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Understanding social determinants of health: A good-news story

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 20 January 2012
in CHNET-Works!

In an earlier posting, I commented on how difficult it is to get many colleagues to understand that conditions of daily life like not getting enough to eat, or having to spend four hours a day commuting to work while dropping off and picking up the kids at school and daycare, might not be good for your health. When you have that kind of day, some of life's less healthy diet choices look awfully attractive. 

ncd-good-news-1
On a tight schedule and a tight budget,
healthy eating options are not always feasible.

The bad news is that it's still difficult. The good news, showing that an increasing number of people are beginning to 'get it,' comes from two medical journal articles that appeared around the time of the UN High-level Meeting on Non-communicable diseases in September, 2011. That's the meeting where, as reported in the Canadian Medical Association Journal, our own government helped to water down a proposed action plan on NCDs.

In Global Heart, the official journal of the World Heart Federation, the incoming president of the Federation (Sidney C. Smith) and a colleague wrote that:

"The challenges [of NCDs] are much farther upstream and multisectoral than other health challenges; what presents as a health issue has its origins in a variety of determinants, and the solutions must incorporate agriculture, the food and beverage industry, and the built environment, among others."

And in the European Journal of Cancer, two UK-based authors warned against a "zero-sum" approach in which cancer control is viewed as competing with other prevention priorities, and made a remarkably clear statement of the case for intersectoral action, also the topic of an earlier posting:

"One of the critical failings time and time again is the development of public policy and actions around inequality and cancer outcomes that are completely dissociated from the actual lifestyles and concepts of individual responsibility that give rise to the situation in the first place. Before even setting the policy agenda for the social determinants of cancer there needs to be an explicit political mechanism that stitches cancer into the various vertical political silos of social policy – for example education and urban planning."

There are people out there who get it. Unfortunately, so far as I can tell neither of these articles is available on an open access basis, so if you don't have access through a university or hospital, make friends with someone who does. Meanwhile, the question becomes: Why don't more people get it? And what can we do to change all that?

Useful opportunities for discussing this question in the specific context of NCDs will no doubt arise at the Fourth Pan-Canadian Conference on Chronic Disease Prevention in Ottawa next month.

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Resources from around the Web: Information abundant, time needed

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Monday, 16 January 2012
in CHNET-Works!

Herewith a potpourri of important portals and blogs from around the Web. If anyone has tips about where to find time to make the best use of them, please let all of us know!

sir-michael-marmot
Sir Michael Marmot speaking in Rio

University College London has just launched the Institute for Health Equity. Headed by Sir Michael Marmot, the Institute's initial activities include leading the "Euro Review" of social determinants of health for WHO's European office. The Institute's site invites contributors to submit projects, reports and case studies, and already features numerous links to "related work" in the UK and elsewhere. It also provides a link to Sir Michael's own blog, where in a posting about the World Conference on Social Determinants of Health in Brazil he describes efforts to ignore the role of the Commission on Social Determinants of Health that he chaired as "attempted airbrushing" based on "objections to the Commission's strong emphasis on inequities in power, money and resources." All absolutely true, and you read it here first in Sir Michael's own words. 

At the Brazil conference, the World Health Organization launched an electronic platform called Action: SDH. Registration (free) is required to access many features of the site, but they are well worth the minute or so required to register and therefore to be able to post content. Like most such 'platform' sites, the value of this one will depend on involvement by members of the community that it is designed to establish.

PolitiquesSociales (en français, but linking to numerous sources in English) is produced by the Centre de recherche sur les politiques et le développement social at l'Université de Montréal. It offers a monthly collection of news items and research products on social policy and inequality around the world, with a strong European flavour. Canadian Social Research Links, updated weekly, is an almost encyclopedic collection of similar material, focusing mainly although not exclusively on Canada. It's produced by Gilles Séguin, a former federal public servant (1975-2003) who worked on social policy issues in various incarnations of what is now called Human Resources and Skills Development Canada. These sites are quite simply indispensable for anyone wanting to build the bridges between public health and social policy that we often neglect. E-mail newsletters from both sites are available by subscription.

