Income Inequality and Health

In this guest post, Ronald Labonté moves from describing the impact of income inequality on health to the implications of this relationship for both the Canadian and global context. He presents two sets of policy reforms necessary for acting on these contexts and illustrates the scope for Canadian engagement with national and global policy options. This post is based on an invited presentation given to the Liberal Open Caucus, Senate of Canada, March 11, 2015. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

Concern about the health effects of income inequality are not new. Considerable attention was paid to the low life expectancies and deprived lives of the poor and the working class throughout the era of industrial capitalism, stretching from the late 18th through to the late 19th centuries. The reasons then were simple. The material contexts in which many of the non-rich lived during this period were the determining factors:

  • poor food
  • inadequate shelter
  • unsafe working conditions
  • lack of potable water or sanitation, and
  • little opportunity for social mobility to a better life apart from petty crime

The reasons today are more complicated, but derive from the basic findings that life expectancy across the income spectrum in countries such as Canada (and indeed, globally) follow a gradient. Those higher up the income ladder have longer, healthier lives; and the pattern holds for each step up the gradient. This pattern has led to contentious efforts to explain these findings, especially since many of those slightly lower on the income ladder are not living in materially deprived circumstances, nor are they necessarily leading unhealthier lifestyles.

The Income Inequality Debate

Sir Michael Marmot, who designed the British Whitehall Studies that first brought international attention to the gradient effect, argued that these life expectancy differences, apart from those explained by proximal behavioural risks, were caused at least in part by negative social comparison, leading to a loss of self-esteem, psychosocial stress and poor health. This later became known as the ‘relative income’ or ‘income inequality’ hypothesis, which essentially stated that health inequalities were worse where income inequalities were greatest. Richard Wilkinson and Kate Pickett in their book, The Spirit Level1 became the most famous proponents of this argument, finding that for each of eleven different health and social problems outcomes are significantly worse in more unequal rich countries:

  • The Spirit Level by Richard Wilkinson and Kate Pickett
    The Spirit Level by Richard Wilkinson and Kate Pickett

    physical health

  • mental health
  • drug abuse
  • education
  • imprisonment
  • obesity
  • social mobility
  • trust and community life
  • violence
  • teenage pregnancies
  • child well-being

Many epidemiologists, however, were and remain skeptical of their use of co-relational data. An earlier 2004 systematic review of the literature concluded that there was little evidence that the size of income inequalities in itself explained differences in health within and between affluent countries, at least so far as the social comparison explanation is concerned.2 These findings are consistent with a larger literature that finds that it is not the scale of income inequality per se that is responsible for these health differences, but rather that those with different levels of income experience different levels of advantage and deprivation and psychosocial stress which is tightly related to their actual conditions or material conditions of life. As the authors of this 2004 study conclude:

“Although we found little evidence to support a direct effect of income inequality on health, this should not be interpreted to mean that factors that drive unequal income distribution at the system level are not important to individual and population health. Reducing income inequality by raising the incomes of more disadvantaged people will improve the health of poor individuals, health reduce health inequalities, and increase average population health (p.83)2.”

Why the Income Gap Still Matters

In other words, it is not so much the size of the gap between top and bottom income groups that accounts for health inequalities, but the fact that there is a gap in the first place. Reducing that gap remains a public health imperative. Moreover, one of the reasons why income inequalities in some countries do not lead to the same health inequalities as in others has to do with how that gap is reduced through the tax-funded provision of public goods (such as accessible quality education and health care, income transfers, even public transportation and active labour market policies).

This finding is similar to an argument made by the Princeton health economist, Angus Deaton3, whose own reading of the literature on income inequalities as a health determinant concluded that “childhood inequalities are the key to understanding much of the evidence, and that public interventions would do well to focus on breaking or weakening the injustice of parental circumstances determining child outcomes.” A more recent study, however, suggests that the income inequality and health hypothesis is still not entirely resolved. Using 31 years of panel data (1975 – 2006) from 21 OECD countries, the analysis found that, as income inequality increased, life expectancy decreased for both men and women, largely the result of excess mortality for children (aged 1 – 14).4

The study could not disentangle the reasons, but suggested that this was probably the result of under-investments in services for low-income parents, working poverty, long work hours and high household debt burdens, all leading to poorer living conditions and diets and high familial stress. Although the study used mortality data only, where there is high childhood mortality there is almost certain to be high childhood morbidity, creating an unhealthy start that accumulates over a lifetime; and demanding a focus on “on breaking or weakening the injustice of parental circumstances determining child outcomes,” as Angus Deaton expressed it.

These findings were underscored further by a comparison in changes in child well-being between 2007 and 2013 in the same 21 wealthy OECD countries5, a period during which income inequalities had risen in many of these countries subsequent to the 2007/2008 financial crisis. Child well-being (an index comprised of measures of health, education, behaviours, housing and environment and safety) improved in some countries but declined in others, including Canada. The declines were greatest in those countries that had experienced the largest increase in income inequality. The causal pathways, once again, were linked to a decline in material resources, maternal stresses creating epigenetic impacts in pregnancy and early childhood, precarious employment and reduced access to health and other public goods and services.

What Can We Conclude from This?

