In this guest post, Adina Preda and Kristin Voigt respond to a Healthy Policies piece which discusses their recent article ‘The Social Determinants of Health: Why Should We Care’.
We would like to thank Courtney for featuring our paper, ‘The Social Determinants of Health: Why Should we Care?’, on this blog and for offering a number of constructive criticisms of our argument. Part of the aspiration for our paper was to encourage more dialogue across disciplines about the normative questions surrounding health inequalities, and we are very pleased to have the opportunity to contribute to it here.
We identified two main concerns that Courtney raised about our argument: one to do with the grounds for advocating a redistribution of the social determinants of health and the other with our use of the evidence.
1. What should health professionals advocate for, and why?
One point of agreement between Courtney and us is that the current distribution of the social determinants of health is unfair and needs to be rectified. However, we think it is crucial that we think more critically about the grounds on which redistribution of the SDH is called for. Our AJOB paper expressed concern about the fact that much of the SDH literature argues for a more equal distribution as a means to reducing health inequalities. As we emphasised in the paper, economic redistribution and other (egalitarian) policies are required by social justice. For example, giving all children an equal start in life, as the SDH literature calls for, is required in and of itself, not because of any contribution it makes to health equity. Accordingly, we think it would be better if health professionals (and others) were to argue for egalitarian policies as a matter of social justice, regardless of any impact such policies might have on health inequalities.
This is important for a number of reasons. One reason is that, as a matter of principle, it remains important to emphasise that egalitarian policies are required as a matter of social justice, not just because of any effects they might have on other goals. Furthermore, as we already mentioned in the paper, if we argue for redistributive policies on the grounds that they will bring about more equal health outcomes but then they fail to do so, these policies might be conceived as having failed, even if they achieved a more equal distribution of the SDH. If, however, we argue for these policies as rectifying broader social injustices (and perhaps in addition offering some plausible possibility of bringing down health inequalities), they would still be considered a success to the extent that they achieve a fairer distribution, even if health inequalities remain unaffected. (We explain this in more detail in our rejoinder in AJOB.)
Courtney assumes that social justice and justice in health go hand in hand and asks in what context calls for social redistribution for the sake of health inequalities could detract from social justice more broadly. We agree that in general this should be the case but we think there are instances where these two goals might pull in different directions. One such instance is gender equality: Policies that seek to address inequalities between men and women – the pay gap, for example – might benefit women’s health and thus ‘exacerbate’ existing health inequalities between men and women. In such instances, it is plausible to argue that gender equality should take priority even though it might increase a health inequality that we don’t regard as fair.
If we could move to an ideally fair distribution right away, this would likely have positive effects on health inequality. For policy purposes, however, the decisions we have to make tend to be on a much smaller scale. We are not moving straight to a fully equal society but, rather, we may be considering different steps we could take towards such a society, such as early education programmes or policies addressing poor housing. The types of policies that most effectively contribute to the reduction of health inequalities may not be the ones that most effectively contribute to social justice, and vice versa. The way the connection between equality in health on the one hand and justice and equality on the other is framed in the SDH debate tends to obscure these possible difficulties.
To sum up, we are concerned that an undue emphasis on health and health inequalities may detract from the main reason for redressing existing inequalities including inequalities in health, which is justice.
Courtney is also concerned that we are not paying sufficient attention to the literature showing that ‘countries with more redistributive social policies have better overall population health’. As such, she argues, redistributive policies seem to explain, in large part, the inequalities in health we see between countries. Since, in our AJOB paper, we ‘suggest that “the most dramatic figures cited in the SDH literature relate to differences in life expectancy across different countries”, we do not think we disregarded this important dimension of the literature although, as we explain below, this was not the most relevant issue for our argument.
We have a number of concerns about Courtney’s line of reasoning here. First, the ‘dramatic’ figures cited in the SDH literature relate to differences in life expectancy between rich and poor countries, not between countries with different levels of redistribution/economic inequality – though there are of course also significant differences in health outcomes across different countries with similar levels of wealth.
