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

A change of scene, and a farewell

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Ted Schrecker
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on Tuesday, 23 April 2013
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Recording artist Lynn Miles sings:  “Burn all the bridges down / Move me to another town.”  I am not burning any bridges, but I am moving to another town – one on the other side of the Atlantic, in fact.  As of June 1, 2013 I will take up an appointment as Professor of Global Health Policy at Durham University. (I cannot resist the observation that Durham County Council is currently the only one in England controlled by the Labour Party, although this may change after the May elections.)  The change of scene and the end of provincial funding for the Population Health Improvement Research Network make this a good time to discontinue writing Health as if Everybody Counted.  For the immediate future the postings will remain on the CHNET-Works web site, and I hope they will continue to serve as a useful resource for those wanting to advance the health equity agenda.  I am also enthusiastic about the possibility of updating, reorganizing and consolidating the postings as an e-book; more news on this as it happens.

As I prepare to leave Canada, I am prompted to reflect on why it is so difficult make change in population health research and practice.  Most of us work in institutions like university faculties, government ministries, local public health agencies, or nonprofits. These institutions respond to external priorities like those of granting councils, cabinets and local elected officials – priorities that tend to be shaped by macro-scale political currents like neoliberalism.  Our institutions also, with a few exceptions, are strongly hierarchical in their internal structure.  Observations of various kinds of organizations show that many individuals working within them adapt with striking facility to the moving target represented by changing requirements for success within the institu¬tion.  In an excellent study of the World Bank, Cheryl Payer described “a cage with glass walls.  Within this barrier the bureau¬crats and technocrats work, argue, debate, cooperate or fall out with one another, attempting to aggrandize their own position or to defeat opponents. They have the illusion of freedom because the barrier is invisible.  The smart or ambitious ones, having once experienced or observed such a collision, remember where the barrier is and avoid it thereafter; those who are slower, stubborn, or angry continue to beat their heads against it until they are bloody.  The recruitment and promotion practices naturally favour the smart ones who don't have bloody heads" (p. 353).

Not everyone adapts eagerly to the requirements for advancement within their institution, although eager adaptation is frequent in Canadian university settings.  Active resistance is likely to be a career-limiting move in many organizations.  Senior managers and external protagonists who set priorities and budgets must at least be comfortable with ideas like health equity if people trying to organize their work around such a concept want to keep their jobs, and the organization’s internal routines must be permeable enough to enable the advocates to make their case.  Academics often have more flexibility, but can still be targeted by governments or commercial interests.  More routinely, they are vulnerable to being marginalized or excluded through the operation of what can be thought of as organizational filters.  For example, if the managers of universities or hospitals (or those to whom they report, like hospital and university boards) decide that securing a permanent teaching or research position requires successful grant applications, then over time the organization becomes populated by people whose research priorities are congruent with those of funding agencies – whether those involve behavioural approaches to health promotion, development of commercial products like new drugs, or military technologies.

Philosopher of science Jon Elster is a master at providing microfoundations for large-scale explanations of social phenomena. In Ulysses and the Sirens, now unfortunately out of print, he wrote that: “If academic personnel apply for military funds in order to be able to conduct the research that they would have done in any case ... the Department of Defence may serve as a filter that selects some applica¬tions and rejects others.  The resulting composition of research will be beneficial to the military interests, while wholly unintended by the individual scientist, who can argue truthfully that no one has told him what to do” (p. 30).  Those who make it through the filters will in turn have an ongoing influence on the direction of the organization as, for example, they serve on appointments committees or advance into administrative posts, having observed the bloody heads of less accommodating colleagues.  The result is a situation in which, as Ken Coates of the University of Saskatchewan has written: “We have self-regulated ourselves into near silence, and our students and the country suffer from the quiet as much as university faculty.” Given granting agencies’ emphasis on biomedical and clinical research and the growing corporate influence in Canadian universities, which has been commented upon even in the Financial Post, it is hard to overstate the importance of this analysis, both for those already ‘in the system’ and for those hoping to make a career in equity-oriented health research.

The experiences of those of us who have worked in such environments are too easily dismissed as anecdotal or otherwise biased; for better or for worse, external validation is needed.  Empirical health policy research has not penetrated very deeply into the power structures and organizational routines of Canadian health ministries, university faculties, research institutes and public health agencies.  Relevant methodologies and perspectives are suggested by contributors to books like Policy Worlds: Anthropology and the Analysis of Contemporary Power and by the work of scholars like Janine Wedel, whose remarkable analysis of how power operates both through formal organizational structures and the informal networks she calls “flex nets” is especially valuable.  It remains to be seen whether those interested in doing this kind of research can make it through the filters, or whether they will find the necessary financial support.  

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Where the health equity action is, around the world

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Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 10 April 2013
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Herewith a selection of promising efforts from around the world (sadly, none from Canada) to implement the health equity agenda.

The Social Determinants of Health Network (SDH-Net) is a four-year collaboration with the aim of building research capacity on social determinants of health in Mexico, Colombia, Brazil, South Africa, Tanzania and Kenya. It involves leading institutions in each of the six, in partnership with similar institutions in Germany, Spain, the United Kingdom and Switzerland.  The network is now in its second year of operation, and mapping reports on research capacity in each LMIC will soon be posted online.  Among other bodies of expertise, the project builds on earlier work by the World Health Organization on social determinants of health and public health programs.  SDH-Net is funded by the European Commission, the executive branch of the European Union, under the seventh Framework Research Programme.

Also funded by the European Union – are you seeing a pattern? – is the European Portal for Action on Health Inequalities.  In addition to links to a verity of external resources, the site offers access to a multilingual policy database that is searchable by EU country, implementation level, characteristics of policy or keyword. On an initial exploration of the database, and perhaps inevitably given the state of health equity intervention research, many of the entries link either to official statements of policy (which may or may not be reflected in actual practices) or to self-reports. Nevertheless, such platforms already serve a valuable purpose in encouraging creative imitation and thinking outside the box.

Still in the EU, a multi-university collaboration on Poverty and Social Exclusion funded by Britain’s Economic and Social Research Council has just released summary findings from report starkly titled The Impoverishment of the UK.  The report found, for instance, that about 5.5 million adults go without essential clothing, about 4 million children and adults are not properly fed by today’s standards, and more than one in four people skimped on their own food in the past year so others in their household could eat.  It should be kept in mind that these findings come from a country where academics are warning that pending benefit cuts may push 200,000 more children into poverty; where the income tax rate paid by the country’s highest earners has just been lowered; and where a wealth tax on houses worth more than £2 million remains controversial.  The survey does not consider direct effects on health, but underscores the fact that in the face of the recommendation by the Commission on Social Determinants of Health to “tackle the inequitable distribution of power, money, and resources,” some countries are moving in the opposite direction.

Finally, a new WHO report on Closing the Health Equity Gap, with a former official in Britain’s Cabinet Office (Ross Gribbin) as one of the two lead authors, draws on the reports of the various knowledge networks set up to support that Commission to identify concrete, and relatively short-term, implications for public policy.  The first main section identifies actions for health systems and health policy: moving toward universal coverage; expanding and redesigning public health programs; improving the measurement of health inequities; and making the case for intersectoral action.  The second main section focuses on cross-government actions in areas such as social protection, urban policy, trade, labour markets, and (commendably) policy and attitudes towards women.  Those who have been working on health equity issues professionally for some time will probably not find much that is new here, but that isn’t the point.  The point is rather to disseminate key messages about practical possibilities for acting on the moral imperative of reducing health inequity to audiences that may be unfamiliar with the concept, or else convinced of its importance but frustrated by the lack of ‘how do we get there from here’ information. 

Unfortunately, the current British trajectory – essentially, a large-scale social experiment on nonconsenting subjects in a jurisdiction that is a world leader in research on socioeconomic disparities and their health consequences – suggests that more information and better messaging may not be adequate to address the raw politics that perpetuate health inequity.

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    I am happy to see someone acknowledge that the "rational" approach to change might not be enough. It strikes me that this model of...
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Our big fat complicated population health problem, Part 2: It may be worse than we thought

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 25 March 2013
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Big fatFew now dispute the importance for population health of the rapidly rising prevalence of overweight and obesity, in countries rich and poor alike.  What to do about it is a matter of greater dispute.  An accumulating body of evidence suggests, as Rob Moodie and colleagues argued earlier this year in The Lancet, that overweight and obesity should be regarded at least in part as an “industrial epidemic” in which “the vectors of spread are not biological agents, but transnational corporations” like those that dominate the food and drink industries. 


