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Health as if everybody counted blog

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A change of scene, and a farewell

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 23 April 2013
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Recording artist Lynn Miles sings:  “Burn all the bridges down / Move me to another town.”  I am not burning any bridges, but I am moving to another town – one on the other side of the Atlantic, in fact.  As of June 1, 2013 I will take up an appointment as Professor of Global Health Policy at Durham University. (I cannot resist the observation that Durham County Council is currently the only one in England controlled by the Labour Party, although this may change after the May elections.)  The change of scene and the end of provincial funding for the Population Health Improvement Research Network make this a good time to discontinue writing Health as if Everybody Counted.  For the immediate future the postings will remain on the CHNET-Works web site, and I hope they will continue to serve as a useful resource for those wanting to advance the health equity agenda.  I am also enthusiastic about the possibility of updating, reorganizing and consolidating the postings as an e-book; more news on this as it happens.

As I prepare to leave Canada, I am prompted to reflect on why it is so difficult make change in population health research and practice.  Most of us work in institutions like university faculties, government ministries, local public health agencies, or nonprofits. These institutions respond to external priorities like those of granting councils, cabinets and local elected officials – priorities that tend to be shaped by macro-scale political currents like neoliberalism.  Our institutions also, with a few exceptions, are strongly hierarchical in their internal structure.  Observations of various kinds of organizations show that many individuals working within them adapt with striking facility to the moving target represented by changing requirements for success within the institu¬tion.  In an excellent study of the World Bank, Cheryl Payer described “a cage with glass walls.  Within this barrier the bureau¬crats and technocrats work, argue, debate, cooperate or fall out with one another, attempting to aggrandize their own position or to defeat opponents. They have the illusion of freedom because the barrier is invisible.  The smart or ambitious ones, having once experienced or observed such a collision, remember where the barrier is and avoid it thereafter; those who are slower, stubborn, or angry continue to beat their heads against it until they are bloody.  The recruitment and promotion practices naturally favour the smart ones who don't have bloody heads" (p. 353).

Not everyone adapts eagerly to the requirements for advancement within their institution, although eager adaptation is frequent in Canadian university settings.  Active resistance is likely to be a career-limiting move in many organizations.  Senior managers and external protagonists who set priorities and budgets must at least be comfortable with ideas like health equity if people trying to organize their work around such a concept want to keep their jobs, and the organization’s internal routines must be permeable enough to enable the advocates to make their case.  Academics often have more flexibility, but can still be targeted by governments or commercial interests.  More routinely, they are vulnerable to being marginalized or excluded through the operation of what can be thought of as organizational filters.  For example, if the managers of universities or hospitals (or those to whom they report, like hospital and university boards) decide that securing a permanent teaching or research position requires successful grant applications, then over time the organization becomes populated by people whose research priorities are congruent with those of funding agencies – whether those involve behavioural approaches to health promotion, development of commercial products like new drugs, or military technologies.

Philosopher of science Jon Elster is a master at providing microfoundations for large-scale explanations of social phenomena. In Ulysses and the Sirens, now unfortunately out of print, he wrote that: “If academic personnel apply for military funds in order to be able to conduct the research that they would have done in any case ... the Department of Defence may serve as a filter that selects some applica¬tions and rejects others.  The resulting composition of research will be beneficial to the military interests, while wholly unintended by the individual scientist, who can argue truthfully that no one has told him what to do” (p. 30).  Those who make it through the filters will in turn have an ongoing influence on the direction of the organization as, for example, they serve on appointments committees or advance into administrative posts, having observed the bloody heads of less accommodating colleagues.  The result is a situation in which, as Ken Coates of the University of Saskatchewan has written: “We have self-regulated ourselves into near silence, and our students and the country suffer from the quiet as much as university faculty.” Given granting agencies’ emphasis on biomedical and clinical research and the growing corporate influence in Canadian universities, which has been commented upon even in the Financial Post, it is hard to overstate the importance of this analysis, both for those already ‘in the system’ and for those hoping to make a career in equity-oriented health research.

The experiences of those of us who have worked in such environments are too easily dismissed as anecdotal or otherwise biased; for better or for worse, external validation is needed.  Empirical health policy research has not penetrated very deeply into the power structures and organizational routines of Canadian health ministries, university faculties, research institutes and public health agencies.  Relevant methodologies and perspectives are suggested by contributors to books like Policy Worlds: Anthropology and the Analysis of Contemporary Power and by the work of scholars like Janine Wedel, whose remarkable analysis of how power operates both through formal organizational structures and the informal networks she calls “flex nets” is especially valuable.  It remains to be seen whether those interested in doing this kind of research can make it through the filters, or whether they will find the necessary financial support.  

