From Poverty to Societal Disintegration:
How Economic Inequality Affects the Health of All Canadians

        For most Canadians real income decreased during the 1990's, and by 1996
the level of child poverty had begun to set ever-increasing records. At the
same time the rich were getting richer, the cause of which is obvious to
Peter Montague, the editor of Rachel's Environmental Newsletter:  "The
growing gap between rich and poor has not been ordained by extraterrestrial
beings.  It has been created by the policies of governments."  While the
extent of increasing economic inequality in Canada has been documented in
reports such as The Growing Gap by the Centre for Social Justice, there has
been little public discussion of the health effects of economic inequality.
This is surprising since prestigious publications such as the British
Medical Journal have stated: "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." Economic inequality may be the major
public health issue facing Canada and other Western nations. Why is this so?

Increasing Poverty
        Poverty is not good for children and other living things. The Canadian
Institute of Child Health's report The Health of Canada's Children
documented the profound variation between poor and non-poor children in
incidence of death and illness, accidents and injuries, mental health and
well-being, school achievement and drop-out, and family violence and child
abuse.
        Explanations for these effects include material deprivation associated
with poverty such as malnutrition, poor housing, and lack of clothing.
More important may be poverty's grinding effects that produce feelings of
hopelessness, lack of control, and depression, all processes that manifest
effects through biological pathways and lead to disease.  Health workers
tend to focus on the health impacts of poverty through programs to teach
skills and provide information and support to change individual lifestyles.
These programs say little about the economic conditions  that create health
problems. Sadly, recent poverty figures suggest that Canadian governments
seem to be working hard to increase, rather than decrease, poverty levels.

Inequality Affects Everybody, Not Just the Poor
        It now appears that economic inequality affects the health of the well-off
as well as the poor. For example, after 20 years of rapidly increasing
economic inequality, the most well-off in Britain now have higher heart
attack and child mortality rates than the least well-off in Sweden. Other
data indicate that societies with less inequality have lower death rates --
even controlling for absolute level of economic resources. This is also so
in USA communities: more economic inequality is associated with greater
death rates – among the well off as well as the poor.
        In Unhealthy Societies: the Afflictions of Inequality,  Richard Wilkinson
shows that societies with greater economic inequality begin to
"disintegrate" --  that is, they show evidence of decreased social cohesion
and increased individual malaise. These are all precursors of  increased
illness and death. To illustrate, the well-off increasingly opt out of the
public discourse. They send their children to private schools, lobby for
two-tiered medical systems, hire security guards for their property; all of
which heightens societal disintegration. In Canada, the well-off grow
wealthier, but become subject to the same threats that the less-well off
experience -- deteriorating health and educational systems, increased crime
and violence, and greater danger on the roads -- among others. All of which
is associated with a lack of personal control; an important predictor of
illness and death.
        Another means by which economic inequality affects Canadian society is
through the tax base.  Societies with greater economic inequality and
poverty have lower tax rates that favour the rich.  In Ontario for example,
income tax breaks to the well-off lead to reduced services to the most
vulnerable.  The result is less social cohesion, greater differences in
health and well-being, and increased evidence of societal disintegration
such as poverty and homelessness.

Societal and Public Health Responses
        Canadians need to become more aware of the effects of increasing economic
inequality. Currently, there is no one societal institution that monitors
the health effects of government policies such as the ones creating
economic inequality.  Possible candidates for such a role are municipal,
provincial and federal public health units.  Acting as a kind of health
ombudsperson, these units could advise governments and institutions on
policies and actions that will enhance the health of the citizenry.  They
could assure that government and institutional actions are assessed for
their impacts on the health of the citizenry. That Canadians tolerate
poverty is shameful.  That Canadians tolerate increasing economic
inequality is hazardous to their health. Ask not for whom the economic
inequality bell tolls, it tolls for thee.

Dennis Raphael is an associate professor of Public Health Sciences at the
University of Toronto, e-mail: [log in to unmask] This column is
adapted from "Public Health Responses to Health Inequalities" published in
the Canadian Journal of Public Health, Nov/Dec, 1998. Much of the
literature on inequality and health can be accessed at
http://weber.u.washington.edu/~eqhlth/




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   Canalising a river
   Grafting a fruit tree
   Educating a person
   Transforming a state
   These are instances of fruitful criticism
   And at the same time instances of art.
       -Bertolt Brecht
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Dennis Raphael, Ph.D.
Associate Professor and Associate Director,
Masters of Health Science Program in Health Promotion
Department of Public Health Sciences
Graduate Department of Community Health
University of Toronto
McMurrich Building, Room 101
Toronto, Ontario, CANADA M5S 1A8
voice:    (416) 978-7567
fax: (416) 978-2087
e-mail:   [log in to unmask]