Public Health Responses to Health Inequalities
Presentation Made September 18, 1997 at the University of Toronto
(www.utoronto.ca/chl5003/raphael.html)
Overview
The issue before us is public health responses to health inequalities. I see a
clear role for public
health to not only respond to health inequalities but to work to address their
causes. I hope that you
will agree with my analysis.
Definition of Public Health
I begin with an uncontentious definition of public health from the Institute of
Public Health,
University Forvie Site, Cambridge, England.
"Public health is the science and art of preventing disease, prolonging life and
promoting health through organized efforts of society."
I add the phrase "of the population" so that it now reads:
"Public health is the science and art of preventing disease, prolonging life and
promoting
the health of the population through organized efforts of society."
The Indisputable Existence of Health Inequalities
There is now uncontested evidence that health inequalities exist both among
and within
populations. In the United Kingdom these findings were brought together in the
Black and the Health
Divide reports (Townsend, Davidson, & Whitehead, 1992). In Canada, the
Health of Canada's
Children Report (CICH, 1994) shows the profound variation in health and
well-being between poor
and not-poor children. Wilkins, Adams, & Brancker (1989) conservatively
attribute 22% of
mortality differences among members of differing neighbourhoods to income
differences. In the
USA, studies find that states with higher inequalities in income distribution show
greater rates of
violence and homicide, alcohol-related deaths, traffic accidents, and deaths
from "other injuries"
among citizens, even after controls for race and median level of income are
applied (Kaplan, et al.,
1996).
How general are these effects? These health inequalities are pervasive. Clear
evidence exists that
inequalities -- related to socioeconomic status -- exist in relation to a) statistics
of mortality and
morbidity; b) accidents and injuries; c) risk behaviours; d) indicators of mental
health and well-being; e) school achievement and drop-out; and f) family violence
and child abuse.
Explanation and Focus
Initially, analyses have focused upon the role of poverty with a number of
explanations advanced
to identify the causes of differences among the poor and not poor. These
explanations fall into four
types: artifactual; life-style; materialist; and psychosocial (Townsend et al,
1992.)
Artifactual arguments see the income level and health status relationship as
reflecting faulty data
definition and collection or due to poor health causing lower income. These
arguments can be easily
dismissed as many analyses have indicated that inequalities do not result from
poor health but rather
are precursors to it. Life-style arguments are more persuasive but a) cannot
account for most of the
variance in health outcomes among groups (Rose & Marmot, 1981); and b) do
not consider the
structural conditions under which lifestyle differences emerge (Seedhouse,
1996).
Materialist arguments may be especially relevant when we focus on the effects
of poverty.
Clearly, conditions of poor housing, sanitation, and poor diet, resulting from lack
of income can and
do contribute to poor health. When combined with psychosocial explanations
related to how poor
individuals experience feelings of uncertainty, lack of control, and low status,
materialist arguments
shed much light on the effects of poverty and economic inequality among
members of the population.
A focus on poverty and related analyses are attractive to many policy makers,
both governmental
and non-governmental, as the problem at hand is focused on the needs of
designated "risk groups."
Potential solutions are also straightforward: develop programs and allocate
resources to reach these
risk groups. The programs can be clinically oriented, that is teach skills, or
provide educational
programs to change faulty life styles. They can even involve providing home
visits, nutritional
supplements, or any other resource that the risk group is seen as lacking.
Recent approaches involve
community-based programs that include components that can empower risk
group individuals.
These approaches share an assumption that a portion of the population is
lacking a resource, be it an
attitude, skill, lifestyle, or community support that can be addressed through
enlightened public
health activities.
More recent analyses challenge the "risk group" metaphor on a number of
levels. First, an
increasing amount of research shows that inequalities in health exist across the
socioeconomic
gradients not just between the poor and not poor. Perhaps more important, they
see the means by
which these socioeconomic gradients in health come about as involving the
basic structure and
function of a society -- and how the population responds to these structures and
functions -- not
simply that this group or that group is lacking a resource that can be remedied
with a new program or
health initiative.
