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Is concern about economic inequality going mainstream?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 19 February 2013
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In a previous posting, I recommended a recent report on economic inequality in The Economist. In its special reports, at least, that magazine has a strong track record of ‘telling it like it is’. Back in 2006, for example, a special report on the world economy admitted that “the usual argument in favour of globalisation–that it will make most workers better off, with only a few low-skilled ones losing out–has not so far been borne out by the facts. Most workers are being squeezed.” And in 2011, The Economist pointed out that Congressional Budget Office figures from the United States support the contention “that the people at the top have made out like bandits over the past few decades, and that now everyone else must pick up the bill.” Now, more evidence suggests that concerns about economic inequality are moving into the mainstream, in Canada and elsewhere.

One of the Occupy movement’s accomplishments has been to direct attention to the growing gap between people at the very top of the income distribution in societies like Canada and the United States – the one-percenters – and the rest of the population. In January 2013, Statistics Canada released updated figures based on tax return data about Canada’s one percenters: based on income, they were those with annual personal incomes above $201,400. These figures refer to individual incomes, not family incomes; a University of Regina Study published in 2012 found that in 2009, the top one percent of “economic families” as defined by StatsCan had wage and salary income (i.e. not including interest, dividends or capital gains) of more than $271,800. The two sets of figures are not directly comparable, since they are based on two different data sets and the Regina figures are restricted to labour income. Yet another analysis, which included all forms of income, identified the top one percent of households (the definition is similar to that of economic families, but not identical) as those with incomes over $366,717 in 2010. More strikingly, the top one percent of households in this analysis accounted for 10.5 of all the income earned by Canadians. All these data refer to income and not to wealth, which most researchers agree is more unevenly distributed than income.

Considerable ideological distance separates Occupiers from the business-oriented Conference Board of Canada, yet the Conference Board has recently expressed considerable concern about Canadian inequality. In an online report card that compares Canadian social policy with that of 16 other high-income countries, it notes that Canada “is not living up to its reputation or its potential” and that “Canada’s ‘D’ grade on the poverty rate for working-age people, and its ‘C’ grades on child poverty, income inequality and gender equity are troubling for a wealthy country.”   The report offers links to more detailed information on various specific domains, such as child poverty (where Canada ranks 15th, ahead only of Italy and the United States); working-age poverty (again, we are 15th, ahead only of Japan and the United States, and not by much); poverty among the elderly (one of Canada’s social policy success stories, but now arguably imperiled by population aging and the fact that only one in four private sector workers has a pension plan); and income inequality (rising, with a “concentration of income among the super-rich”). Despite Canada’s overall “B” grade on social indicators, which cover much more than income (and do not address concentrations of wealth), the overall pattern of increasing inequality is clear. So is the fact that other countries do much more than Canada to reduce income inequality by way of taxes and transfers.  

Perhaps an even less likely source of concern about inequality is the World Economic Forum. Yet the eighth (2013) edition of a Forum report on “global risks,” based on “an annual survey of over 1,000 experts,” estimates that severe income disparity is the most likely of any of the 50 risks studied to occur over the next ten years, and that a major systemic financial failure is the risk with the highest potential impact. (The economic processes driving inequality and magnifying financial risk are of course closely connected, as we know from the events of the last five years.) The simple fact that the report’s authors consider severe income disparity as a global risk says a lot. In the global frame of reference, further gloom about prospects for reducing health inequity comes from the fact that water supply crises are rated as having both high likelihood and high impact, and food shortage crises are rated as having high impact although lower likelihood.

Almost five years after the release of the report of the Commission on Social Determinants of Health, it should not be necessary to revisit the connections of economic inequality and its consequences with health inequity. (An earlier posting, which has drawn more hits than any other in this series, addressed some of these connections.) It’s also worth emphasizing that reducing inequality is not about the ‘politics of envy’ or some similar construct. It’s about the near impossibility of healthy life near the bottom of the economic ladder even in the richest countries in the world; the ubiquity of socioeconomic gradients in health; and the fact that if societies want to invest more in policies that equalize opportunities to live a long and healthy life, the resources will have to come from somewhere. If not from those who have captured a very substantial portion of the gains from the pre-2008 period of sustained economic growth, then from whom? As US President Obama famously and correctly said, this is not class warfare; it’s math.

There is also a more subtle political point. Once economic inequalities have become sufficiently extreme, the idea of a ‘common future’ may become an illusion; the gap between the rich and the rest will simply be too wide, whether we define the rich in terms of the top one percent, five percent or even 20 percent. The problem is that we cannot locate this threshold (if it exists) in statistical terms, and will only know that we have crossed it once we have done so. Writing in the US context Robert Reich, later a cabinet secretary in the Clinton administration, raised this possibility more than 20 years ago in an article on “the secession of the successful” – at a time when economic inequalities were less extreme than they are today.   It remains to be seen whether heightened concern about those inequalities today can have an impact on social policy and reducing health inequity, or whether secession of the successful is already a fait accompli.

Related resources

“The global economy is disequalizing,” interview with The Broker (Netherlands) as part of an ongoing series on inequality.

Richard Wilkinson, “How economic inequality harms societies” (online video)

Are social determinants of health moving into the mainstream?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 11 February 2013
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In a hard-hitting report, a panel of the US National Research Council and the Institutes of Medicine has addressed the question of why the United States, despite spending far more per person on health care than any other country in the world, is falling behind other high-income countries in health status.  Readers familiar with Evans and Stoddart’s critique of the “thermostat model” will experience a strong sense of déjà vu.

The figures are striking.  For example, relative to the 16 other high-income countries selected for comparison, the United States “had the highest rate of child deaths due to negligence, maltreatment, or physical assault.”  It has the highest average body mass index (BMI) of the 17 countries among people aged 15-44.  And the list goes on.  In the words of the study:  “The U.S. health disadvantage is pervasive: it affects all age groups up to age 75 and is observed for multiple diseases, biological and behavioral risk factors, and injuries. More specifically, when compared with the average for other high-income countries, the United States fares worse in nine health domains: adverse birth outcomes; injuries, accidents, and homicides; adolescent pregnancy and sexually transmitted infections; HIV and AIDS; drug-related mortality; obesity and diabetes; heart disease; chronic lung disease; and disability.”  

The report’s focus on structural influences and on the life course perspective is notable, and a summary is wroth quoting at length.  “[T]the absence of green space today may be the product of zoning decisions two decades ago. Such influences also extend over a person’s lifetime: that is, the upstream-downstream continuum can also be a temporal experience for an individual. An individual’s struggle through middle age with exertional angina from coronary artery disease may have originated in adolescence with the adoption of cigarette smoking, perhaps as a coping mechanism for a stressful childhood … or simply because the family lived in a poor neighborhood where smoking was the norm. In turn, the family’s move into that poor neighborhood may have resulted from financial setbacks that occurred before the child was born. Health trajectories unfold not only over a lifetime, but also across generations as people are subject to changing health influences stemming from family, neighborhood, and public policies. …. The key dynamic trajectories of health, risk factors, socioeconomic circumstances, and physical and institutional environments are all integrally linked and cannot be decomposed in a reductionist fashion.”   

