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Manufacturing Diabetes

Posted by guest blogger Colleen Fuller
guest blogger Colleen Fuller
Colleen Fuller is co-founder and President of PharmaWatch (http://pharmawatchcan
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on Tuesday, 24 July 2012
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One of the things that drives me crazy is how the drug industry, instead of manufacturing useful medicines for existing diseases, manufactures diseases or epidemics and then the drugs to treat them. This is exactly backwards, but it is something that is happening more and more frequently.

One example is "pre-diabetes." Canadians are being bombarded with dire warnings about the skyrocketing number of people with diabetes – an "economic tsunami" according to the pharma-friendly Canadian Diabetes Association. The term pre-diabetes is not new — in the early postwar years many thought that women who gave birth to "large babies" were likely to develop Type 2 diabetes later in life, and they were described as being pre-diabetic (and, in line with sexist medical thinking, irresponsible as well). By the mid-1960s the association between pregnancy and pre-diabetes seems to have morphed into a diagnosis of gestational diabetes among pregnant women. But today, we're being told that pre-diabetes is an epidemic among people on the verge of developing the real thing and the main reason, according to the popular narrative, is obesity and, well, irresponsible sloth.

So let's parse out this picture. In Canada, the CDA says there are 2.7 million people with diabetes, including Type 1 (about 10% of the total), Type 2 or gestational diabetes. The numbers of people with diabetes is increasing in each category. But there are six million who are diagnosed as being "pre-diabetic" — a term that refers to those who are assumed to be at risk for Type 2. So the number of people who may get diabetes is actually higher than those who actually have it. Unfortunately, all of these different types, including the haves and the may-gets, are conflated into a single figure of nine million people.

How do they arrive at these scary numbers? One way is with a test that measures blood glucose levels. In 1997, the American Diabetes Association lowered the threshold that was used to arrive at a diagnosis of Type 2 diabetes from a fasting blood sugar level of 7.8 mmol/L to one of 7.0 mmol/L, a change that added another 1.9 million Americans to the list of people with this condition. Despite doubts about the evidence to support this move — not to mention warnings about the high cost as well as psychological and emotional impact of such an approach — the new standard was soon applied in Canada as well.

That same year the ADA introduced a new test to determine whether people had what was described as Impaired Fasting Glucose (IFG), a tool it said would help clinicians predict who would progress to Type 2 diabetes. In other words, to help doctors diagnose people with "pre-diabetes". The threshold was initially established at between 6.1 and 6.9 mmol/L, but by 2003, that level had dropped to 5.6 mmol/L. The change in the threshold increased the number of Americans diagnosed with IFG/pre-diabetes from 3.2% of the population to 9.7%.

Again voices of doubt were heard around the world. While the European Diabetes Epidemiology Group saw value in determining IFG levels, it looked at the evidence and rejected the higher threshold. Equally important, the Europeans preferred the more descriptive term "non-diabetic hyperglycaemia", and urged the diabetes community to avoid the use of the term "pre-diabetes" when describing those with an impaired fasting glucose. The EDEG pointed out that many people who meet the threshold for non-diabetic hyperglycaemia revert to normal glucose levels in subsequent testing. In addition, they said, "there is no fixed state of pre-diabetes" and warned of the emergence of a "pandemic" if the lower thresholds were used.

The controversy over the ADA thresholds went viral, leading to heightened scrutiny of the evidence used to support not only the glucose cut-offs, but of all the various tests used to diagnose Type 2 and "pre-" diabetes. By the end of the last decade, studies were pushing the use of a test called Hemoglobin A1c (HbA1c) to diagnose Type 2 diabetes and today, for better or worse, this is the standard used internationally, along with the "diagnostic cut-point" of 6.5%. In 2010, the ADA recommended that the HbA1c be applied to diagnose "pre-diabetes" as well, at a threshold of 5.7%.

As a diagnostic tool, the A1c test has its champions and its critics, including those who argue that the much higher costs associated with it increases the burden on the health care system. In addition, usefulness in certain populations is limited. The CDA's new pharma-sponsored guidelines will be published in March 2013, and it's likely that they, too, will embrace the HbA1c to diagnose pre-diabetes regardless of the fact that this is not a medical condition. So not only is this controversial diagnostic tool being used in spite of its limited utility, it is being used to diagnose a disease that, according to the EGED, doesn't exist. We are, after all, in epidemic mode!

The diagnosis of pre-diabetes is bad news for patients and their families, most of whom have no idea about all the drama in the background. But it's also bad news for society as a whole because of the enormous costs associated with treating millions of people who do not have a medical condition. But for the pharmaceutical and diagnostic industries, it's a great turn of events — and there's little doubt that Big Pharma has influenced the lower thresholds that have been put in place.

One of the companies that is hoping to benefit from a diagnosis of "pre-diabetes" is Sanofi, one of the largest pharmaceutical companies in the world. It has just unveiled a study that says insulin glargine (brand name Lantus) can delay full-blown Type 2 diabetes in those diagnosed with being on the verge of having the real thing. It's no coincidence, of course, that glargine is a Sanofi product and one of the most expensive insulins on the market.

The emergence of "pre-diabetes", according to one marketing firm, "should be viewed as an opportunity for pharmaceutical companies and manufacturers of blood glucose meters and nutriceutical products" who can educate physicians about new treatments for the pre-disease. And it's a big market — a much bigger market than the one made up of people who already have diabetes.

One of the most aggravating myths is that Type 2 is a "lifestyle" disease, brought on by sloth, laziness and poor eating habits. But the truth is that being poor is more likely to lead to diabetes than lifestyle choices — the poorest people are 4.14 times more likely to have Type 2 diabetes than those in the highest income category. And poverty isn't something that can be treated with a drug or a medical device.

Canada needs a strategy to reduce the chances that people will develop Type 2 diabetes. Key elements of such a strategy would be poverty reduction, including among the elderly, single women, Aboriginal people and people of colour; increased public funding for education; job security; and a more equitable distribution of wealth across the population.

* This article was originally posted June 27, 2012 on PharmaWatch Canada. Thanks to guest blogger Colleen Fuller for permission to repost here.

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Fighting back against health inequity and its origins

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 17 July 2012
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Despite rising inequality of market incomes and solemn assertions by governments that compensatory social policies are unaffordable, there are Canadian voices calling for change, within and outside the health research and policy community.

One of the most important of these is the Canadian Women’s Health Network (CWHN), which has just launched a new, user-friendly web site.  CWHN has been going since 1993, functioning as a clearinghouse and information broker on a variety of women’s health issues ranging from depression to domestic violence.  “Health is a human right that, because of poverty, politics and dwindling resources for health and social services, eludes many women” is part of its mission statement; recent links on its website connect users with a feature article and archived webinar on women and alcohol and a Conference Board of Canada report on the generally mid-pack performance of Canadian health care among OECD countries. CWHN is now seeking alternative sources of funding since support from our national government will end in 2013, as part of a larger pattern of funding cuts to women’s health research and advocacy.  Gotta pay for those fighter jets and new prison cells somehow.

fighting back pic 1Unemployment protest in Barcelona, June 2011.
Photo by Bonnie Ann Cain-Wood, reproduced under Creative Commons Licence 2.0
Another source of dissenting voices is the trade union movement. The Canadian Auto Workers, now Canada's largest private sector union representing workers in all sectors of the economy, has released a new study that tracked the economic trajectories of 260 workers laid off from three Ontario manufacturing plants. Not surprisingly, the study found that major economic hardship followed; loss of incomes, benefits and security was routine. A long line of Canadian studies going back at least to Paul Grayson's work on manufacturing plant closures in the 1980s (1) has found a similar pattern, as have many in the United States. The landmark Code Red study in Hamilton did not directly track worker earnings, but documented the consequences of manufacturing job losses in a city especially hard hit by deindustrialization. Depending on the future of this blog, a bibliography of key sources on what sociologists call 'downward mobility' as a consequence of economic restructuring, and the health effects, will be provided in a future posting.

Few people now question the fact that earnings and economic opportunity in North America are rapidly polarizing, with consequences for health over the life course and across generations that we can only begin to anticipate. A more dramatic and accelerated preview is now unfolding in parts of Europe, with (for example) official unemployment rates of more than 20 percent overall, and more than 50 percent among young people, in Greece and Spain.  Can economic polarization that consigns a substantial proportion of a nation’s population to permanent uncertainty and insecurity be recognized as a public health issue of overwhelming importance?  Or are the public health professionals whose voices might drive that recognition already too solidly entrenched in the ranks of the comfortable?  Just asking, as they say.

(1) Grayson P. Corporate Strategy and Plant Closures: The SKF Experience. Toronto: Our Times, 1985.  Now apparently out of print, and certainly hard to find.

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Code Red for maternal and child health: The BORN project *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Thursday, 12 July 2012
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In 1997, Ontario’s health ministry set a goal of reducing the percentage of babies born with low birthweight (less that 2,500 grams at birth) from 5.7 to 4 percent by 2010.  Such babies are at increased risk for poor health outcomes, and their care involves substantial health system costs.  The target was not met; in fact, by 2010 the figure had risen to 6.5 percent.   In a followup to the Code Red project, described in a previous posting, researchers at McMaster University and reporters at the Hamilton Spectator examined 535,000 Ontario birth records to find out why.  The results of the BORN project, which turned into a much larger-scale investigation into the socioeconomic influences on maternal and child health, offer a disturbing look not only at the reasons but also at the straightforward economic consequences.

