Poverty, Policy and Public Health
Health Promotion Ontario
Spring Conference
May 13-14 2008
Grace-Edward Galabuzi, Ph.D
Ryerson University
Poverty, Policy and Health
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Context: Social citizenship
Social exclusion
Dimensions of social exclusion
Social Determinants of Health
Social disparities and Health Status
Racialization, immigrant status and social
determinants of health
• Reversing Social exclusion – Poverty elimination
strategies
Social Citizenship
• “relationship between the individual and the state as well
as among individuals, is the concrete expression of the
fundamental principle of equality among members of the
political community”
– Rights and responsibilities
– Equal Access
– Belonging
• Social inequality and poverty represent a threat to
citizenship
Social Inclusion
• Characterized by society’s widely shared social
experiences and active participation
• Equal access to opportunities and life chances
• Ability to develop the full range of human capacities
• Capacity and willingness of society to keep all its citizens
within reach of common aspirations
• Full citizenship as a relationship between individuals and
the state and among groups of individuals in society
Social Exclusion
• Represents a form of alienation experienced by particular
groups and individuals in society
• Analysis points to structures, processes and outcomes
• Occurs in multiple dimensions
• Is a key determinant of access to processes of production,
wealth, income, power and participation
• Reproduced by structures and processes of inequality and
unequal outcomes
• Is responsible for the generation of health disparities in
society
Key aspects of Social Exclusion
• Denial of civil engagement through legal
sanction and other institutional mechanisms.
• Denial of access to social goods - health
care, education, housing.
• Denial of opportunity to participate actively
in society.
• Economic exclusion.
Social exclusion and health status
• The most important consequences of health
disparities are avoidable death, disease, disability,
distress and discomfort
• However, health disparities also cost individuals,
communities, the health system and Canadian
society as a whole.
• Health disparities are inconsistent with Canadian
values of equality:
– They threaten the social cohesiveness of community and society,
– They challenge the sustainability of the health system,
– They undermine the Canadian economy
Social Determinants of Health
• Shift from reliance on health behaviours (smoking, diet,
exercise, etc.) as most important predictors of health status
• Towards rather social and economic characteristics of
individuals and populations
• Poor social and economic conditions and inequalities in
access to resources and services have greater impact on an
individual or group’s health and well being than behaviors
• Groups experiencing some form of social exclusion tend to
sustain higher health risks and lower health status.
Understanding health disparities
• According to Health Disparities Taskforce,
(2004), these characteristics are key factors
influencing health disparities in Canada :
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Socio-economic status (SES)
Aboriginal and other racial identity
Gender status
Disability
Geographic location (neighbourhood selection)
Poverty, Income inequality and
Health Disparities
“Canadians at the bottom of the economic
ladder were more likely to die from just
about every disease from which people can
die from than the more well-off, including
cancers, heart disease, diabetes, and
respiratory diseases among others.”
Wilkins, Adams, & Brancker (2000)
Differential impacts of health disparities
• The death rate from injury among Aboriginal infants is 4
times the rate for Canada as a whole, and 3 times among
teenagers.
• Young blacks are four times (10.1 per 100,000) as likely to
be victims of gun related homicides as other members of
the population (2.4 per 100,000).
• Only 47% among Canadians in the bottom income quintile
report their health as excellent or very good compared with
73% in the top quintile
• People in the lowest quintile are five times more likely to
rate their health as fair or poor than people in the highest
• Aboriginal peoples are twice as likely to report fair or poor
health status than non-Aboriginal peoples with the same
income levels.
