Social Determinants of Health:
Why is There Such a Gap Between Our
Knowledge and Its Implementation?
Dennis Raphael
York University, Toronto, Canada
Presentation made at
Ryerson Polytechnic University
Toronto, Ontario, October 4, 2002
What Do We Know ?
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Population Health
Example 1: Cardiovascular Health
Example 2: Diabetes
Social Determinants in Canada Today
What Do We Do?
• Governments – Policy Making
• Public Health Units - Activities
• Disease Associations, e.g., Heart and Stroke
Foundation, Diabetes Association – Messages
• Health Care Providers and Planners - Focus
Poverty and Health: Literary Perspectives
We know what makes us ill.
When we are ill we are told
That it’s you who will heal us.
When we come to you
Ou
rags are torn off us
And
you listen all over our naked body.
As to
the cause of our illness
One
glance at our rags would
Tell you
more. It is the same cause that wears out Our bodie
and our clothes.
-- Bertolt
Brecht, A Worker’s Speech to a Doctor, 1938.
Poverty and Health:
Academic Perspectives
It is one of the greatest of contemporary
social injustices that people who live in the
most disadvantaged circumstances have
more illnesses, more disability and shorter
lives than those who are more affluent.
-- Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling
Inequalities in Health: An Agenda for Action.
Canadian Government Statements on Social
Determinants of Health I
All policies which have a direct bearing
on health need to be coordinated. The
list is long and includes, among others,
income security, employment, education,
housing, business, agriculture,
transportation, justice and technology.
-- Achieving Health For All: A Framework for
Health Promotion, J. Epp. Ottawa: Health and
Welfare Canada, 1986.
Canadian Government Statements on
Social Determinants of Health II
There is strong evidence indicating that factors outside
the health care system significantly affect health. These
“determinants of health” include income and social
status, social support networks, education, employment
and working conditions, physical environments, social
environments, biology and genetic endowment,
personal health practices and coping skills, healthy
child development, health services, gender and culture.
-- Taking Action on Population Health: A Position Paper for
Health Promotion and Programs Branch Staff. Ottawa: Health
Canada, 1998.
Canadian Government Statements on
Social Determinants of Health III
In the case of poverty, unemployment, stress,
and violence, the influence on health is direct,
negative and often shocking for a country as
wealthy and as highly regarded as Canada.
-- The Statistical Report on the Health of Canadians.
Ottawa: Health Canada, 1998.
Social Determinants of Health:
The Solid Facts
- social gradient
- stress
- early life
- social exclusion
- work
- unemployment
- social support
- addictions
- food
- transport
- World Health Organization, 1998
Ottawa Charter’s Prerequisites of Health
• peace
• shelter
• education
• food
• income
• a stable eco-system
• sustainable resources
• social justice
• equity
World Health Organization, 1986
Health Canada’s Determinants of Health
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•
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Income and Social Status
Social Support Networks
Education
Employment/Working Conditions
Social Environments
Physical Environments
Personal Health Practices and Coping Skills
Healthy Child Development
Biology and Genetic Endowment
Health Services
Gender
Culture
Why Emphasize Social Determinants?
• Social determinants of health have a
direct impact on health
• Social determinants predict the greatest
proportion of health status variance
• Social determinants of health structure
health behaviours
• Social determinants of health interact
with each other to produce health
Poverty and Health:
Mechanisms
Poverty can affect health in a number of ways:
• income provides the prerequisites for health, such as
shelter, food, warmth, and the ability to participate in
society;
• living in poverty can cause stress and anxiety which
can damage people’s health;
• low income limits peoples’ choices and militates
against desirable changes in behaviour.
- Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in
Health: An Agenda for Action.
Defining Poverty
Individuals, families and groups in the
population can be said to be in poverty when they
lack the resources to obtain the type of diet,
participate in the activities and have the living
conditions and amenities which are customary, or
at least widely encouraged, or approved, in the
societies to which they belong. They are, in
effect, excluded from ordinary living patterns,
customs and activities
-- Townsend, 1979, p.31
The North York Heart Health Network
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Community-based coalition of over 45 groups.
