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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
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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HEST: A new frontier for action 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 Tuesday, 28 February 2012
in CHNET-Works!

In December 1995, Cynthia Wiggins was hit by a dump truck while crossing several lanes of traffic in suburban Buffalo, New York; shortly afterward, she died from her injuries. The 17-year-old African-American woman had to cross the arterial road from her bus stop because the bus that took her from downtown to her job in the posh Walden Galleria mall was not allowed on mall property. It was later revealed that the local public transportation authority had for years tried, unsuccessfully, to get permission to stop in the mall's parking lot. In 1999, a lawsuit charging the mall's owners with racial discrimination was settled for $2.55 million (to benefit Ms Wiggins' son) without admission of liability.

Ms Wiggins' death is an especially dramatic example of the connections between transportation policy and social exclusion: specifically, support for a form of apartheid in the United States long after it was challenged in legislation and jurisprudence. In Los Angeles, The Bus Riders' Union has used a variety of tactics, including litigation under national civil rights legislation, to seek improvements in a transit service that mainly serves a darker-skinned, subaltern population unable to afford the costs of driving in a car-oriented metropolis. Although we are not (yet) familiar with similar extremes in Canada, an important and neglected 2009 report prepared for Human Resources and Social Development Canada on mobility and social exclusion in Hamilton, Toronto and Montréal concluded that "the evidence uncovered in terms of mobility and accessibility patterns is suggestive of social exclusionary processes that may prevent various vulnerable groups," specifically low income people, seniors and single parent households, "from accessing the places required for their daily needs." Since social exclusion functions as a social determinant of (ill) health, the role of transportation in social exclusion should automatically be of concern to the public health community.

There are more immediate reasons for concern. One involves the health consequences of transport-related (mainly automotive) air pollution, reviewed among many other places in a 2005 WHO-Europe report and in the same year by the Ontario College of Family Physicians. It is also likely that an inverse relation exists between income and exposure, although the relation is complicated both by the limitations of measuring exposure based on residential location (most people don't spend most of their time at home) and by the "particular social geography" of cities like Montréal. (I would be delighted if readers can identify useful literature reviews on this topic.)

A second issue is the relation between metropolitan form and injuries and deaths from road accidents, where data on the socioeconomic gradient are hard to find and primary data are often collected by law enforcement agencies, using categories that have limited relevance to population health. (Again, readers are invited to contribute sources to the conversation.) A 2003 article by Reid Ewing and colleagues developed a "sprawl index" for 448 metropolitan counties in the United States, matched this against "all-mode" traffic fatality statistics, and concluded that "sprawl is a significant risk factor for traffic fatalities, especially for pedestrians." In the ten counties with the most compact urban form, fatality rates averaged 5.6 per 100,000 population; in the ten counties with the least compact form – that is, the most sprawling ones – the average was 26.3 per 100,000 population. However, hazardous environments for pedestrians are common even in cities that are relatively compact by North American standards.

hest-picture-1-1-of-1Hazardous environments for pedestrians are common, as shown in this picture taken from the University of Ottawa’s downtown campus.

A third reason for concern involves the relation among transport policy, the built environment, and overweight and obesity, which are now recognized as one of the most urgent public health challenges. The idea of obesogenic environments has gained widespread acceptance, and represents an essential challenge to the emphasis on 'lifestyles' or 'healthy choices' that characterizes many health promotion efforts. Isolating the specific contribution of transport policy is complicated by the fact that in the metropolitan environment, many things are going on at once. For example, neighbourhoods may be more conducive to physical activity ('walkable'), but may also have few full-service grocery stores but lots of convenience stores and fast-food outlets, or neighbourhoods where the built environment is conducive to walkability may also be those where crime is highest. However, some evidence shows a direct link between settlement patterns or transportation and obesity. For example, a 2004 study using a sprawl index – not the same one used by Ewing and colleagues – and self-reports of Body Mass Index (BMI) found that each 1-point increase in the sprawl index (on a scale of 100, values for large US metropolitan areas ranged from 6 to 100) was associated with a 0.5 percent increase in the risk of obesity, after individual-level variables like income, gender, age and education were controlled for. Almost by definition, urban sprawl implies a high reliance on automobiles for transportation, as shown in a classic graph produced by Jeffrey Kenworthy

hest-picture-2-1Source: P. Newman and J. Kenworthy, “‘Peak Car Use’: Understanding the Demise of Automobile Dependence,” World Transport Policy and Practice 17 (June 2011), reproduced with permission.