In this vein, an important  exposé in the November-December 2012 issue of Mother Jones tried to answer the question of how the sugar industry “kept scientists from asking: Does sugar kill?”  The authors obtained documents dating back to 1942 describing the industry’s use of a strategy that David Michaels, a former senior official of the US government, has called “manufacturing uncertainty”.  The strategy was perfected by the tobacco and asbestos industries, but has been applied far more widely to resist regulation and other policy interventions aimed at protecting public health.  On March 20, The Guardian  reported on a series of talks given in Britain by Robert Lustig, an endocrinologist who argues that: “The food industry has made [sugar] into a diet staple because they know when they do, you buy more.”   This point is of special importance because of the continuing insistence, notably in the documents supporting and emanating from the UN High-level Meeting on Non-communicable Diseases, that public-private collaborations can contribute meaningfully to prevention of such conditions as cardiovascular disease and diabetes.  And evidence is accumulating that fructose, in particular, has destructive effects that go beyond its direct contribution to excessive caloric intake – a point that was emphasized during a panel on sugary drinks I recently attended at the 15th Public Health Research Conference at Mexico’s impressive National Institute of Public Health.

As noted in an earlier posting, rising overweight and obesity represent a complex problématique that cannot be isolated from issues of political economy, health equity and social justice.  On the political economy front, a fascinating recent open-access article on “exporting obesity” argues that the combination of farm subsidies in the United States and the removal of trade and investment barriers between the US and Mexico under the North American Free Trade Agreement  led to rapid transformation of the Mexican “consumer food environment” in several unhealthy ways.  One of these involved a dramatic increase in US exports of (subsidized) corn to Mexico, partly in the form of high-fructose corn syrup (HFCS) following a 2006 World Trade Organization ruling against a Mexican tax on soft drinks sweetened with anything other than cane sugar.  Pediatric obesity researcher Michael Goran, one of the panelists at the Mexican meeting, has made a similar point.  These exports have, in turn, no doubt contributed to a prevalence of obesity in Mexico that is actually higher among adults than in Canada.  So, too, has the rapid transformation of the Mexican food system through foreign direct investment.


On the social justice front, an article written by Goran and colleagues, including the Director of Health Assessment and Epidemiology for Los Angeles County’s Department of Public Health, demonstrates a pronounced socioeconomic gradient in the prevalence of childhood and adolescent obesity in the sprawling county, “with a striking fourfold difference in childhood obesity prevalence between the communities with the highest and lowest levels of EH [economic hardship].”  Equity concerns have often been left aside in discussions of how best to deal with overweight, obesity, and their health consequences.  This finding underscores the urgency of addressing not only the challenges presented by corporate interests in the food industry but also such issues as economic deprivation, access to and affordability of healthy diets, and disparities in access to safe options for physical activity as part of any comprehensive approach to the problem.

LA

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Public Health ethics: A new Canadian resource of international significance

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Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 15 March 2013
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Over the past several years, public health ethics has emerged as a distinct field of inquiry, reflecting a realization that principles and institutions developed since the 1970s to deal with ethical challenges in clinical and research settings are relevant to, but also insufficient for, addressing the issues that arise as policies and interventions affect (or neglect) health and its distribution at the level of populations.  An international journal on Public Health Ethics was established in 2008; in the previous year, the Public Health Agency of Canada organized the first national roundtable on public health ethics, a remarkably stimulating one-day event in Montréal.


Several Canadian organizations have now collaborated to support the production of a casebook on Population and Public Health Ethics, published electronically by the University of Toronto’s Joint Centre for Bioethics.   All cases submitted in response to a call for cases in 2011 were first peer-reviewed; accepted cases were then analyzed in a short essay by an invited author unconnected to the authors of the case.  (Full disclosure: I was both a peer reviewer and the author of one of the case analyses.) 


The result is a readable, intellectually challenging and hard-hitting collection of 16 cases dealing with issues as diverse as the ethics of public health surveillance; mandatory immunization of public health personnel; health status on First Nations reserves; and the health consequences of oil sands development.   The cases are presented under three headings – research, policy, and practice – although it is sometimes difficult to identify clear boundaries among these domains.  Readers are likely to cheer some of the analyses and conclusions, and perhaps to cringe at others.  In my case, one of the major cringe-inducers is the frequency with which the theoretical frameworks cited originate with authors from south of the Canada-US border, despite the intellectual vitality of the health ethics enterprise in Canada.


But that’s the point.  Stimulating debate and controversy about such questions is one of the ways in which initiatives like the new casebook add value to health policy and practice.  Despite the last several years of intensive efforts to advance health equity as a priority, we lack effective public forums for discussing such basic questions as whether core competencies in public health ethics should be specified for practitioners.  (The University of Toronto’s Ross Upshur raises this question in his introduction to the volume.)   Next steps: perhaps a multi-agency research initiative on public health ethics, or a multinational conference on comparative perspectives and policy solutions?

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Sir Michael Marmot on social determinants of health: Blending evidence and passion

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Ted Schrecker
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On an unseasonably warm day in May 2012, Sir Michael Marmot came to Canada for a short visit with the Public Health Agency of Canada and the University of Ottawa, supported by the CIHR Institute of Population and Public Health. His presentation at the University of Ottawa, from which we present video excerpts here, is simultaneously a succinct and a passionate defence of the social determinants of health agenda and its ethical foundations.

Sir Michael is introduced by the Hon. Monique Bégin, a former Canadian Minister of Health and Welfare and a member of the Commission on Social Determinants of Health. She comments that: "Canada ... is so wealthy, despite the scary global economic times, that it manages to mask the reality of poverty, social exclusion, discrimination, employment erosion, mental health, and youth suicides. While one of the world's biggest spenders on health care, we have one of the worst records when it comes to providing an effective social safety net."

The first part of Sir Michael's presentation offers a bit of anecdotal history about the internal processes of the commission. He then makes two main points. First, he is hopeful that the Commission's report may be one of a few international commission reports, like that of the Brundtland Commission on sustainable development (1987) that have a real impact. At least, he says, officials like Commonwealth ministers are talking the language of social determinants of health. Second, he distinguishes the economic case for acting on social determinants of health from the moral case, based on social justice. In words that echo the long-ago wisdom of Anatole France, he concludes that: "The freedom to wallow in poverty," or to be unemployed, "is not a freedom that is much prized."

In the next part of his presentation, Sir Michael emphasizes the importance of the Commission's focus on inequalities of power, money and resources. He goes on to describe history of the British strategic review on health equity, which he also chaired, and its organization around a lifecourse framework; his efforts to advance interest in social determinants of health as president of the British Medical Association; and how initial cynicism was transformed into enthusiastic takeup of his message about the importance of social determinants of women's health among British obstetricians and gynecologists.

Finally, Sir Michael argues that social protection policy matters for health. "The greater the social spending, the lower the all-cause mortality, for 18 EU countries." And he explains a remarkable initiative by the Merseyside Fire & Rescue Service (that's Liverpool, for readers too young to remember where the Beatles came from) to address social determinants of health by helping people apply for grants to improve their housing, quit smoking and increase their levels of physical activity using the gymnasia at fire stations. He ends with the observation that "We are involved in an intensely ethical concern. We are trying to get a more just society."

 

What can we in Canada learn from this presentation? That could be a long disquisition, but the short version is: blending evidence and passion matters, and we have too few leaders in population health and health social science who are capable of doing so.

Acknowledgements: Many thanks to CIHR's Institute of Population and Public Health for offering these video files.

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Is concern about economic inequality going mainstream?

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Ted Schrecker
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In a previous posting, I recommended a recent report on economic inequality in The Economist. In its special reports, at least, that magazine has a strong track record of ‘telling it like it is’. Back in 2006, for example, a special report on the world economy admitted that “the usual argument in favour of globalisation–that it will make most workers better off, with only a few low-skilled ones losing out–has not so far been borne out by the facts. Most workers are being squeezed.” And in 2011, The Economist pointed out that Congressional Budget Office figures from the United States support the contention “that the people at the top have made out like bandits over the past few decades, and that now everyone else must pick up the bill.” Now, more evidence suggests that concerns about economic inequality are moving into the mainstream, in Canada and elsewhere.