Texas timesPointing out that the United States has the highest relative poverty rates of the 17 countries, the report notes the accumulation of social disadvantages and their health consequences over an individual’s lifetime and across generations.  Other, more domain-specific explorations include an intriguing comparison between approaches to road traffic safety in the United States and elsewhere in the high-income world and the topical observation that rates of death by homicide involving firearms are an order of magnitude higher than in other OECD countries.  (The accompanying picture, taken at the entrance to a Houston, Texas emergency room, may suggest a partial explanation; the need for such a warning would be almost inconceivable elsewhere in the high-income world.) 

There is no point in trying to provide a more extensive summary of a very long document here; suffice it to say that the report is essential reading for all those concerned with health equity.  A wonderful commentary from the British think tank Chatham House correctly warned that:  “Rather than indulge in self-congratulatory comparisons with America's dismal health record, other industrialized countries would be wise to ask themselves if … global trends may soon erode their own hard-earned health gains of past decades.”  Perhaps predictably, the report’s recommendations emphasize the need for further research, and research syntheses.  Nevertheless, there are important steps forward.   On research methods, the report observes:   “The premise that randomized controlled trials are the ‘gold standard’ for establishing causal relationships has put the accumulation of knowledge about the social determinants of health at a distinct disadvantage.”  Numerous earlier papers, including one that colleagues and I published more than a decade ago, have made a similar point, but it has yet to be recognized.  And a key recommendation for further research synthesis emphasizes comparative investigation of the influence of public policy “in one or more health domains.”  Our own health funding agencies would do well to take note.  Social determinants of health may not yet have become mainstream, but there is hope.

More on diet and population health

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 08 January 2013
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A recent posting featured two important research syntheses on overweight and obesity. Another, especially useful for non-specialist audiences, appeared as a special report on “The big picture” in the December 15 issue of The Economist.

Commendably, the report does not sugar-coat the difficult politics of reducing overweight and obesity. It notes, for example, that “while lots of people remain fat, the associated ailments represent big business for the drug companies.”  It is candid about the role of companies like soft-drink manufacturers and fast-food chains in contributing to the epidemic of overweight, and the conflicts of interest that can arise in partnerships like one between Nestlé and the International Diabetes Federation, or the “Responsibility Deal” between food and alcohol companies and Britain’s Department of Health. (In negotiations about the action plan that emerged from the UN Summit on non-communicable diseases in September 2011, Canada was among the countries pressing for removal of text that mentioned such conflicts.) And it presents a succinct overview of efforts to deal with overweight and obesity through taxation and regulation. So far, those efforts have met with modest success, although that may be a consequence of modest ambition rather than of limitations intrinsic to the available policy instruments.

Unfortunately, the report is not open-access, although non-subscribers will be able to read part of it online. Unfortunately as well, the report pays insufficient attention to connections between the built environment and overweight, or to the cost of a healthy diet. Nevertheless, it is a refreshing signal that approaches going beyond the usual health promotion nostrums are moving into the policy mainstream.

Shortly before the Economist report appeared, Britain’s Department of Environment, Food and Rural Affairs released its annual Family Food Survey for the year 2011. Among the survey’s disturbing findings: fruit and vegetable purchases were 10 percent lower in 2011 than in 2007, with an even larger decline among the bottom fifth of Britain’s income distribution. Households in the lowest tenth of the income distribution were spending 17 percent more on food in 2011 than in 2007. A report in The Guardian quoted the director of the consumer protection organization Which? as saying: “One in six people say rising food prices are making it difficult to eat healthily,” and the preceding month a report in the same newspaper warned of a “nutrition recession” - this in a country where benefit caps planned for 2013 will cut the incomes of many people in full-time jobs as well as those who cannot find work. 

Closer to home, Ottawa's deparment of public health released the lastest issue of an annual calculation showing that if you are living on social assistance and paying market rents in the city, it is arithmetically impossible - as it is much of the rest of the province- to pay for the diet recommended by Ontario's Public Health Standards. In the capital of a weathly G7 country, 48,000 people a month turn to food banks. Against the background of ongoing concern about health care spending and areport recommending an immediate increase in Ontario social assistance rates to " the lower rate category, single adults receiving Ontario Works, as a down payment on adequacy while the system undergoes transformation," it may be worth asking`just how does making healthiy diets unaffordable contribute to a healthier population and lower health system costs down the road?

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  • animateur@chnet-works.ca
    animateur@chnet-works.ca says #
    Hi Ted wow - as usual, very thought provoking posting! Thank you!

So you think you have free health care?

Posted by guest blogger Sarah Giles
guest blogger Sarah Giles
Sarah Giles is a family physician with an interest in remote and rural medicine.
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Many doctors do not openly discuss the social determinants of health. It's the dirty little secret of Canadian medicine: income makes a huge difference to your health. In the land of "free" health care, living in poverty is still going to have the biggest effect on a patient's health.

At the recent Canadian Medical Association annual meeting in Yellowknife, doctors finally seemed to acknowledge the poverty=poor health situation. Why has it taken so long for doctors to acknowledge the problem? A cynic might say that it is because the vast majority of doctors come from privileged backgrounds, have an income in the top 5% of Canadians, and generally don't care about or understand the poor. A more forgiving person might argue that, coming from such privileged backgrounds and having little to no formal teaching on the subject, many doctors are unaware of the devastating impact of poverty on their patients. And, in fairness, some doctors do not get much exposure to the poor.

A wise physician once told me: "If you don't know your patient's financial situation, you don't know your patient." Truer words have never been uttered. Yesterday I saw a wheezing little boy in clinic. He is a known asthmatic who had not taken his puffers in 3 months. It would have been easy to dismiss the mother as lazy and "non-compliant". Instead, the aunt (who recently gained custody of the little boy), explained to me that she was now looking after 4 children and could not afford the insurance co-pay on these potentially life-saving medications. She didn't qualify for income support and she had insurance – but she still couldn't afford the medications. So much for universal health care.

Patients with low socioeconomic status face a number of challenges within our system. For the homeless, the first challenge is getting a health card. You need a fixed address to get one and then the organizational skills to hold on to it and renew it every few years. Small wonder that the homeless go to the ER more than almost any population – that's the only place they will be seen without a health card.

