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

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

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

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

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

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

 

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

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

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Are social determinants of health moving into the mainstream?

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on Lundi, 11 Février 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.

Housing, equity, and economic apartheid

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Mardi, 15 Janvier 2013
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Maclaren

CBC News reported on January 9, 2013 that the residents of a high-rise Ottawa Community Housing building in Ottawa had been without hot water since November 30.  The people affected included a 77-year-old man in a wheelchair.  The revelation says a lot about the value of public broadcasting, and local CBC news bureaus in particular.  It also says a lot about the barriers to getting social determinants of health, like adequate housing, on the policy agenda.


It could be worse.  The residents of 415 MacLaren Street could have been stranded on upper floors by non-functioning elevators, which happened in 2010 to residents of a downtown Toronto Community Housing building.  But that’s not the point. 


A bit of background: public housing in Ontario used to be a responsibility shared among three levels of government.  However, the national government and most provincial governments have largely retreated from housing, content to leave it to the private market and to municipal governments that have limited revenue-raising options.  Canada is the only G7 country without a national housing strategy.


This might not be a problem if the market economy provided adequate incomes for all, or if Canadian social policy compensated for the failings of the market.  Neither is the case.  Market incomes at the bottom of the income scale have actually been dropping, and by the middle of the last decade it became clear that social policy had retreated from redistribution, big-time. Housing is only part of the equation.  For example, a hard-hitting report on social assistance in Ontario that recommended immediate increases in benefit rates and allowable labour market earnings for  “the lowest rate category, single adults receiving Ontario Works, as a down payment on adequacy” has vanished from the political landscape without a trace.  This is not only a Canadian problem.  In the United Kingdom, where the Conservative-Liberal Democratic coalition government is proposing to cap benefit rates while lowering the top income tax rate for the ultra-rich, a spokesman for the Labour Party – the Labour Party – won’t say anything more than that they “support the principle of a benefit cap, but with the important caveat that it should not render people homeless.”


For whatever reason, we tolerate a deepening form of economic apartheid, perhaps at least covertly buying the argument that those on limited incomes are the authors of their own misfortune.  The recent history of plant closings across Canada, briefly discussed in a previous posting and to be covered at greater length in a forthcoming one, is just one piece of evidence among many that undercut this belief.  But then, how often are such self-serving beliefs susceptible to refutation by evidence?


Historian and sociologist Margaret Somers describes the belief system that tolerates such economic apartheid as market fundamentalism – ironically borrowing the term from George Soros, one of the world’s richest men.  There are alternative perspectives.  One views the minimal material prerequisites for a healthy life, including adequate housing, as human rights – a position entrenched in international law by the International Covenant on Economic, Social and Cultural Rights, to which Canada is a party.  The current UN Special Rapporteur on the Right to Housing (be honest, now: did you know there was such a person?) is charismatic Brazilian architect Raquel Rolnik.  Her most recent annual report to the UN General Assembly is an important piece of historical scholarship and a stinging, carefully documented critique of the “financialization” of the housing sector, which has paid off handsomely for financial institutions and for many of the propertied, while marginalizing others.  In calling for “a paradigm shift from housing policies based on the financialization of housing to a human rights-based approach,” she is challenging market fundamentalism and asserting what Somers calls “the right to have rights” independent of the marketplace.


Unless professionals and advocates concerned with social determinants of health can get their heads around that simple message, as it applies to housing and many other policy fields, the future of the health equity agenda has to be reckoned as dim. 

Additional resources:
In an online video of an event at the City University of New York, Ms Rolnik delivers a powerful indictment of the financialization of housing (her presentation starts at about the one-hour mark in the video).  All her annual reports and reports of country visits, like those of her predecessor, are available on the Special Rapporteur’s official web page.

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Good news and bad on health equity

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Vendredi, 06 Juillet 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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Suitable for framing

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Lundi, 18 Juin 2012
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Herewith a selection of quotations and images charting the path of social determinants of health in policy analysis. We start with a trip in the wayback machine, to 1983 and a review article(1)on hypertension in Canada by Helen Johansen, then with the Health Protection Branch of Health and Welfare Canada.

