1. Ryerson Polytechnic University Toronto, Ontario, October 4, 2002
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 ? What Do We Do? 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,

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,

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,

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
ASMR x 100,000

40. Diabetes, Females
ASMR x 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,

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
0.18
0.20
0.22
0.24
Median Share of Income
300
425
550
675
800
Rate per 100,000 Population
Working-Aged Male (25-64) Mortality by Median Share
U.S. States and Canadian Provinces
WAMWeightedCan&US June 16, :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) MS LA AL CA TX FL NH MN
PEI
NFLD NB
SASK
ONT
ALTA BC
MAN
QUE NS SC ME

56. Low Income %

57. 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

58. 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

59. 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

60. USA, Canada, and Sweden Rankings on Compared to
Other Industrialized Nations
(Ranking, 1 is best)
Measure USA Canada Sweden
Income Inequality (1990) 18 of
Child Poverty (1990) 17 of
Infant Mortality (1996) 24 of
Youth Suicide ( ) 15 of
High School Drop-Outs (1996) 17 of
Youth Homicide ( ) 22 of
Wages (1996) 13 of
Unemployment (1996) 2 of
Elderly Poverty (1990) 15 of
Life Expectancy (1996) 20 of

61. 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, Ottawa: National Council of Welfare Reports, Autumn, 2000.

62. 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.

63. 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

64. 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.

65. Barriers to Effective Action on the 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?

66. 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

67. 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

68. 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.

70. Critical Analysis I: Reasons for Resistance
Lack of Epidemiological Theory
Health 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 Promotion
Assists 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.

71. 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.

72. Critical Analysis III: The Holy Trinity
As with any area of medical or scientific research,
the selection of ‘factors” to be studied cannot be
immune from prevailing social values and
ideologies. ... It is also evident that so called
lifestyle or behavioural factors (such as the holy
trinity of risks - diet, smoking and exercise)
receive a disproportionate amount of
attention. As we have seen, the identification and
confirmation of risk factors is often subject to
controversy and the evidence about causal links
is not unequivocal.  
Nettleton, S. (1997). Surveillance, Health Promotion and the Formation
of a Risk Identity in Debates and Dilemmas in Promoting Health.
London UK: MacMillan.

73. 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, 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.

74. 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

75. 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

76. 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

77. Dennis Raphael School of Health Policy and Management York University Toronto, Canada , ext