One of the Occupy movement’s accomplishments has been to direct attention to the growing gap between people at the very top of the income distribution in societies like Canada and the United States – the one-percenters – and the rest of the population. In January 2013, Statistics Canada released updated figures based on tax return data about Canada’s one percenters: based on income, they were those with annual personal incomes above $201,400. These figures refer to individual incomes, not family incomes; a University of Regina Study published in 2012 found that in 2009, the top one percent of “economic families” as defined by StatsCan had wage and salary income (i.e. not including interest, dividends or capital gains) of more than $271,800. The two sets of figures are not directly comparable, since they are based on two different data sets and the Regina figures are restricted to labour income. Yet another analysis, which included all forms of income, identified the top one percent of households (the definition is similar to that of economic families, but not identical) as those with incomes over $366,717 in 2010. More strikingly, the top one percent of households in this analysis accounted for 10.5 of all the income earned by Canadians. All these data refer to income and not to wealth, which most researchers agree is more unevenly distributed than income.

Considerable ideological distance separates Occupiers from the business-oriented Conference Board of Canada, yet the Conference Board has recently expressed considerable concern about Canadian inequality. In an online report card that compares Canadian social policy with that of 16 other high-income countries, it notes that Canada “is not living up to its reputation or its potential” and that “Canada’s ‘D’ grade on the poverty rate for working-age people, and its ‘C’ grades on child poverty, income inequality and gender equity are troubling for a wealthy country.”   The report offers links to more detailed information on various specific domains, such as child poverty (where Canada ranks 15th, ahead only of Italy and the United States); working-age poverty (again, we are 15th, ahead only of Japan and the United States, and not by much); poverty among the elderly (one of Canada’s social policy success stories, but now arguably imperiled by population aging and the fact that only one in four private sector workers has a pension plan); and income inequality (rising, with a “concentration of income among the super-rich”). Despite Canada’s overall “B” grade on social indicators, which cover much more than income (and do not address concentrations of wealth), the overall pattern of increasing inequality is clear. So is the fact that other countries do much more than Canada to reduce income inequality by way of taxes and transfers.  

Perhaps an even less likely source of concern about inequality is the World Economic Forum. Yet the eighth (2013) edition of a Forum report on “global risks,” based on “an annual survey of over 1,000 experts,” estimates that severe income disparity is the most likely of any of the 50 risks studied to occur over the next ten years, and that a major systemic financial failure is the risk with the highest potential impact. (The economic processes driving inequality and magnifying financial risk are of course closely connected, as we know from the events of the last five years.) The simple fact that the report’s authors consider severe income disparity as a global risk says a lot. In the global frame of reference, further gloom about prospects for reducing health inequity comes from the fact that water supply crises are rated as having both high likelihood and high impact, and food shortage crises are rated as having high impact although lower likelihood.

Almost five years after the release of the report of the Commission on Social Determinants of Health, it should not be necessary to revisit the connections of economic inequality and its consequences with health inequity. (An earlier posting, which has drawn more hits than any other in this series, addressed some of these connections.) It’s also worth emphasizing that reducing inequality is not about the ‘politics of envy’ or some similar construct. It’s about the near impossibility of healthy life near the bottom of the economic ladder even in the richest countries in the world; the ubiquity of socioeconomic gradients in health; and the fact that if societies want to invest more in policies that equalize opportunities to live a long and healthy life, the resources will have to come from somewhere. If not from those who have captured a very substantial portion of the gains from the pre-2008 period of sustained economic growth, then from whom? As US President Obama famously and correctly said, this is not class warfare; it’s math.

There is also a more subtle political point. Once economic inequalities have become sufficiently extreme, the idea of a ‘common future’ may become an illusion; the gap between the rich and the rest will simply be too wide, whether we define the rich in terms of the top one percent, five percent or even 20 percent. The problem is that we cannot locate this threshold (if it exists) in statistical terms, and will only know that we have crossed it once we have done so. Writing in the US context Robert Reich, later a cabinet secretary in the Clinton administration, raised this possibility more than 20 years ago in an article on “the secession of the successful” – at a time when economic inequalities were less extreme than they are today.   It remains to be seen whether heightened concern about those inequalities today can have an impact on social policy and reducing health inequity, or whether secession of the successful is already a fait accompli.

Related resources

“The global economy is disequalizing,” interview with The Broker (Netherlands) as part of an ongoing series on inequality.

Richard Wilkinson, “How economic inequality harms societies” (online video)

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Are social determinants of health moving into the mainstream?

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Ted Schrecker
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on Monday, 11 February 2013
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In a hard-hitting report, a panel of the US National Research Council and the Institutes of Medicine has addressed the question of why the United States, despite spending far more per person on health care than any other country in the world, is falling behind other high-income countries in health status.  Readers familiar with Evans and Stoddart’s critique of the “thermostat model” will experience a strong sense of déjà vu.

The figures are striking.  For example, relative to the 16 other high-income countries selected for comparison, the United States “had the highest rate of child deaths due to negligence, maltreatment, or physical assault.”  It has the highest average body mass index (BMI) of the 17 countries among people aged 15-44.  And the list goes on.  In the words of the study:  “The U.S. health disadvantage is pervasive: it affects all age groups up to age 75 and is observed for multiple diseases, biological and behavioral risk factors, and injuries. More specifically, when compared with the average for other high-income countries, the United States fares worse in nine health domains: adverse birth outcomes; injuries, accidents, and homicides; adolescent pregnancy and sexually transmitted infections; HIV and AIDS; drug-related mortality; obesity and diabetes; heart disease; chronic lung disease; and disability.”  

The report’s focus on structural influences and on the life course perspective is notable, and a summary is wroth quoting at length.  “[T]the absence of green space today may be the product of zoning decisions two decades ago. Such influences also extend over a person’s lifetime: that is, the upstream-downstream continuum can also be a temporal experience for an individual. An individual’s struggle through middle age with exertional angina from coronary artery disease may have originated in adolescence with the adoption of cigarette smoking, perhaps as a coping mechanism for a stressful childhood … or simply because the family lived in a poor neighborhood where smoking was the norm. In turn, the family’s move into that poor neighborhood may have resulted from financial setbacks that occurred before the child was born. Health trajectories unfold not only over a lifetime, but also across generations as people are subject to changing health influences stemming from family, neighborhood, and public policies. …. The key dynamic trajectories of health, risk factors, socioeconomic circumstances, and physical and institutional environments are all integrally linked and cannot be decomposed in a reductionist fashion.”   

Texas timesPointing out that the United States has the highest relative poverty rates of the 17 countries, the report notes the accumulation of social disadvantages and their health consequences over an individual’s lifetime and across generations.  Other, more domain-specific explorations include an intriguing comparison between approaches to road traffic safety in the United States and elsewhere in the high-income world and the topical observation that rates of death by homicide involving firearms are an order of magnitude higher than in other OECD countries.  (The accompanying picture, taken at the entrance to a Houston, Texas emergency room, may suggest a partial explanation; the need for such a warning would be almost inconceivable elsewhere in the high-income world.) 

There is no point in trying to provide a more extensive summary of a very long document here; suffice it to say that the report is essential reading for all those concerned with health equity.  A wonderful commentary from the British think tank Chatham House correctly warned that:  “Rather than indulge in self-congratulatory comparisons with America's dismal health record, other industrialized countries would be wise to ask themselves if … global trends may soon erode their own hard-earned health gains of past decades.”  Perhaps predictably, the report’s recommendations emphasize the need for further research, and research syntheses.  Nevertheless, there are important steps forward.   On research methods, the report observes:   “The premise that randomized controlled trials are the ‘gold standard’ for establishing causal relationships has put the accumulation of knowledge about the social determinants of health at a distinct disadvantage.”  Numerous earlier papers, including one that colleagues and I published more than a decade ago, have made a similar point, but it has yet to be recognized.  And a key recommendation for further research synthesis emphasizes comparative investigation of the influence of public policy “in one or more health domains.”  Our own health funding agencies would do well to take note.  Social determinants of health may not yet have become mainstream, but there is hope.

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Housing, equity, and economic apartheid

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Ted Schrecker
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Maclaren

CBC News reported on January 9, 2013 that the residents of a high-rise Ottawa Community Housing building in Ottawa had been without hot water since November 30.  The people affected included a 77-year-old man in a wheelchair.  The revelation says a lot about the value of public broadcasting, and local CBC news bureaus in particular.  It also says a lot about the barriers to getting social determinants of health, like adequate housing, on the policy agenda.