Let's say that you are on income support or disability. Your health should be good, right? You likely have housing, get your meds covered, and can even access some allied health resources. But can you afford to eat? Studies show that, actually, in Ontario you can't afford to eat a healthy diet on income support. And, even if you could, you likely live in an area where there are lots of expensive "convenience" stores but very few places to buy fresh produce or healthy foods with a short shelf-life. It's much easier to buy crappy food than anything with nutritional value. So, you put on some weight and develop diabetes. Your meds are covered but since your family doctor isn't part of one of those fancy health teams that you get in rich neighbourhoods, you can't access a dietitian because you Community Health Centre hasn't been able to fill the position and all of the other dietitians charge $70 per hour to tell you what you already know – eat better (more expensive and inaccessible) food.

giles-guest-blog-pic-1 giles-guest-blog-pic-2
Healthy foods are available in some low-income neighbourhoods,
but often "it's much easier to buy crappy food."
Photos: T. Schrecker

Now let's pretend that you have developed crippling insomnia. You can't sleep. You got fired from your last job for falling asleep during the day because you couldn't sleep at night. You are now on income support but that's going to run out soon. You are sure you could get back into the work force if you could just sleep six hours per night. You have tried trazodone and amitriptyline – the infamously ineffective sleep aids – but they didn't work. Your doctor now gives you an option: try zopiclone – a sleep aid that works and has little addictive potential – or try clonazepam – a highly addictive benzodiazepine that requires higher and higher doses as your body becomes habituated to it and a drug with considerable street value. The choice is obvious, you want zopiclone. Unfortunately, the provincial formulary will only cover the highly addictive medication with a street value. Zopiclone will cost you at least a dollar a day – a dollar you don't have.

Nobody ever claimed that life was fair. It is intuitively obvious that the more money you have, the more access you have to goods and services. But should money make such a difference that it can determine how healthy you will be or how long you will live? If we, as Canadians, want to continue to be proud of our "universal" health care, we need to make some changes.

Provincial and non-insured health benefits (NIHB) formularies are set by a bunch of experts sitting in a room. The formulary, to those of us in practice, seems to be arbitrary. There is no explanation as to why one drug is covered and another is not. Recent drug shortages have made life even more difficult as drugs that I would commonly substitute in for a short drug are often not on formulary (for instance, amitriptyline is covered but we couldn't get any; gabapentin is not covered for anything other than seizures so I had nothing to give my patients with neuropathic pain). I'm not sure why we need ten drugs in one category covered when we could have three instead, buy in bulk, and use those savings to incorporate other drugs into the formulary.

Provincial and NIHB formularies need to help doctors decrease addictions to opioids and benzodiazepines. They could do this by covering medications that are currently believed to be less addictive. For instance, I can prescribe OxyNeo (the new version of Oxycontin) until the cows come home but prescribing a long fentanyl patch or long acting codeine requires special forms. Doctors can prescribe massive doses of narcotics but need a special license to prescribe the meds required to help people break their addictions (Suboxone and methadone). Certain non-steroidal anti-inflammatory drugs (NSAIDs) require special permission but massive doses of benzodiazepines don't raise flags in the system. Private insurance fills these gaps for many patients, but creates a two-tiered system.

When poor people get injured their lack of access to out patient allied health services (such as physiotherapy) and non-addictive medications decreases their chances of returning to the work force. If outpatient allied health services were easily available to patients, they would be able to get off of income support faster and be less likely to remain in chronic pain.

Imagine if the thousands of people off work for mental health reasons were able easily to access free psychological help? In Ottawa, the going rate for a psychologist is $160/hr. I know of very few people who can afford this. If they could afford it, many people could remain in the work force or stay off of the streets. Instead, we rely on NGOs to provide care that should really be universally available.

In short, I'm sick of being a doctor who sees such discrepancies in the availability of care, medication, and overall health status between the poor and the rich. I am glad that the CMA is finally taking note of the problem – but how are we going to address it? Having the current Canadian government pull the social safety net out from under those who have the most precarious balance is not going to help matters. Is it only a matter of time before I recommend that patients find a way to get sent to jail so that they can get the medication, rehab, and care they require? There has got to be a better way.

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  • animateur@chnet-works.ca
    animateur@chnet-works.ca says #
    Brilliant posting as always Ted.

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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Hamilton, Ontario: “Code Red” for 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 Wednesday, 30 May 2012
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For Canadians of a certain age, the southern Ontario city of Hamilton (now an amalgamation of an older core municipality with several suburbs and exurbs) will always be Steel City, after the industry that was once its economic backbone. Today the city's steel industry has shrunk dramatically, as part of the deindustrialization that has ravaged the city's economy. Steel producer Stelco, which employed 25,000 people as recently as 1980, employed (as US Steel) only 1500 people in 2011. Other industrial employers, such as Firestone Tire and Rubber, International Harvester, Procter and Gamble, Dominion Glass, Camco, Siemens Canada and Westinghouse have left the city altogether. These job losses combined with a pattern of migration (by those who could afford it) from the downtown neighbourhoods surrounding major industrial plants to the suburbs to produce drastic economic inequalities within the city's boundaries. Thus, median family income in 2005 in the affluent exurb of Ancaster, formerly an independent municipality, was almost twice as high as the average for the former core city of Hamilton.

The health gradient associated with these inequalities has been documented in a remarkable collaboration between McMaster University researchers Neil Johnston and Patrick DeLuca and Hamilton Spectator investigative reporter Steve Buist. Their work produced a series of stories in the Spectator in 2010, is summarized in a new journal article+, and provides a template that should be used by university-community coalitions in cities throughout Ontario and elsewhere.

code-red-pic-1-500Source: McMaster University and Hamilton SpectatorThe researchers started with 12,000 death records and 400,000 hospital admission and emergency room (ER) visit records from 2006 – 2008, for everyone listing a Hamilton home address. Identifying information was removed to ensure privacy, and a hospital research ethics board indicated that no formal review was required. Twelve health variables were identified, and patient records were sorted by home address into Hamilton's 135 census tracts, for which socioeconomic data from the 2006 census were also obtained. Local school boards provided information on high school completion. The data were then turned into a series of maps, only a few of which are shown here, that show census tracts grouped by quintile, but data are also available for each individual census tract.

As one of the articles in the original series put it: "Those neighbourhoods with high rates of emergency room visits, no family physician, respiratory-related problems and psychiatric emergencies are the same neighbourhoods, in general, that have the lowest median incomes, lowest dwelling values, highest rates of people living below the poverty line and highest dropout rates from school."

"In parts of the lower-central portion of Hamilton," the story continued, "where poverty is deeply entrenched, some neighbourhoods live with Third World health outcomes and Third World lifespans."

code-red-pic-2-500Source: McMaster University and Hamilton SpectatorSome specifics: in one high-income census tract on Hamilton Mountain, where only 4.1 percent of the over-15 population lived on incomes below the Low-Income Cutoff (LICO) in 2005 and median family income was more than $68,000, average age at death was 86.3 years. In one low-income downtown census tract (35 percent of people over 15 living below the LICO, median family income just under $40,000) it was 65.5 years – a difference of 21 years.

The journal article that summarizes Code Red findings adds: "Also, there was a 22-year difference in the average age of a patient attending hospital with a cardiovascular-related emergency—from 57 years at one extreme to 79 years at the other. With respect to acute-care hospital bed use, one neighbourhood in the lower inner city had a rate of 729 days of acute-care hospital bed use per 1,000 people between the ages of 16–69. At the other extreme, an affluent suburban neighbourhood had a rate of 46 days of acute-care bed use per 1,000 people between the ages of 16 and 69. Other statistics presented included one inner-city neighbourhood having a rate of children living below the poverty line of 68.5 per cent while there were seven neighbourhoods where the rate of children living below the poverty line was 0 per cent."

code-red-pic-3-500Source: McMaster University and Hamilton SpectatorIn addition, a composite of all health and socioeconomic indicators was generated to produce a single ranking of each of the city's 130 census tracts. This ranking, too, was mapped by quintile. Combined, the two adjacent census tracts that placed lowest in this ranking had more than 40 percent of their population living below the LICO and the highest rates of hospital use – more than 1400 bed-days per person, or more than 17 times the rate for one suburban census tract. They also ranked near the bottom on many other health indicators.