  • Income inequalities in themselves are likely not the best explanation for health inequalities
  • Within and between countries, however, there are stark health differences between people at different income levels
  • Part of this difference can be explained by different lifestyles (e.g. smoking rates, poor diets, lack of physical exercise), but not all of the difference
  • Lifestyle differences themselves are socially constructed and relate in many ways to affordability of healthier foods, more secure housing, opportunities for recreation and other ‘social determinants of health’
  • Psychosocial stresses associated with income inequality may account for some of the differences in health outcomes, but are more likely the result of material deprivations or shortfalls, and changes in employment or economic conditions that create greater precariousness and insecurity
  • Early childhood experiences (from pregnancy onwards) set the table for later life inequalities: both in income, and in health
  • Children are not born poor; they are born into poor families, and supports to reduce poverty by raising income levels of the bottom 40 percent of households become one of the most important policy levers that governments can use to create greater health equity over the lifespan

It is finally important to emphasize that it is generally the same economic policies and public policy responses that give rise to income differentials between people, and to the widening income inequalities that still appear to have an influence on the material conditions affecting peoples’ health opportunities.

How Well Is Canada Faring?

Since 1991, at least, Canada hasn’t made much progress in shrinking this income and health gap. Differences in the remaining years of life expectancy at age 25 for men in highest compared to the lowest income quintile was 7.1 in 1991. In 2006 it was still 7.1. For women the differences were 4.9 in 1991 and, well, in 2006: still 4.9.

How do these average individual differences stack up when the whole population is considered?

In 2013, Statistics Canada published the most comprehensive look at income differentials in mortality. The study examined cause-specific mortality rates by income adequacy among Canadian adults, using data from the 1991 to 2006 Canadian census mortality and cancer follow-up study. This study followed 2.7 million people aged 25 or older at baseline, 426,979 of whom died during the 16-year period. Age-standardized mortality rates (ASMRs), rate ratios, rate differences and excess mortality were calculated by income adequacy quintile for various causes of death.6 The result:

“If all cohort members had experienced the age-specific mortality rates of those in the highest quintile, the all-cause ASMRs would have been 19% lower for men and 17% lower for women. Extrapolated to the total non-institutional adult population, that amounts to an estimated 40,000 fewer deaths per year (25,000 fewer among men and 15,000 fewer among women)—the equivalent of eliminating all ischemic heart disease deaths (p.17)6.”

Two colleagues of mine, Dennis Raphael and Toba Bryant rather sensationally described these findings in this way:

“The health effects of income inequality in Canada are like 110 passenger jet falling out of the sky every day, 365 days a year.” 7

This led to some ridicule in a Financial Post blog 8, for which I have some sympathy. Describing the airplane analogy as “junk science,” the author, Peter Taylor, correctly points out that these figures are not about income inequality, which would require a measure of the size of the gap between rich and poor. Rather, it is about the fact “that people at the bottom of the income ladder tend to die earlier than those at the top.” As Taylor goes on:

“Why this is so is cause for vigorous debate. It could be a simple lack of resources. Low income Canadians might lack the ability to successfully navigate the complexities of Medicare. It might also reflect the fact lifestyle risk factors such as smoking, drinking and lack of exercise are more prevalent among lower incomes. Whatever the reasons, however, there’s a world of difference between acknowledging a link between poverty and health, and indicting income inequality as the cause of 40,000 deaths a year.” 8 plane

Fair enough, and Taylor is pretty correct in identifying the proximal causes of some of these gradient differences in health as they relate to one’s level of income. But we seem to be much more complacent in making similar claims that compare the mortality risks of smokers vs. non-smokers. Is it so misleading to describe the life expectancy differences between the richest 1/5th and the rest of Canadians as an inequality? More to the point: Taylor is wrong to ridicule public health’s concerns with these differences as “junk science”, arguing that public health should stick to vaccinations and steer clear of economics. The causes of these income differences in Canadian deaths are located within the economic and political policy choices that affect income distributions, and the social and environmental contexts that in turn affect poorer lifestyles, poorer living conditions and poorer opportunities for health.

That makes them a public health concern, just as the impoverished circumstances of early European industrial capitalism were the incubator of modern public health and its concerns with the conditions that create infectious and other diseases.

The Global Context

To put these findings into a larger global frame, since that is where most of my work is now focused:

  1. Income inequalities are at the highest level amongst OECD nations since 1985 – incidentally a period not only of economic recession, but also of the global diffusion of neoliberal economic models and market de-regulation.
  2. These inequalities are not just in relative income, but also in absolute income, including Canada.
  3. There is a negative and statistically significant impact between the scale of income inequalities and economic growth9. Income inequalities thus have a bearing on health due to any of the health-positive ‘trickle down’ effects of economic growth.
  4. The negative effect of income inequalities on growth is greatest when the gap between lower and median income households rises. Although the ‘breakaway’ wealth of the 1% is unrelated to economic growth (whether positive or negative), this breakaway wealth nonetheless correlates with decreases in the share of economic product going to labour (vs. to capital) and to a disproportionate control over politics and policy by a very small economic elite.
  5. Globally, wealth inequalities are even more extreme, as groups like OXFAM have been challenging much of the world on. Just 67 individuals (some estimate 72, but what’s another 5?) now have more wealth than the bottom 3.5 billion of the world’s population.10 10 individuals in Africa have more wealth than bottom 50% of that still impoverished continent.11labonte2
  6. Why wealth inequalities matter: globally we cannot eliminate life-threatening poverty without shifting economic policies to greater redistribution, both pre- and post-market. And certainly not if we are concerned with the ecological limits of growth, since as the 2009 UK Sustainability Commission noted, “there is as yet no credible, socially just, ecologically sustainable scenario of continually growing incomes for a world of nine billion people.”12

Acting on these global contexts and the national level requires two interrelated sets of policy reforms:

  1. Pre-market: elimination of low pay and precarious employment conditions through strengthened core labour rights, high minimum wages and strengthened collective bargaining to establish or re-establish a social contract between capital and labour; and changes in working hours and remuneration allowing employment opportunities to be more equitably shared.
  2. Post-market: redistribution through progressive taxation of incomes, inheritance, and rents; improved royalties on resources especially in low-income countries; capital controls to prevent legal or illicit capital flight; closure of tax havens; and a financial transaction tax or other systems of global taxation.

