Dear Mr. Martin:
I do not know if you have ever bothered to read any Health Canada
documents that consider this issue, but your policies are
contributing to the weakening of Canadian life and to poorer
population health. Have you ever considered what the creation of
a mass of underclass Canadians means for this country, your
leadership aspirations, and your legacy?
Best wishes,
Dennis Raphael
Addressing Health Inequalities in Canada
Dennis Raphael
Department of Public Health Sciences
University of Toronto
address correspondence to [log in to unmask]
Presentation made at the Annual Meeting of the Canadian Public
Health Association
October 23, 2000, Ottawa, Canada
Summary
The idea that low income and poverty are determinants of
poor health is uncontested. Whatever indicator of health is used,
those who live in poverty show evidence of poorer health. It is
not surprising then that societies with greater numbers of poor
people also have poorer population health. Additionally, there
is increasing evidence that societies with greater numbers of
poor people begin to show a spillover effect by which the health
of the not poor also begin to deteriorate as well.
The mechanism underlying this process of increasing
poverty combined with deteriorating population health is
increasing economic inequality. Economic inequality is most
likely to increase within societies that provide increasing
financial gains to the well-off at the expense of the poor. As
well, these societies are more likely to be the ones reducing
investment in social infrastructure, and weakening social and
economics supports that are available to the population. The
form these developments take is that of governments making policy
decisions that weaken the welfare state and move their nations to
ones where decisions are influenced by the play of market forces.
Recent conceptualizations outline how population health
is weakened by these policy developments. These concepts are
consistent with Health Canada formulations of population health.
Indeed, Health Canada documents explicitly recognize how
increasing economic inequality and associated increases in levels
of poverty weakens population health while the provision of
social supports enhances it. Yet, government policies at every
level seem to be at odds with these concepts, and in fact, seem
designed to weaken population health.
The means of improving population health contained within
the health promotion literature are as timely today as ever. The
basic prerequisites of peace, shelter, education, food, income, a
stable eco-system, sustainable resources, social justice and
equity should be provided. And health promotion actions of
building healthy public policy, creating supportive environments,
strengthening community action, developing personal skills, and
reorienting health services need to continue.
Barriers to these actions are many. These include
competition between varying concepts of health and health
determinants; political issues related to the actions of
government masters; institutional issues related to what are
deemed appropriate health promotion activities; personal issues
of knowledge and competence in policy analysis and community
development; and attitudinal issues related to the motivation and
commitment of health workers to address these issues.
Addressing Health Inequalities in Canada
This paper considers the impact of poverty on population
health. It does so through an analysis that sees increasing
poverty and its related health effects as resulting from
government policies that increase economic inequality and weaken
social infrastructure. It then goes on to consider means by which
these issues can be addressed by health workers. The paper
concludes with an analysis of existing barriers to effective
action to improve population health.
Poverty is a Determinant of Poor Health
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.1,p.1
Poverty Affects the Health of Individuals
The idea that low income and poverty are determinants of
poor health is uncontested. This is not a new revelation as the
effects of poverty on health have been known since the 19th
century.2 Whatever indicator of health is used, those who live in
poverty have poorer health. An extensive discussion of various
poverty indicators is available but what is not in debate is that
the extent of poverty has been increasing over the past decade.3
Within Canada, individuals living within the poorest 20% of
neighbourhoods are more likely to die of just about every disease
from which people can die of than the more well-off.4 These
include cancers, heart disease, diabetes, and respiratory
diseases among others. It has been conservatively estimated that
22% of premature years of life lost to Canada can be attributed
to income differences. These data are from the period prior to
the recent increases in poverty among Canadians.
The Health of Canada's Children Reports documents the
variation in health and well-being between poor and not-poor
children. Health differences exist in the incidence of illness
and death, hospital stays, accidental injuries, mental health and
well-being, school achievement and drop-out, family violence and
child abuse, among others. In fact, poor children showed higher
incidences of just about any health-related problem, however
defined.5,6
A recent study provides further evidence on the health
effects of poverty upon children and families.7 Using a series of
aggregated measures, children in low-income families (annual
income < $20,000) were twice as likely (25% compared to 12%) to
be living in poorly functioning families as children in high
income families (annual income >$80,000). The percentage of
children identified as living in poorly functioning families also
differed across the socioeconomic range. These differences were
also seen for measures of chronic stress among parents, living in
substandard housing, living within problem neighbourhoods, having
less friendly neighbourhoods, and a very large number of other
indicators of health and well-being. Finally, 50% of parents
earning <$20,000 rated their children as not being in excellent
health; the corresponding figures for those earning >$80,000 was
32%.
How Does Poverty Affect the Health of Adults and Children?
