Social determinants of health The_Canadian_Facts-2nd_ed.pdf

Social Determinants of Health: The Canadian Facts Juha Mikkonen Dennis Raphael [COVER] Social Determinants of Health THE CANADIAN FACTS 2nd Edition Dennis Raphael Toba Bryant Juha Mikkonen Alexander Raphael Social Determinants of Health: The Canadian Facts, 2nd Edition Raphael, D., Bryant, T.,...

Social Determinants of Health: The Canadian Facts Juha Mikkonen Dennis Raphael [COVER] Social Determinants of Health THE CANADIAN FACTS 2nd Edition Dennis Raphael Toba Bryant Juha Mikkonen Alexander Raphael Social Determinants of Health: The Canadian Facts, 2nd Edition Raphael, D., Bryant, T., Mikkonen, J. and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. The publication is available at http://www.thecanadianfacts.org/ Cover Design by Alexander Raphael and Juha Mikkonen. Cover photo: Double-crested cormorant (Phalacrocorax auritus) nesting at Tommy Thompson Park, Toronto. Photographs by Alexander Raphael. Formatting, Design and Content Organization by Juha Mikkonen. Funding for this project was provided by Ontario Tech University Faculty of Health Sciences. Copyright © 2020 Dennis Raphael, Toba Bryant, Juha Mikkonen and Alexander Raphael. Library and Archives Canada Cataloguing in Publication Social Determinants of Health: The Canadian Facts, 2nd Edition / Dennis Raphael, Toba Bryant, Juha Mikkonen and Alexander Raphael ISBN 978-0-9683484-2-0 1. Public health—Social aspects—Canada. 2. Public health—Economic aspects—Canada. 3. Medical policy— Social aspects—Canada. I. Raphael, Dennis, II. Bryant, Toba, III Mikkonen, Juha and IV Raphael, Alexander Social Determinants of Health: The Canadian Facts (2nd Edition) Authors and Contributors Foreword to the Second Edition by Claire Betker, RN, PhD, CCHN(C) Foreword to the First Edition by the Honourable Monique Bégin 1. Introduction..................................................................................................................................11 2. Stress, Bodies, and Illness...............................................................................................................15 3. Income and Income Distribution.................................................................................................17 4. Education......................................................................................................................................21 5. Unemployment and Job Security..................................................................................................24 6. Employment and Working Conditions........................................................................................27 7. Early Child Development..............................................................................................................31 8. Food Insecurity.............................................................................................................................34 9. Housing........................................................................................................................................38 42 10. Social Exclusion.................................................................................................................................... 45 11. Social Safety Net.............................................................................................................................. 12. Health Services...........................................................................................................................48 13. Geography...................................................................................................................................52 14. Disability......................................................................................................................................55 15. Indigenous Ancestry....................................................................................................................59 16. Gender........................................................................................................................................63 67 17. Immigration.................................................................................................................................. 18. Race ............................................................................................................................................71 75 19. Globalization ................................................................................................................................. 20. What You Can Do ......................................................................................................................79 21. Epilogue: The Welfare State and the Social Determinants of Health..........................................84 Appendix I. Resources and Supports.................................................................................................88 Appendix II. Quotation Sources........................................................................................................91 AUTHORS AND CONTRIBUTORS Dennis Raphael, PhD (Toronto, Canada) is a Professor of Health Policy and Management at the School of Health Policy and Management at York University. He is the editor of Social Determinants of Health: Canadian Perspectives (2016, 3rd edition), Health Promotion and Quality of Life in Canada: Essential Readings (2010); Immigration, Public Policy, and Health: Newcomer Experiences in Developed Nations (2016) and Tackling Health Inequalities: Lessons from International Experiences (2012); co-editor of Staying Alive: Critical Perspectives on Health, Illness, and Health Care (2019, 3rd edition). He is author of About Canada: Health and Illness (2016, 2nd edition) and Poverty in Canada: Implications for Health and Quality of Life (2020, 3rd edition) and co-author with Toba Bryant of The Politics of Health in the Canadian Welfare State (2020). He manages the Social Determinants of Health Listserv at York University. Contact: draphael [at] yorku.ca Toba Bryant, PhD (Toronto, Canada) is an Associate Professor, Faculty of Health Sciences, at Ontario Tech University in Oshawa, Ontario. She is author of Health Policy in Canada (2016, 2nd edition), and coauthor with Dennis Raphael of The Politics of Health in the Canadian Welfare State. Dr. Bryant is co-editor of Staying Alive: Critical Perspectives on Health, Illness, and Health Care (2019, 3rd edition). She has published numerous book chapters and articles on policy change, housing as a social determinant of health, health within a population health perspective, the welfare state, health equity and community quality of life. Her most recent work is concerned with the effects of plant closures on the health and well-being of laid-off workers and their communities in Oshawa and how these communities are responding to these threats in an age of economic globalization. Contact: toba.bryant [at] uoit.ca Juha Mikkonen, PhD (Helsinki, Finland) is a public policy professional and social psychologist with 18 years of professional experience. Dr. Mikkonen has held leadership positions in numerous non-profit organizations to promote health and well-being. He is Executive Director of the Finnish Association for Substance Abuse Prevention EHYT. He received his PhD in Health Policy