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The Unkindest Cut

Posted by guest blogger Sarah Giles
guest blogger Sarah Giles
Sarah Giles is a family physician with an interest in remote and rural medicine.
User is currently offline
on Thursday, 05 July 2012
in CHNET-Works!

In the face of the Harper government's proposed cuts to refugee health care, there has not been a massive outcry from the nation's doctors. Certainly, we have heard from a vocal minority of individuals, such as the 80 doctors who briefly occupied cabinet minister Joe Oliver's Toronto office on May 11, 2012 and those who participated in a national day of protest on June 18, 2012 (about 400 people in Ottawa and others scattered across the country), but, in general, the response from doctors has been underwhelming.

First, it's important to highlight that the major associations of health care providers (Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, College of Family Physicians of Canada, Canadian Nurses' Association, Canadian Dental Association, Canadian Pharmacists Association, Canadian Association of Optometrists and Canadian Association of Social Workers) have signed a position statement in which they have asked the federal government to rescind some of the proposed cuts to the Interim Federal Health Program (IFHP). IFHP, for those who are unfamiliar with it, is a program that provides health care funding from federal coffers until a refugee is eligible for coverage under provincial programs.

Despite the federal government's assertion that IFHP provides refugees with "superior health care" in comparison to other Canadians, the program only actually provides essential and emergency health services to treat and prevent serious medical conditions such as prenatal care, some vaccines, and essential prescription medications should a refugee be unable to afford such items. Yes, eyeglasses and a few other services such as limited physiotherapy are provided, but the program is not overly generous as is quite similar to programs for Canadians on income support programs.

The federal government naïvely suggests that its proposed cuts will save Canadians $100 million. Refugee health problems will not go away; instead, they will fester untreated until they become a medical emergency that lands these vulnerable people in the emergency room.

Here's a quick (fictional) example of how this program will cost Canadians more money and cause refugees' health to deteriorate. Havinder is a refugee who is an insulin-dependent diabetic who has been stable on his medications for some time. On July 2, he runs out of insulin but cannot afford to buy more. He tries to drink more water and walk more to decrease his sugar levels, but as the week goes on, he feels worse and worse. He is unable to attend work because he is lethargic. He can't sleep because he is urinating every thirty minutes. He develops a terrible headache that he can't shake. Havinder goes to bed on July 7 and on July 8, his wife can't wake him up. An ambulance is called; he is taken to the local emergency room where he is quickly diagnosed with an advanced case of diabetic ketoacidosis. He is admitted to the ICU and remains in hospital for two weeks. The federal government refuses to pay for his care, so the provincial government (which is responsible for hospital funding) is forced to cover the cost of the two weeks in hospital as there is no way that Havinder can pay the twenty thousand dollar hospital bill. Havinder is discharged home with prescriptions that he cannot afford to fill and the cycle starts all over again.

The health care providers in the hospital understand that Havinder's entire $20,000 hospital stay could have been avoided with a $20 vial of insulin. They appreciate that Havinder has had a needless brush with death and that there may be some permanent sequelae. The hospital staff, at least in the short term, will still get paid. They may shake their heads at the insanity of policies behind the new policy, but it won't affect their finances until provincial taxes go up to cover the short fall in hospital budgets.

Doctors working in refugee health clinics around the country will be forced to evaluate how they can continue to provide services when they will no longer be paid by the IFHP. They will wonder whether there is a point to seeing patients who will never be able to afford the services and treatments that the doctors will recommend. They can treat pneumonias and prevent infectious disease with drugs and vaccines – but how can doctors do this when there isn't any funding available to procure such items? They will know that having unvaccinated refugees will cause a significant public health risk through the erosion of "herd immunity".

So, doctors certainly understand that the health of refugees, and indeed the health of the general public is at risk with these proposed cuts, but very few of us are actually actively speaking out or protesting. Why is this?