The study found a strong socioeconomic gradient in low birthweight.  “Of the 20 neighbourhoods in Ontario with the worst,” i.e. highest, “rates of low-birth-weight babies, three of them are in the lower part of the former City of Hamilton” – in other words, the low-income downtown.  In one of the neighbourhoods, “74 percent of children live below the poverty line” and more than one family in four is headed by a single mother – statistically, one of the most important risk factors for poverty.  There are also some conspicuous outliers.  For example, the high-income Toronto suburb of Vaughan has the highest incidence of low birth weight in Ontario: 16.4 percent – emphasizing the complex causal pathways that may be involved.  McMaster researcher Neil Johnston, who was part of the study team, noted that there is “not a single smoking gun.  It’s almost a conspiracy of things that preclude [mothers] from ensuring the child they’re carrying will be as healthy as possible.”

born pic 1 prenatal care Ont1

One of those things is uneven access to prenatal care:  in some Ontario communities, like downtown Windsor, just over half of all expectant mothers receive prenatal care during the first trimester; in other communities, for the most part relatively wealthy, more than 19 out of 20 mothers receive first-trimester care.  Interestingly, although a socioeconomic gradient exists across neighbourhoods in Hamilton, levels of access are generally high.  Another issue is teenage pregnancy.   Within the region at the west end of Lake Ontario there is a steep socioeconomic gradient.  In one of Hamilton’s poorest downtown areas, between 2006 and 2010 one in seven babies was born to a teen mother.  In a wealthy area of nearby Burlington, where the median household income is three times as high, among a comparable number of births not a single one involved a teenage mother.  Comparable differences were observed across the province, with many of the highest rates (between 20 and 40 percent of births to teen mothers) observed in low-income First Nations reserves across northern Ontario.  Conversely, in 20 rural and suburban municipalities across southern Ontario, including high-income Richmond Hill and Oakville, the highest percentage of teen mothers was 1.8.  (The Town of Vaughan was one of these, showing the complexity of the low birthweight problem.)

born-pic-2teen-mom-rate2

As with the original Code Red series, the statistics are accompanied by interviews that should be required reading for every student of public health or health promotion.  Interviews with people like “Kristen,” pregnant at 16 after her boyfriend poked holes in the condoms because “he figured it would make me stay with him,” and researcher Lea Caragata, who points out the links among poverty, economic insecurity and lack of a sense of the future. “For those middle-class kids in Ancaster, pregnancy will ruin their prospects and their aspirations …”  It is critically important not to pathologize teen motherhood, but equally important to recognize that all too often it ensures the reproduction of patterns of disadvantage and marginalization across generations.

All of us concerned with action on health equity need to ask questions like the one posed at the start of the third and final instalment of the series:

born-pic-3-quotation

Turning around the Ontario situation will require coordination among a variety of service providers – a “symphony orchestra” rather than “a wonderful jam session,” in the words of McMaster’s Johnson, who emphasizes that the province “must take accountability for what happens” in the health system.  This is easier said than done – too often no one anywhere in the health care system seems accountable for outcomes, as shown by Ontario’s lacklustre performance in diabetes management – yet the challenges raised by the series are even bigger.  One set is summarized in Lea Caragata’s passionate critique of the “opportunity deficit” facing too many of today’s youth.   Another, related set is suggested by remarkable calculations that show the Gini coefficient – a standard measure of income inequality – at the neighbourhood level.

“It turns out that the Hamilton neighbourhoods with the greatest income inequality are also the same neighbourhoods with the highest levels of poverty. …. Perhaps it’s a coincidence,” said the final story, that these neighbourhoods “also happen to be the neighbourhoods that performed poorly for any number of health variables based on the findings of both Code Red and Born.

“Perhaps it’s not a coincidence.”

In Canada as in much of the rest of the world, economic restructuring and social policy retrenchment are driving an increase in economic inequality on every scale from the neighbourhood to the nation.  By failing to face up to this trend and address its consequences for health, we are betting the future of many Ontarians on its being just a coincidence.  We are also, of course, betting hundreds of millions, if not billions of dollars in future health care costs that could be avoided.    

Or, perhaps, we just don’t care?

born-pic-4-Gini coefficients

* Sincere thanks to the Hamilton Spectator and the Center for Spatial Analysis, McMaster University for the illustrations

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Good news and bad on 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 Friday, 06 July 2012
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Herewith a selection of events from around the web, and the world. First, some good news. The Caledon Institute for Social Policy, a non-profit with a long history of progressive social policy analysis that is now headed by two accomplished alumni of the recently deceased National Council of Welfare, has announced that it will take over preparing and publishing two of the Council's most important data series: those on welfare incomes and the profile of poverty in Canada. These are core resources, and Caledon is to be congratulated on this initiative, which will be part of a new Canada Social Report. I hope that one or more Canadian academic institutions will offer to support them, financially and with other resources.

My current institutional home, the Bruyère Research Institute, has produced a valuable set of tips for keeping seniors safe in the heat. As I write we're at humidex 34 here in Ottawa, so the importance of such advice can't be overestimated. Eric Klinenberg's remarkable "social autopsy" of the 1995 Chicago heat wave reminds us that a clear socioeconomic gradient exists with respect to opportunities to stay safe in the heat. Many people can't afford air conditioning or a breezy cottage, and in Chicago the elderly on moderate incomes in particular found themselves isolated by fear of crime and other elements of the urban environment from locations that could at least have kept them cool.

In a world that may experience extreme heat and weather events with greater frequency as a result of human-induced climate change, such warnings assume special importance. They may also not be enough. On June 30, it was reported that a combination of violent storms and extreme heat had caused the deaths of at least 12 people in the United States, and millions more were "facing temperatures in the 40s without electricity, and without air conditioning." Record temperatures and wildfires in Colorado had forced the evacuation of 32,000 people and the cancellation of the iconic Pikes Peak Hill Climb, a motor sports event with almost religious significance for aging gearheads like yours truly. But not to worry, say the climate change sceptics; the evidence is insufficient and these may be natural variations from the mean. Everything will be fine.

Finally, a shift to the global frame of reference. A little-noticed resolution adopted in May by the World Health Assembly, the governing body of the World Health Organization, called on the "international community" to support action on social determinants of health and, more concretely, on WHO's Director-General "to duly consider social determinants of health" and to continue advocacy for their importance within the UN System. Supporting documentation pointed out that implementing the resolution would require an additional $33.6 million between 2012 and 2017, and that the cash-strapped WHO had no resources in its current core budget for these activities. To put the amount into context, it's equivalent to the cost of 22 of the 588 Tomahawk cruise missiles the US Department of Defense planned to buy between 2010 and 2012 ... and Tomahawk was just a drop in the United States' $1.5 trillion arms procurement budget over those years. What was it that the Commission on Social Determinants of Health had to say about "a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics"?

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The Unkindest Cut

Posted by guest blogger Sarah Giles
guest blogger Sarah Giles
Sarah Giles is a family physician with an interest in remote and rural medicine.
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on Thursday, 05 July 2012
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In the face of the Harper government's proposed cuts to refugee health care, there has not been a massive outcry from the nation's doctors. Certainly, we have heard from a vocal minority of individuals, such as the 80 doctors who briefly occupied cabinet minister Joe Oliver's Toronto office on May 11, 2012 and those who participated in a national day of protest on June 18, 2012 (about 400 people in Ottawa and others scattered across the country), but, in general, the response from doctors has been underwhelming.

First, it's important to highlight that the major associations of health care providers (Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, College of Family Physicians of Canada, Canadian Nurses' Association, Canadian Dental Association, Canadian Pharmacists Association, Canadian Association of Optometrists and Canadian Association of Social Workers) have signed a position statement in which they have asked the federal government to rescind some of the proposed cuts to the Interim Federal Health Program (IFHP). IFHP, for those who are unfamiliar with it, is a program that provides health care funding from federal coffers until a refugee is eligible for coverage under provincial programs.

Despite the federal government's assertion that IFHP provides refugees with "superior health care" in comparison to other Canadians, the program only actually provides essential and emergency health services to treat and prevent serious medical conditions such as prenatal care, some vaccines, and essential prescription medications should a refugee be unable to afford such items. Yes, eyeglasses and a few other services such as limited physiotherapy are provided, but the program is not overly generous as is quite similar to programs for Canadians on income support programs.

The federal government naïvely suggests that its proposed cuts will save Canadians $100 million. Refugee health problems will not go away; instead, they will fester untreated until they become a medical emergency that lands these vulnerable people in the emergency room.

Here's a quick (fictional) example of how this program will cost Canadians more money and cause refugees' health to deteriorate. Havinder is a refugee who is an insulin-dependent diabetic who has been stable on his medications for some time. On July 2, he runs out of insulin but cannot afford to buy more. He tries to drink more water and walk more to decrease his sugar levels, but as the week goes on, he feels worse and worse. He is unable to attend work because he is lethargic. He can't sleep because he is urinating every thirty minutes. He develops a terrible headache that he can't shake. Havinder goes to bed on July 7 and on July 8, his wife can't wake him up. An ambulance is called; he is taken to the local emergency room where he is quickly diagnosed with an advanced case of diabetic ketoacidosis. He is admitted to the ICU and remains in hospital for two weeks. The federal government refuses to pay for his care, so the provincial government (which is responsible for hospital funding) is forced to cover the cost of the two weeks in hospital as there is no way that Havinder can pay the twenty thousand dollar hospital bill. Havinder is discharged home with prescriptions that he cannot afford to fill and the cycle starts all over again.

The health care providers in the hospital understand that Havinder's entire $20,000 hospital stay could have been avoided with a $20 vial of insulin. They appreciate that Havinder has had a needless brush with death and that there may be some permanent sequelae. The hospital staff, at least in the short term, will still get paid. They may shake their heads at the insanity of policies behind the new policy, but it won't affect their finances until provincial taxes go up to cover the short fall in hospital budgets.

Doctors working in refugee health clinics around the country will be forced to evaluate how they can continue to provide services when they will no longer be paid by the IFHP. They will wonder whether there is a point to seeing patients who will never be able to afford the services and treatments that the doctors will recommend. They can treat pneumonias and prevent infectious disease with drugs and vaccines – but how can doctors do this when there isn't any funding available to procure such items? They will know that having unvaccinated refugees will cause a significant public health risk through the erosion of "herd immunity".

