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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

“Divided we stand”: OECD on inequality, and reasons for caring

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 06 January 2012
in CHNET-Works!

The Organisation for Economic Co-operation and Development (OECD) is a group of high-income (and some middle-income) countries that historically has paid attention mainly to conventional economic indicators such as growth, productivity and innovation. It does other things as well, including providing some of the best statistical overviews and assessments of its members' foreign aid performance. And recently, it has been addressing the consequences of increasing economic inequality within the borders of many of its members.

Divided-we-stand-pic-1Ermenegildo Zegna Boutique in Chile, one of the OECD’s most unequal countriesA December 2011 OECD report provides a description of those increases, an analyses of their causes, and country-by-country data that have some sobering implications for Canada. The report finds that income inequality increased in most OECD countries over the past three decades, although the level of inequality varies widely. The average income (adjusted for household size) of the richest 10 percent of the population is 5 or 6 times the average income of the poorest 10 percent in the Nordic countries, but 10 times that of the poorest in Canada, 14 to 1 in the United States, and 27 to 1 in Mexico and Chile. The report identifies a number of contributors to rising inequality of market incomes, including several aspects of globalization; technological change (which to the authors' credit it describes as hard to disentangle from globalization); changes in hours worked, which have favoured higher earners; and changes in household structure.

There is much room for debate here, notably about the role of globalization and the reasons for rising labour market incomes at the top of the income distribution, which have played a major role in increasing inequality, but also about the OECD's view that inequality can be reduced through raising workers' educational levels. This is worth doing, but effects on inequality are likely to be offset by growth in the kinds of work susceptible to 'offshoring'. For policy purposes, a point of particular interest is how taxes and benefit systems change the distribution of income, and how their effect varies across countries and over time. Like earlier analyses, the report points out that taxes and benefits in some countries (many in Continental Europe) are more strongly redistributive than in others (like the United States and Chile). Generically: "Until the mid-1990s, tax-benefit systems in many OECD countries offset more than half of the rise in market-income inequality. However, while market-income inequality continued to rise after the mid-1990s, much of the stabilizing effect of taxes and benefits on household income inequality declined."

The country note for Canada points out that the share of all income flowing to the richest 1% of Canadians grew from 8.1% in 1980 to 13.3% in 2007 – a trend that closely parallels an even more extreme pattern in the United States, where the income share of the top 1% is now higher than at any point since the Great Depression. (Readers interested in exploring comparative trends in top incomes may want to explore the World Top Incomes Database.) The OECD also points to the declining redistributive effect of Canadian taxes and transfers – a point made a few years ago in a Statistics Canada study, which observed: "Redistribution grew enough in the 1980s to offset 130% of the growth in family market-income inequality -- more than enough to keep after-tax income inequality stable. However, in the 1990-to-2004 period, redistribution did not grow at the same pace as market-income inequality and offset only 19% of the increase in family market-income inequality." The OECD note identifies a somewhat less dramatic retreat from redistribution, reflecting the fact that many ways of doing such calculations exist - for example, the OECD study restricted its analysis to the population aged 15-64 - but the general trend is clear.

Why should population health researchers be concerned with rising economic inequality? There are several reasons, most of which are familiar. First, rising inequality may lead to increases in poverty, however it is defined, although that is not necessarily the case. Second, socioeconomic gradients in health usually exist across the entire income spectrum. Intuitively, we would expect these gradients to be steeper when economic gradients are also steeper, other things being equal, although this is a difficult proposition to test because of the impact of policies that do not directly affect income distribution. Third, income inequality is only part of the story: wealth inequality, which the OECD study did not address, is normally greater than income inequality, and insecure and precarious jobs (which have their own health implications, including higher exposure to on-the-job hazards) are concentrated at the bottom of the income scale. Fourth, it is argued – notably by Richard Wilkinson and colleagues – that higher levels of economic inequality within a society lead to overall lower levels of health, although the mechanisms of action remain unclear.

Divided-we-stand-pic-2Photo by Paul Keller, reproduced under a Creative Commons LicenceA final reason has received less attention in the context of health policy; it involves a phenomenon that former US Cabinet secretary Robert Reich called the "secession of the successful". Past a certain high level of income and wealth, people need less from government, and different things. As one Arizonan interviewed for an article on politics in that state put it: "People who have swimming pools don't need state parks. If you buy your books at Borders you don't need libraries. If your kids are in private school, you don't need K-12. The people here, or at least those who vote, don't see the need for government." To which we could add: people who can afford to drive or fly everywhere don't need public transportation; people with secure incomes gain little from public financing of social or subsidized housing; people who could afford private insurance may resist paying taxes to keep a public health insurance system afloat for the less healthy and less wealthy; and so on.

