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Sir Michael Marmot on social determinants of health: Blending evidence and passion

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 20 February 2013
in CHNET-Works!

On an unseasonably warm day in May 2012, Sir Michael Marmot came to Canada for a short visit with the Public Health Agency of Canada and the University of Ottawa, supported by the CIHR Institute of Population and Public Health. His presentation at the University of Ottawa, from which we present video excerpts here, is simultaneously a succinct and a passionate defence of the social determinants of health agenda and its ethical foundations.

Sir Michael is introduced by the Hon. Monique Bégin, a former Canadian Minister of Health and Welfare and a member of the Commission on Social Determinants of Health. She comments that: "Canada ... is so wealthy, despite the scary global economic times, that it manages to mask the reality of poverty, social exclusion, discrimination, employment erosion, mental health, and youth suicides. While one of the world's biggest spenders on health care, we have one of the worst records when it comes to providing an effective social safety net."

The first part of Sir Michael's presentation offers a bit of anecdotal history about the internal processes of the commission. He then makes two main points. First, he is hopeful that the Commission's report may be one of a few international commission reports, like that of the Brundtland Commission on sustainable development (1987) that have a real impact. At least, he says, officials like Commonwealth ministers are talking the language of social determinants of health. Second, he distinguishes the economic case for acting on social determinants of health from the moral case, based on social justice. In words that echo the long-ago wisdom of Anatole France, he concludes that: "The freedom to wallow in poverty," or to be unemployed, "is not a freedom that is much prized."

In the next part of his presentation, Sir Michael emphasizes the importance of the Commission's focus on inequalities of power, money and resources. He goes on to describe history of the British strategic review on health equity, which he also chaired, and its organization around a lifecourse framework; his efforts to advance interest in social determinants of health as president of the British Medical Association; and how initial cynicism was transformed into enthusiastic takeup of his message about the importance of social determinants of women's health among British obstetricians and gynecologists.

Finally, Sir Michael argues that social protection policy matters for health. "The greater the social spending, the lower the all-cause mortality, for 18 EU countries." And he explains a remarkable initiative by the Merseyside Fire & Rescue Service (that's Liverpool, for readers too young to remember where the Beatles came from) to address social determinants of health by helping people apply for grants to improve their housing, quit smoking and increase their levels of physical activity using the gymnasia at fire stations. He ends with the observation that "We are involved in an intensely ethical concern. We are trying to get a more just society."

 

What can we in Canada learn from this presentation? That could be a long disquisition, but the short version is: blending evidence and passion matters, and we have too few leaders in population health and health social science who are capable of doing so.

Acknowledgements: Many thanks to CIHR's Institute of Population and Public Health for offering these video files.

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Is concern about economic inequality going mainstream?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 19 February 2013
in CHNET-Works!

In a previous posting, I recommended a recent report on economic inequality in The Economist. In its special reports, at least, that magazine has a strong track record of ‘telling it like it is’. Back in 2006, for example, a special report on the world economy admitted that “the usual argument in favour of globalisation–that it will make most workers better off, with only a few low-skilled ones losing out–has not so far been borne out by the facts. Most workers are being squeezed.” And in 2011, The Economist pointed out that Congressional Budget Office figures from the United States support the contention “that the people at the top have made out like bandits over the past few decades, and that now everyone else must pick up the bill.” Now, more evidence suggests that concerns about economic inequality are moving into the mainstream, in Canada and elsewhere.

One of the Occupy movement’s accomplishments has been to direct attention to the growing gap between people at the very top of the income distribution in societies like Canada and the United States – the one-percenters – and the rest of the population. In January 2013, Statistics Canada released updated figures based on tax return data about Canada’s one percenters: based on income, they were those with annual personal incomes above $201,400. These figures refer to individual incomes, not family incomes; a University of Regina Study published in 2012 found that in 2009, the top one percent of “economic families” as defined by StatsCan had wage and salary income (i.e. not including interest, dividends or capital gains) of more than $271,800. The two sets of figures are not directly comparable, since they are based on two different data sets and the Regina figures are restricted to labour income. Yet another analysis, which included all forms of income, identified the top one percent of households (the definition is similar to that of economic families, but not identical) as those with incomes over $366,717 in 2010. More strikingly, the top one percent of households in this analysis accounted for 10.5 of all the income earned by Canadians. All these data refer to income and not to wealth, which most researchers agree is more unevenly distributed than income.