Finally, there is the need to shift transportation patterns in order to limit climate change, which itself is likely to have substantial adverse health impacts that will be inequitably distributed, falling first and hardest on people and regions that contributed least to the buildup of greenhouse gases. A 2009 article in The Lancet pointed out that transport emissions are rising faster than all other categories, and argued using scenarios for London and Delhi that there would be substantial health benefits from moving to "sustainable transport" including both lower-emission motor vehicles and more walking and cycling, quite independent of the effects on climate change. Elsewhere, a recent assessment of the effects of reducing automobile usage for short trips (1.6 km or less) in the Midwestern United States came to similar conclusions, and further projected several billion dollars a year in health care cost savings. As with other studies cited here these are only selections from a very large literature, but the pattern is clear.

So far as I know, the acronym HEST (for Healthy, Equitable and Sustainable Transportation) is my own invention. There is no shortage of useful information about how to begin, starting with a WHO evidence review mentioned in an earlier posting that identified transportation as an important area for action to reduce health inequity. Kenworthy has listed "ten key transport and planning decisions for sustainable city development," including de-emphasis of freeway and road; planning for employment and housing growth in the city centre and sub-centres; and – critically – a planning process that "is a visionary 'debate and decide' process, not a 'predict and provide,' computer-driven process." (A recent Toronto Star commentary on how the city's planning is now driven by the "pseudo-science" of traffic engineering made a similar point.) Ewing and colleagues have described the "five D's of development": density, diversity, design destination accessibility, and distance to transit. This source is one chapter in an excellent book called Making Healthy Places published by Island Press. World Streets, a web site specifically devoted to "equity-based transport," is another valuable and provocative resource.

Some Canadian organizations have taken up the challenge. I've already mentioned the work of the Ontario College of Family Physicians. In 2007, Toronto Public Health produced a report on air pollution, traffic and health that concluded: "Given there is a finite amount of public space in the city for all modes of transportation, there is a need to reassess how road space can be used more effectively to enable the shift to more sustainable transportation modes" like "walking, cycling and on-road public transit." (I don't think the city's current mayor has read it.) And Alberta Health Services has produced a well researched and hard-hitting fact sheet on urban sprawl and health. Doubtless much more is going on, and I hope readers will post appropriate news, citations and links. 



Predictably, our colleagues in other countries have been less polite and more proactive. Margaret Douglas and colleagues in Britain's NHS (including the Director of Public Health for a primary care trust in Manchester) wonder whether cars are the new tobacco, pointing to the multiple negative effects on health and sustainability of auto-oriented transport systems and the influence of the "car lobby." Also from the UK, writing in the December, 2011 issue of Public Health Today Philip Insall calls for a 20 mph speed limit in residential areas, noting that some continental cities have already made this move and that it would eliminate up to 580 child deaths and serious injuries each year. (Lower speed limits are just one kind of traffic calming measure; many others involve design changes, as noted in an important review by the Canada's National Collaborating Centre for Healthy Public Policy just released last November.) And Andy Jones, writing about obesogenic environments, says: "Maybe we just need to force society to change. Excluding traffic from city centres, radically increasing parking charges, forcing employees to walk at least part of the way to work by removing workplace car parks" as well as taxing high-fat foods.

Forcing society to change can be difficult when we have things like elections, and that's as it should be. Canada's public health community could, however, be much more energetic in advocating for such changes, and providing leadership to ensure that their equity and health benefits are part of the public debate during and between elections.

* Unfortunately, as with previous postings some hyperlinks lead to sources that are not available on an open-access basis. I have tried to find open-access materials wherever possible.

Recent Comments Show all comments
  • Ted Schrecker
    Ted Schrecker says #
    Yes, I'd encourage you and all readers to send the links to your elected representatives!
  • says #
    Thanks for posting these comments Ted. I would wish our municipal councillors would read it through. I will send the link to my MP...

“Divided we stand”: OECD on inequality, and reasons for caring

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 January 2012
in CHNET-Works!

The Organisation for Economic Co-operation and Development (OECD) is a group of high-income (and some middle-income) countries that historically has paid attention mainly to conventional economic indicators such as growth, productivity and innovation. It does other things as well, including providing some of the best statistical overviews and assessments of its members' foreign aid performance. And recently, it has been addressing the consequences of increasing economic inequality within the borders of many of its members.

