2. Poverty, Policy and Public Health Health Promotion Ontario Spring Conference May 13-14 2008 Grace-Edward Galabuzi, Ph.D Ryerson University

3. Poverty, Policy and Health Context: Social citizenship Social exclusion Dimensions of social exclusion Social Determinants of Health Social disparities and Health Status Racialization, immigrant status and social determinants of health Reversing Social exclusion – Poverty elimination strategies

4. Social Citizenship “relationship between the individual and the state as well as among individuals, is the concrete expression of the fundamental principle of equality among members of the political community” –Rights and responsibilities –Equal Access –Belonging Social inequality and poverty represent a threat to citizenship

5. Social Inclusion Characterized by society’s widely shared social experiences and active participation Equal access to opportunities and life chances Ability to develop the full range of human capacities Capacity and willingness of society to keep all its citizens within reach of common aspirations Full citizenship as a relationship between individuals and the state and among groups of individuals in society

6. Social Exclusion Represents a form of alienation experienced by particular groups and individuals in society Analysis points to structures, processes and outcomes Occurs in multiple dimensions Is a key determinant of access to processes of production, wealth, income, power and participation Reproduced by structures and processes of inequality and unequal outcomes Is responsible for the generation of health disparities in society

7. Key aspects of Social Exclusion Denial of civil engagement through legal sanction and other institutional mechanisms. Denial of access to social goods - health care, education, housing. Denial of opportunity to participate actively in society. Economic exclusion.

8. Social exclusion and health status The most important consequences of health disparities are avoidable death, disease, disability, distress and discomfort However, health disparities also cost individuals, communities, the health system and Canadian society as a whole. Health disparities are inconsistent with Canadian values of equality: –They threaten the social cohesiveness of community and society, –They challenge the sustainability of the health system, –They undermine the Canadian economy

9. Social Determinants of Health Shift from reliance on health behaviours (smoking, diet, exercise, etc.) as most important predictors of health status Towards rather social and economic characteristics of individuals and populations Poor social and economic conditions and inequalities in access to resources and services have greater impact on an individual or group’s health and well being than behaviors Groups experiencing some form of social exclusion tend to sustain higher health risks and lower health status.

10. Understanding health disparities According to Health Disparities Taskforce, (2004), these characteristics are key factors influencing health disparities in Canada : –Socio-economic status (SES) –Aboriginal and other racial identity –Gender status –Disability –Geographic location (neighbourhood selection)

11. Poverty, Income inequality and Health Disparities “Canadians at the bottom of the economic ladder were more likely to die from just about every disease from which people can die from than the more well-off, including cancers, heart disease, diabetes, and respiratory diseases among others.” Wilkins, Adams, & Brancker (2000)

12. Differential impacts of health disparities The death rate from injury among Aboriginal infants is 4 times the rate for Canada as a whole, and 3 times among teenagers. Young blacks are four times (10.1 per 100,000) as likely to be victims of gun related homicides as other members of the population (2.4 per 100,000). Only 47% among Canadians in the bottom income quintile report their health as excellent or very good compared with 73% in the top quintile People in the lowest quintile are five times more likely to rate their health as fair or poor than people in the highest Aboriginal peoples are twice as likely to report fair or poor health status than non-Aboriginal peoples with the same income levels.

13. Dimensions of Social Exclusion among Racialized populations Racialized groups and new immigrants experience differential life chances. Characteristics include: A double digit racialized income gap Chronically higher than average levels of unemployment, Deepening levels of poverty Differential access to housing and neighbourhood segregation Disproportionate contact with the criminal Justice system Higher health risks

14. Racialized youth labour market participation Racialized Youth in the Labour Market, 2001 Age 15-24Labour Market Unemployment Participation Rate All ‘Youth’ persons 58.4%13.3% Immigrant Youth55.0% 14.8% Racialized Youth43.7% 16.1% Racialized youth – Can born48.4% 15.5% Arab Youth45.1% 16% Black Youth – Can. Born33.2% 21.4% Chinese Youth37.1% 17% Latin American Youth50.9% 14% Filipino Youth57.2% 10% South Asian Youth48.5% 15% Vietnamese Youth46% 16% Japanese Youth 44% 13% Aboriginal Youth- 22.8% _____________________________________________________ Source: Census of Canada. Catalogue 97F0012XCB200102 & Profiles of Ethnic communities in Canada: Statistics Canada – Catalogue no. 89-621-XIE