On to a couple of blogs that more closely resemble this one. Healthy Barbs is written by Barbara Brenner, a lawyer and former executive director of San Francisco-based Breast Cancer Action. Brenner brings both rare wit and a litigator's rigorous style to commenting on such matters as how foundation support for the supposedly independent Institute of Medicine that is part of the US National Academy of Sciences may have influenced the content of a recent report on environmental causes of breast cancer. Brenner is also interviewed in a new National Film Board feature-length documentary on how corporate-backed marketing has distorted on breast cancer politics: Pink Ribbons, Inc . Watch for it in Canadian theatres on February 3.

Finally, there's a Canadian blog called DrPHealth, by a public health professional who writes "with some anonymity to protect its author as it strives to increase transparency, promote justice and champion equity." Like Brenner, the author is rigorous about posting references and hyperlinks to his/her sources, which moves this site to the top of those I would recommend to students and practicing professionals alike. One recent posting led me to a new Canadian Public Health Association knowledge centre site, which in turn led me to at least two interesting-looking electronic resources. I won't comment further, since I have not had a chance to explore these, but once again the potential is clear.

Now, about a source for those 48-hour days ...

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It's all about priorities: How to think about health equity, part 2 - Talking taxes

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 13 January 2012
in CHNET-Works!

In the previous posting, I argued for a closer look at public spending priorities, suggesting that governments have in fact been quite successful in finding money for a variety of purposes when it suits them. Here I look at the revenue side of the equation: an area where advocates for population health and health equity have, if anything, been even more timid.

Taxes do at least three things. First, they supply revenues for public purposes such as education, health care, and defence. Second, they create incentives to engage in certain kinds of behaviour and not others, with tax breaks for business investment and so-called sin taxes that raise the price of alcohol and tobacco being the most obvious example. Third, the way in which tax revenues are raised – how and from whom – can moderate (or, in some cases, magnify) trends in income and wealth inequality. As noted in an earlier posting, like many other countries Canada has conspicuously retreated from using taxes to moderate market-driven patterns of income inequality.

Canada faced a serious fiscal crisis in the 1990s. A combination of sustained growth in the United States, our major trading partner, and far-reaching spending cuts in successive federal budgets starting in 1995 turned a federal deficit of $42 billion in 1993-94 into a balanced budget by 1997/98. However, having balanced the budget both the Liberal governments of Jean Chrétien and Paul Martin and (especially) their post-2006 Conservative successors made a momentous choice: reducing income taxes, and eventually the GST, rather than reinvesting in social provision and economic infrastructure. By 2010, the federal government was claiming that its policies would reduce tax revenues "by an estimated $220 billion over 2008-2009 and the following five fiscal years" (1, p. 49). Clearly, the authors of the budget thought such reduction of fiscal capacity was a good thing.

Provincial governments, notably in Ontario and British Columbia, followed a similar route, with the benefit of tax cuts concentrated among their wealthiest residents. Ontario government figures showed that between 1995 and 1998, the richest one per cent of Ontarians (with incomes above $177,000), saw their annual tax bills drop by an average of $10,785 (2). When the BC liberals came to power in 2001, they followed a similar course, with provincial income tax reductions worth $644 a year to a resident earning $40,000 a year, but $7,797 to her senior manager paid five times that amount (3). A subsequent tax cut, in 2007, was calculated based on provincial budget figures to be worth $82 per year to a British Columbian with a taxable income of $20,000, but ten times that to a taxpayer with an income over $100,000 (4).

What were the consequences? According to the Organisation for Economic Co-operation and Development, tax revenues of all levels of government in Canada added up to 32 per cent of our Gross Domestic Product (GDP) in 2009, the lowest proportion since 1980. To put these figures into perspective, between 1990 and 2000 the figure never fell below 35 percent, and total tax revenues in the Nordic welfare states are between 42 and 48 percent of GDP. As noted in an earlier posting, these countries have child poverty rates lower than 5 percent on a standard cross-national comparative measure, according to the Luxembourg Income Study; Canada's are over 15 percent. The OECD estimated Canadian central (i.e., federal) government revenues at 13.3 per cent of GDP in 2009, the lowest proportion since the mid-1980s.

