Social Determinants of Health: Canadian Perspectives (3rd Edition) PDF

Chapter 1 SOCIAL DETERMINANTS OF HEALTH: KEY ISSUES AND THEMES...

Chapter 1 SOCIAL DETERMINANTS OF HEALTH: KEY ISSUES AND THEMES Dennis Raphael INTRODUCTION Social determinants of health are the economic and social conditions that shape the health of individuals, communities, and jurisdictions as a whole. Social determinants of health are the primary determinants of whether individuals stay healthy or become ill (a narrow definition of health). Social determinants of health also determine the extent to which a person possesses the physical, social, and personal resources to identify and achieve personal aspirations, satisfy needs, and cope with the environment (a broader definition of health). Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members. Important considerations include both their quality and their distribution amongst the population (Graham, 2004a). These resources include, but are not limited to, conditions of childhood; access to income; education and literacy; food, housing, and employment; working conditions; and health and social services. An emphasis upon societal conditions as determinants of health contrasts with the traditional health sciences and public health focus upon Copyright © 2016. Canadian Scholars. All rights reserved. biomedical and behavioural risk factors such as cholesterol levels, body weight, physical activity, diet, and tobacco and excessive alcohol use. Since a social determinants of health approach sees the mainsprings of health as being how a society organizes and distributes economic and social resources, it directs attention to public policies as means of improving health. It also requires consideration of the political, economic, and social forces that shape policy decisions. Concern with the social determinants of health is not new. It has been known since the mid-19th century that living conditions are the primary determinants of health (Engels, 1987; Virchow, 1985). And since then hundreds of studies have demonstrated that the material and social circumstances that people are exposed to in their homes, workplaces, and communities are far more important to their health than so-called lifestyle choices such as using tobacco or excessive alcohol consumption, eating fruits and vegetables, or partaking in physical activity. This relationship between living and working conditions and health outcomes applies across developed and developing nations Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  4 Social Determinants of Health (Gordon, 2010; Nettleton, 1997; Tesh, 1990). These findings have not been lost upon the writers of Canadian government and public health documents. Since the mid-1970s, Canadian governmental and public health agencies have produced numerous statements and policy documents that have contributed to health promotion efforts worldwide. In large part, Canada’s reputation as a “health-promotion powerhouse” comes from the high quality of the concepts and ideas contained within these documents (Rootman, Dupéré, Pederson, & O’Neill, 2012). Nevertheless, even a cursory examination of prevailing governmental activities focused on actually promoting health—as opposed to documents talking about promoting health— sees little evidence that applications of these concepts have been put into practice (Bryant, Raphael, Schrecker, & Labonté, 2011). The profound gap between Canadian health promotion word and deed is well documented (Hancock, 2011; Raphael, 2008). Instead of efforts to improve Canadians’ living conditions, individualized approaches focused on biomedical and behavioural risk factors—with some notable exceptions—dominate governmental, media, and disease association discussions and health promotion efforts (Raphael, 2012a). When living conditions are considered by governmental authorities, it is usually to identify those Canadians whose living conditions are said to put them at risk for making “unhealthy lifestyle choices” rather than creating public policy to improve their living circumstances. Rather than improving the adverse living and working conditions people are experiencing, activities focus on targeting the victims of these adverse living and working conditions for behavioural change. This is the case even though health behaviours are known to be rather less important determinants of health than these conditions themselves. The effect of all this is to add insult (victim blaming) to injury (the experience of adverse living and working conditions) (Raphael, 2011a). Interestingly, there is significant public concern about social determinants of health such as income inequality, precarious employment, and a weakening social safety net, but the strong links between these and health are not generally recognized (Broadbent Institute, 2014; Shankardass, Lofters, Kirst, & Quiñonez, 2012). Considering the ongoing barrage of lifestyle messaging that Canadians have been subjected to for decades, it is not Copyright © 2016. Canadian Scholars. All rights reserved. surprising that Canadians have limited awareness of the important role social determinants of health such as income, employment, and working conditions play in determining health (Eyles et al., 2001; Kenney & Moore, 2013; Paisley, Midgett, Brunetti, & Tomasik, 2001). The mass media reinforces these understandings through its uncritical reporting of any and all studies of how a particular gene or behaviour (e.g., drinking coffee or white wine, eating peanuts, consuming tomatoes, sleeping more than or less than eight hours a night, watching too much TV, playing computer games, etc.) either protects from or predicts various adverse health outcomes (Gasher et al., 2007; Hayes et al., 2007; Raphael, 2011b). That these findings may be weak and contradictory to findings presented a week or two earlier does little to slow these reporting onslaughts. This volume therefore has two rather daunting tasks: (1) to advance the understandings Canadians hold concerning the social determinants of health; and (2) to provide support for efforts to improve the quality and equitable distribution of the social determinants of health through the development of health-promoting public policies. Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  Social Determinants of Health 5 In this chapter, I review the social determinants of health concept and present recent theoretical developments and empirical findings. I provide the rationale for selecting the social determinants of health included in the volume and explore a number of key themes in the field. Throughout this presentation, the social determinants of health approach is contrasted with the traditional approach to disease prevention focused on biomedical and behavioural risk factors. I conclude by asking the reader to consider how Canadians’ understandings concerning the determinants of health and current Canadian policy environments affect both the quality and distribution of these social determinants of Canadians’ health and Canadian policy makers’ receptivity to the ideas contained within this volume. AN HISTORICAL PERSPECTIVE ON THE SOCIAL DETERMINANTS OF HEALTH During the mid-1800s, political economist Friedrich Engels studied how poor housing, clothing, diet, and lack of sanitation led directly to the infections and diseases associated with early death among working-class people in England. Engels identified material living conditions, day-to-day stress, and the adoption of health-threatening behaviours as the primary contributors to social class differences in health (Engels, 1987): All conceivable evils are heaped upon the poor.… They are given damp dwellings, cellar dens that are not waterproof from below or garrets that leak from above.… They are supplied bad, tattered, or rotten clothing, adulterated and indigestible food. They are exposed to the most exciting changes of mental condition, the most violent vibrations between hope and fear…. They are deprived of all enjoyments except sexual indulgence and drunkenness and are worked every day to the point of complete exhaustion of their mental and physical energies.… (p. 129) Around the same time, Rudolph Virchow ( 1985) identified how health- threatening living conditions were rooted in public policy making and emphasized the Copyright © 2016. Canadian Scholars. All rights reserved. role that politics plays in promoting health and preventing disease (see Box 1.1). These issues never completely disappeared from public health preoccupations, but over the past 40 years have received rather less emphasis than biomedical and behavioural approaches to health promotion and disease prevention (Raphael, 2001a). British Contributions The 1980 publication of the Black Report and the 1992 publication of the Health Divide in the United Kingdom (UK) (Townsend et al., 1992) sparked interest in how social conditions shape health. These UK reports described how lowest employment-level groups showed a greater likelihood of a wide range of diseases and premature death from illness or injury at every stage of the life cycle. Additionally, health differences occurred in a step-wise progression across the socioeconomic range, with professionals having the best health and manual labourers the worst. Skilled workers’ health was midway between the extremes. These health differences emerged even though the UK had developed a Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  6 Social Determinants of Health Box 1.1 Rudolph Virchow and the social determinants of health German physician Rudolph Virchow’s (1821–1902) medical discoveries were so extensive that he is known as the “Father of Modern Pathology.” But he was also a trailblazer in identifying how societal policies determine health. In 1848, Virchow was sent by the Berlin authorities to investigate the epidemic of typhus in Upper Silesia. His Report on the Typhus Epidemic Prevailing in Upper Silesia argued that lack of democracy, feudalism, and unfair tax policies in the province were the primary determinants of the inhabitants’ poor living conditions, inadequate diet, and poor hygiene that fuelled the epidemic. Virchow stated that “Disease is not something personal and special, but only a manifestation of life under modified (pathological) conditions.” Arguing “Medicine is a social science and politics is nothing else but medicine on a large scale,” Virchow drew the direct links between social conditions and health. He argued that improved health required recognition that “If medicine is to fulfil her great task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society?” ( 1985). The authorities were not happy with the report and Virchow was relieved of his government position. But he continued his pathology research within university settings and went on to a parallel career as a member of Berlin City Council and the Prussian Diet, where he focused on public health issues consistent with his Upper Silesia report. Virchow also bitterly opposed Otto von Bismarck’s plans for national rearmament and was challenged to a duel by said gentleman. Virchow declined participation. universally accessible health care system at the end of the Second World War. These two reports—and the many that have followed up on these themes—stimulated the study of health inequalities and the factors that determine these inequalities, and directed attention to the role that public policy plays in either increasing or reducing health inequalities (Acheson, 1998; Benzeval, Judge, & Whitehead, 1995; Gordon, Shaw, Dorling, & Davey Smith, 1999; Marmot & Wilkinson, 2006; Smith, Bambra, & Hill, 2015). Health inequalities and the social determinants of these inequalities continue as active areas of inquiry among British researchers (Raphael & Bryant, 2015). These studies frequently focus on inequalities in health among members of different employment strata Copyright © 2016. Canadian Scholars. All rights reserved. with recognition that membership in such groups is strongly correlated with income and education levels. British researchers also study the health effects of poverty and how indicators of