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A change of scene, and a farewell

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Mardi, 23 Avril 2013
in CHNET-Works!

Recording artist Lynn Miles sings:  “Burn all the bridges down / Move me to another town.”  I am not burning any bridges, but I am moving to another town – one on the other side of the Atlantic, in fact.  As of June 1, 2013 I will take up an appointment as Professor of Global Health Policy at Durham University. (I cannot resist the observation that Durham County Council is currently the only one in England controlled by the Labour Party, although this may change after the May elections.)  The change of scene and the end of provincial funding for the Population Health Improvement Research Network make this a good time to discontinue writing Health as if Everybody Counted.  For the immediate future the postings will remain on the CHNET-Works web site, and I hope they will continue to serve as a useful resource for those wanting to advance the health equity agenda.  I am also enthusiastic about the possibility of updating, reorganizing and consolidating the postings as an e-book; more news on this as it happens.

As I prepare to leave Canada, I am prompted to reflect on why it is so difficult make change in population health research and practice.  Most of us work in institutions like university faculties, government ministries, local public health agencies, or nonprofits. These institutions respond to external priorities like those of granting councils, cabinets and local elected officials – priorities that tend to be shaped by macro-scale political currents like neoliberalism.  Our institutions also, with a few exceptions, are strongly hierarchical in their internal structure.  Observations of various kinds of organizations show that many individuals working within them adapt with striking facility to the moving target represented by changing requirements for success within the institu¬tion.  In an excellent study of the World Bank, Cheryl Payer described “a cage with glass walls.  Within this barrier the bureau¬crats and technocrats work, argue, debate, cooperate or fall out with one another, attempting to aggrandize their own position or to defeat opponents. They have the illusion of freedom because the barrier is invisible.  The smart or ambitious ones, having once experienced or observed such a collision, remember where the barrier is and avoid it thereafter; those who are slower, stubborn, or angry continue to beat their heads against it until they are bloody.  The recruitment and promotion practices naturally favour the smart ones who don't have bloody heads" (p. 353).

Not everyone adapts eagerly to the requirements for advancement within their institution, although eager adaptation is frequent in Canadian university settings.  Active resistance is likely to be a career-limiting move in many organizations.  Senior managers and external protagonists who set priorities and budgets must at least be comfortable with ideas like health equity if people trying to organize their work around such a concept want to keep their jobs, and the organization’s internal routines must be permeable enough to enable the advocates to make their case.  Academics often have more flexibility, but can still be targeted by governments or commercial interests.  More routinely, they are vulnerable to being marginalized or excluded through the operation of what can be thought of as organizational filters.  For example, if the managers of universities or hospitals (or those to whom they report, like hospital and university boards) decide that securing a permanent teaching or research position requires successful grant applications, then over time the organization becomes populated by people whose research priorities are congruent with those of funding agencies – whether those involve behavioural approaches to health promotion, development of commercial products like new drugs, or military technologies.

Philosopher of science Jon Elster is a master at providing microfoundations for large-scale explanations of social phenomena. In Ulysses and the Sirens, now unfortunately out of print, he wrote that: “If academic personnel apply for military funds in order to be able to conduct the research that they would have done in any case ... the Department of Defence may serve as a filter that selects some applica¬tions and rejects others.  The resulting composition of research will be beneficial to the military interests, while wholly unintended by the individual scientist, who can argue truthfully that no one has told him what to do” (p. 30).  Those who make it through the filters will in turn have an ongoing influence on the direction of the organization as, for example, they serve on appointments committees or advance into administrative posts, having observed the bloody heads of less accommodating colleagues.  The result is a situation in which, as Ken Coates of the University of Saskatchewan has written: “We have self-regulated ourselves into near silence, and our students and the country suffer from the quiet as much as university faculty.” Given granting agencies’ emphasis on biomedical and clinical research and the growing corporate influence in Canadian universities, which has been commented upon even in the Financial Post, it is hard to overstate the importance of this analysis, both for those already ‘in the system’ and for those hoping to make a career in equity-oriented health research.