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Closer to the here-and-now, a team of researchers with Toronto’s Institute for Clinical Evaluative Sciences wrote in a 2009 report comparing public health policies across Canada’s provinces that:

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A similar point comes from an important new report on overweight and obesity from the Institute of Medicine south of the border (the quotation is from the web summary):

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More about this report, and about recent studies that have been quoted as casting doubt on the importance of “food deserts,” in a subsequent posting. I invite comments from readers on the latter point, in particular; meanwhile, some of the comments posted on the New York Times article that describes the studies  offer valuable insights into the real world of life on a limited income, where both money and hours in the day are in short supply.

Most recently, the authors of a May, 2012 report on income differences among patients using hospitals in Toronto began the study with a brief discussion of health equity in which they noted:

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The phrase currently used to describe the policies needed to address those core social determinants of health is “intersectoral action,” which was the topic of an earlier posting. The unequal distribution of opportunities to be healthy was central to the work of the WHO Commission on Social Determinants of Health. It was also central to the public health strategy proposed in a 2007 report to Norway’s Storting  (the national legislative body) by the country’s Ministry of Health and Care Services, and was communicated in an image that remains remarkably powerful.

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What we should learn from this brief journey was captured in a 2011 Toronto conference presentation by Nancy Edwards, director of CIHR’s Institute of Population and Public Health.

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Against the background of this accumulated wisdom, why is so much activity still focused on individual-level behaviour change and lifestyle modification, and so little on structural disadvantage? The question is, of course, too ingenuous by half. In a commentary written shortly after the World Conference on Social Determinants of Health in October, 2011, Sir Michael Marmot captured the underlying realpolitikof resistance as it played out at the conference:

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It should now be clear that “less safe” policy directions are the only ones that will generate meaningful progress toward reducing health inequities. How willing are those of us who profess a commitment to that objective, perhaps especially those with academic tenure or collective agreement protection (I have never had the former, and have not had the latter for two decades) to insist on those directions? Can viable coalitions for change be built outside the universe of health researchers and front-line workers, for example by making long-overdue common cause with the trade union movement? Such questions may decide the future of health equity in a Canadian political context that, at least over the short term, looks distinctly hostile.

(1)  Johansen H.  Hypertension in Canada: Risk factor review and recommendations for further work. Canadian Journal of Public Health, 1983;74:123-128.

Social determinants of health: Glum tidings on the inequality front

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Lundi, 11 Juin 2012
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The Commission on Social Determinants of Health was emphatic about the role of “the inequitable distribution of power, money and resources” in sustaining socioeconomic gradients in health.  Such inequitable distributions do not just happen; they are the result of choices about how societies govern their economies and distribute the rewards they generate.  Globalization has undoubtedly narrowed the range of such choices – think about Eduardo Galeano’s “magic galleon that spirits factories away to poor countries” (1) and the shift of power in Europe from electorates to bond investors and credit rating agencies – but has not eliminated them.  Three recent publications offer important and sobering insights into how those choices have played out in Canada.

The most recent report on child poverty from UNICEF’s Innocenti Research Centre points out that: “It is now more than 20 years … since the Government of Canada announced that it would ‘seek to eliminate child poverty by the year 2000.’ Yet Canada’s child poverty rate is higher today than when that target was first announced.”  The poverty rate referred to here is not Canada’s Low Income Cut-Off, but rather a standardized relative measure referring to a household disposable income of less than 50 percent of the national median, after adjustments for family size.  Canada, as we can see, does not rank especially well on this measure.   Much of the report is devoted to comparing this measure with an alternative one constructed around 14 specific measures of child well being, for which data are available only for European countries, but among countries for which both measures are available there is a clear correlation between rankings.  

glum tidingsSource: UNICEF Innocenti Research Centre (2012), Measuring Child Poverty:
New league tables of child poverty in the world’s rich countries.
At the other end of the economic scale, a new paper by five Canadian economists explores some of the driving forces behind Canada’s steadily rising level of inequality –in particular, the growing share of income flowing to the top one percent of the income distribution.  “The top income share almost doubled” from about 8 percent in the late 1970s “to reach 14 percent in recent years.  Such an uneven distribution of income has not been seen since the dark days of the Great Depression.”   In a clearly written review of the issues, the report goes on to make a number of important points:

  • The range of occupations represented in the top one percent is far wider than stereotypes would suggest, with only 10 percent of top earners working in financial services as of 2005 (the date covered in the last compulsory Long Form Census, from which many of the report’s data are drawn)
  • Growing inequality is a function not only of changes in the distribution of market income but also, and crucially, of the retreat from redistribution that began in the 1990s
  • “Younger workers, especially those with limited education, face a world with worse earnings prospects than their fathers’ generation,” suggesting a future of further inequality in market incomes as older cohorts of workers who have maintained their wages retire
  • Revenues from increasing income taxes only on the top once percent would probably be relatively modest, even before considering the impact of strategies for tax avoidance that are available to many of the rich

The report also has, to my way of thinking, at least two shortcomings.  

