In a letter to the Medical Reform Group, the City now indicates that the
dietary supplement form can be completed by a physician, nurse
practitioner, certified midwife or dietitian.  Below are the comments for a
press conference I prepared that has now been cancelled. The refs may be of
value- dr
------------------------------
     Comments by Dr. Dennis Raphael of the School of Health Policy and
    Management at York University on the Issue of Providing the Dietary
    Supplement for those on Social Assistance in Ontario, July 26, 2005

                               Introduction
I am going to place the issue of the nutrition supplement for persons on
social assistance within the context of what we know about keeping people
healthy and the living situation of those on social assistance in Ontario.
This is a public policy issue that profoundly affects the health of those
most vulnerable to disease and illness.

The actions of City of Toronto officials in making receipt of the
supplement more difficult contradicts their professed commitment to the
maintaining health of its citizens.  It also conflicts with four decades of
federal, provincial, and municipal public policy statements on the
determinants of health and the importance of promoting health. Their
actions violate numerous international covenants on human rights to which
Canada is a signatory.[1, 2]

                            Poverty and Health
It is documented that the primary factor that determine whether people are
able to maintain health and avoid illness is the amount of income available
to them.[3]  Income is important because it provides the conditions under
which people can participate in the activities normally expected within a
society.[4] In nations such as Canada, this involves having an adequate
diet, decent housing, and being involved in social, cultural, and
recreational activities expected by those living in an advanced
industrialized society.[5]

Failure to achieve adequate living conditions such as diet and shelter are
primary threats to health, a point repeatedly emphasized by the World
Health Organization [6, 7], Health Canada [8, 9], and the Canadian Public
Health Association [10, 11]. It is well documented that social assistance
rates made available to Canadians in general, and Ontarians in particular,
are not adequate to maintain health.[12, 13].

Looking at nutrition – which we are constantly reminded by public health
and other government spokespersons is an essential determinant of health –
University of Toronto researchers report in the Canadian Journal of Public
Health that the resources provided through social assistance are not
adequate to maintain health in general and a healthy diet in
particular.[14]  It should not be surprising these researchers also report
in this same journal that people living on social assistance report
profoundly poorer health than those not living under such conditions.[15]

Why should this be the case?  A series of documents and policy statements
from Health Canada [16, 17]  and the Canadian Public Health Association
[18, 19] and empirical research from Statistics Canada [20, 21] explains
living conditions associated with being on social assistance in Ontario are
related to a wide range of diseases and illnesses that include heart
disease, type II diabetes, respiratory diseases, and cancers, among
others.[22-24] And children’s health is especially susceptible to living
under conditions of deprivation.[25] Health Canada states:

      In the case of poverty, unemployment, stress, and violence, the
      influence on health is direct, negative and often shocking for a
      country as wealthy and as highly regarded as Canada.[16], p. 3

Health science now accepts that people who live under conditions associated
with social assistance are much more likely to experience material
deprivation --  including poor diets -- which influence health.[3, 26-30]
These same people also experience profoundly higher levels of daily stress
and anxiety which is also a primary determinant of poor health.[31-33] The
World Health organization states:

      Poor conditions lead to poorer health.  An unhealthy material
      environment and unhealthy behaviour have direct harmful effects, but
      the worries and insecurities of daily life and the lack of supportive
      environments also have an influence.[34]

                 Government Statements on Health Promotion
Where do our governments stand on issues of maintaining health?  The
federal government has been churning out documents on “health promotion”
and “population health” since 1974. [35-37] These documents recognize that
the primary determinants of health are living conditions.  And first among
these determinants is income and social status.  Premier Dalton McGuinty
has signaled his commitment to promoting health by establishing a Ministry
of Health Promotion.

Municipally, Toronto’s Board of Health and City Council have endorsed the
Toronto Charter on the Social Determinants of Health which recognizes that
that social assistance payments in Canada, including Ontario, fall well
below what is needed to maintain health in general and a healthy diet in
particular.[38]

      The growing vulnerability of lower-income Canadians threatens early
      childhood, education, food security, housing, social inclusion, and
      ultimately, health. Low-income Canadians are twice as likely to
      report poor health as compared to high-income Canadians [39].

This is not Rocket Science.  While Toronto Medical Officer of Health, the
current Provincial Medical Officer of Health Dr. Sheela Basrur stated:

      In Toronto today, social and economic inequities must be reduced by
      supporting those most in need while protecting the health of the
      population as a whole. We can only make a difference in the overall
      health of all our citizens if we also make gains in those communities
      where health outcomes are likely to be much worse (State of the
      City’s Health, January 22, 2001).

Those living under conditions associated with social assistance rates
cannot be healthy.  The research clearly demonstrates this.  Making
available the dietary supplement to all those who require it would be a
small beginning in responding to the health crisis that government policies
have created for those living on social assistance.  Such action would
immediately improve the health of those receiving the supplement. Such
action would also improve the quality of life for all of us. The Medical
officer of health for Montreal states:

      Inequalities in health and well-being can be traced back to
      socioeconomic inequalities, that is to the harsh living conditions
      which marginalize so many of our fellow citizens, not only limiting
      their access to essential goods, but depriving them as well of any
      meaningful role in social life.[40], p. 60

What better way for the City of Toronto and the Province of Ontario to
demonstrate its commitment to health promotion than to allow those unable
to afford a decent and healthy diet to begin doing so? Why is this being
resisted?

