Strong Language

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Strong Language

• Use strong language. Health disparities are the
  number one health problem in the country and
  health care alone is powerless to overcome them.
  The health disparity between groups in Canadian
  society and the impact of the gap must be
  reported and highlighted. This is a difficult
  message to get across in the current environment
  where the public is preoccupied with funding for
  health care. But it needs to be done.
• Health Council of Canada
• January 2005
• with help from Steven Lewis

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But if I let your people go, Ill have to hire
temps!
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• Canada ranks 17th amongst industrialized
  countries in terms of percentage of children
  living in relative poverty
• (50 below the mean) 20.0
• Single parent households 59.2
• Aboriginal households 43.4
• Visible minority households 35.9
• Innocenti Report Card No. 1, UNICEF, June 2000
• The Canadian Fact Book on Poverty, 2000

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The Growing Gap
Yalnizyan A. The Growing Gap A Report on Growing
Inequity between the Rich and Poor in Canada,
1998
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Powerlessness as a Determinant of Health

• National Population Health Survey (1999) found
  that among Canadians in the lower third of income
  distribution, 47 reported seeing the world as
  not being meaningful, events as being
  incomprehensible, and lifes challenges as being
  unmanageable.

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What I Know You Know(Probably Better Than I Do)

• Health disparities are large
• Women live 6 years longer than men
• Aboriginal men die 7 years sooner than
  non-aboriginal men
• Aboriginal women die 5 years sooner than
  non-aboriginal women
• Men in highest income quintile live 5 years
  longer than men in lowest gap among women is 2
  years

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What You Know (contd)

• 73 of Canadians in top income quintile report
  excellent or very good health compared to 47 in
  bottom quintile
• People in lowest quintile 5x as likely to report
  poor or fair health as those in top quintile
• Aboriginal people 2x as likely to report poor or
  fair health as people with same income levels
• Death rates due to injury among aboriginal
  infants 4x higher preschoolers 5x higher
  teenagers 3x higher than rest of population

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Strongest Predictors of Disparities in Canada

• Socio-economic status
• Gender
• Aboriginal status
• Geographic location

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Thats an excellent suggestion, Ms. Triggs.
Perhaps one of the men here would like to make
it.
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How These Manifest

• Problems in early childhood development
• Chronic diseases and years spent with a
  disability
• Joblessness and/or job insecurity (both good
  predictors of permanent or temporary ill health)
• Low self-esteem and sense of control
• A circle of disadvantage ill health diminishes
  economic opportunity, economic deprivation
  creates ill health

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Before I operate, I want you to know youre in
my parking space.
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Health Advocate (FRCPC)

• Specialists recognize the importance of advocacy
  activities in responding to the challenges
  represented by those socio-cultural,
  environmental and biological factors that
  determine the health of individuals, groups,
  communities and society. They recognize advocacy
  as an essential and fundamental component of
  health promotion that occurs at the level of the
  individuals, family, community and society.
  Health advocacy is appropriately expressed both
  by individuals and the collective responses of
  specialist physicians in influencing public
  health and policy.

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Dr Charles Hastings (1918)

• "Every nation that permits people to remain under
  fetters of preventable disease and permits social
  conditions to exist that make it impossible for
  them to be properly fed, clothed and housed so as
  to maintain a high degree of resistance and
  physical fitness, and, who endorses a wage that
  does not afford sufficient revenue for the home,
  a revenue that will make possible development of
  a sound mind and body, is trampling on a primary
  principle of democracy."
• Torontos first Medical Officer of Health

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General Requirements

• Identify the important determinants of health
  affecting individuals and communities.
• Contribute effectively to improved health of
  individuals and communities.
• Recognize and respond to those issues where
  advocacy is appropriate.

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Health Protection and Promotion Act

•     The purpose of this Act is to provide for the
  organization and delivery of public health
  programs and services, the prevention of the
  spread of disease and the promotion and
  protection of the health of the people of
  Ontario.  R.S.O. 1990, c. H.7, s. 2.

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Response of Council of Medical Officers of Health

• Individual support given to MOH action on minimum
  wage and poverty
• Interest expressed to establish a working group
  on Determinants of Health
• Working Group developed alPHa resolution for the
  establishment of Mandatory Program on DOH
• Working Group members aware of and connected to
  DOH stream of OPHA conference
• Behind the scenes action on food security and
  social assistance recipients

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Albert Camus

• Ends do not justify means,
• but rather, means justify means,
• and means have a way of becoming ends,
• so it is well to be
• scrupulous and uncompromising
• as to means.