Second, Courtney switches here from talking about (reducing) social inequalities in health and improving overall health. As we emphasised in the paper, we think it is important to keep these two goals distinct. Improvements in overall population health are perfectly consistent with increased health inequality (as Courtney acknowledges as well). Our concern in the paper – and the claim we were examining – was that redistributive policies would not reduce health inequalities.
Third, as we pointed out, it is problematic to assume that the best way to redress a health inequality is to remove or alter its (ultimate) cause. Even if one of the causes of health inequalities is social or economic inequality, it does not follow that the best way to address health inequalities is greater social or economic equality.
Courtney also suggests that we are more concerned about the possibility that we could implement policies might fail to reduce health inequalities (a type I error) than we are about the possibility that we could fail to argue for policies that could, after all, reduce health inequalities (a type II error). Further Courtney claims that even if such policies will not have the desired effect, they are, as it were, ‘risk-free’ because ‘they will not harm anyone’s health’ (emphasis added). This, however, is precisely the kind of over-emphasis on health we caution against. We do not think that such policies should be evaluated only in terms of their effects on health. Thinking of risk purely as health risk obscures other important considerations. Health is, of course, valuable but it cannot be the only thing that matters. We are not concerned that redistributive policies have bad effects, we are concerned about advocating for them because of their effects and the opportunity costs involved in selecting one policy over another.
At this point, we think, it is just not sufficiently clear that what social justice requires is what justice in health requires: we do not as yet have a good understanding of what justice in health requires, and of the means through which it would be best achieved. This is precisely what this multi-disciplinary dialogue should aim to clarify.
*We borrow this expression from Gopal Sreenivasan. [http://www.thehastingscenter.org/Publications/HCR/Detail.aspx?id=842]
In a provocative and recently published article, philosophers Adina Preda and Kristin Voigt question policy recommendations which call for more equal distributions of social factors as a means of reducing social inequalities in health. The article has already been commented on from a variety of angles. In this blog post, I’ll briefly outline the authors’ arguments and then highlight some areas of the authors’ analysis which I find additionally problematic. I conclude that public health professionals should continue to advocate for more equal distributions of social resources.
Broadly speaking, the authors first question the normative assumptions about the fairness of health inequalities as described in the social determinants of health (SDH) literature, particularly in high-profile publications such as the Marmot Review. The specific normative assumptions identified are that (1) only avoidable health inequalities are unfair and (2) only socially caused inequalities are avoidable. The authors move to illustrate why natural/biological inequalities might also be unfair, an argument which, to me, seems sound and which I’ll leave aside here. The authors then identify two possible reasons why health inequalities resulting from social inequalities are unfair either because (1) social inequalities are themselves unjust or (2) health inequalities themselves are unjust.
The authors, while conceding that they themselves believe inequalities in the distribution of SDH are unjust, dismiss those that would appeal to the first reason. They argue that if social inequalities are unjust, then “[they] ought to be redressed because (social) justice requires it, rather than because of their effects on health”. The authors “do not deny that showing the effects of social inequalities on health may strengthen the argument for redistribution” but argue that “this cannot be put forward as the main reason for such redistribution” (p30).
In a challenge to the second reason, the authors ask whether “there is any reason to claim that health inequalities are unfair when they result from a fair albeit unequal distribution of social goods” (p30). Here, two philosophical accounts of social justice are reviewed, Rawlsian and luck egalitarian, but neither are found to offer an adequate answer to this question.
Finally, the authors argue that “even if it is the case that health inequalities are unfair, it does not follow that they ought to be redressed by altering the distribution of SDH” (32). This is argued primarily on the basis of empirical uncertainties about the effectiveness of redistributive policy interventions. For example, the authors point to evidence that health inequalities have persisted in countries where the state has otherwise reduced inequalities in income and wealth. The authors also draw attention to evidence that shows that improvements in peoples’ socioeconomic conditions are unlikely to result in immediate improvements in health.
