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The diabetes crisis: health care not doing its part? *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 11 May 2012
in CHNET-Works!

I do not ordinarily write about the health care industry (and it is an industry). I decided to break this rule after reading a recent report in the Ottawa Citizen on a decision by the Champlain Local Health Integration Network (or LHIN, Ontario's version of a regional health authority) to hire two chiropodists to provide free foot care to diabetics – a service otherwise not covered by provincial health insurance, and therefore unaffordable for many. Lack of appropriate foot care was cited as one of the reasons for the region's high rate of hospitalization for diabetic foot infections, which sometimes lead to amputations.

Diabetes is not an equal-opportunity disabler. As noted in an earlier posting, a pronounced socioeconomic gradient exists in the prevalence of Type 2 diabetes, and limited incomes seriously compromise patients' ability to manage the disease effectively. This helps to explain why diabetes mortality has declined faster among higher-income patients in Ontario. But even aside from these important issues, which suggest at the very least a need to broaden insurance coverage, Ontario's health care system seems not to be doing its part. Province-wide, according to health ministry figures, as of late 2010 fewer than two out of five Ontarians with diabetes had received all three of the tests recommended for diabetes management – blood glucose every six months, cholesterol (LDL) every year, and retinal eye examination every two years – in the appropriate period. (Nationally, a clear socioeconomic gradient exists for receipt of these tests; it would be interesting to know whether the same is true in Ontario.) And a recent article by Tara Kiran and colleagues at the University of Toronto, based on Ontario Health Insurance Plan records, points out that the 2002 introduction of a new billing code specifically to reimburse physicians for diabetes management tasks had, by the end of 2008, led to only modest increases in monitoring.

This is part of a more general, Canada-wide picture. Jeffrey Turnbull, past president of the Canadian Medical Association, has pointed out that in one of the OECD's more expensive health care systems (although it's not one of the more expensive when only public spending is considered) chronic disease management is "woefully inadequate" and "Canada now ranks below Slovenia in terms of effectiveness and last or second last in terms of money spent" on health care. With specific reference to diabetes care, 2008 figures from the Commonwealth Fund show that Canada ranked far behind the Netherlands, New Zealand and the United Kingdom in the percentage of adults with diabetes who received appropriate monitoring.

Now, I am an outsider to most of the quotidian operations of health care institutions; I don't have ready answers. Health system managers seem to be proliferating, yet few signs can be found of the "new management systems and new accountabilities" that Dr. Turnbull called for. Surely it's not unreasonable to ask that health ministries and regional health authorities have routines in place to benchmark diabetes management, and myriad other health care processes, against the world's best and transform the way they do things to match the leaders' performance.

* Tara Kiran provided valuable help with research for this posting. All views expressed are exclusively my own.

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Small steps toward walkability

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Thursday, 26 April 2012
in CHNET-Works!

Toronto’s Department of Public Health, a leader in such areas as publicizing the conflict between eating a healthy diet and keeping a roof over your head when living on a low income, has issued a new report with important recommendations for improving health by promoting walking and cycling.

Among the recommendations: reducing speed limits to 30 km/h on residential streets and 40 km/h on most others, and installing “leading pedestrian signals” at major intersections.  (These are signals that give pedestrians a walk signal a few seconds before the light turns green for vehicle traffic, improving drivers’ ability to seen them.)  The report also notes the need for more investments in pedestrian and cycling infrastructure, and for working with Metrolinx (the regional public transportation authority, now facing drastic funding shortfalls as a consequence of provincial austerity measures) to promote active transportation.

The report is based on a longer study that undertook an extensive review of the evidence on active transportation and health, emphasizing the equity dimension.  It noted, in particular, that “low-income families often live in high-rise neighbourhoods in Toronto’s suburbs,” which are hostile to pedestrians and cyclists.  Roads are wide; marked pedestrian crossings few and far between; pedestrian collisions are more frequent even though pedestrian volumes are lower; and three-quarters of parents do not feel comfortable letting their children walk unaccompanied in their neghbourhoods.

creative-commons-licencePhoto: Richard Drdul,
reproduced under a Creative Commons licence
The longer study also argued for traffic calming strategies: engineering measures to slow down traffic, like speed bumps and curb extensions, which have resulted in major reductions in injuries and fatalities when implemented in Europe.  A more extensive review of traffic calming and health was published late last year by Canada’s National Collaborating Centre for Healthy Public Policy, and will be the topic of a CHNET-Works Fireside Chat on May 10.
 