Divided-we-stand-pic-1Ermenegildo Zegna Boutique in Chile, one of the OECD’s most unequal countriesA December 2011 OECD report provides a description of those increases, an analyses of their causes, and country-by-country data that have some sobering implications for Canada. The report finds that income inequality increased in most OECD countries over the past three decades, although the level of inequality varies widely. The average income (adjusted for household size) of the richest 10 percent of the population is 5 or 6 times the average income of the poorest 10 percent in the Nordic countries, but 10 times that of the poorest in Canada, 14 to 1 in the United States, and 27 to 1 in Mexico and Chile. The report identifies a number of contributors to rising inequality of market incomes, including several aspects of globalization; technological change (which to the authors' credit it describes as hard to disentangle from globalization); changes in hours worked, which have favoured higher earners; and changes in household structure.

There is much room for debate here, notably about the role of globalization and the reasons for rising labour market incomes at the top of the income distribution, which have played a major role in increasing inequality, but also about the OECD's view that inequality can be reduced through raising workers' educational levels. This is worth doing, but effects on inequality are likely to be offset by growth in the kinds of work susceptible to 'offshoring'. For policy purposes, a point of particular interest is how taxes and benefit systems change the distribution of income, and how their effect varies across countries and over time. Like earlier analyses, the report points out that taxes and benefits in some countries (many in Continental Europe) are more strongly redistributive than in others (like the United States and Chile). Generically: "Until the mid-1990s, tax-benefit systems in many OECD countries offset more than half of the rise in market-income inequality. However, while market-income inequality continued to rise after the mid-1990s, much of the stabilizing effect of taxes and benefits on household income inequality declined."

The country note for Canada points out that the share of all income flowing to the richest 1% of Canadians grew from 8.1% in 1980 to 13.3% in 2007 – a trend that closely parallels an even more extreme pattern in the United States, where the income share of the top 1% is now higher than at any point since the Great Depression. (Readers interested in exploring comparative trends in top incomes may want to explore the World Top Incomes Database.) The OECD also points to the declining redistributive effect of Canadian taxes and transfers – a point made a few years ago in a Statistics Canada study, which observed: "Redistribution grew enough in the 1980s to offset 130% of the growth in family market-income inequality -- more than enough to keep after-tax income inequality stable. However, in the 1990-to-2004 period, redistribution did not grow at the same pace as market-income inequality and offset only 19% of the increase in family market-income inequality." The OECD note identifies a somewhat less dramatic retreat from redistribution, reflecting the fact that many ways of doing such calculations exist - for example, the OECD study restricted its analysis to the population aged 15-64 - but the general trend is clear.

Why should population health researchers be concerned with rising economic inequality? There are several reasons, most of which are familiar. First, rising inequality may lead to increases in poverty, however it is defined, although that is not necessarily the case. Second, socioeconomic gradients in health usually exist across the entire income spectrum. Intuitively, we would expect these gradients to be steeper when economic gradients are also steeper, other things being equal, although this is a difficult proposition to test because of the impact of policies that do not directly affect income distribution. Third, income inequality is only part of the story: wealth inequality, which the OECD study did not address, is normally greater than income inequality, and insecure and precarious jobs (which have their own health implications, including higher exposure to on-the-job hazards) are concentrated at the bottom of the income scale. Fourth, it is argued – notably by Richard Wilkinson and colleagues – that higher levels of economic inequality within a society lead to overall lower levels of health, although the mechanisms of action remain unclear.

Divided-we-stand-pic-2Photo by Paul Keller, reproduced under a Creative Commons LicenceA final reason has received less attention in the context of health policy; it involves a phenomenon that former US Cabinet secretary Robert Reich called the "secession of the successful". Past a certain high level of income and wealth, people need less from government, and different things. As one Arizonan interviewed for an article on politics in that state put it: "People who have swimming pools don't need state parks. If you buy your books at Borders you don't need libraries. If your kids are in private school, you don't need K-12. The people here, or at least those who vote, don't see the need for government." To which we could add: people who can afford to drive or fly everywhere don't need public transportation; people with secure incomes gain little from public financing of social or subsidized housing; people who could afford private insurance may resist paying taxes to keep a public health insurance system afloat for the less healthy and less wealthy; and so on.

What happens to the political prospects for reducing health inequity by way of social policy when a small but highly influential segment of the population needs government mainly for roads, police and prisons – and perhaps regards enhancing its own security through private purchases as routine? I recently returned from a workshop in Johannesburg, one of several South African cities that are more economically unequal than any other developing world cities included in United Nations Human Settlements Programme study (p. 73). The workshop was held in a guest house with an electronically activated gate, in a suburb where many properties were fenced with razor wire, and almost every one boasted a private security service's "armed response" sign. This is commonplace in South African cities. From Arizona to South Africa, does the interaction of inequality and privatization suggest a self-reinforcing process that can only be reversed through internal revolt or catastrophic external events (think the Great Depression and the second World War)? Health economist Robert Evans, quoted in a previous posting, wonders: "If we are back to a pre-war income distribution, how much of our post-war social policies can survive?" We should pay more attention to this question.