So, doctors certainly understand that the health of refugees, and indeed the health of the general public is at risk with these proposed cuts, but very few of us are actually actively speaking out or protesting. Why is this?

First, we must examine those who become doctors in Canadian society. We know from many studies that doctors overwhelmingly come from high income earning families. Most, though certainly not all, doctors have never had to consider forgoing a prescription in order to buy food. Most doctors were accepted into medical school by doing well in undergraduate classes and not rocking the boat. Most doctors are people pleasers who have gone to great lengths throughout their training to jump as high as humanly possible when commanded to – often without thinking about why they were asked to jump in the first place. The medical establishment rewards with promotions and positions of power those who do not threaten the status quo. There are very, very few (at least openly) radical doctors. Perhaps those doctors who occupied Mr Oliver's office are the only politically active doctors in the entire Greater Toronto Area?

Or maybe doctors feel beaten down. We are essentially civil servants – the provincial government sets our wages, tells us whether or not there is funding for another hip replacement surgery, and dictates that we are not eligible for vacation pay, benefits, or pensions. In Ontario, doctors have just received a substantial pay cut and they were not able to participate in that decision making process. Maybe we just feel that governments are not listening to us.

Doctors have used the term "evidence-based medicine" for some time. We try to use science to dictate our practice rather blindly doing what has worked in the past. If interventions are shown to be expensive and ineffective, we do our best not to use them. W why are Canadians, especially doctors, willing to endure non-evidence based politics. We know that the cuts to the IFHP will hurt the most vulnerable members of Canadian society. We can guarantee that provincial health costs will rise far more than the supposed savings at the federal level and yet, very few of us are raising hell about the issue.

We need to stop depending on our organizational bodies (the Canadian Medical Association, RCPSC, etc.) to represent our patients' rights. We need to stand up and demand that the federal government protect our most vulnerable patients. Our organizational bodies look after doctors' concerns and will put out the odd position statement to support patients, but it is not their primary responsibility. We, who are educated and well compensated, need to press everyone we know to stop this disastrous change in policy. This cut makes no sense on any level – be it fiscal or compassionate. Let's rally the troops and help keep Canada a place where we are proud to live and practice.

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Suitable for framing

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 18 June 2012
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Herewith a selection of quotations and images charting the path of social determinants of health in policy analysis. We start with a trip in the wayback machine, to 1983 and a review article(1)on hypertension in Canada by Helen Johansen, then with the Health Protection Branch of Health and Welfare Canada.

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Closer to the here-and-now, a team of researchers with Toronto’s Institute for Clinical Evaluative Sciences wrote in a 2009 report comparing public health policies across Canada’s provinces that:

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A similar point comes from an important new report on overweight and obesity from the Institute of Medicine south of the border (the quotation is from the web summary):

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More about this report, and about recent studies that have been quoted as casting doubt on the importance of “food deserts,” in a subsequent posting. I invite comments from readers on the latter point, in particular; meanwhile, some of the comments posted on the New York Times article that describes the studies  offer valuable insights into the real world of life on a limited income, where both money and hours in the day are in short supply.

Most recently, the authors of a May, 2012 report on income differences among patients using hospitals in Toronto began the study with a brief discussion of health equity in which they noted:

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The phrase currently used to describe the policies needed to address those core social determinants of health is “intersectoral action,” which was the topic of an earlier posting. The unequal distribution of opportunities to be healthy was central to the work of the WHO Commission on Social Determinants of Health. It was also central to the public health strategy proposed in a 2007 report to Norway’s Storting  (the national legislative body) by the country’s Ministry of Health and Care Services, and was communicated in an image that remains remarkably powerful.

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What we should learn from this brief journey was captured in a 2011 Toronto conference presentation by Nancy Edwards, director of CIHR’s Institute of Population and Public Health.

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Against the background of this accumulated wisdom, why is so much activity still focused on individual-level behaviour change and lifestyle modification, and so little on structural disadvantage? The question is, of course, too ingenuous by half. In a commentary written shortly after the World Conference on Social Determinants of Health in October, 2011, Sir Michael Marmot captured the underlying realpolitikof resistance as it played out at the conference:

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It should now be clear that “less safe” policy directions are the only ones that will generate meaningful progress toward reducing health inequities. How willing are those of us who profess a commitment to that objective, perhaps especially those with academic tenure or collective agreement protection (I have never had the former, and have not had the latter for two decades) to insist on those directions? Can viable coalitions for change be built outside the universe of health researchers and front-line workers, for example by making long-overdue common cause with the trade union movement? Such questions may decide the future of health equity in a Canadian political context that, at least over the short term, looks distinctly hostile.

(1)  Johansen H.  Hypertension in Canada: Risk factor review and recommendations for further work. Canadian Journal of Public Health, 1983;74:123-128.

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Social determinants of health: Glum tidings on the inequality front

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 June 2012
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The Commission on Social Determinants of Health was emphatic about the role of “the inequitable distribution of power, money and resources” in sustaining socioeconomic gradients in health.  Such inequitable distributions do not just happen; they are the result of choices about how societies govern their economies and distribute the rewards they generate.  Globalization has undoubtedly narrowed the range of such choices – think about Eduardo Galeano’s “magic galleon that spirits factories away to poor countries” (1) and the shift of power in Europe from electorates to bond investors and credit rating agencies – but has not eliminated them.  Three recent publications offer important and sobering insights into how those choices have played out in Canada.

The most recent report on child poverty from UNICEF’s Innocenti Research Centre points out that: “It is now more than 20 years … since the Government of Canada announced that it would ‘seek to eliminate child poverty by the year 2000.’ Yet Canada’s child poverty rate is higher today than when that target was first announced.”  The poverty rate referred to here is not Canada’s Low Income Cut-Off, but rather a standardized relative measure referring to a household disposable income of less than 50 percent of the national median, after adjustments for family size.  Canada, as we can see, does not rank especially well on this measure.   Much of the report is devoted to comparing this measure with an alternative one constructed around 14 specific measures of child well being, for which data are available only for European countries, but among countries for which both measures are available there is a clear correlation between rankings.  

glum tidingsSource: UNICEF Innocenti Research Centre (2012), Measuring Child Poverty:
New league tables of child poverty in the world’s rich countries.
At the other end of the economic scale, a new paper by five Canadian economists explores some of the driving forces behind Canada’s steadily rising level of inequality –in particular, the growing share of income flowing to the top one percent of the income distribution.  “The top income share almost doubled” from about 8 percent in the late 1970s “to reach 14 percent in recent years.  Such an uneven distribution of income has not been seen since the dark days of the Great Depression.”   In a clearly written review of the issues, the report goes on to make a number of important points:

  • The range of occupations represented in the top one percent is far wider than stereotypes would suggest, with only 10 percent of top earners working in financial services as of 2005 (the date covered in the last compulsory Long Form Census, from which many of the report’s data are drawn)
  • Growing inequality is a function not only of changes in the distribution of market income but also, and crucially, of the retreat from redistribution that began in the 1990s
  • “Younger workers, especially those with limited education, face a world with worse earnings prospects than their fathers’ generation,” suggesting a future of further inequality in market incomes as older cohorts of workers who have maintained their wages retire
  • Revenues from increasing income taxes only on the top once percent would probably be relatively modest, even before considering the impact of strategies for tax avoidance that are available to many of the rich

The report also has, to my way of thinking, at least two shortcomings.  

First, and perhaps unavoidably given data limitations, it deals only with income and not with wealth.  Wealth distributions are often more unequal than incomes, and many forms of intergenerational wealth transfers (e.g. bequests of valuable principal residences) do not show up in income figures.  The report points out the role of assortative mating (of two high earners) in increasing household income inequality; its contribution to inequality in household wealth may be more significant.

Perhaps more seriously, the report takes the concept of ‘skill’ as entirely unproblematic, treating the education level associated with a particular occupation as a rough proxy.  However, there is often no clear connection between the intrinsic complexity of the tasks involved and the credentials of those performing them; in terms of labour market outcomes it makes more sense to ask what kinds of tasks, including some very complex ones, are amenable to ‘offshoring’ in low-wage jurisdictions.

Robert Evans, the iconoclastic health economist whose work was the topic of an earlier posting, likewise organizes a recent article around the one-percenters’ growing share of income and on that fact that “these trends,” both in Canada and the United States, “are to a considerable extent a consequence of conscious, deliberate agency by more or less organized and coherent interest groups.”  His most immediate concern is what the retreat from redistribution means for the future of Canadian public health insurance (“a casualty in the class war,” in Evans’ words) now that federal cash transfers to the provinces for health care no longer come with even minimal conditions.

Evans is, as always, playful with his literary allusions; Sherlock Holmes enthusiasts are directed to his endnote 11 and the accompanying text.

Outside the health care field, he emphasizes the health consequences of the “degrading” of environments where people live and work that is associated with rising inequality – a special concern in view of the prospects of a global economic realignment in which many ‘good jobs’ have simply disappeared from the high income world.  Reducing the effects of that realignment on health disparities will require more, not fewer redistributive economic and social policies – certainly not the austerity measures that are now worsening the current recession.  If one agrees with Evans’ analysis of the sources of successful resistance to such policies, then the precarious state of the social determinants of health agenda in Canada is hardly surprising. 

(1)  Galeano E. (2000).  Upside Down: A primer for the looking glass world.  New York: Picador.

Source: UNICEF Innocenti Research Centre (2012), Measuring Child Poverty:

New league tables of child poverty in the world’s rich countries.

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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
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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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Food security: Canada gets a warning

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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Olivier De Schutter, the second United Nations Special Rapporteur on the Right to Food, is one of the most thoughtful thematic mandate holders, as they are called in UN-speak. (There are currently 36 such mandates.) His reports and commentaries provide articulate critiques not only of the policies of specific national governments, but also of an international agri-food system that is conspicuously failing to protect and fulfil the right of all to an adequate diet – one of the most basic social determinants of health.