Public discussion of the opportunity costs and social and health consequences of these reductions in fiscal capacity, which international relations scholar Richard Falk has called "the social disempowerment of the state" that "follows from the impact of neoliberal ideas" (5), has been effectively nonexistent in Canada; we have been let down on this point by political leaders of every stripe. Going back to Ron Labonté's long-ago exercise, quoted in the preceding posting, we ought to ask what Canada's governments might do with just that additional 3 percent of GDP (about $40 billion) in lost fiscal capacity. Invest more in early childhood education and care – an area where, according to UNICEF's Innocenti Research Centre, Canada lags behind almost every other wealthy country? (The report in question identified ten "minimum standards for protecting the rights of children in their most vulnerable years," and found that Canada met only one of them.) Reduce the child poverty that Parliament declared its intention to eliminate, way back in 1989? Finance dental care for the poor? And what might be accomplished if we were willing to raise governments' share of GDP even a few more percentage points closer to the levels that are commonplace in much of Europe? (This would not be a matter just of raising income and payroll taxes. The tax on gasoline in every country in what used to be called western Europe is far higher than in Canada, and even drivers in middle-income Chile pay more per litre than Canadians, according to figures from the International Energy Agency.

Priorities-part-2-pic-1-gasoline-prices-table

I am not making a blanket argument for bigger government; many areas of public spending could and probably should shrink. Prisons, fighter aircraft and the salaries of senior university administrators come readily to mind; we all have our own lists. In this posting and the preceding one, I have made the argument that the resources available to Canadians are more than sufficient for any objective related to social determinants of health that we might reasonably wish to accomplish. When we are told that such objectives are unaffordable, the real message is either (a) that other areas of spending are more important, or (b) that tax cuts are more important. The more value any society assigns to tax cuts, the harder the choices it will have to make about spending priorities in the public sector, and their direct and indirect impacts on health equity.

 

  1. Department of Finance Canada. Budget 2010: Leading the Way on Jobs and Growth. Ottawa: Department of Finance Canada; 2010.
  2. Ontario Jobs and Investment Board. Report to Taxpayers: Jobs and the Economy. Toronto: Government of Ontario; April 1998.
  3. BC Ministry of Finance figures cited by Lunman K. New B.C. Premier Slashes Income Taxes for all Residents in First Day on the Job. The Globe and Mail, June 7, 2001.
  4. Murray, Stuart. Who Gets What from the 2007 BC Tax Cut? Vancouver: Canadian Centre for Policy Alternatives; May 2007.
  5. Falk RA. Human Rights Horizons: The Pursuit of Justice in a Globalizing World. New York and London: Routledge; 2000.
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It's all about priorities: How to think about health equity, part 1 – expenditure budgets

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 10 January 2012
in CHNET-Works!

The Commission on Social Determinants of Health made a compelling case that the "unequal distribution of health-damaging experiences is not in any sense a 'natural' phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics." Serious efforts to reduce health inequity by way of public policy must start with the budgetary priorities of governments at every level: what they spend money on, what they reject as unaffordable, and what they don't even think about.

More than 20 years ago Ron Labonté, then president of the Ontario Public Health Association and now a professor and former colleague at the University of Ottawa, published an article in the Canadian Journal of Public Health asking whether health care spending might not actually be creating risks to health, diverting resources from expenditure objectives that might actually lead to higher returns in terms of health outcomes. He pointed out that the $350 million increase in funding for hospitals' capital spending provided for in the 1990-91 Ontario provincial budget could, if used for other purposes, have financed 70,000 rent-geared-to-income housing units, 547,000 more subsidized daycare spaces, or 12,750 transition shelter beds for battered women and their children.

With 20/20 hindsight, this approach was both creative and destructive. It was destructive in that it positioned health care and investments in social determinants of health as direct competitors for resources. Tactically, this is a battle those of us concerned with how conditions of life and work affect the health of people with limited resources will always lose, and perhaps we should: even in countries that supposedly provide universal access to health care, such people all too often end up at the back of the queue.

