This is in the University of Toronto Bulletin's end forum (Monday). Available
on line at http://www.utoronto.ca in the News and/or U of T Bulletin Sections.
Unhealthy Times: A Primer on How to Make a Healthy Society Sick
Dennis Raphael, University of Toronto
In Hard Right Turn: The New Face of Neo-Conservatism in Canada,
political scientist Brooke Jeffrey argues that Premiers Ralph Klein and Mike
Harris and Alliance leader Stockwell Day all share a wish to move Canada
closer to economic and social policies implemented by the USA.
Many observers believe that the current Chretien Liberal government has
already accomplished this task in large part by stealth, particularly in the
areas of tax policy, social welfare program spending, and health policy.
Indeed, the Honourable Jean Chretien and his finance minister Paul Martin
have done more to dismantle Canada's social programs and create inequality
and poverty than Premiers Klein and Harris and Mr. Day ever dreamed of!
Conrad Black drops all subtlety and wants us to join the US right now! What
could Canadians expect from a population health perspective as we continue
to go down this path of Americanization of social and economic policy?
An increasing volume of policy and health research would suggest that
neo-liberal policies such as those being followed by Mr. Chretien and Mr.
Martin would create greater economic inequality among Canadians and that
this would translate into poorer population health. Poorer population health
would result since economic inequality creates poverty; weakens social
structures that support health such as social and community services; and
decreases social cohesion. In fact these findings are so consistent that the
British Medical Journal recently editorialized: "What matters in determining
mortality and health in a society is less the overall wealth of that society and
more how evenly wealth is distributed. The more equally wealth is
distributed the better the health of that society."
Much of the research that indicates that increasing economic inequality
leads to poor population health has been brought together in three key
volumes. The Society and Population Health Reader, Volume I: Income
Inequality and Health (NY, The New Pr ess, 1999) contains 40 articles with an
international and US emphasis. The Widening Gap: Health Inequalities and
Policy in Britain (Bristol UK, The Policy Press, 1999) describes the UK
situation, and Health and Wealth: How Social and Economic Factors Affect
Our Well-being (Toronto, Lorimer, 1999) overviews the Canadian scene. With
this as background, is there any evidence that the greater economic
inequality seen in the USA -- the policy model for an increasing number of
politicians of which Tom Long was the most outspoken -- is associated with
greater incidence of poverty and poor health?
Health Status of Americans
Despite spending a greater percentage of GDP (13.5%) on health care than
any other industrialized nation, the USA compares poorly in international
health status comparisons. Healthy policy experts G. Anderson and J.
Poullier have said that: "For nearly all available outcome
measures, the United States ranked near the bottom of the OECD countries in
1996, and the rate of improvement for most of the indicators has been slower
than the median OECD country." This data indicated that among the 29 OECD
nations, USA life expectancy ranked 19th for females and 22th for
males. The World Health Organization recently calculated "Healthy Life
Expectancy" among 139 nations and the USA placed 24th in these rankings.
The reasons given for this low ranking included the very poor health status of
native Americans, rural African Americans, and inner city poor. The
USA also has very high levels of cancers related to tobacco use, coronary
heart disease rate, and levels of violence, especially homicide, when
compared to other industrialized nations.
The US-based Fordham Institute for Innovation in Social Policy has for the
past 12 years reported overall USA and state scores on an Index of Social
Health that consists of 16 indicators of health and well-being. As documented
in the Social Health of the Nation, NY, Oxford,1999, overall scores on the
Index have been declining in the United States since the mid 1970s even as
GDP has increased. From 1970-1996, indicators worsened for child abuse,
child poverty, teenage suicide, number of health care uninsured, average
weekly wages, inequality, and violent crime. As Canadian public policy has
moved towards the US market, rather than western European social welfare
orientation, scores on this index have been declining for Canada as well (see
Brink & Zessman, 1997,
http://www.hrdc-drhc.gc.ca/stratpol/arb/publications/research/abr-97-9e.shtml.)
What is particularly illuminating are comparisons of USA social indicators
with other nations. For comparison purposes, I have included rankings of
Canada and Sweden. The following figures were culled from various
international sources. Outside of unemployment rates, the USA compares
very unfavourably to other industrialized nations.
