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Resources from around the Web: Information abundant, time needed

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 16 January 2012
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Herewith a potpourri of important portals and blogs from around the Web. If anyone has tips about where to find time to make the best use of them, please let all of us know!

sir-michael-marmot
Sir Michael Marmot speaking in Rio

University College London has just launched the Institute for Health Equity. Headed by Sir Michael Marmot, the Institute's initial activities include leading the "Euro Review" of social determinants of health for WHO's European office. The Institute's site invites contributors to submit projects, reports and case studies, and already features numerous links to "related work" in the UK and elsewhere. It also provides a link to Sir Michael's own blog, where in a posting about the World Conference on Social Determinants of Health in Brazil he describes efforts to ignore the role of the Commission on Social Determinants of Health that he chaired as "attempted airbrushing" based on "objections to the Commission's strong emphasis on inequities in power, money and resources." All absolutely true, and you read it here first in Sir Michael's own words. 

At the Brazil conference, the World Health Organization launched an electronic platform called Action: SDH. Registration (free) is required to access many features of the site, but they are well worth the minute or so required to register and therefore to be able to post content. Like most such 'platform' sites, the value of this one will depend on involvement by members of the community that it is designed to establish.

PolitiquesSociales (en français, but linking to numerous sources in English) is produced by the Centre de recherche sur les politiques et le développement social at l'Université de Montréal. It offers a monthly collection of news items and research products on social policy and inequality around the world, with a strong European flavour. Canadian Social Research Links, updated weekly, is an almost encyclopedic collection of similar material, focusing mainly although not exclusively on Canada. It's produced by Gilles Séguin, a former federal public servant (1975-2003) who worked on social policy issues in various incarnations of what is now called Human Resources and Skills Development Canada. These sites are quite simply indispensable for anyone wanting to build the bridges between public health and social policy that we often neglect. E-mail newsletters from both sites are available by subscription.

On to a couple of blogs that more closely resemble this one. Healthy Barbs is written by Barbara Brenner, a lawyer and former executive director of San Francisco-based Breast Cancer Action. Brenner brings both rare wit and a litigator's rigorous style to commenting on such matters as how foundation support for the supposedly independent Institute of Medicine that is part of the US National Academy of Sciences may have influenced the content of a recent report on environmental causes of breast cancer. Brenner is also interviewed in a new National Film Board feature-length documentary on how corporate-backed marketing has distorted on breast cancer politics: Pink Ribbons, Inc . Watch for it in Canadian theatres on February 3.

Finally, there's a Canadian blog called DrPHealth, by a public health professional who writes "with some anonymity to protect its author as it strives to increase transparency, promote justice and champion equity." Like Brenner, the author is rigorous about posting references and hyperlinks to his/her sources, which moves this site to the top of those I would recommend to students and practicing professionals alike. One recent posting led me to a new Canadian Public Health Association knowledge centre site, which in turn led me to at least two interesting-looking electronic resources. I won't comment further, since I have not had a chance to explore these, but once again the potential is clear.

Now, about a source for those 48-hour days ...

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It's all about priorities: How to think about health equity, part 2 - Talking taxes

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 13 January 2012
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In the previous posting, I argued for a closer look at public spending priorities, suggesting that governments have in fact been quite successful in finding money for a variety of purposes when it suits them. Here I look at the revenue side of the equation: an area where advocates for population health and health equity have, if anything, been even more timid.

Taxes do at least three things. First, they supply revenues for public purposes such as education, health care, and defence. Second, they create incentives to engage in certain kinds of behaviour and not others, with tax breaks for business investment and so-called sin taxes that raise the price of alcohol and tobacco being the most obvious example. Third, the way in which tax revenues are raised – how and from whom – can moderate (or, in some cases, magnify) trends in income and wealth inequality. As noted in an earlier posting, like many other countries Canada has conspicuously retreated from using taxes to moderate market-driven patterns of income inequality.

Canada faced a serious fiscal crisis in the 1990s. A combination of sustained growth in the United States, our major trading partner, and far-reaching spending cuts in successive federal budgets starting in 1995 turned a federal deficit of $42 billion in 1993-94 into a balanced budget by 1997/98. However, having balanced the budget both the Liberal governments of Jean Chrétien and Paul Martin and (especially) their post-2006 Conservative successors made a momentous choice: reducing income taxes, and eventually the GST, rather than reinvesting in social provision and economic infrastructure. By 2010, the federal government was claiming that its policies would reduce tax revenues "by an estimated $220 billion over 2008-2009 and the following five fiscal years" (1, p. 49). Clearly, the authors of the budget thought such reduction of fiscal capacity was a good thing.

Provincial governments, notably in Ontario and British Columbia, followed a similar route, with the benefit of tax cuts concentrated among their wealthiest residents. Ontario government figures showed that between 1995 and 1998, the richest one per cent of Ontarians (with incomes above $177,000), saw their annual tax bills drop by an average of $10,785 (2). When the BC liberals came to power in 2001, they followed a similar course, with provincial income tax reductions worth $644 a year to a resident earning $40,000 a year, but $7,797 to her senior manager paid five times that amount (3). A subsequent tax cut, in 2007, was calculated based on provincial budget figures to be worth $82 per year to a British Columbian with a taxable income of $20,000, but ten times that to a taxpayer with an income over $100,000 (4).

What were the consequences? According to the Organisation for Economic Co-operation and Development, tax revenues of all levels of government in Canada added up to 32 per cent of our Gross Domestic Product (GDP) in 2009, the lowest proportion since 1980. To put these figures into perspective, between 1990 and 2000 the figure never fell below 35 percent, and total tax revenues in the Nordic welfare states are between 42 and 48 percent of GDP. As noted in an earlier posting, these countries have child poverty rates lower than 5 percent on a standard cross-national comparative measure, according to the Luxembourg Income Study; Canada's are over 15 percent. The OECD estimated Canadian central (i.e., federal) government revenues at 13.3 per cent of GDP in 2009, the lowest proportion since the mid-1980s.