The experiences of those of us who have worked in such environments are too easily dismissed as anecdotal or otherwise biased; for better or for worse, external validation is needed.  Empirical health policy research has not penetrated very deeply into the power structures and organizational routines of Canadian health ministries, university faculties, research institutes and public health agencies.  Relevant methodologies and perspectives are suggested by contributors to books like Policy Worlds: Anthropology and the Analysis of Contemporary Power and by the work of scholars like Janine Wedel, whose remarkable analysis of how power operates both through formal organizational structures and the informal networks she calls “flex nets” is especially valuable.  It remains to be seen whether those interested in doing this kind of research can make it through the filters, or whether they will find the necessary financial support.  

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Where the health equity action is, around the world

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Mercredi, 10 Avril 2013
in CHNET-Works!

Herewith a selection of promising efforts from around the world (sadly, none from Canada) to implement the health equity agenda.

The Social Determinants of Health Network (SDH-Net) is a four-year collaboration with the aim of building research capacity on social determinants of health in Mexico, Colombia, Brazil, South Africa, Tanzania and Kenya. It involves leading institutions in each of the six, in partnership with similar institutions in Germany, Spain, the United Kingdom and Switzerland.  The network is now in its second year of operation, and mapping reports on research capacity in each LMIC will soon be posted online.  Among other bodies of expertise, the project builds on earlier work by the World Health Organization on social determinants of health and public health programs.  SDH-Net is funded by the European Commission, the executive branch of the European Union, under the seventh Framework Research Programme.

Also funded by the European Union – are you seeing a pattern? – is the European Portal for Action on Health Inequalities.  In addition to links to a verity of external resources, the site offers access to a multilingual policy database that is searchable by EU country, implementation level, characteristics of policy or keyword. On an initial exploration of the database, and perhaps inevitably given the state of health equity intervention research, many of the entries link either to official statements of policy (which may or may not be reflected in actual practices) or to self-reports. Nevertheless, such platforms already serve a valuable purpose in encouraging creative imitation and thinking outside the box.

Still in the EU, a multi-university collaboration on Poverty and Social Exclusion funded by Britain’s Economic and Social Research Council has just released summary findings from report starkly titled The Impoverishment of the UK.  The report found, for instance, that about 5.5 million adults go without essential clothing, about 4 million children and adults are not properly fed by today’s standards, and more than one in four people skimped on their own food in the past year so others in their household could eat.  It should be kept in mind that these findings come from a country where academics are warning that pending benefit cuts may push 200,000 more children into poverty; where the income tax rate paid by the country’s highest earners has just been lowered; and where a wealth tax on houses worth more than £2 million remains controversial.  The survey does not consider direct effects on health, but underscores the fact that in the face of the recommendation by the Commission on Social Determinants of Health to “tackle the inequitable distribution of power, money, and resources,” some countries are moving in the opposite direction.

Finally, a new WHO report on Closing the Health Equity Gap, with a former official in Britain’s Cabinet Office (Ross Gribbin) as one of the two lead authors, draws on the reports of the various knowledge networks set up to support that Commission to identify concrete, and relatively short-term, implications for public policy.  The first main section identifies actions for health systems and health policy: moving toward universal coverage; expanding and redesigning public health programs; improving the measurement of health inequities; and making the case for intersectoral action.  The second main section focuses on cross-government actions in areas such as social protection, urban policy, trade, labour markets, and (commendably) policy and attitudes towards women.  Those who have been working on health equity issues professionally for some time will probably not find much that is new here, but that isn’t the point.  The point is rather to disseminate key messages about practical possibilities for acting on the moral imperative of reducing health inequity to audiences that may be unfamiliar with the concept, or else convinced of its importance but frustrated by the lack of ‘how do we get there from here’ information. 

Unfortunately, the current British trajectory – essentially, a large-scale social experiment on nonconsenting subjects in a jurisdiction that is a world leader in research on socioeconomic disparities and their health consequences – suggests that more information and better messaging may not be adequate to address the raw politics that perpetuate health inequity.

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Our big fat complicated population health problem, Part 2: It may be worse than we thought

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Lundi, 25 Mars 2013
in CHNET-Works!