It is hard to argue with the authors’ concluding call for greater theoretical development about the ethics of health inequalities. This is something also called for in public health literature. Moreover, greater collaborative attention to these issues between philosophers and public health researchers is, as they suggest, much needed. Overall however, I find important shortcomings with the authors’ conclusion that we should be weary of public health calls for more equal distributions of social resources.
To begin with, I wonder whether claims about the unfairness of health inequalities, which are based on the recognition that social inequalities themselves are unjust, can be dismissed so easily. While the authors acknowledge that such claims can add strength to petitions for social justice (p30) they also argue that they can detract from such claims (p34). But in what scenario would we see appeals for social redistribution on the basis of health inequalities detract from social justice appeals? It seems to me, any effort which focuses on social injustices (regardless if it is through a lens of health equity) is strengthening attention to those issues.
Here the authors might reply that attention to social justice may be detracted if redistribution does not actually lead to more equal health outcomes. Indeed, they source evidence which questions the link between redistributive policies and health. However, their choice of evidence in this regard seems problematically selective. For example, the authors point to evidence which shows that social inequalities in health have persisted in Scandinavian countries, where social policies are typically more redistributive than in other countries. The authors fail to point out however, that the same literature base which has supported this finding has also shown that countries with more redistributive social policies have better overall population health. As such, redistributive policies seem to explain, in large part, the inequalities in health we see between countries. Since the authors themselves suggest that “the most dramatic figures cited in the SDH literature relate to differences in life expectancy across different countries”, it’s not clear why they would disregard this important dimension of the literature.
The authors also draw on evidence from the UK where they claim “there has been perhaps the most sustained effort to reduce social inequalities in health through large-scale social interventions” (p33). They note that such “efforts have had disappointingly small effects on social inequalities in health, with inequalities in some indicators not only stagnating but in fact widening” (p33). However, towards this end they cite work by Mackenbach (2010) who, in the very article they source, acknowledges that a potential reason why health inequalities have persisted in the UK is precisely because efforts were not aimed at broader redistributive policies. In other words, the large-scale social interventions the authors highlight were in fact not interventions involving broader redistributive policies. Mackenbach states: “One possible analysis of the causes of the failure of the English strategy to reduce health inequalities…then is that this failure is due to the fact that inequalities in income and wealth in England have remained unchanged or even widened” (p1252).
Preda and Voigt also flag evidence which shows that improvements in peoples’ socioeconomic position might not result in immediate improvements in health. But such evidence does not question the effectiveness of redistributive policies as the authors suggest; one could argue it rather highlights the pervasive damage poor socioeconomic position can have on health and the importance of using appropriate time-scales when evaluating interventions.
Even though the choice of evidence the authors focus on seems problematic for these outlined reasons, the authors do suggest that there may be more to the story. For instance, they recognize that “[o]ne possibility is that we simply have not yet seen large-scale social changes of the sort envisaged by proponents of the [health equity] model” (p33). In doing so, they leave room for uncertainty regarding the relationship between redistributive social policies and health. They also recognize that this relationship is complex and difficult to assess using standard medical standards of evidence. However, all these issues are framed problematically as well.
First, this uncertainty is used to argue against policy recommendations for a fairer distribution of social factors. However, how we treat uncertainty in public health is itself, a matter of public health ethics. As has been argued elsewhere, we need not rely on evidence of the sort generated by medical models of health. More importantly, the authors seem singularly concerned about the impacts of incorrectly advocating for redistributive policies (in the case that health inequalities will not improve as a result) but do not recognize the potential health dangers of not advocating for redistributive policies (in the case that such policies are necessary for reducing health inequalities). In epidemiological terms, the authors are more concerned about a type I error, a false positive, than a type II error, a false negative. This focus on type 1 errors, with little consideration of errors of the second kind, is often found in arguments claiming that more evidence is needed to take action on the social determinants of health.