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What Doesnt Seem to Mitigate Disparities

• Spending more on health care without targeting to
  high-needs populations
• Increases in total GDP or average income
• Population-wide preventive programs (the well-off
  respond better than the disadvantaged)
• A fragmented and episode-oriented health care
  system (not good at addressing complex,
  multi-faceted needs)

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What Does Seem to Mitigate Disparities

• Classic public health measures, especially clean
  water, infection control
• Low unemployment rates
• Strong social safety net
• Early childhood development programs such as Head
  Start
• Universal access to health care
• A more egalitarian political ethos

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Public Policy Dilemmas

• No one advocates persistent or worsening health
  disparities
• Disparities arise largely as a result of
  inequality of socio-economic circumstance
• There is considerable debate about and resistance
  to reducing inequality of socio-economic
  circumstance
• Dilemma can society be serious about reducing
  disparities without re-examining its overall
  notion of distributive justice?

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Provincial Government Role

• Shift emphasis from health care to programs to
  address determinants in fed-prov negotiations
• Assign responsibility for disparities reduction
  to government as a whole, not health sector
• Invest intensively in early childhood programs
• Remove barriers to post-secondary education for
  lower SES populations
• Develop partnerships for meaningful work that
  encourages private sector to create jobs

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Municipal Government Role

• Will increase in future as urbanization continues
• Remove financial barriers to cultural and
  recreational opportunities
• Monitor concentration of poverty and design
  zoning and incentives to integrate communities
  more fully
• Partner to create adequate housing and
  opportunities for ownership
• Design environments for equal access to public
  space, parks, recreation

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Health Sector Role (I)

• Advocate for including disparities in performance
  indicators frameworks and reporting (the 70
  agreed to by FPT process are silent on
  disparities)
• Sustain a public awareness campaign to show how
  health is unevenly distributed
• Reframe the discussion of health problems away
  from exclusive disease preoccupation
• Report successes and failures by SES and other
  relevant disparities groupings

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Health Sector Role (II)

• Develop primary health care compatible with needs
  of disadvantaged populations
• Integrated, comprehensive, physically accessible
  services
• Mental health component
• Close ties with education, social services
• Encourage providers to locate practices where
  needs are greatest
• Understand causes of and remove the barriers to
  access to specialist services among disadvantaged

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Health Sector Role (III)

• Partner with businesses and opinion leaders to
  sensitize them to disparities issues
• Build public support for determinants investment
  while maintaining a first rate health care system
• Advocate for government policies at all levels
  that are likely to address disparities
• Work with media to shift their focus from the ER
  crise du jour to the realities of disparities and
  their social and economic consequences

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Summary

• The hard facts of disparities are not embedded in
  the public consciousness
• The health sector alone has some capacity to
  reduce disparities by making key programs more
  effective and responsive
• It has a major role to play in communication,
  reporting, and advocacy
• Disparities are not inevitable - we can progress
• We have much to learn from European reports and
  experiences

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SDHU Discussion Paper on DOH Summary

• Sept 29, 2006
• V. Etches for R. Pellizzari

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Background

• No formal mandate to address underlying
  socio-economic risks to health
• OPHA-alPHa 2005 conference stream
• Funding from PHAC to write paper
• Reference panel (OPHA, PHAC, OPC)
• Fit with Provincial Priorities
• success for students better health strong
  people, strong economy

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Need how big is the problem?

• Repeatedly, income level is significantly related
  to health outcomes
• Natl Pop Health Survey less education, less
  excellent health status
• Higher occupational class, lower mortality
• Poor housing associated with adverse physical and
  mental health outcomes
• 10 of Canadian households experience food
  insecurity each year

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AppropriatenessAre we the best people to do it?

• Public health sector strategies
• Advocacy
• Programming (Access, Targeted programs)
• Community Capacity Building/Partnerships
• Research/Reporting
• Indicators important for evaluation of impact

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Impact how much can we fix it?

• Public health sector experience
• Lanark, Leeds and Grenville Health Forum
• Region of Waterloo intersectoral planning
• Sudbury District Low Wage Worker Action Group
• Algoma Food Security Committee
• British public health involvement in housing
• Canadian Pop Health Initiative producing a
  compendium of natural experiments related to
  addressing SDOH
• Swedens National Public Health Goals
  intersectoral

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Capacity are we able to do it?

• Immediate action could involve
• Providing leadership
• Working as a change agent regarding municipal
  policies that impact health
• Serving as knowledge brokers
• Facilitating multi-sectoral collaboration

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Challenges

• Public recognition of the impact of
  socio-economic determinants vs. traditional risk
  factors is lacking
• The impact of PH programs alone will be limited,
  and felt over the long-run
• Holding multiple sectors accountable for health
  outcomes is difficult
• The PH workforce does not reflect diverse
  populations to be served
• Reallocation of resources is difficult
• Evidence of impact of interventions is limited

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Recommendations

• That a general and a program standard related to
  the social and economic determinants of health be
  incorporated in the revisions to the mandate.
• Use an explicit theory or model of pop health.
• That an inter-ministerial committee be assembled
  as soon as possible with key in-services related
  to the health impact of social and economic
  conditions and opportunities for policy
  recommendations and implementation.

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Next steps

• Consultation
• Research and knowledge exchange
• Healthy public policy assessment and advocacy
• Public health capacity building