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Health as if everybody counted blog

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Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 06 November 2012
in CHNET-Works!

"The fog comes," Carl Sandburg famously wrote, "on little cat feet." With roughly the same amount of fanfare, in September a consortium led by Sir Michael Marmot published a summary of its findings on how to reduce health inequities in the 53 countries of the World Health Organization's European region. The region includes some of the wealthiest countries in the world, and some of those with the smallest disparities in health, but is hardly homogeneous. Mortality among children under 5 ranges from just over 2 per 1000 live births in Iceland to more than five times that figure in Bulgaria and Romania. Child poverty on a standardized cross-national measure is higher than 30 percent in Romania, three times as high as in the Nordic countries and a few others. And urban air pollution (concentration of particulate matter) is more than five times as high in the capitals of Turkey and Bulgaria as in those of Estonia and Iceland.

The consortium's argument will be familiar to readers of earlier reports in this vein, including the original Commission on Social Determinants of Health, but several points are worth mentioning because of their direct and immediate transferability to the Canadian context.

  • who euro-review-pic-1Air pollution remains a health hazard in many European cities.
    Photo: eifelyeti110’s photostream; reproduced under a Creative Commons 2.0 licence
    The consortium writes that "[h]uman rights are central in our approach to action on the social determinants of health". The fact that this was not true of the 2008 report has been identified as a significant omission by the distinguished human rights scholar Audrey Chapman, among others.
  • Social protection – including "a minimum standard of healthy living for all" that includes a nutritious and sustainable diet – is clearly and correctly identified as essential for reducing health inequity. Further, the consortium refers approvingly to the United Nations Social Protection Floor Initiative, a relatively low profile effort that is explicitly linked to a human rights approach. Could this be the start of an overdue convergence of concerns about health equity and social policy that often have been addressed by separate organizations and groups of professionals working in isolation from one another?
  • The effects of unemployment and exposure to hazardous work environments are foregrounded, at a time when youth unemployment is higher than 50 percent in two WHO Euro countries and a source of concern throughout the region.
  • Also foregrounded is the issue of health inequities among older Euro region residents – a concern with much broader applicability as populations age and social exclusion threatens to increase, especially in countries with high levels of economic inequality, a troubling trend that was evident even before the economic crisis.
  • Most importantly, both the economic crisis and many policy responses are identified as threats to health equity. In the consortium's words: "Recognition of the health and social consequences of economic austerity packages must be a priority in further shaping of economic and fiscal policy in European countries," with health and social affairs ministries and – at the transnational level – the World Health Organization, UNICEF, and the International Labour Organization given a voice.

who euro-review-pic-2Social exclusion threatens the European elderly, especially those with limited resources.
Photo: Zilverbat.’s photostream, reproduced under a Creative Commons 2.0 licence
Think, for a moment, about what institutionalizing this last recommendation would mean in a Canadian jurisdiction like Ontario.

My previous posting featured an important new report on redesigning social assistance in Ontario. Its arrival, too, could be described with reference to little cat feet. Ontario would do well to adopt both the consortium's insights about the inseparability of social protection and health and its view that "current economic difficulties are a reason for action on social determinants of health not inaction." But where will the necessary leadership come from? However well intentioned the proponents of taxes on 'junk food,' availability restrictions and warning labels on French fries may be, it may not come from them.

Related resource of interest

Video of Sir Michael Marmot's keynote speech at the Canadian Medical Association annual meeting in August 2012, which focused on health equity, is now available online.

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Unemployment isn’t working for public health, 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, 17 October 2012
in CHNET-Works!

On January 1 of this year, workers at the Electro-Motive Diesel locomotive plant in London, Ontario were locked out of their jobs after refusing to take a 50 percent pay cut. In February, the parent company (Caterpillar Inc.) closed the plant and moved production to Indiana. Now, a story in The Globe and Mail reports that just 68 of the 485 union workers who lost their jobs have found new full-time work. Marriages are crumbling; food bank use is climbing; and the plant stands vacant. (Readers may want to access both this and an earlier, equally important story – also by reporter Tavia Grant, whose coverage has been stellar – before the Globe's content moves behind a paywall.) The situation of former Electro-Motive workers is part of a larger picture of deindustrialization: citywide, one in 15 Londoners – an estimated 24,000 people - live in a household receiving Ontario Works ('welfare'). This means, by definition, an income well below Statistics Canada's Low Income Cutoff.

electro-motive-london-1The vacant plant in London, Ontario previously occupied by
Electro-Motive Diesel

Many health researchers and practitioners in Canada have been slow to grasp the health implications of economic restructuring and the changing nature of work. (The authors of the landmark Code Red study in Hamilton, the topic of an earlier posting, are a notable exception.) Elsewhere, understandings are more advanced. One of the nine knowledge networks that supported the WHO Commission on Social Determinants of Health addressed employment and working conditions; a fine summary of its findings appeared in BMJ in 2010. The International Labour Organization has for years been promoting what it calls a Decent Work Agenda. The agenda does not specifically refer to health but recognizes the importance of employment and working conditions for overall well-being, especially in the context of the post-2008 economic crisis. Until July 2012, the ILO's Global Job Crisis Observatory kept tabs on how the crisis was affecting employment, and is still a valuable source of background.

So long as governments see little alternative to the reorganization of production across national borders in search of lower labour costs and more 'flexible' employment regimes, an increasing proportion of the population – certainly in the high-income world – can anticipate a future of shrinking earnings, precarious employment, and reliance on multiple but often unpredictable income streams. This is not a fact of nature, but rather a consequence of political choices. The Commission on Social Determinants of Health correctly attributed the unequal distribution of opportunities for leading a healthy life to "a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics." Nowhere is this clearer than in the decline of employment as a central concern of public policy. It is time for all those concerned with studying and protecting population health to come clean on this point, and to demand that political leaders do the same. Where, for example, are the voices of the province's Medical Officers of Health on this issue?

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Fighting back against health inequity and its origins

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 17 July 2012
in CHNET-Works!

Despite rising inequality of market incomes and solemn assertions by governments that compensatory social policies are unaffordable, there are Canadian voices calling for change, within and outside the health research and policy community.

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

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

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

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

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