Frustrated by limited mandate and neglect of
societal issues in heart health.
Commissioned literature review and report on
income and heart health to raise awareness.
Released the report Inequality is Bad for Our Hearts:
Why Low Income and Social Exclusion are Major
Causes of Heart Disease in Canada in November
2001.
Updated revision Social Justice is Good for Our
Hearts: Why Societal Factors -- Not Lifestyles -- are
Major Causes of Heart Disease in Canada and
Elsewhere released May, 2002.
Heart Disease in North America:
The Missing Messages
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The emphasis by health units and the media on medical and
lifestyle risk factors as the major causes of cardiovascular
disease (CVD) in Canada is inaccurate.
Low income is a major cause of CVD in Canada.
Social exclusion provides a process by which low income can be
understood to cause CVD.
Canadian policy directions are inconsistent with what is known
about reducing the incidence of CVD.
Lifestyle approaches and messages are not only inaccurate but
potentially damaging to population health.
The health sector and the media have been negligent in ignoring
the role societal factors play in CVD and other diseases.
The Evidence Concerning Low Income and Heart
Disease: The Hard Data
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•
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•
Statistics Canada estimated that in 1996, 23% of
years of life lost for all causes prior to age 75 in
Canada could be attributed to income differences.
The diseases most responsible for income-related
differences in death rates were cardiovascular
diseases.
In 1996, 22% of all the years lost that can be
attributed to income differences were caused by
cardiovascular disease.
These income differences account for an annual
excess of 24% or 6,366 premature deaths from
cardiovascular disease.
PYLL(0-74) by Cause, 1996
0
5
10
15
20
25
23.1
Income-Related
19.2
Injuries
17.6
Circulatory
Infectious
5.3
Perinatal
4.9
Ill-defined
4.8
All other
35
30.9
Neoplasms
Congenital
30
3.8
13.5
%
Excess PYLL(0-74) by Cause, 1996
0
5
10
15
20
Circulatory
21.6
Injuries
16.9
Neoplasms
14
Infectious
12.2
Ill-defined
8.3
Perinatal
Digestive
All other
25
7.1
5.4
14.5
%
Figure 5: Cardiovascular Deaths Per 100,000, Urban Canada, 1996
280
240
200
160
120
80
40
0
268
203
119
1st (Highest Income)
236
225
218
128
118
127
2nd
3rd
4th
Neighbourhoods by Income Quintile, Urban Canada
Males
Females
143
5th (Lowest Income)
Figur e 7 : Heart Attack Hospital Admissions by A rea Income,
Ontario , 199 4-97
13,935
13,115
11,837
12,000
9,000
6,000
8,090
4,614
3,000
0
1st (Highest Income)
2nd
3rd
4th
Neighbourhoods by Income Quintile, Ontario
5th (Lowest Income)
Figure 9: Greater Risk of Heart Disease in Low Income Areas, USA, 1988-97
160%
160%
120%
90%
80%
90%
90%
80%
70%
60%
60%
50%
50%
40%
40%
30%
0%
White Males
White Females
Black Males
Black Females
Low Income Area - Adjusted for Age and Study Site
Low Income Area - Adjusted for Preceding and Individual Socioeconomic Characteristics
Low Income Area - Adjusted for Preceding and All Behavioural and Medical Factors
It was found that those living in lower income
areas were much more likely to develop
coronary heart disease than those in well-off
neighbourhoods. These effects remained
strong even after controlling for tobacco use,
level of physical activity, presence of
hypertension or diabetes, level of cholesterol,
and body mass index.
- Summary of Neighbourhood of Residence and
Incidence of Coronary Heart Disease, A. Roux, S.
Merkin, D. Arnett, et al. New England Journal of
Medicine, 2001, 345, 99-106.
