In this guest post, authors Arne Ruckert, Ronald Labonté and Ashley Schram outline what’s at stake for Canada in the Trans-Pacific Partnership Trade Deal. This is an update of a piece originally posted at the Centre for International Policy’s Blog(updated 28/9/2015). Arne Ruckert is a Senior Research Associate in the Faculty of Medicine and a part-time Professor in the School of Political Studies at the University of Ottawa. Ronald Labonté is Canada Research Chair in Globalization & Health Equity, and Professor, School of Epidemiology, Public Health and Preventive Medicine at the University of Ottawa. Ashley Schram is a PhD candidate in Population Health at the University of Ottawa studying the health impacts of international trade and investment agreements.
The Trans-Pacific Partnership is nearing the end game of negotiations, creating a market of 800 million people with a combined economic clout of US$28-trillion annually. After the US Congress granted fast-track authority to President Obama, a final agreement amongst the 12 Pacific-rim countries involved in the trade deal is now within reach. Reportedly ‘98% done’ trade ministers are meeting in Atlanta in early October to see if they can clinch an agreement. So what’s at stake for Canada?
Agricultural market access remains a sticking point for some of the TPP’s prospective members. Media coverage of the TPP in Canada has been dominated by Canadian supply management in dairy and poultry, which limits market access in these products for other countries. Canada is under pressure in the press and from some TPP countries to dismantle supply management if it wants to remain part of the final negotiations. Yet Canada has participated in past free trade deals without dismantling supply management, with Canada’s Minister of International Trade Ed Fast stating that “supply management has never prevented us from concluding trade agreements, and we have confidence that we will be able to do that with the TPP as well” (cited in Lu, 2015).
There are good (health and broader public policy) reasons for why Canada would want to continue with supply management, including guaranteeing a safe and stable stock of dairy and poultry products at affordable cost. A reasonable compromise for Canada would be maintaining its supply management but making some concessions in terms of increasing market access for other TPP countries in these products. However, latest reports indicate that Canada could provide sufficient market access to American dairy producers that it could tip the supply-management system into a fast (or slow) track to its end. The triangulated deal would have New Zealand dairy gain greater access to the US, the US gain greater access to Canada and Canada (perhaps) gain greater market access across the TPP for its beef exports. Health concerns or food security issues do not appear prominent in any of these compromises, and Canada’s dairy farmers are not amused. Similarly, rules of origin for the auto sector to which two TPP countries have already agreed (the US and Japan) could cost a large number of already rather beleaguered Canadian autoworkers.
There are other areas of the TPP overlooked in most media discussions that have potentially much stronger and lasting impacts. Foremost is Investor-State–Dispute Settlement (ISDS) provisions, which will grant multinational corporations the right to sue TPP governments over public policy decisions perceived as damaging to their investments and business operations (Hilary, 2014; Ruckert, Schram, Labonté, 2015). Canada is already the most sued developed country in the world because of NAFTA’s ISDS process, and the TPP will significantly increase the number of foreign investors eligible to sue (Sinclair and Trews, 2015). Strong civil society and academic critiques of ISDS have recently led to greater caution about how they should be included within new trade treaties. The Transatlantic Trade and Investment Partnership (TTIP) under negotiation between the US and the EU also contains an ISDS chapter, with concerns about its provisions voiced on both sides of the ocean. Rather than reject ISDS outright, European parliamentarians in July passed a compromise amendment which calls for replacing the ISDS system “with a new system…subject to democratic principles and scrutiny, where potential cases are treated in a transparent manner by publicly appointed, independent professional judges in public hearings and which includes an appellate mechanism, where…the jurisdiction of courts of the EU and of the member states is respected, and where private interests cannot undermine public policy objectives.” (Bridges Weekly, 2015: 4). The EU amendment appears to address many of the critics’ concerns with ISDS, and the Canadian government should push for the TPP to adopt a similar position. Investor protection would be strengthened, but so would government’s ability to pursue new public policy objectives without fear of an investor challenge.
