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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

Policies for health equity: Learning from the Danes

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 01 November 2011
in CHNET-Works!

Since the report of the Commission on Social Determinants of Health appeared in 2008, several efforts have been made to apply its insights to specific country and regional challenges. The most familiar of these are the review carried out in the United Kingdom, now competed, and the one under way in WHO's European Region – both led by Sir Michael Marmot himself. A less publicized review, led by distinguished public health researcher Finn Diderichsen, was recently completed in Denmark. The English-language version of its report is forthcoming in the Scandinavian Journal of Public Health, and is presented here in pre-publication form.

In many respects, Denmark is a leader in health and social policy. At least until recently, its economic policy dealt successfully with the issues facing a small, open economy by way of a labour market policy known as flexicurity that combines limited job protection with a high level of income protection and training provision. According to OECD figures, in 2009 a laid-off Danish worker could expect to receive unemployment benefits worth 47.7 percent of previous earnings, as compared with 11.7 percent in Canada – a figure that reflects Canada's restrictive eligibility requirements and low insured earnings ceilings. denmark posting 12 determinantsDanish child poverty rates are among the lowest in the OECD, according to figures from the Luxembourg Income Study, although the report notes a worrying increase between 2001 and 2007, partly attributable to reduced unemployment benefits. The country recently adopted a tax on foods high in saturated fats, in an effort to create economic incentives for healthier eating. At the same time, the new report is motivated by concern about the "Scandinavian Welfare Paradox of Health": Scandinavian countries with relatively low levels of economic inequality do not in fact exhibit the lowest levels of health inequality among the high-income countries, at least when crude measures such as mortality and self-reported health are used.

The report's authors identified a list of 12 determinants of health, using a straightforward model developed by Diderichsen and colleagues more than a decade ago for understanding connections among economic and social policies, macro-level variables like social stratification, and individual health outcomes.

denmark posting child pover

(Their original article does not appear to be available on an open-access basis, but pages 15-17 of the new Danish report provide a first-rate short description of the model.) For each of the 12 determinants in the list, they then provide a brief account of the relevant research evidence and an inventory of measures that are likely to be effective in reducing health inequality. Preventing increases in income inequality is identified as a priority, as are planning measures to counteract the tendency of housing markets to increase residential segregation. The inventories sometimes combine conventional 'downstream' interventions with more contextual ones. For example, with respect to interventions for early child development, the inventory includes maternity visits by health nurses and active recruitment of children with special needs through day care institutions and kindergarten classes but also elimination of childhood poverty. And suggested measures to reduce overweight, obesity and their health consequences include taxation and healthy choice programs in school and workplace cafeterias, but also (unspecified) measures to increase physical activity in disadvantaged residential areas.

Like many such reviews, the report focuses on the importance of cross-sectoral policy coordination while emphasizing both its difficulty and the lack of "positive international experiences vis-à- vis reducing inequalities." In an interesting reflection on Britain's lack of success , the report notes (for example) the long period of time required to demonstrate reductions, because the influences on health inequalities operate across the life course, and the fact that "far too many initiatives constitute single temporary projects in local deprived areas" rather than influences on broader public policies. (This observation will sound uncannily familiar to Canadians!)

It is always difficult to assess the comprehensiveness of such reviews without detailed knowledge of the country context, but a few aspects strike the foreign reader as curious. For example, although limited accessibility of healthy foods in thinly populated areas and poor neighbourhoods (the problem of food deserts) is noted, no specific measures to improve accessibility in such areas are proposed. And from a Canadian vantage point, the recommendation to increase school completion through "practical learning targeted at young people who cannot complete a normal academic school program" sounds like a recipe for stigmatization, increased stratification and a less, rather than more inclusive society.

