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Diabetes in Canada: Parts of the story

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 04 January 2012
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Shortly before this past Christmas, with minimal publicity, the Public Health Agency of Canada released a valuable collection of facts and figures on Diabetes in Canada. It points out (for instance) that in the decade after 1998/99, the prevalence of diabetes among Canadians increased by 70 percent (to 2.4 million), with a predicted increase in prevalence to 3.7 million by 2018/19. Further, "although only 3.1% of all deaths in Canada were attributed to diabetes in 2007, more than a quarter (29.9% of individuals who died had diabetes in 2008/09. Diabetes itself does not typically lead directly to death, but the complications associated with diabetes do." Thus, prevalence figures substantially understate its overall contribution to the burden of illness borne by Canadians; that contribution includes cardiovascular disease (the most frequent complication), eye disease, kidney disease, increased infection from minor injuries and a variety of other conditions.

Diabetes-posting-pic-1Healthy food choices: not always availableThe report's importance in drawing attention to the magnitude of the diabetes-related burden of illness is beyond question, yet its contribution to understanding that burden from a health equity perspective is limited. For the most part the authors adopt a conventional risk factor approach to the causes of diabetes, starting (predictably and non-controversially) with a description of overweight and obesity, and the contributions of limited physical activity and unhealthy eating. A list of self-reported barriers to physical activity is reproduced, as is a list of factors influencing food choices that includes nutritional knowledge, perceptions of healthy eating, media advertising and "lower socio-economic status and social inequity," which is not further explored.

The report's treatment of socioeconomic gradients is similarly descriptive, confined to gradients among adult Canadians across Canada, stated by income quintile and education level, in self-reported obesity, physical inactivity, inadequate fruit and vegetable consumption, and daily tobacco smoking. Curiously, data on socioeconomic gradients in actual prevalence of diabetes are not presented, although according to Canadian Community Health Survey data prevalence of Type 2 diabetes in the lowest household income group (income less than $15,000) is more than four times as high as in the highest income group (over $80,000). According to the authors of this last study, "individual risk behaviours do not explain a substantial part of the income association," suggesting "that the diabetes burden associated with poor health behaviours should be looked at through the lens of socioeconomic conditions."

Diabetes-map-1Age- and sex-adjusted diabetes prevalence per 100 persons of all ages, Toronto, 2001-02. Source: Booth GL, Creatore MI, Gozdyra P, Glazier RH. Diabetes in Toronto, Chapter 2: Patterns of Diabetes Prevalence, Complications and Risk Factors. Toronto: Institute for Clinical and Evaluative Sciences; 2007. Reproduced by permission.

 

Diabetes-map-2Average annual household income, Toronto, 2000. Source: Creatore MI, Gozdyra P, Booth GL, Ross K, Glazier RH. Diabetes in Toronto, Chapter 3: Socioeconomic Status and Diabetes. Toronto: Institute for Clinical and Evaluative Sciences; 2007. Reproduced by permission.

Finer-grained examinations of how socioeconomic conditions affect the origin, management and prognosis of diabetes can be found in several places. The Toronto diabetes atlas project of the Institute for Clinical Evaluative Sciences produced a multi-volume mapping of diabetes prevalence and a range of neighbourhood characteristics; just two of the 140 maps generated by the project are shown here. To oversimplify a complex set of findings, the project found that higher-income neighbourhoods generally had lower prevalence of diabetes. Prevalence was especially high in low-income neighbourhoods outside the downtown core, with high proportions of recent immigrants and members of recent minority groups. These neighbourhoods tended to have lower population densities, poor walkability, limited access to public transit and long distances to stores selling fresh fruits and vegetables (the 'food desert' problem) and other so-called healthy resources like parks. Conversely, high incomes seemed to have a protective effect against diabetes, even in neighbourhoods where adverse outcomes would be expected based on place-related characteristics. "We noted a striking mismatch," the authors concluded, "between areas of Toronto where healthy resources were most needed and where they were located."

