Social Determinants of Health: Why is There Such a Gap Between Our Knowledge and Its Implementation? Dennis Raphael York University, Toronto, Canada

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Social Determinants of HealthWhy is There Such
a Gap Between Our Knowledge and Its
Implementation? Dennis Raphael York
University, Toronto, Canada

• Presentation made at
• Ryerson Polytechnic University
• Toronto, Ontario, October 4, 2002

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What Do We Know ?

• Population Health
• Example 1 Cardiovascular Health
• Example 2 Diabetes
• Social Determinants in Canada Today
• What Do We Do?
• Governments Policy Making
• Public Health Units - Activities
• Disease Associations, e.g., Heart and Stroke
  Foundation, Diabetes Association Messages
• Health Care Providers and Planners - Focus

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Poverty and Health Literary Perspectives

• We know what makes us ill.
  When we are ill we are told
  That its you who will heal
  us.
• When we come to you
  Our rags are torn off us
  And you listen all
  over our naked body. As to the
  cause of our illness
  One glance at our rags would
  Tell you more. It is the same cause
  that wears out Our bodies and our clothes.
  -- Bertolt
  Brecht, A Workers Speech to a Doctor, 1938.

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Poverty and Health Academic Perspectives

• It is one of the greatest of contemporary
  social injustices that people who live in the
  most disadvantaged circumstances have more
  illnesses, more disability and shorter lives than
  those who are more affluent.
• -- Benzeval, Judge, Whitehead, 1995, p.xxi,
  Tackling Inequalities in Health An Agenda for
  Action.

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Canadian Government Statements on Social
Determinants of Health I

• All policies which have a direct bearing
• on health need to be coordinated. The
• list is long and includes, among others,
• income security, employment, education,
• housing, business, agriculture,
• transportation, justice and technology.
  
• -- Achieving Health For All A Framework for
  Health Promotion, J. Epp. Ottawa Health and
  Welfare Canada, 1986.

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Canadian Government Statements on Social
Determinants of Health II

• There is strong evidence indicating that
  factors outside the health care system
  significantly affect health. These determinants
  of health include income and social status,
  social support networks, education, employment
  and working conditions, physical environments,
  social environments, biology and genetic
  endowment, personal health practices and coping
  skills, healthy child development, health
  services, gender and culture.
• -- Taking Action on Population Health A
  Position Paper for Health Promotion and Programs
  Branch Staff. Ottawa Health Canada, 1998.

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Canadian Government Statements on Social
Determinants of Health III

• In the case of poverty, unemployment, stress,
  and violence, the influence on health is direct,
  negative and often shocking for a country as
  wealthy and as highly regarded as Canada.
• -- The Statistical Report on the Health of
  Canadians. Ottawa Health Canada, 1998.

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Social Determinants of HealthThe Solid Facts

• - social gradient - stress
• - early life - social exclusion
• - work - unemployment
• - social support - addictions
• - food - transport
• - World Health Organization, 1998

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Ottawa Charters Prerequisites of Health

• peace
• shelter
• education
• food
• income
• a stable eco-system
• sustainable resources
• social justice
• equity
• World Health Organization, 1986

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Health Canadas Determinants of Health

• Income and Social Status
• Social Support Networks
• Education
• Employment/Working Conditions
• Social Environments
• Physical Environments
• Personal Health Practices and Coping Skills
• Healthy Child Development
• Biology and Genetic Endowment
• Health Services
• Gender
• Culture

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Why Emphasize Social Determinants?

• Social determinants of health have a direct
  impact on health
• Social determinants predict the greatest
  proportion of health status variance
• Social determinants of health structure health
  behaviours
• Social determinants of health interact with each
  other to produce health

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Poverty and Health Mechanisms

• Poverty can affect health in a number of ways
• income provides the prerequisites for health,
  such as shelter, food, warmth, and the ability to
  participate in society
• living in poverty can cause stress and anxiety
  which can damage peoples health
• low income limits peoples choices and militates
  against desirable changes in behaviour.
• - Benzeval, Judge, Whitehead, 1995, p.xxi,
  Tackling Inequalities in Health An Agenda for
  Action.