disadvantage cluster together (Gordon & Townsend, 2000; Lansley & Mack, 2015; Pantazis, Gordon, & Levitas, 2006). Much of the best research and data on the links between social determinants of health and health outcomes are British, as are some of the best theorizations of how these factors influence health across the lifespan. The UK is also the source of many ideas about how to apply these findings to promote health (Graham, 2004b; Raphael & Bryant, 2015). Canadian Contributions Canadians have actively theorized the relationship between economic and social conditions and health. In 1974, the federal government’s A New Perspective on the Health of Canadians identified human biology, environment, lifestyle, and health care organization Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  Social Determinants of Health 7 as determinants of health (Lalonde, 1974). The document was important in outlining determinants of health outside of the health care system. Another Canadian government document, Achieving Health for All: A Framework for Health Promotion, outlined reducing inequities between income groups as an important goal of government policy (Epp, 1986). This would be accomplished by implementing policies in support of health in the areas of income security, employment, education, housing, business, agriculture, transportation, justice, and technology, among others. Health Canada’s (1998) Taking Action on Population Health: A Position Paper for Health Promotion and Programs Branch Staff states that: 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. (p. 1) Canadian Public Health Association (CPHA) documents tell a similar story. In 1986, its Action Statement for Health Promotion in Canada identified advocating for healthy public policies as the single best strategy to affect the determinants of health (CPHA, 1996). Priority actions included reducing inequalities in income and wealth, and strengthening communities through local alliances to change unhealthy living conditions. In 2000, the CPHA endorsed an action plan that recognized poverty’s profound influence upon health and identified means to reduce it (CPHA, 2000). Other CPHA reports document the health effects of unemployment, income insecurity, homelessness, and general economic conditions (Manzano & Raphael, 2010). Yet despite these contributions, there has been little if any penetration of these concepts into Canadian public policy making. This is in sharp contrast to elsewhere where the social determinants of health and their role in creating health inequalities has been the subject of concerted governmental action at all levels of government (Raphael, 2012b). The Copyright © 2016. Canadian Scholars. All rights reserved. discrepancy between Canadian rhetoric and action may be due to the dominant ideologies that shape Canada’s economic and political systems. The study of the social determinants of health therefore deals with three key problems: 1. What are the societal factors (e.g., income, education, employment conditions, etc.) that shape health and help explain health inequalities? 2. What are the societal forces (e.g., economic, social, political) that shape the quality and distribution of these factors? 3. What is it about Canada’s economic and political systems that make addressing the social determinants of health through public policy so difficult? The next section identifies key concepts and themes informing the study of the social determinants of health. Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  8 Social Determinants of Health WHAT EXACTLY ARE THE SOCIAL DETERMINANTS OF HEALTH? The term “social determinants of health” grew out of researchers’ attempts to identify the specific exposures by which members of different socioeconomic groups came to experience varying health outcomes. While it was well-documented that individuals in various socioeconomic groups experienced differing health outcomes, the specific factors and means by which these factors led to these health outcomes remained unidentified. The term “social determinants of health” made its debut in the 1979 volume The Political Economy of Health (Doyle & Pennell, 1979), in which the issues of social and economic organization of society and the health-related effects of the distribution of income and resource distribution were raised. Also noted were the health effects of stress that results from unemployment and insecure employment. In 1996, Tarlov took the environment health field from the Lalonde Report—the others being biology and genes, health care, and lifestyle—and fleshed out broader “social determinants of health” (Tarlov, 1996). In his model, inequalities in housing, education, social acceptance, employment, and income translate into disease-related processes through the experienced contrast between expectation and reality. The World Health Organization (WHO) followed this work up with its Social Determinants of Health: The Solid Facts document (Wilkinson & Marmot, 2003). In Canada, Social Determinants of Health: The Canadian Facts detailed the Canadian scene (Mikkonen & Raphael, 2010). The WHO’s Commission on Social Determinants of Health provided an encyclopedic analysis of how social determinants of health come to affect health (WHO, 2008). The social determinants of health concept also helps explain how nations come to differ in overall population health. As one illustration, the health of Americans compares poorly to the health of citizens in most other industrialized nations (Organisation for Economic and Co-operative Development, 2013). This is the case for life expectancy, infant mortality, and death by childhood injury, despite the US’s overall greater wealth (Bezruchka, 2012). In contrast, the population health of Norway is generally superior to most other nations (Fosse, 2012). Could the same social determinants of health that explain health differences within national populations account for health differences seen between Copyright © 2016. Canadian Scholars. All rights reserved. national populations? And why would nations differ so