The study also considered cost issues. Based on figures provided by Ontario's Ministry of Health and Long-term Care, it found that ER, hospital and ambulance use over the two years covered by the study cost $2,060 for every person living in one low-income, downtown neighbourhood. In one suburban neighbourhood, these costs added up to just $138 per person – raising the question of whether resources could be better used to eliminate social and economic conditions that make the ER and the hospital frequent ports of call for people with extensive health care needs, limited resources, and (often) no family physician.

That question is central to efforts to advance health equity, and it came up often in the course of research for Code Red, which was much more than a statistical exercise. The Spectator series included interviews with Hamiltonians as diverse as the head of a community foundation, a young paramedic whose role is that of a first responder to health emergencies, a family physician operating a one-person practice in the downtown neighbourhood where he grew up, a woman recovering from homelessness and crack addiction and the chief of emergency medicine at one of the city's hospitals. The stories told add to the statistics, as disturbing as they already are, what philosopher Jon Elster has called the texture of everyday life.

code-red-pic-4City of Industry, March 2007; photo by Chip Walsh,
reproduced under Creative Commons 2.0 licence
At least in Hamilton, the health gradient has an environmental dimension. The Niagara escarpment divides the city by elevation between the low-lying downtown and Hamilton Mountain (as the escarpment is called locally) and surrounding suburbs. As one story in the series pointed out, the escarpment "acts like a catcher's mitt for offshore breezes from Lake Ontario, trapping pollution over the lower city, particularly the northeast" – where the city's major industries were historically located, and where current levels of deprivation are highest. The story went on to note that despite deindustrialization, pollution levels in this part of the city still exceed recommended levels far more often than in rural areas. An earlier study, covering the period 1985-94, found that total suspended particulate (TSP) pollution exposure levels and dwelling values (a useful proxy for neighbourhood socioeconomic status) were inversely related – an important finding, since smaller particulates in particular are linked to respiratory damage.

In academic terms, some are likely to critique the study for not using age-standardized measures of mortality. However, the authors made "a conscious decision ... to treat the data in the simplest fashion possible so as not to confuse a lay audience," and unadjusted data may actually be more meaningful from a health equity perspective, because of what they reveal about the extent of health disparities 'on the ground'. The same is true of objections related to the difficulty of disentangling causation from selection, which was not the objective. As an associate medical officer of health interviewed for the series put it: "People don't move to a neighbourhood and then the neighbourhood makes them poor. They're often in those neighbourhoods because they can't afford to live other places." From an equity perspective, that's the point.

In the words of one of the authors, the Code Red stories "really seemed to strike a nerve in Hamilton." They influenced the subsequent municipal election campaign; played a role in decisions to locate two new hospital treatment centres in central areas of the city where need is greatest; led to the creation of a new staff position in municipal government; and have attracted extensive interest from various audiences. Against a background of fiscal austerity that often proceeds on irrational lines, it may be too early to assess (or to expect) more systemic effects. The study nevertheless represents a critical advance not only in our understanding of health equity in Canada but also in our knowledge transfer capabilities – the kind of work that health research funding agencies should be supporting and encouraging.

* Neil Johnston and Steve Buist provided valuable assistance with this posting. All non-attributed views are exclusively my own.

+Contact Neil Johnston, This e-mail address is being protected from spambots. You need JavaScript enabled to view it for a copy

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  • Kenneth Thompson
    Kenneth Thompson says #
    Ted, thanks for this.. and thanks to the Code Red team for doing this extraordinary work. As a Pittsburgher, I am very keen to s...

Fostering blissful ignorance about poverty?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 23 April 2012
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Many readers of the federal budget will have missed the decision to shut down the National Council of Welfare, a small and independent-minded unit of the Government of Canada that since 1962 has been a source of information about the extent and depth of poverty and inadequate social provision in Canada. With its demise, a resource for advocacy on social determinants of health has been lost. It is still possible to use the Council's site to access an interactive map showing that (for example) inflation-adjusted social assistance incomes in Ontario are no higher than they were in 1986. And the ground-breaking 2011 study on The Dollars and Sense of Solving Poverty is still available. To quote just one provocative finding from its summary: "The poverty gap in Canada in 2007—the money it would have taken to bring everyone just over the poverty line—was $12.3 billion. The total cost of poverty that year was double or more using the most cautious estimates," although these are admittedly incomplete and fragmentary. The public health community would be well advised to act fast and download the Council's publications before they are consigned to the memory hole.

Another disturbing set of findings about economic insecurity comes from the latest annual survey of Canadian family finances (families of two or more people) from the Vanier Institute of the Family. Some of the study's findings will be familiar: for instance, after-tax income of the poorest 20 percent of Canadian families (two or more people) rose by just 19 percent between 1990 and 2009; the incomes of the richest 20 percent rose by 35 percent. We know from other studies that the trend toward increasing inequality is even more extreme when we look only at the top one percent of the Canadian income distribution: 246,000 people with an average income in 2007 of $404,000 who accounted for 32 percent of all the growth in incomes between 1997 and 2007.

blissful-pic-1Source: Department of Finance Canada.
This illustration is taken from an official Government of Canada publication;
it is used here without Government of Canada endorsement.

Other Vanier findings are less familiar, and more disturbing. For instance, Canada's official unemployment rate in early 2012 would have been 9 percent, rather than 7.6 percent, if the participation rate had been as high as before the recession; 'discouraged workers' who have given up the search for work are not counted as unemployed. And although the overall insolvency rate (bankruptcies and proposals to creditors per 100,000 population) dropped slightly in 2010 and 2011, insolvencies among people aged 55-64 increased by almost 600 percent between 1990 and 2010. Among people over 65 they rose by 1747 percent. This suggests that one of the signal accomplishments of postwar Canadian social policy, cutting the percentage of poor seniors to one of the lowest in the OECD, may be in danger.

As noted in an earlier posting, addressing the possible consequences for population health of such trends unavoidably raises questions of public health ethics. One approach would be to set up an elegant prospective epidemiological study, wait 10 or 15 years, and hope that the casualties, their survivors, or someone are still interested in the answers. Another approach, adopted by the Commission on Social Determinants of Health, is to act on what we now know or can presume with a high degree of confidence, drawing on various sources of evidence and research traditions. So far, our political leaders – and, it must be said, a few of our public health colleagues – seem more interested in punishing the poor and economically insecure, or just ignoring them, than in equalizing opportunities to lead healthy lives. Inequality trends are important for many reasons, but one is that they give the lie to claims that such equalization is unaffordable.