Big fatFew now dispute the importance for population health of the rapidly rising prevalence of overweight and obesity, in countries rich and poor alike.  What to do about it is a matter of greater dispute.  An accumulating body of evidence suggests, as Rob Moodie and colleagues argued earlier this year in The Lancet, that overweight and obesity should be regarded at least in part as an “industrial epidemic” in which “the vectors of spread are not biological agents, but transnational corporations” like those that dominate the food and drink industries. 


In this vein, an important  exposé in the November-December 2012 issue of Mother Jones tried to answer the question of how the sugar industry “kept scientists from asking: Does sugar kill?”  The authors obtained documents dating back to 1942 describing the industry’s use of a strategy that David Michaels, a former senior official of the US government, has called “manufacturing uncertainty”.  The strategy was perfected by the tobacco and asbestos industries, but has been applied far more widely to resist regulation and other policy interventions aimed at protecting public health.  On March 20, The Guardian  reported on a series of talks given in Britain by Robert Lustig, an endocrinologist who argues that: “The food industry has made [sugar] into a diet staple because they know when they do, you buy more.”   This point is of special importance because of the continuing insistence, notably in the documents supporting and emanating from the UN High-level Meeting on Non-communicable Diseases, that public-private collaborations can contribute meaningfully to prevention of such conditions as cardiovascular disease and diabetes.  And evidence is accumulating that fructose, in particular, has destructive effects that go beyond its direct contribution to excessive caloric intake – a point that was emphasized during a panel on sugary drinks I recently attended at the 15th Public Health Research Conference at Mexico’s impressive National Institute of Public Health.

As noted in an earlier posting, rising overweight and obesity represent a complex problématique that cannot be isolated from issues of political economy, health equity and social justice.  On the political economy front, a fascinating recent open-access article on “exporting obesity” argues that the combination of farm subsidies in the United States and the removal of trade and investment barriers between the US and Mexico under the North American Free Trade Agreement  led to rapid transformation of the Mexican “consumer food environment” in several unhealthy ways.  One of these involved a dramatic increase in US exports of (subsidized) corn to Mexico, partly in the form of high-fructose corn syrup (HFCS) following a 2006 World Trade Organization ruling against a Mexican tax on soft drinks sweetened with anything other than cane sugar.  Pediatric obesity researcher Michael Goran, one of the panelists at the Mexican meeting, has made a similar point.  These exports have, in turn, no doubt contributed to a prevalence of obesity in Mexico that is actually higher among adults than in Canada.  So, too, has the rapid transformation of the Mexican food system through foreign direct investment.


On the social justice front, an article written by Goran and colleagues, including the Director of Health Assessment and Epidemiology for Los Angeles County’s Department of Public Health, demonstrates a pronounced socioeconomic gradient in the prevalence of childhood and adolescent obesity in the sprawling county, “with a striking fourfold difference in childhood obesity prevalence between the communities with the highest and lowest levels of EH [economic hardship].”  Equity concerns have often been left aside in discussions of how best to deal with overweight, obesity, and their health consequences.  This finding underscores the urgency of addressing not only the challenges presented by corporate interests in the food industry but also such issues as economic deprivation, access to and affordability of healthy diets, and disparities in access to safe options for physical activity as part of any comprehensive approach to the problem.

LA

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Public Health ethics: A new Canadian resource of international significance

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

Over the past several years, public health ethics has emerged as a distinct field of inquiry, reflecting a realization that principles and institutions developed since the 1970s to deal with ethical challenges in clinical and research settings are relevant to, but also insufficient for, addressing the issues that arise as policies and interventions affect (or neglect) health and its distribution at the level of populations.  An international journal on Public Health Ethics was established in 2008; in the previous year, the Public Health Agency of Canada organized the first national roundtable on public health ethics, a remarkably stimulating one-day event in Montréal.


Several Canadian organizations have now collaborated to support the production of a casebook on Population and Public Health Ethics, published electronically by the University of Toronto’s Joint Centre for Bioethics.   All cases submitted in response to a call for cases in 2011 were first peer-reviewed; accepted cases were then analyzed in a short essay by an invited author unconnected to the authors of the case.  (Full disclosure: I was both a peer reviewer and the author of one of the case analyses.) 