Public discussion of the opportunity costs and social and health consequences of these reductions in fiscal capacity, which international relations scholar Richard Falk has called "the social disempowerment of the state" that "follows from the impact of neoliberal ideas" (5), has been effectively nonexistent in Canada; we have been let down on this point by political leaders of every stripe. Going back to Ron Labonté's long-ago exercise, quoted in the preceding posting, we ought to ask what Canada's governments might do with just that additional 3 percent of GDP (about $40 billion) in lost fiscal capacity. Invest more in early childhood education and care – an area where, according to UNICEF's Innocenti Research Centre, Canada lags behind almost every other wealthy country? (The report in question identified ten "minimum standards for protecting the rights of children in their most vulnerable years," and found that Canada met only one of them.) Reduce the child poverty that Parliament declared its intention to eliminate, way back in 1989? Finance dental care for the poor? And what might be accomplished if we were willing to raise governments' share of GDP even a few more percentage points closer to the levels that are commonplace in much of Europe? (This would not be a matter just of raising income and payroll taxes. The tax on gasoline in every country in what used to be called western Europe is far higher than in Canada, and even drivers in middle-income Chile pay more per litre than Canadians, according to figures from the International Energy Agency.

Priorities-part-2-pic-1-gasoline-prices-table

I am not making a blanket argument for bigger government; many areas of public spending could and probably should shrink. Prisons, fighter aircraft and the salaries of senior university administrators come readily to mind; we all have our own lists. In this posting and the preceding one, I have made the argument that the resources available to Canadians are more than sufficient for any objective related to social determinants of health that we might reasonably wish to accomplish. When we are told that such objectives are unaffordable, the real message is either (a) that other areas of spending are more important, or (b) that tax cuts are more important. The more value any society assigns to tax cuts, the harder the choices it will have to make about spending priorities in the public sector, and their direct and indirect impacts on health equity.

 

  1. Department of Finance Canada. Budget 2010: Leading the Way on Jobs and Growth. Ottawa: Department of Finance Canada; 2010.
  2. Ontario Jobs and Investment Board. Report to Taxpayers: Jobs and the Economy. Toronto: Government of Ontario; April 1998.
  3. BC Ministry of Finance figures cited by Lunman K. New B.C. Premier Slashes Income Taxes for all Residents in First Day on the Job. The Globe and Mail, June 7, 2001.
  4. Murray, Stuart. Who Gets What from the 2007 BC Tax Cut? Vancouver: Canadian Centre for Policy Alternatives; May 2007.
  5. Falk RA. Human Rights Horizons: The Pursuit of Justice in a Globalizing World. New York and London: Routledge; 2000.
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It's all about priorities: How to think about health equity, part 1 – expenditure budgets

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 10 January 2012
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The Commission on Social Determinants of Health made a compelling case that the "unequal distribution of health-damaging experiences is not in any sense a 'natural' phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics." Serious efforts to reduce health inequity by way of public policy must start with the budgetary priorities of governments at every level: what they spend money on, what they reject as unaffordable, and what they don't even think about.

More than 20 years ago Ron Labonté, then president of the Ontario Public Health Association and now a professor and former colleague at the University of Ottawa, published an article in the Canadian Journal of Public Health asking whether health care spending might not actually be creating risks to health, diverting resources from expenditure objectives that might actually lead to higher returns in terms of health outcomes. He pointed out that the $350 million increase in funding for hospitals' capital spending provided for in the 1990-91 Ontario provincial budget could, if used for other purposes, have financed 70,000 rent-geared-to-income housing units, 547,000 more subsidized daycare spaces, or 12,750 transition shelter beds for battered women and their children.

With 20/20 hindsight, this approach was both creative and destructive. It was destructive in that it positioned health care and investments in social determinants of health as direct competitors for resources. Tactically, this is a battle those of us concerned with how conditions of life and work affect the health of people with limited resources will always lose, and perhaps we should: even in countries that supposedly provide universal access to health care, such people all too often end up at the back of the queue.

The approach was nevertheless creative in that it directed attention to the broader question of how governments spend the considerable resources at their disposal, with what consequences for health. Any serious effort to implement a Health in All Policies approach, or similar rubrics that have been proposed for reducing health inequities, requires a hard look at local, state or provincial, and national budgets. These are nothing more or less than the roadmap of governmental priorities and therefore in democratic societies, at least in theory, the priorities of a decisive plurality of voters. As governments across Canada prepare budgets that must deal with the continuing fallout from the economic meltdown of 2008, this point should be kept in mind.

Priorities-part-1-pic-1-Ottawa-freeway-1-of-1What do recent budgets tell us about those priorities? Let's look at a few examples. Canada's national government has adopted changes in the criminal law that will cost billions of dollars to implement, roughly doubling federal and provincial spending on jails and prisons between fiscal 2009/10 and 2015/16 according to the Office of the Parliamentary Budget Officer, on the basis of what must charitably be called limited evidence of need or effectiveness. Apparently, criminal law doesn't need to be evidence-based, or meet any clear standard of cost-effectiveness. The Minister of Justice himself has said that "[w]e're not governing on the basis of the latest statistics," and that the government does not "put price tags in legislation". Late last year, the national government also found $477 million to contribute to building US military satellites. Here in Ontario, it's often arithmetically impossible to eat a healthy diet on a low income if you're paying market rents and more than 150,000 people are on waiting lists for affordable housing, yet the same day that figure was published the province found $200 million to widen a freeway through downtown Ottawa.

Somehow, my search for loonies in jacket pockets never turns out quite that well. Isn't magic wonderful?

