Joe Levy wrote:

> First let me congratulate you both on the tone and substance of your
> comments, observations and musings regarding my colleague's work that
> I have been both directly and indirectly involved with. Poverty is one
> of the most pernicious determinants of disease at the micro, meso and
> macro levels in developed and underdeveloped nations. We all agree
> with the model presented by Dennis that there is a relationship
> between poverty and disease/health in modern society and we thank him
> for his solid research. However, I also think that we need to develop
> a health paradigm that is based on a Person x Environment interaction
> model  ( see my 1991 article: A conceptual meta-paradigm for the study
> of health behaviour and health promotion in Health Education Research,
> Vol. 6 No. 2, 1991, 195-202) that many of us in "public health" and
> "health promotion" practice. Raising minimum wage, providing other
> income equalizing programs will not make smoking, obesity, diabetes,
> sexual abuse, racism and environmental degradation disappear. Actually
> a policy of strictly "income redistribution" without an educational,
> lifestyle and environmental foundation will not dramatically improve
> the health or our democratic society and in some cases improved
> economic status contributes to an unhealthy society. Many societies
> were better off when their income was lower than when it increased.
> The complex and interactive relationship between poverty and health (
> it is not linear!) cannot be addressed by simply disregarding the role
> of education and lifestyle in the model. As long as the cigarette
> companies are allowed to entice 10 year-olds to smoke, the elimination
> of poverty will never address the fact that everyday around the world,
> poor or rich, millions of children become addicted to smoking!
> Clearly, poverty has to be reduced and it will have a tremendous
> impact because of all the other variables that are a concomitant of
> income- education, self-esteem, social support ,etc. However, to
> simply state out of hand that "lifestyle" should not be supported or
> that health care practitioners should abandon their "lifestyle" work
> and direct all their attention to the reduction of poverty is far too
> simplistic, naive and exclusive. A more inclusive and efficacious
> model is to work on both in a very complex and interactive way and
> that is the work of "health planners" like myself who see the role of
> lifestyle as being another "independent variable" in the model in the
> same way as "poverty" and "social support" or "ethnicity" are all
> independent variables. Newfoundland has the lowest suicide rate in
> Canada, while economically being one of the poorest Provinces in
> Canada. Why are suicide rates lower in Newfoundland than in Ontario?
> It has nothing to do with $$$$ it has everything to do with social
> support and other complex personal and environmental variables. Dennis
> had given us lots to work with but we should not throw out the baby
> with the bathwater.
> Joseph Levy
> Professor
> School of Health Policy and Management
> York University
>
>
> Ron Dovell wrote:
>
>> "Public Health Units and Poverty in Ontario: Part of the Solution or
>>
>> Part of the Problem?"
>> Thank you for disseminating this referenced document and promoting
>> discussion. I still have some uncertainty on this and am therefore
>> rephrasing and reposting for further discussion.
>>
>> This is a timely paper on poverty, health and health unit programs.
>> It
>> is relevant to current health promotion planning, particularly
>> within
>> the newly formed macro Health Regions of British Columbia. It is
>> also
>> relevant to planning models such as the 'conceptual model for
>> prevention
>> in BC' currently being drafted by the province and health regions.
>> Since
>> I cannot send an attachment, you need to visualize a schematic of
>> the
>> model. Healthy British Columbians is the central component of the
>> model.
>> Immediately adjacent are 5 programs/issues dealing with 'lifestyle'
>> risks such as tobacco, nutrition, physical activity etc. Medium term
>>
>> (5-10 years) impacts proposed to flow from the model are all
>> directed at
>> changing behaviour. Such behaviour is commonly articulated as being
>> grouped into a lifestyle construct. Peripheral boxes of the model
>> are to
>> promote healthy environments (e.g. policies), preventive services,
>> education and infrastructure supports (e.g. information). This is a
>> common layout of models to represent general health
>> promotion/prevention
>> activities (i.e. the health of a central target population
>> surrounded by
>> proximal risk factors and then distal policies/environment). This
>> layout
>> tends to align with our thinking regarding the 'causal chain of
>> disease'.
