SDOH-Listserv Bulletin No. 4, February 16, 2004
The Toronto Charter on the Social Determinants of Health
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On the first anniversary of the ratification of the Toronto Charter, it
seemed appropriate to provide the background to the Charter, the Charter
itself, and recent developments related to its development.
Comments, reflections, and stories of similar local experiences are
welcome.
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Toronto Charter Outlines Future Health Policy Directions for Canada
From November 29 to December 1, 2002 a conference of over 400
Canadian social and health policy experts, community representatives, and
health researchers met at York University in Toronto, Canada to consider
the state of ten key social or societal determinants of health across
Canada; explore the implications of these conditions for the health of
Canadians; and outline policy directions to improve the health of Canadians
by influencing the quality of these determinants of health. The conference
took place at a time when Canadian social and health policies were
undergoing profound changes related to shifting political, economic, and
social conditions (Bryant, 2002).
The conference was funded by the Policy Research Program of Health
Canada ? with support from the Canadian Institutes for Health Research --
in the tradition of Canadian government action on the determinants of
health. It brought together representatives from a wide range of sectors:
labour, childcare, food security, social development, anti-poverty,
housing, education, and many others.
Selecting the Social Determinants of Health to be Considered
The Ottawa Charter for Health Promotion identifies the prerequisites
for health as peace, shelter, education, food, income, a stable ecosystem,
sustainable resources, social justice and equity (World Health
Organization, 1986). These prerequisites of health are clearly concerned
with structural aspects of society and the organisation and distribution of
economic and social resources.
Health Canada outlines various determinants of health -- some of
which are social determinants -- of income and social status, social
support networks, education, employment and working conditions, physical
and social environments, biology and genetic endowment, personal health
practices and coping skills, healthy child development, and health services
(Health Canada, 1998). Within this framework, the specific concepts of
physical and social environments can be criticised for lacking grounding in
concrete experiences of peoples' lives and lacking policy relevance ? i.e.
there usually is no Ministry of Physical Environments or Ministry of Social
Environments.
A British working group charged with the specific task of
identifying social determinants of health named the social [class health]
gradient, stress, early life, social exclusion, work, unemployment, social
support, addiction, food, and transport (Wilkinson and Marmot, 2003). This
listing is more grounded in the everyday experience of people's lives and
policy-making structures and avoids the potential problem of policy
irrelevance. Indeed, the stimulus for this work was the European Office of
the World Health Organization wanting to raise these issues among
policymakers and the public.
The organizers of the 2002 York University Social Determinants of
Health Across the Life Span conference synthesized these formulations to
identify ten key social determinants of health especially relevant to
Canadians. Four criteria were used to identify these social determinants of
health (Raphael, 2004).
The 1st criterion was that the social determinant be consistent with
most existing formulations of the social determinants of health and
associated with an existing empirical literature as to its relevance to
health. All these social determinants of health are important to the health
of Canadians.
The 2nd criterion was that the social determinant of health be
consistent with lay/public understandings of the factors that influence
health and well-being. This was ascertained through assessment of available
empirical work on Canadians' understandings of what aspects of Canadian
life contribute to health and well-being. All these social determinants of
health are understandable to Canadians.
The 3rd criterion was that the social determinant of health be clearly
aligned with existing governmental structures and policy frameworks (e.g.
Ministries of Housing, Labour, Education, etc.) All these social
determinants of health have clear policy relevance to Canadian
decision-makers and citizens.
The 4th criterion was that the social determinant of health be an
area of either active governmental policy activity (e.g. health care
services, education) or policy inactivity that have provoked sustained
criticism (e.g. food security, housing, social safety net). All these
social determinants of health are especially timely and relevant. Ten
social determinants of health ? early life, education, employment and
working conditions, food security, health services, housing, income and
income distribution, social exclusion, the social safety net, and
unemployment and job insecurity were examined.
The inclusion of health services, housing and the social safety net as
social determinants of health is unusual. Health services are included in
the belief that a well-organized and rationalized health care system could
be an important social determinant of health ? if this is not currently the
case. Housing is normally included within another determinant (e.g.
physical environments or social exclusion) which is surprising considering
its centrality to human health and well-being. The social safety net is
increasingly recognized as an important determinant of the health of
populations but to date is not explicitly included in available
formulations.
The Toronto Charter
As a result of the conference, the Toronto Charter on the Social
Determinants of Health was developed. It drew upon initial feedback by
conference participants and was then ratified by conference participants.