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Defining Poverty

• Individuals, families and groups in the
  population can be said to be in poverty when they
  lack the resources to obtain the type of diet,
  participate in the activities and have the living
  conditions and amenities which are customary, or
  at least widely encouraged, or approved, in the
  societies to which they belong. They are, in
  effect, excluded from ordinary living patterns,
  customs and activities
• -- Townsend, 1979, p.31

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The North York Heart Health Network

• Community-based coalition of over 45 groups.
• Frustrated by limited mandate and neglect of
  societal issues in heart health.
• Commissioned literature review and report on
  income and heart health to raise awareness.
• Released the report Inequality is Bad for Our
  Hearts Why Low Income and Social Exclusion are
  Major Causes of Heart Disease in Canada in
  November 2001.
• Updated revision Social Justice is Good for Our
  Hearts Why Societal Factors -- Not Lifestyles
  -- are Major Causes of Heart Disease in Canada
  and Elsewhere released May, 2002.
•  

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Heart Disease in North America The Missing
Messages

• The emphasis by health units and the media on
  medical and lifestyle risk factors as the major
  causes of cardiovascular disease (CVD) in Canada
  is inaccurate.
• Low income is a major cause of CVD in Canada. 
• Social exclusion provides a process by which low
  income can be understood to cause CVD. 
• Canadian policy directions are inconsistent with
  what is known about reducing the incidence of
  CVD.
• Lifestyle approaches and messages are not only
  inaccurate but potentially damaging to population
  health.
• The health sector and the media have been
  negligent in ignoring the role societal factors
  play in CVD and other diseases.

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The Evidence Concerning Low Income and Heart
Disease The Hard Data

• Statistics Canada estimated that in 1996, 23 of
  years of life lost for all causes prior to age 75
  in Canada could be attributed to income
  differences.
• The diseases most responsible for income-related
  differences in death rates were cardiovascular
  diseases.
• In 1996, 22 of all the years lost that can be
  attributed to income differences were caused by
  cardiovascular disease.
• These income differences account for an annual
  excess of 24 or 6,366 premature deaths from
  cardiovascular disease.

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PYLL(0-74) by Cause, 1996

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Excess PYLL(0-74) by Cause, 1996

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It was found that those living in lower income
areas were much more likely to develop coronary
heart disease than those in well-off
neighbourhoods. These effects remained strong
even after controlling for tobacco use, level of
physical activity, presence of hypertension or
diabetes, level of cholesterol, and body mass
index. - Summary of Neighbourhood of Residence
and Incidence of Coronary Heart Disease, A.
Roux, S. Merkin, D. Arnett, et al. New England
Journal of Medicine, 2001, 345, 99-106.
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Critical Periods of the Life Course

• Foetal development
• Birth
• Nutrition, growth and health in adulthood
• Educational Career
• Leaving parental home
• Entering labour market
• Establishing social and sexual relationships
• Job loss or insecurity
• Parenthood
• Episodes of illness
• Labour market exit
• Chronic sickness
• Loss of full independence
  
• -- Shaw et al., The Widening Gap, 1999, p. 106.

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Low Income and Heart Disease Researchers
Conclusions

• Our results suggest that despite the presence
  of significant socio-economic differentials in
  health behaviours, these differences account for
  only modest proportion of socio-economic
  disparities in mortality. Thus, public health
  policies and interventions that exclusively focus
  on individual risk behaviours have limited
  potential for reducing socio-economic disparities
  in mortality.
• -- Socioeconomic Factors, Health Behaviors,
  and Mortality, P.M. Lantz, J.S. House, J.M.
  Lepkowski, D.R. Williams, R.P. Mero, J.J. Chen,
  Journal of the American Medical Association,
  1998, 279, 1703-1708.

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Low Income and Heart Disease Researchers
Conclusions

• These estimates of risk reduction may be
  compared with the much smaller estimates of the
  effects of improvements in adult lifestyle... Our
  findings add to the evidence that protection of
  fetal and infant growth is a key area in
  strategies for the primary prevention of coronary
  heart disease.
• -- Early Growth and Coronary Heart Disease
  in Later Life Longitudinal Study. J.G.
  Eriksson, T. Forsen, J. Tuomilehto, C. Osmond,
  D.J. Barker. British Medical Journal, 2001, 322,
  949-953.