USA, Canada, and Sweden Rankings on Compared to Other Industrialized
Nations
(Ranking, 1 is best)
Measure USA Canada Sweden
Income Inequality (1990) 18 of 18 11 3
Child Poverty (1990) 17 of 17 14 2
Infant Mortality (1996) 24 of 29 17 2
Youth Suicide (1992-1995) 15 of 22 16 10
High School Drop-Outs (1996) 17 of 17 16 10
Youth Homicide (1992-1995) 22 of 22 19 5
Wages (1996) 13 of 23 15 6
Unemployment (1996) 2 of 10 7 8
Elderly Poverty (1990) 15 of 17 4 5
Life Expectancy (1996) 20 of 29 4 3
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It should be noted that while Canada's rate of youth homicide ranking is close
to that of the USA, the actual figures are 43/100,000 for the USA and
5/100,000 for Canada -- the closest nation to the USA is Northern Ireland with
a rate of 22/100,000. Older Canadians considering supporting the Alliance
should take note of the rankings on elderly living in poverty.
In addition to having the greatest incidence of child poverty, the USA
spends a smaller percentage of GDP on social services and supports than
most OECD nations. International health analyst T. Smeeding notes:
"American low income families are at a distinct disadvantage compared
with similarly situated families in other nations."
Current Trends
It has been increasingly argued that economic inequality is the key factor
driving many of the health-related effects seen in highly unequal nations. The
USA has witnessed an unprecedented increase in income and wealth
inequality in the past two decades. Former Secretary of Labor, Robert
Reich observes: "Almost two decades ago, inequality of income, wealth, and
opportunity in the United States began to widen, and today the gap is greater
than at any time in living memory. All the rungs on the economic ladder are
farther apart than they were a generation ago and the space between them
continues to spread." A recent report concluded: "More U.S. children are in
deep poverty than in the two comparison nations [of Canada and the UK]... the
income disparities between the rich and poor and near poor are much larger
in the United States than in Canada or the United Kingdom."
Indeed, a recent study in the British Medical Journal found that Canadian
mortality rates as of 1991 were very much lower than those in the USA as
was degree of economic inequality. There is a striking graphic in the article
that shows how all the Canadian provinces are bunched in a circle of low
mortality and greater income equality (Ross, N., Wolfson, M. C., Dunn, J. R.,
Berthelot, J. M., Kaplan, G. A., and Lynch, J. W. "Income Inequality and
Mortality in Canada and the United States." Br. Med. J. 320 (2000): 898-902.
The article is on-line at www.bmj.com and every University of
Toronto community member -- especially my colleagues at the Faculty of
Medicine -- should have a look at it!
But that was in 1991; the most recent Canadian figures indicate that by
1998, Canadian income inequality continued an increase that began in 1994.
Bruce Little of the Globe and Mail concludes: "Market forces are the main
reason for less income equality in 1998 than in 1994. But there's little
question that changing government policies after 1994 played a role as well."
All of these trends have led one US observer, Peter Montague, editor of
Rachel's Environment & Health Weekly to comment:
"In the U.S., government policies of the past 20 years have promoted,
encouraged and celebrated inequality. These are choices that we, as a
society, have made. Now one half of our society is afraid of the other half,
and the gap between us is expanding. Our health is not the only thing in
danger. They that sow the wind shall reap the whirlwind."
Few social or policy analysts - left or right - dispute the view that many
new right and neo-liberal proposals such as the flat income tax would serve
to further increase economic inequality. Considering the accumulating
literature concerning the health effects of such policy changes, Canadians at
all levels of income and wealth need to ask: Is this the future we want?
Dennis Raphael is an associate professor of public health sciences at the
University of Toronto (email:[log in to unmask]). Much of this material
first appeared in the October, 2000 issue of Policy Options published by the
Institute for Research on Public Policy. A further analysis of the health
effects of public policy is contained in his chapter From Increasing Poverty to
Societal Disintegration: How Economic Inequality Affects the Health of
Individuals and Communities which will appear shortly in Unhealthy Times:
the Political Economy of Health and Health Care in Canada (Toronto: Oxford
University Press, H. Armstrong, P. Armstrong, & D. Coburn, editors).
Our Web Sites have information and reports from all of our Quality of Life
Projects!
http://www.utoronto.ca/qol http://www.utoronto.ca/seniors
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In the early hours I read in the paper of epoch-making projects
On the part of pope and sovereigns, bankers and oil barons.
With my other eye I watch
The pot with the water for my tea
The way it clouds and starts to bubble and clears again
And overflowing the pot quenches the fire.
-- Bertolt Brecht
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Dennis Raphael, Ph.D.
Associate Professor
Department of Public Health Sciences
Graduate Department of Community Health
University of Toronto
McMurrich Building, Room 308
Toronto, Ontario, CANADA M5S 1A8
voice: (416) 978-7567
fax: (416) 978-2087
e-mail: [log in to unmask]
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