Sir Michael Marmot on social determinants of health: Blending evidence and passion

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 20 February 2013
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On an unseasonably warm day in May 2012, Sir Michael Marmot came to Canada for a short visit with the Public Health Agency of Canada and the University of Ottawa, supported by the CIHR Institute of Population and Public Health. His presentation at the University of Ottawa, from which we present video excerpts here, is simultaneously a succinct and a passionate defence of the social determinants of health agenda and its ethical foundations.

Sir Michael is introduced by the Hon. Monique Bégin, a former Canadian Minister of Health and Welfare and a member of the Commission on Social Determinants of Health. She comments that: "Canada ... is so wealthy, despite the scary global economic times, that it manages to mask the reality of poverty, social exclusion, discrimination, employment erosion, mental health, and youth suicides. While one of the world's biggest spenders on health care, we have one of the worst records when it comes to providing an effective social safety net."

The first part of Sir Michael's presentation offers a bit of anecdotal history about the internal processes of the commission. He then makes two main points. First, he is hopeful that the Commission's report may be one of a few international commission reports, like that of the Brundtland Commission on sustainable development (1987) that have a real impact. At least, he says, officials like Commonwealth ministers are talking the language of social determinants of health. Second, he distinguishes the economic case for acting on social determinants of health from the moral case, based on social justice. In words that echo the long-ago wisdom of Anatole France, he concludes that: "The freedom to wallow in poverty," or to be unemployed, "is not a freedom that is much prized."

In the next part of his presentation, Sir Michael emphasizes the importance of the Commission's focus on inequalities of power, money and resources. He goes on to describe history of the British strategic review on health equity, which he also chaired, and its organization around a lifecourse framework; his efforts to advance interest in social determinants of health as president of the British Medical Association; and how initial cynicism was transformed into enthusiastic takeup of his message about the importance of social determinants of women's health among British obstetricians and gynecologists.

Finally, Sir Michael argues that social protection policy matters for health. "The greater the social spending, the lower the all-cause mortality, for 18 EU countries." And he explains a remarkable initiative by the Merseyside Fire & Rescue Service (that's Liverpool, for readers too young to remember where the Beatles came from) to address social determinants of health by helping people apply for grants to improve their housing, quit smoking and increase their levels of physical activity using the gymnasia at fire stations. He ends with the observation that "We are involved in an intensely ethical concern. We are trying to get a more just society."

 

What can we in Canada learn from this presentation? That could be a long disquisition, but the short version is: blending evidence and passion matters, and we have too few leaders in population health and health social science who are capable of doing so.

Acknowledgements: Many thanks to CIHR's Institute of Population and Public Health for offering these video files.

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Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 06 November 2012
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"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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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 Friday, 17 August 2012
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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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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
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on Thursday, 12 July 2012
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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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Good news and bad on health equity

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 July 2012
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Herewith a selection of events from around the web, and the world. First, some good news. The Caledon Institute for Social Policy, a non-profit with a long history of progressive social policy analysis that is now headed by two accomplished alumni of the recently deceased National Council of Welfare, has announced that it will take over preparing and publishing two of the Council's most important data series: those on welfare incomes and the profile of poverty in Canada. These are core resources, and Caledon is to be congratulated on this initiative, which will be part of a new Canada Social Report. I hope that one or more Canadian academic institutions will offer to support them, financially and with other resources.

My current institutional home, the Bruyère Research Institute, has produced a valuable set of tips for keeping seniors safe in the heat. As I write we're at humidex 34 here in Ottawa, so the importance of such advice can't be overestimated. Eric Klinenberg's remarkable "social autopsy" of the 1995 Chicago heat wave reminds us that a clear socioeconomic gradient exists with respect to opportunities to stay safe in the heat. Many people can't afford air conditioning or a breezy cottage, and in Chicago the elderly on moderate incomes in particular found themselves isolated by fear of crime and other elements of the urban environment from locations that could at least have kept them cool.

In a world that may experience extreme heat and weather events with greater frequency as a result of human-induced climate change, such warnings assume special importance. They may also not be enough. On June 30, it was reported that a combination of violent storms and extreme heat had caused the deaths of at least 12 people in the United States, and millions more were "facing temperatures in the 40s without electricity, and without air conditioning." Record temperatures and wildfires in Colorado had forced the evacuation of 32,000 people and the cancellation of the iconic Pikes Peak Hill Climb, a motor sports event with almost religious significance for aging gearheads like yours truly. But not to worry, say the climate change sceptics; the evidence is insufficient and these may be natural variations from the mean. Everything will be fine.

