Social Determinants of Health: Why is There Such a Gap Between Our Knowledge and Its Implementation? Dennis Raphael York University, Toronto, Canada Presentation.

Social Determinants of Health:Why is There Such a Gap Between Our Knowledge and Its Implementation?

Dennis Raphael York University, Toronto, Canada

Presentation made at Ryerson Polytechnic University

Toronto, Ontario, October 4, 2002

What Do We Know ?• Population Health• Example 1: Cardiovascular Health• Example 2: Diabetes• Social Determinants in Canada Today

What Do We Do?• Governments – Policy Making• Public Health Units - Activities• Disease Associations, e.g., Heart and Stroke

Foundation, Diabetes Association – Messages• Health Care Providers and Planners - Focus

Poverty and Health: Literary Perspectives

We know what makes us ill. When we are ill we are told That it’s you who will heal us.

When we come to you Our rags are torn off us And you listen all over our naked body. As to the cause of our illness One glance at our rags would Tell you more. It is the same cause that wears out Our bodies and our clothes. -- Bertolt Brecht, A Worker’s Speech to a Doctor, 1938.

Poverty and Health: Academic Perspectives

It is one of the greatest of contemporary social injustices that people who live in the most disadvantaged circumstances have more illnesses, more disability and shorter lives than those who are more affluent.

-- Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.

Canadian Government Statements on Social Determinants of Health I

All policies which have a direct bearing on health need to be coordinated. The list is long and includes, among others, income security, employment, education, housing, business, agriculture, transportation, justice and technology.

-- Achieving Health For All: A Framework for Health Promotion, J. Epp. Ottawa: Health and Welfare Canada, 1986.

Canadian Government Statements on Social Determinants of Health II

There is strong evidence indicating that factors outside the health care system significantly affect health. These “determinants of health” include income and social status, social support networks, education, employment and working conditions, physical environments, social environments, biology and genetic endowment, personal health practices and coping skills, healthy child development, health services, gender and culture.

-- Taking Action on Population Health: A Position Paper for Health Promotion and Programs Branch Staff. Ottawa: Health Canada, 1998.

Canadian Government Statements on Social Determinants of Health III

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.

-- The Statistical Report on the Health of Canadians. Ottawa: Health Canada, 1998.

Social Determinants of Health:The Solid Facts

- social gradient - stress

- early life - social exclusion

- work - unemployment

- social support - addictions

- food - transport- World Health Organization, 1998

Ottawa Charter’s Prerequisites of Health• peace • shelter • education• food• income• a stable eco-system• sustainable resources• social justice• equity World Health Organization, 1986

Health Canada’s Determinants of Health• Income and Social Status• Social Support Networks • Education • Employment/Working Conditions • Social Environments • Physical Environments • Personal Health Practices and Coping Skills • Healthy Child Development • Biology and Genetic Endowment • Health Services • Gender• Culture

Why Emphasize Social Determinants?

• Social determinants of health have a direct impact on health

• Social determinants predict the greatest proportion of health status variance

• Social determinants of health structure health behaviours

• Social determinants of health interact with each other to produce health

Poverty and Health: Mechanisms

Poverty can affect health in a number of ways:• income provides the prerequisites for health, such as

shelter, food, warmth, and the ability to participate in society;

• living in poverty can cause stress and anxiety which can damage people’s health;

• low income limits peoples’ choices and militates against desirable changes in behaviour.

- Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.

Defining Poverty Individuals, families and groups in the

population can be said to be in poverty when they lack the resources to obtain the type of diet, participate in the activities and have the living conditions and amenities which are customary, or at least widely encouraged, or approved, in the societies to which they belong. They are, in effect, excluded from ordinary living patterns, customs and activities

-- Townsend, 1979, p.31

The North York Heart Health Network

• Community-based coalition of over 45 groups.• Frustrated by limited mandate and neglect of

societal issues in heart health.• Commissioned literature review and report on

income and heart health to raise awareness.• Released the report Inequality is Bad for Our Hearts:

Why Low Income and Social Exclusion are Major Causes of Heart Disease in Canada in November 2001.

• Updated revision Social Justice is Good for Our Hearts: Why Societal Factors -- Not Lifestyles -- are Major Causes of Heart Disease in Canada and Elsewhere released May, 2002.

Heart Disease in North America: The Missing Messages

• The emphasis by health units and the media on medical and lifestyle risk factors as the major causes of cardiovascular disease (CVD) in Canada is inaccurate.

• Low income is a major cause of CVD in Canada. 

• Social exclusion provides a process by which low income can be understood to cause CVD. 