Diabetes-posting-pic-2Activity-friendly urban environments like this may be inaccessible to people in low-income neighourhoodsThere is also, as I have pointed out in previous postings, the simple arithmetic impossibility of eating a healthy diet for many people living on low incomes if they are also paying market prices for housing. Indeed, a series of interviews by York University's Dennis Raphael and colleagues (1) with people trying to manage diabetes in Toronto on incomes below Statistics Canada's Low-Income Cutoff (LICO) found food insecurity and inability to afford an adequate diet widespread "even with almost two-thirds [of participants] living in some form of government-assisted housing or shelter." Two recent articles (2,3) by Claudia Chaufan and colleagues similarly explore the interaction of low incomes, limited availability (and high local prices) of healthy food, high transportation costs and other variables like insecure employment in a Latino and immigrant neighbourhood in Northern California, concluding that structural factors limit the relevance of health and lifestyle education interventions – a point that should by now be familiar, but nevertheless merits continued repetition. One interview respondent summed up the range of problems: "You know, it's a full time job to be poor."

Variables like those identified in the Toronto and Northern California studies are not prominent in the PHAC report, beyond brief generic discussion of healthy food choices and of the built environment. New York-based researchers Rodrick and Deborah Wallace have eloquently compared individualized explanations of obesity that focus on imbalance between caloric intake and exercise to "the remark by US President Calvin Coolidge on the eve of the Great Depression that 'unemployment occurs when large numbers of people are out of work' ... and as Raphael pointed out in a holiday posting on his Social Determinants of Health listserv, the word "poverty" appears nowhere in the PHAC report. (I checked; it doesn't.) That report remains useful, yet at the same time shows how very much still needs to be done to integrate social justice and social determinants into the everyday worldview of public health professionals.

 

(1) Raphael D, Daiski I, Pilkington B, Bryant T, Dinca-Panaitescu D, Dinca-Panaitescu S. A toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics: the experiences of poor Canadians with Type 2 diabetes. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).

(2) The Twin Epidemics of Poverty and Diabetes: Understanding Diabetes Disparities in a Low-Income Latino and Immigrant Neighborhood. Journal of Community Health 2011;36:1032-43, (full text unfortunately not available for open access).

(3) Chaufan C, Constantino S, Davis M. 'It's a full time job being poor': understanding barriers to diabetes prevention in immigrant communities in the USA. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).

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“Logics of expulsion”

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 09 December 2011
in CHNET-Works!

saskia-sassen-picAt the Global Health Conference in Montréal last month, I had the privilege of being on a panel with Saskia Sassen, the Robert S. Lynd Professor of Sociology at Columbia University. She is one of the most intellectually sophisticated scholars writing in English (and indeed in various other languages) about how globalization is transforming societies rich and poor alike – and in the process affecting who has the chance to live a long and healthy life.

Saskia Sassen is perhaps most closely identified with her research on the global cities (New York. London, Tokyo) that function as command centres for the world economy. Her subsequent research expanded, in various ways, on how global reorganization of production and (especially) finance has redistributed power. In a 1996 book called Losing Control? Sovereignty in the Age of Globalization, she wrote about the shift of power from citizens to unaccountable coalitions of investors who comprise "a sort of global, cross-border economic electorate, where the right to vote is predicated on the possibility of registering capital." In the preceding year, a Wall Street Journal editorial warned financial markets of the need for "dramatic action" in the federal budget; political scientist Donald Savoie argues that this warning played a major role in the $29 billion in federal spending cuts that followed. At a time when bond markets and credit rating agencies have more say over the fate of many European governments than their own electorates, Sassen's observation is more important than ever.

Her most recent project is even more relevant to population health. She argues that contemporary globalization is generating "a savage sorting of winners and losers" within as well as across national borders, continuing and intensifying a pattern that began with the use of structural adjustment programs – familiar to many in the global health field – as a "disciplining regime" in the aftermath of debt crises. More specifically, she describes new and often brutal "logics of expulsion". One of these involves the phenomenon of land grabs: large-scale purchases or long-term leases of productive agricultural land by food-importing countries or transnational agrifood corporations. North American media have been predictably silent on this topic, but it has received considerable coverage in The Guardian, which is the English-language paper you need to read if you really want to know what is going on in the world.