The preliminary report of Prof. De Schutter's mission to Canada, which wound up on May 16, is sobering reading for a country that is often prone to self-congratulation on its human rights record. He points out that according to the 2004 Canadian Community Health Survey, 7.7 percent of Canadian households reported moderate or severe food insecurity – this before the financial crisis of 2008 and subsequent recession – and "was disconcerted by the deep and severe food insecurity" faced by aboriginal people, the legacy in part of a "long history of political and economic marginalization."

de-schutter-pic-1UN Photo/Jean-Marc Ferre.
Reproduced under Creative Commons Licence 2.0.
His report directly links food insecurity and increasing reliance on food banks to low incomes and the high cost of housing – a link that has been referred to in earlier postings. "In the view of the Special Rapporteur, social assistance levels need to be increased immediately to correspond to the costs of basic necessities," and minimum wages should be set at a living wage level as required by the International Covenant on Economic, Social and Cultural Rights, to which Canada is a state party.

Population health researchers have effectively documented the extent of food insecurity in Canada; the work of the University of Toronto's Valerie Tarasuk is especially powerful in this respect, as are the reports of the Toronto Department of Public Health. We have perhaps not taken advantage of opportunities to frame food security as a human rights issue, a matter of priorities. Maybe food security for all is just more important than freeway widenings or fighter aircraft ... or maybe we don't even need to make those choices. Prof. DeSchutter pointed out that: "The tax-to-GDP ratio of Canada ... is now in the lowest third of OECD countries. Consequently, Canada has the fiscal space to address the basic human needs of its most marginalized and disempowered." I've made a similar observation in a previous posting.

Predictably, the official response was less than cordial. Cabinet minister Jason Kenney, at roughly zero risk of food insecurity, referred to "lectures to wealthy and developed countries" as "a discredit to the United Nations." He might want to have a talk with Department of Justice lawyers about the nature of obligations under human rights treaties, but that's a topic for another day. Clearly, Prof. De Schutter's intervention gives a boost to those who would address the politics and priorities that deprive people in such a "wealthy and developed country" of food security.

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The diabetes crisis: health care not doing its part? *

Posted by Ted Schrecker
Ted Schrecker
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I do not ordinarily write about the health care industry (and it is an industry). I decided to break this rule after reading a recent report in the Ottawa Citizen on a decision by the Champlain Local Health Integration Network (or LHIN, Ontario's version of a regional health authority) to hire two chiropodists to provide free foot care to diabetics – a service otherwise not covered by provincial health insurance, and therefore unaffordable for many. Lack of appropriate foot care was cited as one of the reasons for the region's high rate of hospitalization for diabetic foot infections, which sometimes lead to amputations.

Diabetes is not an equal-opportunity disabler. As noted in an earlier posting, a pronounced socioeconomic gradient exists in the prevalence of Type 2 diabetes, and limited incomes seriously compromise patients' ability to manage the disease effectively. This helps to explain why diabetes mortality has declined faster among higher-income patients in Ontario. But even aside from these important issues, which suggest at the very least a need to broaden insurance coverage, Ontario's health care system seems not to be doing its part. Province-wide, according to health ministry figures, as of late 2010 fewer than two out of five Ontarians with diabetes had received all three of the tests recommended for diabetes management – blood glucose every six months, cholesterol (LDL) every year, and retinal eye examination every two years – in the appropriate period. (Nationally, a clear socioeconomic gradient exists for receipt of these tests; it would be interesting to know whether the same is true in Ontario.) And a recent article by Tara Kiran and colleagues at the University of Toronto, based on Ontario Health Insurance Plan records, points out that the 2002 introduction of a new billing code specifically to reimburse physicians for diabetes management tasks had, by the end of 2008, led to only modest increases in monitoring.

This is part of a more general, Canada-wide picture. Jeffrey Turnbull, past president of the Canadian Medical Association, has pointed out that in one of the OECD's more expensive health care systems (although it's not one of the more expensive when only public spending is considered) chronic disease management is "woefully inadequate" and "Canada now ranks below Slovenia in terms of effectiveness and last or second last in terms of money spent" on health care. With specific reference to diabetes care, 2008 figures from the Commonwealth Fund show that Canada ranked far behind the Netherlands, New Zealand and the United Kingdom in the percentage of adults with diabetes who received appropriate monitoring.

Now, I am an outsider to most of the quotidian operations of health care institutions; I don't have ready answers. Health system managers seem to be proliferating, yet few signs can be found of the "new management systems and new accountabilities" that Dr. Turnbull called for. Surely it's not unreasonable to ask that health ministries and regional health authorities have routines in place to benchmark diabetes management, and myriad other health care processes, against the world's best and transform the way they do things to match the leaders' performance.

* Tara Kiran provided valuable help with research for this posting. All views expressed are exclusively my own.

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Small steps toward walkability

Posted by Ted Schrecker
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Toronto’s Department of Public Health, a leader in such areas as publicizing the conflict between eating a healthy diet and keeping a roof over your head when living on a low income, has issued a new report with important recommendations for improving health by promoting walking and cycling.

Among the recommendations: reducing speed limits to 30 km/h on residential streets and 40 km/h on most others, and installing “leading pedestrian signals” at major intersections.  (These are signals that give pedestrians a walk signal a few seconds before the light turns green for vehicle traffic, improving drivers’ ability to seen them.)  The report also notes the need for more investments in pedestrian and cycling infrastructure, and for working with Metrolinx (the regional public transportation authority, now facing drastic funding shortfalls as a consequence of provincial austerity measures) to promote active transportation.

The report is based on a longer study that undertook an extensive review of the evidence on active transportation and health, emphasizing the equity dimension.  It noted, in particular, that “low-income families often live in high-rise neighbourhoods in Toronto’s suburbs,” which are hostile to pedestrians and cyclists.  Roads are wide; marked pedestrian crossings few and far between; pedestrian collisions are more frequent even though pedestrian volumes are lower; and three-quarters of parents do not feel comfortable letting their children walk unaccompanied in their neghbourhoods.

creative-commons-licencePhoto: Richard Drdul,
reproduced under a Creative Commons licence
The longer study also argued for traffic calming strategies: engineering measures to slow down traffic, like speed bumps and curb extensions, which have resulted in major reductions in injuries and fatalities when implemented in Europe.  A more extensive review of traffic calming and health was published late last year by Canada’s National Collaborating Centre for Healthy Public Policy, and will be the topic of a CHNET-Works Fireside Chat on May 10.
 
Predictably, the Toronto Public Health recommendations were greeted with howls of outrage from some of Toronto’s more retrograde politicians, but as readers of a previous posting (and the longer Toronto study) will know, such measures are either already in place or under serious consideration in many European cities.  This is, literally, an issue of street-level politics: will the “right to the city,” in Henri Lefebvre’s frequently cited phrase, favour pedestrians and cyclists or people protected by two tons of steel and airbags?  In many other Canadian cities, we’re still waiting for Toronto-style public health leadership.

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Fostering blissful ignorance about poverty?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 23 April 2012
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Many readers of the federal budget will have missed the decision to shut down the National Council of Welfare, a small and independent-minded unit of the Government of Canada that since 1962 has been a source of information about the extent and depth of poverty and inadequate social provision in Canada. With its demise, a resource for advocacy on social determinants of health has been lost. It is still possible to use the Council's site to access an interactive map showing that (for example) inflation-adjusted social assistance incomes in Ontario are no higher than they were in 1986. And the ground-breaking 2011 study on The Dollars and Sense of Solving Poverty is still available. To quote just one provocative finding from its summary: "The poverty gap in Canada in 2007—the money it would have taken to bring everyone just over the poverty line—was $12.3 billion. The total cost of poverty that year was double or more using the most cautious estimates," although these are admittedly incomplete and fragmentary. The public health community would be well advised to act fast and download the Council's publications before they are consigned to the memory hole.

Another disturbing set of findings about economic insecurity comes from the latest annual survey of Canadian family finances (families of two or more people) from the Vanier Institute of the Family. Some of the study's findings will be familiar: for instance, after-tax income of the poorest 20 percent of Canadian families (two or more people) rose by just 19 percent between 1990 and 2009; the incomes of the richest 20 percent rose by 35 percent. We know from other studies that the trend toward increasing inequality is even more extreme when we look only at the top one percent of the Canadian income distribution: 246,000 people with an average income in 2007 of $404,000 who accounted for 32 percent of all the growth in incomes between 1997 and 2007.

blissful-pic-1Source: Department of Finance Canada.
This illustration is taken from an official Government of Canada publication;
it is used here without Government of Canada endorsement.

Other Vanier findings are less familiar, and more disturbing. For instance, Canada's official unemployment rate in early 2012 would have been 9 percent, rather than 7.6 percent, if the participation rate had been as high as before the recession; 'discouraged workers' who have given up the search for work are not counted as unemployed. And although the overall insolvency rate (bankruptcies and proposals to creditors per 100,000 population) dropped slightly in 2010 and 2011, insolvencies among people aged 55-64 increased by almost 600 percent between 1990 and 2010. Among people over 65 they rose by 1747 percent. This suggests that one of the signal accomplishments of postwar Canadian social policy, cutting the percentage of poor seniors to one of the lowest in the OECD, may be in danger.

As noted in an earlier posting, addressing the possible consequences for population health of such trends unavoidably raises questions of public health ethics. One approach would be to set up an elegant prospective epidemiological study, wait 10 or 15 years, and hope that the casualties, their survivors, or someone are still interested in the answers. Another approach, adopted by the Commission on Social Determinants of Health, is to act on what we now know or can presume with a high degree of confidence, drawing on various sources of evidence and research traditions. So far, our political leaders – and, it must be said, a few of our public health colleagues – seem more interested in punishing the poor and economically insecure, or just ignoring them, than in equalizing opportunities to lead healthy lives. Inequality trends are important for many reasons, but one is that they give the lie to claims that such equalization is unaffordable.