Dennis Raphael is an associate professor of Health Policy and Management at
York University.  He is editor of Social Determinants of Health: Canadian
Perspectives, published by Canadian Scholars’ Press.

                                References
[1] United Nations. Universal Declaration of Human Rights. New York: United
Nations; 1948.
[2] United Nations. Commitments of the U.N. World Summit on Social
Development. Copenhagen: United Nations; 1995.
[3] Raphael D, editor. Social Determinants of Health: Canadian
Perspectives. Toronto: Canadian Scholars Press; 2004.
[4] Townsend P. The International Analysis of Poverty. Milton Keynes:
Harvester Wheatsheaf; 1993.
[5] Galabuzi GE. Social exclusion. In Raphael D, editor. Social
determinants of health: Canadian perspectives. Toronto: Canadian Scholars
Press.; 2004.
[6] World Health Organization. Ottawa Charter for Health Promotion. Geneva,
Switzerland: World Health Organization  European Office; 1986.
[7] World Health Organization. Belfast Declaration. Copenhagen: World
Health Organization; 2003.
[8] Health Canada. Taking Action on Population Health:  A Position Paper
for Health Promotion and Programs Branch Staff. Ottawa: Health Canada;
1998.
[9] Health Canada. Healthy Development of Children and Youth: the role of
the determinants of health. Health Canada; 1999.
[10] Canadian Public Health Association. Reducing poverty and its negative
effects on health: resolution passed at the 2000 CPHA Annual Meeting.
Canadian Public Health Association; 2000.
[11] Canadian Public Health Association. Inequities in Health. Ottawa,
Canada: Canadian Public Health Association (CPHA); 1993.
[12] National Council of Welfare. Poverty Profile 2001. Ottawa: National
Council of Welfare; 2004.
[13] National Council of Welfare. Income for Living. Ottawa: National
Council of Welfare; 2004.
[14] Vozoris N, Davis B, Tarasuk V. The affordability of a nutritious diet
for households on welfare in Toronto. Canadian Journal of Public Health
2002;93(1):36-40.
[15] Vozoris N, Tarasuk V. The health of Canadians on welfare. Canadian
Journal of Public Health 2004;95:115-120.
[16] Health Canada. Statistical Report on the Health of Canadians. Health
Canada, Statistics Canada, Canadian Institute for Health Information; 1999.
[17] Health Canada. Population Health Approach. Ottawa: Health Canada;
2004.
[18] Canadian Public Health Association. Health Impacts of Social and
Economic Conditions: Implications for Public Policy. Ottawa, Canada:
Canadian Public Health Association; 1997.
[19] Canadian Public Health Association. Action Statement for Health
Promotion in Canada. Ottawa: Canadian Public Health Association; 1996.
[20] Wilkins R, Berthelot J-M, Ng E. Trends in mortality by neighbourhood
income in urban Canada from 1971 to 1996. Health Reports (Stats Can)
2002;13(Supplement):1-28.
[21] Wilkins R, Houle C, Berthelot J-M, Ross DP. The Changing Health Status
of Canada's Children. ISUMA 2000;1(2):57-63.
[22] Raphael D. Addressing health inequalities in Canada. Leadership in
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[23] Raphael D, Anstice S, Raine K. The social determinants of the
incidence and management of Type 2 Diabetes Mellitus: Are we prepared to
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[24] Raphael D, Farrell ES. Beyond medicine and lifestyle: addressing the
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[25] Canadian Institute on Children's Health. The Health of Canada's
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Children's Health (CICH); 2000. Report No.: ISBN 0-919747-56-6.
[26] Benzeval M, Judge K, Whitehead M. Tackling Inequalities in Health: An
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[27] Acheson D. Independent inquiry into inequalities in health. London:
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[28] Davey Smith G, editor. Inequalities in health: Life course
perspectives. Bristol UK: Policy Press; 2003.
[29] Marmot M, Wilkinson R. Social Determinants of Health. Oxford, UK:
Oxford University Press; 2000.
[30] Thomson C, Hole D, Twelves C, Brewster D, Black R. Prognostic Factors
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[31] Brunner E, Marmot MG. Social organization, stress, and health. In
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[32] Lupien S, King E, Meaney M, McEwan B. Can Poverty get under your Skin?
Basal Cortisol Levels and Cognitive Function in Children from Low and High
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[33] Raphael D. When social policy is health policy: why increasing poverty
and low income threatens Canadians' health and health care system. Canadian
Review of Social Policy 2003;51:9-28.
[34] Wilkinson R, Marmot M. Social Determinants of Health: The Solid Facts.
Copenhagan, Denmark: World Health Organization, European Office; 2003. p.
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[35] Lalonde M. A New Perspective on the Health of Canadians: A Working
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[36] Epp J. Achieving health for all: a framework for health promotion.
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[37] Health Canada. The Population Health Template: Key Elements and
Actions That Define A Population Health Approach. Strategic Policy
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[38] Raphael D, Bryant T, Curry-Stevens A. Toronto Charter outlines future
health policy directions for Canada and elsewhere. Health Promotion
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[39] Raphael D, Curry-Stevens A. Toronto charter for a healthy Canada.
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for Social Justice; 2003.
[40] Lessard R. Social Inequalities in Health: Annual Report of the Health
of the Population. Montreal: Direction de la sante publique; 1997.