The Toronto Board of Health and Toronto City Council have since endorsed
the Charter. It has also been endorsed by Ottawa City Council and the
Peterborough Board of Health. We hope that it will go before additional
municipal councils across Canada for endorsement. Conference presentations
are available in English and French (Centre for Social Justice, 2003) and
electronic versions of the Charter are available in English, French, and
Spanish (Raphael and Curry-Stevens, 2003). The conference served to
reintroduce the concept of the social determinants of health to Canadians
at a time of increasing influence of neo-liberal ideology in Canada and the
weakening of the welfare state (Coburn, 2001).
Health Canada is preparing summaries and policy implications of the
presentations, and four articles based on the Conference appeared in the
prestigious Canadian journal Policy Options (Institute for Research in
Public Policy, 2003). The book "Social Determinants of Health: Canadian
Perspectives" will contain contributions by most conference presenters
(Raphael, 2004).
Additional efforts are being made to bring this issue to public
attention and to influence the policy community. A public relations
campaign on the social determinants of health is being offered (Centre for
Social Justice, 2003). There is also a concerted policy effort on the part
of Health Canada and various civil society actors to raise and address a
variety of important social determinants of health. The cooperation of the
labour movement and other progressive societal sectors with university
researchers is an especially promising development.
This Charter itself has and will continue to be a tool for promoting
health and social justice, both within and outside of Canada. It can
provide a powerful impetus for social change, notably by municipal council
endorsement followed by political action. The contents of the Charter
should be especially relevant for health promoters in jurisdictions where
the social determinants of health are being weakened by short-sighted
governmental policymaking.
References
Bryant, T. (2002). The role of knowledge in public health and health
promotion policy change. Health Promotion International 17(1), 89-98.
Available at
http://quartz.atkinson.yorku.ca/QuickPlace/draphael/Main.nsf/h_Library/447035B86769627885256E3900033E00/?OpenDocument
Centre for Social Justice (2003). Social Determinants of Health
Across the Life-Span: Conference and Presentations. Toronto: Author. On
line at http://www.socialjustice.org .
Coburn, D. (2001). Health, health care, and neo-liberalism. In H.
Armstrong, P. Armstrong & D. Coburn (eds.), Unhealthy Times: The Political
Economy of Health and Care in Canada Toronto: Oxford University Press, pp.
45-65.
Health Canada (1998). Taking Action on Population Health: A Position
Paper for Health Promotion and Programs Branch Staff, Health Canada:
Ottawa, Canada. On-line at: http://www.hc-sc.gc.ca/hppb/phdd/pdf/tad_e.pdf
.
Kirby, M. J. (2002). The Health of Canadians: The Federal Role.
Ottawa: Standing Senate Committee on Social Affairs, Science and
Technology. On line at
http://www.parl.gc.ca/37/2/parlbus/commbus/senate/Com-e/SOCI-E/rep-e/repoct02vol6-e.htm
.
Institute for Research in Public Policy (2003). Policy Options,
Dossier, March 2003. On line at http://www.irpp.org/po/index.htm .
Raphael, D. (2003). When social policy is health policy: Why
increasing poverty and low income threatens Canadians' health and health
care system. Canadian Review of Social Policy, 51, 9-28. On line at
http://quartz.atkinson.yorku.ca/QuickPlace/draphael/Main.nsf/h_Library/BB1C486F21DAA6AF85256DA200601657/?OpenDocument
Raphael, D. & Curry-Stevens, A. (2003). The Toronto Charter for a
Healthy Canada. Toronto: York University School of Health Policy and
Management and the Centre for Social Justice. On line in English, French,
and Spanish at
http://quartz.atkinson.yorku.ca/QuickPlace/draphael/Main.nsf/h_Library/DD7BEC96FA3D0DAF85256CD9005F5534/?OpenDocument
Raphael, D. (ed.) (July, 2004). Social Determinants of Health:
Canadian Perspectives. Toronto: Canadian Scholars Press. Table of Contents
available at
http://quartz.atkinson.yorku.ca/QuickPlace/draphael/Main.nsf/h_Library/DF8B70136A04791A85256E390002F2F2/?OpenDocument
Wilkinson, R. and Marmot, M. (2003). Social Determinants of Health:
The Solid Facts. Copenhagen: World Health Organization European Office.