The approach was nevertheless creative in that it directed attention to the broader question of how governments spend the considerable resources at their disposal, with what consequences for health. Any serious effort to implement a Health in All Policies approach, or similar rubrics that have been proposed for reducing health inequities, requires a hard look at local, state or provincial, and national budgets. These are nothing more or less than the roadmap of governmental priorities and therefore in democratic societies, at least in theory, the priorities of a decisive plurality of voters. As governments across Canada prepare budgets that must deal with the continuing fallout from the economic meltdown of 2008, this point should be kept in mind.

Priorities-part-1-pic-1-Ottawa-freeway-1-of-1What do recent budgets tell us about those priorities? Let's look at a few examples. Canada's national government has adopted changes in the criminal law that will cost billions of dollars to implement, roughly doubling federal and provincial spending on jails and prisons between fiscal 2009/10 and 2015/16 according to the Office of the Parliamentary Budget Officer, on the basis of what must charitably be called limited evidence of need or effectiveness. Apparently, criminal law doesn't need to be evidence-based, or meet any clear standard of cost-effectiveness. The Minister of Justice himself has said that "[w]e're not governing on the basis of the latest statistics," and that the government does not "put price tags in legislation". Late last year, the national government also found $477 million to contribute to building US military satellites. Here in Ontario, it's often arithmetically impossible to eat a healthy diet on a low income if you're paying market rents and more than 150,000 people are on waiting lists for affordable housing, yet the same day that figure was published the province found $200 million to widen a freeway through downtown Ottawa.

Somehow, my search for loonies in jacket pockets never turns out quite that well. Isn't magic wonderful?

Now, obviously governments have to balance a multitude of competing priorities, and health is only one of them. The point of the examples is that the tension of greatest concern is not necessarily between health care and 'upstream' interventions, and that all too often, ensuring that everyone has the same opportunities to lead a healthy life – what health equity is about – is far down the list.

Driving changes in budgetary priorities is essential to reducing health inequity, and will require more of the kind of creativity shown in Labonté's long-ago article. Public health associations could commission or carry out health equity impact assessments (HEIAs) of municipal, provincial and national budgets. Enterprising professors could ask their graduate students to do the same as a course assignment or group project. (To its considerable credit, Ontario's Ministry of Health and Long-term Care now has an internal HEIA process, but it only applies within the health system – arguably, not where HEIA is most needed.) And all of us concerned with health equity will need to forge individual and organizational alliances far beyond our usual institutions, communities of practice and comfort zones.

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“Divided we stand”: OECD on inequality, and reasons for caring

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 January 2012
in CHNET-Works!

The Organisation for Economic Co-operation and Development (OECD) is a group of high-income (and some middle-income) countries that historically has paid attention mainly to conventional economic indicators such as growth, productivity and innovation. It does other things as well, including providing some of the best statistical overviews and assessments of its members' foreign aid performance. And recently, it has been addressing the consequences of increasing economic inequality within the borders of many of its members.

Divided-we-stand-pic-1Ermenegildo Zegna Boutique in Chile, one of the OECD’s most unequal countriesA December 2011 OECD report provides a description of those increases, an analyses of their causes, and country-by-country data that have some sobering implications for Canada. The report finds that income inequality increased in most OECD countries over the past three decades, although the level of inequality varies widely. The average income (adjusted for household size) of the richest 10 percent of the population is 5 or 6 times the average income of the poorest 10 percent in the Nordic countries, but 10 times that of the poorest in Canada, 14 to 1 in the United States, and 27 to 1 in Mexico and Chile. The report identifies a number of contributors to rising inequality of market incomes, including several aspects of globalization; technological change (which to the authors' credit it describes as hard to disentangle from globalization); changes in hours worked, which have favoured higher earners; and changes in household structure.

There is much room for debate here, notably about the role of globalization and the reasons for rising labour market incomes at the top of the income distribution, which have played a major role in increasing inequality, but also about the OECD's view that inequality can be reduced through raising workers' educational levels. This is worth doing, but effects on inequality are likely to be offset by growth in the kinds of work susceptible to 'offshoring'. For policy purposes, a point of particular interest is how taxes and benefit systems change the distribution of income, and how their effect varies across countries and over time. Like earlier analyses, the report points out that taxes and benefits in some countries (many in Continental Europe) are more strongly redistributive than in others (like the United States and Chile). Generically: "Until the mid-1990s, tax-benefit systems in many OECD countries offset more than half of the rise in market-income inequality. However, while market-income inequality continued to rise after the mid-1990s, much of the stabilizing effect of taxes and benefits on household income inequality declined."