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  • Ted Schrecker
    Ted Schrecker says #
    Where will this information come from? Good question. Much of it could be reconstructed from other publicly available data source...
  • animateur@chnet-works.ca
    animateur@chnet-works.ca says #
    Hi Ted thanks for posting this blog! I had no idea that the National Council of Welfare was cut. Maybe I'm in good company? I woul...

Life A.D. (After Drummond), Part 2: Structural adjustment for Ontario?

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On February 15 the Government of Ontario released a far-reaching report on reorganizing public service provision in response to the budget deficits that followed the post-2008 recession. The central theme of the report was that “just to meet the government’s goal of a balanced budget seven years hence, the government will have to cut even more deeply from its spending on a real per-capita basis, and over a much longer period than the Harris government did in the 1990s, without the option of an immediate deep cut in social assistance rates” (p. 121). Ontarians will remember that the Harris government cut those rates by 21 percent almost immediately after coming to power. Despite some increases, in 2009 they remained (depending on the type of household receiving assistance) between 17 and 38 percent lower than in 1996 after adjusting for inflation, according to the National Council of Welfare.

The Commission says much that is important and worthwhile about health care in Ontario, starting with the recognition that Ontario does not really have a health care system, but rather “a series of disjointed services working in many different silos” (p. 152), and that Ontario health care does not perform well based on international comparisons. Well grounded hypothetical descriptions of patient trajectories spotlight shortcomings in health care performance (pp. 153, 159, 164), measured against what ought to happen as a matter of routine. The report makes a compelling case for improving coordination among the silos, through measures both large and small, and making the non-system’s current approach to complex and chronic conditions (the management of which is also very costly) more effective – all of which should have been accomplished long ago, for reasons unrelated to cost. The report urges “aggressive” negotiation with the Ontario Medical Association on compensation (p. 189) – bringing to mind Robert Evans’ long-standing insistence that "cost containment is in aggregate income control, by definition" – and, perhaps more importantly from a health policy perspective, insists on moving “critical health policy decisions out of the context of negotiations with the Ontario Medical Association and into a forum that includes broad stakeholder consultation” (p. 185).

life-ad-part-2-pic-1 A leaner, meaner Ontario: Locked out workers at the Electro-Motive plant in London, Ontario, January 2012. Photo: CAW Media; reproduced under a creative commons licenceAlthough such changes are overdue, hard questions remain unanswered. The Commission proposes to strengthen Ontario’s 14 Local Health Integration Networks (LHINs, the province’s variation on regional health authorities) so that they can improve coordination among silos and health care management in general. But can these entities accomplish such critical tasks as ensuring that best practices are rapidly adopted province-wide? What are the pitfalls of specifying that the accountability of LHINs, currently with no requirements for public participation, is to the Ministry of Health, as per the Commission’s recommendations, rather than to the clients they serve? And the proposed transformation of an organization called Health Quality Ontario, now an advisory body, into “a regulatory body to enforce evidence-based directives to guide treatment decisions and OHIP [Ontario Health Insurance Plan] coverage” (p. 186) could be a dream or a nightmare. Since “nothing works” is a fiscally attractive conclusion, we can imagine immense pressure to compromise transparency and scientific integrity, and ignore standard of proof issues, in the interests of cost containment.

The report further acknowledges the importance of social determinants of health: “Socio-economic factors such as education and income explain 50 percent” of population health outcomes, and the physical environment another 10 percent (p. 132) although the percentages, drawn from a Canadian Senate Committee report, appear to be guesstimates and no supporting evidence is provided. This acknowledgement is ironic, to say the least, given what the Commission has to say about social policy.

The Commission’s proposed 0.5 percent limit on annual spending growth for all social programs means that no increase in social assistance rates is envisioned, despite the decline from mid-1990s levels. In fact, the Commission proposes slowing the provincial takeover of social assistance costs downloaded to municipalities during the Harris era (p. 483), prolonging the nineteenth-century practice of leaving “poor relief” to local governments. (Unfortunately, some surveys find that nineteenth-century attitudes toward economic hardship remain widespread.) No new resources are contemplated for social or affordable housing, despite the existence of multi-year waiting lists in much of the province. As the Toronto Star’s Thomas Walkom and a policy analyst for the Ontario Nurses’ Association have pointed out, despite Drummond’s long career as a professional economist, the report ignores the employment consequences of taking billions of dollars out of the provincial economy. Walkom predicts that implementation of the Drummond recommendations would cause unemployment in Ontario to rise to 11 percent by 2018, “even without another global crisis”. Poverty reduction is nowhere acknowledged as a legitimate goal or priority of government; indeed, the word “poverty” appears only six times in the text of the 562-page report.

To put this discussion into context: on Thanksgiving weekend in 2010, the Premier of Ontario was quoted by CBC News as urging Ontarians to donate to food banks, and in March, 2011 395,000 Ontarians relied on a food bank to feed themselves at least once. Rents and food prices are not going down. So the Commission has said to a significant proportion of Ontarians: forget about any hope that your opportunities to lead a healthy life will improve before 2017-2018. The cupboard is bare.

But is it, really? In order to answer this question, we have to look at both the revenue side and the expenditure side of Ontario’s public finances, in historical perspective. The Commission itself emphasizes that “spending is neither out of control nor wildly excessive. Ontario runs one of the lowest-cost provincial governments in Canada relative to its GDP and has done so for decades” (p. 5). Further, it notes that the provincial treasury’s “own-source revenues” – taxes and user fees collected by the province, as distinct from revenues received from federal transfers – as a percentage of provincial Gross Domestic Product (GDP) were considerably lower (13.65 percent) in 2010-2011 than in 1999-2000, midway through the Harris era (15.9 percent). Although precise comparisons are impossible, this is consistent with estimates by the Canadian Centre for Policy Alternatives that, every year since the start of the century, provincial tax cuts (mainly in personal income tax rates) begun in 1995 have reduced revenues by between $10 billion and almost $18 billion relative to the revenues that would have been received if tax rates had remained at their 1994-95 levels. In other words, well before the post-2008 and its undeniable effects on revenue stream, the province’s fiscal capacity was suffering from major self-inflicted wounds.

life-ad-part-2-pic-2

The Commission was instructed not to consider the possibility of raising taxes. However, as shown in the illustration, if we accept the Commission’s estimates of the growth of the provincial economy and the spending restraints incorporated into the Drummond Commission’s “preferred scenario,” but are willing to consider tax increases sufficient to return own-source revenues as a percentage of provincial GDP to their 1999-2000 level by 2017-2018, we see that the budget is in surplus by more than $22 billion. Stated another way, if the province were to pursue what Hugh Mackenzie of the Canadian Centre for Policy Alternatives has called “an adult conversation about the public services we need and the revenue we are going to have to raise to pay for them,” the provincial budget could be balanced in the target year while making available $22 billion more than the Drummond projections for program spending. According to one commentator the province is not even planning pre-budget legislative hearings, thus making it difficult to start such a conversation. Indeed, the Commission’s description of the provincial budget as “a powerful educational tool” (p. 13) suggests that most of the key immediate decisions have already been made. Its proposal for a centralized expenditure management process involving the Premier’s Office, Cabinet Office and Ministry of Finance that “should stay in place for at least several years” warns of little room for debate in the future (pp. 140-141). Shouldn’t public finance be a matter for public debate?