Another logic of expulsion arises from the aftermath of the 2008 collapse of the market for securities backed by sub-prime mortgages. In a remarkable video of a presentation to a September, 2011 homelessness conference (basically a longer version of her Montréal presentation), Sassen points out that subsequent foreclosures in the United States have created a largely invisible army of close to 30 million displaced people, including many who were renting properties that were foreclosed. The state, through law, has been an active participant in these expulsions. We have, as she points out, gone far beyond the anodyne language of social exclusion that has recently become popular in some social and health policy circles.

Sassen also makes the critical point that profits made from the securities in question were completely unrelated to whether or not the people originally taking out the mortgages had any hope of making the payments; profits were made, rather, by packaging and selling on the mortgages. Predictably, homelessness – which is not good for your health – is on the rise in the United States. Another illustration of the consequences of the crisis in the country where it originated: in September 2011, a record one in seven Americans was receiving the food vouchers commonly known as Food Stamps, and millions more were eligible. Like the proliferation of foreclosures, this new pattern of impoverishment can be traced directly to domestic and international policy choices designed to create new profit centres in the global financial services industry, on the principle that markets know best.

glittering-towers-pic
Photo by Joseph Bergantine,
licensed under a Creative Commons United States licence

In intellectual terms, the events of 2008 confirmed that idea's zombie status (as Bob Evans, featured in my previous posting, would say), but the zombie masters have revived it with frightening tenacity. The statistics from the United States also show that the study of globalization and health can no longer focus on distant countries 'out there'. In the future, wherever we are in the high-income world (think about the 46 percent youth unemployment rate in Spain), globalization's casualties will live among us, sometimes literally in the shadows of the glittering towers where globalization's winners live, work and play.

I have only scratched the surface of Saskia Sassen's work, but have tried to show why everyone concerned with health equity should consider it indispensable. Read it, and you'll quickly understand why the December, 2011 Foreign Policy "top 100 global thinkers" features her as the first sociologist to make the list.

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What's it like to be poor in Canada?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 09 December 2011
in CHNET-Works!

For many Canadians who have fallen through the cracks of our increasingly unequal economy and frayed social safety nets, this festive season is anything but. CBC radio's The Current recently aired a multi-part series on being poor in Canada. The first part of the series addressed such issues as child poverty and the fact that the poor pay more for a range of goods and services, from food to banking. This was followed up with two call-in sessions that ran in every time zone; the second session featured political leaders including social service ministers from Nova Scotia, Ontario, Manitoba and Alberta. At least for the moment, audio of all the programs is available by clicking on the hyperlinks. More soon on a new OECD report that documents the 30-year increase in economic inequality in most of the high-income world.

Tags: economic, poverty
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Robert G. Evans: An Appreciation

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Thursday, 01 December 2011
in CHNET-Works!

evans-photo-1Few people who have heard University of British Columbia health economist Bob Evans speak will forget his formidable intellect, ruthless wit and remarkable knowledge of Dickens. A younger generation of population health researchers and practitioners may not realize the extent of his contribution to the study not only of health systems but also of what are now called social determinants of health – notably, as director of the Population Health Program of the Canadian Institute for Advanced Research from 1987 to 1997. (Unfortunately, that program has now been discontinued.)

A classic 1990 article that he wrote with Greg Stoddart – "Producing Health, Consuming Health Care" - contrasted the "reactive" orientation of health care with "the egregious fact that people are suffering, and in some cases dying, as a consequence of processes not directly connected to health care," a fact that "elicits neither rebuttal nor response." Plus ça change, one is tempted to say.

