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People who get it, Part 2

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Vendredi, 14 Septembre 2012
in CHNET-Works!

I've tried to make the case in previous postings for considering public finance as a public health issue. In a new article in Foreign Affairs,(1) Massachusetts Institute of Technology political scientist Andrea Louise Campbell makes several relevant arguments. She isn't concerned with health, and she is writing in the US context, but many of the analytical issues are relevant to our situation.

Campbell starts with the observation that the percentage of GDP that Americans pay in taxes is lower than in any high-income country: 24.1 percent. In the OECD as a whole, the figure is lower only in Chile (which has no national personal income tax) and Mexico. For Canada, the figure is 32 percent – higher than the United States, but a dramatic contrast with the Nordic countries, Italy, Belgium, Austria and France, where the figures are over 40 percent. She also points out that the drastic increase in economic inequality in the US, in particular concentration at the top of the economic scale (the one percenters, defined literally and statistically), is partly attributable to cuts in personal income tax during the Bush II presidency. (We know by way of the work of Emmanuel Saez that it is also a consequence of a steady rise in the market incomes of the one-percenters that began circa 1980; the relation between that trend and subsequent public policies must be left for another posting.)

There is more to the picture, though. Campbell points out that the much higher tax revenues available to European governments come not from higher and strongly progressive income taxes, as we might like to think, but rather from high consumption taxes, which are actually regressive: in other words, their impact is proportionally larger as you move down the income scale "because lower-income households tend to spend everything they earn." What, then, accounts for the contrast between the US and most of continental Europe in such matters as poverty and income inequality? Part of the answer lies not on the revenue side, but rather on the expenditure side: "In Europe, regressive taxes are matched with highly redistributive states. In the United States, mildly progressive taxes are matched with a not very redistributive state." Still another contributor is the much higher prevalence of low-wage jobs in the US ... and although Campbell does not make the point, that in turn probably has a lot to do with the weakness of unions, in particular outside the public sector.

tom slaterTom Slater, University of Edinburgh

Geographer Tom Slater, at the University of Edinburgh, is likewise concerned with various dimensions of economic inequality. Much of his earlier work was concerned with the process of gentrification and how it disrupts the lives of people who are displaced. In one forthcoming paper, he offers a powerful critique of the "cottage industry" of neighbourhood effects research in urban studies. Like Campbell, he is not specifically concerned with health, but much of what he says is immediately relevant to the study of neighbourhood effects on health. It has already been pointed out, in a widely cited article by Steven Cummins and colleagues, that most of the usual study designs are likely to understate such effects, because they involve a static definition of place (normally with reference to residential location) rather than a relational one that reflects the complexities of daily life on limited resources.

Slater's critique is more fundamental: such studies presume that where people live is the problem, rather than asking "why do people live where they do in cities? If where any given individual lives affects their life chances as deeply as neighbourhood effects proponents believe, it seems crucial to understand why that individual is living there in the first place" (italics in original). Failing to begin by questioning the operations of an economic system that sorts people across metropolitan space based on their purchasing power in land and housing markets means that "neighbourhoods ... become the problem rather than the expression of the problem to be addressed." This warning should be kept in mind by health researchers who generally tend to shy away from such structural explanations, preferring instead to focus on how neighbourhoods are conducive to certain kinds of 'health behaviours' like smoking and unhealthy eating.

In another forthcoming paper, Slater borrows a term from a book edited by Robert Proctor and Londa Schiebinger - Agnotology: The Making and Unmaking of Ignorance – in which the contributors address the question of "what keeps ignorance alive, or allows it to be used as a political instrument?" Canadian readers even vaguely familiar with the track record of our current national government need no explanation of this question's importance. (Proctor's interest in this topic began with research on the tobacco industry's efforts to create doubt about the health effects of smoking; David Michaels, who has done superb work on how industries manufacture uncertainty with respect to impacts on health and the environment, is one of the contributors.)

Slater argues that a right-wing think tank in Britain has played an important role in producing and sustaining ignorance about the root causes of poverty, ascribing it to failures of personal responsibility and the creation of 'dependency' by already minimal programs of social provision in much the same way as the protagonists of welfare 'reform' in the United States during the 1990s. The Conservative-led government that came to power in 2010 enthusiastically adopted this analysis, proposing workfare requirements and multi-billion-pound cuts in benefits while ignoring research evidence that such measures "do not lift people out of poverty, but rather remove them from welfare rolls, expand dramatically the contingent of the working and non-working poor, and affect their daily existence negatively in almost every way imaginable." The lack of available jobs, as a result of decades of deindustrialization, is simply ignored - a point also made eloquently by Owen Jones in his book Chavs: The Demonization of the Working Class.