If we consider the risks involved in each of these scenarios however, we find that what we risk in one case is worse than what we risk in the other. In the first case, if we advocate for redistributive policies, but are mistaken in our belief that health inequalities will be reduced, there is almost no evidence to suggest that a more equal distribution of social factors will harm anyone’s health. Health inequalities may indeed widen when everybody’s resources improve (since the better-off are often better able to take advantage of these resources), but again there is no evidence that makes us think that health would worsen for anyone because of a more equal distribution of social resources (it just may not improve as fast for everyone). Furthermore, if redistributive policies fail to reduce health inequalities, we are still left with greater social justice. This is an important consideration since, as the authors concede, current distributions of social resources are undeniably unjust.
In the second scenario however, if we fail to advocate for redistributive social policies (in the case that reducing health inequalities depends on this), not only is there the risk that social injustices persist, but here we have evidence which suggests that health inequalities may indeed widen and overall levels of health may decrease. Studies have for example, pointed to the damaging health impacts of current austerity agendas which serve to further increase unequal distributions of social factors.
Preda and Voigt are correct in that public health scholars do need to engage with philosophical debates surrounding health inequalities and the normative assumptions implicit in their work. For the reasons outlined above however, public health scholars should continue their calls for more equal social policies in the name of health equity.
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:
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:
trust and community life
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
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:
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.
These inequalities are not just in relative income, but also in absolute income, including Canada.
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.
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.
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.11
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:
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.
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?
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.
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
In this guest post, Beth Thomas discusses what the Scottish Referendum means to her as a medical student and as a citizen of Scotland. Beth is currently a final year medical student at the University of Glasgow who has been working with Medsin UK for the past 5 years. She is currently the Scottish and Northern Irish Coordinator of Medsin UK and as such has been working on numerous campaigns including promoting health equity in Glasgow.
The referendum to decide whether the people of Scotland want independence from England is only days away, and everywhere you turn as a voter in Scotland you are faced by a barrage of information regarding the pros and cons of a yes or a no vote. And yet, whichever way we vote on the 18th of September, a fundamental truth remains; that this will be a pivotal moment in Scottish history. A moment when the government of Scotland, be it as an independent country or as a more devolved part of the United Kingdom, will have an opportunity to set an agenda to revolutionise the issues faced by Scots today. As a member of Medsin UK, as a medical student, and as a citizen of Scotland, I want that agenda to prioritise health equity.
The city of Glasgow is famous for many things; deep fried mars bars and football spring to mind for starters. But one thing that comes up time and time again when I introduce my place of study at international meetings: ‘isn’t that the place with the lowest life expectancy in the developed world?’.
We have the NHS, we have a strong welfare system and we are the largest city in Scotland, and yet some men born in Glasgow today can only expect to live to the age of 54. We have known about ‘the Glasgow effect’ for many years now, a study from 2003-2007 found that premature deaths in Glasgow were 30% higher than Liverpool and Manchester even though both of those English cities are home to populations who have comparable experiences of post industrialised Britain.
Since the publication of the Marmot report (‘fair society, healthy lives) in 2008 and ‘it’s not just deprivation’ in 2010, the Scottish government has begun to address the fundamental inequities in the social determinants of health which underpin the massive gap in life expectancy within the city. But these are not issues that can be addressed overnight, as Carol Tennahill, the director of the Glasgow centre for population health says, the long term nature of the changes ‘do not fit into a political agenda much shorter than that’.
The change in the political system of Scotland that is inevitable after this Scottish referendum gives an opportunity to cement the commitment to reducing health inequities in Scotland into longer term political vision. While the current governing Scottish National Party has been working to address these social issues, that is not a guarantee that future Scottish governments will do so.
It is here, that we as young people need to stand up and be counted. We need to make sure that politicians are aware that we do not want to belong to the city with the lowest life expectancy in the developed world, but the city that revolutionised the health of its people by addressing inequities in the social determinants of health. We are approaching one of the most important days in Scottish history; let’s not miss this opportunity to have our say.
Occupy Wall Street protests are taking hold in a growing number of US cities. These protests seek to draw attention to extreme corporate influence which leaves no part of the county’s social, political nor economic infrastructure untouched. Growing commentary has covered much ground on the causes, faults, and promise of the movement. However, a stone that has yet to be overturned is one that should have public health professionals, as well as anyone who cares about the health of their community, taking to the streets. While protesters are no doubt occupying Wall Street for a variety of reasons, in the process they are also confronting some of the most important determinants of health.
