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The different worlds of metropolitan health

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 14 December 2012
in CHNET-Works!

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
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 30 November 2012
in CHNET-Works!

 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
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 06 November 2012
in CHNET-Works!

"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
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Sunday, 28 October 2012
in CHNET-Works!

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

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Wednesday, 17 October 2012
in CHNET-Works!

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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