November 2008: Inequality Spawns Sickness

Addressing the Social Determinants of Health in Canada
November 1, 2008

Excerpts from Social Determinants of Health: Canadian Perspectives, 2nd edition

Introducing the Social Determinants of Health

Social determinants of health are the economic and social conditions that shape the health of individuals, communities, and jurisdictions as a whole. Social determinants of health are the primary determinants of whether individuals stay healthy or become ill (a narrow definition of health). Social determinants of health also determine the extent to which a person possesses the physical, social, and personal resources to identify and achieve personal aspirations, satisfy needs, and cope with the environment (a broader definition of health). Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members.

These resources include, but are not limited to, conditions of childhood, income, availability and quality of education, food, housing, employment, working conditions, and health and social services. An emphasis upon societal conditions as determinants of health contrasts with the traditional health sciences and public health focus upon biomedical and behavioural risk factors such as cholesterol levels, body weight, physical activity, diet, and tobacco and alcohol use.

Since a social-determinants-of-health approach sees the mainsprings of health as being how a society organizes and distributes economic and social resources, it directs attention to economic and social policies as means of improving it. It also requires consideration of the political, economic, and social forces that shape policy decisions.

Concern with the social determinants of health is not new. It has been known since the mid-19th century that living conditions are the primary determinants of health. And since then hundreds of studies have demonstrated that the material and social circumstances to which people in developed nations such as Canada are exposed to in their homes, workplaces, and communities are far more important to their health than so-called “lifestyle choices” such as using tobacco or alcohol, eating fruits and vegetables, or partaking in physical activity.

These findings have not been lost upon the writers of Canadian government and public health documents. Since the mid-1970s, Canadian governmental and public health agencies have produced numerous statements and policy documents that have contributed to health promotion efforts worldwide. In large part, Canada’s reputation as a “health-promotion powerhouse” comes from the high quality of the concepts and ideas contained within these documents.

Nevertheless, even a cursory examination of prevailing governmental and public health activities focused on actually promoting health—as opposed to documents talking about promoting health—sees little evidence that applications of these concepts have been made in practice. The profound gap between Canadian health promotion word and deed has been documented. Instead of efforts to improve Canadians’ living conditions, individualized approaches focused on biomedical and behavioural risk factors—with some exceptions—dominate governmental, public health, and disease association, and other health-promotion efforts.

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Recent Developments

There have been some notable developments in the social determinants of health field since 2004. Internationally, the World Health Organization’s establishment of an International Commission on the Social Determinants of Health has stimulated discussion. To date, the commission has produced excellent background papers on the social determinants of health and has begun to produce numerous final reports dealing with a range of important issues. (See the October Monitor, pp 28-29.) Two of the commission’s knowledge networks (Globalization and Health and Early Childhood Development) are centred in Canada, and another (Workplace Health) has significant Canadian representation. The concept has enjoyed increased mention in the international academic literature and reviews are available. The Canadian Senate’s Subcommittee on Population Health has also undertaken a review of the social determinants of health.

Within Canada, a few Canadian health units have distinguished themselves by their work in raising the importance of the social determinants of health. And there is clear evidence that those working in specific social determinants of health concept areas such as employment security and working conditions, early childhood education and care, housing, income, and food security, health and social services, and poverty reduction are more aware of how their issues impact health.

Non-governmental agencies such as the United Ways across Canada and the United Nations Association of Canada have drawn upon the social determinants of health concept to advance their work. However, though it is clear that the social determinants of health concept has attained a greater visibility among these varied sectors, there is little evidence that the concept has significantly contributed to any Canadian public policy advances in the service of health. When governments have produced health-enhancing public policies such as new housing programs or enhanced early childhood education programs, it is difficult to discern if health considerations have been considered in their decisions. This has not been the case in other countries where social determinants of health concepts have been actively incorporated into the making of public policy.

For the most part, the social determinants of health concept within the Canadian public health scene has been limited to the production of even more policy documents declaring its importance, with rather little to show for the effort. This may be a result of governing parties’ political ideologies shaping policy-makers’ receptiveness to the social determinants of health concept. Government policy-makers will hesitate to advocate public policies that are seen as inconsistent with the views of the elected representatives who effectively serve as their employer. Identifying how these barriers may be overcome constitutes an important goal of our work.