On-line at: Available at
http://www.who.dk/document/e81384.pdf
World Health Organization (1986). Ottawa Charter for Health Promotion
. Geneva: Author. On line at http://www.hc-sc.gc.ca/hppb/phdd/docs/charter/
Strengthening the Social Determinants of Health:
The Toronto Charter for a Healthy Canada
From November 29 to December 1, 2002 a conference of over 400 Canadian
social and health policy experts, community representatives, and health
researchers met at York University in Toronto, Canada to: a) consider the
state of ten key social or societal determinants of health across Canada;
b) explore the implications of these conditions for the health of
Canadians; and c) outline policy directions to improve the health of
Canadians by influencing the quality of these determinants of health. The
conference took place at a time when Canadian social and health policies
were undergoing profound changes related to shifting political, economic,
and social conditions.
Ten social determinants of health ? early life, education, employment and
working conditions, food security, health services, housing, income and
income distribution, social exclusion, the social safety net, and
unemployment and job insecurity were chosen on the basis of their
prominence in Health Canada and World Health Organization policy statements
and documents.
The conference was a response to accumulating evidence that growing social
and economic inequalities among Canadians are contributing to higher health
care costs and other social burdens. Indeed, the Kirby Report on the
Federal Role in Health Care points out that 75% of our health is determined
by physical, social, and economic environments. Evidence was also
accumulating that a high level of poverty ? an outcome of the growing gap
between rich and poor ? has profound societal effects as poor children are
at higher risk for health and learning problems in childhood, adolescence,
and later life, and are less likely to achieve their full potential as
contributors to Canadian society.
The Social Determinants of Health Across the Life-Span Conference coincided
with the release of the Romanow Report on the Future of Health Care in
Canada that called for strengthening the Canadian health care system by
expanding its coverage, resisting privatization, and increasing financial
investment. The report also discusses the importance of economic and social
determinants of health. The evidence heard at the conference reinforced
the view that immediate and long-term improvements in the health of
Canadians depend upon investments that address the sources of health and
disease.
The participants at the Social Determinants of Health Across the Life-Span
Conference therefore resolve:
Whereas the evidence is overwhelming that the health of Canadians is
profoundly affected by the social and economic determinants of health,
including ? but not restricted to ? early life, education, employment
and working conditions, food security, health care services, housing,
income and its distribution, social exclusion, the social safety net,
and unemployment and employment security; and
Whereas the evidence presented at the conference clearly indicates that
the state and quality of these key determinants of health are linked to
Canada's political, economic and social environments and that many
governments across Canada have not responded adequately to the growing
threats to the health of Canadians in general, and the most vulnerable
in particular; and
Whereas these social determinants of health are also human rights as
defined in the Universal Declaration of Human Rights and the
International Covenant on Economic, Social and Cultural Rights, which
Canada is obliged to protect and promote; and
Whereas the evidence presented indicates that investments in the basic
social determinants of health will profoundly improve the health of
Canadians most exposed to health threatening conditions ? the poor, the
marginalized, and those Canadians excluded from participation in aspects
of Canadian society by virtue of their living conditions ? therefore
providing health benefits for all Canadians; and
Whereas the evidence presented to us has indicated the following to be
the case:
1. Early childhood development is threatened by the lack of affordable
licensed childcare and continuing high levels of family poverty. It has
been demonstrated that licensed quality childcare improves developmental
and health outcomes of Canadian children in general, and children-at-risk
in particular. Yet, while a national childcare program has been promised,
90% of Canadian families with children lack access to such care.
2. Education as delivered through public education systems has helped to
make Canada a world leader in educational outcomes but our education
systems are now at risk due to funding instability and poorly developed
curriculum in many provinces. These conditions may weaken the trend toward
greater number of students graduating despite evidence that those who do so
show significantly better health and family functioning than non-graduates.
3. Employment and working conditions are deteriorating for some groups ?
especially young families ? with potential attendant health risks. One in
three adult jobs are now either peripheral or precarious as a result of
increasing contracting out of core jobs and privatization of public
employment. These jobs are often temporary, with low pay and high stress.
Precarious working situations are directly related to the weakening of
labour legislation in many jurisdictions. These changes threaten the gains
made by workers in the past, jeopardizing their health and well-being.
4. Food security among Canadians and their families is declining as a
result of policies that reduce income and other resources available to
low-income Canadians. In Canada, food insecurity exists among 10.2% of
Canadian households representing 3 million people. Monthly food bank use
is 747,665 or 2.4% of the total Canadian population, which is double the
1989 figure; 41% of the food bank users or 305,000 are children under the
age of 18.