much in terms of the quality and distribution of the social determinants of health experienced by their citizens? Current Concepts of the Social Determinants of Health There are a variety of contemporary approaches to social determinants of health. The commonalities among these are particularly illuminative. The Ottawa Charter for Health Promotion identifies the “prerequisites for health” as peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity (WHO, 1986). These prerequisites of health are concerned with structural aspects of society and the organization and distribution of economic and social resources. In 1992, Dahlgren and Whitehead formulated their rainbow model of health determinants in which the “living and working conditions” arch identified agriculture and food production, education, work environment, unemployment, water and sanitation, health care services, and housing as contributors to health (Dahlgren & Whitehead, 1992). Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  Social Determinants of Health 9 Health Canada outlines various determinants of health—many of which are social determinants—of income and social status, social support networks, education, employment and working conditions, physical and social environments, biology and genetic endowment, personal health practices and coping skills, healthy child development, health services, gender, and culture (Health Canada, 1998). These determinants were adapted from work done by the Canadian Institute for Advanced Research (Evans, Barer, & Marmor, 1994). Within this framework, the specific concepts of physical and social environments have been criticized for lacking grounding in concrete experiences of people’s lives and lacking policy relevance—that is, there usually is no Ministry of Physical Environments or Ministry of Social Environments (Bryant et al., 2004). A British working group charged with specifying the social determinants of health identified the social (class health) gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transport (Wilkinson & Marmot, 2003). This listing is more grounded in the everyday experience of people’s lives and policy-making structures and avoids the potential problem of policy irrelevance. Indeed, the stimulus for this work was the European Office of the WHO aiming to raise these issues among policy makers and the public. Finally, the US Centers for Disease Control and Prevention (CDC) highlights social determinants of health of socioeconomic status, transportation, housing, access to services, discrimination by social grouping (e.g., race, gender, or class), and social or environmental stressors (CDC, 2006). ORIGINS OF THE CANADIAN SOCIAL DETERMINANTS OF HEALTH CONFERENCE AND THIS VOLUME As I became more familiar with the social determinants of health field, my surprise grew at Canada’s shortcomings in addressing these important issues through public policy action. As noted, numerous studies indicated that various social determinants of health have far greater influence on health and the incidence of illness than traditional biomedical and behavioural risk factors. Additionally, scholarship on the state and quality of various social determinants of health in Canada had been finding their quality to be deteriorating. Yet for Copyright © 2016. Canadian Scholars. All rights reserved. the most part, policy makers, the media, and the general public remained poorly informed concerning these issues. Indeed, it appears at times—especially during the retrenchments in public policy that began during the late 1980s and continue to this day—that much of the public policy agenda seems designed to threaten, rather than support, the health of Canadians by weakening the quality of many social determinants of health and making their distribution less equitable (Raphael, 2001b; Raphael & Bryant, 2006). These concerns about the neglect of the social determinants of health led to my applying through York University’s School of Health Policy and Management to Health Canada’s Policy Research Program for funding to organize a national conference entitled Social Determinants of Health across the Lifespan: A Current Accounting and Policy Implications. The purpose of the conference was to: (1) consider the state of several key social determinants of health across Canada; (2) explore the implications of these conditions for the health of Canadians; and (3) outline policy directions to strengthen these social determinants of health. The conference was organized around a synthesis that Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  10 Social Determinants of Health identified 12—since increased to 16—social determinants of health especially relevant to Canadians (see Box 1.2). Some of these are actually social locations in that they refer to aspects of one’s personal identity such as Indigenous ancestry, disability, gender, immigrant status, and race. In Canadian society, these social locations are indicators of power and influence, and are strongly related to access to economic and social resources, that is, the social determinants of health. Four criteria were used to identify these social determinants of health. The first criterion was that the social determinant be consistent with most existing formulations of the social determinants of health and associated with an existing empirical literature as to its relevance to health. All these social determinants of health are important to the health of Canadians. The second criterion was that the social determinant of health be consistent with lay/public understandings of the factors that influence health and well-being. This was ascertained through assessment of available empirical work on Canadians’ understandings of what aspects of Canadian life contribute to health and well-being. All these social determinants of health are understandable to Canadians. The third criterion was that the social determinant of health be clearly aligned with existing governmental structures and policy frameworks (e.g., ministries of education, housing, labour, Indigenous