At several points in its report the Commission underscores the difficulties created by the government’s refusal to consider tax increases, anticipating (for instance) a $38.5 billion shortfall in financing planned and necessary public transit investments in the Greater Toronto and Hamilton Area. For those who can afford to drive everywhere, this means only the inconvenience of more traffic jams; for those who can’t, it may seriously limit mobility … and of course that foregone investment also means lost employment. The Commission states that its budget-balancing strategy would mean “tough decisions that will entail reduced benefits for some” (p. 69) – although not, it seems, for everyone. On the matter of soaring compensation for people like Drummond’s fellow commissioners at the top of public sector salary scales, the report says that “focus must remain on the larger picture, which is the government’s need to get the right people into the right positions at a cost that is both compatible with its fiscal circumstances and appropriately aligned with private-sector compensation” (p. 138). Well, workers at Electro-Motive Diesel’s London, Ontario plant know about that kind of alignment: they were locked out after refusing a 50 percent pay cut before the parent company closed the plant and moved the work to Indiana. In the Ontario of tomorrow, it seems that what Saskia Sassen calls “the savage sorting of winners and losers” characteristic of the contemporary global marketplace is to be accepted, and indeed welcomed.

life-ad-part-2-pic-3

Any assessment of the Commission’s implications for population health (and never was there a better example of the need to apply health equity impact assessment to macro-scale economic and social policies) should keep this in mind. As pointed out by (among others) economist Erin Weir of the United Steelworkers, there is quite a bit in the report that those of us committed to social justice can support. At the same time, the report is about much more than public finance. Effectively, it recommends for Ontario a variant of the structural adjustment programs* of marketization and social policy retrenchment demanded by the International Monetary Fund in return for loans enabling low- and middle-income countries to reschedule their debts to external lenders, in the process creating widespread economic hardship and seldom leading to long-term economic improvements. Equity, for both the IMF and the Drummond Commission, was an unaffordable luxury. Against a background of worsening economic disparities that would be further magnified in the future envisioned by the Commission, what is the future of health equity in Ontario? And who will decide?

 

* For readers unfamiliar with the history of structural adjustment, two excellent recent review are Babb, S. (2005), The Social Consequences of Structural Adjustment: Recent Evidence and Current Debates, Annual Review of Sociology, 31, 199-222 and Pfeiffer, J. & Chapman, R. (2010), Anthropological Perspectives on Structural Adjustment and Public Health, Annual Review of Anthropology, 39, 149-165. Unfortunately, so far as I know neither of these is available on an open-access basis.

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

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Ted Schrecker
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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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Diabetes in Canada: Parts of the story

Posted by Ted Schrecker
Ted Schrecker
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Shortly before this past Christmas, with minimal publicity, the Public Health Agency of Canada released a valuable collection of facts and figures on Diabetes in Canada. It points out (for instance) that in the decade after 1998/99, the prevalence of diabetes among Canadians increased by 70 percent (to 2.4 million), with a predicted increase in prevalence to 3.7 million by 2018/19. Further, "although only 3.1% of all deaths in Canada were attributed to diabetes in 2007, more than a quarter (29.9% of individuals who died had diabetes in 2008/09. Diabetes itself does not typically lead directly to death, but the complications associated with diabetes do." Thus, prevalence figures substantially understate its overall contribution to the burden of illness borne by Canadians; that contribution includes cardiovascular disease (the most frequent complication), eye disease, kidney disease, increased infection from minor injuries and a variety of other conditions.

Diabetes-posting-pic-1Healthy food choices: not always availableThe report's importance in drawing attention to the magnitude of the diabetes-related burden of illness is beyond question, yet its contribution to understanding that burden from a health equity perspective is limited. For the most part the authors adopt a conventional risk factor approach to the causes of diabetes, starting (predictably and non-controversially) with a description of overweight and obesity, and the contributions of limited physical activity and unhealthy eating. A list of self-reported barriers to physical activity is reproduced, as is a list of factors influencing food choices that includes nutritional knowledge, perceptions of healthy eating, media advertising and "lower socio-economic status and social inequity," which is not further explored.

The report's treatment of socioeconomic gradients is similarly descriptive, confined to gradients among adult Canadians across Canada, stated by income quintile and education level, in self-reported obesity, physical inactivity, inadequate fruit and vegetable consumption, and daily tobacco smoking. Curiously, data on socioeconomic gradients in actual prevalence of diabetes are not presented, although according to Canadian Community Health Survey data prevalence of Type 2 diabetes in the lowest household income group (income less than $15,000) is more than four times as high as in the highest income group (over $80,000). According to the authors of this last study, "individual risk behaviours do not explain a substantial part of the income association," suggesting "that the diabetes burden associated with poor health behaviours should be looked at through the lens of socioeconomic conditions."

Diabetes-map-1Age- and sex-adjusted diabetes prevalence per 100 persons of all ages, Toronto, 2001-02. Source: Booth GL, Creatore MI, Gozdyra P, Glazier RH. Diabetes in Toronto, Chapter 2: Patterns of Diabetes Prevalence, Complications and Risk Factors. Toronto: Institute for Clinical and Evaluative Sciences; 2007. Reproduced by permission.

 

Diabetes-map-2Average annual household income, Toronto, 2000. Source: Creatore MI, Gozdyra P, Booth GL, Ross K, Glazier RH. Diabetes in Toronto, Chapter 3: Socioeconomic Status and Diabetes. Toronto: Institute for Clinical and Evaluative Sciences; 2007. Reproduced by permission.

Finer-grained examinations of how socioeconomic conditions affect the origin, management and prognosis of diabetes can be found in several places. The Toronto diabetes atlas project of the Institute for Clinical Evaluative Sciences produced a multi-volume mapping of diabetes prevalence and a range of neighbourhood characteristics; just two of the 140 maps generated by the project are shown here. To oversimplify a complex set of findings, the project found that higher-income neighbourhoods generally had lower prevalence of diabetes. Prevalence was especially high in low-income neighbourhoods outside the downtown core, with high proportions of recent immigrants and members of recent minority groups. These neighbourhoods tended to have lower population densities, poor walkability, limited access to public transit and long distances to stores selling fresh fruits and vegetables (the 'food desert' problem) and other so-called healthy resources like parks. Conversely, high incomes seemed to have a protective effect against diabetes, even in neighbourhoods where adverse outcomes would be expected based on place-related characteristics. "We noted a striking mismatch," the authors concluded, "between areas of Toronto where healthy resources were most needed and where they were located."