and Equity from York University and a Master’s Degree in Social Sciences from the University of Helsinki. Dr. Mikkonen is a practice-oriented expert in substance abuse prevention, health equity, intersectoral action, and the social determinants of health. Previously, as a consultant, Dr. Mikkonen provided expert advice to think tanks and international organizations including the World Health Organization. His public policy contributions include over 80 articles, books, reports, and professional presentations. Contact: mikkonen [at] iki.fi Alexander Raphael (Toronto, Canada) is a third-year photography student in the Bachelor of Fine Arts Image Arts Program at Ryerson University in Toronto. Mr. Raphael has served as the official photographer for the Society for the Advancement of Science in Africa’s 2019 Conference in Toronto and the 2018 Restructuring Work: A Discussion on the Topic of Labour and the Organization of Global Capitalism Conference in Oshawa. He has a professional photography practice in Toronto. Contact: alexraph62 [at] gmail.com AUTHORS AND CONTRIBUTORS • 5 AUTHORS AND CONTRIBUTORS Julia Fursova, PhD, Environmental Studies, is a Post-Doctoral Fellow in Evaluation, Faculty of Education, York University. Her doctoral research examined community action for health justice in urban environments with the focus on the role of non-profit organizations in advancing community participation. She contributed the section on Geography. Morris DC Komakech, MPH, is a PhD Candidate in Health Policy and Equity at York University. His research interests include the social determinants of health, public policy, health equity and the political economy of health. He contributed the section on Race. Ronald Labonté, PhD, is Distinguished Professor and former Canada Research Chair in Globalization and Health Equity in the School of Epidemiology and Public Health, University of Ottawa; and Professor, College of Medicine and Public Health, Flinders University, Australia. He contributed the section on Globalization. Ambreen Sayani, MD, PhD, Health Policy and Equity, holds a Canadian Institutes of Health Research funded Postdoctoral Fellowship in Patient-Oriented research at Women’s College Hospital, Toronto and is a Research Affiliate at the MAP-Centre for Urban Health Solutions, St. Michael’s Hospital. She contributed the section on Immigration. Printed and bound colour copies of this document are available. Details are provided at www.thecanadianfacts.org 6 • AUTHORS AND CONTRIBUTORS FOREWORD TO THE SECOND EDITION The World Health Organization’s Commission on Social Determinants of Health’s final report in 2008 entitled Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health demonstrated how the conditions in which people live and work directly affect their health. Health inequities are differences in health that result from the social conditions in which people live, are systematic across a population, and are considered unfair since most can be avoided. Health inequities are a serious and growing public health issue locally, nationally, and globally. A key approach to reducing health inequities is to address these issues by investing in the social determinants of health that contribute to the majority of health inequities. Creating opportunities for all people to be healthy and lead a dignified life is more than a health issue, it is also a matter of social justice. It is a real pleasure to write the foreword to the Social Determinants of Health: The Canadian Facts, 2nd edition. The first edition, downloaded close to one million times over the past 10 years, provided an accessible and concise introduction to the social determinants of health and contributed significantly to shifting our thinking about what contributes to health and health inequities and what we can do to promote health and reduce these health equities. In this 2nd edition, authors Dennis Raphael, Toba Bryant, Juha Mikkonen and Alexander Raphael provide a very welcome updated perspective on each of the 17 social determinants of health as well as further details of how they matter even more today. This second edition of The Canadian Facts is well-organized, easy to use, and provides a comprehensive source of Canadian data and information about these 17 key social determinants of health which so strongly shape the health of Canadians. This document will be widely used by students, researchers, academics, practitioners, civil society, professional and community organizations, as well as policy and decision makers. As one of six National Collaborating Centres funded by the Public Health Agency of Canada to 2028, the National Collaborating Centre for Determinants of Health (NCCDH) translates and exchanges knowledge and evidence to address the social determinants of health and promote health equity. We support knowledge use to improve health systems, specifically public health systems, including practice, programs, services, structures, research and policies. The Social Determinants of Health: The Canadian Facts is a ‘go to’ resource for the NCCDH and its partners. As the honorable Monique Bégin said in the foreword to the 1st edition, the “Social Determinants of Health: The Canadian Facts, is about us, Canadian society, and what we need to put faces and voices to the inequities – and the health inequities in particular – that exist in our midst.” She predicted that providing a concrete description of the complex and challenging problems that exist across Canada in terms of the social determinants of health would move us to action. This 2nd edition provides an updated description of these “facts” and is certain to be an impetus for real action at all levels. Claire Betker, RN, PhD, CCHN(C) Scientific Director | Directrice scientifique National Collaborating Centre for Determinants of Health | Centre de collaboration nationale des déterminants de la santé St. Francis Xavier University | Université St. Francis Xavier FOREWORD TO THE SECOND EDITION • 7 FOREWORD TO THE FIRST EDITION does it do to treat people’s illnesses, to then send them back to the conditions that made them sick? We have known for a very long time that health This wonderful document, Social Determinants of Health: The Canadian Facts, is about us, Canadian society, and what we need to put faces and voices to the inequities – and the health inequities in particular – that exist in our midst. Only when we see a concrete description of these complex and challenging problems, when we read about their various expressions in all the regions of the country and among the many sub-groups making up Canada, can we move to action. inequities exist. These inequities affect all Canadians but they have especially strong impacts upon the health of those living in poverty. Adding social sciences evidence – the understanding of social structures and of power relationships – we have now accumulated indisputable evidence that “social injustice is killing people on a grand scale.” When the World Health Organization’s Commission on Social Determinants of Health published its final report (containing the quote above) that demonstrated how the conditions in which people live and work directly affect the quality of their health, we nodded in agreement. Everyone agrees that populations of Bangladesh, Sierra Leone or Haiti have low life expectancy, are malnourished, live in