Most of the OECD nations, however, have been going in the opposite direction in both of these policy areas. Respecting taxation and globally, the picture is even more pronounced, with net global taxation in the past 10 years (2002 – 2012) on a steady decline, resulting in USD 30 trillion more in untaxed wealth floating around the world now than just a decade ago (author calculations based on the World Bank data set). Yet OECD and IMF studies generally conclude that low income inequality is robustly associated with better economic growth, and that redistribution through progressive taxation that lowers income inequality “is benign in terms of its impact on growth (p.4).”13 Several recent studies have affirmed this:

  • A US review of econometric studies that concluded that raising the marginal tax rate from its present low 35% to its historic high of 68% would have no impact on factors driving economic growth, but would reduce poverty, inequality and stimulate growth through public spending.14
  • An IMF study that more cautiously suggest that capping the marginal rate at 60% would have little or no effect on growth rates.15
  • Emmanuel Saez and Thomas Piketty, although never believing this would be achieved, have argued that there is no economically justifiable reason why the marginal rate shouldn’t be at 80%.16
  • More recently, a paper drawing on the concept of economic optimality concluded that a 90% marginal rate tax on incomes > $300,000 may lead to some declines in GDP and aggregate wealth, but would also lead to greater overall well-being and happiness.17

This leaves unchallenged the fact, from an environmental vantage, we need to abandon the concept of growth as a measure of prosperity and develop other metrics that capture the capabilities and social interactions that are the bases of health and happiness.12

Not a Crisis of Scarcity, but a Deficit of Fairness

But what these bases nonetheless tells us is that, in Canada, and in much of the rest of the rich world, we do not have a problem of scarcity; we have a severe deficit of fairness, whether we frame our social justice remedies as increasing equal opportunity or improving equal outcome. This deficit, in turn, still diffuses globally, characterizing differences within and between nations.

With respect to the pre-market reforms mentioned above, and in the words of Henry Ford a century ago:

“I have to pay workers enough that they can afford to buy my cars.”

With respect to post-market conditions we need to enhance, and in the words of the American jurist, Oliver Wendell Holmes, expressed at another time when income and wealth inequalities were racing out of control:

“Taxes are the price we pay for a civilized society.”

Repeated opinion polls find that the majority of Canadians would agree to paying higher taxes, if such revenues went into the health and education, environmental protection, and other public good programs that most Canadians value – all investments that would lower market inequalities perhaps even better than income transfers or tax credits alone (the market has a way of stealing new dollars from the pockets of the poor, through higher food, housing or other commodity or service prices).

For Canadians, we should heed the caution of an OECD cross-national study that suggests that once a nation’s Gini income co-efficient rises above 0.3 there will be as much as a 9.6% increase in adult mortality (15-60 age group).18 In Canada, we are now considerably above the 0.3 Gini threshold, even after taking account of our (now slightly less generous) post-tax and transfers.

As a country, Canada is unlikely to proceed alone in making dramatic policy shifts in our taxation, minimum wage or social protection policies. To do so would put us in a competitive disadvantage with our Anglo-American economic neighbours and, with open global financial markets, risk capital flight (licit or otherwise) by corporations and high-income earners. Compared to many northern European countries, however, we could embrace much higher marginal taxes than we levy at present. But we would also need to engage in changing the rules of the global economy such that the growing gap between the tops, bottoms and most of the in-betweens is stopped, and then shrunk. Reducing inequalities, and not just eliminating absolute poverty, is now on the global Sustainable Development Goals agenda, which will be normatively binding on all nations if approved at a special UN General Assembly this September. There is renewed global discussion of global financial taxes of one form or another; and on the need to levy a social protection pool based on countries’ abilities to pay, to be drawn upon based on needs.

Indeed, there is no shortage of potential policy initiatives that can address income inequalities and remedy the negative health externalities these create, if not by their scale so much as simply by their existence. It is unlikely that the present Canadian government will embrace these new global policy discussions with any earnest, since it has had a long-standing political platform of going in the opposite direction.

But at the very least these policy options need national debate and a healthy re-kindling.

Can the Canadian Senate add more fuel to this important policy fire?

References

1. Wilkinson, R. and Pickett, K. (2010) The Spirit Level: Why More Equal Societies Almost Always Do Better, London: Penguin.

2. Lynch, J., Smith, G.D., Harper, S., et al. (2004) “Is Income Inequality a Determinant of Population Health? Part 1: A Systematic Review,” Milbank Quarterly, 82(1):5-99.

3. Deaton, A. (2011) What does the empirical evidence tell us about the injustice of health inequalities? Mimeo: Centre for Health and Wellbeing, Princeton University. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1746951

4. Torre, R. and Myrskylä, M. (2014) “Income inequality and population health: An analysis of panel data for 21 developed countries, 1975–2006,” Population Studies, 68:1-13.

5. Pickett, K., and Wilkinson, R. (2015) “The Ethical and Policy Implications of Research on Income Inequality and Child Well-Being,” Pediatrics, 135 (Supplement 2):S39-S47.

6. Tjepkema, M., Wilkins, R. and Long, A. (2013) “Cause-specific mortality by income adequacy in Canada: A 16-year follow-up study,” Health Reports, 24(7):14-22.