What happens to the political prospects for reducing health inequity by way of social policy when a small but highly influential segment of the population needs government mainly for roads, police and prisons – and perhaps regards enhancing its own security through private purchases as routine? I recently returned from a workshop in Johannesburg, one of several South African cities that are more economically unequal than any other developing world cities included in United Nations Human Settlements Programme study (p. 73). The workshop was held in a guest house with an electronically activated gate, in a suburb where many properties were fenced with razor wire, and almost every one boasted a private security service's "armed response" sign. This is commonplace in South African cities. From Arizona to South Africa, does the interaction of inequality and privatization suggest a self-reinforcing process that can only be reversed through internal revolt or catastrophic external events (think the Great Depression and the second World War)? Health economist Robert Evans, quoted in a previous posting, wonders: "If we are back to a pre-war income distribution, how much of our post-war social policies can survive?" We should pay more attention to this question.

1The Gini coefficient, a standard measure of income inequality, in Johannesburg is 0.75 according to this study – more unequal than the national distribution of income in any country in the world. By comparison the Gini coefficients in Mexico and Chile, the two most unequal countries in the OECD, were 0.494 and 0.476 in the late 2000s, according to the OECD.

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Diabetes in Canada: Parts of the story

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 04 January 2012
in CHNET-Works!

Shortly before this past Christmas, with minimal publicity, the Public Health Agency of Canada released a valuable collection of facts and figures on Diabetes in Canada. It points out (for instance) that in the decade after 1998/99, the prevalence of diabetes among Canadians increased by 70 percent (to 2.4 million), with a predicted increase in prevalence to 3.7 million by 2018/19. Further, "although only 3.1% of all deaths in Canada were attributed to diabetes in 2007, more than a quarter (29.9% of individuals who died had diabetes in 2008/09. Diabetes itself does not typically lead directly to death, but the complications associated with diabetes do." Thus, prevalence figures substantially understate its overall contribution to the burden of illness borne by Canadians; that contribution includes cardiovascular disease (the most frequent complication), eye disease, kidney disease, increased infection from minor injuries and a variety of other conditions.

Diabetes-posting-pic-1Healthy food choices: not always availableThe report's importance in drawing attention to the magnitude of the diabetes-related burden of illness is beyond question, yet its contribution to understanding that burden from a health equity perspective is limited. For the most part the authors adopt a conventional risk factor approach to the causes of diabetes, starting (predictably and non-controversially) with a description of overweight and obesity, and the contributions of limited physical activity and unhealthy eating. A list of self-reported barriers to physical activity is reproduced, as is a list of factors influencing food choices that includes nutritional knowledge, perceptions of healthy eating, media advertising and "lower socio-economic status and social inequity," which is not further explored.

The report's treatment of socioeconomic gradients is similarly descriptive, confined to gradients among adult Canadians across Canada, stated by income quintile and education level, in self-reported obesity, physical inactivity, inadequate fruit and vegetable consumption, and daily tobacco smoking. Curiously, data on socioeconomic gradients in actual prevalence of diabetes are not presented, although according to Canadian Community Health Survey data prevalence of Type 2 diabetes in the lowest household income group (income less than $15,000) is more than four times as high as in the highest income group (over $80,000). According to the authors of this last study, "individual risk behaviours do not explain a substantial part of the income association," suggesting "that the diabetes burden associated with poor health behaviours should be looked at through the lens of socioeconomic conditions."

Diabetes-map-1Age- and sex-adjusted diabetes prevalence per 100 persons of all ages, Toronto, 2001-02. Source: Booth GL, Creatore MI, Gozdyra P, Glazier RH. Diabetes in Toronto, Chapter 2: Patterns of Diabetes Prevalence, Complications and Risk Factors. Toronto: Institute for Clinical and Evaluative Sciences; 2007. Reproduced by permission.

 

Diabetes-map-2Average annual household income, Toronto, 2000. Source: Creatore MI, Gozdyra P, Booth GL, Ross K, Glazier RH. Diabetes in Toronto, Chapter 3: Socioeconomic Status and Diabetes. Toronto: Institute for Clinical and Evaluative Sciences; 2007. Reproduced by permission.