It could be worse.  The residents of 415 MacLaren Street could have been stranded on upper floors by non-functioning elevators, which happened in 2010 to residents of a downtown Toronto Community Housing building.  But that’s not the point. 


A bit of background: public housing in Ontario used to be a responsibility shared among three levels of government.  However, the national government and most provincial governments have largely retreated from housing, content to leave it to the private market and to municipal governments that have limited revenue-raising options.  Canada is the only G7 country without a national housing strategy.


This might not be a problem if the market economy provided adequate incomes for all, or if Canadian social policy compensated for the failings of the market.  Neither is the case.  Market incomes at the bottom of the income scale have actually been dropping, and by the middle of the last decade it became clear that social policy had retreated from redistribution, big-time. Housing is only part of the equation.  For example, a hard-hitting report on social assistance in Ontario that recommended immediate increases in benefit rates and allowable labour market earnings for  “the lowest rate category, single adults receiving Ontario Works, as a down payment on adequacy” has vanished from the political landscape without a trace.  This is not only a Canadian problem.  In the United Kingdom, where the Conservative-Liberal Democratic coalition government is proposing to cap benefit rates while lowering the top income tax rate for the ultra-rich, a spokesman for the Labour Party – the Labour Party – won’t say anything more than that they “support the principle of a benefit cap, but with the important caveat that it should not render people homeless.”


For whatever reason, we tolerate a deepening form of economic apartheid, perhaps at least covertly buying the argument that those on limited incomes are the authors of their own misfortune.  The recent history of plant closings across Canada, briefly discussed in a previous posting and to be covered at greater length in a forthcoming one, is just one piece of evidence among many that undercut this belief.  But then, how often are such self-serving beliefs susceptible to refutation by evidence?


Historian and sociologist Margaret Somers describes the belief system that tolerates such economic apartheid as market fundamentalism – ironically borrowing the term from George Soros, one of the world’s richest men.  There are alternative perspectives.  One views the minimal material prerequisites for a healthy life, including adequate housing, as human rights – a position entrenched in international law by the International Covenant on Economic, Social and Cultural Rights, to which Canada is a party.  The current UN Special Rapporteur on the Right to Housing (be honest, now: did you know there was such a person?) is charismatic Brazilian architect Raquel Rolnik.  Her most recent annual report to the UN General Assembly is an important piece of historical scholarship and a stinging, carefully documented critique of the “financialization” of the housing sector, which has paid off handsomely for financial institutions and for many of the propertied, while marginalizing others.  In calling for “a paradigm shift from housing policies based on the financialization of housing to a human rights-based approach,” she is challenging market fundamentalism and asserting what Somers calls “the right to have rights” independent of the marketplace.


Unless professionals and advocates concerned with social determinants of health can get their heads around that simple message, as it applies to housing and many other policy fields, the future of the health equity agenda has to be reckoned as dim. 

Additional resources:
In an online video of an event at the City University of New York, Ms Rolnik delivers a powerful indictment of the financialization of housing (her presentation starts at about the one-hour mark in the video).  All her annual reports and reports of country visits, like those of her predecessor, are available on the Special Rapporteur’s official web page.

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More on diet and population health

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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A recent posting featured two important research syntheses on overweight and obesity. Another, especially useful for non-specialist audiences, appeared as a special report on “The big picture” in the December 15 issue of The Economist.

Commendably, the report does not sugar-coat the difficult politics of reducing overweight and obesity. It notes, for example, that “while lots of people remain fat, the associated ailments represent big business for the drug companies.”  It is candid about the role of companies like soft-drink manufacturers and fast-food chains in contributing to the epidemic of overweight, and the conflicts of interest that can arise in partnerships like one between Nestlé and the International Diabetes Federation, or the “Responsibility Deal” between food and alcohol companies and Britain’s Department of Health. (In negotiations about the action plan that emerged from the UN Summit on non-communicable diseases in September 2011, Canada was among the countries pressing for removal of text that mentioned such conflicts.) And it presents a succinct overview of efforts to deal with overweight and obesity through taxation and regulation. So far, those efforts have met with modest success, although that may be a consequence of modest ambition rather than of limitations intrinsic to the available policy instruments.

Unfortunately, the report is not open-access, although non-subscribers will be able to read part of it online. Unfortunately as well, the report pays insufficient attention to connections between the built environment and overweight, or to the cost of a healthy diet. Nevertheless, it is a refreshing signal that approaches going beyond the usual health promotion nostrums are moving into the policy mainstream.

Shortly before the Economist report appeared, Britain’s Department of Environment, Food and Rural Affairs released its annual Family Food Survey for the year 2011. Among the survey’s disturbing findings: fruit and vegetable purchases were 10 percent lower in 2011 than in 2007, with an even larger decline among the bottom fifth of Britain’s income distribution. Households in the lowest tenth of the income distribution were spending 17 percent more on food in 2011 than in 2007. A report in The Guardian quoted the director of the consumer protection organization Which? as saying: “One in six people say rising food prices are making it difficult to eat healthily,” and the preceding month a report in the same newspaper warned of a “nutrition recession” - this in a country where benefit caps planned for 2013 will cut the incomes of many people in full-time jobs as well as those who cannot find work. 

Closer to home, Ottawa's deparment of public health released the lastest issue of an annual calculation showing that if you are living on social assistance and paying market rents in the city, it is arithmetically impossible - as it is much of the rest of the province- to pay for the diet recommended by Ontario's Public Health Standards. In the capital of a weathly G7 country, 48,000 people a month turn to food banks. Against the background of ongoing concern about health care spending and areport recommending an immediate increase in Ontario social assistance rates to " the lower rate category, single adults receiving Ontario Works, as a down payment on adequacy while the system undergoes transformation," it may be worth asking`just how does making healthiy diets unaffordable contribute to a healthier population and lower health system costs down the road?

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  • Dot Bonnenfant
    Dot Bonnenfant says #
    Hi Ted wow - as usual, very thought provoking posting! Thank you!
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The different worlds of metropolitan health

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Ted Schrecker
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Sometime in 2008, for the first time in history, more than half of the world’s population lived in urban areas.  In Canada, as for all high-income countries, the proportion is far higher; definitional issues complicate the picture, but we know that more than 46 percent of Canadians live within metropolitan areas centred around Toronto, Montréal, Vancouver, Calgary, Edmonton and Ottawa.  A June, 2012 article on “shaping cities for health” by a group of authors convened by The Lancet and University College London sheds some light – although I think not quite enough – on what urbanization means for the future of health equity. 


The authors begin with recognition that that “rich and poor people live in very different epidemiological worlds, even within the same city.”  Finally, someone gets this!  In itself, this recognition is an advance on much current thinking about urban health, which tends to use of place of residence as a proxy for the entire range of exposures that comprise the metropolitan “riskscape.”  The concept of an epidemiological world urgently needs to be incorporated into future study designs and academic curricula on place and health.  The authors of the Lancet piece emphasize the complexity of the influences on health in cities (I prefer the term metropolitan health to the more familiar urban health, because it reflects the interaction of cities with the economics, politics and demographics of their surrounding suburbs and exurbs).  And they note the limited concrete advances resulting from the WHO-led Healthy Cities movement that began in 1984 although other authors, it must be said, are more optimistic.


The Lancet authors opt for a “more restricted” focus, “on how urban planning could shape the physical aspects of an urban environment to promote health,” concentrating on five specific sets of issues: sanitation and wastewater management; building standards and indoor air quality; transportation, mobility and physical activity; the urban heat island effect; and urban food production.  (Some of these are obviously more relevant than others to high-income countries like Canada.)   And they argue that “many people know what a healthy urban environment would look like,” although one could quibble with the generality of their list.

Lancet pic 1

Here is where, in my view, the analysis runs into trouble, because the question ‘healthy for whom?’ recedes into the background.  The authors acknowledge the significance of conflicting interests – for example, those of people who can afford to drive everywhere (and the businesses that cater to them) and the generally poorer individuals who can’t and don’t – such that “the needs of vulnerable groups in urban societies are often forgotten.”  Truer words were never written.  Yet the same paragraph refers to “engag[ing] stakeholders in detailed and problem-orientated argumentation on potential solutions,” as if the process were some kind of event in the senior common room, with “inclusion of the full range of community representatives within such deliberation and debate.”