Dimensions of Social Exclusion
among Racialized populations
Racialized groups and new immigrants experience
differential life chances. Characteristics include:
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A double digit racialized income gap
Chronically higher than average levels of unemployment,
Deepening levels of poverty
Differential access to housing and neighbourhood
segregation
• Disproportionate contact with the criminal Justice system
• Higher health risks
Racialized youth labour market
participation
Racialized Youth in the Labour Market, 2001
Age 15-24
Labour Market
Participation
All ‘Youth’ persons
58.4%
Immigrant Youth
55.0%
Racialized Youth
43.7%
Racialized youth – Can born
48.4%
Arab Youth
45.1%
Black Youth – Can. Born
33.2%
Chinese Youth
37.1%
Latin American Youth
50.9%
Filipino Youth
57.2%
South Asian Youth
48.5%
Vietnamese Youth
46%
Japanese Youth
44%
Aboriginal Youth
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Unemployment
Rate
13.3%
14.8%
16.1%
15.5%
16%
21.4%
17%
14%
10%
15%
16%
13%
22.8%
Source: Census of Canada. Catalogue 97F0012XCB200102 & Profiles of Ethnic communities in Canada: Statistics
Canada – Catalogue no. 89-621-XIE
Inequality in employment incomes
Average Income (all sources) by select racialized community, 2001
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Men
Women
Total
dollars
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All Canadian earners
36,800
22,885
29,769
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African community
27,864
Arab community
32,336
Caribbean community
29,840
Chinese community
29,322
Filipino community
27,612
Jamaican community
30,087
Haitian community
21,595
Japanese community
43,644
Korean community
23,370
Latin American community
27,257
South Asian community
31,396
Vietnamese community
27,849
West Asian community
28,719
Source: Statistics Canada, 2001 Census of Canada.
19,639
19,264
22,842
20,974
22,532
23,575
18,338
24,556
16,919
17,930
19,511
18,560
18,014
23,787
26,519
25,959
25,018
24,563
26,412
19,782
33,178
20,065
22,463
25,629
23,190
23,841
The Racialization of Poverty
• The Racialization of poverty represents a disproportionate and
persistent experience of low income among racialized groups
• It is linked to the process of the deepening social exclusion of racialized
and immigrant communities.
• A key contributing factor is the concentration of economic, social and
political power in fewer hands that has emerged as the state has
retreated from its regulatory role in the economy.
• The experience of poverty includes powerlessness, marginalisation,
voicelessness, vulnerability, and insecurity.
• The various dimensions of the experience of poverty interact in
important ways to reproduce and reinforce social exclusion
• Racialized people are two or three times as likely to be
poor than other Canadians
Racialization of Poverty
Low income by select racialized community, 2000
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Adult
Adult
Unattached
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Total Canadian population
15%
38%
Children
under15
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47%
40%
33%
27%
18%
34%
47%
16%
48%
32%
28%
35%
43%
African Community
39%
Arab community
36%
Caribbean community
26%
Chinese community
26%
Filipino community
16%
Jamaican community
26%
Haitian community
39%
Japanese community
18%
Korean community
43%
Latin American community
28%
South Asian community
23%
Vietnamese community
27%
West Asian community
37%
Source: Statistics Canada, 2001 Census of Canada.
56%
52%
44%
55%
48%
41%
61%
48%
72%
53%
49%
49%
56%
18%
Income inequality among recent
immigrants
• In 2006 Asians immigrants aged 25 to 54, had an employment rate of
63.8%, compared to 83.1% for their counterparts born in Canada.
• Recent immigrants born in Europe had higher unemployment rates
than the Canadian born at 8.4%, above the average (4.9%) of people
born in Canada.
• Latin American immigrants had an unemployment rate 2.1 times
higher than their Canadian-born counterparts.
• African-born recent immigrants had an unemployment rate that was
more than four times higher than that of their Canadian-born
counterparts.
• Low income rates rose to 47.0% in 1995, then fell back to 35.8% in
2000.
Neighbourhood dimensions of
racialization and Social Exclusion
• In Canada’s urban areas, the spatial concentration of poverty or
residential segregation is intensifying along racial lines.
• Immigrants in Toronto and Montreal are more likely than nonimmigrants to live in neighbourhoods with high rates of poverty
• Young immigrants living in low income areas often struggle with
alienation from their parents and their community, as well as the
broader society and some of its institutions.
• They are also the disproportionate targets of crime and
criminalization. Black youth are four times as likely to be victims of
gun violence as other Canadians
Low Income in Toronto, 2001
70
60
50
40
30
20
10
0
% Low Income Toronto
54.2
44.6
34.9
31.4
Aborig.
People
of Colour
26.3
17.3
17.6
Cdn-born
Imm
<1986
Imm
Imm
1986-95 1996-01
Non
Perm
Res.