• Canadian policy directions are inconsistent with what is known about reducing the incidence of CVD.

• Lifestyle approaches and messages are not only inaccurate but potentially damaging to population health.

• The health sector and the media have been negligent in ignoring the role societal factors play in CVD and other diseases.

The Evidence Concerning Low Income and Heart Disease: The Hard Data

• Statistics Canada estimated that in 1996, 23% of years of life lost for all causes prior to age 75 in Canada could be attributed to income differences.

• The diseases most responsible for income-related differences in death rates were cardiovascular diseases.

• In 1996, 22% of all the years lost that can be attributed to income differences were caused by cardiovascular disease.

• These income differences account for an annual excess of 24% or 6,366 premature deaths from cardiovascular disease.

PYLL(0-74) by Cause, 1996

30.9

19.2

17.6

5.3

4.9

4.8

3.8

13.5

23.1

0 5 10 15 20 25 30 35

Neoplasms

Income-Related

Injuries

Circulatory

Infectious

Perinatal

Ill-defined

Congenital

All other

%

Excess PYLL(0-74) by Cause, 1996

21.6

16.9

14

12.2

8.3

7.1

5.4

14.5

0 5 10 15 20 25

Circulatory

Injuries

Neoplasms

Infectious

Ill-defined

Perinatal

Digestive

All other

%

203218 225

236

268

119 128 118 127143

Neighbourhoods by Income Quintile, Urban Canada

1st (Highest Income) 2nd 3rd 4th 5th (Lowest Income)

0

40

80

120

160

200

240

280

Males Females

Figure 5: Cardiovascular Deaths Per 100,000, Urban Canada, 1996

4,614

8,090

11,837

13,935

13,115

Neighbourhoods by Income Quintile, Ontario1st (Highest Income) 2nd 3rd 4th 5th (Lowest Income)

0

3,000

6,000

9,000

12,000

Figure 7: Heart Attack Hospital Admissions by Area Income, Ontario , 1994-97

90%

160%

50%

90%

70%

90%

30%

50%60% 60%

40%

80%

White Males White Females Black Males Black Females

0%

40%

80%

120%

160%

Low Income Area - Adjusted for Age and Study Site

Low Income Area - Adjusted for Preceding and Individual Socioeconomic Characterist ics

Low Income Area - Adjusted for Preceding and All Behavioural and Medical Factors

Figure 9: Greater Risk of Heart Disease in Low Income Areas, USA, 1988-97

It was found that those living in lower income areas were much more likely to develop coronary heart disease than those in well-off neighbourhoods. These effects remained strong even after controlling for tobacco use, level of physical activity, presence of hypertension or diabetes, level of cholesterol, and body mass index.

- Summary of Neighbourhood of Residence and Incidence of Coronary Heart Disease, A. Roux, S. Merkin, D. Arnett, et al. New England Journal of Medicine, 2001, 345, 99-106.

Critical Periods of the Life Course• Foetal development• Birth• Nutrition, growth and health in adulthood• Educational Career• Leaving parental home• Entering labour market• Establishing social and sexual relationships• Job loss or insecurity• Parenthood• Episodes of illness• Labour market exit• Chronic sickness• Loss of full independence -- Shaw et al., The Widening Gap, 1999, p. 106.

Low Income and Heart Disease: Researchers’ Conclusions

Our results suggest that despite the presence of significant socio-economic differentials in health behaviours, these differences account for only modest proportion of socio-economic disparities in mortality. Thus, public health policies and interventions that exclusively focus on individual risk behaviours have limited potential for reducing socio-economic disparities

in mortality.

-- Socioeconomic Factors, Health Behaviors, and Mortality, P.M. Lantz, J.S. House, J.M. Lepkowski, D.R. Williams, R.P. Mero, & J.J. Chen, Journal of the American Medical Association, 1998, 279, 1703-1708.

Low Income and Heart Disease: Researchers’ Conclusions

These estimates of risk reduction may be compared with the much smaller estimates of the effects of improvements in adult lifestyle... Our findings add to the evidence that protection of fetal and infant growth is a key area in strategies for the primary prevention of coronary heart disease.

-- Early Growth and Coronary Heart Disease in Later Life: Longitudinal Study. J.G. Eriksson, T. Forsen, J. Tuomilehto, C. Osmond, D.J. Barker. British Medical Journal, 2001, 322, 949-953.

Heart Health In Ontario

• Major $17,000,000 5-year initiative by Conservative Government.

• Specific focus on lifestyle factors of diet, activity, and tobacco use.