Now, obviously governments have to balance a multitude of competing priorities, and health is only one of them. The point of the examples is that the tension of greatest concern is not necessarily between health care and 'upstream' interventions, and that all too often, ensuring that everyone has the same opportunities to lead a healthy life – what health equity is about – is far down the list.

Driving changes in budgetary priorities is essential to reducing health inequity, and will require more of the kind of creativity shown in Labonté's long-ago article. Public health associations could commission or carry out health equity impact assessments (HEIAs) of municipal, provincial and national budgets. Enterprising professors could ask their graduate students to do the same as a course assignment or group project. (To its considerable credit, Ontario's Ministry of Health and Long-term Care now has an internal HEIA process, but it only applies within the health system – arguably, not where HEIA is most needed.) And all of us concerned with health equity will need to forge individual and organizational alliances far beyond our usual institutions, communities of practice and comfort zones.

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“Divided we stand”: OECD on inequality, and reasons for caring

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 January 2012
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The Organisation for Economic Co-operation and Development (OECD) is a group of high-income (and some middle-income) countries that historically has paid attention mainly to conventional economic indicators such as growth, productivity and innovation. It does other things as well, including providing some of the best statistical overviews and assessments of its members' foreign aid performance. And recently, it has been addressing the consequences of increasing economic inequality within the borders of many of its members.

Divided-we-stand-pic-1Ermenegildo Zegna Boutique in Chile, one of the OECD’s most unequal countriesA December 2011 OECD report provides a description of those increases, an analyses of their causes, and country-by-country data that have some sobering implications for Canada. The report finds that income inequality increased in most OECD countries over the past three decades, although the level of inequality varies widely. The average income (adjusted for household size) of the richest 10 percent of the population is 5 or 6 times the average income of the poorest 10 percent in the Nordic countries, but 10 times that of the poorest in Canada, 14 to 1 in the United States, and 27 to 1 in Mexico and Chile. The report identifies a number of contributors to rising inequality of market incomes, including several aspects of globalization; technological change (which to the authors' credit it describes as hard to disentangle from globalization); changes in hours worked, which have favoured higher earners; and changes in household structure.

There is much room for debate here, notably about the role of globalization and the reasons for rising labour market incomes at the top of the income distribution, which have played a major role in increasing inequality, but also about the OECD's view that inequality can be reduced through raising workers' educational levels. This is worth doing, but effects on inequality are likely to be offset by growth in the kinds of work susceptible to 'offshoring'. For policy purposes, a point of particular interest is how taxes and benefit systems change the distribution of income, and how their effect varies across countries and over time. Like earlier analyses, the report points out that taxes and benefits in some countries (many in Continental Europe) are more strongly redistributive than in others (like the United States and Chile). Generically: "Until the mid-1990s, tax-benefit systems in many OECD countries offset more than half of the rise in market-income inequality. However, while market-income inequality continued to rise after the mid-1990s, much of the stabilizing effect of taxes and benefits on household income inequality declined."

The country note for Canada points out that the share of all income flowing to the richest 1% of Canadians grew from 8.1% in 1980 to 13.3% in 2007 – a trend that closely parallels an even more extreme pattern in the United States, where the income share of the top 1% is now higher than at any point since the Great Depression. (Readers interested in exploring comparative trends in top incomes may want to explore the World Top Incomes Database.) The OECD also points to the declining redistributive effect of Canadian taxes and transfers – a point made a few years ago in a Statistics Canada study, which observed: "Redistribution grew enough in the 1980s to offset 130% of the growth in family market-income inequality -- more than enough to keep after-tax income inequality stable. However, in the 1990-to-2004 period, redistribution did not grow at the same pace as market-income inequality and offset only 19% of the increase in family market-income inequality." The OECD note identifies a somewhat less dramatic retreat from redistribution, reflecting the fact that many ways of doing such calculations exist - for example, the OECD study restricted its analysis to the population aged 15-64 - but the general trend is clear.

Why should population health researchers be concerned with rising economic inequality? There are several reasons, most of which are familiar. First, rising inequality may lead to increases in poverty, however it is defined, although that is not necessarily the case. Second, socioeconomic gradients in health usually exist across the entire income spectrum. Intuitively, we would expect these gradients to be steeper when economic gradients are also steeper, other things being equal, although this is a difficult proposition to test because of the impact of policies that do not directly affect income distribution. Third, income inequality is only part of the story: wealth inequality, which the OECD study did not address, is normally greater than income inequality, and insecure and precarious jobs (which have their own health implications, including higher exposure to on-the-job hazards) are concentrated at the bottom of the income scale. Fourth, it is argued – notably by Richard Wilkinson and colleagues – that higher levels of economic inequality within a society lead to overall lower levels of health, although the mechanisms of action remain unclear.

Divided-we-stand-pic-2Photo by Paul Keller, reproduced under a Creative Commons LicenceA final reason has received less attention in the context of health policy; it involves a phenomenon that former US Cabinet secretary Robert Reich called the "secession of the successful". Past a certain high level of income and wealth, people need less from government, and different things. As one Arizonan interviewed for an article on politics in that state put it: "People who have swimming pools don't need state parks. If you buy your books at Borders you don't need libraries. If your kids are in private school, you don't need K-12. The people here, or at least those who vote, don't see the need for government." To which we could add: people who can afford to drive or fly everywhere don't need public transportation; people with secure incomes gain little from public financing of social or subsidized housing; people who could afford private insurance may resist paying taxes to keep a public health insurance system afloat for the less healthy and less wealthy; and so on.

What happens to the political prospects for reducing health inequity by way of social policy when a small but highly influential segment of the population needs government mainly for roads, police and prisons – and perhaps regards enhancing its own security through private purchases as routine? I recently returned from a workshop in Johannesburg, one of several South African cities that are more economically unequal than any other developing world cities included in United Nations Human Settlements Programme study (p. 73). The workshop was held in a guest house with an electronically activated gate, in a suburb where many properties were fenced with razor wire, and almost every one boasted a private security service's "armed response" sign. This is commonplace in South African cities. From Arizona to South Africa, does the interaction of inequality and privatization suggest a self-reinforcing process that can only be reversed through internal revolt or catastrophic external events (think the Great Depression and the second World War)? Health economist Robert Evans, quoted in a previous posting, wonders: "If we are back to a pre-war income distribution, how much of our post-war social policies can survive?" We should pay more attention to this question.