Predictably, the Toronto Public Health recommendations were greeted with howls of outrage from some of Toronto’s more retrograde politicians, but as readers of a previous posting (and the longer Toronto study) will know, such measures are either already in place or under serious consideration in many European cities.  This is, literally, an issue of street-level politics: will the “right to the city,” in Henri Lefebvre’s frequently cited phrase, favour pedestrians and cyclists or people protected by two tons of steel and airbags?  In many other Canadian cities, we’re still waiting for Toronto-style public health leadership.

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Fostering blissful ignorance about poverty?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Monday, 23 April 2012
in CHNET-Works!

Many readers of the federal budget will have missed the decision to shut down the National Council of Welfare, a small and independent-minded unit of the Government of Canada that since 1962 has been a source of information about the extent and depth of poverty and inadequate social provision in Canada. With its demise, a resource for advocacy on social determinants of health has been lost. It is still possible to use the Council's site to access an interactive map showing that (for example) inflation-adjusted social assistance incomes in Ontario are no higher than they were in 1986. And the ground-breaking 2011 study on The Dollars and Sense of Solving Poverty is still available. To quote just one provocative finding from its summary: "The poverty gap in Canada in 2007—the money it would have taken to bring everyone just over the poverty line—was $12.3 billion. The total cost of poverty that year was double or more using the most cautious estimates," although these are admittedly incomplete and fragmentary. The public health community would be well advised to act fast and download the Council's publications before they are consigned to the memory hole.

Another disturbing set of findings about economic insecurity comes from the latest annual survey of Canadian family finances (families of two or more people) from the Vanier Institute of the Family. Some of the study's findings will be familiar: for instance, after-tax income of the poorest 20 percent of Canadian families (two or more people) rose by just 19 percent between 1990 and 2009; the incomes of the richest 20 percent rose by 35 percent. We know from other studies that the trend toward increasing inequality is even more extreme when we look only at the top one percent of the Canadian income distribution: 246,000 people with an average income in 2007 of $404,000 who accounted for 32 percent of all the growth in incomes between 1997 and 2007.

blissful-pic-1Source: Department of Finance Canada.
This illustration is taken from an official Government of Canada publication;
it is used here without Government of Canada endorsement.

Other Vanier findings are less familiar, and more disturbing. For instance, Canada's official unemployment rate in early 2012 would have been 9 percent, rather than 7.6 percent, if the participation rate had been as high as before the recession; 'discouraged workers' who have given up the search for work are not counted as unemployed. And although the overall insolvency rate (bankruptcies and proposals to creditors per 100,000 population) dropped slightly in 2010 and 2011, insolvencies among people aged 55-64 increased by almost 600 percent between 1990 and 2010. Among people over 65 they rose by 1747 percent. This suggests that one of the signal accomplishments of postwar Canadian social policy, cutting the percentage of poor seniors to one of the lowest in the OECD, may be in danger.

As noted in an earlier posting, addressing the possible consequences for population health of such trends unavoidably raises questions of public health ethics. One approach would be to set up an elegant prospective epidemiological study, wait 10 or 15 years, and hope that the casualties, their survivors, or someone are still interested in the answers. Another approach, adopted by the Commission on Social Determinants of Health, is to act on what we now know or can presume with a high degree of confidence, drawing on various sources of evidence and research traditions. So far, our political leaders – and, it must be said, a few of our public health colleagues – seem more interested in punishing the poor and economically insecure, or just ignoring them, than in equalizing opportunities to lead healthy lives. Inequality trends are important for many reasons, but one is that they give the lie to claims that such equalization is unaffordable.

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“A social movement, based on evidence”? *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 21 March 2012
in CHNET-Works!

Sir Michael Marmot, who chaired the Commission on Social Determinants of Health and later led a review of influences on health inequalities in England, has called for "a social movement, based on evidence, to reduce inequalities in health" (1) and even claims to identify the beginnings of such a movement. Has such a movement begun to coalesce, and what are the prospects for its success?

In a recent book on women's resistance to workplace sexual harassment in the United States, Carrie Baker defines social movements as "a mixture of informal networks and formal organizations outside of conventional politics that make clear demands for fundamental social, political, or economic change and utilize unconventional or protest tactics" (p. 4) and argues that the resistance she studied fits that definition, even though much of the action took place in courtrooms, administrative hearings, and Congressional committees. Crucially, the coalitions that formed to fight sexual harassment connected women who were not otherwise similarly situated in socioeconomic terms. Restaurant workers, middle managers in banks and federal agencies, and lawyers trying to make partner in their firms were united - sometimes temporarily and precariously – by lack of legal protection from sexual harassment by male colleagues and superiors.