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Heart Health In Ontario

• Major 17,000,000 5-year initiative by
  Conservative Government.
• Specific focus on lifestyle factors of diet,
  activity, and tobacco use.
• Clear neglect of structural (societal and
  community) factors in heart health despite
  profound evidence of their importance.
• Contradicts 25 years of Health Canada and CPHA
  statements on health determinants.
• Similar neglect of societal issues by media,
  health units, and disease-oriented associations.
•  

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Sector Reactions to the Reports

• Enthusiastic
• Social development/social welfare sectors 
• Anti-poverty community
• Faith communities
• Ambivalent and Guarded
• Public health units in Ontario
• Lifestyle-oriented health promoters
• Illness-oriented foundations
• The media
• Hostile or at least not excited!
• Ontario Ministry of Health/Long-Term Care
• Heart Health community in Ontario

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Diabetes Prevalence in Ontario by Neighbourhood
Income Quintile, 1999
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Increased Risk of Diabetes in Ontario Among Low
Income Residents, 1997/97
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Diabetes, Males
ASMR x 100,000
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Diabetes, Females
ASMR x 100,000
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Implications of Increasing Family Poverty

• Given the disturbing increases in income
  inequality in the United States, Great Britain,
  and other industrial countries, it is vital to
  consider the impact of placing ever larger
  numbers of families with children into lower SES
  groups. In addition to placing children into
  conditions which are detrimental to their
  immediate health status, there may well be a
  negative behavioural and psychosocial health
  dividend to be reaped in the future.
• -- Why Do Poor People Behave Poorly?
  Variation in Adult Health Behaviours and
  Psychosocial Characteristics by Stages of the
  Socioeconomic Life Course, J.W. Lynch, G.A.
  Kaplan, J.T. Salonen. Social Science and
  Medicine, 1997, 44, 809-819.

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Recommendations for Action

• The first and most important set of
  recommendations is concerned with reducing the
  incidence of low income among citizens.
• The second set of recommendations is concerned
  with reducing the incidence of social exclusion.
  
• The third set involves restoring the supports by
  which Canadians have traditionally been assisted
  in their navigation of the life course.

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• Ten Tips For Better Health - Donaldson, 1999
• 1. Don't smoke. If you can, stop. If you can't,
  cut down.
• 2. Follow a balanced diet with plenty of fruit
  and vegetables.
• 3. Keep physically active.
• 4. Manage stress by, for example, talking things
  through and making time to relax.
• 5. If you drink alcohol, do so in moderation.
• 6. Cover up in the sun, and protect children from
  sunburn.
• 7. Practise safer sex.
• 8. Take up cancer screening opportunities.
• 9. Be safe on the roads follow the Highway Code.
  
• 10. Learn the First Aid ABC airways,
  breathing, circulation.

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Ten Tips for Staying Healthy - Dave Gordon, 1999.

• 1. Don't be poor. If you can, stop. If you can't,
  try not to be poor for long.
• 2. Don't have poor parents.
• 3. Own a car.
• 4. Don't work in a stressful, low paid manual
  job.
• 5. Don't live in damp, low quality housing.
• 6. Be able to afford to go on a foreign holiday
  and sunbathe.
• 7. Practice not losing your job and don't become
  unemployed.
• 8. Take up all benefits you are entitled to, if
  you are unemployed, retired or sick or disabled.
• 9. Don't live next to a busy major road or near a
  polluting factory.
• 10. Learn how to fill in the complex housing
  benefit/ asylum application forms before you
  become homeless and destitute.

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Avoiding the Life-Style Trap

• Lifestyle choices are heavily structured by life
  circumstances
• Lifestyle choices by themselves account for
  modest proportions of health status
• Lifestyle choices are difficult to change without
  considering life contexts
• Lifestyle choice emphases can have unintended
  side-effects that work against health

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Economic Inequality Affects Health in Three Main
Ways

• Economically Unequal Societies have Greater
  Levels of Poverty
• Economic Unequal Societies Provide Fewer Social
  Safety Nets
• Economically Unequal Societies Have Weaker Social
  Cohesion

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Economic Inequality is Dangerous to the Health of
Everybody

• Economic inequality is especially bad for the
  health of poor people
• Economic inequality is bad for the health of
  well-off people
• Economic inequality weakens communities
• Economic inequality weakens societies
• Is economic inequality Un-Canadian?