1The Gini coefficient, a standard measure of income inequality, in Johannesburg is 0.75 according to this study – more unequal than the national distribution of income in any country in the world. By comparison the Gini coefficients in Mexico and Chile, the two most unequal countries in the OECD, were 0.494 and 0.476 in the late 2000s, according to the OECD.

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Diabetes in Canada: Parts of the story

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

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

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

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

 

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

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

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

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

 

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

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

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

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“Logics of expulsion”

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 09 December 2011
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saskia-sassen-picAt the Global Health Conference in Montréal last month, I had the privilege of being on a panel with Saskia Sassen, the Robert S. Lynd Professor of Sociology at Columbia University. She is one of the most intellectually sophisticated scholars writing in English (and indeed in various other languages) about how globalization is transforming societies rich and poor alike – and in the process affecting who has the chance to live a long and healthy life.

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

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

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

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

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

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

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

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What's it like to be poor in Canada?

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

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

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

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

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

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

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

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

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

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

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

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

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

See also:

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

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

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First snow, and a New York state of mind

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

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

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

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

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

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Getting real about intersectoral action

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Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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Many policies that affect social determinants of health, and therefore the prospects for reducing health inequity, are outside the control (and sometimes beyond the competence) of government ministries, departments and agencies responsible for health protection and public health. Advancing health equity therefore requires what is variously described as a health in all policies approach (which was the theme of Finland's presidency of the European Union in 2006), a whole of government approach, or intersectoral action.

In parallel with the work of the WHO Commission on Social Determinants of Health, the Public Health Agency of Canada produced a synthesis of 18 country case studies of intersectoral action. The level of detail varied considerably, and to their considerable credit the authors of the report warned about the lack of a standard reporting format, and further that "the majority of case studies were written from one perspective only in most cases from the perspective of a representative of the health sector. The tone of the case studies was often positive (rather than critical)," as might be expected from what were essentially self-reports, "and we had no opportunity to determine what the opposing views, if any, might be." Indeed, a cynic might observe that intersectoral action is far easier to talk about than to carry out with demonstrable improvements in outcomes.

A new series of monographs produced by WHO in Geneva, in collaboration with the WHO Regional Office for the Western Pacific, now offers valuable resources for moving beyond rhetoric in intersectoral action, drawn from experiences in countries rich and poor alike. Reports produced so far address housing, education and transportation: three of the most important social determinants of health, with special importance from an equity perspective.

The key message of the housing monograph is that health equity can be a guiding principle and catalyst for sustainable housing and development policies, organized around advancing the right to housing for all citizens. It identifies numerous opportunities for intersectoral action to achieve eight objectives: sound construction, safety and security, adequate size, availability of basic services, affordability, accessibility, tenure, and protection from climate change. Several of these are directly relevant to Ontario, where waiting times for affordable housing can be measured in years and where – in pre-recession 2007 – 13.9 percent of urban households (17.2 percent of Toronto households) were in "core housing need" as defined by Canada Mortgage and Housing Corporation. This means that their housing requires major repairs, lacks enough bedrooms for the size and composition of the household, or costs more than 30 percent of before-tax household income; the core housing need concept does not take into account problems related to neighbourhood characteristics or inadequate transportation, so understates the opportunities for creative policy initiatives.

cat-1The education monograph is organized around recognition that universal access to education opportunities is one of the most powerful determinants of child well-being, health equity and development. Critically, the monograph recognizes that "disparities in educational attainment among learners are often based on living conditions outside the realm of schools," taking the imperative for intersectoral action to a new level. We may think that such problems are not a serious issue in Canada, but the work of such researchers as Human Early Learning Partnership scholar Paul Kershaw at the University of British Columbia provides an urgent wake-up call. Kershaw has advocated a New Deal for Families that would combine increased income support with flexible working hours (flextime) and drastically expanded access to affordable quality child care services. As one of those childless-by-choice individuals whose cohabitants are quadrupedal and furry, I more than most people need this kind of reminder about the financial and logistical stressors involved with raising children on wages that are stagnating while housing costs and other daily expenses are skyrocketing.

The road transport monograph focuses on multiple health impacts and inequities associated with reliance on private automobiles for transportation. These include both the obvious (reduced physical activity, environmental pollution, injury risks that are disproportionately borne by those who cannot afford vehicles) and the less obvious, like the high costs that car-oriented transportation planning imposes on working class families. (An important US study found that such families in 28 metropolitan areas were spending, on average, 28 percent of their incomes for housing and 29 percent for transportation.) This monograph is especially rich in examples of policies that have been implemented successfully, on scales ranging from the local to the national. These include road safety measures, road tolls and congestion charges, integration of traffic injury data and health and sustainability criteria into municipal transport policy, and a variety of improvements to public transportation. It is fair to say that Canada is far from the cutting edge in applying many such measures. In a country where more than three out of every five commuters drive to work in every metropolitan area, scope for local initiatives abounds.

stree-cap-3In this vein, a thoroughly parochial example shows the obstacles to making intersectoral action happen. Following several fatal and nearly fatal road accidents involving pedestrians and cyclists, my local councillor in downtown Ottawa (Diane Holmes) convened a well attended "sidewalk Summit" on how to improve pedestrian safety. In particular, participants complained about the danger of crossing Bronson Avenue, a four-lane arterial road connecting the city centre with the airport that will undergo a costly reconstruction starting this winter. Ms Holmes told Summit participants that engineers on city staff have so far rejected proposals to make the street more pedestrian-friendly because the suggested changes would mean a 60-second delay for drivers on the 1.1 kilometre downtown segment of Bronson, bisecting a neighbourhood that is far from wealthy – this despite abundant evidence of the health benefits of improving the walkability of cities.