social-movement-pic-1ACT UP demonstration, St. Patrick's Cathedral, New York City, December 10, 1989. Photo: Richard B. Levine

A parallel can be drawn with what is almost certainly the most successful contemporary health-related social movement, that involving treatment and prevention of HIV/AIDS. At the forefront of that movement was the AIDS Coalition to Unleash Power (ACT UP), co-founded in New York City in 1987 by playwright Larry Kramer, who was to become identified as the public face of the movement. ACT-UP quickly adopted the tactic of mounting high-profile demonstrations in places including Wall Street, the US Food and Drug Administration in Washington, DC, and St. Patrick's Cathedral (to protest against Catholic opposition to AIDS education and condom distribution). Some of ACT UP's approaches were controversial, but it "added enterprise and erudition" to confrontation, and the organization and its tactics quickly spread nationally, and even internationally.

In the early years of the epidemic, AIDS was an equal opportunity killer. This is less true today, yet the solidarity forged in the formative years of AIDS activism survives and crosses both class and national boundaries, as seen for example in the transnational support that South Africa's Treatment Action Campaign (TAC) has mobilized. That support was critical in convincing pharmaceutical companies to abandon legal efforts to prevent South Africa's government from buying lower-cost generic antiretrovirals, and TAC continues to appeal to a global audience for maintaining access to AIDS treatment.

social-movement-pic-2ACT UP demonstration, Paris, 2005. Photo: Kenji-Baptiste Oikawa, reproduced under a Creative Commons Licence.

Here's the rub.

Effective social movements are not based on evidence. Social movements can use evidence in various creative ways, but they are based on rage, hopelessness, desperation, hope, or combinations of these. That's where their energy comes from. Normally, as shown by the examples of ACT UP and resistance to sexual harassment, their protagonists share a particular vulnerability even though they may otherwise have little in common. If we go farther back in history, the movement for female suffrage and the trade union movement are useful case studies; movements to abolish slavery, in which some protagonists had no personal stake yet were willing to place themselves at considerable risk, provides a partial counterexample.

What shared passions or vulnerabilities (and effective social movements require at least one of these, and often both) will provide the basis for reducing health inequity by way of action on social determinants of health in Canada? What more needs to be known about social movements in order to create an effective one around this agenda? The answers are far from clear, which may be why the agenda is making slow progress.

social-movement-pic-3Launch of Poverty Free Ontario Campaign, Sudbury, September 2011. Photo: Cait Mitchell (used with permission).

Public health researchers and practitioners, whatever their level of commitment (which varies greatly), are at minimal risk from many of the conditions of life and work that are most destructive of health: inadequate incomes, precarious employment, hazardous exposures on the job, and the physiologically corrosive levels of stress that go along with all of those. Perhaps that is why the enterprise of health promotion still focuses far too much attention on health literacy, "choosing your sandwich with care," and similar constructs that ignore the quotidian challenges of too little money, too many demands in the workplace (including, for women in particular, the domestic workplace), and too few hours in the day. Prof. Marmot's 2004 book The Status Syndrome is eloquent on the topic of these challenges. Further, few efforts appear to have been made to make common cause and build working relationships with anti-poverty organizations or the trade union movement. (I would love to hear from readers about exceptions to this generalization, in Canada or elsewhere, for future postings.)

Gratifyingly, some health professionals now understand the importance of such alliances. For example, in a special section on advocacy in the March 2012 issue of Canadian Nurse, Joyce Douglas of the Canadian Nurses' Association writes: "Front-line nurses can speak from experience and work with organizations, associations and movements that advocate for wages that people can live on, affordable housing, healthy environments and social inclusion." As Ontario and many other provinces face hard choices about how to reduce their post-recession deficits, let's hope health professionals of all kinds understand the issues and the stakes.

* A conversation with Kumanan Rasanathan helped to clarify some of the ideas presented here, but all blame rests with me.

(1) The hyperlink is to a video interview with Prof. Marmot; the phrase is also the title of his response to a series of commentaries on his two reports that appeared in Social Science & Medicine.

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Life A.D. (After Drummond), Part 2: Structural adjustment for Ontario?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Monday, 19 March 2012
in CHNET-Works!

On February 15 the Government of Ontario released a far-reaching report on reorganizing public service provision in response to the budget deficits that followed the post-2008 recession. The central theme of the report was that “just to meet the government’s goal of a balanced budget seven years hence, the government will have to cut even more deeply from its spending on a real per-capita basis, and over a much longer period than the Harris government did in the 1990s, without the option of an immediate deep cut in social assistance rates” (p. 121). Ontarians will remember that the Harris government cut those rates by 21 percent almost immediately after coming to power. Despite some increases, in 2009 they remained (depending on the type of household receiving assistance) between 17 and 38 percent lower than in 1996 after adjusting for inflation, according to the National Council of Welfare.