1The Gini coefficient, a standard measure of income inequality, in Johannesburg is 0.75 according to this study – more unequal than the national distribution of income in any country in the world. By comparison the Gini coefficients in Mexico and Chile, the two most unequal countries in the OECD, were 0.494 and 0.476 in the late 2000s, according to the OECD.

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First snow, and a New York state of mind

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 29 November 2011
in CHNET-Works!

aging-blog-snowThe first snow of winter came (briefly) to Ottawa last week. Snowball-fighters were thrilled, but for the growing number of our senior citizens and for other people whose mobility is limited the snow was less welcome. It foreshadowed months during which routine errands are more difficult and worry about painful and disabling falls can't be avoided because the city – like every other municipality in Canada that I know - gives low priority to such activities as sidewalk and bus stop snow clearance. The winter weather that is just an inconvenience for some of us acts like a set of prison bars for others.

I mention this small-scale, but important example to introduce questions of how to adapt our cities and the choices that shape them to the health needs of an aging population and, more generally of how to make the metropolitan environments that are home to four out of every five Canadians more inclusive and health-positive. In a book published in 2000, a research team led by two Canadian researchers (Richard Stren, now retired from the University of Toronto and Mario Polèse, now at l'Institut national de la recherche scientifique in Montréal) looked at the "social sustainability" of ten cities, in countries as diverse as Canada and El Salvador. They defined social sustainability, which is an admittedly imprecise concept, in terms of "social integration, with improvements in the quality of life for all segments of the population" (emphasis added).

Taking health equity seriously in the metropolitan context means reorganizing many of the choices we make about cities around social sustainability. To understand the consequences of failing to do this, consider Eric Klinenberg's "social autopsy" of a 1995 heat wave that killed more than 700 people in Chicago: fear of crime kept seniors on low or moderate incomes, in particular, socially isolated and barricaded into apartments where they could not afford air conditioning, while a downsized city government failed to link residents with services that could have saved their lives. In a less extreme example, Ottawa-based researcher Theresa Grant found that older people in less wealthy neighbourhoods of the city are more affected by traffic hazards, and face greater challenges in creating walkable space.

Outcomes of this kind are not inevitable. Like many other influences on health inequity, they reflect how we choose to use the resources and institutions available to us. A 2008 New York Academy of Medicine report provides a valuable illustration of how to start doing better, and of why the intersectoral action I wrote about in my previous posting is so important. The authors used a variety of existing data sets to map neighbourhood characteristics like the relative affordability of housing, the characteristics of housing (walk-up buildings present special difficulties for many seniors; so do buildings where the elevators are few or unreliable), the distance to the closest bus stop, and walkability across the city's five constituent boroughs, and to make suggestions for improvement. The World Health Organization, with support from the Public Health Agency of Canada, has created a Global Age-Friendly Cities Guide that provides checklists for outdoor spaces and buildings, transportation, housing, social inclusion, community support and health services. In 2010, WHO launched a Global Network of Age-Friendly Cities, which was the topic of a conference this past September in Dublin; members of the Network have committed to continually assessing and improving their age-friendliness. New York was the first city to join the Network, which now has several Canadian members including London, Waterloo and Welland in Ontario; Saanich in British Columbia; and Edmonton in Alberta.

The Network is a promising and exciting initiative that merits active engagement on the part of Canadian researchers, practitioners, and governments. It could be immensely valuable in identifying evidence-based best practices in metropolitan design and policy – a task that is politically fraught, but essential if decision-makers (and those who elect them) are to have clear performance benchmarks and create incentives for continuous improvement. Meanwhile, whether or not their cities are part of the Network, local and regional public health units can become actively engaged in debates about issues far outside their 'silos'. The coming of winter tells us that they can start with thoroughly mundane questions of servicing priorities: is one more plowing of arterial roads really more important than clearing sidewalks of snow and ice in neighbourhoods where seniors live and which they must navigate? But the questioning must not end there.

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  • Janet Jull
    Janet Jull says #
    Thanks to Dr. Schrecker for identifying an important example of how an everyday event such as a snow fall can have such significan...
  • Lynelle Hamilton
    Lynelle Hamilton says #
    Points well taken. One should also extend these comments to folks with sensory and physical impairments. Also of note is the prec...
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