This is far from an isolated case. Intersectoral action to advance health equity requires, first of all, improving information flows within and across organizations that develop and implement policies that affect health. Okay, we already knew that, but the "how-to" often remains elusive, and I hope that readers will post comments about both their successes and their frustrations. Perhaps more basically, we need to address questions of leadership and accountability: Who elected the engineers? To whose priorities do they respond, and why? In local planning decisions and in national policies, health equity means that everyone has to count.

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A question, and an invitation

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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question iconIs this blog useful? How can we make it more so? Please post a comment – and if you think the blog is worthwhile please circulate postings to your colleagues, create a link from your own web page, circulate the URL on Facebook (just copy and paste it into the "what's on your mind?" callout at the top of your wall), etc.

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What part of “social injustice is killing people” don’t you understand?

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Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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What part of "social injustice is killing people" don't you understand?

I'm prompted to write this posting by several recent conversations with people who argue (to quote one example) that it is not clear how critiques of economic processes and their distributional impacts "relate to health beyond the truism that poverty is bad for health." Well, if that's the case then the highest priority for any discussion of justice and health should be the ways in which those processes generate and perpetuate poverty, shouldn't it? (Philosopher Thomas Pogge has been making this point in the context of global justice eloquently, for many years; see in particular the section of his web page listing publications on this topic.)

I am not at all convinced that the connection between poverty (however defined) and ill health is a "truism" based on the amount of time I have spent slowly and carefully explaining the point over the past several years, so here are a few elaborations. They start with the most obvious: not getting enough to eat, on an ongoing basis, is bad for health. Can we agree on that?

Well, the number of undernourished people in the world in 2006-2008 was estimated by the United Nations Food and Agriculture Organization at 850 million, roughly the same number as in 1979-1981. (This refers to insufficient caloric intake for the activities of daily living; it has nothing to do with the four basic food groups.) Although such estimates are necessarily imprecise, more recent trends have certainly not been helped by rising food prices; global food price indices are more than twice as high as over the period 1990-2000, and a recent UNICEF report identified similar price levels in 58 individual countries. FAO's most recent annual report on world food insecurity noted a range of causes, concluding: "Climate change and an increased frequency of weather shocks, increased linkages between energy and agricultural markets due to growing demand for biofuels, and increased financialization of food and agricultural commodities all suggest that price volatility is here to stay."

So much for the global picture, but not relevant to rich Canada, right? Wrong. Using 1998 survey data from the province of Québec, the University of Ottawa's Lise Dubois found that in census tracts that ranked in the top 20 percent on scores of both material and social deprivation, almost one in four families experienced food insecurity [1]. Closer still to home, Toronto's Department of Public Health has for many years estimated the cost of eating the Nutritious Food Basket recommended by Ontario's Ministry of Health and Long-term Care for several categories of families living on the income provided by provincial income support programs, if they are also paying market rents. In 2010, as shown in the accompanying healthy eating toronto-1table please, it was quite simply impossible for many people. (The Association of Local Public Health Agencies has shown that the same was true throughout the province at least as of 2008, and a coalition of dietitians and nutritionists has done a similar calculation for British Columbia.) No wonder more than 400,000 Ontarians a month were turning to food banks. Subsidized or social housing is an option in theory, but in early 2011 more than 66,000 households were on a waiting list in the City of Toronto.

Apart from direct consequences like inadequate diet or giving up dental care in order to pay for food and housing, the stress of having to cope with life on an inadequate or precarious income is itself a contributor to ill health, as pointed out by Sir Michael Marmot in his unjustly neglected book The Status Syndrome. Life for a single mother who has to drop one child off at daycare and another at school as part of a two-hour one-way commute on foot and by transit to a low-wage job is far more stressful than for a comfortable suburbanite; among other things, there's not a lot of time or energy left to seek out healthy foods, or for comparison shopping to stretch the budget. (And yes, in my experience this does have to be explained to people, especially if they haven't set foot on a bus in years.) Colloquial references to stress distract us from the fact that the concept has a clear, and relatively well understood, physiological dimension and that its effects cumulate over time. Bruce McEwen, a leading researcher in the field, wrote more than a decade ago that "considerations of stress and health are becoming useful in understanding gradients of health across the full range of education and income, referred to as 'socioeconomic status' or SES. SES is as powerful a determinant of mortality as smoking, exposure to carcinogens, and many genetic risk factors".

SES is not only about incomes; factors like race and gender matter as well. (The concept of intersectionality, as used in feminist research, responds to this insight.) One of the more striking demonstrations of how social inequality gets under your skin was produced by Arline Geronimus and colleagues, who used data from the US National Health and Nutrition Examination Survey (NHANES) to design a measure of allostatic load – a key concept in the physiology of stress – for black and white adults, subdividing the sample by gender and into poor and non-poor based on household incomes. They found that allostatic load scores rose with age for all groups, but being poor, being black and being female each operated independently to increase the probability of a high score, and "in each age group the mean score for Blacks was roughly comparable to that for Whites who were 10 years older." In other words, living near the bottom of social hierarchies, and in particular near the bottom of multiple hierarchies, wears you out over time in biologically measurable ways. In another important study on stress effects, Bird and colleagues used allostatic load scores based on NHANES data to identify "significantly greater biological wear and tear" from living in census tracts where SES was lower, independent of individual characteristics. (Unfortunately, the full text of the study is not available on an open access basis.)