15. Inequality in employment incomes Average Income (all sources) by select racialized community, 2001 _______________________________________________________________________ Men Women Total dollars _____________________________________________________________________ All Canadian earners36,80022,88529,769 African community27,86419,63923,787 Arab community32,33619,26426,519 Caribbean community29,84022,84225,959 Chinese community29,32220,97425,018 Filipino community27,61222,53224,563 Jamaican community30,08723,57526,412 Haitian community21,59518,33819,782 Japanese community43,64424,55633,178 Korean community23,37016,91920,065 Latin American community27,25717,93022,463 South Asian community31,39619,51125,629 Vietnamese community27,84918,56023,190 West Asian community28,71918,01423,841 Source: Statistics Canada, 2001 Census of Canada.

16. The Racialization of Poverty The Racialization of poverty represents a disproportionate and persistent experience of low income among racialized groups It is linked to the process of the deepening social exclusion of racialized and immigrant communities. A key contributing factor is the concentration of economic, social and political power in fewer hands that has emerged as the state has retreated from its regulatory role in the economy. The experience of poverty includes powerlessness, marginalisation, voicelessness, vulnerability, and insecurity. The various dimensions of the experience of poverty interact in important ways to reproduce and reinforce social exclusion Racialized people are two or three times as likely to be poor than other Canadians

17. Racialization of Poverty Low income by select racialized community, 2000 ________________________________________________________________________ AdultAdultChildren Unattachedunder15 ________________________________________________________________________ Total Canadian population15%38%18% African Community39%56%47% Arab community36%52%40% Caribbean community26%44%33% Chinese community26%55%27% Filipino community16%48%18% Jamaican community26%41%34% Haitian community39%61%47% Japanese community18%48%16% Korean community43%72%48% Latin American community28%53%32% South Asian community23%49%28% Vietnamese community27%49%35% West Asian community37%56%43% Source: Statistics Canada, 2001 Census of Canada.

18. Income inequality among recent immigrants In 2006 Asians immigrants aged 25 to 54, had an employment rate of 63.8%, compared to 83.1% for their counterparts born in Canada. Recent immigrants born in Europe had higher unemployment rates than the Canadian born at 8.4%, above the average (4.9%) of people born in Canada. Latin American immigrants had an unemployment rate 2.1 times higher than their Canadian-born counterparts. African-born recent immigrants had an unemployment rate that was more than four times higher than that of their Canadian-born counterparts. Low income rates rose to 47.0% in 1995, then fell back to 35.8% in 2000.

19. Neighbourhood dimensions of racialization and Social Exclusion In Canada’s urban areas, the spatial concentration of poverty or residential segregation is intensifying along racial lines. Immigrants in Toronto and Montreal are more likely than non- immigrants to live in neighbourhoods with high rates of poverty Young immigrants living in low income areas often struggle with alienation from their parents and their community, as well as the broader society and some of its institutions. They are also the disproportionate targets of crime and criminalization. Black youth are four times as likely to be victims of gun violence as other Canadians

20. Low Income in Toronto, 2001

21. Racialized neighbourhoods Toronto Area racialized enclaves experience high poverty rates University unemployment low income loneparent Chinese 21.2%11.2%28.4% 11.7% South Asian 11.8% 13.1% 28.3% 17.6% Black 8.7%18.3% 48.5% 33.7%

22. Racism as a determinant of health Health disparities related to racism compromise health status and lead to disproportionate exposure to such conditions as diabetes and hypertension The psychological pressures of daily resisting racism and other oppressions add up to a complex of factors that undermine the health status of racialized and immigrant group members. Many racialized and immigrant workers are forced to accept work in workplaces where they face poor and sometimes hazardous working conditions that compromises their health. Some trade off employment opportunities and intensified work (overtime, multiple jobs) for safe and healthy work habits