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ME
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Low Income

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Economic Inequality and Health Policy
Implications

• Poverty and economic inequality is on the rise in
  the USA and Canada
• Poverty is bad for health
• Economic inequality is dangerous for the health
  of all of us
• Policy decisions create poverty and economic
  inequality
• Citizens can influence policy decisions to
  improve health

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Economic Inequality Affects Health in Three Main
Ways

• Economically Unequal Societies have Greater
  Levels of Poverty
• Economic Unequal Societies Provide Fewer Social
  Safety Nets
• Economically Unequal Societies Have Weaker Social
  Cohesion

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What Creates Poverty and Income Inequality?

• The growing gap between rich and poor has not
  been ordained by extraterrestrial beings. It has
  been created by the policies of governments
  taxation, training, investment in children and
  their education, modernization of businesses,
  transfer payments, minimum wages and health
  benefits, capital availability, support for green
  industries, encouragement of labour unions,
  attention to infrastructure and technical
  assistance to entrepreneurs, among others.
• Peter Montague

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USA, Canada, and Sweden Rankings on Compared to
Other Industrialized Nations (Ranking,
1 is best) Measure USA Canada
Sweden Income Inequality (1990) 18 of 18 11
3 Child Poverty (1990) 17 of 17 14 2 Infant
Mortality (1996) 24 of 29 17 2 Youth Suicide
(1992-1995) 15 of 22 16 10 High School Drop-Outs
(1996) 17 of 17 16 10 Youth Homicide
(1992-1995) 22 of 22 19 5 Wages (1996) 13 of
23 15 6 Unemployment (1996) 2 of
10 7 8 Elderly Poverty (1990) 15 of
17 4 5 Life Expectancy (1996) 20 of 29 4 3
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Canadian Policy Directions

• It has become obvious that people on the low
  end of the income scale are cut off from the
  ongoing economic growth that most Canadians are
  enjoying. It is also obvious that in these times
  of economic prosperity and government surpluses
  that most governments are not yet prepared to
  address these problems seriously, nor are they
  prepared to ensure a reasonable level of support
  for low-income people either inside or outside of
  the paid labour force.
• -- Poverty Profile, 1998. Ottawa National
  Council of Welfare Reports, Autumn, 2000.

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Reducing Health Inequalities

• We consider that without a shift of resources
  to the less well off, both in and out of work,
  little will be accomplished in terms of a
  reduction of health inequalities by interventions
  addressing particular downstream influences.
  
• -- Report of the Acheson Independent Inquiry
  into Inequalities in Health, 1998, p. 33.

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Social Inequalities in HealthMontreal Medical
Officers Report I

• Having scanned the health and well-being of
  Montrealers from one end of the life cycle to the
  other, we note the important role played by
  poverty. Inequalities in health and well-being
  can be traced back to socioeconomic inequalities,
  that is to the harsh living conditions which
  marginalize so many of our fellow citizens, not
  only limiting their access to essential goods,
  but depriving them as well of any meaningful role
  in social life.
• -- Lessard, 1997, p.60

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Social Inequalities in HealthMontreal Medical
Officers Report II

• For anyone interested in public health, social
  inequalities in health must be a major concern.
  But we know that the solution is not to invest
  more in the health system or in new technologies.
  These inequalities must rather be met head-on
  and well-targeted actions must be undertaken to
  ensure that they will not become worse.
  
• -- Lessard, 1997, p. 20.

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Barriers to Effective Action onthe Social
Determinants of Health

• Ideological - What is health and its
  determinants?
• Political - How do government actions affect
  health?
• Institutional - What is appropriate health
  action?
• Personal - Do I have the knowledge to affect
  health?
• Attitudinal - Do I need the hassle?