First, and perhaps unavoidably given data limitations, it deals only with income and not with wealth.  Wealth distributions are often more unequal than incomes, and many forms of intergenerational wealth transfers (e.g. bequests of valuable principal residences) do not show up in income figures.  The report points out the role of assortative mating (of two high earners) in increasing household income inequality; its contribution to inequality in household wealth may be more significant.

Perhaps more seriously, the report takes the concept of ‘skill’ as entirely unproblematic, treating the education level associated with a particular occupation as a rough proxy.  However, there is often no clear connection between the intrinsic complexity of the tasks involved and the credentials of those performing them; in terms of labour market outcomes it makes more sense to ask what kinds of tasks, including some very complex ones, are amenable to ‘offshoring’ in low-wage jurisdictions.

Robert Evans, the iconoclastic health economist whose work was the topic of an earlier posting, likewise organizes a recent article around the one-percenters’ growing share of income and on that fact that “these trends,” both in Canada and the United States, “are to a considerable extent a consequence of conscious, deliberate agency by more or less organized and coherent interest groups.”  His most immediate concern is what the retreat from redistribution means for the future of Canadian public health insurance (“a casualty in the class war,” in Evans’ words) now that federal cash transfers to the provinces for health care no longer come with even minimal conditions.

Evans is, as always, playful with his literary allusions; Sherlock Holmes enthusiasts are directed to his endnote 11 and the accompanying text.

Outside the health care field, he emphasizes the health consequences of the “degrading” of environments where people live and work that is associated with rising inequality – a special concern in view of the prospects of a global economic realignment in which many ‘good jobs’ have simply disappeared from the high income world.  Reducing the effects of that realignment on health disparities will require more, not fewer redistributive economic and social policies – certainly not the austerity measures that are now worsening the current recession.  If one agrees with Evans’ analysis of the sources of successful resistance to such policies, then the precarious state of the social determinants of health agenda in Canada is hardly surprising. 

(1)  Galeano E. (2000).  Upside Down: A primer for the looking glass world.  New York: Picador.

Source: UNICEF Innocenti Research Centre (2012), Measuring Child Poverty:

New league tables of child poverty in the world’s rich countries.

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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 Mercredi, 30 Mai 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, Cette adresse email est protégée contre les robots des spammeurs, vous devez activer Javascript pour la voir. 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...

Food security: Canada gets a warning

Posted by Ted Schrecker
Ted Schrecker
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on Jeudi, 17 Mai 2012
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Olivier De Schutter, the second United Nations Special Rapporteur on the Right to Food, is one of the most thoughtful thematic mandate holders, as they are called in UN-speak. (There are currently 36 such mandates.) His reports and commentaries provide articulate critiques not only of the policies of specific national governments, but also of an international agri-food system that is conspicuously failing to protect and fulfil the right of all to an adequate diet – one of the most basic social determinants of health.

The preliminary report of Prof. De Schutter's mission to Canada, which wound up on May 16, is sobering reading for a country that is often prone to self-congratulation on its human rights record. He points out that according to the 2004 Canadian Community Health Survey, 7.7 percent of Canadian households reported moderate or severe food insecurity – this before the financial crisis of 2008 and subsequent recession – and "was disconcerted by the deep and severe food insecurity" faced by aboriginal people, the legacy in part of a "long history of political and economic marginalization."

de-schutter-pic-1UN Photo/Jean-Marc Ferre.
Reproduced under Creative Commons Licence 2.0.
His report directly links food insecurity and increasing reliance on food banks to low incomes and the high cost of housing – a link that has been referred to in earlier postings. "In the view of the Special Rapporteur, social assistance levels need to be increased immediately to correspond to the costs of basic necessities," and minimum wages should be set at a living wage level as required by the International Covenant on Economic, Social and Cultural Rights, to which Canada is a state party.

