The Determinants of Health in the City

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The Determinants of Health in the City

• or
•  Beyond Health Care 

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bythe Hon. Monique BéginHealth
AdministrationUniversity of Ottawa

• George Brown College Toronto
• 23 November 2005

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• This wonderful title comes from a Canadian
  conference organized here by Dr. Trevor Hancock
  in 1984.
• Dr Hancock was an Associate Medical Officer of
  Health for the City of Toronto from 1981 - 86.

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As Jessie Parfit, author of a history of health
in Oxford, England from 1770 to 1974, remarked

• Many would be surprised to learn that the
  greatest contribution to the health of the nation
  over the past 150 years was made, not by doctors
  or hospitals, but by local government.

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Presentation Outline

• 1.THINK GLOBALLY
• The WHO Commission on the Social Determinants
  of Health

• 2. ACT LOCALLY
• George Browns Health in the City
• Symposium

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1st Part the WHO Commission

• CSDH/WHO launched in Santiago de Chile in March
  2005.
• Three years mandate
• 20 Commissioners (2 Canadians Stephen Lewis and
  myself)
• Chair Sir Michael Marmot
• About 3-4 full meetings a year
• First report in one year!

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What good does it do to treat people's illnesses
...
then send them back to the conditions that made
them sick?
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Why one more Commission???
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History trends and opportunities
2005 Commission social Determinants of
Health
2000s "pendulum swing" and new chance for action.
2005
1990s paradigm of health as "private" issue
dominant some exceptions.
2002
Determinants re-emerge under Health for All
agenda (1970s), action falters in 1980s.
Social dimensions of health affirmed in WHO
Constitution (1948), downplayed during 1950s era
of disease campaigns.
2001
2000
C-PHC S-PHC
Reforms Minimum Packages MDG
Scaling-up
1993
1982
1978
1948
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(No Transcript)
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THE SOLID FACTS 10 MESSAGES

• THE SOCIAL GRADIENT
• STRESS
• EARLY LIFE
• SOCIAL EXCLUSION
• WORK

• UNEMPLOYMENT
• SOCIAL SUPPORT
• ADDICTION
• FOOD
• TRANSPORT

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There are inequalities

• Between countries
• and
• Within countries

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UNDER 5 MORTALITY RATE PER 1000 LIVE BIRTHS
SOURCE THE WORLD HEALTH REPORT 2004,WHO
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PROBABILITY OF DYING BETWEEN AGES 15 AND 60
(males)
SOURCE THE WORLD HEALTH REPORT 2004,WHO
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Probability of Survival From Age 15-65 Years
Among US Blacks Whites
probability of survival
US White Poor White US Black Poor Black Males
Males Males Males
Geronimus et al, NEJM 1996
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THE WIDENING TREND IN MORTALITY BY EDUCATION IN
RUSSIA,1989-2001
45 p20 probability of living to 65 yrs when
aged 20 yrs
Murphy, Bobak, Nicholson, Rose, and Marmot, 2005
under review
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TWO TYPES OF SUCCESS IN REDUCING MORTALITY

• Growth-mediated if economic growth is widespread
  and participatory e.g. Hong Kong or S. Korea -
  poverty removal and public health.
• Support led Costa Rica, Kerala, Sri Lanka -
  enhanced quality of life through social services
  and education.

A.Sen Innocenti Lecture, Florence 1995
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On the occasion of his winning of the 1998 Nobel
Prize in Economics
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Pilars of the Commissions work

• KNs or Knowledge Networks
• Country Work
• Civil Society involvement
• Action at the global level

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KNOWLEDGE NETWORK THEMES
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Country Teams

• Focus Countries interested in or using a SD
  approach to policy/programs
• Purpose demonstrate, document, and evaluate
  policy, practice, leadership and scaling-up
• Distribution all regions
• Composition Government leaders, KNs, civil
  society, WHO, Commissioners
• Partnerships "experienced" countries partner
  with those beginning to implement

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Civil Society

• Commissioners emphasized the need to include
  civil society in the Commission, including groups
  not only involved in health issues. Civil Society
  can help the Commission speak with a voice to
  many, and it is a responsibility to engage with
  them these are the kind of representatives that
  understand what we are talking about and the
  strategy. Consequently, the Commission needs to
  have networking processes and areas of interest.

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Work at the Global Level

• World Bank
• UNICEF
• ILO
• IMF
• UN
• MDGs
• etc. etc.