• Clear neglect of structural (societal and community) factors in heart health despite profound evidence of their importance.

• Contradicts 25 years of Health Canada and CPHA statements on health determinants.

• Similar neglect of societal issues by media, health units, and disease-oriented associations.

Sector Reactions to the Reports

Enthusiastic Social development/social welfare sectors  Anti-poverty community Faith communities

Ambivalent and Guarded Public health units in Ontario Lifestyle-oriented health promoters Illness-oriented foundations The media

Hostile – or at least not excited! Ontario Ministry of Health/Long-Term Care Heart Health community in Ontario

Diabetes Prevalence in Ontario by Neighbourhood Income Quintile, 1999

7.05 6.785.76

5.12

7.76

0123456789

Q1 (Lowest) Q2 Q3 (Middle) Q4 Q5 (Highest)

Neighbourhoood Classified by Mean Income

Dia

bet

es P

reva

len

ce R

ate

Increased Risk of Diabetes in Ontario Among Low Income Residents, 1997/97

1.51.2 1

3.8

2.32

11.4

0

1

2

3

4

5

Low Low-Middle Upper-Middle High

Income Level

Dia

bete

s P

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atio

Males Females

Diabetes, Males

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4

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8

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1971 1976 1981 1986 1991 1996

Q1 - Richest

Q2

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Q4

Q5 - Poorest

ASMR x 100,000

Diabetes, Females

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2

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8

10

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1971 1976 1981 1986 1991 1996

Q1 - Richest

Q2

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Q4

Q5 - Poorest

ASMR x 100,000

Implications of Increasing Family Poverty

Given the disturbing increases in income inequality in the United States, Great Britain, and other industrial countries, it is vital to consider the impact of placing ever larger numbers of families with children into lower SES groups. In addition to placing children into conditions which are detrimental to their immediate health status, there may well be a negative behavioural and psychosocial health dividend to be reaped in the future.

-- Why Do Poor People Behave Poorly? Variation in Adult Health Behaviours and Psychosocial Characteristics by Stages of the Socioeconomic Life Course, J.W. Lynch, G.A. Kaplan, & J.T. Salonen. Social Science and Medicine, 1997, 44, 809-819.

Recommendations for Action

• The first and most important set of recommendations is concerned with reducing the incidence of low income among citizens.

• The second set of recommendations is concerned with reducing the incidence of social exclusion.

• The third set involves restoring the supports by which Canadians have traditionally been assisted in their navigation of the life course.

Ten Tips For Better Health - Donaldson, 1999

1. Don't smoke. If you can, stop. If you can't, cut down.

2. Follow a balanced diet with plenty of fruit and vegetables.

3. Keep physically active.

4. Manage stress by, for example, talking things through and making time to relax.

5. If you drink alcohol, do so in moderation.

6. Cover up in the sun, and protect children from sunburn.

7. Practise safer sex.

8. Take up cancer screening opportunities.

9. Be safe on the roads: follow the Highway Code.

10. Learn the First Aid ABC : airways, breathing, circulation.

Ten Tips for Staying Healthy - Dave Gordon, 1999.

1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.

2. Don't have poor parents.

3. Own a car.

4. Don't work in a stressful, low paid manual job.

5. Don't live in damp, low quality housing.

6. Be able to afford to go on a foreign holiday and sunbathe.

7. Practice not losing your job and don't become unemployed.

8. Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled.

9. Don't live next to a busy major road or near a polluting factory.

10. Learn how to fill in the complex housing benefit/ asylum application forms before you become homeless and destitute.

Avoiding the Life-Style Trap

• Lifestyle choices are heavily structured by life circumstances

• Lifestyle choices by themselves account for modest proportions of health status

• Lifestyle choices are difficult to change without considering life contexts

• Lifestyle choice emphases can have unintended side-effects that work against health

Economic Inequality Affects Health in Three Main Ways

• Economically Unequal Societies have Greater Levels of Poverty

• Economic Unequal Societies Provide Fewer Social Safety Nets

• Economically Unequal Societies Have Weaker Social Cohesion

Economic Inequality is Dangerous to the Health of Everybody

• Economic inequality is especially bad for the health of poor people

• Economic inequality is bad for the health of well-off people

• Economic inequality weakens communities

• Economic inequality weakens societies

• Is economic inequality Un-Canadian?