Racialized neighbourhoods
Toronto Area racialized enclaves experience
high poverty rates
University unemployment
low income loneparent
Chinese
21.2%
11.2%
28.4%
11.7%
South Asian
11.8%
13.1%
28.3%
17.6%
Black
8.7%
18.3%
48.5%
33.7%
Racism as a determinant of health
• Health disparities related to racism compromise health status and lead
to disproportionate exposure to such conditions as diabetes and
hypertension
• The psychological pressures of daily resisting racism and other
oppressions add up to a complex of factors that undermine the health
status of racialized and immigrant group members.
• Many racialized and immigrant workers are forced to accept work in
workplaces where they face poor and sometimes hazardous working
conditions that compromises their health.
• Some trade off employment opportunities and intensified work
(overtime, multiple jobs) for safe and healthy work habits
Racialized Disparities in Healthcare
Access
Chen, Wilkins and Ng (1996) analysis of the 1994 National Population
Health Survey found that after adjusting for age, non-European immigrants
had significantly lower hospitalization rate than European immigrants
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Ng et al (2005) found that non-European immigrants were twice as likely as
the Canadian-born to indicate deterioration in their health between 1994 and
2003
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Matuk (1996) found that women from racialized groups were less likely to
have had a pap test and have lower survival rates for cancer than women from
non-racialized groups.
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Racialization and the health care
system
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Language barriers often lead to barriers to equal access
Documented lack of cultural sensitivity in service delivery
Underdeveloped cultural competencies
Broader systemic barriers to access of health services
Inadequate funding for Ethno-cultural community health
services
• Inadequate funding for research and treatment of particular
conditions that disproportionately affect racialized
populations
Racism and Mental Health
• Many racialized group members and immigrants with mental health
issues and mental illness' identify racism as a critical issue in their
lives.
• One of the reasons the health status of immigrants declines is because
of the experiences of dealing with everyday forms of racism.
• A study conducted by Noh and Beiser confirms that Southeast Asian
refugees in Canada reporting discrimination experienced higher
depression than their counterparts who reported none.
• Skilled immigrants experiencing mounting barriers in gaining
employment and access to civil society, also report impacts on their
mental health
(Beiser, 1988)
Immigrant status as a determinant
of health status
• Immigrants tend to start out with above average health
status because the immigration selection process imposes a
high standard of health status. It is reasonable to expect
that the health status of immigrants will decline with length
of stay in Canada
• But increased health risks arising from inability to access
key health services due to such considerations as cultural
competence gaps in the health care system, the inability of
the immigrants to optimally make demands on the system
or socio-economic vulnerabilities tend to exacerbate this
• Studies also show adverse psychopathological results from
exposure to adversity and other vulnerabilities that are part
of the process of migration.
Black Creek Income Security, Race and
Health Project - Indicators
Black Creek Comparison (2001)
Bl Crk Toronto
Total Immigrants in Population
Racialised Groups
Home Language Not Eng/Fr
No Knowledge of English/French
Low Income Population
Unemployment Rate
62.6%
74.8%
30.0%
6.9%
40.4%
9.9
42.8%
42.8%
18.8%
5.1%
22.5%
7.0
Initial Focus Group Findings about
Labor Market
Headache, stress, depression (“heart is sinking”)
 Sleeplessness, frustrations
 Heart problems, back problems, weight problems,
stomach and ulcer ailments,
 Arthritis
 Inability to buy nutritious food, pay rent, and
cover medical expenses
 Can’t afford childcare
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Reversing Social exclusion and
declining health status
• International research consistently shows that most health disparities
can be traced to non-medical determinants (UK: Whitehall Studies)
• The most appropriate and effective way to improve overall population
health is by improving the health of those disproportionately affected
by health disparities
• Taking action on key social factors known to influence health is
essential to reducing health disparities.
• The focus should be on such poverty and social disadvantage
enhancing drivers such as – social class, race, gender, immigrant
status, disability
• The vulnerabilities these factors generate mutually reinforce the
downward spiral of health status
• The Public health system has a key role to play in mitigating the causes
and effects of social determinants of health through interventions with
socially marginalized individuals, populations and communities
Effective Anti-poverty Strategies
• A commitment to targets and goals – 25 in 5 years (2013) ,
50 in 10 years (2018)
• Structural changes in living conditions
– Employment
– Income
– Social resources
• Sustainable employment – work that pays and is secure
• Improvements in social programs – adequacy and dignity
• Investments in public goods – housing, education, health