Now it is all very well to say “that planners need to engage in widespread policy debate to instill healthy city values in the policy process,” but what about the raw power differentials that are familiar to me, and to every urban activist I have ever met, from engagement with the real world of planning processes, which are often driven by economic actors who have no need or desire to engage in public debate?  (They can buy the access they need.)  Urban planners are seldom autonomous; they usually work for one or another agency of the state.  What about the interests, resources and allegiances of those who direct their work? 


Context outside the metropolis matters, as well.  Discussing Detroit’s promising future in urban fruit and vegetable growing, the authors show limited awareness of the etiology of the city’s decline in the deindustrialization that has devastated communities throughout the high-income world.  This is a key illustration of how metropolitan economies are connected to global-scale flows and processes, a point that will be familiar to anyone even tangentially acquainted with Saskia Sassen’s work.   And there is little recognition of the role of real estate capitalism, itself a global phenomenon, in driving patterns of dispossession and exclusion and corrupting planning processes.  (One of the three best books on the political economy of New York City is called From Welfare State to Real Estate.)  


These are relatively minor disagreements with an important, multidisciplinary, and brilliantly well documented article.  Anyone concerned with metropolitan health will learn a lot from it.  At the same time, we must not forget that the metropolis is a terrain of political conflict among interests with vastly unequal resources, and that many of the most powerful influences on health equity within the metropolis may originate far outside its borders.  Against this background, how realistic is a ‘let us reason together’ approach to metropolitan health, especially if reducing inequities is a primary objective?  Better, perhaps, to start from a concept like the “right to the city,” in Henri Lefebvre’s oft-cited phrase.

Lancet  pic 2

Some additional resources: 
UN Habitat, Cities in a Globalizing World (London: Earthscan, 2001) – empirically a bit dated now, but still a classic


UN  Habitat, State of the World’s Cities 2010/2011: Bridging the Urban Divide.  London: Earthscan, 2008


World Health Organization, Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings (Nairobi: UN Habitat and WHO, 2010)

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Our big fat complicated population health problem: Perspectives from both sides of the Atlantic

Posted by Ted Schrecker
Ted Schrecker
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 Overweight and obesity contribute directly to a variety of adverse health outcomes, as pointed out in a recent Lancet series.  At least in high-income countries, these conditions exhibit a pronounced socioeconomic gradient, and therefore present both a challenge and an opportunity.  A challenge, because of the complex etiology of overweight and obesity; an opportunity, because of the tremendous improvements in health that can be anticipated from any population-wide shift toward healthy weights.

Two recent syntheses of research findings offer useful insights, and also a few (intentional and unintentional) warnings, about how best to address overweight and obesity. A report by a committee of the US Institute of Medicine got the diagnosis absolutely right, from a health equity perspective: “If a community has no safe places to walk or play, lacks food outlets offering affordable healthy foods, and is bombarded by advertisements for unhealthy foods and beverages, its residents will have less opportunity to engage in physical activity and eating behaviors that that allow them to achieve and maintain a healthy weight.” Unfortunately this valuable analysis was not, in the end, used to arrive at system-level recommendations appropriate to the scale of the problem. The committee described its approach in terms of “large-scale transformative approaches,” but in its proposed responses it drifted back into behavioural nostrums like “mak[ing] physical activity and integral and routine part of life” and “mak[ing] schools a national focal point for obesity prevention” – an example of the phenomenon Jennie Popay and colleagues have described as “lifestyle drift.” 

Blog-Overweight

Some environments are far more supportive of maintaining healthy weights than others.

 

A recent literature review on policy interventions to tackle the obesogenic environment produced by the Scottish Collaboration for Public Health Research and Policy, a research unit headed by expat Canadian John Frank, is more effective at avoiding what I have come to think of as the lifestyle trap. Focused on the situation of working-age adults, the review is organized using a framework called ANGELO (Analysis Grid for Environments Linked to Obesity): a simple four-by-two matrix in which four aspects of the environment – physical, economic, political or legislative, and sociocultural – are each analyzed at two levels, micro (the household or community) and macro (the region, province or nation). The authors make a point that has broad applicability in other population health contexts: “[M]any strategies aimed at obesity prevention may not be expected to have a direct impact on BMI, but rather on pathways that will alter the context in which eating, physical activity and weight control occur. Any restriction on the concept of a successful outcome … is therefore likely to overlook many possible intervention measures that could contribute to obesity prevention.”

 

 The authors of the review are candid about the difficulties facing large-scale interventions that are expensive or challenge vested interests, yet do not shrink from asking tough questions about the need for these, noting (for example) that the transport mode split in urban areas is 84% by car versus 9 percent walking in the United States, while it’s 36% by car versus 39% walking in Sweden. “Suffice it to say, it has been a concerted combination of infrastructure provision, integrated transport planning and disincentives for private cars which has helped to bring about the higher active travel rates,” which include a much larger role for cycling as well. And they argue that because of the relatively high price elasticity of soft drink taxation, it should be considered as a promising intervention along with price reductions of healthy foods like fruit and vegetables. (As an aside on a related point, I once heard a leading aboriginal health researcher wonder why Ontario can ensure that a bottle of whisky costs the same in the province’s far north as in downtown Toronto, but can’t or won’t do this for a carton of milk or a bag of apples.)

 

A further step in the Scottish review was to create another matrix classifying potential interventions on two criteria: certainty of effectiveness and potential population impact. Here a sugared beverage tax scored high on both criteria, as did healthy eating advocacy campaigns backed with supportive regulation, although curiously none of the policies that have been adopted to increase the costs of car travel scored similarly high, despite the authors’ extensive documentation of the role of public policy and their warning about defining successful outcomes too narrowly. But this is a minor disagreement with an important research synthesis on a complex problem that also provides a methodological template for reviews in other areas. It should be read by everyone concerned with social determinants of health, even if not specifically with overweight. Health policy analysis has joined other, more familiar high quality products for which Scotland is justifiably known far beyond its borders.  

 Blog-overweight 2

 Not the only quality product of Scotland.

 

 

 

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Posted by Ted Schrecker
Ted Schrecker
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"The fog comes," Carl Sandburg famously wrote, "on little cat feet." With roughly the same amount of fanfare, in September a consortium led by Sir Michael Marmot published a summary of its findings on how to reduce health inequities in the 53 countries of the World Health Organization's European region. The region includes some of the wealthiest countries in the world, and some of those with the smallest disparities in health, but is hardly homogeneous. Mortality among children under 5 ranges from just over 2 per 1000 live births in Iceland to more than five times that figure in Bulgaria and Romania. Child poverty on a standardized cross-national measure is higher than 30 percent in Romania, three times as high as in the Nordic countries and a few others. And urban air pollution (concentration of particulate matter) is more than five times as high in the capitals of Turkey and Bulgaria as in those of Estonia and Iceland.

The consortium's argument will be familiar to readers of earlier reports in this vein, including the original Commission on Social Determinants of Health, but several points are worth mentioning because of their direct and immediate transferability to the Canadian context.

  • who euro-review-pic-1Air pollution remains a health hazard in many European cities.
    Photo: eifelyeti110’s photostream; reproduced under a Creative Commons 2.0 licence
    The consortium writes that "[h]uman rights are central in our approach to action on the social determinants of health". The fact that this was not true of the 2008 report has been identified as a significant omission by the distinguished human rights scholar Audrey Chapman, among others.
  • Social protection – including "a minimum standard of healthy living for all" that includes a nutritious and sustainable diet – is clearly and correctly identified as essential for reducing health inequity. Further, the consortium refers approvingly to the United Nations Social Protection Floor Initiative, a relatively low profile effort that is explicitly linked to a human rights approach. Could this be the start of an overdue convergence of concerns about health equity and social policy that often have been addressed by separate organizations and groups of professionals working in isolation from one another?
  • The effects of unemployment and exposure to hazardous work environments are foregrounded, at a time when youth unemployment is higher than 50 percent in two WHO Euro countries and a source of concern throughout the region.
  • Also foregrounded is the issue of health inequities among older Euro region residents – a concern with much broader applicability as populations age and social exclusion threatens to increase, especially in countries with high levels of economic inequality, a troubling trend that was evident even before the economic crisis.
  • Most importantly, both the economic crisis and many policy responses are identified as threats to health equity. In the consortium's words: "Recognition of the health and social consequences of economic austerity packages must be a priority in further shaping of economic and fiscal policy in European countries," with health and social affairs ministries and – at the transnational level – the World Health Organization, UNICEF, and the International Labour Organization given a voice.

who euro-review-pic-2Social exclusion threatens the European elderly, especially those with limited resources.
Photo: Zilverbat.’s photostream, reproduced under a Creative Commons 2.0 licence
Think, for a moment, about what institutionalizing this last recommendation would mean in a Canadian jurisdiction like Ontario.