fearful and unhealthy environments, and are having a terrible time just trying to survive. But what does that have to do with us in Canada? For years, we bragged that we were identified by the United Nations as “the best country in the world in which to live”. We have since dropped a few ranks, but our bragging continues. We would be the most surprised to learn that, in all countries – and that includes Canada – health and illness follow a social gradient: the lower the socioeconomic position, the worse the health. The truth is that Canada – the ninth richest country in the world – is so wealthy that it manages to mask the reality of poverty, social exclusion and discrimination, the erosion of employment quality, its adverse mental health outcomes, and youth suicides. While one of the world’s biggest spenders in health care, we have one of the worst records in providing an effective social safety net. What good 8 • FOREWORD TO THE FIRST EDITION A document like this one, accessible and presenting the spectrum of existing inequities in health, will promote awareness and informed debate, and I welcome its publication. Following years of a move towards the ideology of individualism, a growing number of Canadians are anxious to reconnect with the concept of a just society and the sense of solidarity it envisions. Health inequities are not a problem just of the poor. It is our challenge and it is about public policies and political choices and our commitments to making these happen. I find it an honour to write this Foreword to Social Determinants of Health: The Canadian Facts, a great initiative of our Canadian advocate for population health, Dennis Raphael, and his colleague from Finland, Juha Mikkonen. The Hon. Monique Bégin, PC, FRSC, OC Member of WHO Commission on Social Determinants of Health Former Minister of National Health & Welfare WHAT PEOPLE ARE SAYING ABOUT THE CANADIAN FACTS “Perhaps now more than ever, Canadians need a straightforward reminder of what is really important to health. The Canadian Facts reminds us that as we worry about the sustainability of the health care system, what we really need to focus on is how to keep people healthy in the first place. Investing in the underlying determinants of health and creating equal opportunities for all for health is fundamental to a prosperous and just society. Kudos to the authors for continuing to make readily accessible the up-to-date Canadian Facts underlying this critical message.” – Penny Sutcliffe, MD, MHSc, FRCPC, Medical Officer of Health/Chief Executive Officer, Public Health Sudbury & Districts “Dennis Raphael, Toba Bryant, Juha Mikkonen and Alexander Raphael have created the go-to guide to social determinants of health in Canada. I consult it regularly, and consider it an essential tool for research, education, and advocacy. I regularly recommend it to clinicians, students, policymakers, journalists and health system designers. It has been a game-changer, providing us with a simple, reliable guide to defining and understanding the social determinants of health. This book should be the first off the shelf for anyone looking to reduce health inequities in Canada.” – Gary Bloch, Family Physician, St. Michael’s Hospital, Toronto; Associate Professor, University of Toronto “The Canadian Facts Second Edition is a pivotal document, succinctly demonstrating the evidence of Canadian public policy makers’ staunch and persistent resistance to action on the social determinants of health. Canada is at a tipping point in terms of neoliberal public policy denial of the facts of worsening wealth inequality and the racialization and marginalization of poverty in our country. The Canadian Facts are the facts of social murder and structural violence laid bare for all of us, especially those with governance power, to wake up and take responsibility and action. The entire document is a call to action to decrease and halt injustices and name the beneficiaries of market-driven and morally bankrupt wealth accumulation in Canada—the hidden side of worsening inequality and its entirely avoidable consequences. The Canadian Facts demonstrates that other countries have successfully tackled wealth distribution for the collective and compassionate good of all. We can too.” – Elizabeth McGibbon, Professor, St. Francis Xavier University WHAT PEOPLE ARE SAYING • 9 WHAT PEOPLE ARE SAYING ABOUT THE CANADIAN FACTS “Under the International Covenant on Economic, Social and Cultural Rights, everyone has rights ‘to an adequate standard of living’ and ‘the enjoyment of the highest attainable standard of physical and mental health.’ Nonetheless, the evidence for comprehensive action on the social determinants of health is overwhelming. Like highly skilled trial lawyers, the authors have assembled this evidence, concisely, clearly and compellingly, into a single document. As a result, the prospect of realizing the rights that constitute an international standard for a decent human life is that much brighter. Bravo!” – Rob Rainer, Former Executive Director, Canada Without Poverty “The Canadian Facts so succinctly described in this readable little book are not nice ones. But beneath the intersecting pathways by which social injustices become health inequalities lies the most sobering message: Things are getting worse. We have lived through three decades where the predatory greed of unregulated markets has allowed (and still allows) some to accumulate ever larger hordes of wealth and power while denying others a fair share of the resources they need to be healthy. This book is a fast-fact reference and an invitation for Canadian health workers to join with social movement activists elsewhere to reclaim for the public good some of these appropriated resources. “ – Ronald Labonté, Professor and Distinguished Research Chair in Globalization and Health Equity, University of Ottawa “With unusual clarity and insight, this informative resource will help change the way readers think about health. It renders visible how underlying social and economic environments influence health outcomes even more than personal behaviors, genetic profiles, or access to healthcare. Solutions, it reminds us, lie not in new medical advances or even ‘right choices,’ but in the political arena: struggling for the social changes that can provide every resident the opportunity to live a healthy and fulfilling life.” – Larry Adelman, creator and executive producer, Unnatural Causes: Is Inequality Making Us Sick? 10 • WHAT PEOPLE ARE SAYING 1. INTRODUCTION A health care system – even the best health care system in the world – will be only one of the ingredients that determine whether your life will be long or short, healthy or sick, full of fulfillment, or empty with despair. – The Honourable Roy Romanow, 2004 The primary factors that shape the health of Canadians are not medical treatments or lifestyle choices but rather the living and working conditions they experience. These conditions have come to be known as the social determinants of health (Figure 1.1). The importance to health of living conditions was established in the mid-1800s and has been enshrined in Canadian government policy documents since the mid-1970s. In fact, Canadian contributions to the social determinants of health concept have been so extensive as to make Canada a “health promotion powerhouse” in the