0.18 0.20 0.22 0.24Median Share of Income

300

425

550

675

800

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nWorking-Aged Male (25-64) Mortality by Median Share

U.S. States and Canadian Provinces

WAMWeightedCan&US June 16, 1999 2:40:26 PM

Mortality Rates Standardized to the Canadian Population in 1991

U.S. States with weighted linear fit (from Kaplan et al., 1996)Canadian Provinces with weighted linear fit (slope not significant)

MSLA

AL

CA

TX

FL

NH

MN

PEI

NFLDNB

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MAN

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SC

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0.15 0.19 0.23 0.27Median Share of Income

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300

400

500

600

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0 P

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Working Age (25-64) Mortality by Median ShareU.S. and Canadian Metropolitan Areas

U.S. cities (n=282) with weighted linear fit (from Lynch et al. 1998)Canadian cities with weighted linear fit (n=53) (slope not significant)

Mortality Rates Standardized to the Canadian Popluation in 1991

FlorenceSC

JacksonvilleNC

SiouxCityIA

MonroeLA

ChicagoIL

TuscaloosaAL

Prince George

WashingtonDC

Oshawa

NewYorkNY

LosAngelesCA

NewOrleansLA

BryanTX

McallenTX

SiouxCityIA

AppletonWI

PortsmouthNH

PineBluffAR

FlorenceSC

MonroeLA

AugustaGA

Montreal

Vancouver

Toronto

Barrie

Oshawa

Shawinigan

WAWeightedCan&US June 29, 1999 12:53:18 PM

91%

103%

48%

62%

91%

89%

Percentage Increase

Total Number of Low Income Children

In Working Low Income Families

In Full Employment Families

In Long Term Unemployed Families

In Two Income Families

In Female Sole Support Families

0% 20% 40% 60% 80% 100% 120%

Figure 14: Changes in Number of Low Income Children in Ontario Since 1989

100%

300%

500%

Seniors Families Singles

0%

100%

200%

300%

400%

500%

Figure 17: Increases in Waiting Lists for Subsidized Housing, 1988-98, Toronto

Low Income

0

5

10

15

20

25

30

35

40

45

1971 1986 1991 1996

Q1-RichestQ2Q3Q4Q5-Poorest

%

Economic Inequality and Health: Policy Implications

• Poverty and economic inequality is on the rise in the USA and Canada

• Poverty is bad for health• Economic inequality is dangerous for the health

of all of us• Policy decisions create poverty and economic

inequality• Citizens can influence policy decisions to

improve health

Economic Inequality Affects Health in Three Main Ways

• Economically Unequal Societies have Greater Levels of Poverty

• Economic Unequal Societies Provide Fewer Social Safety Nets

• Economically Unequal Societies Have Weaker Social Cohesion

What Creates Poverty and Income Inequality?

• The growing gap between rich and poor has not been ordained by extraterrestrial beings. It has been created by the policies of governments: taxation, training, investment in children and their education, modernization of businesses, transfer payments, minimum wages and health benefits, capital availability, support for green industries, encouragement of labour unions, attention to infrastructure and technical assistance to entrepreneurs, among others.

– Peter Montague

USA, Canada, and Sweden Rankings on Compared to Other Industrialized Nations

(Ranking, 1 is best)

Measure USA Canada SwedenIncome Inequality (1990) 18 of 18 11 3Child Poverty (1990) 17 of 17 14 2Infant Mortality (1996) 24 of 29 17 2Youth Suicide (1992-1995) 15 of 22 16 10High School Drop-Outs (1996) 17 of 17 16 10Youth Homicide (1992-1995) 22 of 22 19 5Wages (1996) 13 of 23 15 6Unemployment (1996) 2 of 10 7 8Elderly Poverty (1990) 15 of 17 4 5Life Expectancy (1996) 20 of 29 4 3

Canadian Policy Directions

It has become obvious that people on the low end of the income scale are cut off from the ongoing economic growth that most Canadians are enjoying. It is also obvious that in these times of economic prosperity and government surpluses that most governments are not yet prepared to address these problems seriously, nor are they prepared to ensure a reasonable level of support for low-income people either inside or outside of the paid labour force.

-- Poverty Profile, 1998. Ottawa: National Council of Welfare Reports, Autumn, 2000.

Reducing Health Inequalities

We consider that without a shift of resources to the less well off, both in and out of work, little will be accomplished in terms of a reduction of health inequalities by interventions addressing particular downstream’ influences.

-- Report of the Acheson Independent Inquiry into Inequalities in Health, 1998, p. 33.

Social Inequalities in Health:Montreal Medical Officer’s Report I

Having scanned the health and well-being of Montrealers from one end of the life cycle to the other, we note the important role played by poverty. 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.