These are just two examples from a rich literature, which goes a long way toward explaining the persistence of socioeconomic gradients in health even when direct material deprivation (like not getting enough to eat, or exposure to toxic chemicals on the job) is not at issue. As Marmot points out, unanticipated expenditures (something as simple as having to come up with $200 to retrieve an illegally parked car that's been towed) and the closed businessprospect of plant or business closures are experienced very differently by workers and their employers, because of the material resources to which they have or don't have access. The literature also suggests that the familiar debate about whether to attribute socioeconomic gradients to material or "psychosocial" factors is for the most part a sterile one. Position in a social hierarchy is reflected in the material world (with apologies to Madonna), and the stresses associated with subaltern status most definitely have biological manifestations and consequences. Surprisingly, many students in public health, health promotion and related fields seem not to be exposed either to this body of research or to the texture of everyday life for the economically and socially marginalized. This last problem may arise from the fact that the relevant work tends to be generated in disciplines like sociology and urban anthropology, which aren't normally central to health curricula. In any event, in education as in research, we have a long way to go.

References


[1] L. Dubois, Food, Nutrition and Population Health: From Scarcity to Social Inequalities. In: J. Heymann, C. Hertzman, M. Barer and R. Evans,eds., Healthier Societies: From Analysis to Action (pp 135-172). Oxford University Press, 2006.

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Health research as if social (in) justice mattered

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Ted Schrecker
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"Social injustice is killing people on a grand scale."

Few of us who were involved with the work of the WHO Commission on Social Determinants of Health will forget the courage shown by the authors of its final report in starting with that observation. How should health research respond to this challenge? If the Commission's perspective were taken to heart, how would research priorities look different?

In an article that appeared on November 1 in the open access journal PLoS Medicine, several of us who were actively involved with the knowledge networks that supported the work of the Commission tried to answer those questions. The article drew on a considerably longer report prepared by the same team at WHO's request in 2009. The observations that follow are my own reflections, and to the extent that they go beyond the published documents do not necessarily reflect the views of my colleagues.

In the article, we frame the answers in terms of the emergence of a Third Wave of health research. The first wave was and is grounded in medicine and the life sciences and focuses on clinical solutions, normally delivered in medical settings or at least by health professionals. The distinguishing characteristic of the second wave is its emphasis on providing the evidence base for interventions directed at improving the health of populations rather than individuals, notably with respect to non-communicable diseases. If we think of vaccines, antibiotics and chemotherapy as typical products of the first wave, then we might think of tobacco control programs and cardiovascular disease prevention initiatives like Finland's North Karelia project, later extended to the entire country, as exemplary of the second wave.

Now, historians are acutely aware of the perils of periodization, which is not implied by the idea of a Third Wave. The idea is not about 'moving on' from the modes of inquiry that characterize the first and second waves, which remain foundational, but about 'moving out' – for example, to consider how social determinants of health (including access to health care), and ultimately health outcomes, are influenced by macro-scale economic and social processes such as the structural adjustment programs mandated by the International Monetary Fund and World Bank starting in the 1980s and, more recently, concurrent crises of finance, food security and global environmental change. Thus if anything, the Third Wave embodies a return to understandings exemplified by Virchow's view of the inseparability of pathology and politics – revisited in a contemporary context by authors like physician/anthropologist Paul Farmer (and many others).

Characteristics of Third WaveThe accompanying panel lists key characteristics of Third Wave research. It must above all be transdisciplinary, and therefore requires pluralism in choice of research methods. This is one of several points where researchers in medicine, life sciences and clinical epidemiology become twitchy. One reviewer of the penultimate draft of the manuscript, who is closely involved with the Cochrane Collaboration, objected to our rejection of hierarchies of evidence, commenting that such hierarchies "demonstrate which studies have higher qualities than others and consequently the results of those with lower qualities have higher uncertainty than those with higher quality". We cut the language in the final version, but the reviewer was missing a crucial point by viewing quality as unidimensional rather than multidimensional. For example, ethnographic studies of pathways to homelessness quite simply yield a different kind of evidence from controlled trials or pre-post studies of interventions designed to reduce the prevalence of homelessness and its devastating effects on health. I would insist that quality can be comparable among the two kinds of studies (and many others), and that these and other forms of inquiry are equally important to the design of effective policies to reduce health inequity. This leads unavoidably into a longer discussion of the politics of evidence, which will be the topic of a later post in this series.

The longer report on which our recent article was based includes numerous examples of specific research questions, under four headings: global factors and processes; structures and processes that differentially affect people's chances to be healthy; health services and system factors; and the effectiveness of policy interventions to reduce health equity. A participant in a 2009 workshop, one of several that fed into the report, cut to the core of this last area when she asked: "How will we know in 20 years which interventions have worked?" Answering this question assumes, first of all, the existence of a universe of relevant interventions to study – an assumption that may be precarious in an environment of crisis-driven austerity programs designed with scant regard for their impacts on health equity. And what interventions are on the horizon to address the dramatic increase in long-term and youth unemployment in many OECD countries? Such questions must not be avoided if the Commission's message about social justice is to be taken seriously.

Despite innovative ventures like the Population Health Improvement Research Network, in Canada as a whole we are far from recognizing the importance of research on social determinants of health that foregrounds health equity. In fact, a recent commentary in the Canadian Journal of Public Health warned that we may be retreating from what was once a leadership position, into more narrowly biomedical and commercially oriented perspectives. (Policies and interventions that address social determinants of health cannot usually be patented and packaged; that's probably how it should be.) How different the research landscape would look if just one transdisciplinary institution focused on Third Wave research, anywhere in the country, had the $96 million annual budget of the Ottawa Hospital Research Institute (motto: "Tomorrow's Health Care Today"), which is just one of many such hospital-based institutions in a single province. We have a long way to go.