eyes of the international health community. Reports from Canada’s Chief Public Health Officer, the Public Health Agency of Canada, and Statistics Canada continue to document the importance of the social determinants of health. But this information – based on decades of research and hundreds of studies in Canada and elsewhere – tells a story unfamiliar to many Canadians. Canadians are only now becoming more aware that our health is shaped by how income and wealth is distributed, whether we are employed, and if so, the working conditions we experience. Furthermore, our well-being is also determined by the health and social services we receive and our ability to obtain quality education, food and housing, among other factors. And contrary to the assumption that Canadians have personal control over these factors, in most cases these living and working conditions are – for better or worse – imposed upon us by the quality of the communities, housing situations, our work settings, health and social service agencies, and educational institutions with which we interact. The COVID-19 crisis has dramatically placed these issues in front of Canadians as those who are already disadvantaged are not only more likely to contract and succumb to COVID-19 but are also the ones bearing the brunt of its adverse economic effects. There is much evidence that the quality of the social determinants of health Canadians experience explain the wide health inequalities that exist among Canadians. How long Canadians live and whether they experience cardiovascular disease, adult-onset diabetes, respiratory disease and a host of other afflictions is very much determined by their living and working conditions. The same goes for the health of their children: differences among Canadian children in their surviving beyond their first year of life, experiencing childhood afflictions such as asthma and injuries, and whether they fall behind in school are strongly related to the social determinants of health they experience. Research is also finding that the quality of these health-shaping living conditions is powerfully determined by decisions governments make in a range of different public policy domains. INTRODUCTION • 11 Governments at the municipal, provincial/territorial, and federal levels create policies, laws, and regulations that influence how much income Canadians receive through employment, family benefits, or social assistance, the quality and availability of affordable housing, the kinds of health and social services and recreational opportunities they can access, and what happens when Canadians lose their jobs during economic downturns. These experiences also provide the best explanations for how Canada compares to other nations in overall health. Canadians generally enjoy better health than Americans, but do not do as well when compared to many other nations with public policies that strengthen the quality and provide more equitable distribution of the social determinants of health. Indeed, the World Health Organization sees health damaging experiences as resulting from “a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics”. Despite this evidence, there is rather little effort by Canadian governments and policymakers to improve the quality and equitable distribution of the social determinants of health through public policy action. Canada compares unfavourably to other wealthy nations in its support of citizens as they navigate the life course. Our income inequality is increasing, and our poverty rates are amongst the highest of wealthy nations. Canadian spending in support of families, persons with disabilities, older Canadians, and employment training is among the lowest of these same wealthy nations. Social Determinants of Health: The Canadian Facts, 2nd edition, provides Canadians with an updated introduction to the social determinants of our health. We first explain how living conditions “get under the skin” to either promote health or cause disease. 12 • INTRODUCTION We then explain, for each of the 17 social determinants of health: 1) Why it is important to health; 2) How we compare on the social determinant of health to other wealthy developed nations; and 3) How the quality of the specific social determinant can be improved. Key sources are provided for each social determinant of health. We conclude with a section that outlines what Canadians can do to improve the quality and equitable distribution of the social determinants of health. An epilogue places these concepts within a welfare state analysis. Social Determinants of Health: The Canadian Facts, 2nd edition is a companion to two other information sources about the social determinants of health. Social Determinants of Health: Canadian Perspectives, 3rd edition (2016) is an extensive compilation of prominent Canadian scholars and researchers’ analyses of the state of the social determinants of health in Canada. About Canada: Health and Illness, 2nd edition (2016) provides this information in a more compact and accessible format for the general public. Improving the health of Canadians is possible but requires Canadians think about health and its determinants in a more sophisticated manner than has been the case to date. The purpose of this second edition of Social Determinants of Health: The Canadian Facts is to stimulate research, advocacy, and public debate about the social determinants of health and means of improving their quality and making their distribution more equitable. The Authors Key sources Bryant, T. (2016). Health Policy in Canada, 2nd edition. Toronto: Canadian Scholars’ Press. Bryant, T., & Raphael, D. (2020). The Politics of Health in the Canadian Welfare State. Toronto: Canadian Scholars’ Press. Raphael, D. (2016). About Canada: Health and Illness, 2nd edition. Halifax: Fernwood Publishers. Raphael, D. (Ed.). (2016). Social Determinants of Health: Canadian Perspectives, 3rd edition. Toronto: Canadian Scholars’ Press. World Health Organization. (2008). Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: WHO. Figure 1.1 A Model of the Determinants of Health Figure shows one influential model of the determinants of health that illustrates how various health-influencing factors are embedded within broader aspects of society. Source: Dahlgren, G. and Whitehead, M. (1991). Policies and Strategies to Promote Social Equity in Health. Stockholm: Institute for Futures Studies. INTRODUCTION • 13 Figure 1.2 Social Determinants of Health Among the variety of models of the social determinants of health that exist, the one developed at a York University Conference held in Toronto in 2002 has proven especially useful for understanding why some Canadians are healthier than others. The 17 social determinants of health in this model are: disability early child development education employment and working conditions food insecurity gender geography globalization health services housing immigration income and income distribution Indigenous ancestry race social exclusion social safety net unemployment and job security Each of these social determinants of health has been shown to have strong effects upon the health of Canadians. These effects are actually much stronger than the ones associated with behaviours such as diet, physical activity, and even tobacco and excessive alcohol use. Source: Raphael, D. (Ed.) (2016). Social Determinants of Health: Canadian Perspectives, 3rd edition. Toronto: Canadian Scholars’ Press. 