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Health as if everybody counted blog


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

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 24 July 2012
in CHNET-Works!

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;

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Manufacturing Diabetes

Posted by guest blogger Colleen Fuller
guest blogger Colleen Fuller
Colleen Fuller is co-founder and President of PharmaWatch (http://pharmawatchcan
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on Tuesday, 24 July 2012
in CHNET-Works!

One of the things that drives me crazy is how the drug industry, instead of manufacturing useful medicines for existing diseases, manufactures diseases or epidemics and then the drugs to treat them. This is exactly backwards, but it is something that is happening more and more frequently.

One example is "pre-diabetes." Canadians are being bombarded with dire warnings about the skyrocketing number of people with diabetes – an "economic tsunami" according to the pharma-friendly Canadian Diabetes Association. The term pre-diabetes is not new — in the early postwar years many thought that women who gave birth to "large babies" were likely to develop Type 2 diabetes later in life, and they were described as being pre-diabetic (and, in line with sexist medical thinking, irresponsible as well). By the mid-1960s the association between pregnancy and pre-diabetes seems to have morphed into a diagnosis of gestational diabetes among pregnant women. But today, we're being told that pre-diabetes is an epidemic among people on the verge of developing the real thing and the main reason, according to the popular narrative, is obesity and, well, irresponsible sloth.

So let's parse out this picture. In Canada, the CDA says there are 2.7 million people with diabetes, including Type 1 (about 10% of the total), Type 2 or gestational diabetes. The numbers of people with diabetes is increasing in each category. But there are six million who are diagnosed as being "pre-diabetic" — a term that refers to those who are assumed to be at risk for Type 2. So the number of people who may get diabetes is actually higher than those who actually have it. Unfortunately, all of these different types, including the haves and the may-gets, are conflated into a single figure of nine million people.

How do they arrive at these scary numbers? One way is with a test that measures blood glucose levels. In 1997, the American Diabetes Association lowered the threshold that was used to arrive at a diagnosis of Type 2 diabetes from a fasting blood sugar level of 7.8 mmol/L to one of 7.0 mmol/L, a change that added another 1.9 million Americans to the list of people with this condition. Despite doubts about the evidence to support this move — not to mention warnings about the high cost as well as psychological and emotional impact of such an approach — the new standard was soon applied in Canada as well.

That same year the ADA introduced a new test to determine whether people had what was described as Impaired Fasting Glucose (IFG), a tool it said would help clinicians predict who would progress to Type 2 diabetes. In other words, to help doctors diagnose people with "pre-diabetes". The threshold was initially established at between 6.1 and 6.9 mmol/L, but by 2003, that level had dropped to 5.6 mmol/L. The change in the threshold increased the number of Americans diagnosed with IFG/pre-diabetes from 3.2% of the population to 9.7%.

Again voices of doubt were heard around the world. While the European Diabetes Epidemiology Group saw value in determining IFG levels, it looked at the evidence and rejected the higher threshold. Equally important, the Europeans preferred the more descriptive term "non-diabetic hyperglycaemia", and urged the diabetes community to avoid the use of the term "pre-diabetes" when describing those with an impaired fasting glucose. The EDEG pointed out that many people who meet the threshold for non-diabetic hyperglycaemia revert to normal glucose levels in subsequent testing. In addition, they said, "there is no fixed state of pre-diabetes" and warned of the emergence of a "pandemic" if the lower thresholds were used.

The controversy over the ADA thresholds went viral, leading to heightened scrutiny of the evidence used to support not only the glucose cut-offs, but of all the various tests used to diagnose Type 2 and "pre-" diabetes. By the end of the last decade, studies were pushing the use of a test called Hemoglobin A1c (HbA1c) to diagnose Type 2 diabetes and today, for better or worse, this is the standard used internationally, along with the "diagnostic cut-point" of 6.5%. In 2010, the ADA recommended that the HbA1c be applied to diagnose "pre-diabetes" as well, at a threshold of 5.7%.

As a diagnostic tool, the A1c test has its champions and its critics, including those who argue that the much higher costs associated with it increases the burden on the health care system. In addition, usefulness in certain populations is limited. The CDA's new pharma-sponsored guidelines will be published in March 2013, and it's likely that they, too, will embrace the HbA1c to diagnose pre-diabetes regardless of the fact that this is not a medical condition. So not only is this controversial diagnostic tool being used in spite of its limited utility, it is being used to diagnose a disease that, according to the EGED, doesn't exist. We are, after all, in epidemic mode!