These are superficial renderings of complex and important papers, but they have several key messages for everyone working in population and public health in Canada. First and foremost, we have much to learn from those working in disciplines that have no direct connection with health, and outside Canada. The retreat of the state in Canada from redistributive policies was well established before the financial crisis. Since then, in Canada as elsewhere, we have been told that expenditure cutbacks – "austerity" – were essential in order to keep government deficits from becoming unmanageable. Most current approaches to austerity are highly selective, though. They involve cuts to expenditures (or moratoria on new investments) that mainly benefit the least well-off; they demand little or no sacrifice from the wealthy; and they focus almost exclusively on the expenditure side. For example, as noted in a previous posting Ontario's Drummond Commission on the province's fiscal future was ordered not to consider the option of raising taxes from their historically low levels – a choice that has clear implications for any society's ability to provide the opportunity for a healthy life to all.

By now it should not be contentious to state that poverty and chronic economic insecurity are hazardous to health. It may not be stating the case too strongly to suggest that controversy on that point is manufactured, in the same sense that controversy about the health hazards of tobacco and the evidence for personal fecklessness as a major cause of poverty are manufactured. To be sure, there is much still to be learned about how social determinants of health affect health equity, but the apparent determination of research funding agencies not to support the relevant lines of inquiry itself merits study using the rubric of agnotology. Finally, Slater's trenchant critique of the neighbourhood effects literature addresses not only the limitations of a particular kind of inquiry, but also the imperative of methodological self-consciousness in all forms of research on health and its social determinants.

(1) Unfortunately, only a summary of the article is available for open access

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People who get it, Part 1

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Mercredi, 05 Septembre 2012
in CHNET-Works!

Optimism is hard to sustain these days. Canadian policy-makers and research funders seem to be losing much of their interest in social determinants of health; health policy remains unresponsive to evidence of easily remediable inequities within our health care systems. Lack of coverage for outpatient prescription drugs is one conspicuous example, as noted in the previous posting. So it's refreshing to feature three Ontario conferences organized by people who 'get' both health equity and social determinants of health. (Full disclosure: I am on the program of the first two events.)

richard wilkinson-1Richard Wilkinson, Professor Emeritus, University of Nottingham.
Photo: Wikimedia Commons
Health Promotion Ontario is a group of health promotion professionals now celebrating its 25th anniversary. On September 27, HPO is holding a one-day conference on the theme "Building Connections between Promoting Health and the Social Determinants of Health." Speakers include Ketan Shankardass of Sir Wilfrid Laurier University; Penny Sutcliffe, the Medical Officer of Health with the Sudbury and District Health Unit; and (via Skype) Richard Wilkinson, one of the world's leading authorities on economic inequalities and health.

In my experience, students in medicine and public health are often far ahead of their profs in understanding the social patterning of disparities in health, and the graduate students at the University of Toronto's School of Public Health provide a stellar example. On September 28, their annual student-led conference will be, to my knowledge, the first meeting in Canada specifically to address the theme "Health, Austerity and Affluence". The opening keynote will be given by Armine Yalnizyan, senior economist with the Canadian Centre for Policy Alternatives, which has a long-standing research program on economic inequality. Other speakers include David McKeown, Toronto's Medical Officer of Health, whose department has a long history of foregrounding health equity issues in its work, notably in a 2008 report on income and health inequalities.

The following month, the Canadian Society for International Health hosts its annual conference in Ottawa (October 21-23). Especially noteworthy is the Sunday morning opening session, which features sociologist Saskia Sassen and economist Dean Jamison. Sassen, whose work was the topic of a previous posting, is one of the most thoughtful observers of globalization and its consequences for human well-being; she is not only an academic but also a multilingual advocate, who somehow finds time to write for publications like the wonderful Occupied Wall Street Journal. Jamison, formerly of the World Bank and now at the University of Washington, was one of the leaders of the Disease Control Priorities Project , whose 2006 book Disease Control Priorities in Developing Countries remains a valuable resource. (Unfortunately, the DCP project web site is temporarily out of service.) Even if you can't attend the entire conference, the Sunday session is well worth taking in if you are from the Ottawa area.

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Affordability of medications: (re)discovering the obvious

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Vendredi, 17 Août 2012
in CHNET-Works!