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“A social movement, based on evidence”? *

Posted by Ted Schrecker
Ted Schrecker
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Sir Michael Marmot, who chaired the Commission on Social Determinants of Health and later led a review of influences on health inequalities in England, has called for "a social movement, based on evidence, to reduce inequalities in health" (1) and even claims to identify the beginnings of such a movement. Has such a movement begun to coalesce, and what are the prospects for its success?

In a recent book on women's resistance to workplace sexual harassment in the United States, Carrie Baker defines social movements as "a mixture of informal networks and formal organizations outside of conventional politics that make clear demands for fundamental social, political, or economic change and utilize unconventional or protest tactics" (p. 4) and argues that the resistance she studied fits that definition, even though much of the action took place in courtrooms, administrative hearings, and Congressional committees. Crucially, the coalitions that formed to fight sexual harassment connected women who were not otherwise similarly situated in socioeconomic terms. Restaurant workers, middle managers in banks and federal agencies, and lawyers trying to make partner in their firms were united - sometimes temporarily and precariously – by lack of legal protection from sexual harassment by male colleagues and superiors.

social-movement-pic-1ACT UP demonstration, St. Patrick's Cathedral, New York City, December 10, 1989. Photo: Richard B. Levine

A parallel can be drawn with what is almost certainly the most successful contemporary health-related social movement, that involving treatment and prevention of HIV/AIDS. At the forefront of that movement was the AIDS Coalition to Unleash Power (ACT UP), co-founded in New York City in 1987 by playwright Larry Kramer, who was to become identified as the public face of the movement. ACT-UP quickly adopted the tactic of mounting high-profile demonstrations in places including Wall Street, the US Food and Drug Administration in Washington, DC, and St. Patrick's Cathedral (to protest against Catholic opposition to AIDS education and condom distribution). Some of ACT UP's approaches were controversial, but it "added enterprise and erudition" to confrontation, and the organization and its tactics quickly spread nationally, and even internationally.

In the early years of the epidemic, AIDS was an equal opportunity killer. This is less true today, yet the solidarity forged in the formative years of AIDS activism survives and crosses both class and national boundaries, as seen for example in the transnational support that South Africa's Treatment Action Campaign (TAC) has mobilized. That support was critical in convincing pharmaceutical companies to abandon legal efforts to prevent South Africa's government from buying lower-cost generic antiretrovirals, and TAC continues to appeal to a global audience for maintaining access to AIDS treatment.

social-movement-pic-2ACT UP demonstration, Paris, 2005. Photo: Kenji-Baptiste Oikawa, reproduced under a Creative Commons Licence.

Here's the rub.

Effective social movements are not based on evidence. Social movements can use evidence in various creative ways, but they are based on rage, hopelessness, desperation, hope, or combinations of these. That's where their energy comes from. Normally, as shown by the examples of ACT UP and resistance to sexual harassment, their protagonists share a particular vulnerability even though they may otherwise have little in common. If we go farther back in history, the movement for female suffrage and the trade union movement are useful case studies; movements to abolish slavery, in which some protagonists had no personal stake yet were willing to place themselves at considerable risk, provides a partial counterexample.

What shared passions or vulnerabilities (and effective social movements require at least one of these, and often both) will provide the basis for reducing health inequity by way of action on social determinants of health in Canada? What more needs to be known about social movements in order to create an effective one around this agenda? The answers are far from clear, which may be why the agenda is making slow progress.

social-movement-pic-3Launch of Poverty Free Ontario Campaign, Sudbury, September 2011. Photo: Cait Mitchell (used with permission).

Public health researchers and practitioners, whatever their level of commitment (which varies greatly), are at minimal risk from many of the conditions of life and work that are most destructive of health: inadequate incomes, precarious employment, hazardous exposures on the job, and the physiologically corrosive levels of stress that go along with all of those. Perhaps that is why the enterprise of health promotion still focuses far too much attention on health literacy, "choosing your sandwich with care," and similar constructs that ignore the quotidian challenges of too little money, too many demands in the workplace (including, for women in particular, the domestic workplace), and too few hours in the day. Prof. Marmot's 2004 book The Status Syndrome is eloquent on the topic of these challenges. Further, few efforts appear to have been made to make common cause and build working relationships with anti-poverty organizations or the trade union movement. (I would love to hear from readers about exceptions to this generalization, in Canada or elsewhere, for future postings.)

Gratifyingly, some health professionals now understand the importance of such alliances. For example, in a special section on advocacy in the March 2012 issue of Canadian Nurse, Joyce Douglas of the Canadian Nurses' Association writes: "Front-line nurses can speak from experience and work with organizations, associations and movements that advocate for wages that people can live on, affordable housing, healthy environments and social inclusion." As Ontario and many other provinces face hard choices about how to reduce their post-recession deficits, let's hope health professionals of all kinds understand the issues and the stakes.

* A conversation with Kumanan Rasanathan helped to clarify some of the ideas presented here, but all blame rests with me.

(1) The hyperlink is to a video interview with Prof. Marmot; the phrase is also the title of his response to a series of commentaries on his two reports that appeared in Social Science & Medicine.

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Life A.D. (After Drummond), Part 2: Structural adjustment for Ontario?

Posted by Ted Schrecker
Ted Schrecker
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On February 15 the Government of Ontario released a far-reaching report on reorganizing public service provision in response to the budget deficits that followed the post-2008 recession. The central theme of the report was that “just to meet the government’s goal of a balanced budget seven years hence, the government will have to cut even more deeply from its spending on a real per-capita basis, and over a much longer period than the Harris government did in the 1990s, without the option of an immediate deep cut in social assistance rates” (p. 121). Ontarians will remember that the Harris government cut those rates by 21 percent almost immediately after coming to power. Despite some increases, in 2009 they remained (depending on the type of household receiving assistance) between 17 and 38 percent lower than in 1996 after adjusting for inflation, according to the National Council of Welfare.

The Commission says much that is important and worthwhile about health care in Ontario, starting with the recognition that Ontario does not really have a health care system, but rather “a series of disjointed services working in many different silos” (p. 152), and that Ontario health care does not perform well based on international comparisons. Well grounded hypothetical descriptions of patient trajectories spotlight shortcomings in health care performance (pp. 153, 159, 164), measured against what ought to happen as a matter of routine. The report makes a compelling case for improving coordination among the silos, through measures both large and small, and making the non-system’s current approach to complex and chronic conditions (the management of which is also very costly) more effective – all of which should have been accomplished long ago, for reasons unrelated to cost. The report urges “aggressive” negotiation with the Ontario Medical Association on compensation (p. 189) – bringing to mind Robert Evans’ long-standing insistence that "cost containment is in aggregate income control, by definition" – and, perhaps more importantly from a health policy perspective, insists on moving “critical health policy decisions out of the context of negotiations with the Ontario Medical Association and into a forum that includes broad stakeholder consultation” (p. 185).

life-ad-part-2-pic-1 A leaner, meaner Ontario: Locked out workers at the Electro-Motive plant in London, Ontario, January 2012. Photo: CAW Media; reproduced under a creative commons licenceAlthough such changes are overdue, hard questions remain unanswered. The Commission proposes to strengthen Ontario’s 14 Local Health Integration Networks (LHINs, the province’s variation on regional health authorities) so that they can improve coordination among silos and health care management in general. But can these entities accomplish such critical tasks as ensuring that best practices are rapidly adopted province-wide? What are the pitfalls of specifying that the accountability of LHINs, currently with no requirements for public participation, is to the Ministry of Health, as per the Commission’s recommendations, rather than to the clients they serve? And the proposed transformation of an organization called Health Quality Ontario, now an advisory body, into “a regulatory body to enforce evidence-based directives to guide treatment decisions and OHIP [Ontario Health Insurance Plan] coverage” (p. 186) could be a dream or a nightmare. Since “nothing works” is a fiscally attractive conclusion, we can imagine immense pressure to compromise transparency and scientific integrity, and ignore standard of proof issues, in the interests of cost containment.

The report further acknowledges the importance of social determinants of health: “Socio-economic factors such as education and income explain 50 percent” of population health outcomes, and the physical environment another 10 percent (p. 132) although the percentages, drawn from a Canadian Senate Committee report, appear to be guesstimates and no supporting evidence is provided. This acknowledgement is ironic, to say the least, given what the Commission has to say about social policy.

The Commission’s proposed 0.5 percent limit on annual spending growth for all social programs means that no increase in social assistance rates is envisioned, despite the decline from mid-1990s levels. In fact, the Commission proposes slowing the provincial takeover of social assistance costs downloaded to municipalities during the Harris era (p. 483), prolonging the nineteenth-century practice of leaving “poor relief” to local governments. (Unfortunately, some surveys find that nineteenth-century attitudes toward economic hardship remain widespread.) No new resources are contemplated for social or affordable housing, despite the existence of multi-year waiting lists in much of the province. As the Toronto Star’s Thomas Walkom and a policy analyst for the Ontario Nurses’ Association have pointed out, despite Drummond’s long career as a professional economist, the report ignores the employment consequences of taking billions of dollars out of the provincial economy. Walkom predicts that implementation of the Drummond recommendations would cause unemployment in Ontario to rise to 11 percent by 2018, “even without another global crisis”. Poverty reduction is nowhere acknowledged as a legitimate goal or priority of government; indeed, the word “poverty” appears only six times in the text of the 562-page report.

To put this discussion into context: on Thanksgiving weekend in 2010, the Premier of Ontario was quoted by CBC News as urging Ontarians to donate to food banks, and in March, 2011 395,000 Ontarians relied on a food bank to feed themselves at least once. Rents and food prices are not going down. So the Commission has said to a significant proportion of Ontarians: forget about any hope that your opportunities to lead a healthy life will improve before 2017-2018. The cupboard is bare.

