The Saint John Times Globe
  Editorial, Monday, October 29, 2001, p. A7

  Being poor, being sick
  An alternative view suggests the tips for better health overlook the role
income plays

  Prof. DENNIS RAPHAEL

  Most Canadians believe that medical and health research is a neutral activity
based on
  the "facts" that exist in the world. And the "facts" that get reported are
that diseases in
  general - and heart disease in particular - are caused by biological
imbalances in our
  bodies that result from faulty lifestyle choices.

  This message is repeated by organizations such as the Heart and Stroke
Foundation
  and our local public health department. A typical message is given by British
Medical
  Officer Liam Donaldson:

  Ten Tips for Better Health

  1. Don't smoke. If you can, stop. If you can't, cut down.

  2. Follow a balanced diet with plenty of fruit and vegetables.

  3. Keep physically active.

  4. Manage stress by, for example, talking things through and making time to
relax.

  5. If you drink alcohol, do so in moderation.

  6. Cover up in the sun, and protect children from sunburn.

  7. Practice safer sex.

  8. Get yourself screened for cancer.

  9. Be safe on the roads: follow the Highway Code.

  10. Learn the First Aid ABC - airways, breathing, circulation.

  The problem with this message is that a wealth of research indicates that the
factors
  that have the greatest impact of whether we develop heart disease are usually
out of
  our personal control. More specifically, many large-scale studies find that
income levels
  rather than medical and lifestyle factors are better predictors of whether we
develop
  diseases such as heart disease and stroke. It is estimated that 23 per cent of
 all
  premature years of life lost prior to age 75 in Canada can be attributed to
income
  differences. Of these premature deaths related to income differences, the
greatest
  proportion of these years lost - 22 per cent - is caused by heart disease and
stroke.

  Income differences in incidence of heart disease account for a 24-per-cent
excess in
  premature deaths from heart disease among Canadians. Were all Canadians' rates
 of
  death from heart disease equal to the wealthiest fifth of Canadians, there
would be at
  least 6,366 fewer deaths each year from heart disease.

  But if low-income people could be weaned from their poor lifestyle choices,
wouldn't
  their health improve? The answer is no. First, even if their habits were as
healthy as we
  might like, the material effects of living on low income or in poverty would
still lead to
  higher rates of illness and death. Numerous studies indicate that the living
conditions of
  low-income and poor children leads to their having a much greater likelihood
of
  developing cardiovascular disease regardless of their lifestyle choices and/or
 income
  status in adulthood.

  Second, the psychological stresses of not having enough income to meet basic
needs is
  a potent predictor of heart disease. The National Population Health Survey
found that
  among Canadians in the lower third of the income distribution, almost half
reported
  seeing the world as not being meaningful, events as being incomprehensible,
and life's
  challenges as being unmanageable. People in the highest third income group
were half
  as likely to report feeling that way.

  Third, decades of research has indicated that low income and poor people lack
the
  same opportunities as others to make healthy lifestyle choices due to lack of
material
  resources and psychological stress. Try exercising and eating fruits and
vegetables
  when your main concern is how you are going to feed your children or pay your
rent.
  Perhaps the message we should be getting is that provided by David Gordon of
Bristol
  University in the U.K.:

  An Alternative Ten Tips for Better Health

  1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.

  2. Don't have poor parents.

  3. Own a car.

  4. Don't work in a stressful, low paid manual job.

  5. Don't live in damp, low quality housing.

  6. Be able to afford to go on a foreign holiday and sunbathe.

  7. Practice not losing your job and don't become unemployed.

  8. Take up all benefits you are entitled to, if you are unemployed, retired or
 sick or
  disabled.

  9. Don't live next to a busy major road or near a polluting factory.

  10. Learn how to apply for public housing before you become homeless and
destitute.

  Since societal features such as the number of people living on low income and
lack of
  services are the greatest influences upon the heart health of the population,
three
  questions must be asked.

  Why is it that the Canadian media and health institutions are so neglectful of
 these
  influences?

  What will it take to shift attention to the societal factors that either
support heart health
  or lead to heart disease?

  Are we prepared to live with the consequences of subjecting so many Canadians
to
  heart threatening living conditions?

  Dennis Raphael PhD, is an associate professor at the School of Health Policy
and
  Management at York University in Toronto. He is the author of "Inequality is
Bad for
  Our Hearts: Why Low Income and Social Exclusion Are Major Causes of Heart
  Disease in Canada," which is posted at http://www.yorku.ca/wellness/heart.pdf.