Finer-grained examinations of how socioeconomic conditions affect the origin, management and prognosis of diabetes can be found in several places. The Toronto diabetes atlas project of the Institute for Clinical Evaluative Sciences produced a multi-volume mapping of diabetes prevalence and a range of neighbourhood characteristics; just two of the 140 maps generated by the project are shown here. To oversimplify a complex set of findings, the project found that higher-income neighbourhoods generally had lower prevalence of diabetes. Prevalence was especially high in low-income neighbourhoods outside the downtown core, with high proportions of recent immigrants and members of recent minority groups. These neighbourhoods tended to have lower population densities, poor walkability, limited access to public transit and long distances to stores selling fresh fruits and vegetables (the 'food desert' problem) and other so-called healthy resources like parks. Conversely, high incomes seemed to have a protective effect against diabetes, even in neighbourhoods where adverse outcomes would be expected based on place-related characteristics. "We noted a striking mismatch," the authors concluded, "between areas of Toronto where healthy resources were most needed and where they were located."

Diabetes-posting-pic-2Activity-friendly urban environments like this may be inaccessible to people in low-income neighourhoodsThere is also, as I have pointed out in previous postings, the simple arithmetic impossibility of eating a healthy diet for many people living on low incomes if they are also paying market prices for housing. Indeed, a series of interviews by York University's Dennis Raphael and colleagues (1) with people trying to manage diabetes in Toronto on incomes below Statistics Canada's Low-Income Cutoff (LICO) found food insecurity and inability to afford an adequate diet widespread "even with almost two-thirds [of participants] living in some form of government-assisted housing or shelter." Two recent articles (2,3) by Claudia Chaufan and colleagues similarly explore the interaction of low incomes, limited availability (and high local prices) of healthy food, high transportation costs and other variables like insecure employment in a Latino and immigrant neighbourhood in Northern California, concluding that structural factors limit the relevance of health and lifestyle education interventions – a point that should by now be familiar, but nevertheless merits continued repetition. One interview respondent summed up the range of problems: "You know, it's a full time job to be poor."

Variables like those identified in the Toronto and Northern California studies are not prominent in the PHAC report, beyond brief generic discussion of healthy food choices and of the built environment. New York-based researchers Rodrick and Deborah Wallace have eloquently compared individualized explanations of obesity that focus on imbalance between caloric intake and exercise to "the remark by US President Calvin Coolidge on the eve of the Great Depression that 'unemployment occurs when large numbers of people are out of work' ... and as Raphael pointed out in a holiday posting on his Social Determinants of Health listserv, the word "poverty" appears nowhere in the PHAC report. (I checked; it doesn't.) That report remains useful, yet at the same time shows how very much still needs to be done to integrate social justice and social determinants into the everyday worldview of public health professionals.

 

(1) Raphael D, Daiski I, Pilkington B, Bryant T, Dinca-Panaitescu D, Dinca-Panaitescu S. A toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics: the experiences of poor Canadians with Type 2 diabetes. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).

(2) The Twin Epidemics of Poverty and Diabetes: Understanding Diabetes Disparities in a Low-Income Latino and Immigrant Neighborhood. Journal of Community Health 2011;36:1032-43, (full text unfortunately not available for open access).

(3) Chaufan C, Constantino S, Davis M. 'It's a full time job being poor': understanding barriers to diabetes prevention in immigrant communities in the USA. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).

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“Logics of expulsion”

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 09 December 2011
in CHNET-Works!

saskia-sassen-picAt the Global Health Conference in Montréal last month, I had the privilege of being on a panel with Saskia Sassen, the Robert S. Lynd Professor of Sociology at Columbia University. She is one of the most intellectually sophisticated scholars writing in English (and indeed in various other languages) about how globalization is transforming societies rich and poor alike – and in the process affecting who has the chance to live a long and healthy life.

Saskia Sassen is perhaps most closely identified with her research on the global cities (New York. London, Tokyo) that function as command centres for the world economy. Her subsequent research expanded, in various ways, on how global reorganization of production and (especially) finance has redistributed power. In a 1996 book called Losing Control? Sovereignty in the Age of Globalization, she wrote about the shift of power from citizens to unaccountable coalitions of investors who comprise "a sort of global, cross-border economic electorate, where the right to vote is predicated on the possibility of registering capital." In the preceding year, a Wall Street Journal editorial warned financial markets of the need for "dramatic action" in the federal budget; political scientist Donald Savoie argues that this warning played a major role in the $29 billion in federal spending cuts that followed. At a time when bond markets and credit rating agencies have more say over the fate of many European governments than their own electorates, Sassen's observation is more important than ever.

