, our own government helped to water down a proposed action plan on NCDs.

In Global Heart, the official journal of the World Heart Federation, the incoming president of the Federation (Sidney C. Smith) and a colleague wrote that:

"The challenges [of NCDs] are much farther upstream and multisectoral than other health challenges; what presents as a health issue has its origins in a variety of determinants, and the solutions must incorporate agriculture, the food and beverage industry, and the built environment, among others."

And in the European Journal of Cancer, two UK-based authors warned against a "zero-sum" approach in which cancer control is viewed as competing with other prevention priorities, and made a remarkably clear statement of the case for intersectoral action, also the topic of an earlier posting:

"One of the critical failings time and time again is the development of public policy and actions around inequality and cancer outcomes that are completely dissociated from the actual lifestyles and concepts of individual responsibility that give rise to the situation in the first place. Before even setting the policy agenda for the social determinants of cancer there needs to be an explicit political mechanism that stitches cancer into the various vertical political silos of social policy – for example education and urban planning."

There are people out there who get it. Unfortunately, so far as I can tell neither of these articles is available on an open access basis, so if you don't have access through a university or hospital, make friends with someone who does. Meanwhile, the question becomes: Why don't more people get it? And what can we do to change all that?

Useful opportunities for discussing this question in the specific context of NCDs will no doubt arise at the Fourth Pan-Canadian Conference on Chronic Disease Prevention in Ottawa next month.

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Resources from around the Web: Information abundant, time needed

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Monday, 16 January 2012
in CHNET-Works!

Herewith a potpourri of important portals and blogs from around the Web. If anyone has tips about where to find time to make the best use of them, please let all of us know!

sir-michael-marmot
Sir Michael Marmot speaking in Rio

University College London has just launched the Institute for Health Equity. Headed by Sir Michael Marmot, the Institute's initial activities include leading the "Euro Review" of social determinants of health for WHO's European office. The Institute's site invites contributors to submit projects, reports and case studies, and already features numerous links to "related work" in the UK and elsewhere. It also provides a link to Sir Michael's own blog, where in a posting about the World Conference on Social Determinants of Health in Brazil he describes efforts to ignore the role of the Commission on Social Determinants of Health that he chaired as "attempted airbrushing" based on "objections to the Commission's strong emphasis on inequities in power, money and resources." All absolutely true, and you read it here first in Sir Michael's own words. 

At the Brazil conference, the World Health Organization launched an electronic platform called Action: SDH. Registration (free) is required to access many features of the site, but they are well worth the minute or so required to register and therefore to be able to post content. Like most such 'platform' sites, the value of this one will depend on involvement by members of the community that it is designed to establish.

PolitiquesSociales (en français, but linking to numerous sources in English) is produced by the Centre de recherche sur les politiques et le développement social at l'Université de Montréal. It offers a monthly collection of news items and research products on social policy and inequality around the world, with a strong European flavour. Canadian Social Research Links, updated weekly, is an almost encyclopedic collection of similar material, focusing mainly although not exclusively on Canada. It's produced by Gilles Séguin, a former federal public servant (1975-2003) who worked on social policy issues in various incarnations of what is now called Human Resources and Skills Development Canada. These sites are quite simply indispensable for anyone wanting to build the bridges between public health and social policy that we often neglect. E-mail newsletters from both sites are available by subscription.

On to a couple of blogs that more closely resemble this one. Healthy Barbs is written by Barbara Brenner, a lawyer and former executive director of San Francisco-based Breast Cancer Action. Brenner brings both rare wit and a litigator's rigorous style to commenting on such matters as how foundation support for the supposedly independent Institute of Medicine that is part of the US National Academy of Sciences may have influenced the content of a recent report on environmental causes of breast cancer. Brenner is also interviewed in a new National Film Board feature-length documentary on how corporate-backed marketing has distorted on breast cancer politics: Pink Ribbons, Inc . Watch for it in Canadian theatres on February 3.

Finally, there's a Canadian blog called DrPHealth, by a public health professional who writes "with some anonymity to protect its author as it strives to increase transparency, promote justice and champion equity." Like Brenner, the author is rigorous about posting references and hyperlinks to his/her sources, which moves this site to the top of those I would recommend to students and practicing professionals alike. One recent posting led me to a new Canadian Public Health Association knowledge centre site, which in turn led me to at least two interesting-looking electronic resources. I won't comment further, since I have not had a chance to explore these, but once again the potential is clear.

Now, about a source for those 48-hour days ...

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It's all about priorities: How to think about health equity, part 2 - Talking taxes

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 13 January 2012
in CHNET-Works!