The diagnosis of pre-diabetes is bad news for patients and their families, most of whom have no idea about all the drama in the background. But it's also bad news for society as a whole because of the enormous costs associated with treating millions of people who do not have a medical condition. But for the pharmaceutical and diagnostic industries, it's a great turn of events — and there's little doubt that Big Pharma has influenced the lower thresholds that have been put in place.

One of the companies that is hoping to benefit from a diagnosis of "pre-diabetes" is Sanofi, one of the largest pharmaceutical companies in the world. It has just unveiled a study that says insulin glargine (brand name Lantus) can delay full-blown Type 2 diabetes in those diagnosed with being on the verge of having the real thing. It's no coincidence, of course, that glargine is a Sanofi product and one of the most expensive insulins on the market.

The emergence of "pre-diabetes", according to one marketing firm, "should be viewed as an opportunity for pharmaceutical companies and manufacturers of blood glucose meters and nutriceutical products" who can educate physicians about new treatments for the pre-disease. And it's a big market — a much bigger market than the one made up of people who already have diabetes.

One of the most aggravating myths is that Type 2 is a "lifestyle" disease, brought on by sloth, laziness and poor eating habits. But the truth is that being poor is more likely to lead to diabetes than lifestyle choices — the poorest people are 4.14 times more likely to have Type 2 diabetes than those in the highest income category. And poverty isn't something that can be treated with a drug or a medical device.

Canada needs a strategy to reduce the chances that people will develop Type 2 diabetes. Key elements of such a strategy would be poverty reduction, including among the elderly, single women, Aboriginal people and people of colour; increased public funding for education; job security; and a more equitable distribution of wealth across the population.

* This article was originally posted June 27, 2012 on PharmaWatch Canada. Thanks to guest blogger Colleen Fuller for permission to repost here.

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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
User is currently offline
on Tuesday, 17 July 2012
in CHNET-Works!

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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Code Red for maternal and child health: The BORN project *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Thursday, 12 July 2012
in CHNET-Works!

In 1997, Ontario’s health ministry set a goal of reducing the percentage of babies born with low birthweight (less that 2,500 grams at birth) from 5.7 to 4 percent by 2010.  Such babies are at increased risk for poor health outcomes, and their care involves substantial health system costs.  The target was not met; in fact, by 2010 the figure had risen to 6.5 percent.   In a followup to the Code Red project, described in a previous posting, researchers at McMaster University and reporters at the Hamilton Spectator examined 535,000 Ontario birth records to find out why.  The results of the BORN project, which turned into a much larger-scale investigation into the socioeconomic influences on maternal and child health, offer a disturbing look not only at the reasons but also at the straightforward economic consequences.

The study found a strong socioeconomic gradient in low birthweight.  “Of the 20 neighbourhoods in Ontario with the worst,” i.e. highest, “rates of low-birth-weight babies, three of them are in the lower part of the former City of Hamilton” – in other words, the low-income downtown.  In one of the neighbourhoods, “74 percent of children live below the poverty line” and more than one family in four is headed by a single mother – statistically, one of the most important risk factors for poverty.  There are also some conspicuous outliers.  For example, the high-income Toronto suburb of Vaughan has the highest incidence of low birth weight in Ontario: 16.4 percent – emphasizing the complex causal pathways that may be involved.  McMaster researcher Neil Johnston, who was part of the study team, noted that there is “not a single smoking gun.  It’s almost a conspiracy of things that preclude [mothers] from ensuring the child they’re carrying will be as healthy as possible.”

born pic 1 prenatal care Ont1

One of those things is uneven access to prenatal care:  in some Ontario communities, like downtown Windsor, just over half of all expectant mothers receive prenatal care during the first trimester; in other communities, for the most part relatively wealthy, more than 19 out of 20 mothers receive first-trimester care.  Interestingly, although a socioeconomic gradient exists across neighbourhoods in Hamilton, levels of access are generally high.  Another issue is teenage pregnancy.   Within the region at the west end of Lake Ontario there is a steep socioeconomic gradient.  In one of Hamilton’s poorest downtown areas, between 2006 and 2010 one in seven babies was born to a teen mother.  In a wealthy area of nearby Burlington, where the median household income is three times as high, among a comparable number of births not a single one involved a teenage mother.  Comparable differences were observed across the province, with many of the highest rates (between 20 and 40 percent of births to teen mothers) observed in low-income First Nations reserves across northern Ontario.  Conversely, in 20 rural and suburban municipalities across southern Ontario, including high-income Richmond Hill and Oakville, the highest percentage of teen mothers was 1.8.  (The Town of Vaughan was one of these, showing the complexity of the low birthweight problem.)