Her most recent project is even more relevant to population health. She argues that contemporary globalization is generating "a savage sorting of winners and losers" within as well as across national borders, continuing and intensifying a pattern that began with the use of structural adjustment programs – familiar to many in the global health field – as a "disciplining regime" in the aftermath of debt crises. More specifically, she describes new and often brutal "logics of expulsion". One of these involves the phenomenon of land grabs: large-scale purchases or long-term leases of productive agricultural land by food-importing countries or transnational agrifood corporations. North American media have been predictably silent on this topic, but it has received considerable coverage in The Guardian, which is the English-language paper you need to read if you really want to know what is going on in the world.

Another logic of expulsion arises from the aftermath of the 2008 collapse of the market for securities backed by sub-prime mortgages. In a remarkable video of a presentation to a September, 2011 homelessness conference (basically a longer version of her Montréal presentation), Sassen points out that subsequent foreclosures in the United States have created a largely invisible army of close to 30 million displaced people, including many who were renting properties that were foreclosed. The state, through law, has been an active participant in these expulsions. We have, as she points out, gone far beyond the anodyne language of social exclusion that has recently become popular in some social and health policy circles.

Sassen also makes the critical point that profits made from the securities in question were completely unrelated to whether or not the people originally taking out the mortgages had any hope of making the payments; profits were made, rather, by packaging and selling on the mortgages. Predictably, homelessness – which is not good for your health – is on the rise in the United States. Another illustration of the consequences of the crisis in the country where it originated: in September 2011, a record one in seven Americans was receiving the food vouchers commonly known as Food Stamps, and millions more were eligible. Like the proliferation of foreclosures, this new pattern of impoverishment can be traced directly to domestic and international policy choices designed to create new profit centres in the global financial services industry, on the principle that markets know best.

glittering-towers-pic
Photo by Joseph Bergantine,
licensed under a Creative Commons United States licence

In intellectual terms, the events of 2008 confirmed that idea's zombie status (as Bob Evans, featured in my previous posting, would say), but the zombie masters have revived it with frightening tenacity. The statistics from the United States also show that the study of globalization and health can no longer focus on distant countries 'out there'. In the future, wherever we are in the high-income world (think about the 46 percent youth unemployment rate in Spain), globalization's casualties will live among us, sometimes literally in the shadows of the glittering towers where globalization's winners live, work and play.

I have only scratched the surface of Saskia Sassen's work, but have tried to show why everyone concerned with health equity should consider it indispensable. Read it, and you'll quickly understand why the December, 2011 Foreign Policy "top 100 global thinkers" features her as the first sociologist to make the list.

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What's it like to be poor in Canada?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 09 December 2011
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For many Canadians who have fallen through the cracks of our increasingly unequal economy and frayed social safety nets, this festive season is anything but. CBC radio's The Current recently aired a multi-part series on being poor in Canada. The first part of the series addressed such issues as child poverty and the fact that the poor pay more for a range of goods and services, from food to banking. This was followed up with two call-in sessions that ran in every time zone; the second session featured political leaders including social service ministers from Nova Scotia, Ontario, Manitoba and Alberta. At least for the moment, audio of all the programs is available by clicking on the hyperlinks. More soon on a new OECD report that documents the 30-year increase in economic inequality in most of the high-income world.

Tags: economic, poverty
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Robert G. Evans: An Appreciation

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Thursday, 01 December 2011
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evans-photo-1Few people who have heard University of British Columbia health economist Bob Evans speak will forget his formidable intellect, ruthless wit and remarkable knowledge of Dickens. A younger generation of population health researchers and practitioners may not realize the extent of his contribution to the study not only of health systems but also of what are now called social determinants of health – notably, as director of the Population Health Program of the Canadian Institute for Advanced Research from 1987 to 1997. (Unfortunately, that program has now been discontinued.)

A classic 1990 article that he wrote with Greg Stoddart – "Producing Health, Consuming Health Care" - contrasted the "reactive" orientation of health care with "the egregious fact that people are suffering, and in some cases dying, as a consequence of processes not directly connected to health care," a fact that "elicits neither rebuttal nor response." Plus ça change, one is tempted to say.