--from Dennis Raphael, Chapter 1: Introduction to the Social Determinants of Health.

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Income Inequality

As we enter 2008, cracks in the armour of conservative pundits have widened. They have, through their faulty economic performance, induced their own political

losses in several areas of Canada. The neoliberal agenda of downsizing, privatization, and deregulation has destabilized quality of life and moved political sensibilities further to the left. Concurrently, movements for democratic reforms are moving to the forefront, for the problems of income inequality have strong ties to the activities of our political leadership (both elected officials and top bureaucrats). It is also a time for civil society to influence the economic and ideological debates in the nation. Controlling capitalism and its companion ideological doctrines must move to the forefront of our policy agenda.

It is imperative for us to proclaim the market’s failure to deliver enough decent jobs, especially for those at and close to the bottom of the income ladder. Incomes are insufficient, and the burdens placed on the tax and transfer system (via the government) to remedy this situation poise us for a worsening of the tax revolt movement as Canadians focus their blame on the taxes they must pay as opposed to their low and stagnating income levels. Blame squarely rests with the market and its inability to offer us a decent living.

So what are we to do? The task is simultaneously pragmatic, tactical, and visionary. At its root, we must require our politicians to work in our best interests.

They must be separated from the moneyed interests that undermine their capacity to work for the common good, and be held to standards that reflect deep understanding of their own privilege. It is time to engender boldness and courage in all of us to build a society with justice for all.

-- from Ann Curry-Stevens, Chapter 3: When Economic Growth Doesn’t Trickle Down: The Wage Dimensions Of Income Polarization.

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Housing and Health

The Ottawa Charter for Health Promotion recognizes shelter as a basic prerequisite for health (World Health Organization, 1986). Yet Canadian political leaders and the housing policies they offer fail to meet the housing needs of many Canadians. Four years ago, I noted that federal NDP leader Jack Layton’s book on homelessness had documented how the number of Canadians who sleep in the streets, use temporary shelters, or spend more than 30-to-50% of their income on housing had been increasing at alarming levels. In 2008, this situation has continued to deteriorate. These developments have clear implications for the health of Canadians.

The first and most obvious question to be considered is: What is the effect of homelessness on health? The second question is: What is the effect of poor housing conditions on health? The third question is: How does spending an excessive amount of income on housing influence the quality of other social determinants of health? Tying all of these issues together is the concept of housing insecurity and its effects on health.

The second question is: Why have health researchers and policy-makers neglected housing as a health issu? Given the existence of a housing crisis, it would be expected that housing and health would be well-developed areas of Canadian research and policy concern. This does not appear to be the case. There is housing and health research in Canada, but much of it is carried out within rather limited models that examine how physical aspects of dwellings affect health. The role that housing plays in relation to other social determinants of health is rarely considered, nor do these models consider how public policies contribute to the housing crisis in Canada.

How can policy-makers be influenced to address housing and health issues? There are policy options than can improve housing, thereby improving health. To see successful implementation of these options requires understanding how policy-makers use different forms of evidence to develop housing policies to support health.

The Housing Crisis

A key issue in Canada, particularly in urban areas, is the lack of affordable private rental accommodation and the private rental market’s inability to produce affordable units. Rental housing affordability emerged as a major issue in the 1980s. It has remained largely unaddressed through the 1990s, and so far also the 2000s. Many analysts attribute the growing number of homeless and housing-insecure in Canada to reduced state provision of social housing.

Indeed, Canada has the most private sector-dominated, market-based system of any Western nation. It also has the smallest social housing sector of any Western nation, with the exception of the United States. Other contributing factors to the crisis are lack of affordable rental accommodation and growth of low-paying jobs or precarious employment that are both insecure employment and low pay. Canada has one of the highest levels of low-paying jobs at 23% and among the highest child poverty rates among Western nations. The result is increasing numbers of families and individuals with insecure housing.

Growing numbers of Canadians are underhoused, living in motels, dependent on the shelter system, or living on the street. Three aspects of the housing crisis have implications for health: homelessness, the experience of poor living conditions, and the effects of housing insecurity on other social determinants of health.

--from Toba Bryant, Chapter 16: Housing and Health: More than Bricks and Mortar.