The TPP also proposes to extend intellectual property rights (IPRs) with implications for drug costs, whether paid for publicly or privately (Hirono et al, 2015; Sinclair, 2013). This is of particular relevance for Canada, which already has the second highest drug prices in the world (Sinclair and Trew, 2015). A recent leak of the TPP IPR chapter shows that the major outstanding disagreements over IPR relate to “patent linkage” and expanded protection of biologics (Grunwald, 2015). Patent linkage prevents the registration and authorization of generic medicines until after the expiry of patents, considerably delaying generic market entry (Canadian Generic Pharmaceutical Association, 2012). Although Canada already has a patent linkage system in place, the TPP is the first time this system would be written into trade treaty obligations, interfering with future cost-saving reforms (Sinclair and Trew, 2015) and weakening the vibrant Canadian generic pharmaceuticals industry which is responsible for the production of two out of every three prescription drugs in Canada. A recent analysis of the draft intellectual property chapter of the TPP suggests that the US has been advocating for patent linkage to extend to biologics, along with a request for longer periods for data exclusivity. It also notes that many TPP member states have been opposed to extended IPRs (Grunwald, 2015), which would provide Canadian negotiators with a platform from which to limit any extension of IPRs in pharmaceuticals beyond those already present in the World Trade Organizations TRIPS agreement.
Finally, TPP provisions for regulatory coherence and transparency have received relatively little mention. As with all recent free trade agreements, the TPP is only marginally about trade, and more about harmonizing regulations (financial, health, and safety standards, etc.) (Sinclair and Trew, 2015). The leaked regulatory coherence chapter outlines various expectations, including the obligation to encourage the use of regulatory impact assessments (RIAs) as practiced in the United States. The proposed regulatory model contains numerous pro-market factors that governments should consider when making domestic regulations. The obligations outlined in the regulatory coherence chapter are explicitly linked those in the transparency chapter (Kelsey, 2015). The transparency chapter (which has not been leaked) is expected to confer rights to affected commercial interests to participate in regulatory processes. The two chapters together will essentially impose: high-level behind the border disciplines on governments through market-centric norms; an ideologically driven commitment to light-touch regulations (whose detrimental effects are best seen in the global financial crisis of 2008); and a structured role for private and especially corporate interests to shape domestic regulations and policy-processes (Kelsey, 2015). Some TPP countries, especially those with developing country status, have raised concerns about these two chapters. Canada should align with these concerns and support their resolution within any final agreement.
Canada should be courageous enough to stand up to the United States (the main force behind these negotiations) and to form coalitions with TPP member countries that have similar concerns about these remaining TPP issues. It has precious little time left to do so. Ultimately, there is no point in signing on to a free trade agreement that represents very little economic benefit to the Canadian economy (and quite possibly economic loss), but which has major political and social implications, including the potential to hamper Canadian sovereignty and to undermine its regulatory autonomy.
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 post, guest blogger Ronald Labonté concludes a two-part blog series about post-2015 development goals. Discussed are their relationship to health and specific steps Canada could take to encourage a healthy and progressive transition. 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.
Part I of this post commented on a number of global and intergovernmental initiatives to define new post-2015 development goals, specifically the sustainable development goals, the UN high level panel report and the health goals mooted by the World Health Organization. It also included brief analyses of the role Canada could play in each. Part II focuses more closely on Canada’s role, with some specific recommendations for a healthy and progressive stance we could be taking.
Aid, trade and health
Canada still lacks foreign policy coherence, in that we pursue trade and investment agreements that could compromise health equity globally, while committing to a charity model of international health aid. (We are far from alone in this regard.) More troubling is the trend to tie development assistance to the trade and economic interests of donor countries. The ‘trade not aid’ rhetoric has led to ever-larger sums of ODA being allocated to ‘aid for trade’. If Canada is to join in this chorus (which seems imminent with the transfer of its aid department to that of foreign affairs and trade) then the rules of trade treaties that we negotiate should clearly provide disproportionate benefits to poorer, aid-recipient countries. This is not presently the case. This lack of foreign policy coherence has salience both for UHC (where high-income countries with health financing and service industries are mobilizing to sweep the global low- and middle-income country field); and for control of noncommunicable diseases, where trade and investment treaties are posing risks to public health regulation (10).
Here, Canada could support growing public health advocacy to establish full health carve outs and strengthened health exceptions in trade treaties, starting with the detailed texts of the ‘agreed in principle’ Comprehensive Economic and Trade Agreement (CETA) with the EU, and the still to be completed 12-nation Trans Pacific Partnership Agreement (TPPA), the other major countries being the USA, Japan and Australia. There is growing support amongst some of the TPPA’s negotiating countries for a tobacco carve out in that treaty, such that no tobacco control policy could be challenged in a trade dispute. Such tobacco exceptionalism, while good for health as far as it goes, could nonetheless be problematic if we are also concerned with the global health risks posed by Big Food, Big Alcohol or Big Pharma. A more radical approach would be to ensure that such treaties include a provision requiring deference to WHO soft law (e.g. the Framework Convention on Tobacco Control) or World Health Assembly approved global actions plans (e.g. on noncommunicable diseases) whenever a public health policy or regulation is subject to a trade or investment dispute. Given Canada’s current obsession with striking trade and investment treaties with as many countries as possible – indeed, the only new foreign policy by our Conservative government commits to a ‘sea change in the way Canada’s diplomatic assets are deployed around the world’ such that all are ‘harnessed to support the commercial success by Canadian companies’ (11) – we are unlikely to lead this charge. At the same time, according to the leaked TPPA chapter on intellectual property rights, Canada has been opposing almost every effort by the USA to extend patent protection in that treaty beyond provisions in the WTO’s TRIPS Agreement (12). So there may be some room for a stronger global public health presence in Canadian trade policy.