5. Health care services can become a social determinant of health by
being reorganized to support health. Many examples of effective ? but
all-too-rarely implemented ? means of preventing deterioration among the
ill through chronic disease management and rehabilitation are available.
Screening that has been carefully assessed for its effectiveness can
support health. Preventing disease in the first place by promoting the
social and living conditions that support healthy lifestyles has also been
neglected. While the Romanow Report reaffirmed the principles of the Canada
Health Act, missing were strong statements about the important roles public
health, health promotion, and long-term care play in supporting health.
6. Housing shortages are creating a crisis of homelessness and housing
insecurity in Canada. Lack of affordable housing is weakening other social
determinants of health as many Canadians are spending more of their income
on shelter. More than 18% of Canadians live in unacceptable housing
situations and one in every five renter households spent 50% or more of
their income on housing in 1996, an increase of 43% since 1991.
7. Income and its equitable distribution have deteriorated during the
past decade. Despite a 7-year stretch of unprecedented economic growth,
almost half of Canadian families have seen little benefit as their wages
have stagnated. Governments at all levels have let the
after-tax-and-transfer income gap between rich and poor grow from 4.8:1 in
1989 to 5.3:1 in 2000. 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.
8. Social exclusion is becoming increasingly common among many
Canadians. Social exclusion is the process by which Canadians are denied
opportunities to participate in many aspects of cultural, economic, social,
and political life. It is especially prevalent among those who are poor,
Aboriginal people, New Canadians, and members of racialized ? or non-white
? groups. As our racialized composition grows, it is unacceptable that
these groups earn 30% less than whites and are twice as likely to be poor.
These trends contribute to social and political instability in our society.
9. Social safety nets are changing in character as a result of shifting
federal and provincial priorities. The 1990s have seen a weakening of these
nets that constitute threats to both the health and well-being of the
vulnerable. The social economy may provide opportunities for community
organizations to provide services in more democratic, transparent and
community-sensitive ways. It may be, however, unable to meet emerging needs
without further burdening caregivers in the community, many of whom are
women, or inadequately compensating them.
10. Unemployment continues at high levels and employment security is
weakening due to the growth of precarious, unstable, and non-advancing
jobs. Higher stress, increasing hours of work, and increasing numbers of
low-income jobs are the mechanisms that link employment insecurity and
unemployment to poor health outcomes. Unionized jobs are the most likely to
help avoid these health-threatening conditions.
11. Canadian women, Aboriginal people, Canadians of colour, and New
Canadians are especially vulnerable to the health-threatening effects of
these deteriorating conditions. This is most clear regarding income and
its distribution, employment and working conditions, housing affordability,
and the state of the social safety net.
It is therefore resolved that:
Governments at all levels should review their current economic, social, and
service policies to consider the impacts of their policies upon these
social determinants of health. Areas of special importance are the
provision of adequate income and social assistance levels, provision of
affordable housing, development of quality childcare arrangements, and
enforcement of anti-discrimination laws and human rights codes. It is also
important to increase support for the social infrastructure including
public education, social and health services, and improvement of job
security and working conditions;
Public health and health care associations and agencies should educate
their members and staff about the impacts of governmental decisions upon
the social determinants of health and advocate for the creation of positive
health promoting conditions. Particularly important is these associations
and agencies joining current debates about Canadian health and social
policy decisions and their impacts upon population health;
The media should begin to seriously cover the rapidly expanding findings
concerning the importance of the social determinants of health and their
impacts upon the health of Canadians. This would strike a balance between
the predominant coverage of health from a biomedical and lifestyle
perspective. It would also help educate the Canadian public about the
potential health impacts of various governmental decisions and improve the
potential for public involvement in public policymaking; and that
Immediate Action
As a means of moving this agenda forward, the conference recommends that
Canada's federal and provincial/territorial governments immediately address
the sources of health and the root causes of illness by matching the $1.5
billion targeted for diagnostic services in the Romanow Report on the
Future of Health Care in Canada and allocating this amount towards two
essential determinants of health for children and families: 1) affordable,
safe housing; and 2) a universal system of high quality educational
childcare; and
Long-Term Action
Similar to governmental actions in response to the Acheson Inquiry into
Health Inequalities in the United Kingdom, the federal government should
establish a Social Determinants of Health Task Force to consider these
findings and work to address the issues raised at this conference. The
Task Force would operate to identify and advocate for policies by all
levels of government to support population health. The federal and
provincial governments would respond to these recommendations in a formal
manner through annual reports on the status of these social determinants of
health.