Critical Periods of the Life Course
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Foetal development
Birth
Nutrition, growth and health in adulthood
Educational Career
Leaving parental home
Entering labour market
Establishing social and sexual relationships
Job loss or insecurity
Parenthood
Episodes of illness
Labour market exit
Chronic sickness
Loss of full independence
-- Shaw et al., The Widening Gap, 1999, p. 106.
Low Income and Heart Disease:
Researchers’ Conclusions
Our results suggest that despite the presence of significant
socio-economic differentials in health behaviours, these
differences account for only modest proportion of socioeconomic disparities in mortality. Thus, public health
policies and interventions that exclusively focus on
individual risk behaviours have limited potential for
reducing socio-economic disparities in mortality.
-- Socioeconomic Factors, Health Behaviors, and Mortality, P.M. Lantz, J.S.
House, J.M. Lepkowski, D.R. Williams, R.P. Mero, & J.J. Chen, Journal of the
American Medical Association, 1998, 279, 1703-1708.
Low Income and Heart Disease:
Researchers’ Conclusions
These estimates of risk reduction may be compared
with the much smaller estimates of the effects of
improvements in adult lifestyle... Our findings add
to the evidence that protection of fetal and infant
growth is a key area in strategies for the primary
prevention of coronary heart disease.
-- Early Growth and Coronary Heart Disease in Later Life:
Longitudinal Study. J.G. Eriksson, T. Forsen, J. Tuomilehto, C.
Osmond, D.J. Barker. British Medical Journal, 2001, 322, 949-953.
Heart Health In Ontario
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Major $17,000,000 5-year initiative by
Conservative Government.
Specific focus on lifestyle factors of diet, activity,
and tobacco use.
Clear neglect of structural (societal and
community) factors in heart health despite
profound evidence of their importance.
Contradicts 25 years of Health Canada and
CPHA statements on health determinants.
Similar neglect of societal issues by media, health
units, and disease-oriented associations.
Sector Reactions to the Reports
 Enthusiastic
 Social development/social welfare sectors
 Anti-poverty community
 Faith communities
 Ambivalent and Guarded
 Public health units in Ontario
 Lifestyle-oriented health promoters
 Illness-oriented foundations
 The media
 Hostile – or at least not excited!
 Ontario Ministry of Health/Long-Term Care
 Heart Health community in Ontario
Diabetes Prevalence Rate
Diabetes Prevalence in Ontario by
Neighbourhood Income Quintile, 1999
9
8
7
6
5
4
3
2
1
0
7.76
7.05
6.78
5.76
Q1 (Lowest)
Q2
Q3 (Middle)
Q4
5.12
Q5 (Highest)
Neighbourhoood Classified by Mean Income
Increased Risk of Diabetes in Ontario
Among Low Income Residents, 1997/97
Diabetes Prevalence Ratio
Males
Females
5
3.8
4
3
2
2.3
1.4
1.5
2
1.2
1
1
1
0
Low
Low-Middle
Upper-Middle
Income Level
High
Diabetes, Males
ASMR x 100,000
22
20
18
16
14
Q1 - Richest
12
10
Q2
8
Q3
6
Q4
4
Q5 - Poorest
2
0
1971 1976 1981 1986 1991 1996
Diabetes, Females
ASMR x 100,000
22
20
18
16
14
Q1 - Richest
12
10
Q2
8
Q3
6
Q4
4
Q5 - Poorest
2
0
1971 1976 1981 1986 1991 1996
Implications of Increasing Family Poverty
Given the disturbing increases in income inequality in the
United States, Great Britain, and other industrial
countries, it is vital to consider the impact of placing ever
larger numbers of families with children into lower SES
groups. In addition to placing children into conditions
which are detrimental to their immediate health status,
there may well be a negative behavioural and
psychosocial health dividend to be reaped in the future.
-- Why Do Poor People Behave Poorly? Variation in Adult Health Behaviours and Psychosocial
Characteristics by Stages of the Socioeconomic Life Course, J.W. Lynch, G.A. Kaplan, & J.T.
Salonen. Social Science and Medicine, 1997, 44, 809-819.
Recommendations for Action
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The first and most important set of
recommendations is concerned with reducing the
incidence of low income among citizens.