Aid for tax reforms instead?
Aid disbursements will be necessary for many low-income countries, especially in sub-Saharan Africa, since taxation reforms are still years away in being effectively developed. But aid is no substitute for domestic economic empowerment; and taxation is fundamental to that empowerment, and to responsible state building and the social contract between well-functioning states and their citizens. Thirty or more years of advice to or obligations on developing country governments by the IMF and World Bank to keep taxes low to attract foreign direct investment have done well for the investors, but poorly for most of the countries’ citizens.
Somewhat late in the game, both the IMF and World Bank are now talking about the need for developing countries to substantially increase their taxation rates and improve their taxation systems (though still favouring regressive consumption over progressive income or corporate taxes). This is not to say that African countries have not been trying to comply, with their tax to GDP ratio in recent years rising to between 17 and 20 percent (13). But this rate is still too low to be adequate (the EU 15 countries average over 40 percent), and still inefficient and full of exemptions for imports, investors and transnational profits. As well, the continuing importance of tariffs as a form of taxation for some of these countries means that in any Canadian trade treaty involving developing countries, including those in South Asia where the tax to GDP is the lowest in the world, high tariff reductions should not be on the agenda until there is evidence of effective and transparent progressive tax systems in place. Why not aid for progressive taxation reforms, rather than (or at least in addition to) aid for trade?
Given that Canada has also become the Western world’s global mining giant thanks to the domestic tax breaks we give to mining companies, we also have a potential role to play in supporting developing countries (especially those in Africa and Latin America) in their efforts to increase their persistently low royalty rates, which were largely imposed during structural adjustment programs in the 1980s and 1990s.
We could also join with other countries in supporting innovations in global taxation. Why is Canada not supporting financial transaction taxes? Why haven’t we joined the very basic UNITAID airline tax? Why are we not doing more to close offshore financial centers, tax havens?
Canada could take an assertive role in the most recent G20 promise to develop a more transparent international tax identification system so that taxes are paid where production profits are earned, avoiding the toxic practice of transfer pricing through tax haven countries (14). In doing so it might also begin to stem the illicit capital flows, especially from Africa, which in the past 40 years has topped $1.4 trillion, more than all of the aid and debt cancellation funds that have gone to the continent, and much of it due to transnational corporate practices, and not simply criminality or corruption (15). There is a modicum of self-interest in this, as some estimates calculate that Canada is absorbing huge tax losses on the more than $160 billion in Canadian income parked mostly in offshore Caribbean branches of Canadian chartered banks (16).
Actions oriented towards such economic and taxation reforms by Canada would move us away from a charity model of intermittent, donor-driven aid to a structural model of global social solidarity and an equitable economic empowerment.
In sum, Canada in preparing for a post-2015 world could:
Continue but strengthen our commitments to maternal/child health
Promote our publicly-funded universal health system as an important model for expanding UHC
Ensure that health concerns (present and future) are fully protected in trade and investment treaties
Aid for trade – if trade treaties actually disproportionately benefit poorer people and countries
Aid for tax reform – to build the transparent and progressive tax systems developing countries need to build effective states and mobilize domestic revenues for health
Join and promote global systems of taxation to prevent tax evasion and illicit capital flight
Work with African and Latin American countries to improve their royalties on extractive industries, notably mining.
10. Friel S., Gleeson D., Thow A-M., Labonté R., Stuckler D., Kay A. and Snowdown W. A new generation of trade policy: potential risks to diet-related health from the trans pacific partnership agreement. Globalization and Health 2013, 9(46): 1-7.
11. See: Government of Canada, 2013. Global Markets Action Plan. http://www.international.gc.ca/global-markets-marches-mondiaux/
In this post, guest blogger Ronald Labonté introduces a two-part blog series about post-2015 development goals. Discussed are their relationship to health and specific steps Canada could take to encourage a healthy and progressive transition. 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.
