Dear Dr. Finkelstein:

Re: Do factors other than need determine utilization of physicians' services in
Ontario?, Murray M. Finkelstein , CMAJ 2001;165(5):565-70

http://www.cma.ca/cmaj/vol-165/issue-5/0565.asp

While I appreciate your findings reported in the CMAJ concerning the poorer
health of low income people in Ontario, do you still have to assume that the
poor
health status of low income people is due to their poor "lifestyle choices."?
How about
a recognition of the difficult life circumstances -- material deprivation,
psychosocial stress, and even lack of shelter and food security -- that
government policies
are subjecting people with low income people and their children to live under.
Indeed, lifestyle and biomedical risk factors account for only a small
percentage of the
variance associated with income-related health differences in Ontario, Canada,
and the rest of the industrialized world, yet you assume that these factors are
responsible for your findings.

Perhaps a word or two about the "Common Sense Revolution" in Ontario and how
its implementation has increased hunger, homelesness, and food insecurity would
have helped readers undersatand some of your findings.

See below!

Best wishes,

Dennis Raphael, PhD
Associate Director and Undergraduate Program Director
School of Health Policy and Management
Atkinson Faculty of Liberal and Professional Studies
York University
4700 Keele Street
Toronto, Ontario M3J 1P3
416-736-2100, ext. 22134
email: [log in to unmask]


Inequality is Bad for Our Hearts:
Why Low Income and Social Exclusion are Major Causes of Heart Disease in
Canada

" Poor conditions lead to poorer health. An unhealthy material environment and
unhealthy behaviours have direct harmful effects, but the worries and
insecurities of daily life and the lack of supportive environments also have an
influence."0

   Heart disease and stroke are the leading killers of Canadians and the leading
causes of hospitalization. The Heart and Stroke Foundation of Canada estimated
the
total cost to Canada of cardiovascular disease as close to $20 billion.
   An extensive body of research now indicates that the economic and social
conditions under which people live their lives, rather than medical treatments
and lifestyle choices, are the major factors determining whether they develop
cardiovascular disease. One of the most important life conditions that determine
whether individuals stay healthy or become ill is their income. In addition, the
overall health of a society appears to be more determined by the distribution of
income
among its members rather than the overall wealth of the society.
   Cardiovascular diseases are the diseases which are most associated with low
income among Canadians. 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 cardiovascular health. This is surprising as
numerous studies
find that socioeconomic circumstances are the main contributors to
cardiovascular
disease, and that circumstances during early life are especially important.
   The report outlines the role that income and its distribution play in the
incidence of cardiovascular disease. There is particular focus on how living on
low income --
combined with government policies that limit access to basic needs and resources
required for health -- contributes to the process of social exclusion by which
individuals are denied full participation in Canadian life. This exploration of
the role of income on cardiovascular health is particularly timely as the
distribution of
income is becoming less equitable in Canada.
   Societal changes that increase the numbers of Canadians living on low income
and foster social exclusion are considered in relation to what is know about the
societal determinants of cardiovascular disease. The hypothesis that increases
in income
inequality are associated with deteriorating health of those who are not living
on low incomes is also examined. Finally, means of addressing the growing
inequalities
in incomes among Canadians and reducing the incidence of social exclusion are
outlined in order to reduce the occurrence of cardiovascular disease in Canada.

Key Messages Contained in this Report
1.  The current emphasis on medical and lifestyle risk factors as means of
preventing cardiovascular disease in Canada is not enough.
2.  Low income is a major cause of cardiovascular disease in Canada.
3.  Social exclusion -- involving processes of material deprivation, lack of
participation in common societal activities, and exclusion from decision-making
and civic participation -- is the means by which low income causes
cardiovascular
disease.
4.  Canadians should be aware that the directions in which Canadian society is
heading are inconsistent with what is known about reducing the incidence of
cardiovascular disease.
5.  These directions -- including greater inequality of distribution of income
-- compromise the cardiovascular health of Canadians at all income levels.
6. Solutions are available to reduce the number of Canadians living on low
incomes and to distribute income more fairly, thereby reducing social exclusion
and
helping to improve the cardiovascular health of Canadians.
This report  was prepared by Dennis Raphael for the North York Heart Health
Network and will be released September, 20, 2001 and posted at
http://www.yorku.ca/wellness/heart.pdf.