•
The second set of recommendations is concerned
with reducing the incidence of social exclusion.
•
The third set involves restoring the supports by
which Canadians have traditionally been assisted in
their navigation of the life course.
Ten Tips For Better Health - Donaldson, 1999
1. Don't smoke. If you can, stop. If you can't, cut down.
2. Follow a balanced diet with plenty of fruit and vegetables.
3. Keep physically active.
4. Manage stress by, for example, talking things through and
making time to relax.
5. If you drink alcohol, do so in moderation.
6. Cover up in the sun, and protect children from sunburn.
7. Practise safer sex.
8. Take up cancer screening opportunities.
9. Be safe on the roads: follow the Highway Code.
10. Learn the First Aid ABC : airways, breathing, circulation.
Ten Tips for Staying Healthy - Dave Gordon, 1999.
1. Don't be poor. If you can, stop. If you can't, try not to be poor for
long.
2. Don't have poor parents.
3. Own a car.
4. Don't work in a stressful, low paid manual job.
5. Don't live in damp, low quality housing.
6. Be able to afford to go on a foreign holiday and sunbathe.
7. Practice not losing your job and don't become unemployed.
8. Take up all benefits you are entitled to, if you are unemployed,
retired or sick or disabled.
9. Don't live next to a busy major road or near a polluting factory.
10. Learn how to fill in the complex housing benefit/ asylum
application forms before you become homeless and destitute.
Avoiding the Life-Style Trap
• Lifestyle choices are heavily structured by
life circumstances
• Lifestyle choices by themselves account for
modest proportions of health status
• Lifestyle choices are difficult to change
without considering life contexts
• Lifestyle choice emphases can have
unintended side-effects that work against
health
Economic Inequality Affects Health in
Three Main Ways
• Economically Unequal Societies have
Greater Levels of Poverty
• Economic Unequal Societies Provide
Fewer Social Safety Nets
• Economically Unequal Societies Have
Weaker Social Cohesion
Economic Inequality is Dangerous to
the Health of Everybody
• Economic inequality is especially bad for
the health of poor people
• Economic inequality is bad for the health
of well-off people
• Economic inequality weakens communities
• Economic inequality weakens societies
• Is economic inequality Un-Canadian?
Working-Aged Male (25-64) Mortality by Median Share
U.S. States and Canadian Provinces
Rate per 100,000 Population
800
U.S. States with weighted linear fit (from Kaplan et al., 1996)
Canadian Provinces with weighted linear fit (slope not significant)
MS
675
LA
SC
AL
FL
550
TX
CA
ME
PEI
QUE
425
NH
NS
NB
MAN
MN
BC
SASK
NFLD
ONT
ALTA
Mortality Rates Standardized to the Canadian Population in 1991
300
0.18
0.20
0.22
Median Share of Income
0.24
WAMWeightedCan&US June 16, 1999 2:40:26 PM
Working Age (25-64) Mortality by Median Share
U.S. and Canadian Metropolitan Areas
U.S. cities (n=282) with weighted linear fit (from Lynch et al. 1998)
Canadian cities with weighted linear fit (n=53) (slope not significant)
600
FlorenceSC
NewOrleansLA
Rate per 100,000 Population
AugustaGA
PineBluffAR
500
NewYorkNY
MonroeLA
400
LosAngelesCA
BryanTX
Shawinigan
SiouxCityIA
PortsmouthNH
McallenTX
300
Barrie
Montreal
Vancouver
AppletonWI
Toronto
Oshawa
Mortality Rates Standardized to the Canadian Popluation in 1991
200
0.15
0.19
0.23
0.27
Figure 14: Changes in Number of Low Income Children in Ontario Since 1989
In Female Sole Support Families
89%
In Two Income Families
91%
In Long Term Unemployed Families
62%
In Full Employment Families
48%
In Working Low Income Families
103%
Total Number of Low Income Children
91%
0%
20%
40%
60%
80%
Percentage Increase
100%
120%
Figure 17: Increases in Waiting Lists for Subsidized Housing, 1988-98, Toronto
500%
500%
400%
300%
300%
200%
100%
100%
0%
Seniors
Families
Singles
Low Income
%
45
40
35
30
25
20
15
10
5
0
Q1-Richest
Q2
Q3
Q4
Q5-Poorest
1971
1986
1991
1996
Economic Inequality and Health:
Policy Implications
• Poverty and economic inequality is on the rise
in the USA and Canada
• Poverty is bad for health
• Economic inequality is dangerous for the
health of all of us
• Policy decisions create poverty and economic
inequality
• Citizens can influence policy decisions to
improve health
Economic Inequality Affects
Health in Three Main Ways
• Economically Unequal Societies have
Greater Levels of Poverty
• Economic Unequal Societies Provide
Fewer Social Safety Nets
• Economically Unequal Societies Have
Weaker Social Cohesion
What Creates Poverty and
Income Inequality?