To the extent that the data allow direct comparisons, we should also be aware that health (and socioeconomic) disparities in Denmark are already smaller than in some other high-income jurisdictions. The report notes that differences in life expectancy between neighbourhoods in Copenhagen "are as large as six to seven years" – lower than the difference of more than 10 years (for men) between some of the richest and poorest neighbourhoods in Montréal or the 17 year difference in London and the 28 year difference in Glasgow noted by Marmot and colleagues. And the poverty rate of 10-20 percent in some Danish parishes identified as a cause for concern in the report should be compared with the more than 40 percent of economic families living below the before-tax Low-Income Cutoff in some of Toronto's inner suburban neighbourhoods. (Because of different poverty measures, this comparison – unlike the international comparison of child poverty rates cited earlier – is only approximate.)

Despite these factors the similarity of the issues faced by Canada and Denmark in a global economic environment that tends to increase economic inequality is striking, and the Danish report will be valuable as a starting point and inspiration for Canadian provinces or local jurisdictions wanting to undertake a systematic and theoretically informed assessment of what works to reduce health disparities.

* We are deeply indebted to Prof. Diderichsen for permission to post this material.

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Introduction

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 25 October 2011
in CHNET-Works!

NewsPHIRN announces a new blog on research and practice related to reducing health inequity.  Written by PHIRN affiliate Ted Schrecker and a variety of invited guest bloggers, Health as if everybody counted will introduce readers to developments around the world that are relevant to Ontario, with a focus on social determinants on health.  The purpose is not only to inform, but also to stimulate online discussion about ways to introduce and advance health equity in all aspects of public policy and public health practice.

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The road to (and from) Rio

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 25 October 2011
in CHNET-Works!

Some background

The title of this blog is inspired by former police reporter Michael Connelly's novels about homicide detective Hieronymus (Harry) Bosch. Raised in foster homes and orphanages after his mother was murdered when he was 12, Bosch is a relentless loner with a strong egalitarian streak, reacting to a Los Angeles Police Department bureaucracy that devotes far more attention to some deaths than to others with the axiom that "everybody counts or nobody counts." "Everyone counts" was also the theme of the United Nations Population Fund's World Population Day 2010, which emphasized the way in which a variety of social arrangements devalue the lives of women and girls.

Everywhere in the world, achieving health equity requires equality of opportunities to lead a healthy life. We must never forget that the lifetime risk of dying in pregnancy or childbirth for women in Canada is one in 5,600 while in sub-Saharan Africa, the world's poorest region, it is one in 31. Closer to home, in 2010 more than 400,000 Ontarians a month were turning to food banks, and in mid-2011 more than 150,000 Ontarians were on waiting lists for affordable housing. Housing and nutrition are among the most basic social determinants of health, and we are far from providing such equality of opportunity. For the moment, not everybody counts. Like the fictional Detective Bosch, those of us working in health equity are trying to change that. The purpose of this blog is to provide resources for bringing about that change, and a forum for discussing cutting-edge research and best practices.

The road to (and from) Rio

Forte de Copacabana On a global scale, that kind of change was a central theme of the World Conference on Social Determinants of Health, hosted by the Government of Brazil and held October 19-21 at the picturesque Forte de Copacabana  in Rio de Janeiro. The conference was a milestone in a process that began in 2005 when the previous director-general of the World Health Organization appointed a Commission on Social Determinants of Health, chaired by Sir Michael Marmot. The Commission's report, released in August 2008, began with the observation that "social injustice is killing people on a grand scale" – not the kind of language we are used to encountering in UN system documents. Some of the activities that followed the release of the report will be the subject of later postings. The Rio conference represented a specific response by WHO to a 2009 resolution (WHA62.14) of the World Health Assembly, WHO's governing body, calling for action on the Commission's report.

