Thank you to all who participated in the discussion about Poverty and
Public Health Practice. The uncertainties and differences of opinion
that have been expressed tend to reflect my own uncertainty about what
to do. In particular, the email copied from Nancy Krieger   To:  Spirit
of 1848 <[log in to unmask]>,  outlined that world-class
experts on this topic do not agree on pathways or proposed actions. The
association between poverty and poor health is well established but
there is less confidence concerning the causal, reciprocal and mediating
paths. This uncertainty has been reflected in our public health models
and subsequent (non)programs.

My own uncertainty continued when I was recently unable to find an
association between SES (using a 6 item scale) and smoking among 10,000
Canadian adolescents: even though the association between smoking and
SES of adults has been well documented.

All of these factors contribute to the inaction of public health
personnel to tackle poverty issues, in addition to the reasons pointed
out by Dennis Raphael, eg. a tendency to look at proximal lifestyle
factors and to shy away from criticizing economic policies of
government. Dennis makes a good point when he notes that models may have
lifestyle factors located between broad social environment policies and
health outcomes but we also need to consider that pathways also exist
outside of the lifestyle variables. This is in line with the
multifaceted modeling advocated by Joe Levy, rather than expecting to
achieve any type of understanding or advancement through a simplistic
conceptual framework. The upcoming forum hosted by Joe's group will help
sort out this complex issue (see: www.yorku.ca/wellness).

Amidst the uncertainty and conflicting perspectives Dr. Lawrence Green
has offered pragmatic advice that we build on our knowledge of best
practices concerning proximal behavioural variables. We should refrain
from utilizing arguments that would take away from good work being done
through current public health practice and refrain from the downplaying
the necessity of acute care services. Rather we need to expand our
theories, models and practices to encompass the broader determinants of
health.

One needs to appreciate that public health practice on poverty, like
other complex issues, will take years to become 'institutionalized'...
or at least prevalent among personnel. In the meantime Dennis has
provided an extensive list of background literature that is recommended
as a basis for discussion of this issue. Most policy/practitioners that
I know would not find the time to wade through this. They want clear
direction based on substantial consensus among experts and the weight of
evidence. Where such consensus/evidence are lacking, there is a tendency
to wait for the academics to provide testing, clarification,
dissemination and advocacy.

For my own part, the issue of poverty will receive greater prominence in
discussions, proposals, surveillance activities and reports. I have
found the discussion on this listserv to be useful and am confident that
others have also benefited.

Thanks again ...

--
Dr. Ronald A Dovell
Health Planning Researcher
Interior Health
B.C.

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