• The growing gap between rich and poor has not
been ordained by extraterrestrial beings. It has
been created by the policies of governments:
taxation, training, investment in children and
their education, modernization of businesses,
transfer payments, minimum wages and health
benefits, capital availability, support for green
industries, encouragement of labour unions,
attention to infrastructure and technical
assistance to entrepreneurs, among others.
– Peter Montague
USA, Canada, and Sweden Rankings on Compared to
Other Industrialized Nations
(Ranking, 1 is best)
Measure
Income Inequality (1990)
Child Poverty (1990)
Infant Mortality (1996)
Youth Suicide (1992-1995)
High School Drop-Outs (1996)
Youth Homicide (1992-1995)
Wages (1996)
Unemployment (1996)
Elderly Poverty (1990)
Life Expectancy (1996)
USA
18 of 18
17 of 17
24 of 29
15 of 22
17 of 17
22 of 22
13 of 23
2 of 10
15 of 17
20 of 29
Canada
11
14
17
16
16
19
15
7
4
4
Sweden
3
2
2
10
10
5
6
8
5
3
Canadian Policy Directions
It has become obvious that people on the low end of
the income scale are cut off from the ongoing
economic growth that most Canadians are enjoying.
It is also obvious that in these times of economic
prosperity and government surpluses that most
governments are not yet prepared to address these
problems seriously, nor are they prepared to ensure
a reasonable level of support for low-income people
either inside or outside of the paid labour force.
-- Poverty Profile, 1998. Ottawa: National Council of Welfare
Reports, Autumn, 2000.
Reducing Health Inequalities
We consider that without a shift of
resources to the less well off, both in and
out of work, little will be accomplished in
terms of a reduction of health inequalities
by interventions addressing particular
downstream’ influences.
-- Report of the Acheson Independent Inquiry into
Inequalities in Health, 1998, p. 33.
Social Inequalities in Health:
Montreal Medical Officer’s Report I
Having scanned the health and well-being of
Montrealers from one end of the life cycle to the other,
we note the important role played by poverty.
Inequalities in health and well-being can be traced
back to socioeconomic inequalities, that is to the
harsh living conditions which marginalize so many of
our fellow citizens, not only limiting their access to
essential goods, but depriving them as well of any
meaningful role in social life.
-- Lessard, 1997, p.60
Social Inequalities in Health:
Montreal Medical Officer’s Report II
For anyone interested in public health, social
inequalities in health must be a major concern.
But we know that the solution is not to invest
more in the health system or in new technologies.
These inequalities must rather be met head-on;
and well-targeted actions must be undertaken to
ensure that they will not become worse.
-- Lessard, 1997, p. 20.
Barriers to Effective Action on
the Social Determinants of Health
• Ideological - What is health and its determinants?
• Political - How do government actions affect health?
• Institutional - What is appropriate health action?
• Personal - Do I have the knowledge to affect health?
• Attitudinal - Do I need the hassle?