This insight is not new to community and public health workers. Labonte
(1992), in his survey
of community health responses to health inequalities found that health workers,
as well as community
members, are well aware that health inequalities are related to the presence of
economic resources
and related societal issues such as homelessness and unemployment. Yet, for
a number of reasons,
community health responses are frequently limited to lifestyle analyses and
programs.
Emerging Conceptions of Health Inequalities
Richard Wilkinson and others have been bringing together work from a number
of disciplines to
make the case that economic inequality, that is, how economic resources are
allocated within a
society, are the major causes of inequalities in health -- however defined. The
effects of inequality
manifest themselves through the mechanisms of decreasing social cohesion
which is then translated
into increased malaise among members of a society. This malaise shows itself
in many forms among
the population including mortality and morbidity, and other indicators of poor
health.
The epidemiological literature clearly shows that economic inequality as
defined through either
the Robin Hood or Gini indices, measures developed to display the degree of
economic inequality
within a society, or simply census tract income levels, is related to increased
mortality and morbidity.
To understand these effects it is necessary to draw upon work in a number of
areas. Psychosocial
approaches such as those of Wallerstein (1992) provide insights into how
relative position in a
society and wide economic inequality are perceived by and affect individuals.
Societal cohesion
theories such as those of Robert Putnam (1993) provide a broader context for
understanding how
social cohesion results from the presence of specific societal structures, that
themselves are related to
economic inequality. Further parts of the puzzle can be provided by economic
analyses such as those
of Linda McQuaig (1993; 1995) who traces the forces responsible for increasing
economic
inequality. Finally, political analyses such as those by James Laxer (1996)
suggest these phenomena
result from increasing globalization and imposition of a neo-conservative
political agenda. As stated
in one recent publication "The growing gap between rich and poor has not been
ordained by
extraterrestrial beings. It has been created by the policies of governments"
(Montague, 1996).
What all of these analyses suggest is that increased economic inequality not
only affects those on
the bottom of the ladder but affects everyone, including those at the top. As a
society begins to
deteriorate, a result of increasing polarisation and alienation, there is
increasing lack of civility, decay
in civil commitment and increased evidence of poor health. These may take the
form of greater
violence, increased risk behaviour, and increased crime. The rich begin to 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 and homes thereby heightening the move
toward disintegration. To
make all this concrete, the well-off on the Eastside of Manhattan and Rosedale
may grow richer, but
they begin to become subject to the same threats on the streets and in their
neighbourhood that the
less-well off experience.
Public Health Responses
Where does this leave us in terms of public health's roles? Public health
responses typically
involve either medical, behavioural, or socio-environmental approaches. In the
medical approach we
have the emphasis on high risk groups, screening of one sort or another, and
emphasis upon health
care delivery.
In the behavioural approach we also have high risk groups, as well as
community and policy
emphases. There is a belief that programs can be developed to educate,
support, enlighten, shift, etc.
individuals in how they behave. In the population approach we can aim at the
entire population in
order to shift the curve. Policies can be developed to support these shifts.
None of these approaches
question the basic assumptions by which a society is structured or functions.
In the socio-environmental approach, we can integrate all of the proceeding
plus a focus on high
risk conditions rather than high risk populations. If we accept this focus with the
added proviso that a
society that tolerates high levels of economic inequality is a high-risk society,
we end up with a
modest proposal for the role that public health can play in the future. A
Modest Proposal for a New Public Health
It is my argument that public health should concentrate on the 3 P's:
participation, policy, and
political action. These 3P's did not originate with me, but were developed by
staff at the Toronto
Public Health Department. The following analysis, while drawing upon the
model provided by
Toronto Public Health, is my own. The 3P's were a response to the traditional
focus of public health.
That is, the 3R's: rats, rabies, and rubella. I consider each P in turn.
Participation
A multitude of research on healthy neighbourhoods clearly shows that
neighbourhood cohesion
and involvement is a determinant of community and personal well-being. Also,
cohesion and
participation are clearly indicated as a determinant of health in health promotion
theory. More
recently, Putnam's (1993) study on civil society in Italy and work summarized
by Wilkinson have
provided empirical validation of its role in promoting health and well-being.