>>
>> The point raised by Dennis is that we should rethink the area of the
>>
>> model (or chain) that we target.  ... and perhaps rewrite
>> the model? We are to pay greater attention to social epidemiology
>> rather
>> than medical epidemiology. Presumably, public
>> health epidemiology is more closely linked with a medical model. Can
>> we
>> all agree that the traditional definition of
>> epidemiology is the 'study of the distribution and determinants of
>> disease in human populations?' Personally, I use a slightly
>> modified definition but the definition and science of epidemiology
>> focuses our attention on humans.
>>
>> The paper by Dennis criticizes a 'lifestyle' approach for prevention
>>
>> activities. This was the main criticism of the 1974 Lalonde
>> report. However, later models further developed the Lalonde model,
>> i.e.
>> a model by the Ontario Premiers Council on Health
>> and a model promoted through the Canadian Institute of Advanced
>> Research. These later models show that behaviours and
>> lifestyle are 'downstream' from genetics and the physical and social
>>
>> environments. The medical-care system is further
>> downstream. Several subsequent papers have highlighted the
>> predominance
>> of the social environment as an upstream
>> determinant of health. Therefore, when Dennis questions that we in
>> public health  may not have appropriate theory to address
>> the broader determinants, it should be pointed out that a number of
>> theories and frameworks are in place - also for example,
>> the widely used PRECEDE-PROCEED framework for health promotion
>> planning
>> begins with an analysis of the broad social
>> setting but the broader social circumstances lead into
>> knowledge/attitude/behavioural patterns and the morbidity/mortality
>> outcomes. The PRECEDE model further emphasizes the predisposing,
>> enabling and reinforcing factors that continue to be
>> connected to social interactions. Most practitioners of public
>> health
>> are aware of these person-environment connections in a
>> general sense. And most would agree that lifestyle 'choices' really
>> are
>> not entirely self-determined choices - consider the
>> associations between risk behaviour and the social environment of
>> children and early adolescents. Part of the socialization
>> process is to learn responsible citizenship but can we really say
>> that
>> children are responsible for behavioural choices?
>> Choices by children are made in relation to the physio-social
>> context
>> that we collectively influence, including items such as
>> socioeconomic status, culture, parental smoking etc.
>>
>> Dennis argues that for the most part Public Health personnel are
>> focused
>> on risk behaviour but should be more focused
>> upstream on the social determinants of health, e.g. poverty. In
>> addition
>> to a dearth of theory, he notes that perhaps one
>> impediment is that government doesn't want criticism of
>> social/economic
>> policies and wants to shift responsibility (&
>> programs) onto individuals via their choices and behaviour.
>> Subsequently, public health workers 'submit' to this ideology and
>> fear advocacy due to dependency on government funding. We are in a
>> conundrum if we are afraid to discuss and advocate
>> on the real problem. Although the fear of genuine advocacy holds
>> merit,
>> in my opinion at this point it is still more fruitful to
>> discuss what we should be focused on rather than why we are focused
>> in
>> any particular area.
>>
>> A number of questions arise ...
>> 1. Do public health personnel emphasize lifestyle factors?
>> 2. Should public health emphasize policy factors such as poverty?
>> 3. Should we depict our models to make the social environment more
>> central ... and therefore, I suppose more central in our
>> subsequent thinking and planning?
>>
>> As long as our models depict the health status of people at the core
>> and
>> lifestyle risk/protective factors immediately adjacent then our
>> attention will tend to focus on these aspects as our main conceptual
>>
>> paradigm for planning, programming and evaluation. An issue such as
>> poverty may be the focus of a specific project/program but will
>> remain
>> peripheral in the broader panorama of public health... and therefore
>>
>> subject to the criticism that overall our emphasis is misplaced.
>>
>> Recognizing that we have limited resources and being spread too thin
>>
>> creates problems, how should we divide (or emphasize) our efforts
>> among
>> these factors? Should we reduce our specific work on tobacco for
>> example
>> and deploy the resources to poverty?
>>
>> I look forward to comments of others. Thank you.
>>
>> --
>> Dr. Ronald A Dovell
>> Health Planning Researcher
>> Interior Health
>> Email:  [log in to unmask]
>>
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