Finally, a shift to the global frame of reference. A little-noticed resolution adopted in May by the World Health Assembly, the governing body of the World Health Organization, called on the "international community" to support action on social determinants of health and, more concretely, on WHO's Director-General "to duly consider social determinants of health" and to continue advocacy for their importance within the UN System. Supporting documentation pointed out that implementing the resolution would require an additional $33.6 million between 2012 and 2017, and that the cash-strapped WHO had no resources in its current core budget for these activities. To put the amount into context, it's equivalent to the cost of 22 of the 588 Tomahawk cruise missiles the US Department of Defense planned to buy between 2010 and 2012 ... and Tomahawk was just a drop in the United States' $1.5 trillion arms procurement budget over those years. What was it that the Commission on Social Determinants of Health had to say about "a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics"?

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Environmental justice: revived and revisited

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 31 January 2012
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With a few exceptions, such as a short 2008 report from the Canadian Policy Research Networks, socioeconomic inequalities in exposure to environmental hazards have not been a central concern of Canadian population health research or public health practice. In the United States, on the other hand, the highly visible and persistent reality of racial segregation has generated a substantial stream of research and activism on environmental justice, including the establishment of units like the Environmental Justice Resource Centre in Atlanta. In 1994, an executive order issued by then-President Clinton required all federal agencies to consider environmental justice in their programs. Official interested waned (to put it politely) under subsequent Republican administrations, but the issues are now being revisited.

The December 2011 issue of the American Journal of Public Health – fortunately, available on an open-access basis – is based on a symposium on Strengthening Environmental Justice Research and Decision Making organized by the US Environmental Protection Agency in March 2010. The articles are a valuable resource for exploring both the strengths and the limitations of current US approaches to the issues, and amply support an editorial conclusion that the EPA's current approach "is not sufficient to end make progress toward ending environmental health disparities and environmental injustices," given its heavy reliance on toxicology and engineering.

env-justice-picture-1-1Reproduced with permission of the US Environmental Protection Agency

Among the many important points raised in the collected articles:

  •  An overview of methodologies points out that most existing studies of the spatial distribution of environmental health hazards rely on census data, so effectively track only nighttime exposure. People's daytime locations and exposures are harder to track, and it's certainly plausible that people living in locations where their exposure to environmental hazards is high are also more likely than others to be working in similar environments.
  •  In assessing the overall distribution of inequalities in the chance to lead a health life, it is essential to consider the combined health effects of chemical exposures and stressors of other kinds, including psychological and social stressors. A companion article by Bruce McEwen, one of the world's leading researchers on the biology of stress, elaborates on the physiological pathways that are likely to be relevant. Since population health researchers often ignore the massive accumulation of human and non-human evidence on this topic, its recognition is especially important.
  • Paula Braveman and colleagues elaborate on a now familiar definition of health equity by dealing explicitly with the issue of strength of evidence and standards of proof, arguing: "It must be plausible, but not necessarily proven, that policies could reduce [health] disparities, including not only policies affecting medical care but also social policies addressing important non-medical determinants of health and health disparities ..."

env-justice-picture-2-1Living near pollution from heavily travelled roads is one of many environmental hazards that are unequally distributed. Photo: Atwater Village Newbie

The symposium also (not always intentionally) underscores the limitations of the US approach. For a variety of reasons, many of which have to do with industry's use of the courts to resist environmental regulation, quantitative risk assessment is "the central paradigm of the Environmental Protection Agency". Especially in the case of cancer risk, it can be difficult to establish links with the spatial distribution of hazards: because of long induction and latency periods, "studies would need to include residential histories for as many as 15 to 30 years before a cancer diagnosis to capture pertinent environmental exposures," even before dealing with the problem of exposures when people are not at home – on the job, for instance. The effect is to build in a bias against regulation that requires "requires positive evidence of 'dead bodies' before acting," in the words of a classic 1978 article by environmental economist Talbot Page, unfortunately not available for open access. More generally, the emphasis on quantitative risk assessment focuses attention and resources on refining measurement techniques and building ever more elaborate models of causal pathways. An alternative, explicitly precautionary approach to environmental justice would focus instead on eliminating hazards once a much lower standard of proof is met. This tension is hardly unique to environmental justice; indeed, as Page pointed out, it is pervasive in the regulation of many kinds of health hazards.

As mentioned, environmental justice issues have had a relatively low profile in Canada. Three Canadian researchers recently argued (I think quite correctly) that institutional health promotion here has simply failed to address environmental health inequalities. Here's one of many areas related to social determinants of health in which even a modest commitment of additional research dollars is likely to generate valuable, if politically awkward, findings.

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
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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.

The road to (and from) Rio

Posted by Ted Schrecker
Ted Schrecker
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on Tuesday, 25 October 2011
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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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