affairs, women’s issues, etc.). All these social determinants of health have clear policy relevance to Canadian decision makers and citizens. The fourth criterion was that the social determinant of health be an area of either active governmental policy activity (e.g., health care services, education) or policy inactivity that has provoked sustained criticism (e.g., food security, housing, social safety net, etc.). All these social determinants of health are especially timely and relevant. The inclusion of health services, geography, the social safety net, disability, immigrant status, and Indigenous ancestry as social determinants of health is not common to most conceptualizations. Health services are included in the belief that a well-organized and rationalized health care system could be an important social determinant of health—if this is not currently the case. In Canada, geography, especially in relation to the North, is an important factor shaping availability of resources. The social safety net is increasingly Copyright © 2016. Canadian Scholars. All rights reserved. recognized as an important determinant of the health of populations, but to date has not been explicitly included in most formulations. Indigenous ancestry is another social determinant of health that is not explicitly explored in most conceptualizations of the social determinants of health. It represents the interaction of culture, public policy, and the mechanisms by which the history of colonialism and systematic exclusion from participation in Canadian life profoundly affects health. Gender and how its meaning is constructed within Canadian society is an important social determinant of health. It interacts with all other social determinants of health to influence the health and well-being of Canadians. Finally, disability, race, and immigrant status are important social locations that determine access to economic and social resources necessary for health. As a result of that conference, the profile of the social determinants of health was raised across Canada. One outcome was the first and second editions of Social Determinants of Health: Canadian Perspectives (Raphael, 2004, 2009). The second was the drafting and ratification of Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  Social Determinants of Health 11 the Toronto Charter on the Social Determinants of Health (Raphael, Bryant, & Curry-Stevens, 2004; see Appendix). The third was the establishment of a “Social Determinants of Health” listserv at York University in Canada. Six years have passed since the second edition of this book appeared, and new insights have arisen concerning the social determinants of health and the barriers to their influencing public policy in the service of health. This volume updates and expands upon the findings and insights presented in that edition. Box 1.2 The Social Determinants of Health Framework The 16 social determinants of health spawned by the York University conference form the basis for the content of this volume. These are: Indigenous ancestry disability early life education employment and working conditions food security gender geography health care services housing immigrant status income and its distribution race social safety net social exclusion unemployment and employment security CURRENT THEMES IN THE SOCIAL DETERMINANTS OF HEALTH FIELD Copyright © 2016. Canadian Scholars. All rights reserved. Five themes inform the presentation and understanding of the material in this volume: (1) empirical evidence concerning the social determinants of health; (2) mechanisms and pathways by which social determinants of health influence health; (3) the importance of a lifecourse perspective; (4) the role that public policy environments play in determining the quality of the social determinants of health within jurisdictions; and (5) the role that political ideology plays in shaping state and societal receptivity to social determinants of health concepts. Each is considered in turn. Theme 1: Empirical Evidence of the Importance of the Social Determinants of Health Much of this volume is concerned with presenting the empirical evidence of how social determinants of health shape health. From an overall perspective, the quality and Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  12 Social Determinants of Health distribution of various social determinants of health to which citizens are exposed provides explanations for: (1) improvement in health outcomes among Canadians over the past 100 years; (2) persistent differences in health outcomes among Canadians; and (3) differences in overall health outcomes among Canada and other developed nations. The Social Determinants of Improved Health among Canadians since 1900 Profound improvements in health outcomes have occurred in industrialized nations such as Canada since 1900. It has been hypothesized that access to improved medical care is responsible for these differences, but best estimates are that only 10 to 15 percent of increased longevity since 1900 is due to improved health care (McKinlay & McKinlay, 1987). As one illustration, the advent of vaccines and medical treatments are usually held responsible for the profound declines in mortality from infectious diseases in Canada since 1900. But by the time vaccines for diseases such as measles, influenza, and polio and treatments for scarlet fever, typhoid, and diphtheria appeared, dramatic declines in mortality had already occurred. Improvements in behaviour (e.g., reductions in tobacco use, changes in diet, etc.) have also been hypothesized as responsible for improved longevity, but most analysts conclude that improvements in health are due to the improving material conditions of everyday life experienced by Canadians since 1900 (McKeown, 1976; McKeown & Record, 1975). These improvements occurred in the areas of early childhood, education, food processing and availability, health and social services, housing, employment security and working conditions, and every other social determinant of health. Much of the current volume is concerned