My previous posting featured an important new report on redesigning social assistance in Ontario. Its arrival, too, could be described with reference to little cat feet. Ontario would do well to adopt both the consortium's insights about the inseparability of social protection and health and its view that "current economic difficulties are a reason for action on social determinants of health not inaction." But where will the necessary leadership come from? However well intentioned the proponents of taxes on 'junk food,' availability restrictions and warning labels on French fries may be, it may not come from them.

Related resource of interest

Video of Sir Michael Marmot's keynote speech at the Canadian Medical Association annual meeting in August 2012, which focused on health equity, is now available online.

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Messages on inequality, from sources far and near

Posted by Ted Schrecker
Ted Schrecker
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Taking health inequity seriously requires direct engagement with increasing economic inequality and the underlying macro-scale economic processes.  A remarkably thoughtful overview of those processes is provided by Zanny Minton Beddoes in a recent special report in The Economist.  (At this writing, the special report is still open access; get it while you can.)   Despite obligatory genuflection to the economic theology that economic inequality reduces ‘efficiency,’ Beddoes focuses on the destructive consequences of rising inequality (especially at the top of the economic pyramid) and on how public policy can and should respond.  Everyone interested in the future of population health should read her report, which is especially scathing on how various US policies actually magnify inequality.  Against the background of that country’s imminent money-driven elections it is worth quoting her concluding critique of the Obama government’s approach as “just a laundry list of small initiatives.  [New Deal initiator Franklin] Roosevelt would have been appalled at the timidity.  A subject of such importance requires something much bolder.”

Closer to home, on October 24 a commission that had been asked to review social assistance in Ontario released its report – with an almost total absence of media attention apart from the Toronto Star.  (Readers and viewers to whom social assistance might actually matter are not highly valued by the managers of commercial media, but even the CBC missed this story.)  Among other findings, the report recommended an immediate increase of $100 per month to “the lowest rate category, single adults receiving Ontario Works, as a down payment on adequacy while the system undergoes transformation.”  This report should serve as an overdue starting point for moving public health advocacy beyond tanning beds, Red Bull and salt to consider underlying distributional issues such as income adequacy.  We know, for example, that eating a healthy diet while keeping a roof over your head in much of Ontario is arithmetically impossible if you are paying market rents.

Will the various communities of researchers, practitioners and advocates concerned with health equity engage with these recommendations, taking advantage of the opportunity offered by the prospect of political change in Ontario?  What kinds of followup will be initiated by Medical Officers of Health, and by university- and hospital-based researchers, who are far removed from having to choose between paying the rent and buying fruits and vegetables or paying their children’s dentist?  We shall see.

 

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Unemployment isn’t working for public health, Part 1

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On January 1 of this year, workers at the Electro-Motive Diesel locomotive plant in London, Ontario were locked out of their jobs after refusing to take a 50 percent pay cut. In February, the parent company (Caterpillar Inc.) closed the plant and moved production to Indiana. Now, a story in The Globe and Mail reports that just 68 of the 485 union workers who lost their jobs have found new full-time work. Marriages are crumbling; food bank use is climbing; and the plant stands vacant. (Readers may want to access both this and an earlier, equally important story – also by reporter Tavia Grant, whose coverage has been stellar – before the Globe's content moves behind a paywall.) The situation of former Electro-Motive workers is part of a larger picture of deindustrialization: citywide, one in 15 Londoners – an estimated 24,000 people - live in a household receiving Ontario Works ('welfare'). This means, by definition, an income well below Statistics Canada's Low Income Cutoff.

electro-motive-london-1The vacant plant in London, Ontario previously occupied by
Electro-Motive Diesel

Many health researchers and practitioners in Canada have been slow to grasp the health implications of economic restructuring and the changing nature of work. (The authors of the landmark Code Red study in Hamilton, the topic of an earlier posting, are a notable exception.) Elsewhere, understandings are more advanced. One of the nine knowledge networks that supported the WHO Commission on Social Determinants of Health addressed employment and working conditions; a fine summary of its findings appeared in BMJ in 2010. The International Labour Organization has for years been promoting what it calls a Decent Work Agenda. The agenda does not specifically refer to health but recognizes the importance of employment and working conditions for overall well-being, especially in the context of the post-2008 economic crisis. Until July 2012, the ILO's Global Job Crisis Observatory kept tabs on how the crisis was affecting employment, and is still a valuable source of background.

So long as governments see little alternative to the reorganization of production across national borders in search of lower labour costs and more 'flexible' employment regimes, an increasing proportion of the population – certainly in the high-income world – can anticipate a future of shrinking earnings, precarious employment, and reliance on multiple but often unpredictable income streams. This is not a fact of nature, but rather a consequence of political choices. The Commission on Social Determinants of Health correctly attributed the unequal distribution of opportunities for leading a healthy life to "a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics." Nowhere is this clearer than in the decline of employment as a central concern of public policy. It is time for all those concerned with studying and protecting population health to come clean on this point, and to demand that political leaders do the same. Where, for example, are the voices of the province's Medical Officers of Health on this issue?

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People who get it, Part 2

Posted by Ted Schrecker
Ted Schrecker
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I've tried to make the case in previous postings for considering public finance as a public health issue. In a new article in Foreign Affairs,(1) Massachusetts Institute of Technology political scientist Andrea Louise Campbell makes several relevant arguments. She isn't concerned with health, and she is writing in the US context, but many of the analytical issues are relevant to our situation.

Campbell starts with the observation that the percentage of GDP that Americans pay in taxes is lower than in any high-income country: 24.1 percent. In the OECD as a whole, the figure is lower only in Chile (which has no national personal income tax) and Mexico. For Canada, the figure is 32 percent – higher than the United States, but a dramatic contrast with the Nordic countries, Italy, Belgium, Austria and France, where the figures are over 40 percent. She also points out that the drastic increase in economic inequality in the US, in particular concentration at the top of the economic scale (the one percenters, defined literally and statistically), is partly attributable to cuts in personal income tax during the Bush II presidency. (We know by way of the work of Emmanuel Saez that it is also a consequence of a steady rise in the market incomes of the one-percenters that began circa 1980; the relation between that trend and subsequent public policies must be left for another posting.)

There is more to the picture, though. Campbell points out that the much higher tax revenues available to European governments come not from higher and strongly progressive income taxes, as we might like to think, but rather from high consumption taxes, which are actually regressive: in other words, their impact is proportionally larger as you move down the income scale "because lower-income households tend to spend everything they earn." What, then, accounts for the contrast between the US and most of continental Europe in such matters as poverty and income inequality? Part of the answer lies not on the revenue side, but rather on the expenditure side: "In Europe, regressive taxes are matched with highly redistributive states. In the United States, mildly progressive taxes are matched with a not very redistributive state." Still another contributor is the much higher prevalence of low-wage jobs in the US ... and although Campbell does not make the point, that in turn probably has a lot to do with the weakness of unions, in particular outside the public sector.

tom slaterTom Slater, University of Edinburgh

Geographer Tom Slater, at the University of Edinburgh, is likewise concerned with various dimensions of economic inequality. Much of his earlier work was concerned with the process of gentrification and how it disrupts the lives of people who are displaced. In one forthcoming paper, he offers a powerful critique of the "cottage industry" of neighbourhood effects research in urban studies. Like Campbell, he is not specifically concerned with health, but much of what he says is immediately relevant to the study of neighbourhood effects on health. It has already been pointed out, in a widely cited article by Steven Cummins and colleagues, that most of the usual study designs are likely to understate such effects, because they involve a static definition of place (normally with reference to residential location) rather than a relational one that reflects the complexities of daily life on limited resources.

Slater's critique is more fundamental: such studies presume that where people live is the problem, rather than asking "why do people live where they do in cities? If where any given individual lives affects their life chances as deeply as neighbourhood effects proponents believe, it seems crucial to understand why that individual is living there in the first place" (italics in original). Failing to begin by questioning the operations of an economic system that sorts people across metropolitan space based on their purchasing power in land and housing markets means that "neighbourhoods ... become the problem rather than the expression of the problem to be addressed." This warning should be kept in mind by health researchers who generally tend to shy away from such structural explanations, preferring instead to focus on how neighbourhoods are conducive to certain kinds of 'health behaviours' like smoking and unhealthy eating.