14 • INTRODUCTION 2. STRESS, BODIES, AND ILLNESS Prolonged stress, or rather the responses it engenders, are known to have deleterious effects on a number of biological systems and to give rise to a number of illnesses. – Robert Evans, 1994 Why Is It Important? People who endure adverse living and working conditions experience concrete material and social deprivation that adversely affect health. These experiences also cause high levels of physiological and psychological stress. These stressful experiences arise from conditions of low income, poor quality housing, food insecurity, inadequate working conditions, insecure employment, and various forms of discrimination based on Indigenous ancestry, disability, gender, immigrant status, and race. Lack of supportive relationships, social isolation, and mistrust of others associated with material and social deprivation further increases stress. At the physiological level, chronic stress leads to prolonged biological reactions that strain the physical body. Stressful situations and continuing threats provoke “fight-or-flight” reactions. These reactions impose chronic stress upon the body if a person does not have enough opportunities for recovery in non-stressful environments. Research evidence convincingly shows that continuous stress – or allostatic load – beginning during childhood weakens resistance to disease and disrupts the functioning of the hormonal, metabolic, and immune systems. Physiological processes provoked by stress make people more vulnerable to many serious illnesses such as cardiovascular disease, adult-onset diabetes, respiratory, and autoimmune diseases, among others. At the psychological level, stressful and poor living conditions cause continuing feelings of shame, insecurity and worthlessness. Under adverse living conditions, everyday life often appears as unpredictable, uncontrollable, and meaningless. Uncertainty about the future raises anxiety and hopelessness that creates exhaustion and makes everyday coping difficult. People who experience high levels of stress often attempt to relieve these pressures by adopting unhealthy coping behaviours, such as excessive use of alcohol, tobacco use, and overeating. These behaviours are generally known to be unhealthy in the long term but are effective in bringing temporary relief. Damaging behaviours, therefore, should be seen as coping responses to adverse life circumstances even though they make the situation worse in the long run. These life circumstances are fundamental causes of disease whose effects operate through various pathways to causes disease. Stressful living conditions make it extremely hard to take up physical leisure activity or practice healthy eating habits because most of one’s energy is directed towards coping with day-to-day life. Similarly, taking drugs – either prescribed or illegal – relieves the symptoms of stress. Healthy living programs aimed at those at risk are not very effective in improving health and quality of life. This is because in many cases, individually oriented STRESS, BODIES, AND ILLNESS • 15 physical activity and healthy eating programs do not address the social determinants of health that are the underlying causes of most illnesses. Such programs may actually increase health inequities because they are most likely to be taken up by those already at low risk of adverse health outcomes. Figure 2.1 Social Determinants of Health and the Pathways to Health and Illness Policy Implications • Promoting health and reducing illness requires a focus on the sources of problems rather than dealing with symptoms. Therefore, the most effective way to improve health is by improving the living and working conditions people experience, thereby reducing the material and social deprivation and physiological and psychological stress that leads to illness. • Elected representatives and decision-makers must commit themselves to implementing public policy that ensures high quality and more equitable distribution of the social determinants of health for every Canadian. This means dealing with the fundamental causes of adverse health outcomes, the problematic living and working conditions that: a) directly threaten health; b) create stress that wears out bodies; and c) causes the uptake of health threatening behaviours. Source: Brunner, E., & Marmot, M. G. (2006). ‘Social Organization, Stress, and Health.’ In M. G. Marmot & R. G. Wilkinson (Eds.), Social Determinants of Health. Oxford: Oxford University Press, Figure 2.2, p. 9. Figure 2.1 shows how the organization of society influences the living and working conditions we experience that then go on to shape health. These processes operate through material, psychosocial, and behavioural pathways. At all stages of life, genetics, early life, and cultural factors are also strong influences upon health. Key sources Brunner, E. & Marmot, M. G. (2006). Social organization, stress, and health. In Marmot M. G. & Wilkinson, R. G. (Eds.) (2006). Social Determinants of Health, 2nd edition (pp. 6-30). Oxford, UK: Oxford University Press. Danese, A. & McEwen, B.S. (2012). Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiology & Behavior, 106, 29-39. Link, B.G. & Phelan J. (1995) Social conditions as fundamental causes of disease. Journal of Health and Social Behavior, (extra issue), 80-94. Raphael, D. (2016). Social structure, living conditions, and health. In Raphael, D. (Ed.), Social Determinants of Health: Canadian Perspectives, 3rd edition (pp. 32-58). Toronto: Canadian Scholars’ Press. 16 • STRESS, BODIES, AND ILLNESS 3. INCOME AND INCOME DISTRIBUTION Health researchers have demonstrated a clear link between income and socio-economic status and health outcomes, such that longevity and state of health rise with position on the income scales. – Andrew Jackson and Govind Rao, 2016 Why Is It Important? Income is perhaps the most important social determinant of health. Level of income shapes overall living conditions that affect physiological and psychological functioning and the take-up of health-related behaviours such as quality of diet, extent of physical activity, tobacco use, and excessive alcohol use. In Canada, income determines the quality of other social determinants of health such as food security, housing, education, early child development, and other prerequisites of health. The relationship between income and health can be studied at two different levels. First, we can observe how health is related to the actual income that an individual or family receives. Second, we can study how income is distributed across the population and how this distribution is related to the overall health of the population. More equal income distribution has proven to be one of the best predictors of better overall health of a society. Income comes to be especially important in societies that provide fewer important services and benefits as a matter of right. In Canada, general government revenues fund public education until grade 12, necessary medically procedures, and libraries, but childcare, housing, post-secondary education, employment training, recreational opportunities, prescription drugs, dental care and resources for retirement must be bought and paid for by individuals. In contrast, in many wealthy