So Resolved, this December 1, 2002, in Toronto, Canada, and Ratified,
February 10, 2003
Toronto Star
LIFE, Friday, March 14, 2003, p. F03
Is it possible that policy is more boring than sex?
Judy Gerstel
I am going to write something today that may be against the best
interests of the Toronto Star.
It won't be libellous. It won't advocate insurrection. It won't even
be subversive.
But it might be boring.
Fear of boring readers (especially 18- to 35-year-olds who are lusted
after by the media and Must Be Entertained) may be the reason you likely
don't already know about the Toronto Charter for a Healthy Canada.
The truth is that stories about sex, food, movies, TV, sex, sports,
money, sex, crime, celebrity and sex are much more likely to attract and
titillate readers than stories about ... health policy.
No matter how you look at it- or write about it- health policy is, uh, not
sexy. And I had seriously considered writing something sexy in this space
today.
In fact, I had considered writing about sex itself, about how, after
the not-at-all naughty '90s and the libido-dampening threat of an AIDS
epidemic, sex is again not only au courant but altogether rampant.
You can blame (or thank) the Internet- the best thing to happen to
sex since the '60s and the Pill- for the proliferation of what New York
Magazine calls "unapologetically no-strings-attached, purely sexual
experience."
Observed the January edition of the magazine, "The rise of Internet
dating has brought a sexual openness (not to mention one-night stands) to
the younger generation not seen since the '70s heyday of Maxwell's Plum."
But enough of what I'm not going to write about today.
Having enticed you this far, and at the risk of being accused of bait
and switch, I'm changing the channel back to the Toronto Charter for a
Healthy Canada.
Those of you of any age who are shallow, superficial and Must Be
Entertained, you may want to flip to the Movie section right now.
The rest of you may be interested to know that what ails us is not
what we think it is and that health is too important to be left to doctors.
The Toronto Charter for a Healthy Canada grew out of a conference at
York University in December.
More than 400 Canadian social and health policy experts, researchers
and community representatives met to talk about the social determinants of
health and how they could and should guide health policy- even though, for
the most, they don't.
The charter was ratified this month by the Toronto Board of Health.
But nothing about the Toronto Charter for a Healthy Canada was
reported in any Toronto newspaper, according to a Star library search.
Little wonder that few of us realize that 75 per cent of our health
is determined by the physical, social and economic environment.
It's a fact that being poor makes you sick. So does being poorly
educated. There's a direct correlation between literacy and health.
Work security, working conditions and social status also can make you
sick.
A famous study linking socioeconomic status and health looked at
civil servants in Britain.
Even though they were all white-collar workers, all had the same
employer, the same access to medical care and none was impoverished, the
rate of premature mortality and poor health increased as the civil service
grade of the employee decreased. The higher ranked they were, the healthier
they were.
The lowest occupation grades were shown to have four times the
mortality risks of the top grade.
Researchers quickly came to understand that the amount of control on
the job, prestige, income and wealth are all matters of life and death.
We like to blame bad health on poor eating habits and sloth, but we
fail to look at what gives rise to them, the depression and hopelessness
rooted in social exclusion, job insecurity, anxiety about putting food on
the table (affecting one out of 10 Canadian households).
Two of the most important social determinants of health targeted by
the Toronto Charter are affordable, safe housing and a universal system of
high quality educational childcare.
Safeguarding the health of children is the very least a country like
Canada can do.
I apologize if all this is boring, but I'm not finished yet.
I'm going to list the 10 social and economic determinants of health
deemed important by the Toronto Charter for a Healthy Canada. And I'm going
to provide the address of the Web site where you can find out more about
the Charter, the conference, and the people who are determined to make this
country healthier: http://www.socialjustice.org/conference/program.htm .
The 10 social determinants of health (any one of which is
considerably more important than how soon you can get to see a specialist):
1. Early childhood development.
2. Education.
3. Employment and working conditions.
4. Food security.
5. Health care services (with an emphasis on prevention, chronic disease
management and rehabilitation).
6. Housing shortages.
7. Income and its equitable distribution.
8. Social exclusion.
9. Social safety nets.
10. Unemployment.
Now, if you like, flip to the Movies section and Be Entertained. And
if you're lucky, I just might write about sex in this space sometime soon.
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