The Commission says much that is important and worthwhile about health care in Ontario, starting with the recognition that Ontario does not really have a health care system, but rather “a series of disjointed services working in many different silos” (p. 152), and that Ontario health care does not perform well based on international comparisons. Well grounded hypothetical descriptions of patient trajectories spotlight shortcomings in health care performance (pp. 153, 159, 164), measured against what ought to happen as a matter of routine. The report makes a compelling case for improving coordination among the silos, through measures both large and small, and making the non-system’s current approach to complex and chronic conditions (the management of which is also very costly) more effective – all of which should have been accomplished long ago, for reasons unrelated to cost. The report urges “aggressive” negotiation with the Ontario Medical Association on compensation (p. 189) – bringing to mind Robert Evans’ long-standing insistence that "cost containment is in aggregate income control, by definition" – and, perhaps more importantly from a health policy perspective, insists on moving “critical health policy decisions out of the context of negotiations with the Ontario Medical Association and into a forum that includes broad stakeholder consultation” (p. 185).

life-ad-part-2-pic-1 A leaner, meaner Ontario: Locked out workers at the Electro-Motive plant in London, Ontario, January 2012. Photo: CAW Media; reproduced under a creative commons licenceAlthough such changes are overdue, hard questions remain unanswered. The Commission proposes to strengthen Ontario’s 14 Local Health Integration Networks (LHINs, the province’s variation on regional health authorities) so that they can improve coordination among silos and health care management in general. But can these entities accomplish such critical tasks as ensuring that best practices are rapidly adopted province-wide? What are the pitfalls of specifying that the accountability of LHINs, currently with no requirements for public participation, is to the Ministry of Health, as per the Commission’s recommendations, rather than to the clients they serve? And the proposed transformation of an organization called Health Quality Ontario, now an advisory body, into “a regulatory body to enforce evidence-based directives to guide treatment decisions and OHIP [Ontario Health Insurance Plan] coverage” (p. 186) could be a dream or a nightmare. Since “nothing works” is a fiscally attractive conclusion, we can imagine immense pressure to compromise transparency and scientific integrity, and ignore standard of proof issues, in the interests of cost containment.

The report further acknowledges the importance of social determinants of health: “Socio-economic factors such as education and income explain 50 percent” of population health outcomes, and the physical environment another 10 percent (p. 132) although the percentages, drawn from a Canadian Senate Committee report, appear to be guesstimates and no supporting evidence is provided. This acknowledgement is ironic, to say the least, given what the Commission has to say about social policy.

The Commission’s proposed 0.5 percent limit on annual spending growth for all social programs means that no increase in social assistance rates is envisioned, despite the decline from mid-1990s levels. In fact, the Commission proposes slowing the provincial takeover of social assistance costs downloaded to municipalities during the Harris era (p. 483), prolonging the nineteenth-century practice of leaving “poor relief” to local governments. (Unfortunately, some surveys find that nineteenth-century attitudes toward economic hardship remain widespread.) No new resources are contemplated for social or affordable housing, despite the existence of multi-year waiting lists in much of the province. As the Toronto Star’s Thomas Walkom and a policy analyst for the Ontario Nurses’ Association have pointed out, despite Drummond’s long career as a professional economist, the report ignores the employment consequences of taking billions of dollars out of the provincial economy. Walkom predicts that implementation of the Drummond recommendations would cause unemployment in Ontario to rise to 11 percent by 2018, “even without another global crisis”. Poverty reduction is nowhere acknowledged as a legitimate goal or priority of government; indeed, the word “poverty” appears only six times in the text of the 562-page report.

To put this discussion into context: on Thanksgiving weekend in 2010, the Premier of Ontario was quoted by CBC News as urging Ontarians to donate to food banks, and in March, 2011 395,000 Ontarians relied on a food bank to feed themselves at least once. Rents and food prices are not going down. So the Commission has said to a significant proportion of Ontarians: forget about any hope that your opportunities to lead a healthy life will improve before 2017-2018. The cupboard is bare.