As with the original Code Red series, the statistics are accompanied by interviews that should be required reading for every student of public health or health promotion.  Interviews with people like “Kristen,” pregnant at 16 after her boyfriend poked holes in the condoms because “he figured it would make me stay with him,” and researcher Lea Caragata, who points out the links among poverty, economic insecurity and lack of a sense of the future. “For those middle-class kids in Ancaster, pregnancy will ruin their prospects and their aspirations …”  It is critically important not to pathologize teen motherhood, but equally important to recognize that all too often it ensures the reproduction of patterns of disadvantage and marginalization across generations.

All of us concerned with action on health equity need to ask questions like the one posed at the start of the third and final instalment of the series:


Turning around the Ontario situation will require coordination among a variety of service providers – a “symphony orchestra” rather than “a wonderful jam session,” in the words of McMaster’s Johnson, who emphasizes that the province “must take accountability for what happens” in the health system.  This is easier said than done – too often no one anywhere in the health care system seems accountable for outcomes, as shown by Ontario’s lacklustre performance in diabetes management – yet the challenges raised by the series are even bigger.  One set is summarized in Lea Caragata’s passionate critique of the “opportunity deficit” facing too many of today’s youth.   Another, related set is suggested by remarkable calculations that show the Gini coefficient – a standard measure of income inequality – at the neighbourhood level.

“It turns out that the Hamilton neighbourhoods with the greatest income inequality are also the same neighbourhoods with the highest levels of poverty. …. Perhaps it’s a coincidence,” said the final story, that these neighbourhoods “also happen to be the neighbourhoods that performed poorly for any number of health variables based on the findings of both Code Red and Born.

“Perhaps it’s not a coincidence.”

In Canada as in much of the rest of the world, economic restructuring and social policy retrenchment are driving an increase in economic inequality on every scale from the neighbourhood to the nation.  By failing to face up to this trend and address its consequences for health, we are betting the future of many Ontarians on its being just a coincidence.  We are also, of course, betting hundreds of millions, if not billions of dollars in future health care costs that could be avoided.    

Or, perhaps, we just don’t care?

born-pic-4-Gini coefficients

* Sincere thanks to the Hamilton Spectator and the Center for Spatial Analysis, McMaster University for the illustrations

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Good news and bad on health equity

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

Herewith a selection of events from around the web, and the world. First, some good news. The Caledon Institute for Social Policy, a non-profit with a long history of progressive social policy analysis that is now headed by two accomplished alumni of the recently deceased National Council of Welfare, has announced that it will take over preparing and publishing two of the Council's most important data series: those on welfare incomes and the profile of poverty in Canada. These are core resources, and Caledon is to be congratulated on this initiative, which will be part of a new Canada Social Report. I hope that one or more Canadian academic institutions will offer to support them, financially and with other resources.

My current institutional home, the Bruyère Research Institute, has produced a valuable set of tips for keeping seniors safe in the heat. As I write we're at humidex 34 here in Ottawa, so the importance of such advice can't be overestimated. Eric Klinenberg's remarkable "social autopsy" of the 1995 Chicago heat wave reminds us that a clear socioeconomic gradient exists with respect to opportunities to stay safe in the heat. Many people can't afford air conditioning or a breezy cottage, and in Chicago the elderly on moderate incomes in particular found themselves isolated by fear of crime and other elements of the urban environment from locations that could at least have kept them cool.

In a world that may experience extreme heat and weather events with greater frequency as a result of human-induced climate change, such warnings assume special importance. They may also not be enough. On June 30, it was reported that a combination of violent storms and extreme heat had caused the deaths of at least 12 people in the United States, and millions more were "facing temperatures in the 40s without electricity, and without air conditioning." Record temperatures and wildfires in Colorado had forced the evacuation of 32,000 people and the cancellation of the iconic Pikes Peak Hill Climb, a motor sports event with almost religious significance for aging gearheads like yours truly. But not to worry, say the climate change sceptics; the evidence is insufficient and these may be natural variations from the mean. Everything will be fine.

Finally, a shift to the global frame of reference. A little-noticed resolution adopted in May by the World Health Assembly, the governing body of the World Health Organization, called on the "international community" to support action on social determinants of health and, more concretely, on WHO's Director-General "to duly consider social determinants of health" and to continue advocacy for their importance within the UN System. Supporting documentation pointed out that implementing the resolution would require an additional $33.6 million between 2012 and 2017, and that the cash-strapped WHO had no resources in its current core budget for these activities. To put the amount into context, it's equivalent to the cost of 22 of the 588 Tomahawk cruise missiles the US Department of Defense planned to buy between 2010 and 2012 ... and Tomahawk was just a drop in the United States' $1.5 trillion arms procurement budget over those years. What was it that the Commission on Social Determinants of Health had to say about "a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics"?

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