Considerable ideological distance separates Occupiers from the business-oriented Conference Board of Canada, yet the Conference Board has recently expressed considerable concern about Canadian inequality. In an online report card that compares Canadian social policy with that of 16 other high-income countries, it notes that Canada “is not living up to its reputation or its potential” and that “Canada’s ‘D’ grade on the poverty rate for working-age people, and its ‘C’ grades on child poverty, income inequality and gender equity are troubling for a wealthy country.”   The report offers links to more detailed information on various specific domains, such as child poverty (where Canada ranks 15th, ahead only of Italy and the United States); working-age poverty (again, we are 15th, ahead only of Japan and the United States, and not by much); poverty among the elderly (one of Canada’s social policy success stories, but now arguably imperiled by population aging and the fact that only one in four private sector workers has a pension plan); and income inequality (rising, with a “concentration of income among the super-rich”). Despite Canada’s overall “B” grade on social indicators, which cover much more than income (and do not address concentrations of wealth), the overall pattern of increasing inequality is clear. So is the fact that other countries do much more than Canada to reduce income inequality by way of taxes and transfers.  

Perhaps an even less likely source of concern about inequality is the World Economic Forum. Yet the eighth (2013) edition of a Forum report on “global risks,” based on “an annual survey of over 1,000 experts,” estimates that severe income disparity is the most likely of any of the 50 risks studied to occur over the next ten years, and that a major systemic financial failure is the risk with the highest potential impact. (The economic processes driving inequality and magnifying financial risk are of course closely connected, as we know from the events of the last five years.) The simple fact that the report’s authors consider severe income disparity as a global risk says a lot. In the global frame of reference, further gloom about prospects for reducing health inequity comes from the fact that water supply crises are rated as having both high likelihood and high impact, and food shortage crises are rated as having high impact although lower likelihood.

Almost five years after the release of the report of the Commission on Social Determinants of Health, it should not be necessary to revisit the connections of economic inequality and its consequences with health inequity. (An earlier posting, which has drawn more hits than any other in this series, addressed some of these connections.) It’s also worth emphasizing that reducing inequality is not about the ‘politics of envy’ or some similar construct. It’s about the near impossibility of healthy life near the bottom of the economic ladder even in the richest countries in the world; the ubiquity of socioeconomic gradients in health; and the fact that if societies want to invest more in policies that equalize opportunities to live a long and healthy life, the resources will have to come from somewhere. If not from those who have captured a very substantial portion of the gains from the pre-2008 period of sustained economic growth, then from whom? As US President Obama famously and correctly said, this is not class warfare; it’s math.

There is also a more subtle political point. Once economic inequalities have become sufficiently extreme, the idea of a ‘common future’ may become an illusion; the gap between the rich and the rest will simply be too wide, whether we define the rich in terms of the top one percent, five percent or even 20 percent. The problem is that we cannot locate this threshold (if it exists) in statistical terms, and will only know that we have crossed it once we have done so. Writing in the US context Robert Reich, later a cabinet secretary in the Clinton administration, raised this possibility more than 20 years ago in an article on “the secession of the successful” – at a time when economic inequalities were less extreme than they are today.   It remains to be seen whether heightened concern about those inequalities today can have an impact on social policy and reducing health inequity, or whether secession of the successful is already a fait accompli.

Related resources

“The global economy is disequalizing,” interview with The Broker (Netherlands) as part of an ongoing series on inequality.

Richard Wilkinson, “How economic inequality harms societies” (online video)

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Are social determinants of health moving into the mainstream?

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 February 2013
in CHNET-Works!

In a hard-hitting report, a panel of the US National Research Council and the Institutes of Medicine has addressed the question of why the United States, despite spending far more per person on health care than any other country in the world, is falling behind other high-income countries in health status.  Readers familiar with Evans and Stoddart’s critique of the “thermostat model” will experience a strong sense of déjà vu.

The figures are striking.  For example, relative to the 16 other high-income countries selected for comparison, the United States “had the highest rate of child deaths due to negligence, maltreatment, or physical assault.”  It has the highest average body mass index (BMI) of the 17 countries among people aged 15-44.  And the list goes on.  In the words of the study:  “The U.S. health disadvantage is pervasive: it affects all age groups up to age 75 and is observed for multiple diseases, biological and behavioral risk factors, and injuries. More specifically, when compared with the average for other high-income countries, the United States fares worse in nine health domains: adverse birth outcomes; injuries, accidents, and homicides; adolescent pregnancy and sexually transmitted infections; HIV and AIDS; drug-related mortality; obesity and diabetes; heart disease; chronic lung disease; and disability.”  