Population health researchers have effectively documented the extent of food insecurity in Canada; the work of the University of Toronto's Valerie Tarasuk is especially powerful in this respect, as are the reports of the Toronto Department of Public Health. We have perhaps not taken advantage of opportunities to frame food security as a human rights issue, a matter of priorities. Maybe food security for all is just more important than freeway widenings or fighter aircraft ... or maybe we don't even need to make those choices. Prof. DeSchutter pointed out that: "The tax-to-GDP ratio of Canada ... is now in the lowest third of OECD countries. Consequently, Canada has the fiscal space to address the basic human needs of its most marginalized and disempowered." I've made a similar observation in a previous posting.

Predictably, the official response was less than cordial. Cabinet minister Jason Kenney, at roughly zero risk of food insecurity, referred to "lectures to wealthy and developed countries" as "a discredit to the United Nations." He might want to have a talk with Department of Justice lawyers about the nature of obligations under human rights treaties, but that's a topic for another day. Clearly, Prof. De Schutter's intervention gives a boost to those who would address the politics and priorities that deprive people in such a "wealthy and developed country" of food security.

Recent Comments Show all comments
  • Ashley Raeside
    Ashley Raeside says #
    Hi Ted, Thanks for profiling De Schutter's review of food insecurity in Canada, and highlighting the sharp contrast in perspectiv...
  • animateur@chnet-works.ca
    animateur@chnet-works.ca says #
    Wow Ted! you really hit the nail on the head on this posting! i wonder if others think we should do a fireside chat on this issue...

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

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Lundi, 19 Mars 2012
in CHNET-Works!

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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Acting on social determinants of health: how much do we need to know?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Vendredi, 09 Mars 2012
in CHNET-Works!

Many readers will remember the sequence of events in which former football star O.J. Simpson was acquitted of the murder of his estranged wife and a friend in a criminal trial, yet found liable for damages in a civil suit brought by the family of one of the victims. Leaving aside the sociological roots of the not-guilty verdict in the United States' tragic history of racial antagonisms, in analytical terms the discrepancy can be explained with reference to the higher standard of proof in a criminal trial (proof beyond a reasonable doubt) than in a civil proceeding where a claim for damages can be sustained on a preponderance of the evidence or, in some common law jurisdictions, on the balance of probabilities.

The idea of a standard of proof is critical to understanding the question posed in the title of this posting. A classic article published in 1978 by economist Talbot Page (1) used this concept to analyze public policies toward "environmental risks" like toxic chemicals, which share such characteristics as incomplete knowledge of the mechanism of action, long latency periods between exposure and illness, and irreversibility. He pointed out that most forms of scientific inquiry are organized around minimizing Type I errors – that is, 'false positives' or incorrect rejections of the null hypothesis. Page used the analogy of the standard of proof in criminal trials, and went on to argue that minimizing Type I errors may be a thoroughly inappropriate principle when applied to use of scientific evidence in public policy, because it fails to take into account uncertainty and consequences. Stated another way, "a risk/benefit assessment," albeit often an implicit one, "is part of every public policy action which is based upon the interpretation of the results of a scientific investigation." (2)

Evidence-picture-1Waiting for "evidence of dead bodies" may be inappropriate when responding to health threats from environmental hazards.
Photo by biofriendly, reproduced under a Creative Commons licence.

This point has often been lost sight of in controversies about controlling toxic exposures in the environment and the workplace, with industry resisting regulation by demanding stronger – usually epidemiological – evidence and trying to cast the issue as one of scientific uncertainty: demanding what another economist has described as a "tobacco industry standard of proof." (3) Page correctly pointed out that: "In its extreme, the approach of limiting false positives requires positive evidence of 'dead bodies' before acting." This is, in fact, the standard of proof that has often been applied to research on the health effects of environmental hazards. A further point of importance is that the conventional threshold of statistical significance – 95 percent – may require extremely large and unmanageable sample sizes when the prevalence of a particular adverse outcome is only moderately elevated over background levels. (4) As Page pointed out, "there is literally no information content in a negative finding unless there is an analysis of ... the probability of a false negative." (1)

Choosing a standard of proof for purposes of public health policy therefore is unavoidably an ethical decision, having to do – as yet another author pointed out at around the same time – with the relative acceptability of being wrong in different kinds of ways (5) while we wait for evidence that may or may not be obtainable. Interestingly, a workshop on conceptual and methodological issues in public health science held at the University of Cambridge in 2010 revisited these questions, suggesting that understanding of them in the relevant research communities remains incomplete, even as they remain topical with respect to such issues as environmental causes of breast cancer .