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 people's
health; and low income limits peoples' choices and militates
against desirable changes in behaviour.1,p. xxi
Recent British studies considered income-related health
differences as arising in four ways.8 Artifactual arguments have
been dismissed as many studies have found that poverty usually
does not result from poor health but is usually a precursor to
it.9 Lifestyle arguments saw poor individuals bringing illness
upon themselves by smoking, drinking to excess, and poor
nutritional habits. However, studies have shown that health
differences remain even after these lifestyle factors are
considered.10 Additionally, a lifestyle focus does not consider
the societal conditions under which lifestyle differences
occur.11
Materialist arguments see people living in poverty
suffering actual material deprivations related to poor diet,
housing, and sanitary conditions which contribute directly to
poor health.12 This argument is the most widely accepted by
health researchers. There are also psychosocial effects of
poverty such as lack of control, feelings of hopelessness, and
loss of esteem that also contribute to poor health.13 The recent
Taking Responsibility for Homelessness report highlights health
issues related to the most extreme indicator of low income among
Canadians, homelessness, and for those not yet homeless, grossly
inadequate housing.14 Canadian studies have also documented the
health-related impacts that result from hunger and lack of
food.15,16 Both homelessness and food insecurity showed massive
increases in Canada during the 1990s.
The most thoughtful analysis of how low income affects
health -- supported by numerous empirical studies -- is presented
by researchers at the University of Bristol. They explain income
differences -- especially poverty effects -- in terms of
how"...the social structure is characterized by a finely graded
scale of advantage and disadvantage, with individuals differing
in terms of the length and level of their exposure to a
particular factor and in terms of the number of factors to which
they are exposed." 17, p.102 These workers emphasize 13 key
critical periods of the life course during which people are
especially vulnerable to social disadvantage. These include
fetal development, nutritional growth and health in childhood,
entering the labour market, job loss or insecurity, and episodes
of illness, among others. Material disadvantage and the absence
of societal supports during these key periods work against
health.
Recent work suggests that "Childhood and adult social
circumstances make independent contributions to the risk of
dying."18, p.142 Evidence is available that poverty and
deprivation during childhood contributes to poor health over the
entire course of the life span even if an individual is removed
from living in poverty subsequent to childhood. The health
consequences of so many Canadian children and families living in
poverty will be manifest for the entire next generation. And
considering the magnitude of the increases in child and family
poverty, such consequences pose direct threats to the
sustainability of the health care system.
Poverty Results from Increasing Economic Inequality
It is not surprising then that societies with greater
numbers of poor people also have poorer population health. The
mechanism underlying this process of increasing poverty combined
with deteriorating population health is increasing economic
inequality. Economic inequality is most likely to increase within
societies that provide increasing financial gains to the well-off
at the expense of the poor.19
Poverty and economic inequality have been increasing in
tandem the past decade. By 1996, the poverty rate in Canada had
risen to 17.9 percent and child poverty reached a 17-year peak of
21%.20 By 1996, 1.5 million Canadian children lived in poverty,
up from 934,000 in 1989.21,22 The Canadian Fact Book on Poverty
provides detailed trends and analyses.23
The Growing Gap report details how by 1996, the 1973 21:1
ratio of pre-tax income between the richest 10% and the poorest
10% of families in Canada had increased to 314:1.24 In Canada the
potential health-related effects of economic inequality had been
kept in check by the presence of strong social programs and the
tax structure. Since 1993, social programs have been weakened
and the after taxes gap has begun to grow; Statistics Canada
reports that during the 1980's the real income of most Canadians
had decreased and child poverty increased, yet the well-off in
Canada became wealthier.25
Poverty is Exacerbated by Weakened Social Infrastructure
Additionally, increasing poverty frequently occurs in
conjunction with the reduction of social safety nets.19 In
Canada, government policies of reducing social safety nets,
decreasing eligibility for benefits, and reducing the absolute
level of these benefits have served to both increase the
incidence of poverty and remove the means by which those living
in poverty can sustain themselves. This shift has occurred in
part as a result of the reorganization of the income tax system
by which the well-off have had their tax rates decreased,
providing less resources for governments to provide social
assistance benefits and social services to those in need. A
detailed analysis of these policy developments is available.26
As well, unequal societies are more likely to be the ones
reducing investment in social infrastructure, and weakening
social and economics supports that are available to the
population. The form these developments take is that of
governments making policy decisions that weaken the welfare state
and move their nations to ones where decisions are influenced by
the play of market forces.27
Canadian Policy and the Increase in Poverty and 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
labor unions, attention to infrastructure and technical
assistance to entrepreneurs, among others.28
As of 1991 Canadians enjoyed remarkably lower mortality
rates and less economic inequality than our neighbours to the
south.29 As well, Canada has traditionally been in the mid levels
of nations in spending on the social safety net,5,26 an important
determinant of health for all individuals, but especially the
poor.30,31 Canada had also been in the mid-level of percentage
of tax revenues as a percentage of gross domestic product being
allocated to services and supports.32 The move of Canada towards
decreased spending on services and supports has occurred
simultaneously with the increase in levels of poverty.26
Even when one level of government attempts to raise the
income of those living in poverty, another level of government's
policy make take the benefit away.33 A recent report from the
National Council of Welfare documents how the federal
government's National Tax Benefit has been clawed back by most
provinces. In Ontario for instance, families on social
assistance now receive less money than they did the last few
years but the federal government now pays a greater portion of
it. Such policies then, end up doing nothing to help raise the
income of those living in poverty.