The country note for Canada points out that the share of all income flowing to the richest 1% of Canadians grew from 8.1% in 1980 to 13.3% in 2007 – a trend that closely parallels an even more extreme pattern in the United States, where the income share of the top 1% is now higher than at any point since the Great Depression. (Readers interested in exploring comparative trends in top incomes may want to explore the World Top Incomes Database.) The OECD also points to the declining redistributive effect of Canadian taxes and transfers – a point made a few years ago in a Statistics Canada study, which observed: "Redistribution grew enough in the 1980s to offset 130% of the growth in family market-income inequality -- more than enough to keep after-tax income inequality stable. However, in the 1990-to-2004 period, redistribution did not grow at the same pace as market-income inequality and offset only 19% of the increase in family market-income inequality." The OECD note identifies a somewhat less dramatic retreat from redistribution, reflecting the fact that many ways of doing such calculations exist - for example, the OECD study restricted its analysis to the population aged 15-64 - but the general trend is clear.

Why should population health researchers be concerned with rising economic inequality? There are several reasons, most of which are familiar. First, rising inequality may lead to increases in poverty, however it is defined, although that is not necessarily the case. Second, socioeconomic gradients in health usually exist across the entire income spectrum. Intuitively, we would expect these gradients to be steeper when economic gradients are also steeper, other things being equal, although this is a difficult proposition to test because of the impact of policies that do not directly affect income distribution. Third, income inequality is only part of the story: wealth inequality, which the OECD study did not address, is normally greater than income inequality, and insecure and precarious jobs (which have their own health implications, including higher exposure to on-the-job hazards) are concentrated at the bottom of the income scale. Fourth, it is argued – notably by Richard Wilkinson and colleagues – that higher levels of economic inequality within a society lead to overall lower levels of health, although the mechanisms of action remain unclear.

Divided-we-stand-pic-2Photo by Paul Keller, reproduced under a Creative Commons LicenceA final reason has received less attention in the context of health policy; it involves a phenomenon that former US Cabinet secretary Robert Reich called the "secession of the successful". Past a certain high level of income and wealth, people need less from government, and different things. As one Arizonan interviewed for an article on politics in that state put it: "People who have swimming pools don't need state parks. If you buy your books at Borders you don't need libraries. If your kids are in private school, you don't need K-12. The people here, or at least those who vote, don't see the need for government." To which we could add: people who can afford to drive or fly everywhere don't need public transportation; people with secure incomes gain little from public financing of social or subsidized housing; people who could afford private insurance may resist paying taxes to keep a public health insurance system afloat for the less healthy and less wealthy; and so on.

What happens to the political prospects for reducing health inequity by way of social policy when a small but highly influential segment of the population needs government mainly for roads, police and prisons – and perhaps regards enhancing its own security through private purchases as routine? I recently returned from a workshop in Johannesburg, one of several South African cities that are more economically unequal than any other developing world cities included in United Nations Human Settlements Programme study (p. 73). The workshop was held in a guest house with an electronically activated gate, in a suburb where many properties were fenced with razor wire, and almost every one boasted a private security service's "armed response" sign. This is commonplace in South African cities. From Arizona to South Africa, does the interaction of inequality and privatization suggest a self-reinforcing process that can only be reversed through internal revolt or catastrophic external events (think the Great Depression and the second World War)? Health economist Robert Evans, quoted in a previous posting, wonders: "If we are back to a pre-war income distribution, how much of our post-war social policies can survive?" We should pay more attention to this question.

1The Gini coefficient, a standard measure of income inequality, in Johannesburg is 0.75 according to this study – more unequal than the national distribution of income in any country in the world. By comparison the Gini coefficients in Mexico and Chile, the two most unequal countries in the OECD, were 0.494 and 0.476 in the late 2000s, according to the OECD.

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