The report’s focus on structural influences and on the life course perspective is notable, and a summary is wroth quoting at length.  “[T]the absence of green space today may be the product of zoning decisions two decades ago. Such influences also extend over a person’s lifetime: that is, the upstream-downstream continuum can also be a temporal experience for an individual. An individual’s struggle through middle age with exertional angina from coronary artery disease may have originated in adolescence with the adoption of cigarette smoking, perhaps as a coping mechanism for a stressful childhood … or simply because the family lived in a poor neighborhood where smoking was the norm. In turn, the family’s move into that poor neighborhood may have resulted from financial setbacks that occurred before the child was born. Health trajectories unfold not only over a lifetime, but also across generations as people are subject to changing health influences stemming from family, neighborhood, and public policies. …. The key dynamic trajectories of health, risk factors, socioeconomic circumstances, and physical and institutional environments are all integrally linked and cannot be decomposed in a reductionist fashion.”   

Texas timesPointing out that the United States has the highest relative poverty rates of the 17 countries, the report notes the accumulation of social disadvantages and their health consequences over an individual’s lifetime and across generations.  Other, more domain-specific explorations include an intriguing comparison between approaches to road traffic safety in the United States and elsewhere in the high-income world and the topical observation that rates of death by homicide involving firearms are an order of magnitude higher than in other OECD countries.  (The accompanying picture, taken at the entrance to a Houston, Texas emergency room, may suggest a partial explanation; the need for such a warning would be almost inconceivable elsewhere in the high-income world.) 

There is no point in trying to provide a more extensive summary of a very long document here; suffice it to say that the report is essential reading for all those concerned with health equity.  A wonderful commentary from the British think tank Chatham House correctly warned that:  “Rather than indulge in self-congratulatory comparisons with America's dismal health record, other industrialized countries would be wise to ask themselves if … global trends may soon erode their own hard-earned health gains of past decades.”  Perhaps predictably, the report’s recommendations emphasize the need for further research, and research syntheses.  Nevertheless, there are important steps forward.   On research methods, the report observes:   “The premise that randomized controlled trials are the ‘gold standard’ for establishing causal relationships has put the accumulation of knowledge about the social determinants of health at a distinct disadvantage.”  Numerous earlier papers, including one that colleagues and I published more than a decade ago, have made a similar point, but it has yet to be recognized.  And a key recommendation for further research synthesis emphasizes comparative investigation of the influence of public policy “in one or more health domains.”  Our own health funding agencies would do well to take note.  Social determinants of health may not yet have become mainstream, but there is hope.

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Housing, equity, and economic apartheid

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 15 January 2013
in CHNET-Works!

Maclaren

CBC News reported on January 9, 2013 that the residents of a high-rise Ottawa Community Housing building in Ottawa had been without hot water since November 30.  The people affected included a 77-year-old man in a wheelchair.  The revelation says a lot about the value of public broadcasting, and local CBC news bureaus in particular.  It also says a lot about the barriers to getting social determinants of health, like adequate housing, on the policy agenda.


It could be worse.  The residents of 415 MacLaren Street could have been stranded on upper floors by non-functioning elevators, which happened in 2010 to residents of a downtown Toronto Community Housing building.  But that’s not the point. 


A bit of background: public housing in Ontario used to be a responsibility shared among three levels of government.  However, the national government and most provincial governments have largely retreated from housing, content to leave it to the private market and to municipal governments that have limited revenue-raising options.  Canada is the only G7 country without a national housing strategy.


This might not be a problem if the market economy provided adequate incomes for all, or if Canadian social policy compensated for the failings of the market.  Neither is the case.  Market incomes at the bottom of the income scale have actually been dropping, and by the middle of the last decade it became clear that social policy had retreated from redistribution, big-time. Housing is only part of the equation.  For example, a hard-hitting report on social assistance in Ontario that recommended immediate increases in benefit rates and allowable labour market earnings for  “the lowest rate category, single adults receiving Ontario Works, as a down payment on adequacy” has vanished from the political landscape without a trace.  This is not only a Canadian problem.  In the United Kingdom, where the Conservative-Liberal Democratic coalition government is proposing to cap benefit rates while lowering the top income tax rate for the ultra-rich, a spokesman for the Labour Party – the Labour Party – won’t say anything more than that they “support the principle of a benefit cap, but with the important caveat that it should not render people homeless.”


