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Health as if everybody counted blog

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Single mothers and income inequality: Demographic reality, an old scary trope revisited, or a little of both?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 24 July 2012
in CHNET-Works!

single mothers 1Photo by: Clementine Gallot,
reproduced under Creative Commons 2.0 licence
On July 15, the New York Times ran a long story on income inequality and family structure. The story led with a comparison between the lives of two women working in the same child care centre in the US Midwest. One "goes home to a trim subdivision and weekends crowded with children's events"; the other, her subordinate, pays more than half an income in rent and "scrapes by on food stamps," the federal food vouchers on which more than 46 million Americans now rely.

Veteran social policy reporter Jason DeParle's point was, superficially, one of straightforward demographics and arithmetic: the birth of children in unmarried households is becoming the norm. In a world where two paychecks are increasingly essential if a household is to do more than scrape by, especially in the lower reaches of the income distribution, that will have a powerful effect on the overall distribution of income within a society – and by extension, on the life chances of children in different categories of households. Assortative mating – the tendency of people with comparable educations and incomes to marry or at least cohabit – magnifies this demographic effect.

There is nothing new about such observations. In 1998, internationally recognized Canadian urbanist Damaris Rose pointed out that the rapid increase in the number of two-earner households was driving out-migration from the island of Montréal to suburbs where home ownership was more affordable, although her concern was not with income inequality per se but rather with effects on urban form 1.  And the 'single' (presumptively young and feckless, presumptively non-white) mother was a central trope in US welfare 'reform' debates of the 1990s. At the same time, it's hard to disregard the differences that two incomes, especially two secure incomes, make in basic life chances.

single mothers 2Photo from The story of single mothers, part of a campaign by Raise the Rates, a coalition of community groups and organizations concerned with the level of poverty and homelessness in British ColumbiaIn response to the Times article, Shawn Fremstad posted a four-part critique on the web site of the Center for Economic Policy Research, one of the United States' best regarded left-of-centre policy research units. Among the points he made, each documented with links to primary research:

More basic questions would appear to be: why and how do some societies make it so much easier than others to raise children with an adequate material standard of living, and adequate social supports? Detailed, fact-based rather than model-based comparisons of policy regimes are surprisingly hard to find, but it is worth quoting a recent book chapter based on the Luxembourg Income Study's cross-national data sets on social policy impacts: "[A]fter accounting for taxes and transfers, fewer than 5% of children in Denmark, Finland, Norway and Sweden live in poor households," as against 15.6% in Canada and 22.2% in the United States 2. Full stop. Five percent versus 15-22%. A 2009 OECD study pointed out that while 24 percent of children in the United States lived in single parent families in 2005/06, the figure was 19 percent in Denmark and 16 percent in Norway. So something else is at work.

The same study concluded that "the empirical literature on the impact of family structure on child outcomes is at an immature stage." Based on a variety of outcome measures, it also concluded that "at a maximum ... the likely causal effect sizes of being brought up in a sole-parent family are small."

This is a complex policy field, but: a society seriously interested in equalizing opportunities to live a healthy life would start from a firm commitment to something like a 5% (or less) solution, and then work backward from there to see what policies would best achieve that goal in a specified time period, only secondarily asking questions about family structure – not least because of the long time frame needed for interventions that address family structure to have an impact, even when sound research evidence exists to support them.

Some societies are clearly more serious than others on this point. Perhaps that's why a journalist like the Times' DeParle, with a long history of questioning conventional wisdom, took the easy road of looking at family structure rather than the rocky road that runs through the effects of decades of offshoring, union-busting, attacks on social provision and tax breaks for the rich. It's a bit like the easy road taken by health promoters who profess a concern for social determinants of health, but end up talking once again about tobacco control and health literacy. Those are not unimportant, but if serious progress toward health equity is the destination, the easy roads are unlikely to get us there.

1. Rose D, Villeneuve P. Engendering Class in the Metropolitan City: Occupational Pairings and Income Disparities among Two-Earner Couples. Urban Geography, 19: 123-159.

2.  Gornick J, Markus J. Child Poverty in Upper-Income Countries: Lessons from the Luxembourg Income Study. In S Kamerman, S Phipps and A Ben-Arieh, eds., From Child Welfare to Child Well-Being (Springer Netherlands, 2010): 339-368;

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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
User is currently offline
on Wednesday, 09 November 2011
in CHNET-Works!

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.


[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.

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
User is currently offline
on Tuesday, 01 November 2011
in CHNET-Works!

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.

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