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Health as if everybody counted blog

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Messages on inequality, from sources far and near

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Sunday, 28 October 2012
in CHNET-Works!

Taking health inequity seriously requires direct engagement with increasing economic inequality and the underlying macro-scale economic processes.  A remarkably thoughtful overview of those processes is provided by Zanny Minton Beddoes in a recent special report in The Economist.  (At this writing, the special report is still open access; get it while you can.)   Despite obligatory genuflection to the economic theology that economic inequality reduces ‘efficiency,’ Beddoes focuses on the destructive consequences of rising inequality (especially at the top of the economic pyramid) and on how public policy can and should respond.  Everyone interested in the future of population health should read her report, which is especially scathing on how various US policies actually magnify inequality.  Against the background of that country’s imminent money-driven elections it is worth quoting her concluding critique of the Obama government’s approach as “just a laundry list of small initiatives.  [New Deal initiator Franklin] Roosevelt would have been appalled at the timidity.  A subject of such importance requires something much bolder.”

Closer to home, on October 24 a commission that had been asked to review social assistance in Ontario released its report – with an almost total absence of media attention apart from the Toronto Star.  (Readers and viewers to whom social assistance might actually matter are not highly valued by the managers of commercial media, but even the CBC missed this story.)  Among other findings, the report recommended an immediate increase of $100 per month to “the lowest rate category, single adults receiving Ontario Works, as a down payment on adequacy while the system undergoes transformation.”  This report should serve as an overdue starting point for moving public health advocacy beyond tanning beds, Red Bull and salt to consider underlying distributional issues such as income adequacy.  We know, for example, that eating a healthy diet while keeping a roof over your head in much of Ontario is arithmetically impossible if you are paying market rents.

Will the various communities of researchers, practitioners and advocates concerned with health equity engage with these recommendations, taking advantage of the opportunity offered by the prospect of political change in Ontario?  What kinds of followup will be initiated by Medical Officers of Health, and by university- and hospital-based researchers, who are far removed from having to choose between paying the rent and buying fruits and vegetables or paying their children’s dentist?  We shall see.

 

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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
User is currently offline
on Wednesday, 05 September 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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Code Red for maternal and child health: The BORN project *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Thursday, 12 July 2012
in CHNET-Works!

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

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

born pic 1 prenatal care Ont1

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

born-pic-2teen-mom-rate2

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

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

born-pic-3-quotation

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

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

“Perhaps it’s not a coincidence.”

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

Or, perhaps, we just don’t care?

born-pic-4-Gini coefficients

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

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