Many policies that affect social determinants of health, and therefore the prospects for reducing health inequity, are outside the control (and sometimes beyond the competence) of government ministries, departments and agencies responsible for health protection and public health. Advancing health equity therefore requires what is variously described as a health in all policies approach (which was the theme of Finland's presidency of the European Union in 2006), a whole of government approach, or intersectoral action.
In parallel with the work of the WHO Commission on Social Determinants of Health, the Public Health Agency of Canada produced a synthesis of 18 country case studies of intersectoral action. The level of detail varied considerably, and to their considerable credit the authors of the report warned about the lack of a standard reporting format, and further that "the majority of case studies were written from one perspective only in most cases from the perspective of a representative of the health sector. The tone of the case studies was often positive (rather than critical)," as might be expected from what were essentially self-reports, "and we had no opportunity to determine what the opposing views, if any, might be." Indeed, a cynic might observe that intersectoral action is far easier to talk about than to carry out with demonstrable improvements in outcomes.
A new series of monographs produced by WHO in Geneva, in collaboration with the WHO Regional Office for the Western Pacific, now offers valuable resources for moving beyond rhetoric in intersectoral action, drawn from experiences in countries rich and poor alike. Reports produced so far address housing, education and transportation: three of the most important social determinants of health, with special importance from an equity perspective.
The key message of the housing monograph is that health equity can be a guiding principle and catalyst for sustainable housing and development policies, organized around advancing the right to housing for all citizens. It identifies numerous opportunities for intersectoral action to achieve eight objectives: sound construction, safety and security, adequate size, availability of basic services, affordability, accessibility, tenure, and protection from climate change. Several of these are directly relevant to Ontario, where waiting times for affordable housing can be measured in years and where – in pre-recession 2007 – 13.9 percent of urban households (17.2 percent of Toronto households) were in "core housing need" as defined by Canada Mortgage and Housing Corporation. This means that their housing requires major repairs, lacks enough bedrooms for the size and composition of the household, or costs more than 30 percent of before-tax household income; the core housing need concept does not take into account problems related to neighbourhood characteristics or inadequate transportation, so understates the opportunities for creative policy initiatives.
The education monograph is organized around recognition that universal access to education opportunities is one of the most powerful determinants of child well-being, health equity and development. Critically, the monograph recognizes that "disparities in educational attainment among learners are often based on living conditions outside the realm of schools," taking the imperative for intersectoral action to a new level. We may think that such problems are not a serious issue in Canada, but the work of such researchers as Human Early Learning Partnership scholar Paul Kershaw at the University of British Columbia provides an urgent wake-up call. Kershaw has advocated a New Deal for Families that would combine increased income support with flexible working hours (flextime) and drastically expanded access to affordable quality child care services. As one of those childless-by-choice individuals whose cohabitants are quadrupedal and furry, I more than most people need this kind of reminder about the financial and logistical stressors involved with raising children on wages that are stagnating while housing costs and other daily expenses are skyrocketing.
The road transport monograph focuses on multiple health impacts and inequities associated with reliance on private automobiles for transportation. These include both the obvious (reduced physical activity, environmental pollution, injury risks that are disproportionately borne by those who cannot afford vehicles) and the less obvious, like the high costs that car-oriented transportation planning imposes on working class families. (An important US study found that such families in 28 metropolitan areas were spending, on average, 28 percent of their incomes for housing and 29 percent for transportation.) This monograph is especially rich in examples of policies that have been implemented successfully, on scales ranging from the local to the national. These include road safety measures, road tolls and congestion charges, integration of traffic injury data and health and sustainability criteria into municipal transport policy, and a variety of improvements to public transportation. It is fair to say that Canada is far from the cutting edge in applying many such measures. In a country where more than three out of every five commuters drive to work in every metropolitan area, scope for local initiatives abounds.
In this vein, a thoroughly parochial example shows the obstacles to making intersectoral action happen. Following several fatal and nearly fatal road accidents involving pedestrians and cyclists, my local councillor in downtown Ottawa (Diane Holmes) convened a well attended "sidewalk Summit" on how to improve pedestrian safety. In particular, participants complained about the danger of crossing Bronson Avenue, a four-lane arterial road connecting the city centre with the airport that will undergo a costly reconstruction starting this winter. Ms Holmes told Summit participants that engineers on city staff have so far rejected proposals to make the street more pedestrian-friendly because the suggested changes would mean a 60-second delay for drivers on the 1.1 kilometre downtown segment of Bronson, bisecting a neighbourhood that is far from wealthy – this despite abundant evidence of the health benefits of improving the walkability of cities.
This is far from an isolated case. Intersectoral action to advance health equity requires, first of all, improving information flows within and across organizations that develop and implement policies that affect health. Okay, we already knew that, but the "how-to" often remains elusive, and I hope that readers will post comments about both their successes and their frustrations. Perhaps more basically, we need to address questions of leadership and accountability: Who elected the engineers? To whose priorities do they respond, and why? In local planning decisions and in national policies, health equity means that everyone has to count.