Why are some people, and more particularly some groupings of people, healthier than others? A large part of the answer depends on a range of variables that have little to do with life-style choices like smoking, diet, and exercise, and nothing at all to do with the bio-medical approach to health — medicines, hospitals, forms of surgery, and so on. It has been shown definitively that our health is shaped by our living conditions, the economic and social conditions of our lives. Variables such as poverty, the inequitable distribution of income, unemployment, adverse working conditions, and inadequate housing have a dramatically adverse impact on health. If as a society we were to put as much effort and resources into improving these conditions — what are called the social determinants of health (SDOH) — as we do into various forms of bio-medicine, our collective health would improve dramatically.
Remarkably, the evidence in support of an SDOH approach to improving our health is overwhelming, and it is accepted as valid by leading health care authorities throughout the world. In recent years this case has been made by the World Health Organization (WHO), the Organization of Economic Cooperation and Development (OECD), the Canadian Senate Subcommittee on Population Health, the Canadian Public Health Association and the Public Health Agency of Canada, among a great many others. The problem is not that governments do not know the value of an SDOH approach; the problem is that our governments have been unwilling to act on the knowledge, other than in small, incremental doses. In fact, over the past thirty years or so governments throughout the world have moved toward a neo-liberal ideology that reduces the role of government, making it particularly difficult to adopt the SDOH approach that would improve our collective health.
In the CCPA-Manitoba publication The Social Determinants of Health in Manitoba, Dennis Raphael (Chapter 2) shows that industrialized countries that have adopted the most neo-liberal, or laissez-faire, approaches to the allocation of society’s resources have the worst health outcomes; those countries in which governments redistribute resources to promote a greater degree of equality, with policies that support families, gender equality, and labour, for example, experience much better health outcomes. As described by Raphael:
“Since a social determinants of health approach sees the sources of health as being how a society organizes and distributes resources, it directs attention to economic and social policies as a means of improving health. It requires consideration of the political, economic, and social forces that shape these policy decisions.”
Understanding the social determinants of health within a regional context is particularly useful for Manitobans given our unique geographic and demographic realities. For example, Winnipeg’s inner-city neighbourhoods and some First Nations communities have among the highest rates of poverty in Canada.
Although the inequality of income is not as bad in Manitoba as in Canada as a whole, it has been worsening since the late 1970s, with the poorest 40 percent of Manitobans earning less in the 2000s than they did in the late 1970s, and the top 10 percent earning more (Fernandez & Hudson Chapter 7).
But health outcomes are not just about the very rich and the very poor. There is an income gradient to the social determinants of health. That is, the poor experience poorer health than those in the mid-income ranges, but those in mid-income ranges experience poorer health than those in the highest income ranges. This is very clearly shown by Brownell, Fransoo and Martens in Chapter 3. They refer to the “inequitable distribution of health” as a product of the inequitable distribution of income. They show that there are dramatic inequities in the distribution of health. For example, men in the lowest income urban areas in Manitoba have a life expectancy ten years less than that of men who live in the highest income urban neighbourhoods. The significance of this difference is made evident by the estimate that the elimination of all cancers would increase average life expectancy by just less than four years. Clearly, public policies that reduce income inequalities are needed if our health is to improve. The vast majority of Manitobans would experience better health if our incomes were more equitably distributed.
Toward a shift in public policy
The evidence is clear, as shown in this new CCPA-Manitoba. book. Improving social and economic disparities in Manitoba will have a positive impact on health outcomes. An SDOH approach would seek the implementation of public policies that promote greater equality. But promoting an SDOH agenda will not be easy. The inequality that produces such negative health outcomes also makes some groups wealthy and powerful, and they are likely to be resistant to changes in the direction of an SDOH agenda. However, as Raphael (Chapter 2) shows, many European countries have been successful in promoting a much stronger SDOH approach, and the health of their citizens is better as a result. Thus improvements to our health by improving the SDOH, while difficult, are possible.
The collection of policy papers that form The Social Determinants of Health in Manitoba make it clear beyond doubt that our collective health would improve if, in addition to working hard to protect and improve our publicly-administered, single-payer, non-profit Medicare system, we were to urge the adoption by governments of an SDOH approach to improving our collective health by reducing inequalities.
To order a copy of The Social Determinants of Health in Manitoba, edited by Lynne Fernandez, Shauna MacKinnon & Jim Silver, contact the CCPA-Manitoba office at 927-3200 or ccpamb@ policyalternatives