7. Raphael, D. and Bryant, T. (2014) “The Health Effects of Income Inequality: A Jet with 110 Canadians Falling Out of the Sky Each Day, Every Day, 365 Days a Year,” http://www.thinkupstream.net/health_effects_of_income_inequality

8. Taylor, P.S. (2015) “Junk Science Week: Death by One Percenter,” FP Comment, March 3. http://business.financialpost.com/2015/03/03/junk-science-week-public-health-officials-are-blaming-income-inequality-for-poor-health-so-they-can-exercise-control-over-the-economy/

9. Cingano, F. (2014), “Trends in Income Inequality and its Impact on Economic Growth”, OECD Social, Employment and Migration Working Papers, No. 163, OECD Publishing. http://dx.doi.org/10.1787/5jxrjncwxv6j-en

10. Moreno K. (2014) The 67 People As Wealthy As The World’s Poorest 3.5 Billion. Forbes March 25. http://www.forbes.com/sites/forbesinsights/2014/03/25/the-67-people-as-wealthy-as-the-worlds-poorest-3-5-billion/

11. Lakner, C. (2015) “The ten richest Africans own as much as the poorest half of the continent,” Let’s Talk Development World Bank blog, March 11. http://blogs.worldbank.org/developmenttalk/ten-richest-africans-own-much-poorest-half-continent

12. Jackson T. (2009) Prosperity without growth: The transition to a sustainable economy?  London: UK Sustainable Development Commission.

13. Ostry, J., Berg, A. and Tsangarides, C. (2014) Redistribution, Inequality and Growth, Washington: International Monetary Fund. http://www.imf.org/external/pubs/ft/sdn/2014/sdn1402.pdf   

14. Fieldhouse, A. (2013) A review of the economic research on the effects of raising ordinary income tax rates, Economic Policy Institute, New York. http://www.epi.org/publication/raising-income-taxes/

15. Elliot, L. (2013) IMF eyes tax potential of the world’s super-rich, The Guardian: http://www.theguardian.com/business/2013/oct/13/imf-meeting-united-states-debt-ceiling.

16. Saez, E. and Picketty, T. (2013) “Why the 1% should pay tax at 80%,” The Guardian, October 24. http://www.theguardian.com/commentisfree/2013/oct/24/1percent-pay-tax-rate-80percent

17. Kindermann, F. and Krueger, D. (2014) “High marginal tax rates on the 1%,”, CEPR’s Policy Portal, November 15. http://www.voxeu.org/article/high-marginal-tax-rates-top-1

18.  Kondo, N., Sembajwe, G., Kawachi, I., van Dam, R., Subramanian, S. and Yamagata, Z. (2009). “Income Inequality, Mortality and Self-Rated Health,” British Medical Journal, 339, b4471.

Acting to reduce health inequity: How much evidence is enough?

It is often asserted that more evidence is needed to take action on the social determinants of health. In this guest post Ted Schrecker identifies such claims as a key obstacle to achieving health equity. He argues that to overcome this obstacle, we must recognize that decisions about how much evidence is enough are irrevocably bound together with important ethical and political choices. Ted is a Professor of Global Health Policy at Durham University.

 We should now be familiar with many hard facts about health equity.  In the United Kingdom, for example, despite rhetorical commitments by the previous government to reduce health disparities between rich and poor, by 2007 such disparities were on many measures greater than at any point since the 1930s.  This was before the economic crisis and subsequent austerity measures, which have disproportionately affected the UK’s poorest regions, including the one where I live and work.

Yet in discussions of policy responses, a frequent refrain is that the evidence is not strong enough to justify addressing the “inequitable distribution of power, money, and resources” that was one of the foci of the WHO’s Commission on Social Determinants of Health.   Tobacco control initiatives and encouraging people to eat a healthy diet are fine, but not so challenges to “the inequality machine [that] is reshaping the whole planet,” in the words of the editor of Le Monde Diplomatique.  Since the Canadian experience shows that a healthy diet is often unaffordable for benefit recipients or the working poor, and more than 47 million people in the United States are relying on the government vouchers known as food stamps, that would seem to be a major omission.

Debates about the strength of evidence are hardly new: think about tobacco, or climate change, or any number of environmental and workplace exposures whose lethality is now widely acknowledged.  The role of ethical and political choices about standards of proof (how much evidence is enough) in these debates is often neglected.  I began a recent article on epidemiology and social determinants of health with an analogy to the case of former professional athlete O.J. Simpson.  Acquitted of the murder of his estranged wife and her friend in a criminal trial, he was nevertheless found liable for damages in a civil proceeding initiated by the survivors of his alleged victims.  The difference simply reflects the much higher standard of proof that must be met, in common law countries, in criminal proceedings.

My points were that (a) the concept of a standard of proof is crucial for public health policy; (b) the choice of a standard of proof with respect to social determinants of health, as for environmental exposures, is a matter of public health ethics with respect to which scientists qua scientists have no special competence; and (c) unreflective insistence on a definition of scientific rigour organized around avoiding false positives, or Type I errors, can be highly destructive of health, and in particular health equity, under conditions of uncertainty.

The complexity of the causal pathways that connect macro-scale economic and social processes with health disparities means that some degree of uncertainty is inescapable.  A recent report on structural influences on obesity from the Scottish Collaboration for Public Health Research and Policy makes this point effectively, noting that “many strategies aimed at obesity prevention may not be expected to have a direct impact on BMI [Body Mass Index], but rather on pathways that will alter the context in which eating, physical activity and weight control occur.  Any restriction on the concept of a successful outcome … is therefore likely to overlook many possible intervention measures that could contribute to obesity prevention.”  Conversely, if the evidentiary bar is set high enough, it can always be claimed that nothing works, or that more research is needed … but waiting for more evidence is itself a decision about risks and benefits.  This point has been understood for decades, yet it continues to be either ignored or willfully misunderstood by (for example) some protagonists in the current debate over European policy toward endocrine-disrupting chemicals in the environment.

