Ron- many thanks for your extremely well thought out and sensitive summary  of a
very complex and profoundly important issue in modern western society where it is
obvious that the rich are getting richer and the poor are getting poorer. There is
no doubt in mind that the raft of "structural" initiatives that people like
Professor Raphael are advocating will lift people out poverty and will ultimately
make a difference in the long-term health profiles. Safe communities, high-quality
schools, decent and affordable housing and better access to health care will all
improve the health and quality of life of all Canadians. This is not in place of
the "lifestyle" strategies that are being developed by Public Health all across
Canada. Yes, child poverty has trebled in the last 20 years, but this is even more
reason to insure that these children's families have not only the economic but also
the educational resources to provide nutritious meals. Every study that has been
reported examining the relationship between income and health, clearly point out
that those lower SES groups consume more unhealthy foods than those in higher SES
even though the "healthy" foods are cheaper to purchase. Clearly whether its
nutrition, physical activity or stress management, too often the intervening
variable  "education"  explains more of the variance than the independent variable
"income." Making a choice to cook a pound of beans as opposed to purchasing french
fries at McDonald's is not on related to income but one related to education and
lifestyle. In the same way that we teach people who own a VW or NISSAN to look
after it in the same way that we teach people who own a MERCEDES, we have to make
sure that whatever our income level, how we eat, sleep, socialize and view the
world is still critical. Indeed for some chronic diseases in our society, being
poor may make you healthier than being rich! So as I've said before, let's not
throw out the baby with the bathwater. Our Forum which was scheduled for June 19
has been rescheduled for February 2003, check our website: www.yorku.ca for the
most update information on what promises to be an extremely important event in
Canadian Lifestyle work as it relates to Poverty and Health.
Joseph

Ron Dovell wrote:

> 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.
>
> Email:  [log in to unmask]
>
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