In another forthcoming paper, Slater borrows a term from a book edited by Robert Proctor and Londa Schiebinger - Agnotology: The Making and Unmaking of Ignorance – in which the contributors address the question of "what keeps ignorance alive, or allows it to be used as a political instrument?" Canadian readers even vaguely familiar with the track record of our current national government need no explanation of this question's importance. (Proctor's interest in this topic began with research on the tobacco industry's efforts to create doubt about the health effects of smoking; David Michaels, who has done superb work on how industries manufacture uncertainty with respect to impacts on health and the environment, is one of the contributors.)

Slater argues that a right-wing think tank in Britain has played an important role in producing and sustaining ignorance about the root causes of poverty, ascribing it to failures of personal responsibility and the creation of 'dependency' by already minimal programs of social provision in much the same way as the protagonists of welfare 'reform' in the United States during the 1990s. The Conservative-led government that came to power in 2010 enthusiastically adopted this analysis, proposing workfare requirements and multi-billion-pound cuts in benefits while ignoring research evidence that such measures "do not lift people out of poverty, but rather remove them from welfare rolls, expand dramatically the contingent of the working and non-working poor, and affect their daily existence negatively in almost every way imaginable." The lack of available jobs, as a result of decades of deindustrialization, is simply ignored - a point also made eloquently by Owen Jones in his book Chavs: The Demonization of the Working Class.

These are superficial renderings of complex and important papers, but they have several key messages for everyone working in population and public health in Canada. First and foremost, we have much to learn from those working in disciplines that have no direct connection with health, and outside Canada. The retreat of the state in Canada from redistributive policies was well established before the financial crisis. Since then, in Canada as elsewhere, we have been told that expenditure cutbacks – "austerity" – were essential in order to keep government deficits from becoming unmanageable. Most current approaches to austerity are highly selective, though. They involve cuts to expenditures (or moratoria on new investments) that mainly benefit the least well-off; they demand little or no sacrifice from the wealthy; and they focus almost exclusively on the expenditure side. For example, as noted in a previous posting Ontario's Drummond Commission on the province's fiscal future was ordered not to consider the option of raising taxes from their historically low levels – a choice that has clear implications for any society's ability to provide the opportunity for a healthy life to all.

By now it should not be contentious to state that poverty and chronic economic insecurity are hazardous to health. It may not be stating the case too strongly to suggest that controversy on that point is manufactured, in the same sense that controversy about the health hazards of tobacco and the evidence for personal fecklessness as a major cause of poverty are manufactured. To be sure, there is much still to be learned about how social determinants of health affect health equity, but the apparent determination of research funding agencies not to support the relevant lines of inquiry itself merits study using the rubric of agnotology. Finally, Slater's trenchant critique of the neighbourhood effects literature addresses not only the limitations of a particular kind of inquiry, but also the imperative of methodological self-consciousness in all forms of research on health and its social determinants.

(1) Unfortunately, only a summary of the article is available for open access

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People who get it, Part 1

Posted by Ted Schrecker
Ted Schrecker
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Optimism is hard to sustain these days. Canadian policy-makers and research funders seem to be losing much of their interest in social determinants of health; health policy remains unresponsive to evidence of easily remediable inequities within our health care systems. Lack of coverage for outpatient prescription drugs is one conspicuous example, as noted in the previous posting. So it's refreshing to feature three Ontario conferences organized by people who 'get' both health equity and social determinants of health. (Full disclosure: I am on the program of the first two events.)

richard wilkinson-1Richard Wilkinson, Professor Emeritus, University of Nottingham.
Photo: Wikimedia Commons
Health Promotion Ontario is a group of health promotion professionals now celebrating its 25th anniversary. On September 27, HPO is holding a one-day conference on the theme "Building Connections between Promoting Health and the Social Determinants of Health." Speakers include Ketan Shankardass of Sir Wilfrid Laurier University; Penny Sutcliffe, the Medical Officer of Health with the Sudbury and District Health Unit; and (via Skype) Richard Wilkinson, one of the world's leading authorities on economic inequalities and health.

In my experience, students in medicine and public health are often far ahead of their profs in understanding the social patterning of disparities in health, and the graduate students at the University of Toronto's School of Public Health provide a stellar example. On September 28, their annual student-led conference will be, to my knowledge, the first meeting in Canada specifically to address the theme "Health, Austerity and Affluence". The opening keynote will be given by Armine Yalnizyan, senior economist with the Canadian Centre for Policy Alternatives, which has a long-standing research program on economic inequality. Other speakers include David McKeown, Toronto's Medical Officer of Health, whose department has a long history of foregrounding health equity issues in its work, notably in a 2008 report on income and health inequalities.

The following month, the Canadian Society for International Health hosts its annual conference in Ottawa (October 21-23). Especially noteworthy is the Sunday morning opening session, which features sociologist Saskia Sassen and economist Dean Jamison. Sassen, whose work was the topic of a previous posting, is one of the most thoughtful observers of globalization and its consequences for human well-being; she is not only an academic but also a multilingual advocate, who somehow finds time to write for publications like the wonderful Occupied Wall Street Journal. Jamison, formerly of the World Bank and now at the University of Washington, was one of the leaders of the Disease Control Priorities Project , whose 2006 book Disease Control Priorities in Developing Countries remains a valuable resource. (Unfortunately, the DCP project web site is temporarily out of service.) Even if you can't attend the entire conference, the Sunday session is well worth taking in if you are from the Ottawa area.

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Affordability of medications: (re)discovering the obvious

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 17 August 2012
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In an earlier posting, I mentioned research by Canada's Dennis Raphael, among others, on the difficulty of managing diabetes on a low income. The cost of a healthy diet is a major part of the problem; another is the cost of medications. In Ontario, prescription medications outside hospital are covered by public health insurance only for people over the age of 65 and for those on extremely low incomes. A new study by researchers at the University of Toronto (1) points out that this may be having a substantial impact on the health of people with diabetes.

We already knew that mortality among high-income Ontarians with diabetes has been declining faster than it has among those with low incomes, leading to a widening equity gap. Starting with a health records database including almost all Ontarians with diabetes and using median household incomes in the Statistics Canada dissemination area where they lived as a proxy for an individual's own income, the researchers found that the socioeconomic gradient for death, acute myocardial infarction (AMI) and stroke is substantially steeper among people under 65, who either pay out of pocket for their medications or rely on private insurance, than it is among those 65 and over whose prescription drugs are covered. "[A]s many as 5,000 deaths and nearly 2,700 AMIs or strokes could have been avoided among younger and middle-aged adults with diabetes if the gap between wealthier and poorer individuals had been identical to that seen among older groups. "

affordability-car-accident-If we could eliminate vehicle accidents as a cause of death in Ontario, wouldn’t we give it a shot?
Photo: Sean Whaley/Nevada News Bureau, reproduced under a
Creative Commons Licence 3.0.
To put that figure of 5,000 into perspective, that's the total number of people who died in Ontario motor vehicle accidents from 2002 through 2007, the years covered by the new study. If we could eliminate such accidents as a cause of death in this province, wouldn't we do it? And since the study looked only at the portion of the population with one disease, the overall toll of avoidable illness and death associated with lack of universal public insurance for prescription medications ("pharmacare") is almost certainly higher.

Lack of pharmacare kills, in other words. Nothing is especially new about this realization. The new study cites previous research on the problem of drug costs for diabetics ... and it's now been more than a decade since a landmark study by Robyn Tamblyn and colleagues showed that emergency department visits and hospital admissions increased, and use of essential medications decreased, after Québec introduced co-payments in its public drug coverage for senior citizens.

Pharmacare is not just an equity issue; it's also an efficiency issue. The market power available to a single public purchaser could be important tool for cost containment. Indeed an important analysis published in the fall of 2010, which appears to have sunk without a trace, suggested that the lack of pharmacare is one of the reasons that prescription drug costs in Canada have been growing faster than in most other OECD countries, and argued that national pharmacare would reduce drug costs by 11.7 – 42.8 percent relative to current practice.

Failing to provide public insurance coverage for prescription drugs outside hospitals doesn't save money. It simply means that fewer costs are borne by the public treasury, and more by private insurers or people who may not be able to pay out-of-pocket, sometimes with fatal consequences.

At least under the current national government, there seems no hope for a federally initiated program. Ontario is one of the few provinces that are probably large enough to go it alone; a consortium of smaller provinces could do the same. Until that happens, the avoidable illnesses and deaths will continue, and we who are concerned with equity should laugh hollowly at all official claims that health policy is evidence-based.