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Policies for health equity: Learning from the Danes

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Since the report of the Commission on Social Determinants of Health appeared in 2008, several efforts have been made to apply its insights to specific country and regional challenges. The most familiar of these are the review carried out in the United Kingdom, now competed, and the one under way in WHO's European Region – both led by Sir Michael Marmot himself. A less publicized review, led by distinguished public health researcher Finn Diderichsen, was recently completed in Denmark. The English-language version of its report is forthcoming in the Scandinavian Journal of Public Health, and is presented here in pre-publication form.

In many respects, Denmark is a leader in health and social policy. At least until recently, its economic policy dealt successfully with the issues facing a small, open economy by way of a labour market policy known as flexicurity that combines limited job protection with a high level of income protection and training provision. According to OECD figures, in 2009 a laid-off Danish worker could expect to receive unemployment benefits worth 47.7 percent of previous earnings, as compared with 11.7 percent in Canada – a figure that reflects Canada's restrictive eligibility requirements and low insured earnings ceilings. denmark posting 12 determinantsDanish child poverty rates are among the lowest in the OECD, according to figures from the Luxembourg Income Study, although the report notes a worrying increase between 2001 and 2007, partly attributable to reduced unemployment benefits. The country recently adopted a tax on foods high in saturated fats, in an effort to create economic incentives for healthier eating. At the same time, the new report is motivated by concern about the "Scandinavian Welfare Paradox of Health": Scandinavian countries with relatively low levels of economic inequality do not in fact exhibit the lowest levels of health inequality among the high-income countries, at least when crude measures such as mortality and self-reported health are used.

The report's authors identified a list of 12 determinants of health, using a straightforward model developed by Diderichsen and colleagues more than a decade ago for understanding connections among economic and social policies, macro-level variables like social stratification, and individual health outcomes.

denmark posting child pover

(Their original article does not appear to be available on an open-access basis, but pages 15-17 of the new Danish report provide a first-rate short description of the model.) For each of the 12 determinants in the list, they then provide a brief account of the relevant research evidence and an inventory of measures that are likely to be effective in reducing health inequality. Preventing increases in income inequality is identified as a priority, as are planning measures to counteract the tendency of housing markets to increase residential segregation. The inventories sometimes combine conventional 'downstream' interventions with more contextual ones. For example, with respect to interventions for early child development, the inventory includes maternity visits by health nurses and active recruitment of children with special needs through day care institutions and kindergarten classes but also elimination of childhood poverty. And suggested measures to reduce overweight, obesity and their health consequences include taxation and healthy choice programs in school and workplace cafeterias, but also (unspecified) measures to increase physical activity in disadvantaged residential areas.

Like many such reviews, the report focuses on the importance of cross-sectoral policy coordination while emphasizing both its difficulty and the lack of "positive international experiences vis-à- vis reducing inequalities." In an interesting reflection on Britain's lack of success , the report notes (for example) the long period of time required to demonstrate reductions, because the influences on health inequalities operate across the life course, and the fact that "far too many initiatives constitute single temporary projects in local deprived areas" rather than influences on broader public policies. (This observation will sound uncannily familiar to Canadians!)

It is always difficult to assess the comprehensiveness of such reviews without detailed knowledge of the country context, but a few aspects strike the foreign reader as curious. For example, although limited accessibility of healthy foods in thinly populated areas and poor neighbourhoods (the problem of food deserts) is noted, no specific measures to improve accessibility in such areas are proposed. And from a Canadian vantage point, the recommendation to increase school completion through "practical learning targeted at young people who cannot complete a normal academic school program" sounds like a recipe for stigmatization, increased stratification and a less, rather than more inclusive society.

To the extent that the data allow direct comparisons, we should also be aware that health (and socioeconomic) disparities in Denmark are already smaller than in some other high-income jurisdictions. The report notes that differences in life expectancy between neighbourhoods in Copenhagen "are as large as six to seven years" – lower than the difference of more than 10 years (for men) between some of the richest and poorest neighbourhoods in Montréal or the 17 year difference in London and the 28 year difference in Glasgow noted by Marmot and colleagues. And the poverty rate of 10-20 percent in some Danish parishes identified as a cause for concern in the report should be compared with the more than 40 percent of economic families living below the before-tax Low-Income Cutoff in some of Toronto's inner suburban neighbourhoods. (Because of different poverty measures, this comparison – unlike the international comparison of child poverty rates cited earlier – is only approximate.)

Despite these factors the similarity of the issues faced by Canada and Denmark in a global economic environment that tends to increase economic inequality is striking, and the Danish report will be valuable as a starting point and inspiration for Canadian provinces or local jurisdictions wanting to undertake a systematic and theoretically informed assessment of what works to reduce health disparities.

* We are deeply indebted to Prof. Diderichsen for permission to post this material.

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Introduction

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 25 October 2011
in CHNET-Works!

NewsPHIRN announces a new blog on research and practice related to reducing health inequity.  Written by PHIRN affiliate Ted Schrecker and a variety of invited guest bloggers, Health as if everybody counted will introduce readers to developments around the world that are relevant to Ontario, with a focus on social determinants on health.  The purpose is not only to inform, but also to stimulate online discussion about ways to introduce and advance health equity in all aspects of public policy and public health practice.

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The road to (and from) Rio

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 25 October 2011
in CHNET-Works!

Some background

The title of this blog is inspired by former police reporter Michael Connelly's novels about homicide detective Hieronymus (Harry) Bosch. Raised in foster homes and orphanages after his mother was murdered when he was 12, Bosch is a relentless loner with a strong egalitarian streak, reacting to a Los Angeles Police Department bureaucracy that devotes far more attention to some deaths than to others with the axiom that "everybody counts or nobody counts." "Everyone counts" was also the theme of the United Nations Population Fund's World Population Day 2010, which emphasized the way in which a variety of social arrangements devalue the lives of women and girls.

