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Health as if everybody counted blog

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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
User is currently offline
on Friday, 14 September 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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Health research as if social (in) justice mattered

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Thursday, 03 November 2011
in CHNET-Works!

"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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