Choice of a standard of proof is one of a larger class of issues and choices at the interface of science, values and politics.  Understanding that interface, and in particular its political dimension, is critical to reducing health inequity.  Thus, when I read an article that exhorts social epidemiologists to concentrate on narrowly defined questions amenable to experimental or quasi-experimental study designs that will generate “the kind of evidence wanted by policymakers,” my immediate reaction is one of revulsion.  The quality of evidence that is demanded by “policymakers” – and the term is itself curiously decontextualized – depends entirely on what those in power have at stake.  Often, no evidence or imaginary evidence is sufficient; think about the weapons of mass destruction that Iraq was confidently declared to possess, or the nonexistent jobs into which George Osborne wants to herd poor under-25s.  Producing research findings that are not “wanted” by Osborne and his kind should be viewed as an ethical imperative.  When public health practitioners and the organisations in which they work are sincerely committed to reducing health inequities in a hostile environment, progressive health researchers should provide all the support we can.  But we must choose allies and audiences with care, and often the most appropriate algorithm for our interactions with those in power is the three R’s:  Resist, Ridicule, and Replace.  More about that in my next posting.

Paul Krugman: America’s Greatest Public Health Champion?

Last week the New York Times reported on a study which documents a reversing trend in life expectancy for the least educated whites in the US. The study shows that since 1990, life expectancy for white Americans without a high school diploma has fallen by five years for women and three years for men. Reading this article, one is likely to deduce that these declines are largely the result of individual health behaviours and life style choices.

Per the NYT,  reasons offered by researchers for this decline include “a spike in prescription drug overdoses among young whites, higher rates of smoking among less educated white women, rising obesity, and a steady increase in the number of the least educated Americans who lack health insurance”.

A range of public health experts are also quoted in the piece and offer roughly the same type of behavioural explanations. At the end of the article, Lisa Berkman, director of the Harvard Center for Population and Development studies, at least begins to shift the focus further up the causal chain and notes that the reversal in life expectancies “should be seen against the backdrop of sweeping changes in the American economy and in women’s lives”, highlighting the deleterious impact of low-wage jobs on women’s health.

Two days later it is Paul Krugman, an economist, not a public health expert, who highlights that worsening trends in life expectancies have taken place in the context of increasing income inequality (see also Katherine Greir’s  piece on Alternet, which Krugman cites).

Is this surprising? Not really. Krugman has noted the corrosive impacts of income inequality before; he’s even made direct references to the Spirit Level, a book which systematically outlines how income inequality is related to societies’ physical and mental health, as well as their levels of drug abuse, education, violence, and community life.

Unfortunately, Krugman’s easy receptivity to the political determinants of health is not mirrored in the work of national public health campaigns. In 2010, the US Department of Health and Human Services launched Healthy People 2020, a 10-year agenda for improving the health of Americans. However, despite its stated goal of achieving health equity by 2020, nowhere in its description of the social determinants of health is attention drawn to income inequality. Moreover, attention is scantily paid to the socio-political factors responsible for unequal distributions of resources important for health: resources like income, food, transportation options, social support, etc.

It is now well evidenced that in places where income inequality is greater, population health outcomes, like life expectancy and infant mortality, are worse. Unfortunately American public health professionals, and health journalists alike, continuously fail to acknowledge and translate the implications of this evidence.

How Not to Think About Social Determinants of Health: A cautionary tale from Canada

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.

Workers locked out at the Electro-Motive plant, London, Ontario. Photo: CAW Media; reproduced under a creative commons licence.

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.

From the Social to the Ultimate Determinants of Health

The notion that health is influenced by society, and the politics governing it, has been around for generations. Rudolf Virchow, known for his advancement of public health, is quoted famously for his 1841 declaration that “medicine is a social science, and politics is nothing else but medicine on a large scale”.

The contemporary uptake of this idea can be found in the increasingly popular concept of ‘social determinants of health’ (SDOH).  Introduced in the 1970s, SDOH theory arose as a critical response to a public health agenda narrowly focused on an individualized and bio-medical understanding of health.  Popularized in the 1990s, SDOH seem to be of increasing concern nowadays and are generally understood to represent the resources by which people control the conditions of their life. These resources include things like food, housing, income, education, employment, our physical environments, as well as their distribution across society.

But should all social determinants be treated with equal concern? In other words, are certain determinants more important than others in influencing the health of populations?

In 1995, researchers Link and Phelan introduced a distinction which begins to answer this question.  Highlighting the importance of SDOH (without explicit reference to the concept), Link and Phelan distinguish between SDOH which ‘contextualize risk factors’ and those which represent the fundamental determinants of health. Whereas the former explain “how people come to be exposed to individually-based risk factors such as poor diet, cholesterol, lack of exercise, or high blood pressure” (p81),the latter are broadly conceptualized to include things like “money, knowledge, power, prestige, and the kinds of interpersonal resources embodied in the concepts of social support and social networks”(p87).

The main point of this distinction is that even if we change the contexts within which people are exposed to individually based risk factors (things like access to parks, healthy foods, and health care), unless we address the fundamental determinants of health, the link between socio-economic status and health will continue to shape population health profiles. This is because fundamental causes are associated with multiple risk factors as well as multiple health outcomes. Moreover, we live in a dynamic world system where new diseases and risk factors are always emerging and those with greater access to resources will always be better positioned to respond to them.

