Presentation made at Ryerson Polytechnic University Toronto, Ontario, October 4, 2002

1. 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

2. 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

6. 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.

7. 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.

10. 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.

11. 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.

12. 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.

14. 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

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

16. 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

17. 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

18. 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.

19. 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

20. 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.

22. 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.

23. 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.

24. PYLL(0-74) by Cause, 1996 %

25. Excess PYLL(0-74) by Cause, 1996 %

29. 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.

32. 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.

33. 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.

34. 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.

35. 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.

36. 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

37. Diabetes Prevalence in Ontario by Neighbourhood Income Quintile, 1999

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

39. Diabetes, Males ASMRx 100,000

40. Diabetes, Females ASMRx 100,000

41. 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.

42. 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.

43. 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.

44. 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.

45. 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

46. 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

47. 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?

50. Working-Aged Male (25-64) Mortality by Median Share U.S. States and Canadian Provinces 800 U.S. States with weighted linear fit (from Kaplan et al., 1996) Canadian Provinces with weighted linear fit (slope not significant) MS LA 675 SC AL Rate per 100,000 Population FL 550 TX CA PEI QUE 425 NH NS NB NFLD MAN MN ONT BC ALTA SASK Mortality Rates Standardized to the Canadian Population in 1991 300 0.18 0.20 0.22 0.24 Median Share of Income WAMWeightedCan&US June 16, 1999 2:40:26 PM ME