First, we must examine those who become doctors in Canadian society. We know from many studies that doctors overwhelmingly come from high income earning families. Most, though certainly not all, doctors have never had to consider forgoing a prescription in order to buy food. Most doctors were accepted into medical school by doing well in undergraduate classes and not rocking the boat. Most doctors are people pleasers who have gone to great lengths throughout their training to jump as high as humanly possible when commanded to – often without thinking about why they were asked to jump in the first place. The medical establishment rewards with promotions and positions of power those who do not threaten the status quo. There are very, very few (at least openly) radical doctors. Perhaps those doctors who occupied Mr Oliver's office are the only politically active doctors in the entire Greater Toronto Area?

Or maybe doctors feel beaten down. We are essentially civil servants – the provincial government sets our wages, tells us whether or not there is funding for another hip replacement surgery, and dictates that we are not eligible for vacation pay, benefits, or pensions. In Ontario, doctors have just received a substantial pay cut and they were not able to participate in that decision making process. Maybe we just feel that governments are not listening to us.

Doctors have used the term "evidence-based medicine" for some time. We try to use science to dictate our practice rather blindly doing what has worked in the past. If interventions are shown to be expensive and ineffective, we do our best not to use them. W why are Canadians, especially doctors, willing to endure non-evidence based politics. We know that the cuts to the IFHP will hurt the most vulnerable members of Canadian society. We can guarantee that provincial health costs will rise far more than the supposed savings at the federal level and yet, very few of us are raising hell about the issue.

We need to stop depending on our organizational bodies (the Canadian Medical Association, RCPSC, etc.) to represent our patients' rights. We need to stand up and demand that the federal government protect our most vulnerable patients. Our organizational bodies look after doctors' concerns and will put out the odd position statement to support patients, but it is not their primary responsibility. We, who are educated and well compensated, need to press everyone we know to stop this disastrous change in policy. This cut makes no sense on any level – be it fiscal or compassionate. Let's rally the troops and help keep Canada a place where we are proud to live and practice.

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Suitable for framing

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Monday, 18 June 2012
in CHNET-Works!
Herewith a selection of quotations and images charting the path of social determinants of health in policy analysis. We start with a trip in the wayback machine, to 1983 and a review article(1)on hypertension in Canada by Helen Johansen, then with the Health Protection Branch of Health and Welfare Canada.

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Closer to the here-and-now, a team of researchers with Toronto’s Institute for Clinical Evaluative Sciences wrote in a 2009 report comparing public health policies across Canada’s provinces that:

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A similar point comes from an important new report on overweight and obesity from the Institute of Medicine south of the border (the quotation is from the web summary):

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More about this report, and about recent studies that have been quoted as casting doubt on the importance of “food deserts,” in a subsequent posting. I invite comments from readers on the latter point, in particular; meanwhile, some of the comments posted on the New York Times article that describes the studies  offer valuable insights into the real world of life on a limited income, where both money and hours in the day are in short supply.

Most recently, the authors of a May, 2012 report on income differences among patients using hospitals in Toronto began the study with a brief discussion of health equity in which they noted:

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The phrase currently used to describe the policies needed to address those core social determinants of health is “intersectoral action,” which was the topic of an earlier posting. The unequal distribution of opportunities to be healthy was central to the work of the WHO Commission on Social Determinants of Health. It was also central to the public health strategy proposed in a 2007 report to Norway’s Storting  (the national legislative body) by the country’s Ministry of Health and Care Services, and was communicated in an image that remains remarkably powerful.

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What we should learn from this brief journey was captured in a 2011 Toronto conference presentation by Nancy Edwards, director of CIHR’s Institute of Population and Public Health.