Poverty Has Spill-Over Effects
Additionally, there is increasing evidence that societies
with greater numbers of poor people begin to show a spillover
effect by which the health of the not poor also begin to
deteriorate as well. Wilkinson brought together much of the
research showing that societies with greater poverty have higher
mortality rates across the entire population.9 For example, after
decades of rapidly increasing economic inequality, the most
well-off in Britain now have higher death rates among adult males
and infants than the least well-off in Sweden.34,35 There are
also findings that the well-off in economically unequal American
communities have greater rates of health problems that the
well-off in relatively equal communities.36 These findings have
led the British Medical Journal to editorialize: "What matters
in determining mortality and health in a society is less the
overall wealth of that society and more how evenly wealth is
distributed. The more equally wealth is distributed the better
the health of that society."37,p.312 Recent Canadian analyses of
these issues are available.19,38
From Rhetoric to Action
Recent conceptualizations outline how population health
is weakened by these policy developments. Lynch has provided a
very up-to-date model by which it is shown how government
policies help create both economic inequality, poverty and
decreased social cohesion.39 These and other conceptualizations
of how government policies threaten population health concepts
are consistent with published Health Canada formulations of
population health.40,41 Indeed, Health Canada documents
explicitly recognize how increasing economic inequality and
associated increases in levels of poverty weakens population
health while the provision of social supports enhances it.
Avoiding Orthodoxy in Identifying Health Determinants
If public health research is to develop more robust and
holistic explanations for patterns of health and illness in
contemporary society, and contribute to more appropriate and
effective policies, then the key is to utilize and build on lay
knowledge - the knowledge that lay people have about illness,
health, risk, disability and death.42, p.267
Determinants of health are the factors that affect health
and well-being. Health Canada has taken direction from the
Canadian Institute of Advanced Research (CIAR) in outlining some
of these health determinants. These 12 determinants of health
include income and social status, social support networks,
physical and social environments, personal health practices and
coping skills, and health services. These were identified by CIAR
workers whose framework may not be the most appropriate for
considering health determinants. Indeed, there may be an
orthodoxy emerging concerning what the determinants of health
are.
To illustrate, another way of thinking about determinants
of health was outlined in a 1998 World Health Organization Task
Force.43,44 In the WHO scheme, the key determinants of health
are social status and income differences, stress, early life,
social exclusion, work, social support, unemployment, addiction,
food, and transport. In 1986, the World Health Organization's
Ottawa Charter for Health Promotion outlined peace, shelter,
education, food, income, a stable ecosystem, sustainable
resources, social justice, and equity as constituting the
prerequisites of health.45 There are implications to accepting
one set of determinants in the CIAR case one outlined by
epidemiologists over another.
It may be that the best exposition of health determinants
may be those given by community members themselves. For example,
in a recent Health Canada funded study, Toronto seniors
identified key health determinants as being governments hearing
seniors' voices, housing, acute illness care, long term care,
income supports, transportation and mobility, promoting healthy
lifestyles, access to information, and hearing voices from
cultural communities.46 It is easily anticipated that inquiry
with groups of other populations would identify health
determinants very different from the ones being followed by
Health. The importance of working with communities and listening
to their voices is one of the main divergence between some
schools of population health and health promotion. The importance
of lay knowledge is increasingly being acknowledged by health
workers. Discussion is needed about how determinants of health
should be identified and the kinds of action needed to address
their effects.
