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Hamilton, Ontario: “Code Red” for health equity?*

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 30 May 2012
in CHNET-Works!

For Canadians of a certain age, the southern Ontario city of Hamilton (now an amalgamation of an older core municipality with several suburbs and exurbs) will always be Steel City, after the industry that was once its economic backbone. Today the city's steel industry has shrunk dramatically, as part of the deindustrialization that has ravaged the city's economy. Steel producer Stelco, which employed 25,000 people as recently as 1980, employed (as US Steel) only 1500 people in 2011. Other industrial employers, such as Firestone Tire and Rubber, International Harvester, Procter and Gamble, Dominion Glass, Camco, Siemens Canada and Westinghouse have left the city altogether. These job losses combined with a pattern of migration (by those who could afford it) from the downtown neighbourhoods surrounding major industrial plants to the suburbs to produce drastic economic inequalities within the city's boundaries. Thus, median family income in 2005 in the affluent exurb of Ancaster, formerly an independent municipality, was almost twice as high as the average for the former core city of Hamilton.

The health gradient associated with these inequalities has been documented in a remarkable collaboration between McMaster University researchers Neil Johnston and Patrick DeLuca and Hamilton Spectator investigative reporter Steve Buist. Their work produced a series of stories in the Spectator in 2010, is summarized in a new journal article+, and provides a template that should be used by university-community coalitions in cities throughout Ontario and elsewhere.

code-red-pic-1-500Source: McMaster University and Hamilton SpectatorThe researchers started with 12,000 death records and 400,000 hospital admission and emergency room (ER) visit records from 2006 – 2008, for everyone listing a Hamilton home address. Identifying information was removed to ensure privacy, and a hospital research ethics board indicated that no formal review was required. Twelve health variables were identified, and patient records were sorted by home address into Hamilton's 135 census tracts, for which socioeconomic data from the 2006 census were also obtained. Local school boards provided information on high school completion. The data were then turned into a series of maps, only a few of which are shown here, that show census tracts grouped by quintile, but data are also available for each individual census tract.

As one of the articles in the original series put it: "Those neighbourhoods with high rates of emergency room visits, no family physician, respiratory-related problems and psychiatric emergencies are the same neighbourhoods, in general, that have the lowest median incomes, lowest dwelling values, highest rates of people living below the poverty line and highest dropout rates from school."

"In parts of the lower-central portion of Hamilton," the story continued, "where poverty is deeply entrenched, some neighbourhoods live with Third World health outcomes and Third World lifespans."

code-red-pic-2-500Source: McMaster University and Hamilton SpectatorSome specifics: in one high-income census tract on Hamilton Mountain, where only 4.1 percent of the over-15 population lived on incomes below the Low-Income Cutoff (LICO) in 2005 and median family income was more than $68,000, average age at death was 86.3 years. In one low-income downtown census tract (35 percent of people over 15 living below the LICO, median family income just under $40,000) it was 65.5 years – a difference of 21 years.

The journal article that summarizes Code Red findings adds: "Also, there was a 22-year difference in the average age of a patient attending hospital with a cardiovascular-related emergency—from 57 years at one extreme to 79 years at the other. With respect to acute-care hospital bed use, one neighbourhood in the lower inner city had a rate of 729 days of acute-care hospital bed use per 1,000 people between the ages of 16–69. At the other extreme, an affluent suburban neighbourhood had a rate of 46 days of acute-care bed use per 1,000 people between the ages of 16 and 69. Other statistics presented included one inner-city neighbourhood having a rate of children living below the poverty line of 68.5 per cent while there were seven neighbourhoods where the rate of children living below the poverty line was 0 per cent."

code-red-pic-3-500Source: McMaster University and Hamilton SpectatorIn addition, a composite of all health and socioeconomic indicators was generated to produce a single ranking of each of the city's 130 census tracts. This ranking, too, was mapped by quintile. Combined, the two adjacent census tracts that placed lowest in this ranking had more than 40 percent of their population living below the LICO and the highest rates of hospital use – more than 1400 bed-days per person, or more than 17 times the rate for one suburban census tract. They also ranked near the bottom on many other health indicators.

The study also considered cost issues. Based on figures provided by Ontario's Ministry of Health and Long-term Care, it found that ER, hospital and ambulance use over the two years covered by the study cost $2,060 for every person living in one low-income, downtown neighbourhood. In one suburban neighbourhood, these costs added up to just $138 per person – raising the question of whether resources could be better used to eliminate social and economic conditions that make the ER and the hospital frequent ports of call for people with extensive health care needs, limited resources, and (often) no family physician.

That question is central to efforts to advance health equity, and it came up often in the course of research for Code Red, which was much more than a statistical exercise. The Spectator series included interviews with Hamiltonians as diverse as the head of a community foundation, a young paramedic whose role is that of a first responder to health emergencies, a family physician operating a one-person practice in the downtown neighbourhood where he grew up, a woman recovering from homelessness and crack addiction and the chief of emergency medicine at one of the city's hospitals. The stories told add to the statistics, as disturbing as they already are, what philosopher Jon Elster has called the texture of everyday life.

code-red-pic-4City of Industry, March 2007; photo by Chip Walsh,
reproduced under Creative Commons 2.0 licence
At least in Hamilton, the health gradient has an environmental dimension. The Niagara escarpment divides the city by elevation between the low-lying downtown and Hamilton Mountain (as the escarpment is called locally) and surrounding suburbs. As one story in the series pointed out, the escarpment "acts like a catcher's mitt for offshore breezes from Lake Ontario, trapping pollution over the lower city, particularly the northeast" – where the city's major industries were historically located, and where current levels of deprivation are highest. The story went on to note that despite deindustrialization, pollution levels in this part of the city still exceed recommended levels far more often than in rural areas. An earlier study, covering the period 1985-94, found that total suspended particulate (TSP) pollution exposure levels and dwelling values (a useful proxy for neighbourhood socioeconomic status) were inversely related – an important finding, since smaller particulates in particular are linked to respiratory damage.

In academic terms, some are likely to critique the study for not using age-standardized measures of mortality. However, the authors made "a conscious decision ... to treat the data in the simplest fashion possible so as not to confuse a lay audience," and unadjusted data may actually be more meaningful from a health equity perspective, because of what they reveal about the extent of health disparities 'on the ground'. The same is true of objections related to the difficulty of disentangling causation from selection, which was not the objective. As an associate medical officer of health interviewed for the series put it: "People don't move to a neighbourhood and then the neighbourhood makes them poor. They're often in those neighbourhoods because they can't afford to live other places." From an equity perspective, that's the point.

In the words of one of the authors, the Code Red stories "really seemed to strike a nerve in Hamilton." They influenced the subsequent municipal election campaign; played a role in decisions to locate two new hospital treatment centres in central areas of the city where need is greatest; led to the creation of a new staff position in municipal government; and have attracted extensive interest from various audiences. Against a background of fiscal austerity that often proceeds on irrational lines, it may be too early to assess (or to expect) more systemic effects. The study nevertheless represents a critical advance not only in our understanding of health equity in Canada but also in our knowledge transfer capabilities – the kind of work that health research funding agencies should be supporting and encouraging.

* Neil Johnston and Steve Buist provided valuable assistance with this posting. All non-attributed views are exclusively my own.

+Contact Neil Johnston, This e-mail address is being protected from spambots. You need JavaScript enabled to view it for a copy

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