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Against the background of this accumulated wisdom, why is so much activity still focused on individual-level behaviour change and lifestyle modification, and so little on structural disadvantage? The question is, of course, too ingenuous by half. In a commentary written shortly after the World Conference on Social Determinants of Health in October, 2011, Sir Michael Marmot captured the underlying realpolitikof resistance as it played out at the conference:

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It should now be clear that “less safe” policy directions are the only ones that will generate meaningful progress toward reducing health inequities. How willing are those of us who profess a commitment to that objective, perhaps especially those with academic tenure or collective agreement protection (I have never had the former, and have not had the latter for two decades) to insist on those directions? Can viable coalitions for change be built outside the universe of health researchers and front-line workers, for example by making long-overdue common cause with the trade union movement? Such questions may decide the future of health equity in a Canadian political context that, at least over the short term, looks distinctly hostile.

(1)  Johansen H.  Hypertension in Canada: Risk factor review and recommendations for further work. Canadian Journal of Public Health, 1983;74:123-128.

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Social determinants of health: Glum tidings on the inequality front

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 11 June 2012
in CHNET-Works!

The Commission on Social Determinants of Health was emphatic about the role of “the inequitable distribution of power, money and resources” in sustaining socioeconomic gradients in health.  Such inequitable distributions do not just happen; they are the result of choices about how societies govern their economies and distribute the rewards they generate.  Globalization has undoubtedly narrowed the range of such choices – think about Eduardo Galeano’s “magic galleon that spirits factories away to poor countries” (1) and the shift of power in Europe from electorates to bond investors and credit rating agencies – but has not eliminated them.  Three recent publications offer important and sobering insights into how those choices have played out in Canada.

The most recent report on child poverty from UNICEF’s Innocenti Research Centre points out that: “It is now more than 20 years … since the Government of Canada announced that it would ‘seek to eliminate child poverty by the year 2000.’ Yet Canada’s child poverty rate is higher today than when that target was first announced.”  The poverty rate referred to here is not Canada’s Low Income Cut-Off, but rather a standardized relative measure referring to a household disposable income of less than 50 percent of the national median, after adjustments for family size.  Canada, as we can see, does not rank especially well on this measure.   Much of the report is devoted to comparing this measure with an alternative one constructed around 14 specific measures of child well being, for which data are available only for European countries, but among countries for which both measures are available there is a clear correlation between rankings.  

glum tidingsSource: UNICEF Innocenti Research Centre (2012), Measuring Child Poverty:
New league tables of child poverty in the world’s rich countries.
At the other end of the economic scale, a new paper by five Canadian economists explores some of the driving forces behind Canada’s steadily rising level of inequality –in particular, the growing share of income flowing to the top one percent of the income distribution.  “The top income share almost doubled” from about 8 percent in the late 1970s “to reach 14 percent in recent years.  Such an uneven distribution of income has not been seen since the dark days of the Great Depression.”   In a clearly written review of the issues, the report goes on to make a number of important points:

  • The range of occupations represented in the top one percent is far wider than stereotypes would suggest, with only 10 percent of top earners working in financial services as of 2005 (the date covered in the last compulsory Long Form Census, from which many of the report’s data are drawn)
  • Growing inequality is a function not only of changes in the distribution of market income but also, and crucially, of the retreat from redistribution that began in the 1990s
  • “Younger workers, especially those with limited education, face a world with worse earnings prospects than their fathers’ generation,” suggesting a future of further inequality in market incomes as older cohorts of workers who have maintained their wages retire
  • Revenues from increasing income taxes only on the top once percent would probably be relatively modest, even before considering the impact of strategies for tax avoidance that are available to many of the rich

The report also has, to my way of thinking, at least two shortcomings.  

First, and perhaps unavoidably given data limitations, it deals only with income and not with wealth.  Wealth distributions are often more unequal than incomes, and many forms of intergenerational wealth transfers (e.g. bequests of valuable principal residences) do not show up in income figures.  The report points out the role of assortative mating (of two high earners) in increasing household income inequality; its contribution to inequality in household wealth may be more significant.