Everywhere in the world, achieving health equity requires equality of opportunities to lead a healthy life. We must never forget that the lifetime risk of dying in pregnancy or childbirth for women in Canada is one in 5,600 while in sub-Saharan Africa, the world's poorest region, it is one in 31. Closer to home, in 2010 more than 400,000 Ontarians a month were turning to food banks, and in mid-2011 more than 150,000 Ontarians were on waiting lists for affordable housing. Housing and nutrition are among the most basic social determinants of health, and we are far from providing such equality of opportunity. For the moment, not everybody counts. Like the fictional Detective Bosch, those of us working in health equity are trying to change that. The purpose of this blog is to provide resources for bringing about that change, and a forum for discussing cutting-edge research and best practices.

The road to (and from) Rio

Forte de Copacabana On a global scale, that kind of change was a central theme of the World Conference on Social Determinants of Health, hosted by the Government of Brazil and held October 19-21 at the picturesque Forte de Copacabana  in Rio de Janeiro. The conference was a milestone in a process that began in 2005 when the previous director-general of the World Health Organization appointed a Commission on Social Determinants of Health, chaired by Sir Michael Marmot. The Commission's report, released in August 2008, began with the observation that "social injustice is killing people on a grand scale" – not the kind of language we are used to encountering in UN system documents. Some of the activities that followed the release of the report will be the subject of later postings. The Rio conference represented a specific response by WHO to a 2009 resolution (WHA62.14) of the World Health Assembly, WHO's governing body, calling for action on the Commission's report.

Roughly 1000 members of national delegations, experts identified by WHO, and civil society representatives converged on Rio for the conference. Key background documents can be downloaded from the WHO web site, and a valuable blow-by-blow description of the conference events was provided by Jim Chauvin of the Canadian Public Health Association, who is also president-elect of the World Federation of Public Health Associations. WHO's current director, Margaret Chan, opened the first day (really half a day) with a powerful speech that began: "Lives hang in the balance, many millions of them. These are lives cut short, much too early, because the right policies were not in place." She was followed by a panel of UN agency officials and government representatives including Kathleen Sebelius, US Secretary of Health and Human Services. Perplexingly, Ms Sibelius lauded the US for its steps to expand health care coverage, making no mention of the fact that countries like Canada come far closer to providing universal coverage (at lower cost) than the 90 percent she said the United States would be glad to achieve.

parallel sessionThe second day consisted of morning and afternoon parallel sessions corresponding to five action areas identified in a discussion paper prepared by the WHO secretariat in Geneva in advance of the conference. Although these sessions were webcast live, unfortunately at the time of writing they do not appear to be available for viewing or downloading after the fact. The third day (again, really a half-day) was dominated by a panel that featured powerful presentations by Finland's new Minister of Health and Social Services, Maria Guzenina-Richardson, and Zimbabwean pediatrician David Sanders, a long-time primary health care activist described as the "star of the day" in The Guardian.

What are such conferences good for?

drafting sessionUnlike the scientific conferences with which many of us are more familiar but in keeping with the standard for diplomatic events, most of the Rio meeting was tightly scripted. (The "annotated session plan" of the parallel session for which I was a rapporteur ran to five single-spaced pages.) The only concrete output from the conference was the aspirational Rio Political Declaration on Social Determinants of Health, endorsed by all WHO member states participating in the conference. As usual with such documents, drafting the declaration began months in advance, with a first draft circulated to WHO member states in August and subsequent drafting sessions in Geneva starting in September. The details were finalized during a day-long drafting session in Rio, operating in parallel with the conference but open only to the representatives of national delegations.

The Declaration was developed using a unanimity rule, meaning there is nothing in it to which any government involved strongly objected. It is nevertheless surprisingly strong in several ways. For example it recognizes the potential of the current economic crisis to undermine health, and governments "pledge to adopt coherent policy approaches that are based on the right to the enjoyment of the highest attainable standard of health" (reference to such rights-based approaches has long been anathema to the United States), including such measures as social protection floors. On the other hand, it contains neither new commitments of resources nor any formal mechanisms for monitoring and accountability. Other omissions were highlighted by civil society participants in the conference, and by Dr. Sanders in his remarks on the last day. For example, the Declaration includes no mention of trade and health; no reference to the ongoing problem of 'brain drain' of health professionals from low- and middle-income countries; and the conference as a whole paid little attention to capital flight, which drains capital from low- and middle-income countries in amounts far larger than the annual value of development assistance. The lack of specifics would seem to underscore the concern expressed by Sir Michael Marmot and colleagues, in a commentary published at the start of the conference, that "social determinants of health have barely penetrated the global agenda ... and the default position of people in the health sector is to focus on health services and prevention of specific diseases."

What does it mean for Canada?

The Declaration is not a treaty; it does not bind WHO member states. Of course, the treaty status of an international agreement is no guarantee of effective implementation, as we know from the history of Canada's commitments under the UN Framework Convention on Climate Change. A useful comparison can be drawn between the 2011 declaration and the similarly aspirational 1978 Alma Ata commitment to achieve Health for All in the year 2000. In the event, the Alma Ata vision was thwarted by several elements of the political environment, notably resistance from the multilateral financial institutions that were emerging as key players in development policy for health. "The Rio summit offers the opportunity to ensure that failure to implement a widely supported agenda does not happen again," wrote Prof. Marmot and colleagues. Despite the lack of specifics, the Rio declaration provides an unequivocal affirmation that an agenda of reducing health disparities by way of social and economic policy and the design of policy-making institutions is both scientifically sound and ethically imperative. Unfortunately, these points remain contested in the quotidian work experience of many of us, and no international agreement can substitute for the myriad initiatives at local, provincial and national levels that will be needed to advance the science and politics of social determinants of health. Sarah Bosely concluded her Guardian coverage, one of the few English-language media mentions of the conference, by saying that "this is one genie that looks unlikely to go back in the bottle". In the Rio declaration, those of us working in the field as researchers, practitioners and advocates have a valuable resource for keeping the genie out and active. More about this in subsequent postings.

 

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