Moving Towards Population Health
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. 47,p.60
While the basic outlines of health determinants are
becoming obvious, government policies at every level seem to be
at odds with these concepts, and in fact, seem designed to weaken
population health. There are no shortages of analyses of how
government policies are threatening health and the means by which
this is happening.46,48 A detailed summary specifically focussed
on Canadian population health is available.19
The means of improving population health contained within
the health promotion literature are as timely today as ever. The
basic prerequisites of peace, shelter, education, food, income, a
stable eco-system, sustainable resources, social justice and
equity should be provided. And health promotion actions of
building healthy public policy, creating supportive environments,
strengthening community action, developing personal skills, and
reorienting health services need to continue. It has been
commented that population health is in itself not an agenda for
action, but rather one of analysis.49,50 Not surprisingly, most
population health documents that are concerned with action draw
heavily from the health promotion literature.
Barriers to Effective Action on Population Health
Ultimately health workers have to decide whether to
identify poverty or poverty's effects as the focus for action.
Canadian public health practice is focussed on the latter with a
proliferation of programs designed to address issues of tobacco,
activity, diet, sexual health, alcohol use that is attempting
to work downstream rather than dealing with the problem at its
source.51 And make no mistake about it: poverty is the cause of
many of the health related issues and behaviours with which
health workers concern themselves.
Barriers to accepting this truth are many. These include
competition between varying concepts of health and health
determinants; political issues related to the actions of
government masters institutional issues related to what are
deemed appropriate health promotion activities; personal issues
of knowledge and competence in policy analysis and community
development; and attitudinal issues related to the motivation and
commitment of health workers to address these issues. Each of
these is considered briefly in turn
Ideological Issues - The concepts of health, health
determinants, and actions to improve health are contested.52
Differences exist among health workers as to medical, lifestyle,
and socio-environmental explanations for health and means to
improve it.53 There is also the ongoing dispute as to the
importance of public health versus health care action. A need
for closure on definitions of health promotion has been
identified.54,55
Political Issues - Many health workers are employed or
funded by the very governments whose policies threaten health.
Many workers proceed in their activities supported by government
and agency documents that at least on paper sanction their
activities. The Medical Officer of Health of the Montreal Region
has been able to raise poverty as a key public health issue.47
Such raising of poverty as a public health issue has to date
not been happening in the New City of Toronto.56
Institutional Issues Related to the first two issues is
the role that an institution sees itself as playing in supporting
health. Clearly, it is less contentious to offer clients
lifestyle programs that place the focus upon individuals rather
than the social conditions and government actions that create
health threatening situations, attitudes and behaviours. Such
courses of least resistance are certainly means of generating
agency activity. Whether they serve to enhance the health of
Canadians is less clear.
Personal Issues of Knowledge and Competence Moving
beyond providing lifestyle programs involves skills of community
development and policy analysis. Many health workers feel they do
not possess the knowledge to challenge policy decisions that
affect health.57,58
Attitudinal and Motivational Issues Life is brutish and
short. Health workers, like many others, find it difficult to
buck the forces that are shifting their work environments. Health
workers know that poverty is the key determinant of health but
feel helpless to raise these issues in the face of pressures to
downplay them. Nonetheless, each health worker has to make
personal decisions about the ethics and morality of their health
enhancing activities and when appropriate speak out in
appropriate formats as to what they see as the factors
threatening the health of their clients and neighbours.
Conclusion
If the misery of our poor be caused not by the laws of
nature, but by our institutions, great is our sin Charles
Darwin59
Enough evidence has accumulated to indicate that policy
decisions that increase poverty and economic inequality work
against population health. This fact is recognized by government
documents, public health association papers, and empirical
research.50 Health workers have an obligation to address the
issue of poverty directly rather than remaining content to deal
with its effects. Canada has consistently been rated as one of
the best rated places on Earth in which to live. Whether it
remains so depends upon whether health workers choose to address
key determinants of health such as poverty in a manner consistent
with the research evidence and ethical health practice.
The forms that such action can take have been detailed
elsewhere.50 By way of summary these actions include the
following:
À Develop Communication Between Various Sectors Concerned
With Poverty and Economic Inequality
À Contribute Papers to Academic and Professional Journals
on Developments In Canada and their Potential For Affecting the
Health Of Canadians
À Use The Media To Educate Canadians About The Consequences
Of Increasing Economic Inequality and Poverty Upon Health
À Lobby Local Health Departments To Begin Taking Seriously
a Determinants Of Health Approach Including Consideration of the
Importance of Economic Inequality and Poverty
À Lobby Governments To Maintain the Community and Service
Structures that Help to Maintain Health And Well-Being
À Begin to Understand the Forces that Create Economic
Inequality and Poverty
.
While some initial beginnings have been made in bringing
together some of the economic inequality, poverty, and health
literature, this information needs to be consolidated, shared
with others concerned with the health of Canadians, and linked
with effective ongoing action to improve health. Most
importantly, Canadian public health workers have to become
reacquainted with the basic principles of health promotion and
begin to seriously address the determinants of health in their
practice.
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