The result is a readable, intellectually challenging and hard-hitting collection of 16 cases dealing with issues as diverse as the ethics of public health surveillance; mandatory immunization of public health personnel; health status on First Nations reserves; and the health consequences of oil sands development.   The cases are presented under three headings – research, policy, and practice – although it is sometimes difficult to identify clear boundaries among these domains.  Readers are likely to cheer some of the analyses and conclusions, and perhaps to cringe at others.  In my case, one of the major cringe-inducers is the frequency with which the theoretical frameworks cited originate with authors from south of the Canada-US border, despite the intellectual vitality of the health ethics enterprise in Canada.


But that’s the point.  Stimulating debate and controversy about such questions is one of the ways in which initiatives like the new casebook add value to health policy and practice.  Despite the last several years of intensive efforts to advance health equity as a priority, we lack effective public forums for discussing such basic questions as whether core competencies in public health ethics should be specified for practitioners.  (The University of Toronto’s Ross Upshur raises this question in his introduction to the volume.)   Next steps: perhaps a multi-agency research initiative on public health ethics, or a multinational conference on comparative perspectives and policy solutions?

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The role of the public sector and carework in wealth creation: Background for debates around the upcoming Ontario budget

Posted by Salimah Valiani
Salimah Valiani
Salimah Valiani is Associate Researcher with the Centre for the Study of Educati
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on Lundi, 11 Mars 2013
in CHNET-Works!

Much like caring work, the role of the public sector in the creation of wealth is regularly undervalued and even disregarded. Due to this, the focus in policy debates is on public sector spending, with the 'necessary' conclusion that the amount of spending must be reduced within the context of provincial and federal budget deficits.

An entirely different approach is to begin with the assumption that carework and public services are part and parcel of wealth creation. Using the Statistics Canada database accounting for sales and purchases of all industries in the Ontario economy, a study by the Centre for the Study of Spatial Economics calculates the value of output generated by one dollar of spending in various sectors. This is one way of operationalizing the assumption that public services contribute to the creation of wealth.

The study shows that public spending in the areas of health care, social services and education creates more value added than private sector investment. To cite some figures, 87 cents worth of economic output is generated through every dollar spent on public health care, education and social services. This is considerably greater than the 61 cents added to economic output through private investment in machinery and equipment.

In turn, though public spending cuts in health, education, social services look good on the balance sheet in the very short term – they shrink economic growth, which isn't beneficial to the economy and society as the whole.

Along the same lines, for every dollar cut from public health care, the Ontario deficit is reduced by merely $1.95.  This compares with a deficit reduction of $2.60 for every extra dollar collected by government through the Harmonized Sales Tax, and $2.70 deficit reduction for every extra dollar collected through personal income tax.

Following this logic, the next question that arises is: Are health care and social service cuts worth it? Because we take carework for granted, we overlook the costs of cutting public health care services – which end up costing us more as the burden of increased illness arising from unmet needs falls on unpaid caregivers, over-extended RNs, and other paid care workers.

Another aspect of public services that is typically disregarded is the financial benefit of public services to citizens. This is likely why the effects of federal and provincial public spending cuts have been so little debated in public discourse.

On average, each citizen or permanent resident of Canada relies on $17,000 worth of public services annually. Health care, education, and personal transfer payments account for approximately 56 per cent of this amount. The rest includes water treatment services, parks, and road maintenance, to mention just a few.

Taking into account these economic and financial benefits of public services, the Ontario Nurses’ Association proposes that ‘social efficiency,’ rather than ‘market efficiency’ is the appropriate framework for health care and other public spending choices in Ontario. Market efficiency is the maximizing of short-term cost savings, while 'social efficiency' is the maximizing of public benefit. Social efficiency in health care is based on practical knowledge sharing and collaborative decision-making in the organization of care. RNs and other frontline care workers are central to formulating socially efficient reform measures – not private consultants working on the basis of short-term calculations. Beyond public services, citizens as a whole must be engaged in discussions of public spending and public revenue generation as part of the decision making process resulting in the 2013-14 Ontario budget.

Related resources

For an in-depth treatment of the ideas and analysis presented here, see the ONA research paper Easy to Take for Granted: The role of the public sector and carework in wealth creation.

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