Perhaps more seriously, the report takes the concept of ‘skill’ as entirely unproblematic, treating the education level associated with a particular occupation as a rough proxy.  However, there is often no clear connection between the intrinsic complexity of the tasks involved and the credentials of those performing them; in terms of labour market outcomes it makes more sense to ask what kinds of tasks, including some very complex ones, are amenable to ‘offshoring’ in low-wage jurisdictions.

Robert Evans, the iconoclastic health economist whose work was the topic of an earlier posting, likewise organizes a recent article around the one-percenters’ growing share of income and on that fact that “these trends,” both in Canada and the United States, “are to a considerable extent a consequence of conscious, deliberate agency by more or less organized and coherent interest groups.”  His most immediate concern is what the retreat from redistribution means for the future of Canadian public health insurance (“a casualty in the class war,” in Evans’ words) now that federal cash transfers to the provinces for health care no longer come with even minimal conditions.

Evans is, as always, playful with his literary allusions; Sherlock Holmes enthusiasts are directed to his endnote 11 and the accompanying text.

Outside the health care field, he emphasizes the health consequences of the “degrading” of environments where people live and work that is associated with rising inequality – a special concern in view of the prospects of a global economic realignment in which many ‘good jobs’ have simply disappeared from the high income world.  Reducing the effects of that realignment on health disparities will require more, not fewer redistributive economic and social policies – certainly not the austerity measures that are now worsening the current recession.  If one agrees with Evans’ analysis of the sources of successful resistance to such policies, then the precarious state of the social determinants of health agenda in Canada is hardly surprising. 

(1)  Galeano E. (2000).  Upside Down: A primer for the looking glass world.  New York: Picador.

Source: UNICEF Innocenti Research Centre (2012), Measuring Child Poverty:

New league tables of child poverty in the world’s rich countries.

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Hamilton, Ontario: “Code Red” for health equity?*

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 30 May 2012
in CHNET-Works!

For Canadians of a certain age, the southern Ontario city of Hamilton (now an amalgamation of an older core municipality with several suburbs and exurbs) will always be Steel City, after the industry that was once its economic backbone. Today the city's steel industry has shrunk dramatically, as part of the deindustrialization that has ravaged the city's economy. Steel producer Stelco, which employed 25,000 people as recently as 1980, employed (as US Steel) only 1500 people in 2011. Other industrial employers, such as Firestone Tire and Rubber, International Harvester, Procter and Gamble, Dominion Glass, Camco, Siemens Canada and Westinghouse have left the city altogether. These job losses combined with a pattern of migration (by those who could afford it) from the downtown neighbourhoods surrounding major industrial plants to the suburbs to produce drastic economic inequalities within the city's boundaries. Thus, median family income in 2005 in the affluent exurb of Ancaster, formerly an independent municipality, was almost twice as high as the average for the former core city of Hamilton.

The health gradient associated with these inequalities has been documented in a remarkable collaboration between McMaster University researchers Neil Johnston and Patrick DeLuca and Hamilton Spectator investigative reporter Steve Buist. Their work produced a series of stories in the Spectator in 2010, is summarized in a new journal article+, and provides a template that should be used by university-community coalitions in cities throughout Ontario and elsewhere.

code-red-pic-1-500Source: McMaster University and Hamilton SpectatorThe researchers started with 12,000 death records and 400,000 hospital admission and emergency room (ER) visit records from 2006 – 2008, for everyone listing a Hamilton home address. Identifying information was removed to ensure privacy, and a hospital research ethics board indicated that no formal review was required. Twelve health variables were identified, and patient records were sorted by home address into Hamilton's 135 census tracts, for which socioeconomic data from the 2006 census were also obtained. Local school boards provided information on high school completion. The data were then turned into a series of maps, only a few of which are shown here, that show census tracts grouped by quintile, but data are also available for each individual census tract.

As one of the articles in the original series put it: "Those neighbourhoods with high rates of emergency room visits, no family physician, respiratory-related problems and psychiatric emergencies are the same neighbourhoods, in general, that have the lowest median incomes, lowest dwelling values, highest rates of people living below the poverty line and highest dropout rates from school."