But is it, really? In order to answer this question, we have to look at both the revenue side and the expenditure side of Ontario’s public finances, in historical perspective. The Commission itself emphasizes that “spending is neither out of control nor wildly excessive. Ontario runs one of the lowest-cost provincial governments in Canada relative to its GDP and has done so for decades” (p. 5). Further, it notes that the provincial treasury’s “own-source revenues” – taxes and user fees collected by the province, as distinct from revenues received from federal transfers – as a percentage of provincial Gross Domestic Product (GDP) were considerably lower (13.65 percent) in 2010-2011 than in 1999-2000, midway through the Harris era (15.9 percent). Although precise comparisons are impossible, this is consistent with estimates by the Canadian Centre for Policy Alternatives that, every year since the start of the century, provincial tax cuts (mainly in personal income tax rates) begun in 1995 have reduced revenues by between $10 billion and almost $18 billion relative to the revenues that would have been received if tax rates had remained at their 1994-95 levels. In other words, well before the post-2008 and its undeniable effects on revenue stream, the province’s fiscal capacity was suffering from major self-inflicted wounds.

life-ad-part-2-pic-2

The Commission was instructed not to consider the possibility of raising taxes. However, as shown in the illustration, if we accept the Commission’s estimates of the growth of the provincial economy and the spending restraints incorporated into the Drummond Commission’s “preferred scenario,” but are willing to consider tax increases sufficient to return own-source revenues as a percentage of provincial GDP to their 1999-2000 level by 2017-2018, we see that the budget is in surplus by more than $22 billion. Stated another way, if the province were to pursue what Hugh Mackenzie of the Canadian Centre for Policy Alternatives has called “an adult conversation about the public services we need and the revenue we are going to have to raise to pay for them,” the provincial budget could be balanced in the target year while making available $22 billion more than the Drummond projections for program spending. According to one commentator the province is not even planning pre-budget legislative hearings, thus making it difficult to start such a conversation. Indeed, the Commission’s description of the provincial budget as “a powerful educational tool” (p. 13) suggests that most of the key immediate decisions have already been made. Its proposal for a centralized expenditure management process involving the Premier’s Office, Cabinet Office and Ministry of Finance that “should stay in place for at least several years” warns of little room for debate in the future (pp. 140-141). Shouldn’t public finance be a matter for public debate?

At several points in its report the Commission underscores the difficulties created by the government’s refusal to consider tax increases, anticipating (for instance) a $38.5 billion shortfall in financing planned and necessary public transit investments in the Greater Toronto and Hamilton Area. For those who can afford to drive everywhere, this means only the inconvenience of more traffic jams; for those who can’t, it may seriously limit mobility … and of course that foregone investment also means lost employment. The Commission states that its budget-balancing strategy would mean “tough decisions that will entail reduced benefits for some” (p. 69) – although not, it seems, for everyone. On the matter of soaring compensation for people like Drummond’s fellow commissioners at the top of public sector salary scales, the report says that “focus must remain on the larger picture, which is the government’s need to get the right people into the right positions at a cost that is both compatible with its fiscal circumstances and appropriately aligned with private-sector compensation” (p. 138). Well, workers at Electro-Motive Diesel’s London, Ontario plant know about that kind of alignment: they were locked out after refusing a 50 percent pay cut before the parent company closed the plant and moved the work to Indiana. In the Ontario of tomorrow, it seems that what Saskia Sassen calls “the savage sorting of winners and losers” characteristic of the contemporary global marketplace is to be accepted, and indeed welcomed.

life-ad-part-2-pic-3

Any assessment of the Commission’s implications for population health (and never was there a better example of the need to apply health equity impact assessment to macro-scale economic and social policies) should keep this in mind. As pointed out by (among others) economist Erin Weir of the United Steelworkers, there is quite a bit in the report that those of us committed to social justice can support. At the same time, the report is about much more than public finance. Effectively, it recommends for Ontario a variant of the structural adjustment programs* of marketization and social policy retrenchment demanded by the International Monetary Fund in return for loans enabling low- and middle-income countries to reschedule their debts to external lenders, in the process creating widespread economic hardship and seldom leading to long-term economic improvements. Equity, for both the IMF and the Drummond Commission, was an unaffordable luxury. Against a background of worsening economic disparities that would be further magnified in the future envisioned by the Commission, what is the future of health equity in Ontario? And who will decide?

 

* For readers unfamiliar with the history of structural adjustment, two excellent recent review are Babb, S. (2005), The Social Consequences of Structural Adjustment: Recent Evidence and Current Debates, Annual Review of Sociology, 31, 199-222 and Pfeiffer, J. & Chapman, R. (2010), Anthropological Perspectives on Structural Adjustment and Public Health, Annual Review of Anthropology, 39, 149-165. Unfortunately, so far as I know neither of these is available on an open-access basis.

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Acting on social determinants of health: how much do we need to know?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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Many readers will remember the sequence of events in which former football star O.J. Simpson was acquitted of the murder of his estranged wife and a friend in a criminal trial, yet found liable for damages in a civil suit brought by the family of one of the victims. Leaving aside the sociological roots of the not-guilty verdict in the United States' tragic history of racial antagonisms, in analytical terms the discrepancy can be explained with reference to the higher standard of proof in a criminal trial (proof beyond a reasonable doubt) than in a civil proceeding where a claim for damages can be sustained on a preponderance of the evidence or, in some common law jurisdictions, on the balance of probabilities.

The idea of a standard of proof is critical to understanding the question posed in the title of this posting. A classic article published in 1978 by economist Talbot Page (1) used this concept to analyze public policies toward "environmental risks" like toxic chemicals, which share such characteristics as incomplete knowledge of the mechanism of action, long latency periods between exposure and illness, and irreversibility. He pointed out that most forms of scientific inquiry are organized around minimizing Type I errors – that is, 'false positives' or incorrect rejections of the null hypothesis. Page used the analogy of the standard of proof in criminal trials, and went on to argue that minimizing Type I errors may be a thoroughly inappropriate principle when applied to use of scientific evidence in public policy, because it fails to take into account uncertainty and consequences. Stated another way, "a risk/benefit assessment," albeit often an implicit one, "is part of every public policy action which is based upon the interpretation of the results of a scientific investigation." (2)

Evidence-picture-1Waiting for "evidence of dead bodies" may be inappropriate when responding to health threats from environmental hazards.
Photo by biofriendly, reproduced under a Creative Commons licence.

This point has often been lost sight of in controversies about controlling toxic exposures in the environment and the workplace, with industry resisting regulation by demanding stronger – usually epidemiological – evidence and trying to cast the issue as one of scientific uncertainty: demanding what another economist has described as a "tobacco industry standard of proof." (3) Page correctly pointed out that: "In its extreme, the approach of limiting false positives requires positive evidence of 'dead bodies' before acting." This is, in fact, the standard of proof that has often been applied to research on the health effects of environmental hazards. A further point of importance is that the conventional threshold of statistical significance – 95 percent – may require extremely large and unmanageable sample sizes when the prevalence of a particular adverse outcome is only moderately elevated over background levels. (4) As Page pointed out, "there is literally no information content in a negative finding unless there is an analysis of ... the probability of a false negative." (1)

Choosing a standard of proof for purposes of public health policy therefore is unavoidably an ethical decision, having to do – as yet another author pointed out at around the same time – with the relative acceptability of being wrong in different kinds of ways (5) while we wait for evidence that may or may not be obtainable. Interestingly, a workshop on conceptual and methodological issues in public health science held at the University of Cambridge in 2010 revisited these questions, suggesting that understanding of them in the relevant research communities remains incomplete, even as they remain topical with respect to such issues as environmental causes of breast cancer .

The question of how much evidence is needed for action on social determinants of health underscores the value-laden nature of choices about the appropriate standard of proof. At least two issues are critical.

First, what kinds of research findings are relevant? Clinical epidemiology now widely accepts a hierarchy of evidence with the randomized controlled trial (RCT) at the top; presumably, this is what two authors writing on global health governance had in mind when they claimed that "[f]ew global health interventions are evidence-based, and interventions to improve population health among the poor are often untested ..." To some of us, this assertion is nothing short of bizarre, and neglects the fact that many interventions outside clinical settings cannot be assessed using RCTs, for reasons of ethics, logistics, or both. Colleagues and I pointed out a decade ago, in the context of research on preventing mental illness, that "choosing certain research strategies and standards of proof means the big questions ... probably will not be studied in ways that demonstrate the effectiveness of larger-scale, contextual interventions, and even the small questions will be asked in ways that seriously circumscribe the set of possible answers."

A methodologically pluralist approach, organized around what a former colleague calls a "portfolio of evidence," will yield more meaningful and policy-relevant answers. Unbeknownst to us, Michael Marmot had made a similar point the previous year in a general discussion of evidence for influences on population health: "The further upstream we go in our search for causes ... the less applicable is the randomized controlled trial. .... We must therefore rely on observational evidence and judgment in formulating policies to reduce inequalities in health. In this process, the best should not be the enemy of the good. While we should not formulate policies in the absence of evidence to support them, we must not be paralyzed into inaction while we wait for the evidence to be absolutely unimpeachable." (6) He continues to make this point.

Food-bank-can-use-help395,000 Ontarians received help from food banks in March, 2011.
Image courtesy Ontario Association of Food Banks.

Second, is it necessary to wait for evidence that a particular policy or intervention leads to improved health outcomes, or is it sufficient to have evidence of reduction in risk factors or what might be called intermediate biological variables (like markers of allostatic load, in the context of prolonged stress) that are known to have an adverse effect on health outcomes? This question gains urgency from knowledge of the cumulative effects of negative contextual influences on health over the life course: "waiting for dead bodies" in this case, as in others, can amount to carrying out a large-scale experiment on non-consenting subjects, the results of which may not be available for a generation. Obviously, ongoing evaluation of interventions and policy changes is important, but how much more do we need to know before (for instance) doing what it takes to reduce food insecurity among people for whom eating a healthy diet while paying market rents is arithmetically impossible?