(1) Unfortunately, full text is not available for open access

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A question about body parts

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 06 August 2012
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The International Consortium of Investigative Journalists recently published an unsettling four-part series on the sources of biological material that is used in such common medical devices as dental implants, heart valve replacements, and skin and bone grafts.  Its focus was on the US market, but it documented sourcing practices both in the United States and offshore that are, to say the least, questionable.  One egregious example involved a New York city-based operation run by a dentist named Michael Mastromarino, now serving federal prison time.  More details on this case are available from stories in New York Magazine, the Washington Post, and Philadelphia Magazine.

Most Canadians will remember the disastrous health consequences of failure to prevent contamination of the blood supply – a crisis that could have been controlled effectively by decision-makers within our borders, although it wasn’t.  The ICIJ series describes inadequately documented trade in other human biological materials, both within and across national borders.  In the United States, efforts to control hazardous imports are minimal and ineffective.  Health professionals interviewed for the series pointed out, for instance, that WalMart routinely tracks merchandise using bar codes, but these are not used to track potentially deadly tissue imports.

How well are Canadians protected from such hazards?  Whom can we ask, and how much trust should we place in the answers?  This is not a rhetorical question, but it’s one with important implications for public safety, and I invite responses from anyone who can shed light on the matter.  If no one can, then maybe it’s time for the Canadian Institutes of Health Research to make this a strategic priority?

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Single mothers and income inequality: Demographic reality, an old scary trope revisited, or a little of both?

Posted by Ted Schrecker
Ted Schrecker
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single mothers 1Photo by: Clementine Gallot,
reproduced under Creative Commons 2.0 licence
On July 15, the New York Times ran a long story on income inequality and family structure. The story led with a comparison between the lives of two women working in the same child care centre in the US Midwest. One "goes home to a trim subdivision and weekends crowded with children's events"; the other, her subordinate, pays more than half an income in rent and "scrapes by on food stamps," the federal food vouchers on which more than 46 million Americans now rely.

Veteran social policy reporter Jason DeParle's point was, superficially, one of straightforward demographics and arithmetic: the birth of children in unmarried households is becoming the norm. In a world where two paychecks are increasingly essential if a household is to do more than scrape by, especially in the lower reaches of the income distribution, that will have a powerful effect on the overall distribution of income within a society – and by extension, on the life chances of children in different categories of households. Assortative mating – the tendency of people with comparable educations and incomes to marry or at least cohabit – magnifies this demographic effect.

There is nothing new about such observations. In 1998, internationally recognized Canadian urbanist Damaris Rose pointed out that the rapid increase in the number of two-earner households was driving out-migration from the island of Montréal to suburbs where home ownership was more affordable, although her concern was not with income inequality per se but rather with effects on urban form 1.  And the 'single' (presumptively young and feckless, presumptively non-white) mother was a central trope in US welfare 'reform' debates of the 1990s. At the same time, it's hard to disregard the differences that two incomes, especially two secure incomes, make in basic life chances.

single mothers 2Photo from The story of single mothers, part of a campaign by Raise the Rates, a coalition of community groups and organizations concerned with the level of poverty and homelessness in British ColumbiaIn response to the Times article, Shawn Fremstad posted a four-part critique on the web site of the Center for Economic Policy Research, one of the United States' best regarded left-of-centre policy research units. Among the points he made, each documented with links to primary research:

More basic questions would appear to be: why and how do some societies make it so much easier than others to raise children with an adequate material standard of living, and adequate social supports? Detailed, fact-based rather than model-based comparisons of policy regimes are surprisingly hard to find, but it is worth quoting a recent book chapter based on the Luxembourg Income Study's cross-national data sets on social policy impacts: "[A]fter accounting for taxes and transfers, fewer than 5% of children in Denmark, Finland, Norway and Sweden live in poor households," as against 15.6% in Canada and 22.2% in the United States 2. Full stop. Five percent versus 15-22%. A 2009 OECD study pointed out that while 24 percent of children in the United States lived in single parent families in 2005/06, the figure was 19 percent in Denmark and 16 percent in Norway. So something else is at work.

The same study concluded that "the empirical literature on the impact of family structure on child outcomes is at an immature stage." Based on a variety of outcome measures, it also concluded that "at a maximum ... the likely causal effect sizes of being brought up in a sole-parent family are small."

This is a complex policy field, but: a society seriously interested in equalizing opportunities to live a healthy life would start from a firm commitment to something like a 5% (or less) solution, and then work backward from there to see what policies would best achieve that goal in a specified time period, only secondarily asking questions about family structure – not least because of the long time frame needed for interventions that address family structure to have an impact, even when sound research evidence exists to support them.

Some societies are clearly more serious than others on this point. Perhaps that's why a journalist like the Times' DeParle, with a long history of questioning conventional wisdom, took the easy road of looking at family structure rather than the rocky road that runs through the effects of decades of offshoring, union-busting, attacks on social provision and tax breaks for the rich. It's a bit like the easy road taken by health promoters who profess a concern for social determinants of health, but end up talking once again about tobacco control and health literacy. Those are not unimportant, but if serious progress toward health equity is the destination, the easy roads are unlikely to get us there.


1. Rose D, Villeneuve P. Engendering Class in the Metropolitan City: Occupational Pairings and Income Disparities among Two-Earner Couples. Urban Geography, 19: 123-159.

2.  Gornick J, Markus J. Child Poverty in Upper-Income Countries: Lessons from the Luxembourg Income Study. In S Kamerman, S Phipps and A Ben-Arieh, eds., From Child Welfare to Child Well-Being (Springer Netherlands, 2010): 339-368; http://dx.doi.org/10.1007/978-90-481-3377-2_19.

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Fighting back against health inequity and its origins

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 17 July 2012
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Despite rising inequality of market incomes and solemn assertions by governments that compensatory social policies are unaffordable, there are Canadian voices calling for change, within and outside the health research and policy community.

One of the most important of these is the Canadian Women’s Health Network (CWHN), which has just launched a new, user-friendly web site.  CWHN has been going since 1993, functioning as a clearinghouse and information broker on a variety of women’s health issues ranging from depression to domestic violence.  “Health is a human right that, because of poverty, politics and dwindling resources for health and social services, eludes many women” is part of its mission statement; recent links on its website connect users with a feature article and archived webinar on women and alcohol and a Conference Board of Canada report on the generally mid-pack performance of Canadian health care among OECD countries. CWHN is now seeking alternative sources of funding since support from our national government will end in 2013, as part of a larger pattern of funding cuts to women’s health research and advocacy.  Gotta pay for those fighter jets and new prison cells somehow.

fighting back pic 1Unemployment protest in Barcelona, June 2011.
Photo by Bonnie Ann Cain-Wood, reproduced under Creative Commons Licence 2.0
Another source of dissenting voices is the trade union movement. The Canadian Auto Workers, now Canada's largest private sector union representing workers in all sectors of the economy, has released a new study that tracked the economic trajectories of 260 workers laid off from three Ontario manufacturing plants. Not surprisingly, the study found that major economic hardship followed; loss of incomes, benefits and security was routine. A long line of Canadian studies going back at least to Paul Grayson's work on manufacturing plant closures in the 1980s (1) has found a similar pattern, as have many in the United States. The landmark Code Red study in Hamilton did not directly track worker earnings, but documented the consequences of manufacturing job losses in a city especially hard hit by deindustrialization. Depending on the future of this blog, a bibliography of key sources on what sociologists call 'downward mobility' as a consequence of economic restructuring, and the health effects, will be provided in a future posting.

Few people now question the fact that earnings and economic opportunity in North America are rapidly polarizing, with consequences for health over the life course and across generations that we can only begin to anticipate. A more dramatic and accelerated preview is now unfolding in parts of Europe, with (for example) official unemployment rates of more than 20 percent overall, and more than 50 percent among young people, in Greece and Spain.  Can economic polarization that consigns a substantial proportion of a nation’s population to permanent uncertainty and insecurity be recognized as a public health issue of overwhelming importance?  Or are the public health professionals whose voices might drive that recognition already too solidly entrenched in the ranks of the comfortable?  Just asking, as they say.

(1) Grayson P. Corporate Strategy and Plant Closures: The SKF Experience. Toronto: Our Times, 1985.  Now apparently out of print, and certainly hard to find.

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