Income Inequality and
Population Health:
Raising the Issue I
• develop communication between various
sectors concerned with economic inequality
• contribute papers to academic and professional
journals on income-related developments and
their potential for affecting the health of
citizens
• use the media to educate citizens about the
consequences of increasing economic
inequality and poverty upon health
Income Inequality and
Population Health:
Raising the Issue II
• lobby local health departments to begin taking
seriously a determinants of health approach
including consideration of the importance of
economic inequality and poverty
• lobby governments to maintain the community
and service structures that help to maintain
health and well-being
• begin to understand the forces that create
economic inequality and poverty
From “Inequality is Bad” to
“Social Justice is Good”
It was clear that additional funds would not be made
available to reprint the “Inequality is Bad” report.
It was also made clear that it would be difficult to find an
internet home for the report in Ontario.
Since the words were deemed as belonging to me,
arrangements were made to:
 Update and revise the report and find a new
sponsor/publisher.
 Find an internet home for the original report.
 Provide additional critical analyses of the lifestyle
approach to heart health in the form of three additional
messages to the original six.
Critical Analysis I:
Reasons for Resistance
 Lack of Epidemiological Theory
Health officials and reporters seem unaware of
recent developments in social epidemiological theory
and population health research findings.
 Commitment to Ideology of Individualism in
Health, Illness and Health Promotion
Assists the neo-liberal and neo-conservative agendas
of blaming individuals for their health problems,
absolving governments of blame for their health
threatening policies that create poverty, inequality,
and social exclusion.
Critical Analysis II:
Side Effects of the Biomedical and Lifestyle Heart
Health Approach
 Removes the issue of the social determinants of
cardiovascular disease and diabetes right off the
public policy agenda.
 Low income people made to feel that they are
responsible for their own poor health (victim
blaming).
 Health workers and the media become complicit
in the process of ‘poor bashing’: Ignoring facts
and repeating stereotypes about people who are
poor.
Critical Analysis III: The Holy Trinity
As with any area of medical or scientific research,
the selection of ‘factors” to be studied cannot be
immune from prevailing social values and
ideologies. ... It is also evident that so called
lifestyle or behavioural factors (such as the holy
trinity of risks - diet, smoking and exercise)
receive a disproportionate amount of
attention. As we have seen, the identification and
confirmation of risk factors is often subject to
controversy and the evidence about causal links
is not unequivocal.
Nettleton, S. (1997). Surveillance, Health Promotion and the Formation
of a Risk Identity in Debates and Dilemmas in Promoting Health.
London UK: MacMillan.
Towards the Future
CIHR Institute of Population and Public Health (IPPH)
awarded $100,000 to D. Raphael, R. Labonte, and R. Colman
to provide an assessment of Needs, Gaps, and Opportunities in
the Conceptualization of Income in Health Research in
Canada.
Health Canada Health Policy Program awarded $113,000 - supplemented with $10,000 from IPPH -- to hold a national
conference on Social Determinants of Health Across the Life
Span: A Current Accounting and Policy Implications, to be
held at York University in late November 2002.
Application being made with Kim Raine, University of
Alberta, to CIHR to study the lives of people with diabetes in
an attempt to understand the increasing mortality among
low income Canadians.
Policy Directions and Population Health
• The policies that Canada has developed to
improve population health reflects its more
egalitarian structure. Examples include various
tax and economic transfer policies that help to
limit income differences across the country, as
well as provision of important social services...
If a healthy population is the goal, we must
enter the political arena and fight to maintain
the social contract that has sustained Canada as
one of the world leaders in health.
• Stephen Bezruchka, CMAJ, 2001
Justice and Fairness I
Where a great proportion of the people
are suffered to languish in helpless
misery, that country must be ill-policed
and wretchedly governed: a decent
provision for the poor is the true test of
civilization.
- Dr. Samuel Johnson
Justice and Fairness II
If the misery of our poor be caused
not by the laws of nature, but by
our institutions, great is our sin.
– Charles Darwin
Dennis Raphael
School of Health Policy and
Management
York University
Toronto, Canada
416-736-2100, ext. 22134
draphael@yorku.ca