In an earlier posting, I mentioned research by Canada's Dennis Raphael, among others, on the difficulty of managing diabetes on a low income. The cost of a healthy diet is a major part of the problem; another is the cost of medications. In Ontario, prescription medications outside hospital are covered by public health insurance only for people over the age of 65 and for those on extremely low incomes. A new study by researchers at the University of Toronto (1) points out that this may be having a substantial impact on the health of people with diabetes.

We already knew that mortality among high-income Ontarians with diabetes has been declining faster than it has among those with low incomes, leading to a widening equity gap. Starting with a health records database including almost all Ontarians with diabetes and using median household incomes in the Statistics Canada dissemination area where they lived as a proxy for an individual's own income, the researchers found that the socioeconomic gradient for death, acute myocardial infarction (AMI) and stroke is substantially steeper among people under 65, who either pay out of pocket for their medications or rely on private insurance, than it is among those 65 and over whose prescription drugs are covered. "[A]s many as 5,000 deaths and nearly 2,700 AMIs or strokes could have been avoided among younger and middle-aged adults with diabetes if the gap between wealthier and poorer individuals had been identical to that seen among older groups. "

affordability-car-accident-If we could eliminate vehicle accidents as a cause of death in Ontario, wouldn’t we give it a shot?
Photo: Sean Whaley/Nevada News Bureau, reproduced under a
Creative Commons Licence 3.0.
To put that figure of 5,000 into perspective, that's the total number of people who died in Ontario motor vehicle accidents from 2002 through 2007, the years covered by the new study. If we could eliminate such accidents as a cause of death in this province, wouldn't we do it? And since the study looked only at the portion of the population with one disease, the overall toll of avoidable illness and death associated with lack of universal public insurance for prescription medications ("pharmacare") is almost certainly higher.

Lack of pharmacare kills, in other words. Nothing is especially new about this realization. The new study cites previous research on the problem of drug costs for diabetics ... and it's now been more than a decade since a landmark study by Robyn Tamblyn and colleagues showed that emergency department visits and hospital admissions increased, and use of essential medications decreased, after Québec introduced co-payments in its public drug coverage for senior citizens.

Pharmacare is not just an equity issue; it's also an efficiency issue. The market power available to a single public purchaser could be important tool for cost containment. Indeed an important analysis published in the fall of 2010, which appears to have sunk without a trace, suggested that the lack of pharmacare is one of the reasons that prescription drug costs in Canada have been growing faster than in most other OECD countries, and argued that national pharmacare would reduce drug costs by 11.7 – 42.8 percent relative to current practice.

Failing to provide public insurance coverage for prescription drugs outside hospitals doesn't save money. It simply means that fewer costs are borne by the public treasury, and more by private insurers or people who may not be able to pay out-of-pocket, sometimes with fatal consequences.

At least under the current national government, there seems no hope for a federally initiated program. Ontario is one of the few provinces that are probably large enough to go it alone; a consortium of smaller provinces could do the same. Until that happens, the avoidable illnesses and deaths will continue, and we who are concerned with equity should laugh hollowly at all official claims that health policy is evidence-based.


(1) Unfortunately, full text is not available for open access

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A question about body parts

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Lundi, 06 Août 2012
in CHNET-Works!

The International Consortium of Investigative Journalists recently published an unsettling four-part series on the sources of biological material that is used in such common medical devices as dental implants, heart valve replacements, and skin and bone grafts.  Its focus was on the US market, but it documented sourcing practices both in the United States and offshore that are, to say the least, questionable.  One egregious example involved a New York city-based operation run by a dentist named Michael Mastromarino, now serving federal prison time.  More details on this case are available from stories in New York Magazine, the Washington Post, and Philadelphia Magazine.

Most Canadians will remember the disastrous health consequences of failure to prevent contamination of the blood supply – a crisis that could have been controlled effectively by decision-makers within our borders, although it wasn’t.  The ICIJ series describes inadequately documented trade in other human biological materials, both within and across national borders.  In the United States, efforts to control hazardous imports are minimal and ineffective.  Health professionals interviewed for the series pointed out, for instance, that WalMart routinely tracks merchandise using bar codes, but these are not used to track potentially deadly tissue imports.

How well are Canadians protected from such hazards?  Whom can we ask, and how much trust should we place in the answers?  This is not a rhetorical question, but it’s one with important implications for public safety, and I invite responses from anyone who can shed light on the matter.  If no one can, then maybe it’s time for the Canadian Institutes of Health Research to make this a strategic priority?