One of the movement’s fundamental concerns, excessive levels of income inequality, is a major determinant of health. In 2007, the top 1% of U.S. earners owned 34.6% of the wealth. In 2009, CEOs of major U.S. corporations took home 263 times the average compensation of American workers. It is now well established (see here, here, and here) that in places where income inequality is greater, population health is worse. It has recently been reported that the combined impact of poverty and income inequality was responsible for 291,000 US deaths in the year 2000 alone.
But the Occupy Wall Street protesters aren’t just demanding a redistribution of income–there is a far superior recognition within the movement. Protesters recognize that social ills, like income inequality, are a consequence of deliberate actions by individuals and groups who impart undue influence on the government. This is important because it is ultimately this undue influence which threatens the quality, availability and distribution of resources important for health. Resources like income, employment, food, healthcare, housing, education, and the environment. By demanding sweeping reform of an entrenched system, protesters are thus taking aim at the ultimate determinants of health. Take a look at the Declaration of the Occupation of New York City for an idea of how protesters have related corporate influence to a range of these resources. Moreover, see this report by the World Health Organization which outlines how these resources in turn influence health.
There are many reasons why the Occupy Wall Street movement should be supported. For those concerned with the public’s health the call to action should be answered without hesitation.
In this guest post, Kate Thomson discusses the elimination of a national taskforce proven to reduce health inequalities in England. She asks whether the shift of responsibility to local authorities will render health equity concerns into unaffordable luxuries. Kate is a Senior Lecturer in the Department of Public Health at Birmingham City University and is currently researching health reforms in the Russian Federation.
Earlier this month, it was reported that a taskforce that supported English primary care trusts and local authorities in tackling health inequalities and other public health issues, had been ‘quietly abolished’. Prime Minister, David Cameron, has been insistent about the government’s commitment to address health inequalities – so how can we interpret this decision, and what is the outlook for sustaining ‘healthy policies’?
The ‘taskforce’ in question combined ten Public Health National Support Teams (NSTs), established in 2006. Each NST provided expertise on a specific issue, for example, Health Inequalities; Tobacco Control and Teenage Pregnancy. They analysed the performance of localities in improving health outcomes and offered tailored advice and toolkits, with a particular focus on supporting areas with the worst outcomes. The involvement was intensive and sought to engage local partnerships and communities. The NSTs’ final report indicates that areas they had visited showed greater improvements in relevant indicators than others; in other words there appears to have been real impact.
This news comes at a fraught time for public health, health and other public services in England. Serious cuts to local budgets are beginning to take effect, ostensibly as a response to wider economic crisis and state debt. Major restructuring of the National Health Service (NHS) is underway via the Health and Social Care Bill . General practitioners (GPs) are to take a more central role in deciding upon and budgeting for the services that are available in their local area – including preventive health services- within new ‘clinical commissioning groups’ (CCGs). Some professional organisations and campaigners have expressed disquiet about the impact of these changes, including their implications for public health.
At the same time, public health structures are being dismantled and reshaped so that they become absorbed into local authorities, rather than existing as separate entities. This is a great opportunity to ensure ‘healthy policies’ as there is potential for public health practitioners’ closer involvement with all areas of local decision making (planning, transport, housing, education, etc.). However there is concern about a loss of authority, as well as about budgets – how will ‘ring-fencing’ public health budgets work out within a context of wider cuts in services? A recent public consultation response did not entirely clear up these questions.
Let us take as an example the issue of teenage pregnancy, which had its own NST and has been a priority over the last decade (in policy terms and in terms of media coverage). The teenage pregnancy NST identified localities that most needed support in meeting targets, provided analysis and detailed tools to help them achieve it; effective practice was also disseminated. Critical debates about the overall (as opposed to symbolic) importance of teenage pregnancy as indicator of an (un)healthy society are important (see this insightful example) – there is an element of moral panic in public discourse on this issue. However, there is also persuasive evidence about the inter-generational impact of health disadvantage, which suggests that both preventive and supportive interventions are necessary in the area of teenage parenthood. There is already concern that general government spending cuts will inevitably hit services that have achieved impact in reducing teenage pregnancy rates and supporting young mothers. How will work in this area be sustained and supported after the loss of taskforce expertise, and in the wake of reorganisations and budget cuts?