Diabetes-posting-pic-2Activity-friendly urban environments like this may be inaccessible to people in low-income neighourhoodsThere is also, as I have pointed out in previous postings, the simple arithmetic impossibility of eating a healthy diet for many people living on low incomes if they are also paying market prices for housing. Indeed, a series of interviews by York University's Dennis Raphael and colleagues (1) with people trying to manage diabetes in Toronto on incomes below Statistics Canada's Low-Income Cutoff (LICO) found food insecurity and inability to afford an adequate diet widespread "even with almost two-thirds [of participants] living in some form of government-assisted housing or shelter." Two recent articles (2,3) by Claudia Chaufan and colleagues similarly explore the interaction of low incomes, limited availability (and high local prices) of healthy food, high transportation costs and other variables like insecure employment in a Latino and immigrant neighbourhood in Northern California, concluding that structural factors limit the relevance of health and lifestyle education interventions – a point that should by now be familiar, but nevertheless merits continued repetition. One interview respondent summed up the range of problems: "You know, it's a full time job to be poor."

Variables like those identified in the Toronto and Northern California studies are not prominent in the PHAC report, beyond brief generic discussion of healthy food choices and of the built environment. New York-based researchers Rodrick and Deborah Wallace have eloquently compared individualized explanations of obesity that focus on imbalance between caloric intake and exercise to "the remark by US President Calvin Coolidge on the eve of the Great Depression that 'unemployment occurs when large numbers of people are out of work' ... and as Raphael pointed out in a holiday posting on his Social Determinants of Health listserv, the word "poverty" appears nowhere in the PHAC report. (I checked; it doesn't.) That report remains useful, yet at the same time shows how very much still needs to be done to integrate social justice and social determinants into the everyday worldview of public health professionals.

 

(1) Raphael D, Daiski I, Pilkington B, Bryant T, Dinca-Panaitescu D, Dinca-Panaitescu S. A toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics: the experiences of poor Canadians with Type 2 diabetes. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).

(2) The Twin Epidemics of Poverty and Diabetes: Understanding Diabetes Disparities in a Low-Income Latino and Immigrant Neighborhood. Journal of Community Health 2011;36:1032-43, (full text unfortunately not available for open access).

(3) Chaufan C, Constantino S, Davis M. 'It's a full time job being poor': understanding barriers to diabetes prevention in immigrant communities in the USA. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).

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What's it like to be poor in Canada?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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For many Canadians who have fallen through the cracks of our increasingly unequal economy and frayed social safety nets, this festive season is anything but. CBC radio's The Current recently aired a multi-part series on being poor in Canada. The first part of the series addressed such issues as child poverty and the fact that the poor pay more for a range of goods and services, from food to banking. This was followed up with two call-in sessions that ran in every time zone; the second session featured political leaders including social service ministers from Nova Scotia, Ontario, Manitoba and Alberta. At least for the moment, audio of all the programs is available by clicking on the hyperlinks. More soon on a new OECD report that documents the 30-year increase in economic inequality in most of the high-income world.

Tags: economic, poverty
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  • Lami Sadare
    Lami Sadare says #
    Dear Wendy, I think that is very middle-class thinking. The factors which act on low-income individuals and families go way beyon...
  • Wendy Burpee
    Wendy Burpee says #
    I am in no way well-informed on this matter... here are some ideas for managing on low incomes: Breastfeed, and eat beans/lentils,...
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What part of “social injustice is killing people” don’t you understand?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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What part of "social injustice is killing people" don't you understand?

I'm prompted to write this posting by several recent conversations with people who argue (to quote one example) that it is not clear how critiques of economic processes and their distributional impacts "relate to health beyond the truism that poverty is bad for health." Well, if that's the case then the highest priority for any discussion of justice and health should be the ways in which those processes generate and perpetuate poverty, shouldn't it? (Philosopher Thomas Pogge has been making this point in the context of global justice eloquently, for many years; see in particular the section of his web page listing publications on this topic.)

I am not at all convinced that the connection between poverty (however defined) and ill health is a "truism" based on the amount of time I have spent slowly and carefully explaining the point over the past several years, so here are a few elaborations. They start with the most obvious: not getting enough to eat, on an ongoing basis, is bad for health. Can we agree on that?

Well, the number of undernourished people in the world in 2006-2008 was estimated by the United Nations Food and Agriculture Organization at 850 million, roughly the same number as in 1979-1981. (This refers to insufficient caloric intake for the activities of daily living; it has nothing to do with the four basic food groups.) Although such estimates are necessarily imprecise, more recent trends have certainly not been helped by rising food prices; global food price indices are more than twice as high as over the period 1990-2000, and a recent UNICEF report identified similar price levels in 58 individual countries. FAO's most recent annual report on world food insecurity noted a range of causes, concluding: "Climate change and an increased frequency of weather shocks, increased linkages between energy and agricultural markets due to growing demand for biofuels, and increased financialization of food and agricultural commodities all suggest that price volatility is here to stay."

So much for the global picture, but not relevant to rich Canada, right? Wrong. Using 1998 survey data from the province of Québec, the University of Ottawa's Lise Dubois found that in census tracts that ranked in the top 20 percent on scores of both material and social deprivation, almost one in four families experienced food insecurity [1]. Closer still to home, Toronto's Department of Public Health has for many years estimated the cost of eating the Nutritious Food Basket recommended by Ontario's Ministry of Health and Long-term Care for several categories of families living on the income provided by provincial income support programs, if they are also paying market rents. In 2010, as shown in the accompanying healthy eating toronto-1table please, it was quite simply impossible for many people. (The Association of Local Public Health Agencies has shown that the same was true throughout the province at least as of 2008, and a coalition of dietitians and nutritionists has done a similar calculation for British Columbia.) No wonder more than 400,000 Ontarians a month were turning to food banks. Subsidized or social housing is an option in theory, but in early 2011 more than 66,000 households were on a waiting list in the City of Toronto.

Apart from direct consequences like inadequate diet or giving up dental care in order to pay for food and housing, the stress of having to cope with life on an inadequate or precarious income is itself a contributor to ill health, as pointed out by Sir Michael Marmot in his unjustly neglected book The Status Syndrome. Life for a single mother who has to drop one child off at daycare and another at school as part of a two-hour one-way commute on foot and by transit to a low-wage job is far more stressful than for a comfortable suburbanite; among other things, there's not a lot of time or energy left to seek out healthy foods, or for comparison shopping to stretch the budget. (And yes, in my experience this does have to be explained to people, especially if they haven't set foot on a bus in years.) Colloquial references to stress distract us from the fact that the concept has a clear, and relatively well understood, physiological dimension and that its effects cumulate over time. Bruce McEwen, a leading researcher in the field, wrote more than a decade ago that "considerations of stress and health are becoming useful in understanding gradients of health across the full range of education and income, referred to as 'socioeconomic status' or SES. SES is as powerful a determinant of mortality as smoking, exposure to carcinogens, and many genetic risk factors".

SES is not only about incomes; factors like race and gender matter as well. (The concept of intersectionality, as used in feminist research, responds to this insight.) One of the more striking demonstrations of how social inequality gets under your skin was produced by Arline Geronimus and colleagues, who used data from the US National Health and Nutrition Examination Survey (NHANES) to design a measure of allostatic load – a key concept in the physiology of stress – for black and white adults, subdividing the sample by gender and into poor and non-poor based on household incomes. They found that allostatic load scores rose with age for all groups, but being poor, being black and being female each operated independently to increase the probability of a high score, and "in each age group the mean score for Blacks was roughly comparable to that for Whites who were 10 years older." In other words, living near the bottom of social hierarchies, and in particular near the bottom of multiple hierarchies, wears you out over time in biologically measurable ways. In another important study on stress effects, Bird and colleagues used allostatic load scores based on NHANES data to identify "significantly greater biological wear and tear" from living in census tracts where SES was lower, independent of individual characteristics. (Unfortunately, the full text of the study is not available on an open access basis.)