Evans and Stoddart described conventional thinking about health and health care in terms of a model "analogous to a heating system governed by a thermostat." If the room gets cold, or the prevalence of illness and injury increase, we turn up the thermostat or increase the flow of resources to health care. Seldom do we consider the efficiency of the furnace; redesigning the envelope of the building is off the radar (perhaps now even more than when the article appeared). Less frequently cited, but equally important, is their critique of the emphasis on individual risk factors (and on lifestyle change) in the nascent field of health promotion, which they presciently viewed as expanding "the 'product line' of the health care system" and serving "to maintain and protect institutions and ways of thinking about health."

These are gross oversimplifications of nuanced arguments, but they make my point about the importance of this contribution to the literature.

Equally memorable is Evans and colleagues' description of advocates of user charges and other incremental introductions of private finance into the health care system as "zombie masters": people with an interest in resurrecting ideas that "may be intellectually dead but are never buried." User charges under whatever name, they pointed out, "serve primarily to move money from one set of pockets to another" – an application of three axioms that are central to Evans' work, and to understanding the value of a political economy perspective on health policy. (Full disclosure: political economy is my own disciplinary background, and many years of research have strengthened my commitment to following the money as a starting point for social scientific explanation.)

First, health systems can be analyzed in terms of three basic questions: Who pays? Who gets (services)? Who gets paid?

tmc-pictureSecond, and relatedly, as "an accounting identity, expenditure on health care is exactly and precisely equal to incomes earned in health care", whether they are the incomes of care providers, pharmaceutical manufacturers, or insurance company shareholders and employees. In the United States, with the most expensive health care in the world, you can observe the payoffs from a system driven by the economic interests of the health care industry. The glittering towers of medical complexes like the one shown here are almost as tall and shiny as the banks.

Third, decisions about health policy have distributional consequences. Health financing regimes like Canada's that rely mainly on general tax revenues redistribute resources from the relatively healthy and wealthy to the unhealthy and less wealthy, and even if the tax system is only modestly progressive the degree of redistribution can be quite substantial. Critiques of Canada's public health insurance systems as "unsustainable" and arguments that private financing should play a larger role have no basis in actual patterns of expenditure. Rather, Evans sees them as efforts to advance an inegalitarian agenda, based on a sound understanding of the redistributive nature of tax-financed public health insurance: the wealthy aim to reduce the tax burden associated with financing for others the standard of care to which they themselves aspire. He further shows that growth of public spending on health care as a percentage of government budgets cannot be separated from events on the revenue side: tax reductions that have disproportionately benefited the affluent. "Had provincial governments not chosen to use the reviving economy as an opportunity to cut tax rates, the share of aggregate provincial revenues devoted to health care would in 2005/06 have been very slightly below its level in 1982/83, over twenty years previously." At least before the economic crisis of 2008, then, governments were suffering from self-inflicted fiscal wounds. Today's continued reluctance to think about raising taxes on the rich suggests that they are still in denial on that point.

There is more. Evans and colleagues have long challenged the claim that population aging will create unsustainable pressures on health systems, pointing out that aging per se accounts for only a small proportion of increases in health care costs. The Canadian Institute for Health Information recently made this point as well, but without Evans' magnificent image of the zombie of "apocalyptic demography," turned loose as convenient. Perhaps the "natural alliance of economic interest between service providers and upper-income citizens to support shifting health financing from public to private sources" described in one of Evans' most relentless critiques of the thoughtless application of textbook economics to real-world health systems has simply found a new fear-inducer for public relations purposes.

As Canadians watch the negotiation of a new federal-provincial-territorial accord on health financing (someday I will write a posting on getting undergraduate political science students excited about fiscal federalism) while the European Union readies itself for the 2012 Year for Active Ageing and Solidarity between Generations (and yes, solidarity is the word used on the official web site), we would do well to think about the implications.

There is still more. Understanding the politics of social determinants of health means coming to grips with how today's rapid growth in incomes at the top of the economic scale strengthens proponents of the inegalitarian agenda throughout the political process, not only with respect to health systems. Evans wonders: "If we are back to a pre-war income distribution, how much of our post-war policies can survive?" This is the topic of a three-part posting to follow shortly. Meanwhile, readers not yet familiar with Bob Evans' work have a treat in store as they encounter his rare analytical gifts and a style that is the antithesis of the anodyne prose found in much academic writing. So much the better, say I.