For whatever reason, we tolerate a deepening form of economic apartheid, perhaps at least covertly buying the argument that those on limited incomes are the authors of their own misfortune.  The recent history of plant closings across Canada, briefly discussed in a previous posting and to be covered at greater length in a forthcoming one, is just one piece of evidence among many that undercut this belief.  But then, how often are such self-serving beliefs susceptible to refutation by evidence?


Historian and sociologist Margaret Somers describes the belief system that tolerates such economic apartheid as market fundamentalism – ironically borrowing the term from George Soros, one of the world’s richest men.  There are alternative perspectives.  One views the minimal material prerequisites for a healthy life, including adequate housing, as human rights – a position entrenched in international law by the International Covenant on Economic, Social and Cultural Rights, to which Canada is a party.  The current UN Special Rapporteur on the Right to Housing (be honest, now: did you know there was such a person?) is charismatic Brazilian architect Raquel Rolnik.  Her most recent annual report to the UN General Assembly is an important piece of historical scholarship and a stinging, carefully documented critique of the “financialization” of the housing sector, which has paid off handsomely for financial institutions and for many of the propertied, while marginalizing others.  In calling for “a paradigm shift from housing policies based on the financialization of housing to a human rights-based approach,” she is challenging market fundamentalism and asserting what Somers calls “the right to have rights” independent of the marketplace.


Unless professionals and advocates concerned with social determinants of health can get their heads around that simple message, as it applies to housing and many other policy fields, the future of the health equity agenda has to be reckoned as dim. 

Additional resources:
In an online video of an event at the City University of New York, Ms Rolnik delivers a powerful indictment of the financialization of housing (her presentation starts at about the one-hour mark in the video).  All her annual reports and reports of country visits, like those of her predecessor, are available on the Special Rapporteur’s official web page.

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More on diet and population health

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 08 January 2013
in CHNET-Works!

A recent posting featured two important research syntheses on overweight and obesity. Another, especially useful for non-specialist audiences, appeared as a special report on “The big picture” in the December 15 issue of The Economist.

Commendably, the report does not sugar-coat the difficult politics of reducing overweight and obesity. It notes, for example, that “while lots of people remain fat, the associated ailments represent big business for the drug companies.”  It is candid about the role of companies like soft-drink manufacturers and fast-food chains in contributing to the epidemic of overweight, and the conflicts of interest that can arise in partnerships like one between Nestlé and the International Diabetes Federation, or the “Responsibility Deal” between food and alcohol companies and Britain’s Department of Health. (In negotiations about the action plan that emerged from the UN Summit on non-communicable diseases in September 2011, Canada was among the countries pressing for removal of text that mentioned such conflicts.) And it presents a succinct overview of efforts to deal with overweight and obesity through taxation and regulation. So far, those efforts have met with modest success, although that may be a consequence of modest ambition rather than of limitations intrinsic to the available policy instruments.

Unfortunately, the report is not open-access, although non-subscribers will be able to read part of it online. Unfortunately as well, the report pays insufficient attention to connections between the built environment and overweight, or to the cost of a healthy diet. Nevertheless, it is a refreshing signal that approaches going beyond the usual health promotion nostrums are moving into the policy mainstream.

Shortly before the Economist report appeared, Britain’s Department of Environment, Food and Rural Affairs released its annual Family Food Survey for the year 2011. Among the survey’s disturbing findings: fruit and vegetable purchases were 10 percent lower in 2011 than in 2007, with an even larger decline among the bottom fifth of Britain’s income distribution. Households in the lowest tenth of the income distribution were spending 17 percent more on food in 2011 than in 2007. A report in The Guardian quoted the director of the consumer protection organization Which? as saying: “One in six people say rising food prices are making it difficult to eat healthily,” and the preceding month a report in the same newspaper warned of a “nutrition recession” - this in a country where benefit caps planned for 2013 will cut the incomes of many people in full-time jobs as well as those who cannot find work. 

Closer to home, Ottawa's deparment of public health released the lastest issue of an annual calculation showing that if you are living on social assistance and paying market rents in the city, it is arithmetically impossible - as it is much of the rest of the province- to pay for the diet recommended by Ontario's Public Health Standards. In the capital of a weathly G7 country, 48,000 people a month turn to food banks. Against the background of ongoing concern about health care spending and areport recommending an immediate increase in Ontario social assistance rates to " the lower rate category, single adults receiving Ontario Works, as a down payment on adequacy while the system undergoes transformation," it may be worth asking`just how does making healthiy diets unaffordable contribute to a healthier population and lower health system costs down the road?

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