This is a rather polemical way of stating the question, but it is useful in order to get at the hard politics of debates about evidence. Many policies and interventions needed to reduce health disparities by way of social determinants of health will be explicitly redistributive – starting with reductions in income inequality, as noted in a forthcoming editorial in the American Journal of Public Health. As mentioned, companies facing costly regulation of their activities have long found it attractive to frame their opposition as based on the insufficiency of scientific evidence. Similarly, those who stand to lose from tackling "the inequitable distribution of power, money, and resources" – one of the three overarching recommendations of the Commission on Social Determinants of Health – may frame their opposition in terms of the need for more evidence rather than simple self-interest. One-percenters, and those on a fast track to that status, are not a natural constituency for redistributive policies. This is not of course the only explanation for hostility to the social determinants of health agenda, but it cannot be disregarded. Against this background, it's especially important to keep in mind that the appropriate questions are not only about the strength of evidence, but also about how uncertainty should be resolved in a context where "deferring a decision is a decision in itself." They are, in other words, rooted firmly in the domain of public health ethics. Only by insisting on this point can we be sure that debates about when and how to act involve – as they should – the language of values and social justice.

(1) Page, T. (1978) A Generic View of Toxic Chemicals and Similar Risks. Ecology Law Quarterly, 7, 207-244.

(2) Darby, W. (1979) An Example of Decision-Making on Environmental Carcinogens: The Delaney Clause. Journal of Environmental Systems , 9, 109-117.

(3) Crocker, T.D. (1984) Scientific Truths and Policy Truths in Acid Deposition Research. In T. Crocker, ed., Economic Perspectives on Acid Deposition Control (pp. 65-79). Ann Arbor Science Acid Precipitation Series vol. 8. Boston: Butterworth.

(4) See e.g. Higginson, J., Muir, C.S., Muñoz, N. (1992) Human Cancer: Epidemiology and Environmental Causes (pp. 39-44). Cambridge: Cambridge University Press.

(5) Jellinek, S. D. (1981) On the Inevitability of Being Wrong. Annals of the New York Academy of Sciences, 363, 43-47.

(6) Marmot, M. (2000). Inequalities in Health: causes and policy implications. In A. Tarlov & R. St.Peter, eds., The Society and Population Health Reader, vol. 2: A State and Community Perspective (pp. 293-309). New York: New Press.

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HEST: A new frontier for action on health equity? *

Posted by Ted Schrecker
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In December 1995, Cynthia Wiggins was hit by a dump truck while crossing several lanes of traffic in suburban Buffalo, New York; shortly afterward, she died from her injuries. The 17-year-old African-American woman had to cross the arterial road from her bus stop because the bus that took her from downtown to her job in the posh Walden Galleria mall was not allowed on mall property. It was later revealed that the local public transportation authority had for years tried, unsuccessfully, to get permission to stop in the mall's parking lot. In 1999, a lawsuit charging the mall's owners with racial discrimination was settled for $2.55 million (to benefit Ms Wiggins' son) without admission of liability.

Ms Wiggins' death is an especially dramatic example of the connections between transportation policy and social exclusion: specifically, support for a form of apartheid in the United States long after it was challenged in legislation and jurisprudence. In Los Angeles, The Bus Riders' Union has used a variety of tactics, including litigation under national civil rights legislation, to seek improvements in a transit service that mainly serves a darker-skinned, subaltern population unable to afford the costs of driving in a car-oriented metropolis. Although we are not (yet) familiar with similar extremes in Canada, an important and neglected 2009 report prepared for Human Resources and Social Development Canada on mobility and social exclusion in Hamilton, Toronto and Montréal concluded that "the evidence uncovered in terms of mobility and accessibility patterns is suggestive of social exclusionary processes that may prevent various vulnerable groups," specifically low income people, seniors and single parent households, "from accessing the places required for their daily needs." Since social exclusion functions as a social determinant of (ill) health, the role of transportation in social exclusion should automatically be of concern to the public health community.

There are more immediate reasons for concern. One involves the health consequences of transport-related (mainly automotive) air pollution, reviewed among many other places in a 2005 WHO-Europe report and in the same year by the Ontario College of Family Physicians. It is also likely that an inverse relation exists between income and exposure, although the relation is complicated both by the limitations of measuring exposure based on residential location (most people don't spend most of their time at home) and by the "particular social geography" of cities like Montréal. (I would be delighted if readers can identify useful literature reviews on this topic.)

A second issue is the relation between metropolitan form and injuries and deaths from road accidents, where data on the socioeconomic gradient are hard to find and primary data are often collected by law enforcement agencies, using categories that have limited relevance to population health. (Again, readers are invited to contribute sources to the conversation.) A 2003 article by Reid Ewing and colleagues developed a "sprawl index" for 448 metropolitan counties in the United States, matched this against "all-mode" traffic fatality statistics, and concluded that "sprawl is a significant risk factor for traffic fatalities, especially for pedestrians." In the ten counties with the most compact urban form, fatality rates averaged 5.6 per 100,000 population; in the ten counties with the least compact form – that is, the most sprawling ones – the average was 26.3 per 100,000 population. However, hazardous environments for pedestrians are common even in cities that are relatively compact by North American standards.

hest-picture-1-1-of-1Hazardous environments for pedestrians are common, as shown in this picture taken from the University of Ottawa’s downtown campus.

A third reason for concern involves the relation among transport policy, the built environment, and overweight and obesity, which are now recognized as one of the most urgent public health challenges. The idea of obesogenic environments has gained widespread acceptance, and represents an essential challenge to the emphasis on 'lifestyles' or 'healthy choices' that characterizes many health promotion efforts. Isolating the specific contribution of transport policy is complicated by the fact that in the metropolitan environment, many things are going on at once. For example, neighbourhoods may be more conducive to physical activity ('walkable'), but may also have few full-service grocery stores but lots of convenience stores and fast-food outlets, or neighbourhoods where the built environment is conducive to walkability may also be those where crime is highest. However, some evidence shows a direct link between settlement patterns or transportation and obesity. For example, a 2004 study using a sprawl index – not the same one used by Ewing and colleagues – and self-reports of Body Mass Index (BMI) found that each 1-point increase in the sprawl index (on a scale of 100, values for large US metropolitan areas ranged from 6 to 100) was associated with a 0.5 percent increase in the risk of obesity, after individual-level variables like income, gender, age and education were controlled for. Almost by definition, urban sprawl implies a high reliance on automobiles for transportation, as shown in a classic graph produced by Jeffrey Kenworthy

hest-picture-2-1Source: P. Newman and J. Kenworthy, “‘Peak Car Use’: Understanding the Demise of Automobile Dependence,” World Transport Policy and Practice 17 (June 2011), reproduced with permission.

Finally, there is the need to shift transportation patterns in order to limit climate change, which itself is likely to have substantial adverse health impacts that will be inequitably distributed, falling first and hardest on people and regions that contributed least to the buildup of greenhouse gases. A 2009 article in The Lancet pointed out that transport emissions are rising faster than all other categories, and argued using scenarios for London and Delhi that there would be substantial health benefits from moving to "sustainable transport" including both lower-emission motor vehicles and more walking and cycling, quite independent of the effects on climate change. Elsewhere, a recent assessment of the effects of reducing automobile usage for short trips (1.6 km or less) in the Midwestern United States came to similar conclusions, and further projected several billion dollars a year in health care cost savings. As with other studies cited here these are only selections from a very large literature, but the pattern is clear.

So far as I know, the acronym HEST (for Healthy, Equitable and Sustainable Transportation) is my own invention. There is no shortage of useful information about how to begin, starting with a WHO evidence review mentioned in an earlier posting that identified transportation as an important area for action to reduce health inequity. Kenworthy has listed "ten key transport and planning decisions for sustainable city development," including de-emphasis of freeway and road; planning for employment and housing growth in the city centre and sub-centres; and – critically – a planning process that "is a visionary 'debate and decide' process, not a 'predict and provide,' computer-driven process." (A recent Toronto Star commentary on how the city's planning is now driven by the "pseudo-science" of traffic engineering made a similar point.) Ewing and colleagues have described the "five D's of development": density, diversity, design destination accessibility, and distance to transit. This source is one chapter in an excellent book called Making Healthy Places published by Island Press. World Streets, a web site specifically devoted to "equity-based transport," is another valuable and provocative resource.

Some Canadian organizations have taken up the challenge. I've already mentioned the work of the Ontario College of Family Physicians. In 2007, Toronto Public Health produced a report on air pollution, traffic and health that concluded: "Given there is a finite amount of public space in the city for all modes of transportation, there is a need to reassess how road space can be used more effectively to enable the shift to more sustainable transportation modes" like "walking, cycling and on-road public transit." (I don't think the city's current mayor has read it.) And Alberta Health Services has produced a well researched and hard-hitting fact sheet on urban sprawl and health. Doubtless much more is going on, and I hope readers will post appropriate news, citations and links. 

hest-picture-3-2

hest-picture-4-2

Predictably, our colleagues in other countries have been less polite and more proactive. Margaret Douglas and colleagues in Britain's NHS (including the Director of Public Health for a primary care trust in Manchester) wonder whether cars are the new tobacco, pointing to the multiple negative effects on health and sustainability of auto-oriented transport systems and the influence of the "car lobby." Also from the UK, writing in the December, 2011 issue of Public Health Today Philip Insall calls for a 20 mph speed limit in residential areas, noting that some continental cities have already made this move and that it would eliminate up to 580 child deaths and serious injuries each year. (Lower speed limits are just one kind of traffic calming measure; many others involve design changes, as noted in an important review by the Canada's National Collaborating Centre for Healthy Public Policy just released last November.) And Andy Jones, writing about obesogenic environments, says: "Maybe we just need to force society to change. Excluding traffic from city centres, radically increasing parking charges, forcing employees to walk at least part of the way to work by removing workplace car parks" as well as taxing high-fat foods.

