Canadian Journal of Public Health, 2001, 92, 441-442.

Cardiovascular Health in Canada:
Are We Fiddling While Rome is Burning?

Dennis Raphael, School of Health Policy and Management,
Atkinson Faculty of Liberal and Professional Studies,
York University, Toronto, Ontario M3J 1P3,
tel: 416-736-2100, ext 22134
email: [log in to unmask]

Acknowledgment
This commentary is drawn from content contained in "Inequality is Bad for Our
Hearts:
Why Low Income and Social Exclusion Are Major Causes of Heart Disease in
Canada." This
report was commissioned by the North York Heart Health Network and is available
at
http://www.yorku.ca/wellness/heart.pdf.

"It is clear that promoting heart health in the community requires consideration

of a complex social, economic and cultural context which goes much beyond the
immediate
issues of risk reduction".,

     Despite these words penned by the late Andres Petrasovits (Health Canada)
in 1992,
 the overwhelming emphasis in the cardiovascular health area continues to be on
the
measurement and modification of biomedical and behavioural risk factors. Most
Canadian
health researchers carry on reporting the prevalence of inactivity, tobacco use,
 and
poor diet among Canadians together with exhortations to improve our lifestyles
and be
screened for biomedical risk factors.
     This business-as-usual process continues despite the increasing body of
literature
that the economic and social conditions under which people live their lives are
the major
 factors determining whether they fall prey to cardiovascular disease.,,  And
some of
the most important life conditions that determine whether individuals stay heart
 healthy
 or become heart disease ill -- such as low income, the degree of  social
exclusion,
and the lack of available health and social services -- are showing ominous
increases
among the population.
     Reviewing the empirical and theoretical literature related to the
determinants of
cardiovascular disease at the request of the community-based North York Heart
Health
Network,  I was surprised by the magnitude of documented income-related effects
upon
cardiovascular health.  Numerous large scale studies find medical and lifestyle
factors
account for rather small amounts of variation in the incidence of cardiovascular
 disease
among populations.,, Analyses identify cardiovascular diseases as the diseases
most
associated with low income among Canadians and concerning explanatory
mechanisms,
longitudinal studies reveal the profound effects upon cardiovascular health in
adulthood
 of adverse childhood circumstances.,,,  Strikingly different levels of
hospitalization
for cardiovascular ailments among income groups reveal the economic costs to
Canadians
of income-related effects. Combined with the studies that show the minimal
success of
lifestyle changes in reducing the risk of cardiovascular disease among those mo
st at risk, one must seriously question the entire approach towards reducing
cardiovascular
disease by those in the cardiovascular health communities.,
     Plausible models of how the material deprivations and related stresses
associated
with living on low incomes contribute to cardiovascular disease are available,
as are
explorations of the heart health damaging effects of income inequality upon the
health
of the entire population....Yet to date, there has been virtually no public
consideration
 in Canada of the role that societal factors such as income play in the
incidence of
cardiovascular disease and how recent changes in income distribution may be
affecting
Canadians' cardiovascular health.
     The latest estimates are that 23% of all premature years of life lost prior
 to
age 75 in Canada can be attributed to income differences and the greatest
proportion
of these years lost are caused by cardiovascular disease. In addition, it is
estimated
that income differences account for a 24% excess in premature deaths (prior to
75 years)
from cardiovascular disease among Canadians.10 Were all Canadians' rates of
death from
 cardiovascular disease equal to those living in the wealthiest quintile of
neighbourhoods,
 there would be 6,366 fewer deaths each year from cardiovascular disease. A
conservative
estimate of the annual costs to Canada of these income-related cardiovascular
effects is
1/5 of the total cost to Canada of cardiovascular disease of $20 billion or $4
billion.6
     At the same time that health researchers focus on biomedical and lifestyle
risk
factors for cardiovascular disease, there is documentation of the increasing
numbers
of Canadians being moved into low income status and the weakening of the social
safety
net.As of 1991, Canadians enjoyed remarkably lower cardiovascular and total
mortality rates
and less economic inequality than our neighbours to the south.  Also, Canada has
 traditionally
een in the mid-levels of nations in the percentage of tax revenues allocated to
spending on
the social safety net, an important determinant of health for all individuals,
but especially
those living on low incomes.,
     But since 1991, income inequality has increased in Canada and a move
towards reduced
spending on services and supports has occurred simultaneously with an increase
in numbers
of Canadians living on low incomes. Since the research literature indicates that
 these
societal features are the greatest influences upon the cardiovascular health of
the population,
two questions must be asked. Why have we been neglectful of these influences?
What will it
take to shift our attention to these issues?
References

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