Public Policy Approaches to Health Inequalities

1. Public Policy Approaches to Health Inequalities Dennis Raphael, PhD School of Health Policy and Management York University, Toronto, Canada Presentation at the Rammelkamp Center for Education and Research Symposium: Health Disparities: From Genetics to Health Policy September 27, 2006, Cleveland, Ohio

2. Overview of Presentation • Health inequalities reflect differences in living conditions • Living conditions are shaped by public policy decisions concerned with the distribution of economic and social resources • Health status – and living conditions – differ profoundly among Americans • The USA has one of the worse population health profiles among developed nations • The USA has one of the worse public policy profiles among developed nations • The solution to health inequalities lies in the political sphere

3. 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. Donaldson, L. (1999), Ten tips for better health., London UK: Stationary Office.

4. I: Health inequalities reflect differences in living conditions

5. 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, 1898-1956. Worker’s Speech to a Doctor

6. Disadvantage 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.

7. 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 Share of Income Held by Lower 50% ME WA Source:Ross N., et al. BMJ 2000;320(7239):898-902.

8. Cleveland

9. Ross, N. et al. (2005). Metropolitan income inequality and working-age mortality: A cross-sectional analysis using comparable data from five countries Journal of Urban Health, 82, 101-110.

10. Social determinants of health as a window into living conditions

11. What are SDOH? • Social determinants of health are the economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole. • Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members.

12. Brunner, E. and Marmot, M. G. (2006), Social organization, stress, and health in Marmot, M. G. and Wilkinson, R. G. (Eds.), Social Determinants of Health, Oxford University Press, Oxford..

13. early life education employment and working conditions food security health services housing income and income distribution social exclusion social safety net unemployment A Policy-Oriented Approach to SDOH Source: Raphael, D. (2004). Social Determinants of Health: Canadian Perspectives. Toronto: Canadian Scholars Press.

14. SDOH and Health • “Measures of social and economic status, including occupation, are extremely powerful predictors of premature heart disease.” • Social Organization, Stress, and Health, E. Brunner & Michael Marmot. In Social Determinants of Health. M.G. Marmot & R.G. Wilkinson (eds.). Oxford: Oxford University Press, 1999, p. 32.

15. Materialist Approach • “Health inequalities result from the differential accumulation of exposures and experiences that have their sources in the material world.” • Lynch JW, Smith GD, Kaplan GA, House JS. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ 2000;320:1220-1224.

16. Neo-Materialist Approach • “The effect of income inequality on health reflects a combination of negative exposures and lack of resources held by individuals, along with systematic underinvestment across a wide range of human, physical, health, and social infrastructure.” • Lynch JW, Smith GD, Kaplan GA, House JS. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ 2000;320:1220-1224.

17. Ten Tips for Staying Healthy - 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. • Source: Gordon, D. Posting on Spirit of 1848 List, April, 1999

18. II. Living Conditions are Shaped by Public Policy Decisions

19. early life – income supports, progressive family policy, availability of childcare, support services education – support for literacy, public spending, tuition policy employment and working conditions – active labour policy, support for collective bargaining, increasing worker control food security – income and poverty policy, food policy, housing policy health services – public spending, access issues, integration of services SDOH and their Public Policy Determinants

20. housing – income and housing policy, rent controls and supplements, provision of social housing income and income distribution – taxation policy, minimum wages, social assistance, social assistance levels, family supports social exclusion – anti-discrimination laws and enforcement, ESL and job training, approving foreign credentials, support of a variety of other health determinants social safety net – spending on a wide range of welfare state areas unemployment – active labour policy, replacement benefits, labour legislation SDOH and their Public Policy Determinants

21. III. Health status – and living conditions – differ profoundly among Americans

27. Living Conditions and Health: Mechanisms Living conditions affect health in a number of ways: • Living conditions provide the prerequisites for health, such as shelter, food, warmth, and the ability to participate in society; • Living conditions can cause stress and anxiety which can damage people’s health; • Living conditions limit peoples’ choices and militates against desirable changes in behaviour. - Adapted from Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.

28. Origins of Disease • A body of evidence is now emerging which shows that health outcomes in adulthood reflect the accumulating influence of poor socio-economic circumstances throughout life. Adverse socio-economic conditions in early life can produce lasting increases in the risk of cardiovascular disease, respiratory illness, and some cancers late in life. • Poverty, Social Exclusion, and Minorities, M. Shaw, D. Dorling, & G. Davey Smith. In Social Determinants of Health. M.G. Marmot & R.G. Wilkinson (eds). Oxford: Oxford University Press, 1999, p.216

29. IV. The USA Population Health ProfileSources: United Nations Human Development Reports (2005), Innocenti Report Cards (2000-2005) and Society at a Glance (OECD, 2005)

36. V. The USA Public Policy Profile

38. Source Organization for Economic Cooperation and Development. (2005). Society at a Glance: OECD Social Indicators 2005 Edition. Paris, France, Figure SS1.1, p.43.

39. Source: Organization for Economic Cooperation and Development. (2005). Society at a Glance: OECD Social Indicators 2005 Edition. Paris, France. Figure SS6.1, p.45.

40. Source: Organization for Economic Cooperation and Development. (2005). Society at a Glance: OECD Social Indicators 2005 Edition. Paris, France. Figure SS6.2, p.45.

41. Source: OECD (2004). Social Expenditure Database www.oecd.org/els/social/expenditure

48. VI. The solution to health inequalities lies in the political sphere

50. Key Tenets of Neo-liberalism • Markets are the most efficient allocators of resources in production and distribution; • Societies are composed of autonomous individuals (producers and consumers) motivated chiefly by material or economic considerations; • Competition is the major market vehicle for innovations • “There is no such thing as society.” • Source: Coburn, D. (2000). Income inequality, social cohesion and the health status of populations: The role of neo-liberalism. Social Science & Medicine, 51(1), 135-146.