The question of how much evidence is needed for action on social determinants of health underscores the value-laden nature of choices about the appropriate standard of proof. At least two issues are critical.

First, what kinds of research findings are relevant? Clinical epidemiology now widely accepts a hierarchy of evidence with the randomized controlled trial (RCT) at the top; presumably, this is what two authors writing on global health governance had in mind when they claimed that "[f]ew global health interventions are evidence-based, and interventions to improve population health among the poor are often untested ..." To some of us, this assertion is nothing short of bizarre, and neglects the fact that many interventions outside clinical settings cannot be assessed using RCTs, for reasons of ethics, logistics, or both. Colleagues and I pointed out a decade ago, in the context of research on preventing mental illness, that "choosing certain research strategies and standards of proof means the big questions ... probably will not be studied in ways that demonstrate the effectiveness of larger-scale, contextual interventions, and even the small questions will be asked in ways that seriously circumscribe the set of possible answers."

A methodologically pluralist approach, organized around what a former colleague calls a "portfolio of evidence," will yield more meaningful and policy-relevant answers. Unbeknownst to us, Michael Marmot had made a similar point the previous year in a general discussion of evidence for influences on population health: "The further upstream we go in our search for causes ... the less applicable is the randomized controlled trial. .... We must therefore rely on observational evidence and judgment in formulating policies to reduce inequalities in health. In this process, the best should not be the enemy of the good. While we should not formulate policies in the absence of evidence to support them, we must not be paralyzed into inaction while we wait for the evidence to be absolutely unimpeachable." (6) He continues to make this point.

Food-bank-can-use-help395,000 Ontarians received help from food banks in March, 2011.
Image courtesy Ontario Association of Food Banks.

Second, is it necessary to wait for evidence that a particular policy or intervention leads to improved health outcomes, or is it sufficient to have evidence of reduction in risk factors or what might be called intermediate biological variables (like markers of allostatic load, in the context of prolonged stress) that are known to have an adverse effect on health outcomes? This question gains urgency from knowledge of the cumulative effects of negative contextual influences on health over the life course: "waiting for dead bodies" in this case, as in others, can amount to carrying out a large-scale experiment on non-consenting subjects, the results of which may not be available for a generation. Obviously, ongoing evaluation of interventions and policy changes is important, but how much more do we need to know before (for instance) doing what it takes to reduce food insecurity among people for whom eating a healthy diet while paying market rents is arithmetically impossible?

This is a rather polemical way of stating the question, but it is useful in order to get at the hard politics of debates about evidence. Many policies and interventions needed to reduce health disparities by way of social determinants of health will be explicitly redistributive – starting with reductions in income inequality, as noted in a forthcoming editorial in the American Journal of Public Health. As mentioned, companies facing costly regulation of their activities have long found it attractive to frame their opposition as based on the insufficiency of scientific evidence. Similarly, those who stand to lose from tackling "the inequitable distribution of power, money, and resources" – one of the three overarching recommendations of the Commission on Social Determinants of Health – may frame their opposition in terms of the need for more evidence rather than simple self-interest. One-percenters, and those on a fast track to that status, are not a natural constituency for redistributive policies. This is not of course the only explanation for hostility to the social determinants of health agenda, but it cannot be disregarded. Against this background, it's especially important to keep in mind that the appropriate questions are not only about the strength of evidence, but also about how uncertainty should be resolved in a context where "deferring a decision is a decision in itself." They are, in other words, rooted firmly in the domain of public health ethics. Only by insisting on this point can we be sure that debates about when and how to act involve – as they should – the language of values and social justice.

(1) Page, T. (1978) A Generic View of Toxic Chemicals and Similar Risks. Ecology Law Quarterly, 7, 207-244.

(2) Darby, W. (1979) An Example of Decision-Making on Environmental Carcinogens: The Delaney Clause. Journal of Environmental Systems , 9, 109-117.