Forcing society to change can be difficult when we have things like elections, and that's as it should be. Canada's public health community could, however, be much more energetic in advocating for such changes, and providing leadership to ensure that their equity and health benefits are part of the public debate during and between elections.

* Unfortunately, as with previous postings some hyperlinks lead to sources that are not available on an open-access basis. I have tried to find open-access materials wherever possible.

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Life A.D. (After Drummond), Part 1

Posted by Ted Schrecker
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As Ontario-based readers will know, on February 15 the Government of Ontario released a far-reaching report on reorganizing public service provision in an era of austerity. The report was the work of a small commission chaired by Don Drummond, a former public servant in the federal Department of Finance and subsequently chief economist for TD Bank. The other commission members were the President of Laurentian University (base salary $304,647 in 2010); the Vice-President for Communications and Community Engagement of the Centre for Addictions and Mental Health (base salary $245,352 in 2010); and the dean of the business school at the University of Western Ontario (base salary $405,000 in 2010). These figures are matters of public record, as they should be, and are available under the Province of Ontario's salary disclosure legislation. The point is that all members of the commission were, to put it mildly, isolated from many of the influences that limit other Ontarians' ability to lead healthy lives.

The report proposed that public spending on health care – the largest item in Ontario's budget, as in that of other provinces – should grow by 2.5 percent annually over the next several years, as compared with the recent trend of 6 percent annual growth. Slower growth was recommended for public education; just 0.5 percent for "social programs"; and spending reductions of 2.4 percent annually in all other programs. However, the 'how to' rather than the 'how much' aspects of the report's recommendations may ultimately be most significant, if implemented.

The report has already generated a flood of commentary, to which I don't propose to add right now. I'll be posting a longer analysis after my presentation at Public Health Ontario's PHO Rounds on March 2, the last part of which will deal briefly with life A.D. (After Drummond). Meanwhile, the Wellesley Institute has commented on the report's neglect of broader social determinants of health that affect the prevalence of and prognosis for conditions like diabetes (the topic of one of my earlier postings). And the Toronto Star's Thomas Walkom pointed out the bias introduced by the government's instructions to the commission not to consider tax increases, at a time when the fiscal capacity of Canadian governments has been drastically reduced, while allowing it to consider user fees that will have a disproportionate impact on low- and middle-income households.

Walkom also pointed out the lack of attention to the employment impacts of a plan to take billions of dollars out of the Ontario economy by way of public spending cuts – indicative of a broader trend in which employment has all but vanished from the public policy agenda except when governments want to trot out the 'job creation' benefits of handouts to one or another corporate client. He predicts that implementation of the Drummond recommendation would lead to an Ontario unemployment rate of 11 percent by 2018, "even without another global crisis". Abundant evidence shows that not only unemployment rates but also the conditions of employment – full-time and secure versus precarious, casualized or entirely informal – and their effects on working conditions are key social determinants of health, so this is a point of some importance. (An aside to readers: would a future posting expanding on this evidence be of any interest?)

As pointed out by (among others) economist Erin Weir of the United Steelworkers, there is quite a bit in the report that those of us committed to social justice can support. There is also quite a bit that might be compatible with a "health in all policies" agenda, and with advancing health equity. Where will the public health community be as debates about the report continue in the coming weeks? How prominently, if at all, will population health and health equity figure in the discussions? Does the public health community, however defined, have an organizational platform capable of rapid, critical and effective response to events in the broader public policy environment? If not, it's high time we did.

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How (some) sociologists think about health inequalities

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An exchange in the most recent issue of the journal Sociology of Health and Illness (for the moment, at least, available for open access) provides a useful overview of theoretical debates about the sources of health inequalities. Graham Scambler's review article summarizes main themes in these debates, starting with a relatively familiar typology of behavioural, material and psychosocial orientations. (Readers who have run across these terms without explanation of their contrasting initial assumptions will find Scambler's summary especially useful.) He then argues that new research directions emphasizing the origins of health inequalities in social structures are needed in order to follow through on the agenda of the Commission on Social Determinants of Health, and rather breathlessly concludes that "there is a need for a political economy of health that transcends the nation-state ... National health inequalities can no longer be explained without reference to transnational social mechanisms." Some of us, of course, have been saying this for quite a long time.

russia-poverty-picA homeless woman and her 14-year-old daughter beg for money in a Moscow metro station,
December 17, 1999.
Photo: Mark Milstein, Getty Images News, Getty Images.

There follow two brief responses. William Cockerham takes a skeptical view of Scambler's emphasis on structures. Then again, since Cockerham has attributed the mortality crisis that followed the collapse of the former Soviet economy to the lack of a "stable and resourceful middle class [that] has served as a powerful social carrier of a positive health lifestyle capable of penetrating the boundaries of other classes" (1, p. 469) – forget about a 50 percent decline in national economic product, official poverty rates over 40 percent and massive capital flight - this is perhaps to be expected. Canadian scholar David Coburn, on the other hand, lauds Scambler's focus on structural influences and indeed argues for a more explicit focus on how the operations of the global market economy magnify economic inequalities and therefore disparities in the chance to lead a healthy life.

I agree with Coburn that "structural analysis too often stays at high levels of abstraction," neglecting what philosopher of science Jon Elster has called the texture of everyday life, which is crucial to understanding how structural influences manifest themselves in the household and the neighbourhood. On this point, my main quarrel with Scambler is his apparent belief that sociology is all there is to the social science of health disparities. Political science and anthropology, to name just two other fields, have a lot to say as well – and the latter discipline, in particular, has done rather a better job of explicating the necessary macro-micro connections. A recent article by James Quesada and colleagues on the situation of Latino migrant labourers in the United States provides just one illustration among many.

(1) Cockerham WC (2007). Health lifestyles and the absence of the Russian middle class. Sociology of Health and Illness, 29, 457-473.

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Environmental justice: revived and revisited

Posted by Ted Schrecker
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With a few exceptions, such as a short 2008 report from the Canadian Policy Research Networks, socioeconomic inequalities in exposure to environmental hazards have not been a central concern of Canadian population health research or public health practice. In the United States, on the other hand, the highly visible and persistent reality of racial segregation has generated a substantial stream of research and activism on environmental justice, including the establishment of units like the Environmental Justice Resource Centre in Atlanta. In 1994, an executive order issued by then-President Clinton required all federal agencies to consider environmental justice in their programs. Official interested waned (to put it politely) under subsequent Republican administrations, but the issues are now being revisited.

The December 2011 issue of the American Journal of Public Health – fortunately, available on an open-access basis – is based on a symposium on Strengthening Environmental Justice Research and Decision Making organized by the US Environmental Protection Agency in March 2010. The articles are a valuable resource for exploring both the strengths and the limitations of current US approaches to the issues, and amply support an editorial conclusion that the EPA's current approach "is not sufficient to end make progress toward ending environmental health disparities and environmental injustices," given its heavy reliance on toxicology and engineering.

env-justice-picture-1-1Reproduced with permission of the US Environmental Protection Agency

Among the many important points raised in the collected articles:

  •  An overview of methodologies points out that most existing studies of the spatial distribution of environmental health hazards rely on census data, so effectively track only nighttime exposure. People's daytime locations and exposures are harder to track, and it's certainly plausible that people living in locations where their exposure to environmental hazards is high are also more likely than others to be working in similar environments.
  •  In assessing the overall distribution of inequalities in the chance to lead a health life, it is essential to consider the combined health effects of chemical exposures and stressors of other kinds, including psychological and social stressors. A companion article by Bruce McEwen, one of the world's leading researchers on the biology of stress, elaborates on the physiological pathways that are likely to be relevant. Since population health researchers often ignore the massive accumulation of human and non-human evidence on this topic, its recognition is especially important.
  • Paula Braveman and colleagues elaborate on a now familiar definition of health equity by dealing explicitly with the issue of strength of evidence and standards of proof, arguing: "It must be plausible, but not necessarily proven, that policies could reduce [health] disparities, including not only policies affecting medical care but also social policies addressing important non-medical determinants of health and health disparities ..."

env-justice-picture-2-1Living near pollution from heavily travelled roads is one of many environmental hazards that are unequally distributed. Photo: Atwater Village Newbie

The symposium also (not always intentionally) underscores the limitations of the US approach. For a variety of reasons, many of which have to do with industry's use of the courts to resist environmental regulation, quantitative risk assessment is "the central paradigm of the Environmental Protection Agency". Especially in the case of cancer risk, it can be difficult to establish links with the spatial distribution of hazards: because of long induction and latency periods, "studies would need to include residential histories for as many as 15 to 30 years before a cancer diagnosis to capture pertinent environmental exposures," even before dealing with the problem of exposures when people are not at home – on the job, for instance. The effect is to build in a bias against regulation that requires "requires positive evidence of 'dead bodies' before acting," in the words of a classic 1978 article by environmental economist Talbot Page, unfortunately not available for open access. More generally, the emphasis on quantitative risk assessment focuses attention and resources on refining measurement techniques and building ever more elaborate models of causal pathways. An alternative, explicitly precautionary approach to environmental justice would focus instead on eliminating hazards once a much lower standard of proof is met. This tension is hardly unique to environmental justice; indeed, as Page pointed out, it is pervasive in the regulation of many kinds of health hazards.

As mentioned, environmental justice issues have had a relatively low profile in Canada. Three Canadian researchers recently argued (I think quite correctly) that institutional health promotion here has simply failed to address environmental health inequalities. Here's one of many areas related to social determinants of health in which even a modest commitment of additional research dollars is likely to generate valuable, if politically awkward, findings.

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Understanding social determinants of health: A good-news story

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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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