The GP Online report that broke this story quoted the head of the Health Inequalities NST as saying that he and others from the team had set up their own consulting company to provide support to local health authorities (commissioning groups). Expertise will therefore continue to be available for localities that choose to spend from their budget: good news that the insight and support will not disappear entirely. This reflects wider shifts in the health and public services landscape in England. There is strong encouragement of entrepreneurship, social enterprises, involvement of private sector and ultimately, competition between providers. From the government’s perspective, stimulating a diversity of provider models will lead to quality improvements, greater choice and the possibility of tailoring services to local needs. These moves are viewed with great concern by those who regard it as a ‘privatisation’ of their beloved NHS; there is also scepticism about the sustainability of an ‘enterprise’ based model.
I am going to sidestep the debate about privatisation, plurality, competition and quality, although it is an important one both nationally and globally. For now let us just acknowledge some practical implications of this specific situation. The NST’s own final report indicates that not all localities they identified as having a need, were committed to working with them. The report talks of lengthy preliminary discussions / correspondence to ‘engage’ the relevant people gain access to work. Under the new regime localities (local authorities and clinical commissioning groups) will presumably no longer be under pressure to allow consultants (e.g. those emerging from NSTs) in. A new Public Health Outcomes Framework will be in place, although its mechanisms (and the sharpness of its ‘teeth’) are yet to be finally defined.
It seems evident that if concerted and sustained action to address complex public health problems and health inequalities is no longer required, and the ‘assistance’ to do so not imposed, some localities will choose to spend their money in other areas. Many aspects of health spending have ‘results’ attached that are far more tangible and easy for local residents to engage with. Traditionally, GPs (who will be closely involved in commissioning local services) have a keen sense of the wider health needs of their constituencies and have long been engaged in preventive and public health measures. However when very large budgets are at stake, is it inevitable that monies might be tracked more readily into more tangible aspects of health and healthcare such as hospital treatment and management of long term conditions?
The tension between ‘localism’ and standard expectations (or ‘bureaucracy’) is acute here. It is very difficult to sustain a claimed commitment to addressing inequalities in health (whose roots after all, are not only ‘local’), while at the same time devolving responsibility for how (and whether) to tackle them, to local organisations. Let us hope that tackling knotty public health issues will not turn into a luxury that areas feel they are unable to afford or support.
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.
In May 2009, the World Health Assembly called on national governments to politically commit to tackle health inequities and to embrace the principles outlined in the final report of World Health Organization’s (WHO) Commission on Social Determinants of Health (CSDOH).
As a Commissioner on the WHO’s CSDOH, Baum notes mixed feelings in response to England’s Marmot Review:
“On the one hand I was glad to see how our Commission’s report translated to a developed country context and very much enjoyed the depth of evidence and support for an approach to health that tackles the underlying determinants.
Another part of me felt a sharp pang of regret that no Australian equivalent of the Marmot Review has been commissioned by the current Government and that I had failed in my mission to ensure that the CSDH’s report was acted on by Australia.”
Baum imagines what an Australian Health and Equity Commission might look like would she be in the position of advising the federal government. Her visions of policies informed by health and equity impact assessments made me wonder if any of the American Commissioners are involved in policy making, and if so, what they have been up to.
Of the 19 Commissioners, three were from the US:
William H. Foege,
David Satcher, and
Looking into the backgrounds and current projects of these Commissioners, the person seemingly closest to a position of informing national policy is definitely Gail Wilensky. Wilensky’s virtual bio details an extensive history of political affiliations. Her website highlights that she “testifies frequently before Congressional committees, [and] serves as an advisor to members of Congress and other elected officials”.
