In this guest post, Ted Schrecker critically discusses the results of a recently published public health study in Canada. Illustrated are the hazardous implications of de-contextualized conceptualizations of health.
In early April 2012, a flurry of news reports described a study of major health risks shortening the lives of people in the Canadian province of Ontario. A typical report described “bad lifestyle choices” as together taking as much as seven years off Ontarians’ life expectancies.
As is often the case, the reality is more complicated. The study, led by Ottawa researcher Douglas Manuel, was based on self-reports from 117,674 interviews in three successive surveys conducted by Canada’s national statistical agency (Statistics Canada) and record linkage of 99,929 of the respondents with their provincial health insurance records. “The primary risk factors of interest were smoking, alcohol consumption, fruit and vegetable consumption, leisure physical activity and stress.” A procedure known as a multivariable Cox proportional hazards model was used to estimate the life expectancy reductions associated with these “behavioural risks,” to use the language of the study report. I’ll return to the problematic nature of this language.
In the full text of the report, the authors are commendably candid about limitations related to possible under-reporting of health risks in the survey on which the report was based – limitations, in many cases, related to the simplistic nature of the survey questions. For instance, the survey asked only about leisure time physical activity, not about activity related to work or quotidian errand-running. The conclusion that Ontarians’ combined exposure reduced overall life expectancy in the province by 7.5 years is no doubt statistically robust, given the data on which it was based. Unfortunately, it’s also a ‘so what’ kind of conclusion. The authors of the report are remarkably unreflective about their focus on proximate risk factors, ignoring the contextual influences that shape individuals’ opportunities to lead healthy lives.
It’s not as if the world just found out about the limitations of risk factor epidemiology, as Courtney McNamara noted in a previous posting. She emphasized Link and Phelan’s excellent work on “social conditions as fundamental causes of disease,” and in its 2008 report the Commission on Social Determinants of Health went to great lengths to foreground the “structural determinants and conditions of daily life” that “are responsible for a major part of health inequities between and within countries.”
None of these insights was incorporated into an interactive life expectancy calculator, based on the study findings, that invites Ontarians to respond to a set of questions that are then used to generate an estimate of how long they can expect to live. Participants are asked such questions as how many servings of fruit or vegetables they ate in the past week; how many were potatoes; and whether any carrots were involved. Other questions relate to leisure-time physical activity, and a strictly dichotomous question (like that in the original survey) asks whether most days are stressful.
Now, if you are paying market rent for housing while living on the sub-poverty social assistance income provided by the province of Ontario, having first exhausted almost all your assets as a condition for eligibility, eating the healthy diet defined by the provincial health ministry is an arithmetic impossibility in much of Ontario. Under these circumstances, hearing a $170k/year researcher and his team tell you that you should eat your carrots and have less stress in your life is not especially helpful. If you are trapped in a low-wage service sector job, or have lost your factory job because the employer locked you out after you refused a 50 percent pay cut and then moved production to a lower-wage jurisdiction, which recently happened to workers at the Electro-Motive plant in London, Ontario, hearing a $170k/year researcher and his team tell you that you should eat your carrots and have less stress in your life is not especially helpful. (Were I in such a situation, class warfare is the first phrase that would come to mind.) And after chasing across town on the bus to shop the specials that are their only chance at a healthy diet, or turning as a last resort to the food banksthat have become an established feature of life in the province (not a lot of carrots there), how many Ontarians living on the margins have time or safe opportunities for “leisure physical activity”?
The researchers’ isolation from the conditions of daily life is revealed with special clarity by their treatment of stress as a variable somehow within the control of those experiencing it. (In The Status Syndrome, Michael Marmot is eloquent on the weaknesses of this presumption.) Before giving one more interview or writing one more grant proposal, all those involved with studies like the one just released in Ontario should read, carefully, Barbara Ehrenreich’s account of life in the low-wage service sector. Nickel-and-Dimed is available both as a book with multiple secondhand sellers and as a feature in Harper’s Magazine, so readily accessible. This view of stress is of course even more pernicious in contexts outside Canada: for example Spain, where unemployment is now over 23 percent in the aftermath of a financial crisis that began in the United States, or the United Kingdom, where housing benefit caps are driving poor families out of central London or into homelessness even as tax rates on the ultra-rich are coming down.
At stake here is a vital instance of what Kristin Shrader-Frechette and Earl McCoy have called a methodological value judgment. Perhaps without being aware of it, Dr. Manuel and his team chose an approach that reinforces the neoliberal tendency to privatize risk and responsibility. Conditions like poverty and ill health are ascribed to the choices and failings of individuals who have little control over macro-scale processes like financial crises and the relocation of production to lower wage jurisdictions, rather than situated with reference to radical inequalities in the opportunity to lead a healthy life. The Commission on Social Determinants of Health understood the pernicious nature of this approach, implicating “poor social policies and programmes, unfair economic arrangements, and bad politics” as pathways to health inequity and structuring one of its three overarching recommendations around “the inequitable distribution of power, money, and resources.”
The most widely agreed-upon axiom of medical ethics is: first, do no harm. Studies and derivative knowledge transfer exercises that neglect structural influences on health fail this basic test, for they are far from harmless.