Public health has an important role in supporting community development and
community
participation. In the City of Toronto and elsewhere public health has worked
closely with community
organizations and members to promote health. Public health is richly resourced
as compared to
community health centres, recreation centres, and the many smaller community
agencies that exist
within Ontario communities. Public health can be a source of information, serve
a coordinating
function, and when necessary, act as an advocate when the agencies that are
so important to
community cohesion and participation, are threatened by faulty and ill-thought
out government
policies and initiatives.
Policy
Governments and other authorities make decisions. Many of these decisions
surely have the
potential to affect the health of the population or particular populations within a
society. If we define
policy as "a principle or course of action chosen to guide decision-making"
(Webster, 1990) surely
public health has a responsibility to develop and advise on policies that will
promote health and
potentially reduce health inequalities.
Some of these policies are straightforward and clearly relate to "lifestyle"
aspects. These would
include smoking regulations and by-laws, emission controls, and mandating of
physical activity in
the schools. But there is a whole range of research and theory that suggests
many broader policies
that are relevant to the health of the population. The Ottawa Charter for Health
Promotion (WHO,
1986) includes shelter, education, food, and income, as basic prerequisites for
health. Seedhouse
(1996) sees the foundations of health as consisting of the meeting of basic
needs of housing,
nutrition, employment, and support through the provision of information and
education, and the
promotion of civic-mindedness.
Some public health authorities speak out and act on these issues. For
example, the cities of
Toronto and Birmingham have in place fair hiring policies. These and other
authorities have taken
positions on the importance of city services, daycare, and supports to those in
the community who
must support ill or disabled relatives. Whether action is taken on all the issues
that are raised by
public health workers is another matter, yet the voice is there.
Another especially relevant and timely issue area concerns maintenance of the
social safety net as
usually defined. A recent analysis indicates that the presence of a social safety
net can help those who
are at most health risk in a society (Bartley, Blane, & Montgomery, 1997). In
other words the
presence of a strong net can help reduce health inequalities. I have only
scratched the surface of how
public policy can affect the health of a population. Surely, such analyses are
relevant in present-day
Ontario.
Political Action
By political action I do not mean endorsing this party or that party. What I
mean is acting on the
recognition that the "the policies, activities, and methods of a government," that
is politics (Webster,
1990) , can have effects on the health of the population of a specific community,
municipality, or
country.
In this role public health acts as an ombudsman responsible for carrying out
and making public
"health impact analyses" of various government policies. I will mention a few
examples of recent
provincial policies that cry out for such health impact analyses. These include
the freezing of social
housing construction, institution of the drug co-payment plans for seniors, the
22% cut in welfare
payments combined with the cuts to income taxes, the attempt, since overturned
by the courts, to
eliminate pay equity settlements to women who work in female dominated
service agencies, and the
proposed legislation that will allow for privatization of water services in the
province.
At the municipal level, such health impact analyses could assess the effects of
the institution of
user fees for libraries, recreation and park services, and increases in public
transportation fares. It
could also concern itself with policies related to work and well-being, a clear
determinant of health
among the population. Such a role seems especially important as cities
amalgamate and rethink their
services.
Lest you think that such an approach is impractical or pie-in-the sky -- I would
point out the City
of Toronto Board of Public Health has been the voice in the wilderness the past
few years speaking
out about the health effects of many provincial policies. These include the
welfare cuts, the
inadequacies of the "welfare diet" advanced by a social services minister, and
the potential effects of
instituting user fees for city services. In its report on "Health and Work"
released last week the Board
of Health urged (Hepburn, 1997):
The new city of Toronto model leadership in enlightened government and
healthy work by
considering all new city policies in light of their impact on the health of
workers living in
the city or employed by the city.
This is only one of 17 recommendations that address issues related to health
and well-being.
Another relevant recommendation reads as follows:
That the government of Ontario mandate and resource health units across
Ontario, in the
context of health promotion and advocacy programs, a) to identify
employment-related
health issues among the population they serve, and b) to address the
issues identified for
the purpose of improving individual, community, and social health.