A SDOH distinction advanced by researches more recently, distinguishes between the structural determinants of health, factors related to social positioning, and the social processes responsible for the distribution of these determinants (sometimes termed the social determinants of health inequalities).  By positioning social processes further upstream, this distinction, like Link and Phelan’s fundamental cause theory, gives strength to the idea that not all social determinants of health should be treated with equal concern.

With even greater discernment of the various ways in which SDOH can be understood, recent work by Dennis Raphael identifies seven unique SDOH discourses, each with divergent policy implications (see the SDOH discourse table below). Raphael uses the term ‘discourse’ to differentiate the various ways researchers talk about SDOH since these different approaches “appear to direct the kinds of research and professional activities that are deemed acceptable” and thus, like the Foucaultian concept of discourse, “involve issues of legitimation, power, and coercion” (p223).

SDOH Discourses

Source: Raphael, D. (2011). A discourse analysis of the social determinants of health, Critical Public Health, 21:2, 221-236

Aside from gaining insight into the type of policy implications associated with each of these discourses, from Raphael’s outline it becomes clear which type of SDOH discourses merely contextualize risk factors (discourses 1 through 3) versus those which address the fundamental determinants of health (discourses 4 through 7).  We are also able to set aside those which focus mainly on the structural determinants of health (discourses 1 through 4), and those which direct attention to the processes responsible for the distribution of these determinants (and thus also responsible for health inequalities) (discourses 5-7). Most importantly however, we are directed to the ultimate determinants of health (discourse 7): “the individuals and groups who through their undue influence upon governments create and benefit from social and health inequalities—and in the process threaten the quality of the SDH to which individuals are exposed and skew their distribution” (p229).

While SDOH theory arose as a critical response to the preponderance of individually and healthcare-based responses to disease, with Raphael’s discourse analysis, we are forced to question how far the SDOH concept has actually begun to address this concern—especially given the respectively diminishing attention directed towards the fundamental determinants of health, the policies responsible for their distribution, and the ultimate drivers of these policies: those who benefit from their disequalizing  consequences.

 

Social Determinants of Health: Resuscitating the Agenda in Rio

In this guest post, Ted Schrecker offers a commentary on how the 2011 World Conference on Social Determinants of Health might restore an otherwise ailing SDOH agenda. Ted is an associate Professor in the University of Ottawa’s Department of Epidemiology and Community Medicine, and a principal scientist at the University’s Institute of Population Health.

The final report of the WHO Commission on Social Determinants of Health, published three years ago, should have represented a milestone in the quest to achieve the goal of Health for All articulated at Alma-Ata in 1978. Based on a synthesis of available evidence that was unprecedented in its scale, the Commission identified conditions of life and work that deny literally billions of people the opportunities for a long and healthful life as “the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.” It went on to identify “changes in the functioning of the global economy” as critical to its objective of closing the health gaps between rich and poor in a generation. The Economist, in a generally laudatory review, said that the Commission was “baying at the moon.” Two months later, after a financial crisis had spread across the world, the Commission appeared remarkably prescient.

So what happened? Despite its heightened relevance post-2008, three years later the social determinants of health (SDH) agenda is in peril, although it could bring major benefits to the majority of the world’s population living in low- and middle-income countries (LMICs) and drive integration of health concerns into debates about how to distribute the pain of post-crisis austerity in high-income economies. The Commission may inadvertently have contributed to the problem by saying little about implementation beyond calling for a global social movement. Beset by budgetary constraints even more acute than usual, and by intense opposition to the agenda from elements of the medical profession both outside and (one suspects) within the organization, WHO is ill equipped to carry the agenda forward. The World Conference on Social Determinants of Health, to be held in Brazil in October 2011, appears directionless and sometimes seems nothing more than a ritual response to a generic World Health Assembly resolution responding to the Commission’s report .

The SDH agenda, and those who could benefit from its aggressive uptake, deserve better.  What to do?  The Global Fund to Fight HIV-AIDS, Tuberculosis and Malaria, now a decade old, provides a promising model. The Fund was established at the initiative of G7 governments convinced of the urgency of improving global health. They, the United States in particular, were also reluctant to commit billions of dollars for disbursement through UN system agencies that often were, and are, politics-driven rather than results-driven. The Global Fund is far from perfect; critiques of its emphasis on specific diseases rather than on strengthening health systems must be heeded. At the same time, the Fund has shown willingness to respond, and core elements of its organizational design – donor commitments of funds not tied to any specific project or beneficiary; independent scientific review; reliance on recipient-originated proposals as an indication of commitment; and rigorous auditing of both financial management and achievement of objectives – have survived the test of a decade well enough to deserve emulation.

Thus, a modest proposal for two initiatives to be taken forward by committed national governments at the October conference.

A Global Fund on Social Determinants of Health could be modeled closely on the existing Global Fund. It might more actively seek proposals from sub-national governments and civil society organizations in LMICs, subject only to assurance from the national government in question that it would not obstruct the initiatives for which funding was proposed. Proposals could range from pilot projects to national scale-ups of policies that had already demonstrated their effectiveness.  Funding criteria would give preference to policies and interventions that do not primarily involve health care providers and to support for intersectoral action.

A second fund, with a subtly different remit, could address governance issues central to SDH. This proposal recognizes the oft-neglected connections between SDH and broader issues of democratic governance (including governance of the global economic system), accountability, and human rights. For example, the annual value of illicit capital flight (a subset of the total) from sub-Saharan countries in the first decade of this century has been estimated at twice the value of the 2005 Gleneagles development assistance commitments, underscoring a major limitation of current initiatives to improve development assistance effectiveness. And the international human rights law framework offers important potential for reducing health inequity in areas ranging from access to essential medicines to protecting against forced evictions that benefit only a wealthy minority of domestic consumers and foreign investors. Thus, eligible proposals for purposes of this Fund might involve efforts as diverse as cross-border collaborations between civil society organizations and national or multilateral agencies to track and repatriate illicit flight capital, and provincial or local efforts to provide legal advocacy in support of economic and social rights.