nations these benefits and services are universally provided as citizen rights. Low income leads to material and social deprivation. The greater the deprivation, the less likely individuals and families are able to afford the basic prerequisites of health such as food, clothing, and housing. Deprivation also contributes to social exclusion by making it harder to participate in cultural, educational, and recreational activities. In the long run, material and social deprivation and the social exclusion it engenders affects one’s health and lessens the abilities to live fulfilling lives free of health problems. Having income so low as to constitute living in poverty is especially dangerous to health. Researchers find that men in the wealthiest 20 percent of neighbourhoods in Canada live on average more than five years longer than men in the poorest 20 percent of neighbourhoods (Figure 3.1). The comparative difference for women is more than two years. Suicide rates in the lowest income neighbourhoods are almost twice those in the wealthiest neighbourhoods. Additionally, a host of studies show that heart disease, adult-onset diabetes, and respiratory disease are far more common among low-income Canadians. Infant mortality INCOME AND INCOME DISTRIBUTION • 17 rates are 46 percent higher in the poorest 20 percent of neighbourhoods than in the richest 20 percent. A Canadian study that followed individuals over time found men in the lowest 20 percent quintile of income have death rates 67 percent higher than the wealthiest 20 percent. For women, the figure is 52 percent. If the death rates for all Canadians were similar to those of the wealthiest 20 percent of Canadians, there would be 19 percent fewer deaths for men and 17 percent fewer for women every year. This is equal to 40,000 fewer deaths a year; 25,000 for men and 15,000 for women. Income differences in health outcomes are seen right across the income gradient from rich to poor. Canada’s overall level of income inequality is above the OECD average (Figure 3.2). As a result of these trends, from 1980 to 2015, the bottom 60 percent of Canadian families experienced very small increases in market incomes in constant dollars while the top 20 percent of Canadian families did very well. After taxes and government transfers, this picture improves somewhat with slight increases for the bottom 60 percent of Canadians, but these increases are dwarfed by the increases experienced by the wealthiest 20 percent of Canadians. Increasing income inequality has led to a hollowing out of the middle class in Canada with significant increases from 1980-2015 in the percentages of Canadian families who are poor or very rich. The percentage of Canadian families who earned middle-level incomes declined from 1980 to 2015 while the percentage of very wealthy Canadians increased as did those near the bottom of the income distribution. There is good reason to think these trends are intensifying. The increases in wealth inequality in Canada are even more troubling. Wealth is probably a better 18 • INCOME AND INCOME DISTRIBUTION indicator of long-term health outcomes as it is a better measure of financial security than income. In 2019, the bottom 20 percent of Canadians were on average in debt for $500 while the average net worth of the wealthiest 20 percent of Canadians was $2,480,300. Indeed, almost half of Canadian families (47 percent) say they would be in financial difficulty if their paycheck was a week late. Thirtyfive per cent said they feel overwhelmed by their level of debt. Since this was the situation before the economic upheavals of the COVID-19 crisis, the situation for many Canadians is now much worse. Policy Implications • There is an emerging consensus that income inequality is a key health policy issue that needs to be addressed by governments and policymakers. • Increasing the minimum wage to a living wage and boosting social assistance levels for those unable to work would provide immediate health benefits for the most disadvantaged Canadians. • Reducing inequalities in income and wealth through progressive taxation and using these revenues to provide universal programs and services are among the best ways of improving health in a society. • More unionized workplaces would reduce income and wealth inequalities in Canada, thereby improving health. Unionization helps to set limits on extreme profit-making that comes at the expense of employees’ health and wellbeing. Key sources Auger, N., & Alix, C. (2016). Income, income distribution, and health in Canada. In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives, 3rd edition (pp. 90-109). Toronto: Canadian Scholars’ Press. Canadian Press (2017). Almost half of Canadian employees living paycheque to paycheque, survey indicates. Ottawa: Author. Available at https://www.cbc.ca/news/business/payroll-salary-survey-1.4276782 Curry-Stevens, A. (2016). Precarious changes: A generational exploration. In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives, 3rd edition (pp. 60-89). Toronto: Canadian Scholars’ Press. Public Health Agency of Canada and Pan-Canadian Public Health Network. (2018). Key Health Inequalities in Canada: A National Portrait. Ottawa: Author. Statistics Canada (2021). Assets and Debts by Net Worth Quintile, Canada, Provinces and Selected Census Metropolitan Areas, Survey of Financial Security. Ottawa: Author. Available at https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=111 0004901&pickMembers%5B0%5D=1.1&pickMembers%5B1%5D=2.27&pickMembers%5B2%5D=4.6&cubeTimeFrame. startYear=2005&cubeTimeFrame.endYear=2019&referencePeriods=20050101%2C20190101 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. Figure Expectancy of Females andCountries, Males by Income Quintile of Neighbourhood, Figure3.1 3.2Life Income Inequality in OECD mid-2000s Canada, 2009-2011 84.8 Q5 -- Richest 81.7 84.1 Q4 80.5 83.8 Q3 79.7 Females Males 83.4 Q2 78.8 81.7 Q1 -- Poorest 76.4 70 72 74 76 78 80 82 84 Life Expectancy in Years Source: Public Health Agency of Canada and Pan-Canadian Public Health Network. (2018). Key Health Inequalities in Canada: A National Portrait. Ottawa: Author. INCOME AND INCOME DISTRIBUTION • 19 Figure 3.2 Income Inequality in OECD Nations, 2019 0.2 0.3 Slovak Republic 0.24 Slovenia 0.24 Czech Republic 0.25 Icelan d 0.26 Denmark 0.26 Norway 0.26 Belgium 0.26 Fin lan d 0.27 Austria 0.28 Poland 0.28 Sweden 0.28 Netherlan ds 0.29 Germany 0.29 Hun gary 0.29 France 0.29 Irelan d 0.30 Switzerland 0.30 Estonia 0.31 Can ada 0.31 Greece 0.32 Portugal 0.32 Australia 0.33 Luxembourg 0.33 Spain 0.33 Italy 0.33 Figure 3.2 Income Inequality in OECD Countries, mid-2000s Japan 0.34 Israel 0.35 Korea 0.36 Latvia 0.36 United Kingdom 0.36 Lithuania 0.37 United States 0.39 Turkey 0.40 Mexico Chile Gini Coefficient of Income Inequality Note: Countries are ranked in increasing order in the Gini coefficient. The income concept used is that of disposable household income in cash, adjusted for household size. Source: Organization for Economic Co-operation and Development (2020). Income inequality. Available at https://data.oecd.org/inequality/income-inequality.htm 20 • INCOME AND INCOME DISTRIBUTION 0.5 0.4 0.46 0.46 4. EDUCATION Canada as a whole performs well on national and international assessments, but disparities exist among populations and regions that do not seem to be diminishing