"In parts of the lower-central portion of Hamilton," the story continued, "where poverty is deeply entrenched, some neighbourhoods live with Third World health outcomes and Third World lifespans."

code-red-pic-2-500Source: McMaster University and Hamilton SpectatorSome specifics: in one high-income census tract on Hamilton Mountain, where only 4.1 percent of the over-15 population lived on incomes below the Low-Income Cutoff (LICO) in 2005 and median family income was more than $68,000, average age at death was 86.3 years. In one low-income downtown census tract (35 percent of people over 15 living below the LICO, median family income just under $40,000) it was 65.5 years – a difference of 21 years.

The journal article that summarizes Code Red findings adds: "Also, there was a 22-year difference in the average age of a patient attending hospital with a cardiovascular-related emergency—from 57 years at one extreme to 79 years at the other. With respect to acute-care hospital bed use, one neighbourhood in the lower inner city had a rate of 729 days of acute-care hospital bed use per 1,000 people between the ages of 16–69. At the other extreme, an affluent suburban neighbourhood had a rate of 46 days of acute-care bed use per 1,000 people between the ages of 16 and 69. Other statistics presented included one inner-city neighbourhood having a rate of children living below the poverty line of 68.5 per cent while there were seven neighbourhoods where the rate of children living below the poverty line was 0 per cent."

code-red-pic-3-500Source: McMaster University and Hamilton SpectatorIn addition, a composite of all health and socioeconomic indicators was generated to produce a single ranking of each of the city's 130 census tracts. This ranking, too, was mapped by quintile. Combined, the two adjacent census tracts that placed lowest in this ranking had more than 40 percent of their population living below the LICO and the highest rates of hospital use – more than 1400 bed-days per person, or more than 17 times the rate for one suburban census tract. They also ranked near the bottom on many other health indicators.

The study also considered cost issues. Based on figures provided by Ontario's Ministry of Health and Long-term Care, it found that ER, hospital and ambulance use over the two years covered by the study cost $2,060 for every person living in one low-income, downtown neighbourhood. In one suburban neighbourhood, these costs added up to just $138 per person – raising the question of whether resources could be better used to eliminate social and economic conditions that make the ER and the hospital frequent ports of call for people with extensive health care needs, limited resources, and (often) no family physician.

That question is central to efforts to advance health equity, and it came up often in the course of research for Code Red, which was much more than a statistical exercise. The Spectator series included interviews with Hamiltonians as diverse as the head of a community foundation, a young paramedic whose role is that of a first responder to health emergencies, a family physician operating a one-person practice in the downtown neighbourhood where he grew up, a woman recovering from homelessness and crack addiction and the chief of emergency medicine at one of the city's hospitals. The stories told add to the statistics, as disturbing as they already are, what philosopher Jon Elster has called the texture of everyday life.

code-red-pic-4City of Industry, March 2007; photo by Chip Walsh,
reproduced under Creative Commons 2.0 licence
At least in Hamilton, the health gradient has an environmental dimension. The Niagara escarpment divides the city by elevation between the low-lying downtown and Hamilton Mountain (as the escarpment is called locally) and surrounding suburbs. As one story in the series pointed out, the escarpment "acts like a catcher's mitt for offshore breezes from Lake Ontario, trapping pollution over the lower city, particularly the northeast" – where the city's major industries were historically located, and where current levels of deprivation are highest. The story went on to note that despite deindustrialization, pollution levels in this part of the city still exceed recommended levels far more often than in rural areas. An earlier study, covering the period 1985-94, found that total suspended particulate (TSP) pollution exposure levels and dwelling values (a useful proxy for neighbourhood socioeconomic status) were inversely related – an important finding, since smaller particulates in particular are linked to respiratory damage.