with the present state and distribution of these social determinants of health and how they shape the health outcomes of Canadians. Particularly important is the question of how recent policy decisions are either improving or weakening the quality and distribution of these social determinants of health. The Social Determinants of Health Inequalities among Canadians Despite dramatic improvements in health in general, significant inequalities in health among Canadians persist (Tjepkema, Wilkins, & Long, 2013). Access to essential medical Copyright © 2016. Canadian Scholars. All rights reserved. procedures is guaranteed by medicare in Canada. Nevertheless, access issues are common and this is particularly the case with regard to required prescription medicines where income is a strong determinant of such access (Raphael, 2007). It is believed, however, that health care issues account for a relatively small proportion of health outcomes differences among Canadians (Siddiqi & Hertzman, 2007). As for differences in health behaviours (e.g., tobacco and excessive alcohol use, diet, and physical activity), studies from as early as the mid-1970s—reinforced by many more studies since then—find their impact upon health to be less important than social determinants of health such as income and others examined in this volume (Raphael & Farrell, 2002; Raphael et al., 2012). Evidence indicates that health differences among Canadians result primarily from experiences of qualitatively different environments associated with the social determinants of health. As an example, an overview of the magnitude of differences in health outcomes related to the social determinant of health of income is provided. Income is especially important as it serves as a marker of different experiences with many social determinants Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  Social Determinants of Health 13 of health (Raphael, Macdonald, et al., 2004). Income is a determinant of health in itself, but it is also a determinant of the quality of early life, education, employment and working conditions, and food security. Income also is a determinant of the quality of housing, the need for a social safety net, the experience of social exclusion, and the experience of unemployment and employment insecurity across the lifespan (Mikkonen & Raphael, 2010). Also, a key aspect of Indigenous ancestry and the experiences of women, immigrants, people of colour, and persons with disabilities in Canada is their greater likelihood of living under conditions of low income (Raphael, 2011c). Income is a prime determinant of Canadians’ premature years of life lost and premature mortality from a range of diseases (see Box 1.3). In the UK, numerous studies indicate that income levels during early childhood, adolescence, and adulthood are all independent predictors of who develops and eventually succumbs to disease (Davey Smith, 2003). Box 1.3 Statistics Canada study of income-related premature mortality In Canada, data on individuals’ income and social status are not routinely collected at death, so national examination of the relationship between income and mortality from various diseases uses census tract of residence to estimate individuals’ income. There is potential for error in these analyses that relate income to death based on residential area, since some low-income people live in well-off neighbourhoods and vice versa. Essentially, these analyses are conservative estimates of the relationship between income level and death rates. The most recent available data show that in 1996, Canadians living within the poorest 20 percent of urban neighbourhoods were more likely to die from cardiovascular disease, cancer, diabetes, and respiratory diseases—among other diseases—than other Canadians (Wilkins et al., 2002). Figure 1.1 shows the percentage of premature years of life lost in urban Canada that can be attributed to various diseases and to income differences. Cancers are the leading cause of premature years of life lost, accounting for 31 percent of these. Injuries and circulatory diseases (heart disease and stroke) are also leading causes of premature years of life lost. However, the percentage of premature years of life lost that can be attributed to income differences among Canadians is also very high at 23 percent, a magnitude that is greater than all years lost to either injuries or circulatory disease, and approaches the Copyright © 2016. Canadian Scholars. All rights reserved. level of cancers. This is also the case in Canada. Income is an exceedingly good predictor of incidence and mortality from a variety of diseases. About 20 percent of excess premature years of life lost prior to age 75 can be attributed to income differences among Canadians (see Figure 1.1). The figure of 20 percent in Figure 1.1 is calculated by using the mortality rates in the wealthiest quintile of neighbourhoods as a baseline and considering all deaths above that rate to be “excess” related to income differences. Therefore, 20 percent of all of the premature years of life lost to Canadians can be accounted for by differences among wealthy, middle-, and low-income Canadians (Wilkins, 2007). Income-related premature years of life lost are focused upon specific diseases. What are the diseases that differentially kill people of varying income levels? As shown in Figure 1.2, the diseases most related to income differences in mortality among Canadians are heart Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  14 Social Determinants of Health Figure 1.1: Percentage of premature years of life lost (0–74 years) to Canadians in urban Canada due to various causes, 1996 Neoplasms 30.9 Income-related 23.1 Injuries 19.2 Circulatory 17.6 Infectious 5.3 Perinatal 4.9 Ill-defined 4.8 Congenital 3.8 All other 13.5 0 5 10 15 20 25 30 35 Source: Adapted from Statistics Canada. (2002).Percentage of Premature Years of Life Lost (0–74 yrs) to Canadians in Urban Canada Due to Various Causes, 1996. Health Reports—Supplement. Catalogue 82-003, Volume 13, 2002 Annual Report, Chart 