(3) Crocker, T.D. (1984) Scientific Truths and Policy Truths in Acid Deposition Research. In T. Crocker, ed., Economic Perspectives on Acid Deposition Control (pp. 65-79). Ann Arbor Science Acid Precipitation Series vol. 8. Boston: Butterworth.

(4) See e.g. Higginson, J., Muir, C.S., Muñoz, N. (1992) Human Cancer: Epidemiology and Environmental Causes (pp. 39-44). Cambridge: Cambridge University Press.

(5) Jellinek, S. D. (1981) On the Inevitability of Being Wrong. Annals of the New York Academy of Sciences, 363, 43-47.

(6) Marmot, M. (2000). Inequalities in Health: causes and policy implications. In A. Tarlov & R. St.Peter, eds., The Society and Population Health Reader, vol. 2: A State and Community Perspective (pp. 293-309). New York: New Press.

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Resources from around the Web: Information abundant, time needed

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Lundi, 16 Janvier 2012
in CHNET-Works!

Herewith a potpourri of important portals and blogs from around the Web. If anyone has tips about where to find time to make the best use of them, please let all of us know!

sir-michael-marmot
Sir Michael Marmot speaking in Rio

University College London has just launched the Institute for Health Equity. Headed by Sir Michael Marmot, the Institute's initial activities include leading the "Euro Review" of social determinants of health for WHO's European office. The Institute's site invites contributors to submit projects, reports and case studies, and already features numerous links to "related work" in the UK and elsewhere. It also provides a link to Sir Michael's own blog, where in a posting about the World Conference on Social Determinants of Health in Brazil he describes efforts to ignore the role of the Commission on Social Determinants of Health that he chaired as "attempted airbrushing" based on "objections to the Commission's strong emphasis on inequities in power, money and resources." All absolutely true, and you read it here first in Sir Michael's own words. 

At the Brazil conference, the World Health Organization launched an electronic platform called Action: SDH. Registration (free) is required to access many features of the site, but they are well worth the minute or so required to register and therefore to be able to post content. Like most such 'platform' sites, the value of this one will depend on involvement by members of the community that it is designed to establish.

PolitiquesSociales (en français, but linking to numerous sources in English) is produced by the Centre de recherche sur les politiques et le développement social at l'Université de Montréal. It offers a monthly collection of news items and research products on social policy and inequality around the world, with a strong European flavour. Canadian Social Research Links, updated weekly, is an almost encyclopedic collection of similar material, focusing mainly although not exclusively on Canada. It's produced by Gilles Séguin, a former federal public servant (1975-2003) who worked on social policy issues in various incarnations of what is now called Human Resources and Skills Development Canada. These sites are quite simply indispensable for anyone wanting to build the bridges between public health and social policy that we often neglect. E-mail newsletters from both sites are available by subscription.

On to a couple of blogs that more closely resemble this one. Healthy Barbs is written by Barbara Brenner, a lawyer and former executive director of San Francisco-based Breast Cancer Action. Brenner brings both rare wit and a litigator's rigorous style to commenting on such matters as how foundation support for the supposedly independent Institute of Medicine that is part of the US National Academy of Sciences may have influenced the content of a recent report on environmental causes of breast cancer. Brenner is also interviewed in a new National Film Board feature-length documentary on how corporate-backed marketing has distorted on breast cancer politics: Pink Ribbons, Inc . Watch for it in Canadian theatres on February 3.

Finally, there's a Canadian blog called DrPHealth, by a public health professional who writes "with some anonymity to protect its author as it strives to increase transparency, promote justice and champion equity." Like Brenner, the author is rigorous about posting references and hyperlinks to his/her sources, which moves this site to the top of those I would recommend to students and practicing professionals alike. One recent posting led me to a new Canadian Public Health Association knowledge centre site, which in turn led me to at least two interesting-looking electronic resources. I won't comment further, since I have not had a chance to explore these, but once again the potential is clear.

Now, about a source for those 48-hour days ...

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  • Ted Schrecker
    Ted Schrecker says #
    Glad you found the sources useful; please pass the word about the blog. The time to read the sources, alas, remains a problem!...
  • Bonnie Hamilton Bogart
    Bonnie Hamilton Bogart says #
    Thanks for this - its all about connecting with reliable and credible sources.
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