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The Politics of Health

Regulation and redistribution are key to improving the many social determinants of health. Although some gains can be achieved via local initiatives, it is clear that overall conditions are continuing to deteriorate because the federal and provincial governments are being run according to the needs, interests, and priorities of transnational corporations. Despite their rhetoric to the contrary, such corporate policies stand in fundamental and concrete opposition to the public interest: they are not conducive to improving the health of Canadians.

What are the prospects for the social determinants of health? The Canadian economy is benefiting from a resource boom that is sheltering us from the downturn in the U.S. economy, where years of deficit-financed consumer spending are coming to a crashing end. As the American economy goes into recession, commodity prices will likely drop, and the Canadian dollar will decline as well. Our economic situation is not based on solid fundamentals; it is more precarious than ever. As David Harvey warns, “When income and wealth inequalities reach a point—as they have today—close to that which preceded the crash of 1929, then the economic imbalances become so chronic as to be in danger of generating a structural crisis.”

In retrospect, neoliberalism delivered wealth for a few, but economic insecurity for the rest. Even when it reached its peak under Clinton and Chrétien, wealth did not trickle down to the majority of working people. Although the rhetoric continues, the neoliberal dream has lost it lustre and its legitimacy. People want progressive policies that will mitigate their pain and reduce their insecurity, policies that the neo-liberals can’t deliver. Progressive politicians seeking popular support have to offer a social democratic program, such as universal health care in the U.S. or a poverty-reduction strategy in Canada.

Unfortunately, there is another route to power, as Naomi Klein describes in The Shock Doctrine. Neoconservative politicians like Bush and Harper play on people’s fears and prejudices. Their “war on terror” caters to those who sell weapons and oil, but leaves people everywhere feeling more fearful and insecure. Although the tactics of disaster capitalism were politically successful in countries around the world, they turned “the already wealthy into the super-rich and the organized working class into the disposable poor.”

Klein concludes that “the cost of that victory has been the widespread loss of faith in the core free-market promise—that increased wealth will be shared.” There will be little improvement in the social determinants of health if Harper can continue selling our resources with so little concern for sustainability or climate change, or continue to bribe voters with their own tax dollars.

At a philosophical and personal level, the solution is to find a better balance between equality and freedom. We need to reclaim equality as a positive social value; it has gone out of fashion in recent decades, having been squelched in the pursuit of free enterprise. The values of the marketplace—individual greed, fear, insecurity—triumphed, and our rich legacy of social values—compassion, caring, sharing—were demeaned. The pertinent question is: What values should govern Canada?

--from David Langille, Chapter 20: Follow the Money: How Business and Politics Define Our Health.

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Towards the Future

Developments in Europe indicate that concerted public health and community efforts can profoundly influence the development of policies that determine the extent of health inequalities and the overall state of population health within a nation. The policy directions being undertaken by nations such as Sweden and Finland are two such examples. Similarly, the success of the WHO European Office Healthy Cities initiative is another example of the power of cities and communities to influence health policy.

Canada has a rich history of concerted public pressure that can lead to positive policy change. And there have been significant efforts in Canada to have a social determinants of health perspective taken seriously. Innovative and bold efforts have been undertaken by health units, municipalities, health and service provider associations, and various non-governmental associations to shine a spotlight on the social determinants of health and promote public policy in the support of health.

The Toronto Charter on the Social Determinants of Health has been endorsed by the Toronto and Ottawa city councils and has gone before additional municipal councils across Canada for endorsement. This Charter itself is a tool for promoting health and social justice, both within and outside of Canada. It can be an impetus for change, notably by municipal council endorsement, followed by political action.

The social determinants of health concept can help make the links between government policy, the market, and the health and well-being of Canadians. For those working in the health sector, it can serve as motivation for working for change. The interests of their clients, patients, or consumers are served by speaking out against poverty, social exclusion, inequality, and inadequate services. There are potent barriers, however, to such actions. We hope that this volume will assist in these efforts.

-- from Dennis Raphael and Ann Curry Stevens, Chapter 24: Surmounting the Barriers: Making Action on the Social Determinants of Health a Public Policy Priority

(Dennis Raphael is a professor of health policy at York University in Toronto and editor of Social Determinants of Health: Canadian Perspectives, 2nd edition. Social Determinants of Health is published by Canadian Scholars’ Press Incorporated [])