Top of the morning Glen.  Thank you for your thoughtful, insightful and most helpful note.  I actually think you and I should talk some time or other (I notice you consult also) because our thinking is so similar.  I have been consulting for some 14 years now and invariably critical of Canadian social policy, and of governments pursuing harmful or poorly thought out policies (for example, killing the federal housing programs as you noted).  I did an interesting piece earlier this year assessing the adequacy of the funding available for the C'ain Strategy on HIV/AIDS.

Your comments about race/racism and gender/sexism are much appreciated because that is where my own thinking was leading ... and yet everyone else was talking about race and gender and Aboriginal status, etc.  I was wondering whether I was missing something.  Perhaps an unwritten project goal, for me, will be to change the language.

I have Paradigms Lost in the ever-growing pile in front of me but will pursue your other suggestions.  

Again, thanks very much.

Martin
  ----- Original Message ----- 
  From: Glen Brown 
  To: [log in to unmask] 
  Sent: Tuesday, August 14, 2001 3:23 PM
  Subject: Re: Population Health and HIV/AIDS


  Hi Martin.

  Good luck on this important topic. I'm pleased to see an interest from Health Canada et al in reviewing current evidence as part of setting future directions. Applying population health theories to HIV/AIDS realities is, I think, tricky work and requires a thoughtful, deft touch.

  A couple of thoughts and a few recommended resources:

  1) I hope you will be open to exploring the ambivalence to pop health theory that you'll encounter in many parts of the HIV/AIDS community. The reaction is genuine and well-grounded. 

  Pop health first surfaced as a major topic in our community when, in the mid-90s, Health Canada began using it as the rationale for dismantling the national HIV/AIDS strategy and its funding for research, community-based services and prevention, and other vital programs. A 'disease-specific' approach didn't fit the pop health paradigm, we were told. Maybe some services would emerge under the new model, maybe not. (This was also during a period where Health Canada was downsizing). Fortunately a protracted, major advocacy campaign was able to shift the government on this. The national strategy was renewed and continues to fund critically important services. 

  Pop health also struck some of us as a bit of a fraud. We in the community were being told to do more with less (or shut down services altogether) because social determinants were where it was at. Meanwhile, government policy was galloping in the opposite direction. If population health has been government policy over the past decade, why have the same governments created a national housing crisis? Why have they gutted income supports for the poor? Etc. Etc. Etc.

  An excellent resource that explores some of these issues was produced by the Canadian AIDS Society, called 'Paradigms Lost." I think its available on their web (www.cdnaids.ca) or through the Canadian HIV/AIDS Clearinghouse at 1-877-999-7740

  2) I hope you'll encourage a realistic approach to 'social determinants'  that analyzes the social relationships that actually shape health. "Race", for example, may or may not have an impact on HIV transmission and disease progression, but "racism" sure the heck does. Similarly for "gender" (I recall filling out Health Canada funding forms which asked how our program would impact on 'gender'. Hmmm. Imagine the program possibilities if they asked us to have an impact on 'sexism' instead).

  Some studies that you may find useful, all I think available from the Clearinghouse number above: "Discrimination and HIV/AIDS in South Asian Communities", from the Alliance for South Asian AIDS Prevention, "Legal, Ethical and Human Rights Issues Facing East and Southeast Asian Canadians in Accessing HIV/AIDS Services in Canada" from the Asian Community AIDS Services, and (brand new) "Improving Access to Legal Services and Health Care for People Living with HIV/AIDS Who are Immigrants, Refugees or Without Status" funded by the Ontario HIV Treatment Network.

  The standard list of determinants has a huge and glaring gap when HIV/AIDS is considered: sexual orientation/homophobia. Gay men have borne and continue to bear the largest brunt of this epidemic in Canada. Any population health model that ignores this will simply miss the boat. There's a new publication exploring this last point called 'Valuing Gay Men's Lives" that can be found at www.gaycanada.com/glhs It makes a number of recommendations related to applying pop health to HIV.

  3) I'm glad to see from your research questions that you will be exploring the application of pop health not only to HIV prevention, but to the health of those who are HIV positive. There is increasing recognition of the interrelation between HIV prevention and care & treatment. We should recognize community development models which address concurrently the social conditions of HIV negative and positive people.

  4) I suspect there are some international initiatives that may prove helpful but may not use the same language or frameworks of population health as have been developed in Canada. The Australian movement has often been far in the lead in analysis, public policy and program development in HIV. The AIDS Council of New South Wales, for instance, writes eloquently about social context and community development in their current strategic plan (http://www.acon.org.au/misc/strategicplan/strategicplan2000.htm)

  5) Other sources: The Canadian Association for HIV Research; The BC Centre for Excellence in HIV/AIDS; the Ontario HIV/AIDS Treatment Network; and the McGill Centre for HIV/AIDS.

  Hope this proves helpful; looking forward to the report.

  Glen Brown
      

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