These are just two examples from a rich literature, which goes a long way toward explaining the persistence of socioeconomic gradients in health even when direct material deprivation (like not getting enough to eat, or exposure to toxic chemicals on the job) is not at issue. As Marmot points out, unanticipated expenditures (something as simple as having to come up with $200 to retrieve an illegally parked car that's been towed) and the closed businessprospect of plant or business closures are experienced very differently by workers and their employers, because of the material resources to which they have or don't have access. The literature also suggests that the familiar debate about whether to attribute socioeconomic gradients to material or "psychosocial" factors is for the most part a sterile one. Position in a social hierarchy is reflected in the material world (with apologies to Madonna), and the stresses associated with subaltern status most definitely have biological manifestations and consequences. Surprisingly, many students in public health, health promotion and related fields seem not to be exposed either to this body of research or to the texture of everyday life for the economically and socially marginalized. This last problem may arise from the fact that the relevant work tends to be generated in disciplines like sociology and urban anthropology, which aren't normally central to health curricula. In any event, in education as in research, we have a long way to go.

References


[1] L. Dubois, Food, Nutrition and Population Health: From Scarcity to Social Inequalities. In: J. Heymann, C. Hertzman, M. Barer and R. Evans,eds., Healthier Societies: From Analysis to Action (pp 135-172). Oxford University Press, 2006.

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  • Ted Schrecker
    Ted Schrecker says #
    Dot and Lorraine, Unfortunately, I think part of the problem is that people do "get it," and understand what policies of reducin...
  • Lorraine Rudolph
    Lorraine Rudolph says #
    I'm torn between praising your blog and moaning "Why don't well-educated, well-fed people get it?"...well, there you have it......
  • animateur@chnet-works.ca
    animateur@chnet-works.ca says #
    Ted - you have hit the nail on the head. thank you for posting this! I'm still wondering why.....what part of this information is...

Policies for health equity: Learning from the Danes

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 01 November 2011
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Since the report of the Commission on Social Determinants of Health appeared in 2008, several efforts have been made to apply its insights to specific country and regional challenges. The most familiar of these are the review carried out in the United Kingdom, now competed, and the one under way in WHO's European Region – both led by Sir Michael Marmot himself. A less publicized review, led by distinguished public health researcher Finn Diderichsen, was recently completed in Denmark. The English-language version of its report is forthcoming in the Scandinavian Journal of Public Health, and is presented here in pre-publication form.

In many respects, Denmark is a leader in health and social policy. At least until recently, its economic policy dealt successfully with the issues facing a small, open economy by way of a labour market policy known as flexicurity that combines limited job protection with a high level of income protection and training provision. According to OECD figures, in 2009 a laid-off Danish worker could expect to receive unemployment benefits worth 47.7 percent of previous earnings, as compared with 11.7 percent in Canada – a figure that reflects Canada's restrictive eligibility requirements and low insured earnings ceilings. denmark posting 12 determinantsDanish child poverty rates are among the lowest in the OECD, according to figures from the Luxembourg Income Study, although the report notes a worrying increase between 2001 and 2007, partly attributable to reduced unemployment benefits. The country recently adopted a tax on foods high in saturated fats, in an effort to create economic incentives for healthier eating. At the same time, the new report is motivated by concern about the "Scandinavian Welfare Paradox of Health": Scandinavian countries with relatively low levels of economic inequality do not in fact exhibit the lowest levels of health inequality among the high-income countries, at least when crude measures such as mortality and self-reported health are used.

The report's authors identified a list of 12 determinants of health, using a straightforward model developed by Diderichsen and colleagues more than a decade ago for understanding connections among economic and social policies, macro-level variables like social stratification, and individual health outcomes.

denmark posting child pover

(Their original article does not appear to be available on an open-access basis, but pages 15-17 of the new Danish report provide a first-rate short description of the model.) For each of the 12 determinants in the list, they then provide a brief account of the relevant research evidence and an inventory of measures that are likely to be effective in reducing health inequality. Preventing increases in income inequality is identified as a priority, as are planning measures to counteract the tendency of housing markets to increase residential segregation. The inventories sometimes combine conventional 'downstream' interventions with more contextual ones. For example, with respect to interventions for early child development, the inventory includes maternity visits by health nurses and active recruitment of children with special needs through day care institutions and kindergarten classes but also elimination of childhood poverty. And suggested measures to reduce overweight, obesity and their health consequences include taxation and healthy choice programs in school and workplace cafeterias, but also (unspecified) measures to increase physical activity in disadvantaged residential areas.

Like many such reviews, the report focuses on the importance of cross-sectoral policy coordination while emphasizing both its difficulty and the lack of "positive international experiences vis-à- vis reducing inequalities." In an interesting reflection on Britain's lack of success , the report notes (for example) the long period of time required to demonstrate reductions, because the influences on health inequalities operate across the life course, and the fact that "far too many initiatives constitute single temporary projects in local deprived areas" rather than influences on broader public policies. (This observation will sound uncannily familiar to Canadians!)

It is always difficult to assess the comprehensiveness of such reviews without detailed knowledge of the country context, but a few aspects strike the foreign reader as curious. For example, although limited accessibility of healthy foods in thinly populated areas and poor neighbourhoods (the problem of food deserts) is noted, no specific measures to improve accessibility in such areas are proposed. And from a Canadian vantage point, the recommendation to increase school completion through "practical learning targeted at young people who cannot complete a normal academic school program" sounds like a recipe for stigmatization, increased stratification and a less, rather than more inclusive society.

To the extent that the data allow direct comparisons, we should also be aware that health (and socioeconomic) disparities in Denmark are already smaller than in some other high-income jurisdictions. The report notes that differences in life expectancy between neighbourhoods in Copenhagen "are as large as six to seven years" – lower than the difference of more than 10 years (for men) between some of the richest and poorest neighbourhoods in Montréal or the 17 year difference in London and the 28 year difference in Glasgow noted by Marmot and colleagues. And the poverty rate of 10-20 percent in some Danish parishes identified as a cause for concern in the report should be compared with the more than 40 percent of economic families living below the before-tax Low-Income Cutoff in some of Toronto's inner suburban neighbourhoods. (Because of different poverty measures, this comparison – unlike the international comparison of child poverty rates cited earlier – is only approximate.)

Despite these factors the similarity of the issues faced by Canada and Denmark in a global economic environment that tends to increase economic inequality is striking, and the Danish report will be valuable as a starting point and inspiration for Canadian provinces or local jurisdictions wanting to undertake a systematic and theoretically informed assessment of what works to reduce health disparities.

* We are deeply indebted to Prof. Diderichsen for permission to post this material.