In response to the argument that governments of the day will not allow
public health to play a
3Ps role, it has happened in the City of Toronto and elsewhere. Additionally,
most provinces have an
ombudsman who plays such a role in regards to government services and
actions. In Ontario:
"Ombudsman Ontario will strive to ensure that people are served justly,
equitably, and fairly by
Ontario governmental organizations." What would the public health
ombudmans role be?
Conclusion: The Role of Public Health
It is my argument that the people of Ontario have a right to have provincial,
municipal and local
institutions that will:
Assure that government and institutional actions are assessed for their
impacts on the
health of the citizenry (political action);
Advise governments and institutions on policies and actions that will enhance
the health
of the citizenry (policy);
Support communities and work to enhance community participation and
cohesion
(participation).
This should be the mandate of Public Health.
References
Bartley, M., Blane, D., & Montgomery, S. (1997). Health and
the life course: why safety nets
matter. British Medical Journal, 314, 1194-1196.
Canadian Institute on Children's Health (1994). The health of Canada's
children: A CICH
profile. Ottawa: Canadian Institute of Child Health.
Hepburn, V. (1997). Report of the task force on health and work. Toronto:
Board of Health.
Kaplan, G. A., Pamuk, E., Lynch, J.W., Cohen, R. D., & Balfour, J. L. (1996).
Income
inequality and mortality in the United States. British Medical Journal, 312,
999-1003.
Labonte, R. (1992). Community health responses to health inequalities. North
York: North
York Community health Promotion research Unit,
Laxer, R. (1996). In search of a new left: Canadian politics after the
neoconservative assault.
Toronto: Penguin.
McQuaig, L. (1993). The wealthy banker's wife: the assault on equality in
Canada. Toronto:
Penguin.
McQuaig, L (1995). Shooting the hippo: death by deficit and other Canadian
myths. Toronto:
Viking.
Montague, P. (1996). Economic inequality and health. Rachel's Environment &
Health
Weekly #497. Annalpolis, IN: Environmental Research Foundation.
Ombudsman Ontario (1997). Annual report. Toronto: Author.
Putnam, R. (1993). Making democracy work: civic traditions in modern Italy.
Princeton:
Princeton University press.
Rose, G. & Marmot, (1981). Social class and coronary heart disease. British
Heart Journal, 1,
13-19.
Seedhouse, D. (1996). Health promotion: philosophy, prejudice, and practice.
New York:
Wiley.
Townsend, P., Davidson, N., & Whitehead, M.: (Eds) (1992). Inequalities in
health: the Black
report and the Health divide. New York: Penguin.
Wallerstein, N. (1992). Powerlessness, empowerment, and health: Implications
for health
promotion programs. American Journal of Health Promotion, 6 (3), 197-205.
Webster, N. (1990). New college dictionary. Chicago: Consolidated Books.
Wilkins, R., Adams, O., & Brancker, A. (1989). Changes in mortality by income
in urban
Canada from 1971 to 1986. Health Reports, 1 (2), 137-174.
Wilkinson, R. (1996). Unhealthy societies: the afflictions of inequality. NY:
Routledge.
World Health Organization (1986). Ottawa charter on health promotion.
Geneva: Author.
Table of Contents
Overview. . . . . . . . . . . . . . . . . . . . . . 1
Definition of Public Health . . . . . . . . . . . . 1
The Indisputable Existence of Health Inequalities . 1
Explanation and Focus . . . . . . . . . . . . . . . 1
Emerging Conceptions of Health Inequalities . . . . 2
Public Health Responses . . . . . . . . . . . . . . 3
A Modest Proposal for a New Public Health . . . . . 4
Participation . . . . . . . . . . . . . . . . . . . 4
Policy. . . . . . . . . . . . . . . . . . . . . . . 4
Political Action. . . . . . . . . . . . . . . . . . 5
Conclusion: The Role of Public Health . . . . . . . 6
References. . . . . . . . . . . . . . . . . . . . . 7
***************************************************
From new transmitters came the old stupidities.
Wisdom was passed on from mouth to mouth.
-Bertolt Brecht
***************************************************
Dennis Raphael, Ph.D.
Associate Professor and Acting 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]
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