See also:

Evans RG. Financing Health Care: Taxation and the Alternatives. Chapter 2 of Mossialos E et al, eds. Funding Health Care: Options for Europe (2002). Buckingham: Open University Press.

Evans RG, Stoddart, GL. Consuming Research, Producing Policy? American Journal of Public Health 93 (2003): 371-379.

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First snow, and a New York state of mind

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 29 November 2011
in CHNET-Works!

aging-blog-snowThe first snow of winter came (briefly) to Ottawa last week. Snowball-fighters were thrilled, but for the growing number of our senior citizens and for other people whose mobility is limited the snow was less welcome. It foreshadowed months during which routine errands are more difficult and worry about painful and disabling falls can't be avoided because the city – like every other municipality in Canada that I know - gives low priority to such activities as sidewalk and bus stop snow clearance. The winter weather that is just an inconvenience for some of us acts like a set of prison bars for others.

I mention this small-scale, but important example to introduce questions of how to adapt our cities and the choices that shape them to the health needs of an aging population and, more generally of how to make the metropolitan environments that are home to four out of every five Canadians more inclusive and health-positive. In a book published in 2000, a research team led by two Canadian researchers (Richard Stren, now retired from the University of Toronto and Mario Polèse, now at l'Institut national de la recherche scientifique in Montréal) looked at the "social sustainability" of ten cities, in countries as diverse as Canada and El Salvador. They defined social sustainability, which is an admittedly imprecise concept, in terms of "social integration, with improvements in the quality of life for all segments of the population" (emphasis added).

Taking health equity seriously in the metropolitan context means reorganizing many of the choices we make about cities around social sustainability. To understand the consequences of failing to do this, consider Eric Klinenberg's "social autopsy" of a 1995 heat wave that killed more than 700 people in Chicago: fear of crime kept seniors on low or moderate incomes, in particular, socially isolated and barricaded into apartments where they could not afford air conditioning, while a downsized city government failed to link residents with services that could have saved their lives. In a less extreme example, Ottawa-based researcher Theresa Grant found that older people in less wealthy neighbourhoods of the city are more affected by traffic hazards, and face greater challenges in creating walkable space.

Outcomes of this kind are not inevitable. Like many other influences on health inequity, they reflect how we choose to use the resources and institutions available to us. A 2008 New York Academy of Medicine report provides a valuable illustration of how to start doing better, and of why the intersectoral action I wrote about in my previous posting is so important. The authors used a variety of existing data sets to map neighbourhood characteristics like the relative affordability of housing, the characteristics of housing (walk-up buildings present special difficulties for many seniors; so do buildings where the elevators are few or unreliable), the distance to the closest bus stop, and walkability across the city's five constituent boroughs, and to make suggestions for improvement. The World Health Organization, with support from the Public Health Agency of Canada, has created a Global Age-Friendly Cities Guide that provides checklists for outdoor spaces and buildings, transportation, housing, social inclusion, community support and health services. In 2010, WHO launched a Global Network of Age-Friendly Cities, which was the topic of a conference this past September in Dublin; members of the Network have committed to continually assessing and improving their age-friendliness. New York was the first city to join the Network, which now has several Canadian members including London, Waterloo and Welland in Ontario; Saanich in British Columbia; and Edmonton in Alberta.

The Network is a promising and exciting initiative that merits active engagement on the part of Canadian researchers, practitioners, and governments. It could be immensely valuable in identifying evidence-based best practices in metropolitan design and policy – a task that is politically fraught, but essential if decision-makers (and those who elect them) are to have clear performance benchmarks and create incentives for continuous improvement. Meanwhile, whether or not their cities are part of the Network, local and regional public health units can become actively engaged in debates about issues far outside their 'silos'. The coming of winter tells us that they can start with thoroughly mundane questions of servicing priorities: is one more plowing of arterial roads really more important than clearing sidewalks of snow and ice in neighbourhoods where seniors live and which they must navigate? But the questioning must not end there.

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