These proposals are obviously presented in preliminary form, intended to stimulate further intensive discussion (and elicit better ideas) within a short time frame. Although the need for substantial new transfers to LMICs cannot be ignored, the two Funds proposed could probably be financed in their first few years with minimal new net expenditure by OECD development assistance providers, through redirecting part of the existing budgets of national aid agencies and major foundations.  In a “looking-glass world” of trillion dollar war budgets and bank bailouts, this argument is morally troubling.  Practically, making-do with existing resources would probably suffice to provide proof of concept; new commitments, whether by high-income countries with a history of innovation or by LMICs that have emerged as leaders in South-South cooperation, would strengthen the proposals from the start, and will be critical for longer term success. The challenge for the World Conference will be relentlessly to foreground the moral imperative of reducing health inequity, mobilizing resources that are abundant by any reasonable definition, while at the same time protecting the prospect of agreement on concrete proposals to restore momentum that has dissipated since 2008.

An Alternative Route to Health Equity: A Second Bill of Rights

In the absence of a US health equity commission, how about a return to Roosevelt’s remedy for an ailing nation—

FDR’s Second Bill of Rights would guarantee:

  • The right to a useful and remunerative job in the industries or shops or farms or mines of the nation;
  • The right to earn enough to provide adequate food and clothing and recreation;
  • The right of every farmer to raise and sell his products at a return which will give him and his family a decent living;
  • The right of every businessman, large and small, to trade in an atmosphere of freedom from unfair competition and domination by monopolies at home or abroad;
  • The right of every family to a decent home;
  • The right to adequate medical care and the opportunity to achieve and enjoy good health;
  • The right to adequate protection from the economic fears of old age, sickness, accident, and unemployment;
  • The right to a good education

Obama and Health Equity: So Close, Yet So Far

A couple of weeks ago, Obama was featured on the front page of the New York Times, laughing in an Iowa bookstore while holding up a copy of  Mitt Romney’s book, ‘No Apology’ and Karl Rove’s book, ‘Courage and Consequence’. On tour celebrating the passage of health care reform legislation, he joked that’d he’d wait for the movies. But in this lighthearted moment, did Obama realize that he was within arm’s reach of a book which contains the single reason why Americans, despite being citizens of one of the richest, most powerful countries in the world and spending exorbitant amounts of money on health care, die younger than their counterparts in any other developed nation? And how would he feel to find out that his championed legislation will do little to address this?

The Spirit Level, unlike Romney and Roves’ books, is no joke. With evidence hard to ignore, it convincingly demonstrates how one single factor, the gap between the rich and the poor, lies at the heart of America’s desperate health condition, and why despite increases in health care coverage, grave health inequities will continue to plague our communities.

And he was so close…

The Great Divide:Health Inequality Research in the UK and the US

Two major health inequality reports were recently released, one in the UK and the other in the US. This is the final post in a series which seeks to better understand the health perspective of these reports. In the first post we talked about the implications of how researchers frame their studies. In the second post we discussed the challenges to building evidence on the social determinants of health (SDOH). In the third post we presented 8 principles which help overcome these challenges. Using these principles as a framework, we will now evaluate the health perspective of the two reports.

Action on the social determinants of health requires that evidence be generated using sound methodological approaches. These approaches must be appropriate to the research questions being asked which in turn should be derived from a specifically defined problem. We will first look at the background of the two reports to get an idea for their specific aims. We will then look at the reports’ adherence to the 8 principles in hopes of gaining a better understanding of each study’s health perspective.

Background of Reports:

County Health Rankings(CHR): CHR is a major component of the US-based Mobilizing Action Toward Community Health (MATCH) project and a collaborative effort between The Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. The CHR project was developed specifically to fulfill MATCH’s first objective: Increase awareness of the many factors that contribute to the health of communities. Researchers hope this increased awareness will ultimately catalyze multi-sector action that will improve health and reduce health inequalities within America.

The final report presents data for every county in each of the 50 States and ranks them both on measures of health outcomes and health determinants. Outcome data includes measurements of both mortality and morbidity. Specific health determinants were chosen across four broad categories, each weighted for its contribution to health: Health Behaviors (30%), Clinical Care (20%), Socio-economic Factors (40%) and Physical Environment (10%). Specific indicators were chosen “based on a review of the literature, expert opinion, and data analysis”.

Fair Society, Healthy Lives (FSHL): Fair Society, Healthy Lives was commissioned by the UK government to “assemble the evidence and advise on the development of a health inequalities strategy in England”. Enlisting the help of nine task groups, researchers relied on scientific evidence, but also “engaged widely with stakeholders and attempted to learn from their insights and experience”. Chair Commissioner, Michael Marmot, was keen to expose the ideological position behind the work, stating that health inequalities are unfair, and “putting them right is a matter of social justice”.

As can be judged from their backgrounds, both projects seek to reduce health inequalities in their respective countries. Both also emphasize the importance of multi-sector engagement. In a previous post we exposed 8 principles that provide a framework for developing evidence on the social determinants of health. By judging the projects’ adherence to these principles we hope to better understand the health perspective of these studies.