In the previous posting, I argued for a closer look at public spending priorities, suggesting that governments have in fact been quite successful in finding money for a variety of purposes when it suits them. Here I look at the revenue side of the equation: an area where advocates for population health and health equity have, if anything, been even more timid.

Taxes do at least three things. First, they supply revenues for public purposes such as education, health care, and defence. Second, they create incentives to engage in certain kinds of behaviour and not others, with tax breaks for business investment and so-called sin taxes that raise the price of alcohol and tobacco being the most obvious example. Third, the way in which tax revenues are raised – how and from whom – can moderate (or, in some cases, magnify) trends in income and wealth inequality. As noted in an earlier posting, like many other countries Canada has conspicuously retreated from using taxes to moderate market-driven patterns of income inequality.

Canada faced a serious fiscal crisis in the 1990s. A combination of sustained growth in the United States, our major trading partner, and far-reaching spending cuts in successive federal budgets starting in 1995 turned a federal deficit of $42 billion in 1993-94 into a balanced budget by 1997/98. However, having balanced the budget both the Liberal governments of Jean Chrétien and Paul Martin and (especially) their post-2006 Conservative successors made a momentous choice: reducing income taxes, and eventually the GST, rather than reinvesting in social provision and economic infrastructure. By 2010, the federal government was claiming that its policies would reduce tax revenues "by an estimated $220 billion over 2008-2009 and the following five fiscal years" (1, p. 49). Clearly, the authors of the budget thought such reduction of fiscal capacity was a good thing.

Provincial governments, notably in Ontario and British Columbia, followed a similar route, with the benefit of tax cuts concentrated among their wealthiest residents. Ontario government figures showed that between 1995 and 1998, the richest one per cent of Ontarians (with incomes above $177,000), saw their annual tax bills drop by an average of $10,785 (2). When the BC liberals came to power in 2001, they followed a similar course, with provincial income tax reductions worth $644 a year to a resident earning $40,000 a year, but $7,797 to her senior manager paid five times that amount (3). A subsequent tax cut, in 2007, was calculated based on provincial budget figures to be worth $82 per year to a British Columbian with a taxable income of $20,000, but ten times that to a taxpayer with an income over $100,000 (4).

What were the consequences? According to the Organisation for Economic Co-operation and Development, tax revenues of all levels of government in Canada added up to 32 per cent of our Gross Domestic Product (GDP) in 2009, the lowest proportion since 1980. To put these figures into perspective, between 1990 and 2000 the figure never fell below 35 percent, and total tax revenues in the Nordic welfare states are between 42 and 48 percent of GDP. As noted in an earlier posting, these countries have child poverty rates lower than 5 percent on a standard cross-national comparative measure, according to the Luxembourg Income Study; Canada's are over 15 percent. The OECD estimated Canadian central (i.e., federal) government revenues at 13.3 per cent of GDP in 2009, the lowest proportion since the mid-1980s.

Public discussion of the opportunity costs and social and health consequences of these reductions in fiscal capacity, which international relations scholar Richard Falk has called "the social disempowerment of the state" that "follows from the impact of neoliberal ideas" (5), has been effectively nonexistent in Canada; we have been let down on this point by political leaders of every stripe. Going back to Ron Labonté's long-ago exercise, quoted in the preceding posting, we ought to ask what Canada's governments might do with just that additional 3 percent of GDP (about $40 billion) in lost fiscal capacity. Invest more in early childhood education and care – an area where, according to UNICEF's Innocenti Research Centre, Canada lags behind almost every other wealthy country? (The report in question identified ten "minimum standards for protecting the rights of children in their most vulnerable years," and found that Canada met only one of them.) Reduce the child poverty that Parliament declared its intention to eliminate, way back in 1989? Finance dental care for the poor? And what might be accomplished if we were willing to raise governments' share of GDP even a few more percentage points closer to the levels that are commonplace in much of Europe? (This would not be a matter just of raising income and payroll taxes. The tax on gasoline in every country in what used to be called western Europe is far higher than in Canada, and even drivers in middle-income Chile pay more per litre than Canadians, according to figures from the International Energy Agency.

Priorities-part-2-pic-1-gasoline-prices-table

I am not making a blanket argument for bigger government; many areas of public spending could and probably should shrink. Prisons, fighter aircraft and the salaries of senior university administrators come readily to mind; we all have our own lists. In this posting and the preceding one, I have made the argument that the resources available to Canadians are more than sufficient for any objective related to social determinants of health that we might reasonably wish to accomplish. When we are told that such objectives are unaffordable, the real message is either (a) that other areas of spending are more important, or (b) that tax cuts are more important. The more value any society assigns to tax cuts, the harder the choices it will have to make about spending priorities in the public sector, and their direct and indirect impacts on health equity.