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Income Inequality and Population HealthRaising
the Issue I

• develop communication between various sectors
  concerned with economic inequality
• contribute papers to academic and professional
  journals on income-related developments and their
  potential for affecting the health of citizens
• use the media to educate citizens about the
  consequences of increasing economic inequality
  and poverty upon health

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Income Inequality and Population HealthRaising
the Issue II

• lobby local health departments to begin taking
  seriously a determinants of health approach
  including consideration of the importance of
  economic inequality and poverty
• lobby governments to maintain the community and
  service structures that help to maintain health
  and well-being
• begin to understand the forces that create
  economic inequality and poverty

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From Inequality is Bad to Social Justice is
Good

• It was clear that additional funds would not be
  made available to reprint the Inequality is Bad
  report.
• It was also made clear that it would be difficult
  to find an internet home for the report in
  Ontario.
• Since the words were deemed as belonging to me,
  arrangements were made to
• Update and revise the report and find a new
  sponsor/publisher.
• Find an internet home for the original report.
• Provide additional critical analyses of the
  lifestyle approach to heart health in the form of
  three additional messages to the original six.

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Critical Analysis I Reasons for Resistance

• Lack of Epidemiological Theory
• Health officials and reporters seem unaware of
  recent developments in social epidemiological
  theory and population health research findings.
• Commitment to Ideology of Individualism in
  Health, Illness and Health Promotion
• Assists the neo-liberal and neo-conservative
  agendas of blaming individuals for their health
  problems, absolving governments of blame for
  their health threatening policies that create
  poverty, inequality, and social exclusion.

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Critical Analysis II Side Effects of the
Biomedical and Lifestyle Heart Health Approach

• Removes the issue of the social determinants of
  cardiovascular disease and diabetes right off the
  public policy agenda.
• Low income people made to feel that they are
  responsible for their own poor health (victim
  blaming).
• Health workers and the media become complicit in
  the process of poor bashing Ignoring facts and
  repeating stereotypes about people who are poor.

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Critical Analysis III The Holy Trinity

• As with any area of medical or scientific
  research,
• the selection of factors to be studied cannot
  be
• immune from prevailing social values and
• ideologies. ... It is also evident that so called
• lifestyle or behavioural factors (such as the
  holy
• trinity of risks - diet, smoking and exercise)
• receive a disproportionate amount of
• attention. As we have seen, the identification
  and
• confirmation of risk factors is often subject to
• controversy and the evidence about causal links
• is not unequivocal.  
• Nettleton, S. (1997). Surveillance, Health
  Promotion and the Formation
• of a Risk Identity in Debates and Dilemmas in
  Promoting Health.
• London UK MacMillan.

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Towards the Future

• CIHR Institute of Population and Public
  Health (IPPH) awarded 100,000 to D. Raphael, R.
  Labonte, and R. Colman to provide an assessment
  of Needs, Gaps, and Opportunities in the
  Conceptualization of Income in Health Research in
  Canada.
• Health Canada Health Policy Program
  awarded 113,000 -- supplemented with 10,000
  from IPPH -- to hold a national conference on
  Social Determinants of Health Across the Life
  Span A Current Accounting and Policy
  Implications, to be held at York University in
  late November 2002.
• Application being made with Kim Raine,
  University of Alberta, to CIHR to study the lives
  of people with diabetes in an attempt to
  understand the increasing mortality among low
  income Canadians.

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Policy Directions and Population Health

• The policies that Canada has developed to improve
  population health reflects its more egalitarian
  structure. Examples include various tax and
  economic transfer policies that help to limit
  income differences across the country, as well as
  provision of important social services... If a
  healthy population is the goal, we must enter the
  political arena and fight to maintain the social
  contract that has sustained Canada as one of the
  world leaders in health.
• Stephen Bezruchka, CMAJ, 2001

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Justice and Fairness I

• Where a great proportion of the people are
  suffered to languish in helpless misery, that
  country must be ill-policed and wretchedly
  governed a decent provision for the poor is the
  true test of civilization.
• - Dr. Samuel Johnson

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Justice and Fairness II

• If the misery of our poor be caused not by the
  laws of nature, but by our institutions, great is
  our sin.
• Charles Darwin

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Dennis RaphaelSchool of Health Policy and
ManagementYork UniversityToronto,
Canada416-736-2100, ext. 22134draphael_at_yorku.ca