-- Lessard, 1997, p.60

Social Inequalities in Health:Montreal Medical Officer’s Report II

For anyone interested in public health, social inequalities in health must be a major concern. But we know that the solution is not to invest more in the health system or in new technologies. These inequalities must rather be met head-on; and well-targeted actions must be undertaken to ensure that they will not become worse.

-- Lessard, 1997, p. 20.

Barriers to Effective Action onthe Social Determinants of Health

• Ideological - What is health and its determinants?

• Political - How do government actions affect health?

• Institutional - What is appropriate health action?

• Personal - Do I have the knowledge to affect health?

• Attitudinal - Do I need the hassle?

Income Inequality and Population Health:Raising the Issue I

• develop communication between various sectors concerned with economic inequality

• contribute papers to academic and professional journals on income-related developments and their potential for affecting the health of citizens

• use the media to educate citizens about the consequences of increasing economic inequality and poverty upon health

Income Inequality and Population Health:Raising the Issue II

• lobby local health departments to begin taking seriously a determinants of health approach including consideration of the importance of economic inequality and poverty

• lobby governments to maintain the community and service structures that help to maintain health and well-being

• begin to understand the forces that create economic inequality and poverty

From “Inequality is Bad” to “Social Justice is Good”

It was clear that additional funds would not be made available to reprint the “Inequality is Bad” report.

It was also made clear that it would be difficult to find an internet home for the report in Ontario.

Since the words were deemed as belonging to me, arrangements were made to:

Update and revise the report and find a new sponsor/publisher.

Find an internet home for the original report. Provide additional critical analyses of the lifestyle approach

to heart health in the form of three additional messages to the original six.

Critical Analysis I: Reasons for Resistance

Lack of Epidemiological TheoryHealth officials and reporters seem unaware of recent developments in social epidemiological theory and population health research findings.

Commitment to Ideology of Individualism in Health, Illness and Health PromotionAssists the neo-liberal and neo-conservative agendas of blaming individuals for their health problems, absolving governments of blame for their health threatening policies that create poverty, inequality, and social exclusion.

Critical Analysis II: Side Effects of the Biomedical and Lifestyle Heart

Health Approach

Removes the issue of the social determinants of cardiovascular disease and diabetes right off the public policy agenda.

Low income people made to feel that they are responsible for their own poor health (victim blaming).

Health workers and the media become complicit in the process of ‘poor bashing’: Ignoring facts and repeating stereotypes about people who are poor.

Critical Analysis III: The Holy Trinity

As with any area of medical or scientific research,the selection of ‘factors” to be studied cannot beimmune from prevailing social values andideologies. ... It is also evident that so calledlifestyle or behavioural factors (such as the holytrinity of risks - diet, smoking and exercise)receive a disproportionate amount ofattention. As we have seen, the identification andconfirmation of risk factors is often subject tocontroversy and the evidence about causal linksis not unequivocal.  

Nettleton, S. (1997). Surveillance, Health Promotion and the Formationof a Risk Identity in Debates and Dilemmas in Promoting Health.London UK: MacMillan.

Towards the Future CIHR Institute of Population and Public Health (IPPH)

awarded $100,000 to D. Raphael, R. Labonte, and R. Colman to provide an assessment of Needs, Gaps, and Opportunities in the Conceptualization of Income in Health Research in Canada.

Health Canada Health Policy Program awarded $113,000 -- supplemented with $10,000 from IPPH -- to hold a national conference on Social Determinants of Health Across the Life Span: A Current Accounting and Policy Implications, to be held at York University in late November 2002.

Application being made with Kim Raine, University of Alberta, to CIHR to study the lives of people with diabetes in an attempt to understand the increasing mortality among low income Canadians.

Policy Directions and Population Health

• The policies that Canada has developed to improve population health reflects its more egalitarian structure. Examples include various tax and economic transfer policies that help to limit income differences across the country, as well as provision of important social services... If a healthy population is the goal, we must enter the political arena and fight to maintain the social contract that has sustained Canada as one of the world leaders in health.

• Stephen Bezruchka, CMAJ, 2001

Justice and Fairness I

Where a great proportion of the people are suffered to languish in helpless misery, that country must be ill-policed and wretchedly governed: a decent provision for the poor is the true test of civilization.

- Dr. Samuel Johnson

Justice and Fairness II

If the misery of our poor be caused not by the laws of nature, but by our institutions, great is our sin.

– Charles Darwin

Dennis RaphaelSchool of Health Policy and

ManagementYork UniversityToronto, Canada

416-736-2100, ext. [email protected]