9, p. 54. disease and stroke. Importantly, premature death by injuries, cancers, infectious disease, and others are all strongly related to income differences among Canadians. A 2013 report by Statistics Canada further highlights how important income is as a social determinant of health. The study shows that income differences are associated with the excess deaths of 40,000 Canadians a year (Tjepkema, Wilkins, & Long, 2013). That’s equal to 110 Canadians dying prematurely each day. How does this report arrive at this conclusion? Researchers followed 2.7 million Canadians over a 16-year period Figure 1.2: Percentage of income-related premature years of life lost (0–74 yrs) caused by specific diseases in urban Canada, 1996 Copyright © 2016. Canadian Scholars. All rights reserved. Circulatory 21.6 Injuries 16.9 Neoplasms 14 Infectious 12.2 Ill-defined 8.3 Perinatal 7.1 Digestive 5.4 All other 14.5 0 5 10 15 20 25 Source: Adapted from Statistics Canada. (2002). Percentage of Income-Related Premature Years of Life Lost (0–74 yrs) Caused by Specific Diseases in Urban Canada, 1996. Health Reports—Supplement. Catalogue 82-003, Volume 13, 2002 Annual Report, Chart 10, p. 54. Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  Social Determinants of Health 15 and calculated death rates from a wide range of diseases and injuries as a function of the person’s income. Canadians in the study were divided into five quintiles of approximately equal numbers from poorest to wealthiest. It then compared the number of deaths of the wealthiest 20 percent of Canadians to the other 80 percent of Canadians. It came to the conclusion that if all Canadians were as healthy as the top 20 percent of Canadian income earners, there would be approximately 40,000 fewer deaths each year. Of these, 25,000 fewer deaths would be among Canadian men and 15,000 among Canadian women. These numbers are comparable to eliminating all deaths from a major killer of Canadians, coronary artery disease. The report also calculates the relative rate of mortality, comparing the likelihood of death between someone in the poorest 20 percent of Canadians and one of the wealthiest 20 percent of Canadians. Overall, this figure is 1.67 for men and 1.52 for women, indicating that a poor male has a 67 percent greater chance of dying each year and a poor woman has a 52 percent greater chance of dying each year than their wealthy counterparts. That’s an overall excess death rate of 19.4 percent for men and 16.6 percent for women. The study goes into further detail, outlining income-related statistics for specific diseases. Table 1.1 shows the greater risk associated with being poor as compared to wealthy and excess mortality associated with income differences between the wealthy and all other Canadians for various diseases and injuries. Poor Canadian males have a 67 percent greater chance of dying each year from heart disease than their wealthy counterparts. For women, it’s a difference of 53 percent. The excess cardiovascular deaths each year associated with not being as healthy as the wealthy are 19 percent for men and 18 percent for women. In relation to mortality from diabetes, the figures are even more striking. Poor Canadian men have a 150 percent greater chance and poor women a 160 percent greater Table 1.1: Greater risk of dying associated with being poor as compared to wealthy (RR) and excess deaths associated with income inequality for various diseases and injuries among Canadians Copyright © 2016. Canadian Scholars. All rights reserved. RR1 Excess deaths (%)2 Disease Men Women Men Women Cardiovascular disease 1.67 1.53 19 18 Cancers 1.46 1.30 16 11 Diabetes 2.49 2.64 36 38 Respiratory disease 2.31 2.11 37 30 HIV/AIDS 3.57 11.10 39 69 Injuries 1.88 1.83 18 17 Notes: 1. Inter-quintile rate ratio between poorest and wealthiest = (Q1-Poorest)/(Q5-Wealthiest); 2. Percent excess deaths due to differences between wealthy and all other Canadians = 100*(Total-Q5)/Total Source: Adapted from Tjepkema, M., Wilkins, R., & Long, A. (2013). Cause-Specific Mortality by Income Adequacy in Canada: A 16-Year Follow-Up Study. Health Reports, 24(7), 14–22: Tables 2 and 3, pp. 17–18. Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  16 Social Determinants of Health chance of dying from diabetes each year than wealthy Canadians. This means that if all Canadians were as healthy as wealthy Canadians, there would be nearly 40 percent fewer deaths from diabetes and nearly 20 percent fewer deaths from cardiovascular disease every year. Similar numbers showing a profound difference between wealthy and poor Canadians and between wealthy and all other Canadians appear for virtually every known disease that can kill Canadians, including cancer, respiratory disease, injuries, HIV/AIDS, and many more. The Statistics Canada report also makes clear that these differences in health outcomes are primarily due to the material living circumstances and the associated psychosocial stresses associated with not being as well-off as the wealthiest 20 percent of Canadians, not differences in health-related behaviours: “Income influences health most directly through access to material resources such as better quality food and shelter” (Tjepkema, Wilkins, & Long, 2013, p. 14). As another example of the importance of income, the incidence and prevalence of adult- onset diabetes in Canada is primarily related to income level, not weight, physical activity, or even education level (Dinca-Panaitescu et al., 2011, 2012). This was also demonstrated to be the case for heart disease as early as the 1970s (Raphael & Farrell, 2002). While governments, medical researchers, and disease associations emphasize traditional adult risk factors (e.g., cholesterol levels, diet, physical inactivity, and tobacco and excessive alcohol use), it is well established that these are relatively poor predictors of heart disease, stroke, and type 2 diabetes rates among populations. The factors making a difference are living under differing conditions of advantage and disadvantage as children and adults, stress or lack