with time. – Charles Ungerleider and Tracey Burns, 2016 Why Is It Important? Education is an important social determinant of health. People with higher education tend to be healthier than those with lower educational attainment. There are various pathways by which education leads to better health. First, level of education is highly correlated with other social determinants of health such as the level of income, employment security, and working conditions. Viewed in this light, education helps people to move up the socioeconomic ladder and provides better access to economic and social resources. Second, higher education makes it easier to enact larger overall changes in the Canadian employment market. Better educated citizens have more opportunities to benefit from new training opportunities if their employment situation suddenly changes. Furthermore, education facilitates citizens’ possibilities for civic activities and engagement in the political process. In other words, people attain better understanding of the world and they become more able to see and influence societal factors that shape their own health. Finally, education increases overall literacy and understanding of how one can promote one’s own health through individual action. With higher education, people attain more sophisticated skills to evaluate how behaviours they adopt might be harmful or beneficial to their health. They achieve greater ability and more resources to allow attainment of healthier lifestyles. On the other hand, it is important to remember that lack of education in itself is not the main factor causing poorer health. The manner by which education influences the population’s health is shaped by public policies. For instance, if adequate income and necessary services such as childcare and job training are available to all, the healththreatening effects of having less education would be much less. In addition, the link between parents’ educational levels and their children’s achievement are weaker when the social determinants of health are more equitably distributed, allowing for greater intergenerational mobility. In international comparisons, the overall state of education in Canada is good (Figure 4.1). Canada is one of a few wealthy nations where immigrant children and children of immigrants perform as well as children born in Canada to Canadian-born parents. Fifty three percent of the population have post-secondary education. However, the troubling aspect in Canada is that children whose parents do not have post-secondary education perform notably worse than children of more educated parents. It has been suggested that the link between children’s educational performance with parents’ EDUCATION • 21 education levels would be reduced if there were affordable and high-quality early learning programs in Canada. The lack of these programs has a major influence on many children’s intellectual and emotional development. High tuition fees influence whether children of low-income families can attain college or university education. In Scandinavian countries that provide free post-secondary education, the link between family background and educational attainment is weaker than is the case in Canada. For example, Swedish children whose parents did not complete secondary school usually outperform children on language and mathematical skills from other nations – including Canada – whose parents completed post-secondary education. Policy Implications • Elected representatives must commit themselves to adequately funding the Canadian education system so that schools are able to provide well-developed curricula for students. • Universal high-quality childcare would reduce the link between parents’ and children’s educational achievement levels, thereby promoting health. • Tuition fees for university and college education must be better managed, reduced or eliminated, so that fees do not exclude children of lower-income families from higher education. 22 • EDUCATION Key sources Frenette, M. (2017). Postsecondary Enrolment by Parental Income: Recent National and Provincial Trends. Ottawa: Statistics Canada. Available at https://www150.statcan.gc.ca/n1/pub/11-626-x/11626-x2017070-eng.htm OECD/EU (2018). Settling In 2018: Indicators of Immigrant Integration. Brussels: Author. Available at https://www.oecd.org/publications/indicators-ofimmigrant-integration-2018-9789264307216-en.htm Raphael, D. (2016). Key immigration issues in developed nations. In D. Raphael (Ed.), Immigration, Public Policy, and Health: Newcomer Experiences in Developed Nations (pp. 317-334). Toronto: Canadian Scholars’ Press. Ronson, B. & Rootman, I. (2016). Literacy and health literacy: New understandings about their impact on health. In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives, 3rd edition (pp. 261290). Toronto: Canadian Scholars’ Press. Ungerleider, C. & Burns, T. (2016). The state and quality of Canadian public elementary and secondary education. In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives, 3rd edition (pp. 240-260). Toronto: Canadian Scholars’ Press. ak R ep u Ic blic el G and re e Au ce D st en ria m T u ar k rk e C y h Sw Bel ile i tz giu er m la n M d a L l ta C ux ze em Ita ch b ly R ou ep rg u C blic ro N F atia e ra EU ther nce to lan ta ds Sl l (2 o 5 G ve n ) er ia m Sw an y Li ed th e n ua n Sp ia a Fi in nl a O La nd EC tv D I ia U tot sra ni a el te l ( d 35 S ) ta Es tes U t ni te N onia d or K w in ay g N Hu dom ew n Ze gar a y Po lan r tu d Ir e g a l Au lan st d C ral i an a ad a Sl ov Figure 4.1 Mean PISA Reading Scores of 15 Year Olds with Different Migration Backgrounds, OECD Nations, 2015 Native-born with foreign-born parents Native-born with native-born parents Foreign-born 550 500 450 400 350 300 Source: OECD (2019). Settling In: Indicators of Immigrant Integration. Paris: Author. EDUCATION • 23 5. UNEMPLOYMENT AND JOB SECURITY Workers are not only more uncertain about the likelihood that they will be retained in their current job, they are also uncertain about whether they will be able to find another job that meets their needs. – Emile Tompa, Michael Polanyi, and Janice Foley, 2016 Why Is It Important? Employment provides income, a sense of identity, and helps to structure day-to-day life. Unemployment frequently leads to material and social deprivation, psychological stress, and the adoption of health-threatening coping behaviours. Unemployment is associated with physical and mental health problems that include depression, anxiety and increased suicide rates. Job insecurity causes exhaustion (burnout), general mental/psychological problems, poor self‐rated health, and a variety of somatic complaints. Job insecurity has been increasing in Canada during the past decades (Figure 5.1). Currently, less than two-thirds of Canadians have a regular or permanent full-time job. Only half of working aged Canadians have had a single full-time job for over six months or more. Precarious forms of work include arrangements such as working part-time (20.3 percent of Canadians), being self-employed (15.3 percent), or having temporary work (11.3 percent). The OECD calculates an employment protection index of rules and regulations that protects employment and provides benefits to temporary workers. Canada performs very poorly on this index, achieving a score that was ranked 35th of 36 nations (Figure 5.2). 