But is it, really? In order to answer this question, we have to look at both the revenue side and the expenditure side of Ontario’s public finances, in historical perspective. The Commission itself emphasizes that “spending is neither out of control nor wildly excessive. Ontario runs one of the lowest-cost provincial governments in Canada relative to its GDP and has done so for decades” (p. 5). Further, it notes that the provincial treasury’s “own-source revenues” – taxes and user fees collected by the province, as distinct from revenues received from federal transfers – as a percentage of provincial Gross Domestic Product (GDP) were considerably lower (13.65 percent) in 2010-2011 than in 1999-2000, midway through the Harris era (15.9 percent). Although precise comparisons are impossible, this is consistent with estimates by the Canadian Centre for Policy Alternatives that, every year since the start of the century, provincial tax cuts (mainly in personal income tax rates) begun in 1995 have reduced revenues by between $10 billion and almost $18 billion relative to the revenues that would have been received if tax rates had remained at their 1994-95 levels. In other words, well before the post-2008 and its undeniable effects on revenue stream, the province’s fiscal capacity was suffering from major self-inflicted wounds.

life-ad-part-2-pic-2

The Commission was instructed not to consider the possibility of raising taxes. However, as shown in the illustration, if we accept the Commission’s estimates of the growth of the provincial economy and the spending restraints incorporated into the Drummond Commission’s “preferred scenario,” but are willing to consider tax increases sufficient to return own-source revenues as a percentage of provincial GDP to their 1999-2000 level by 2017-2018, we see that the budget is in surplus by more than $22 billion. Stated another way, if the province were to pursue what Hugh Mackenzie of the Canadian Centre for Policy Alternatives has called “an adult conversation about the public services we need and the revenue we are going to have to raise to pay for them,” the provincial budget could be balanced in the target year while making available $22 billion more than the Drummond projections for program spending. According to one commentator the province is not even planning pre-budget legislative hearings, thus making it difficult to start such a conversation. Indeed, the Commission’s description of the provincial budget as “a powerful educational tool” (p. 13) suggests that most of the key immediate decisions have already been made. Its proposal for a centralized expenditure management process involving the Premier’s Office, Cabinet Office and Ministry of Finance that “should stay in place for at least several years” warns of little room for debate in the future (pp. 140-141). Shouldn’t public finance be a matter for public debate?

At several points in its report the Commission underscores the difficulties created by the government’s refusal to consider tax increases, anticipating (for instance) a $38.5 billion shortfall in financing planned and necessary public transit investments in the Greater Toronto and Hamilton Area. For those who can afford to drive everywhere, this means only the inconvenience of more traffic jams; for those who can’t, it may seriously limit mobility … and of course that foregone investment also means lost employment. The Commission states that its budget-balancing strategy would mean “tough decisions that will entail reduced benefits for some” (p. 69) – although not, it seems, for everyone. On the matter of soaring compensation for people like Drummond’s fellow commissioners at the top of public sector salary scales, the report says that “focus must remain on the larger picture, which is the government’s need to get the right people into the right positions at a cost that is both compatible with its fiscal circumstances and appropriately aligned with private-sector compensation” (p. 138). Well, workers at Electro-Motive Diesel’s London, Ontario plant know about that kind of alignment: they were locked out after refusing a 50 percent pay cut before the parent company closed the plant and moved the work to Indiana. In the Ontario of tomorrow, it seems that what Saskia Sassen calls “the savage sorting of winners and losers” characteristic of the contemporary global marketplace is to be accepted, and indeed welcomed.

life-ad-part-2-pic-3

Any assessment of the Commission’s implications for population health (and never was there a better example of the need to apply health equity impact assessment to macro-scale economic and social policies) should keep this in mind. As pointed out by (among others) economist Erin Weir of the United Steelworkers, there is quite a bit in the report that those of us committed to social justice can support. At the same time, the report is about much more than public finance. Effectively, it recommends for Ontario a variant of the structural adjustment programs* of marketization and social policy retrenchment demanded by the International Monetary Fund in return for loans enabling low- and middle-income countries to reschedule their debts to external lenders, in the process creating widespread economic hardship and seldom leading to long-term economic improvements. Equity, for both the IMF and the Drummond Commission, was an unaffordable luxury. Against a background of worsening economic disparities that would be further magnified in the future envisioned by the Commission, what is the future of health equity in Ontario? And who will decide?

 

* For readers unfamiliar with the history of structural adjustment, two excellent recent review are Babb, S. (2005), The Social Consequences of Structural Adjustment: Recent Evidence and Current Debates, Annual Review of Sociology, 31, 199-222 and Pfeiffer, J. & Chapman, R. (2010), Anthropological Perspectives on Structural Adjustment and Public Health, Annual Review of Anthropology, 39, 149-165. Unfortunately, so far as I know neither of these is available on an open-access basis.

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