Health Perspectives:

The first principle emphasizes that research on SDOH should assert a commitment to equity and specifically the Right to good health for all populations. While FSHL strongly advocates that equality in health is “a matter of fairness and social justice”, it does not make the explicit claim that health is indeed a human right. CHR makes an even smaller commitment to the idea of equity. It exposes only broad health inequalities that exist across county lines and does so neither through a lens of fairness, social justice nor human rights.

Related to a studies’ degree of commitment to equity is the second principle that specifies the need to ensure that the right types of questions are being asked and that appropriate methods are being used to answer them. Both studies are concerned with the reduction of health inequalities. However, CHR’s lack of commitment to equity has serious implications for its entire methodological approach. For instance, CHR’s framework for compiling data neither expands our conceptualizations of evidence nor does it draw on wide range of research, both key components of the third principle. The report also completely ignores principle four by excluding from its analysis the systematic differences in health outcomes across various social groups. By contrast, FSHL incorporates evidence from a wide variety of stakeholders and focuses entirely on the the health gradient within the UK.

The fifth principle specifies that research should strive to move beyond descriptions of observations to the identification of causal mechanisms. CHR has a comprehensive model that incorporates the influence of programs and policies on health determinants but it is extremely linear and disregards the interplay and interaction of various determinants. Additionally, while CHR accounts for a lag time between determinants and their health impacts, this consideration pales in comparison to the emphasis placed on the lifecourse perspective in FSHL. In sum, while CHR assigns different weights to the health impact of clinical care, behavioral influences, socio-economic conditions, and the physical environment, FSHL explains how socio-economic conditions influence all of these determinants, from access to care to an individual’s choice to engage in unhealthy behaviors. FSHL also demonstrates how specific policies such as taxes and wage laws influence the structural determinants of health, something which is less explicit in CHR.

Excluding the many axes of differentiation in a society from its analysis, CHR also fails to meet both principles 6 and 7 which emphasize the need to accurately describe dynamic social structures. In contrast, FSHL integrates into its report a framework for both reducing and monitoring reductions in health inequalities across time and various axes of differentiation.

The eighth and final principle, highlights the need for bias to be explicated in a way which allows us to understand any political biases inherent in the research. This permits us to determine to what level these biases have influenced the selection and interpretation of the evidence. FSHL’s ideologic premise is eagerly explicated early on the report. However, while CHR does a good job of making it’s scientific methodology transparent and its evidence easily accessible, no political biases are acknowledged.

Understanding variations in how health inequality research is pursued is important because different health perspectives can undermine attention to the broader determinants of health inequalities and hinder the development of healthy public policies.

Implications of Health Perspectives:

There are three main implications of CHR’s health perspective. First, with no acknowledgment of the Universal Right to Health, CHR sets no precedent for health campaigns to approach health as a governmental responsibility.

Second, without highlighting the social gradient in health, the report fails to direct appropriate attention to the upstream decisions and institutions responsible for the unequal distribution of resources necessary for health.

A third implication is that while CHR may catalyze action that improves health on a population level, it is possible that large inequalities across social groups will persist. The social determinants of health are not necessarily the same as the social determinants of health inequalities.  Health inequalities are linked to social disadvantage. Social disadvantage is systematically distributed and responsible for the social gradient in health, which remains consistently under reported in CHR.

CHR intends to be a “call to action”, helping “community leaders see that where we live, learn, work, and play influences how healthy we are and how long we live”. Therefore, it may be argued that exposing health inequalities across social gradients was not the intention of the report. Indeed the issue is indirectly addressed in the FAQ section of their website with a question that asks: How do you account for the fact that a number of the measures used may hide disparities that exist in the county? CHR responds by encouraging “communities to use the Rankings as a starting point to delve more deeply into data that may highlight the disparities within counties”.

Community-driven solutions to health inequalities are essential. However, in order to identify and tackle the social determinants of health inequalities, communities must first know what they are and be able to accurately describe them. CHR offers little strategic or comprehensive direction in this regard.

FSHL manages to tackle each of the eight principles. While it doesn’t explicitly acknowledge health as human right, it does show a strong commitment to equity.  Like CHR it emphasizes the role communities play in reducing inequalities. Outlined in the UK report however is a much more comprehensive strategy for various communities to work from. One that encourages policies which have a “proportionate effect across the social gradient” as well as the lifecourse.

Conclusion:

The true policy implications of both reports remains to be seen. The differences between the two reports and how health inequalities are approached is however, astounding.

Michael Marmot, Chair of the FSHL project, also chaired the WHO’s Commission on Social Determinants of Health (CSDOH). He had a significant role in the release of CSDOH’s final report: Closing the Gap in a Generation, released in August 2008. Fair Society, Healthy Lives is the UK’s response to this report. It could therefore be argued that his perspective is better aligned with the principals of developing research on health inequalities than researchers of CHR. However, Dr. Gail Wilensky is an advisor to the Robert Wood Johnson Foundation and was also a Commissioner on the WHO’s CSDOH.

Moreover, evidence linking social disadvantage to health is not new. It is widely available and in fact, much of the evidence comes from the US. In a background report CHR even makes reference, albeit scant, to the social gradient and Michael Marmot’s work.

Despite their difference in perspective, both reports deserve attention and discussion.

The Robin Hood Tax: Support from the US!

A coalition of campaigners in Britain have joined forces in support of what they’ve cleverly labeled The Robin Hood Tax.  By skimming only 0.05% off of all speculative banking transactions, The Robin Hood Tax  “is a tiny tax on bankers that would raise billions to tackle poverty and climate change.”

While the campaign has already generated a huge amount of online activism, some 350 economists from all over the world are calling upon world leaders to support the Robin Hood Tax.   We need to support these efforts here in the US. Check out a brilliant video about the tax below and start spreading the news!