Roughly 1000 members of national delegations, experts identified by WHO, and civil society representatives converged on Rio for the conference. Key background documents can be downloaded from the WHO web site, and a valuable blow-by-blow description of the conference events was provided by Jim Chauvin of the Canadian Public Health Association, who is also president-elect of the World Federation of Public Health Associations. WHO's current director, Margaret Chan, opened the first day (really half a day) with a powerful speech that began: "Lives hang in the balance, many millions of them. These are lives cut short, much too early, because the right policies were not in place." She was followed by a panel of UN agency officials and government representatives including Kathleen Sebelius, US Secretary of Health and Human Services. Perplexingly, Ms Sibelius lauded the US for its steps to expand health care coverage, making no mention of the fact that countries like Canada come far closer to providing universal coverage (at lower cost) than the 90 percent she said the United States would be glad to achieve.

parallel sessionThe second day consisted of morning and afternoon parallel sessions corresponding to five action areas identified in a discussion paper prepared by the WHO secretariat in Geneva in advance of the conference. Although these sessions were webcast live, unfortunately at the time of writing they do not appear to be available for viewing or downloading after the fact. The third day (again, really a half-day) was dominated by a panel that featured powerful presentations by Finland's new Minister of Health and Social Services, Maria Guzenina-Richardson, and Zimbabwean pediatrician David Sanders, a long-time primary health care activist described as the "star of the day" in The Guardian.

What are such conferences good for?

drafting sessionUnlike the scientific conferences with which many of us are more familiar but in keeping with the standard for diplomatic events, most of the Rio meeting was tightly scripted. (The "annotated session plan" of the parallel session for which I was a rapporteur ran to five single-spaced pages.) The only concrete output from the conference was the aspirational Rio Political Declaration on Social Determinants of Health, endorsed by all WHO member states participating in the conference. As usual with such documents, drafting the declaration began months in advance, with a first draft circulated to WHO member states in August and subsequent drafting sessions in Geneva starting in September. The details were finalized during a day-long drafting session in Rio, operating in parallel with the conference but open only to the representatives of national delegations.

The Declaration was developed using a unanimity rule, meaning there is nothing in it to which any government involved strongly objected. It is nevertheless surprisingly strong in several ways. For example it recognizes the potential of the current economic crisis to undermine health, and governments "pledge to adopt coherent policy approaches that are based on the right to the enjoyment of the highest attainable standard of health" (reference to such rights-based approaches has long been anathema to the United States), including such measures as social protection floors. On the other hand, it contains neither new commitments of resources nor any formal mechanisms for monitoring and accountability. Other omissions were highlighted by civil society participants in the conference, and by Dr. Sanders in his remarks on the last day. For example, the Declaration includes no mention of trade and health; no reference to the ongoing problem of 'brain drain' of health professionals from low- and middle-income countries; and the conference as a whole paid little attention to capital flight, which drains capital from low- and middle-income countries in amounts far larger than the annual value of development assistance. The lack of specifics would seem to underscore the concern expressed by Sir Michael Marmot and colleagues, in a commentary published at the start of the conference, that "social determinants of health have barely penetrated the global agenda ... and the default position of people in the health sector is to focus on health services and prevention of specific diseases."

What does it mean for Canada?

The Declaration is not a treaty; it does not bind WHO member states. Of course, the treaty status of an international agreement is no guarantee of effective implementation, as we know from the history of Canada's commitments under the UN Framework Convention on Climate Change. A useful comparison can be drawn between the 2011 declaration and the similarly aspirational 1978 Alma Ata commitment to achieve Health for All in the year 2000. In the event, the Alma Ata vision was thwarted by several elements of the political environment, notably resistance from the multilateral financial institutions that were emerging as key players in development policy for health. "The Rio summit offers the opportunity to ensure that failure to implement a widely supported agenda does not happen again," wrote Prof. Marmot and colleagues. Despite the lack of specifics, the Rio declaration provides an unequivocal affirmation that an agenda of reducing health disparities by way of social and economic policy and the design of policy-making institutions is both scientifically sound and ethically imperative. Unfortunately, these points remain contested in the quotidian work experience of many of us, and no international agreement can substitute for the myriad initiatives at local, provincial and national levels that will be needed to advance the science and politics of social determinants of health. Sarah Bosely concluded her Guardian coverage, one of the few English-language media mentions of the conference, by saying that "this is one genie that looks unlikely to go back in the bottle". In the Rio declaration, those of us working in the field as researchers, practitioners and advocates have a valuable resource for keeping the genie out and active. More about this in subsequent postings.

 

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