In academic terms, some are likely to critique the study for not using age-standardized measures of mortality. However, the authors made "a conscious decision ... to treat the data in the simplest fashion possible so as not to confuse a lay audience," and unadjusted data may actually be more meaningful from a health equity perspective, because of what they reveal about the extent of health disparities 'on the ground'. The same is true of objections related to the difficulty of disentangling causation from selection, which was not the objective. As an associate medical officer of health interviewed for the series put it: "People don't move to a neighbourhood and then the neighbourhood makes them poor. They're often in those neighbourhoods because they can't afford to live other places." From an equity perspective, that's the point.

In the words of one of the authors, the Code Red stories "really seemed to strike a nerve in Hamilton." They influenced the subsequent municipal election campaign; played a role in decisions to locate two new hospital treatment centres in central areas of the city where need is greatest; led to the creation of a new staff position in municipal government; and have attracted extensive interest from various audiences. Against a background of fiscal austerity that often proceeds on irrational lines, it may be too early to assess (or to expect) more systemic effects. The study nevertheless represents a critical advance not only in our understanding of health equity in Canada but also in our knowledge transfer capabilities – the kind of work that health research funding agencies should be supporting and encouraging.

* Neil Johnston and Steve Buist provided valuable assistance with this posting. All non-attributed views are exclusively my own.

+Contact Neil Johnston, This e-mail address is being protected from spambots. You need JavaScript enabled to view it for a copy

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Food security: Canada gets a warning

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

Olivier De Schutter, the second United Nations Special Rapporteur on the Right to Food, is one of the most thoughtful thematic mandate holders, as they are called in UN-speak. (There are currently 36 such mandates.) His reports and commentaries provide articulate critiques not only of the policies of specific national governments, but also of an international agri-food system that is conspicuously failing to protect and fulfil the right of all to an adequate diet – one of the most basic social determinants of health.

The preliminary report of Prof. De Schutter's mission to Canada, which wound up on May 16, is sobering reading for a country that is often prone to self-congratulation on its human rights record. He points out that according to the 2004 Canadian Community Health Survey, 7.7 percent of Canadian households reported moderate or severe food insecurity – this before the financial crisis of 2008 and subsequent recession – and "was disconcerted by the deep and severe food insecurity" faced by aboriginal people, the legacy in part of a "long history of political and economic marginalization."

de-schutter-pic-1UN Photo/Jean-Marc Ferre.
Reproduced under Creative Commons Licence 2.0.
His report directly links food insecurity and increasing reliance on food banks to low incomes and the high cost of housing – a link that has been referred to in earlier postings. "In the view of the Special Rapporteur, social assistance levels need to be increased immediately to correspond to the costs of basic necessities," and minimum wages should be set at a living wage level as required by the International Covenant on Economic, Social and Cultural Rights, to which Canada is a state party.

Population health researchers have effectively documented the extent of food insecurity in Canada; the work of the University of Toronto's Valerie Tarasuk is especially powerful in this respect, as are the reports of the Toronto Department of Public Health. We have perhaps not taken advantage of opportunities to frame food security as a human rights issue, a matter of priorities. Maybe food security for all is just more important than freeway widenings or fighter aircraft ... or maybe we don't even need to make those choices. Prof. DeSchutter pointed out that: "The tax-to-GDP ratio of Canada ... is now in the lowest third of OECD countries. Consequently, Canada has the fiscal space to address the basic human needs of its most marginalized and disempowered." I've made a similar observation in a previous posting.

Predictably, the official response was less than cordial. Cabinet minister Jason Kenney, at roughly zero risk of food insecurity, referred to "lectures to wealthy and developed countries" as "a discredit to the United Nations." He might want to have a talk with Department of Justice lawyers about the nature of obligations under human rights treaties, but that's a topic for another day. Clearly, Prof. De Schutter's intervention gives a boost to those who would address the politics and priorities that deprive people in such a "wealthy and developed country" of food security.

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