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IMPROVED HEALTH HEALTH EQUITY
Integrating Social Determinants of Health into
Policy and Programs
Leadership
Learning
Advocacy
Action
Communication/Exchange
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Progress can be achieved in short time periods
In 7 years
In 9 years
In 15 years
LIFE EXPECTANCY
POTABLE WATER
PRIMARY SCHOOL ENROLLMENT
POVERTY
15m
56 yrs
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89
48 yrs
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7m
Sri Lanka 1946 - 53
South Africa 1994-2001
China 1990 - 99
Botswana 1970 - 85
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2nd Part George Brown Health in the City
Symposium

• Your 2nd such Symposium
• Promote an Interprofessional Education Model
• Promote students healthy lifestyles choices
• and careers in health care and community
  services
• Build stronger connections with Guidance
  Counsellors and Community Partners

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Your biggest challenge

• Interprofessional Education
• Interdisciplinarity

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In Universities, interdisciplinarity

• Was a sin 10 years ago
• Is now the new fad and is becoming a reality
• We do observe real successes in some new
  programs, and partners are making a real effort
  to understand the internal logic of disciplines
  and approaches different than their own, but
  governance of interdisplinarity has not followed!

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Why interprofessional education?

• For many reasons
• The pendulum towards specialization went too far.
  It did enrich knowledge, no question, but there
  is nobody to put the pieces of knowledge
  together!
• The patient-client-citizen wants a holistic
  approach. People need a comprehensive view of the
  problems in their lives.
• Health is multifaceted as we saw in the
  determinants of health.

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Interprofessional Education has its own challenge

• Must develop at the same time RIGOUR and DIALOGUE

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Will it pay back?

• Will our students find jobs?

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JLI report recommends at least 1,000,000 health
workers required in SSA over next 6 years to
ensure access to essential health interventions.
More information http//www.globalhealthtrust.org
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Jobs in Canada?...

• Should definitely develop more and more, and not
  just in hospital settings.
• But lets not forget that it is about truly
  working together, even in traditional
  environments.

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However

• Up to now,  corporatism  by the various
  professions has played a rather negative role in
  the health care field.
• The motive might have been good quality of care
  and safety of patients.
• Tomorrows challenge
• imagining points of connection in the workplace.

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Why Health in the City?
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A bit of history!...

• In a 1984 one-day workshop entitled Healthy
  Toronto 2000, Trevor Hancock and Leonard Duhl
  proposed a model of a Healthy Community. This
  motivated the World Health Organization (WHO) to
  initiate its Healthy Cities Project. The Healthy
  Cities or Healthy Communities movement, now
  includes more than 7500 cities and towns
  worldwide, in at least 20 regional and national
  networks.

In a 1984 one-day workshop entitled
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In Ontario,

• Ten years ago, there were 77 communities members
  of the Ontario Healthy Communities Coalition.
• Unable to find recent figures, I however
  regularly see projects
• The Caledon Institute Action for Neighbourhood
  Change projects e.g. Scarborough Village,
  Thunder Bay.
• Centre for Research on Inner City Health, St.
  Michaels Hospital, etc.

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The idea was that if we could develop better
health locally, and multiply the projects, in 20
years we would have better health globally.
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Quite the contrary has happened
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in part because the philosophy behind Healthy
Cities rested almost only on the then new ideas
of health promotion, meaning healthy lifestyles,
thus re-orienting cities from medical care to
health.
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It remains true that health is created in the
context of everyday life where people love, work
and play.
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But as I hope the social determinants of health
are now teaching us, healthy lifestyles are not
the whole story.This is not to critique in any
way your wonderful and most relevant Initiative.
Let me try to situate it with the next slide.
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Dahlgren and Whitehead layered influences
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As I told our Minister of Public Health, Dr.
Carolyn Bennett

• I wish every Memorandum to Cabinet, on any
  possible topic, from any existing Minister, had
  to have a mandatory paragraph entitled
   Consequences on health outcomes of Canadians! 

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Back to Thinking Globally, Acting Locally

• Your Interprofessional Learning Clinic as a safe
  space to explore a interdisciplinary approach
  BRAVO!
• Your Smartroom technology BRAVO!
• Rooms for students to discuss informally together
  BRAVO!
• Above all, your patient-centred care BRAVO!

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Also great is

• Your objective to develop an integrated client
  care model with interdisciplinary assessment and,
  later, treatment plans.

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THE SUCCESS OF AN ECONOMY AND OF A SOCIETY
CANNOT BE SEPARATED FROM THE LIVES THAT THE
MEMBERS OF THE SOCIETY ARE ABLE TO LEADWE NOT
ONLY VALUE LIVING WELL AND SATISFACTORILY, BUT
ALSO APPRECIATE HAVING CONTROL OVER OUR OWN
LIVESAmartya Sen, Development as Freedom
(1999)