24 • UNEMPLOYMENT AND JOB SECURITY Part-time work is reflecting greater income and employment insecurity: the percentage of men with part-time work as a main job is increasing while the percentage of women with part-time work as a main job is declining. Researchers suggest that these trends are associated with more intense work life, decreased job security and income polarization between the rich and poor. Unemployment is related to poor health through various pathways. First, unemployment often leads to material deprivation and poverty by reducing income and removing benefits previously provided by one’s employer. Second, losing a job is a stressful event that lowers one’s self-esteem, disrupts daily routines, and increases anxiety. Third, unemployment increases the likelihood of turning to unhealthy coping behaviours such as tobacco use and problem drinking. Often, insecure employment consists of intense work with non-standard working hours. Intense working conditions are associated with higher rates of stress, bodily pains, and a high risk of injury. Excessive hours of work increase chances of physiological and psychological problems such as sleep deprivation, high blood pressure, and heart disease. Consequently, job insecurity has negative effects on personal relationships, parenting effectiveness, and children’s behaviour. Women are over-represented in precarious forms of work. In 2018, 14 percent of employed women were temporary employees while the figure for men was 12.8 percent. Six percent of women were employed in involuntary part-time employment, while for men it was 3.8 percent. The OECD finds that Canada is ranked 12th highest amongst 32 nations in the proportion of total employment that is temporary. Finally, women, youth, seniors, and workers without post-secondary education are more likely to be working part-time or temporary jobs. Policy Implications • National and international institutions need to be legally mandated to make agreements that provide the basic standards of employment and work for everyone. • Power inequalities between employers and employees need to be reduced through stronger legislation governing equal opportunity in hiring, pay, training, and career advancement. • Unemployed Canadians must be provided access to adequate income, training, and employment opportunities through enhanced government support. Key sources De Witte H, Pienaar J and De Cuyper N. (2016). Review of 30 years of longitudinal studies on the association between job insecurity and health and well‐being: Is there causal evidence? Australian Psychologist, 51, 18-31. Fong, F. (2018). Navigating Precarious Employment in Canada: Who is Really at Risk? Toronto: Chartered Professional Accountants of Canada. Available at https://tinyurl.com/y7xpecel Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities (2019). Precarious Work: Understanding the Changing Nature of Work in Canada. Ottawa: Author. Available at https://www. ourcommons.ca/Content/Committee/421/HUMA/ Reports/RP10553151/humarp19/humarp19-e.pdf Tompa, E., Polanyi, M. & Foley, J. (2016). Health consequences of labour market flexibility and worker insecurity. In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives, 3rd edition (pp. 8898). Toronto: Canadian Scholars’ Press. Tremblay, D. G. (2016). Precarious work and the labour market. In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives, 3rd edition (pp. 110-129). Toronto: Canadian Scholars’ Press. • Workers, employers, government officials, and researchers need to develop a new vision of what constitutes healthy and productive work. • More policy-relevant research must be pursued to support government’s decision-making and provide an accurate and up-to-date picture of job security in Canada. UNEMPLOYMENT AND JOB SECURITY • 25 Figure 5.1 Increases in Part-time and Temporary Work in Canada as a Percentage of Total Employment, 1976-2016 Source: Statistics Canada (2020). Labour Force Survey; table 282-0002, 282-0080. Figure 5.2 Employment Protection, OECD Nations, 2019 0.0 Netherlands Czech Republic Portugal Latvia Turkey Chile Germ any Italy France Slovak Republic Sweden Greece Korea Israel Norway Austria Poland Mexico Luxembourg Lithuania Slovenia Belgium Spain Finland Estonia Australia New Zealand Hungary Iceland Denmark Switzerland Japan United Kingdom Ireland Canada United States 0.4 0.09 0.8 0.59 1.2 1.6 1.67 1.64 1.59 1.56 1.53 1.43 1.37 1.35 1.23 2.0 1.81 2.4 2.67 2.60 2.56 2.56 2.51 2.45 2.45 2.42 2.37 2.33 2.29 2.23 2.15 2.14 2.13 2.08 2.07 2.05 2.00 Degree of Employment Protection Source: OECD (2020). Strictness of employment protection. Paris: Author. Available at https://stats.oecd.org/Index.aspx?DataSetCode=EPL_OV# 26 • UNEMPLOYMENT AND JOB SECURITY 2.8 3.2 3.26 3.14 3.02 2.98 3.6 4.0 3.61 6. EMPLOYMENT AND WORKING CONDITIONS The relationship between working conditions and health outcomes is an important public health concern. – Peter Smith and Michael Polanyi, 2016 Why Is It Important? Working conditions are an important social de- terminant of health because of the great amount of time we spend in our workplaces. People who are already most vulnerable to poor health outcomes due to their lower income and education are also the ones most likely to experience health threatening working conditions. Researchers have identified a host of work dimensions which shape health outcomes. The dimensions include factors such as: 1) employment security; 2) physical conditions at work; 3) work pace and stress; 4) working hours; and 5) opportunities for self-expression and individual development at work. Research evidence has also shown that imbalances between efforts to meet demands (e.g., time pressures, responsibility) and rewards (e.g., salary, respect from supervisors) often lead to significant health problems. When workers perceive that their efforts are not being adequately rewarded, they are more likely to develop a range of physical and mental afflictions (Figure 6.1). Similarly, increased health problems are seen among workers who experience high demands but have little control over how to meet these demands. These high-stress jobs predispose individuals to high blood pressure, cardiovascular diseases, and development of physical and psychological difficulties such as depression and anxiety. High-strain jobs are especially common among low-income women working in the sales and service sector. Canadian women score higher than men in reporting high stress levels from “too many hours or too many demands.” A 2016 Statistics Canada survey reported that 10.5 percent of Canadians felt they might lose their job in the next six months. Forty-eight percent did not feel their job “offers good prospects for career advancement.” The same survey found 26.2 percent felt that the workload was “not manageable”, and 25.2 percent “often could not complete their assigned work during regular hours.” Finally, 33.6 percent could not “choose their sequence of tasks” and 23 percent could not “provide input into work decisions.” Statistics Canada found in a 2010 study a rather large prevalence of work-related stress among Canadians. Almost 5.5 percent reported work was extremely stressful, 23.3 percent reported it was quite a bit stressful, and 41.5 percent reported it as a bit stressful. Canadians whose jobs were extremely stressful were three times m