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Single mothers and income inequality: Demographic reality, an old scary trope revisited, or a little of both?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Mardi, 24 Juillet 2012
in CHNET-Works!

single mothers 1Photo by: Clementine Gallot,
reproduced under Creative Commons 2.0 licence
On July 15, the New York Times ran a long story on income inequality and family structure. The story led with a comparison between the lives of two women working in the same child care centre in the US Midwest. One "goes home to a trim subdivision and weekends crowded with children's events"; the other, her subordinate, pays more than half an income in rent and "scrapes by on food stamps," the federal food vouchers on which more than 46 million Americans now rely.

Veteran social policy reporter Jason DeParle's point was, superficially, one of straightforward demographics and arithmetic: the birth of children in unmarried households is becoming the norm. In a world where two paychecks are increasingly essential if a household is to do more than scrape by, especially in the lower reaches of the income distribution, that will have a powerful effect on the overall distribution of income within a society – and by extension, on the life chances of children in different categories of households. Assortative mating – the tendency of people with comparable educations and incomes to marry or at least cohabit – magnifies this demographic effect.

There is nothing new about such observations. In 1998, internationally recognized Canadian urbanist Damaris Rose pointed out that the rapid increase in the number of two-earner households was driving out-migration from the island of Montréal to suburbs where home ownership was more affordable, although her concern was not with income inequality per se but rather with effects on urban form 1.  And the 'single' (presumptively young and feckless, presumptively non-white) mother was a central trope in US welfare 'reform' debates of the 1990s. At the same time, it's hard to disregard the differences that two incomes, especially two secure incomes, make in basic life chances.

single mothers 2Photo from The story of single mothers, part of a campaign by Raise the Rates, a coalition of community groups and organizations concerned with the level of poverty and homelessness in British ColumbiaIn response to the Times article, Shawn Fremstad posted a four-part critique on the web site of the Center for Economic Policy Research, one of the United States' best regarded left-of-centre policy research units. Among the points he made, each documented with links to primary research:

More basic questions would appear to be: why and how do some societies make it so much easier than others to raise children with an adequate material standard of living, and adequate social supports? Detailed, fact-based rather than model-based comparisons of policy regimes are surprisingly hard to find, but it is worth quoting a recent book chapter based on the Luxembourg Income Study's cross-national data sets on social policy impacts: "[A]fter accounting for taxes and transfers, fewer than 5% of children in Denmark, Finland, Norway and Sweden live in poor households," as against 15.6% in Canada and 22.2% in the United States 2. Full stop. Five percent versus 15-22%. A 2009 OECD study pointed out that while 24 percent of children in the United States lived in single parent families in 2005/06, the figure was 19 percent in Denmark and 16 percent in Norway. So something else is at work.

The same study concluded that "the empirical literature on the impact of family structure on child outcomes is at an immature stage." Based on a variety of outcome measures, it also concluded that "at a maximum ... the likely causal effect sizes of being brought up in a sole-parent family are small."

This is a complex policy field, but: a society seriously interested in equalizing opportunities to live a healthy life would start from a firm commitment to something like a 5% (or less) solution, and then work backward from there to see what policies would best achieve that goal in a specified time period, only secondarily asking questions about family structure – not least because of the long time frame needed for interventions that address family structure to have an impact, even when sound research evidence exists to support them.

Some societies are clearly more serious than others on this point. Perhaps that's why a journalist like the Times' DeParle, with a long history of questioning conventional wisdom, took the easy road of looking at family structure rather than the rocky road that runs through the effects of decades of offshoring, union-busting, attacks on social provision and tax breaks for the rich. It's a bit like the easy road taken by health promoters who profess a concern for social determinants of health, but end up talking once again about tobacco control and health literacy. Those are not unimportant, but if serious progress toward health equity is the destination, the easy roads are unlikely to get us there.


1. Rose D, Villeneuve P. Engendering Class in the Metropolitan City: Occupational Pairings and Income Disparities among Two-Earner Couples. Urban Geography, 19: 123-159.

2.  Gornick J, Markus J. Child Poverty in Upper-Income Countries: Lessons from the Luxembourg Income Study. In S Kamerman, S Phipps and A Ben-Arieh, eds., From Child Welfare to Child Well-Being (Springer Netherlands, 2010): 339-368; http://dx.doi.org/10.1007/978-90-481-3377-2_19.

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