Evans and Stoddart described conventional thinking about health and health care in terms of a model "analogous to a heating system governed by a thermostat." If the room gets cold, or the prevalence of illness and injury increase, we turn up the thermostat or increase the flow of resources to health care. Seldom do we consider the efficiency of the furnace; redesigning the envelope of the building is off the radar (perhaps now even more than when the article appeared). Less frequently cited, but equally important, is their critique of the emphasis on individual risk factors (and on lifestyle change) in the nascent field of health promotion, which they presciently viewed as expanding "the 'product line' of the health care system" and serving "to maintain and protect institutions and ways of thinking about health."

These are gross oversimplifications of nuanced arguments, but they make my point about the importance of this contribution to the literature.

Equally memorable is Evans and colleagues' description of advocates of user charges and other incremental introductions of private finance into the health care system as "zombie masters": people with an interest in resurrecting ideas that "may be intellectually dead but are never buried." User charges under whatever name, they pointed out, "serve primarily to move money from one set of pockets to another" – an application of three axioms that are central to Evans' work, and to understanding the value of a political economy perspective on health policy. (Full disclosure: political economy is my own disciplinary background, and many years of research have strengthened my commitment to following the money as a starting point for social scientific explanation.)

First, health systems can be analyzed in terms of three basic questions: Who pays? Who gets (services)? Who gets paid?

tmc-pictureSecond, and relatedly, as "an accounting identity, expenditure on health care is exactly and precisely equal to incomes earned in health care", whether they are the incomes of care providers, pharmaceutical manufacturers, or insurance company shareholders and employees. In the United States, with the most expensive health care in the world, you can observe the payoffs from a system driven by the economic interests of the health care industry. The glittering towers of medical complexes like the one shown here are almost as tall and shiny as the banks.

Third, decisions about health policy have distributional consequences. Health financing regimes like Canada's that rely mainly on general tax revenues redistribute resources from the relatively healthy and wealthy to the unhealthy and less wealthy, and even if the tax system is only modestly progressive the degree of redistribution can be quite substantial. Critiques of Canada's public health insurance systems as "unsustainable" and arguments that private financing should play a larger role have no basis in actual patterns of expenditure. Rather, Evans sees them as efforts to advance an inegalitarian agenda, based on a sound understanding of the redistributive nature of tax-financed public health insurance: the wealthy aim to reduce the tax burden associated with financing for others the standard of care to which they themselves aspire. He further shows that growth of public spending on health care as a percentage of government budgets cannot be separated from events on the revenue side: tax reductions that have disproportionately benefited the affluent. "Had provincial governments not chosen to use the reviving economy as an opportunity to cut tax rates, the share of aggregate provincial revenues devoted to health care would in 2005/06 have been very slightly below its level in 1982/83, over twenty years previously." At least before the economic crisis of 2008, then, governments were suffering from self-inflicted fiscal wounds. Today's continued reluctance to think about raising taxes on the rich suggests that they are still in denial on that point.

There is more. Evans and colleagues have long challenged the claim that population aging will create unsustainable pressures on health systems, pointing out that aging per se accounts for only a small proportion of increases in health care costs. The Canadian Institute for Health Information recently made this point as well, but without Evans' magnificent image of the zombie of "apocalyptic demography," turned loose as convenient. Perhaps the "natural alliance of economic interest between service providers and upper-income citizens to support shifting health financing from public to private sources" described in one of Evans' most relentless critiques of the thoughtless application of textbook economics to real-world health systems has simply found a new fear-inducer for public relations purposes.

As Canadians watch the negotiation of a new federal-provincial-territorial accord on health financing (someday I will write a posting on getting undergraduate political science students excited about fiscal federalism) while the European Union readies itself for the 2012 Year for Active Ageing and Solidarity between Generations (and yes, solidarity is the word used on the official web site), we would do well to think about the implications.

There is still more. Understanding the politics of social determinants of health means coming to grips with how today's rapid growth in incomes at the top of the economic scale strengthens proponents of the inegalitarian agenda throughout the political process, not only with respect to health systems. Evans wonders: "If we are back to a pre-war income distribution, how much of our post-war policies can survive?" This is the topic of a three-part posting to follow shortly. Meanwhile, readers not yet familiar with Bob Evans' work have a treat in store as they encounter his rare analytical gifts and a style that is the antithesis of the anodyne prose found in much academic writing. So much the better, say I.

See also:

Evans RG. Financing Health Care: Taxation and the Alternatives. Chapter 2 of Mossialos E et al, eds. Funding Health Care: Options for Europe (2002). Buckingham: Open University Press.

Evans RG, Stoddart, GL. Consuming Research, Producing Policy? American Journal of Public Health 93 (2003): 371-379.

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