23. Racialized Disparities in Healthcare Access Chen, Wilkins and Ng (1996) analysis of the 1994 National Population Health Survey found that after adjusting for age, non-European immigrants had significantly lower hospitalization rate than European immigrants Chen, Wilkins and Ng (1996) analysis of the 1994 National Population Health Survey found that after adjusting for age, non-European immigrants had significantly lower hospitalization rate than European immigrants Ng et al (2005) found that non-European immigrants were twice as likely as the Canadian-born to indicate deterioration in their health between 1994 and 2003 Ng et al (2005) found that non-European immigrants were twice as likely as the Canadian-born to indicate deterioration in their health between 1994 and 2003 Matuk (1996) found that women from racialized groups were less likely to have had a pap test and have lower survival rates for cancer than women from non-racialized groups. Matuk (1996) found that women from racialized groups were less likely to have had a pap test and have lower survival rates for cancer than women from non-racialized groups.

24. Racialization and the health care system Language barriers often lead to barriers to equal access Documented lack of cultural sensitivity in service delivery Underdeveloped cultural competencies Broader systemic barriers to access of health services Inadequate funding for Ethno-cultural community health services Inadequate funding for research and treatment of particular conditions that disproportionately affect racialized populations

25. Racism and Mental Health Many racialized group members and immigrants with mental health issues and mental illness' identify racism as a critical issue in their lives. One of the reasons the health status of immigrants declines is because of the experiences of dealing with everyday forms of racism. A study conducted by Noh and Beiser confirms that Southeast Asian refugees in Canada reporting discrimination experienced higher depression than their counterparts who reported none. Skilled immigrants experiencing mounting barriers in gaining employment and access to civil society, also report impacts on their mental health (Beiser, 1988)

26. Immigrant status as a determinant of health status Immigrants tend to start out with above average health status because the immigration selection process imposes a high standard of health status. It is reasonable to expect that the health status of immigrants will decline with length of stay in Canada But increased health risks arising from inability to access key health services due to such considerations as cultural competence gaps in the health care system, the inability of the immigrants to optimally make demands on the system or socio-economic vulnerabilities tend to exacerbate this Studies also show adverse psychopathological results from exposure to adversity and other vulnerabilities that are part of the process of migration.

27. Black Creek Income Security, Race and Health Project - Indicators Black Creek Comparison (2001)Bl Crk Toronto Total Immigrants in Population62.6% 42.8% Racialised Groups74.8% 42.8% Home Language Not Eng/Fr30.0% 18.8% No Knowledge of English/French 6.9% 5.1% Low Income Population40.4% 22.5% Unemployment Rate 9.9 7.0

28. Initial Focus Group Findings about Labor Market Headache, stress, depression (“heart is sinking”) Headache, stress, depression (“heart is sinking”) Sleeplessness, frustrations Sleeplessness, frustrations Heart problems, back problems, weight problems, stomach and ulcer ailments, Heart problems, back problems, weight problems, stomach and ulcer ailments, Arthritis Arthritis Inability to buy nutritious food, pay rent, and cover medical expenses Inability to buy nutritious food, pay rent, and cover medical expenses Can’t afford childcare Can’t afford childcare

29. Reversing Social exclusion and declining health status International research consistently shows that most health disparities can be traced to non-medical determinants ( UK: Whitehall Studies) The most appropriate and effective way to improve overall population health is by improving the health of those disproportionately affected by health disparities Taking action on key social factors known to influence health is essential to reducing health disparities. The focus should be on such poverty and social disadvantage enhancing drivers such as – social class, race, gender, immigrant status, disability The vulnerabilities these factors generate mutually reinforce the downward spiral of health status The Public health system has a key role to play in mitigating the causes and effects of social determinants of health through interventions with socially marginalized individuals, populations and communities

30. Effective Anti-poverty Strategies A commitment to targets and goals – 25 in 5 years (2013), 50 in 10 years (2018) Structural changes in living conditions –Employment –Income –Social resources Sustainable employment – work that pays and is secure Improvements in social programs – adequacy and dignity Investments in public goods – housing, education, health