 

  1. Department of Finance Canada. Budget 2010: Leading the Way on Jobs and Growth. Ottawa: Department of Finance Canada; 2010.
  2. Ontario Jobs and Investment Board. Report to Taxpayers: Jobs and the Economy. Toronto: Government of Ontario; April 1998.
  3. BC Ministry of Finance figures cited by Lunman K. New B.C. Premier Slashes Income Taxes for all Residents in First Day on the Job. The Globe and Mail, June 7, 2001.
  4. Murray, Stuart. Who Gets What from the 2007 BC Tax Cut? Vancouver: Canadian Centre for Policy Alternatives; May 2007.
  5. Falk RA. Human Rights Horizons: The Pursuit of Justice in a Globalizing World. New York and London: Routledge; 2000.
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It's all about priorities: How to think about health equity, part 1 – expenditure budgets

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 10 January 2012
in CHNET-Works!

The Commission on Social Determinants of Health made a compelling case that the "unequal distribution of health-damaging experiences is not in any sense a 'natural' phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics." Serious efforts to reduce health inequity by way of public policy must start with the budgetary priorities of governments at every level: what they spend money on, what they reject as unaffordable, and what they don't even think about.

More than 20 years ago Ron Labonté, then president of the Ontario Public Health Association and now a professor and former colleague at the University of Ottawa, published an article in the Canadian Journal of Public Health asking whether health care spending might not actually be creating risks to health, diverting resources from expenditure objectives that might actually lead to higher returns in terms of health outcomes. He pointed out that the $350 million increase in funding for hospitals' capital spending provided for in the 1990-91 Ontario provincial budget could, if used for other purposes, have financed 70,000 rent-geared-to-income housing units, 547,000 more subsidized daycare spaces, or 12,750 transition shelter beds for battered women and their children.

With 20/20 hindsight, this approach was both creative and destructive. It was destructive in that it positioned health care and investments in social determinants of health as direct competitors for resources. Tactically, this is a battle those of us concerned with how conditions of life and work affect the health of people with limited resources will always lose, and perhaps we should: even in countries that supposedly provide universal access to health care, such people all too often end up at the back of the queue.

The approach was nevertheless creative in that it directed attention to the broader question of how governments spend the considerable resources at their disposal, with what consequences for health. Any serious effort to implement a Health in All Policies approach, or similar rubrics that have been proposed for reducing health inequities, requires a hard look at local, state or provincial, and national budgets. These are nothing more or less than the roadmap of governmental priorities and therefore in democratic societies, at least in theory, the priorities of a decisive plurality of voters. As governments across Canada prepare budgets that must deal with the continuing fallout from the economic meltdown of 2008, this point should be kept in mind.

Priorities-part-1-pic-1-Ottawa-freeway-1-of-1What do recent budgets tell us about those priorities? Let's look at a few examples. Canada's national government has adopted changes in the criminal law that will cost billions of dollars to implement, roughly doubling federal and provincial spending on jails and prisons between fiscal 2009/10 and 2015/16 according to the Office of the Parliamentary Budget Officer, on the basis of what must charitably be called limited evidence of need or effectiveness. Apparently, criminal law doesn't need to be evidence-based, or meet any clear standard of cost-effectiveness. The Minister of Justice himself has said that "[w]e're not governing on the basis of the latest statistics," and that the government does not "put price tags in legislation". Late last year, the national government also found $477 million to contribute to building US military satellites. Here in Ontario, it's often arithmetically impossible to eat a healthy diet on a low income if you're paying market rents and more than 150,000 people are on waiting lists for affordable housing, yet the same day that figure was published the province found $200 million to widen a freeway through downtown Ottawa.

Somehow, my search for loonies in jacket pockets never turns out quite that well. Isn't magic wonderful?

Now, obviously governments have to balance a multitude of competing priorities, and health is only one of them. The point of the examples is that the tension of greatest concern is not necessarily between health care and 'upstream' interventions, and that all too often, ensuring that everyone has the same opportunities to lead a healthy life – what health equity is about – is far down the list.

Driving changes in budgetary priorities is essential to reducing health inequity, and will require more of the kind of creativity shown in Labonté's long-ago article. Public health associations could commission or carry out health equity impact assessments (HEIAs) of municipal, provincial and national budgets. Enterprising professors could ask their graduate students to do the same as a course assignment or group project. (To its considerable credit, Ontario's Ministry of Health and Long-term Care now has an internal HEIA process, but it only applies within the health system – arguably, not where HEIA is most needed.) And all of us concerned with health equity will need to forge individual and organizational alliances far beyond our usual institutions, communities of practice and comfort zones.

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