of stress associated with such conditions, and the adoption or denial of health-threatening behaviours as a means of coping with these differing circumstances. In fact, difficult living circumstances during childhood are especially good predictors of these diseases (Barker, Osmond, & Simmonds, 1989; Davey Smith & Hart, 2002; Eriksson et al., 1999). In addition to predicting adult incidence and death from disease, income differences— and the other social determinants of health related to income—are also related to the health of Canadian children and youth. Canadian children living in low-income families Copyright © 2016. Canadian Scholars. All rights reserved. are more likely to experience greater incidence of a variety of illnesses, hospital stays, accidental injuries, mental health problems, lower school achievement and early drop-out, family violence and child abuse, among other issues (Raphael, 2014a). In fact, low-income children show higher incidences of just about any health-, social-, or education-related problem, however defined. These differences in problem incidence occur across the income range, but are most concentrated among low-income children (Raphael, 2010a, 2010b). The Social Determinants of Health Differences between Nations Profound differences in overall health outcomes exist between developed and developing nations. Much of this has to do with the lack of the basic necessities of life (food, water, sanitation, primary health care, etc.) common to developing nations. Yet among developed nations such as Canada, less profound but highly significant differences in health outcomes indicators such as life expectancy, infant mortality, incidence of disease, and death from injuries exist. An excellent example is comparison of health outcomes differences and the Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  Social Determinants of Health 17 hypothesized social determinants of these health outcomes differences among Canada, the US, and Norway. Table 1.2 shows how Canada, the US, and Norway fare on a number of social determinants of health and indicators of population health. Canada now ranks 13th among the member nations of the OECD in life expectancy (we ranked 8th in 1980) and 26th in infant mortality (we ranked 10th in 1980) (OECD, 2013). Our low birthweight rate falls behind 11 other nations, most of which are not as wealthy as Canada, and our ratings for child well-being were so poor it led UNICEF Canada to offer a special report on the Canadian situation entitled Stuck in the Middle (UNICEF Canada, 2013). We now spend less of our gross domestic product (GDP) on social programs and supports expenditures than even the US (OECD, 2014). Canada is amongst the lowest in covering health care expenses through the public system. And if you fall upon hard times, Canada provides one of the the lowest minimum-income supports. This is the case despite Canada being ranked 11th of 34 OECD nations in overall wealth, that is, GDP per capita adjusted for spending power (Ekonoifakta, 2015). Scholarship has noted that the US takes an especially laissez-faire approach to providing various forms of security (employment, food, income, and housing) and health and social Table 1.2: Norway, Canada, and US rankings on selected social determinants of health and indicators of population health in comparison to other OECD nations (c. 2010) (n=34) Measure Ranking (1 is best) Norway Canada US Social Determinants of Health % Living in poverty1 (2010) 8 23 30 No money for food during past year 1 9 20 29 (2011/2012) Income inequality1 (2010) 3 23 31 Copyright © 2016. Canadian Scholars. All rights reserved. Public social expenditure (2010) 1 16 26 23 Minimum-income benefit (single person) 1 14 27 29 (2011) Public share health spending4 (2012) (n=30) 3 20 30 Health Life expectancy2 (2011) 10 13 26 Infant mortality (2011) 2 4 26 30 Low birthweight2 (2011) 5 12 28 Child well-being (2009-2011) (n=29) 3 2 17 26 Notes: 1. OECD. (2014). Society at a glance. Paris: OECD; 2. OECD. (2013). Health at a glance. Paris: OECD; 3. Innocenti Research Centre (2013). Child well-being in rich countries: A comparative overview. Florence: Innocenti Research Centre; 4. Canadian Institute for Health Information (CIHI). (2014). National health expenditure trends, 1975 to 2014. Ottawa: Author. Social Determinants of Health, Third Edition : Canadian Perspectives, edited by Dennis Raphael, Canadian Scholars, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/york/detail.action?docID=6336469. Created from york on 2022-09-12 19:54:35.  18 Social Determinants of Health services, while Norway’s welfare state makes extraordinary efforts to provide security and services (Bezruchka, 2012; Fosse, 2012; Raphael, 2012b). The sources of these differences in public policy appear to be in differing commitments to citizen support informed by the political ideologies of governing parties within each nation (Raphael, 2012b). Nations such as Norway, whose policies reduce unemployment, minimize income and wealth inequality, and address numerous social determinants of health, show evidence of improved population health using indicators such as infant mortality and life expectancy (Fosse, 2012). At the other end, nations with minimal commitments to such efforts, such as the United States, show rather worse indicators of population health (Bezruchka, 2012). Theme 2: Mechanisms and Pathways by Which Social Determinants of Health Influence Health To secure the policy relevance of the social determinants of health and build support for their strengthening, it is important to understand how social determinants of health come to influence health and cause disease. Theoretical thinking considers how social determinants of health “get under the skin” to influence health. The Black and Health Divide reports considered two primary mechanisms for understanding health inequalities: cultural/ behavioural and materialist/structuralist (Townsend, Davidson, & Whitehead, 1992). The cultural/behavioural explanation holds that individuals’ behavioural choices (e.g., toba