A quick Google search also identifies Wilensky as an advisor to the Robert Wood Johnson Foundation (RWJF). In some ways, the closest the US has gotten to a US Commission on Health Equity is the work done by this group. (Though in a previous post I show how many of the fundamental principals necessary to building evidence on the social determinants of health were largely ignored in a recent project undertaken by RWJF).
Published in the context of US health care reform, the article intends to remind everyone that health isn’t just about health care. While the piece mentions many resources important for health, it fails to really drive home that it is political decisions which create and re-enforce unequal distributions of resources important for health.
(Side note: Health Affairs is published and copyrighted by Project HOPE — The international health foundation where Wilensky “develops and analyzes policies relating to health care and the economy” According to her resume, she has been doing this at Project Hope for the last 17 years).
I continue on my Google hunt and find that Wilensky is also a Health-Care Expert at the National Center for Policy Analysis (NCPA). The NCPA’s mission is “to provide private sector, free-market solutions to public policy problems”. Her history with this group might also explain her recent role as an advisor on GE Healthcare’s new business strategy, Healthymagination.
My search also turns up a profile on Wilensky at Forbes.com. The site highlights a handful corporate health care boards Wilensky acts as a director on. It also documents her compensation for these positions. State of the Divison places Wilensky’s 2008 stock holdings in these companies at $20.3 million. A profile at Bloomberg Businessweek details more of Wilensky’s corporate affiliations.
Unlike Baum, Wilensky has the influential ears of members of Congress and other elected officials. However, with such large personal investments in private health care corporations, one need not wonder where her priorities lie when making policy recommendations.
In a quiet debate published by The Lancet, American public health researchers dispute “who owns health inequalities” , and what health-care reform legislation will do to reduce them. But are these researchers missing the proverbial forest for the trees?
The conversation begins with a piece by Constance Nathanson (2010) which asserts, among other things, that in the absence of universal health care, public health institutions, not the US government, ‘own’ health inequalities in the US and that “adopting some form of universal health care is the USA’s last best hope for reversing health inequalties”.
Researchers Nancy Kreiger and Anne-Emanuelle Birn, however, point to “government-sponsored insurance programmes that cover a third of Americans (Medicare for older and disabled people; Medicaid for millions living in poverty)” and contend that indeed the “USA does “own” health inequalities, albeit inadequately”. Kreiger and Brin also challenge Nathanson’s second point by asserting that “universal medical care alone cannot resolve health inequalities” and cite the need for “societal efforts [which] tackle directly the conditions in which people live and work: the social determinants of health”.
In a response piece, Nathanson seems confused and is not sure if Kreiger and Brin think she is “too hard on the USA or not hard enough”. Nathanson does accept that indeed, “universal medical care alone will not resolve health inequalities” but states that without a “recognition of health inequalities as a significant public and political problem and a responsibility of government—[Americans] are unlikely to have either universal medical care or significant progress toward “tackling the conditions in which people live and work”.
I don’t blame Kreiger and Brin for their response to Nathanson’s article. When I read the piece, I found deciphering Nathanson’s central message difficult and like Kreiger and Brin, was shocked to read what appeared to be an over-simplified and dismal prediction for action on health inequalities in the US.
However, after reading through the debate, it becomes clear that the entire dispute seems to have resulted from disparate interpretations of ‘ownership’. Nathanson contends that the US government does not “own” health inequalities because there has not been a formal acknowledgment by the government of their existence. Krieger and Brin attribute ownership of health inequalities to the US government because of the significant burden that befalls governmental institutions in responding to health inequalities.
So both sides are correct, the US government has done little to formally acknowledge inequalities in health, and in the absence of this acknowledgment, the burden for addressing inequalities falls on last-resort, government-sponsored programs.
But who working in public health in the US doesn’t already know this?
What has this debate done to move forward an agenda which seeks to actively reduce health inequalities in the US? A major question that has been sidelined in this debate is, why hasn’t the American government formally acknowledged pervasive health inequalities?
In England, a government commissioned investigation into health inequities has produced a blueprint for taking action on the social determinants of health.
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.