In 2000 the world committed to health and a paternalistic egalitarianism, as the Millennium Development Goals (MDGs) promised reductions in extreme poverty and hunger, and measurable progress in water and sanitation, education and a host of specific health targets. There was lots to criticize in the MDGs: lack of ambition in the targets (especially for poverty), failure to consider the already surging pandemic of noncommunicable diseases, lack of equity stratifiers for the targets, huge holes in the data used to measure progress, and a resounding silence on any of the economic and political systems that were fuelling global financial speculation, transnational corporate power and gross inequities in income and wealth. Still, the MDGs galvanized some important initiatives and have chocked up some successes.
As the 2015 clock on the MDGs ticks down, there’s been a flurry of intergovernmental, civil society and social mediated consultations on what the world’s nations should commit to next. If the 2000 MDGs were a bureaucratic exercise in synthesizing what states had already more or less agreed upon during the 1990s, the post-2015 has opened the floodgates to consultation processes to such an extent that one becomes either exhausted with keeping up with the opportunities to input, or cynical about why bothering to.
Bracketing an excess of cynicism to strike a balance between realism and defeatism, this two-part blog series offers a few reflections on the competing post-2015 goal streams and Canada’s potential role within them. The first post will reflect on sustainable development goals, the UN high-level panel, and health goals in the post-2015 context. The second post will discuss aid-for-trade and aid-for-taxation strategies, and summarize how Canada can prepare for the post-2015 world.
Sustainable Development Goals
No one outside of the US Tea Party any longer insists that climate change is a left-wing environmentalist plot. (Although it would be nice if there were more left-wing environmentalists at the political and economic levels where they are needed.) The problem with these goals, an output of the Rio+10 initiative, rests with the term itself, a throwback to the late 1980s Bruntland Commission (Our Common Future) (1) and the first wave of efforts to harness economic development to environmental sustainability. Back then Canada was a leader, jumping enthusiastically on the ‘roundtables on economy and environment’ governance ideal promoted by the Commission. I recall an environmental lawyer leaving one of such meeting, complaining that the business folks around the table ‘Just don’t get it!’ To which a senior government official gently chided, ‘Oh, but they do. You see, they got the noun and you got the adjective.’
We continue to live under the illusion that, with claims of a slowly greening economy, we can consume our way out of a problem of over-consumption. We can even invest our savings on the Dow Jones Sustainability Index, feeling better that our retirement returns derive from companies deemed to be operating in a ‘sustainable’ way. We just have to pretend that there is consensus on how to measure good corporate environmentalism so that we aren’t fooled by such as Pepsi-Cola’s claim that in India it is replacing more water than it takes to supply the sub-continent with its sugary beverages (2). As for our greening economy: Why should the USA use trade rules to challenge China’s heavy subsidization of its solar and wind turbine industries? Yes, it puts the US-based industries at a competitive disadvantage, but it drives up global prices and slows diffusion of possibly important climate change reducers. Why not exclude from trade rules subsidies on all new products that reduce the human environmental footprint, a race to the top rather than a slide to the bottom?
Canada scores very poorly on this account. Our exit from the Kyoto Accord in 2011 and our drive to become a fossil-fuel superpower have transformed Canada from a once-upon-a-time eco-leader (we were, after all, the birthplace of Greenpeace and home of the increasingly pessimistic David Suzuki) to one of the bottom-placing eco-destroyers. The potentially healthy challenge for Canada is that if the post-2015 goals achieve their mooted intent of applying to all countries, alongside the increasing anger of developing countries at the rich club reneging on its climate change commitments, we may be dragged back into accountable commitments to a greener future.
But the gravest challenge for a post-2015 sustainably developed future lies in the fallout of the Great Financial Crisis, which became the Great Recession and persists as the Great Austerity. Most domestic political attention has drifted back to conventional economics of spurring growth by re-energizing the real economy of production and consumption (jobs, jobs, jobs). This is saleable in the short-term, although the quality of new employment with respect to pay, benefits, security, and health and safety remain vexing complications under neoliberalism’s labour market ‘flexibilization’. But it grates against the reality that we cannot use conventional economics to grow incomes for a world of soon to be 9 billion producers and consumers (3). We don’t have enough of a planet to do so. Add to that our oft-proclaimed ‘time bomb’ – an aging population living longer, with demographers and politicians concerned with increasing the size of the active labour force (those aged 20 – 65 or 70) to sustain the social contract (health care, pensions and benefits) for the swelling cohort of elders. This continuous priming of the base of the demographic pyramid is simply an environmental ponzi scheme, one that only radical redistribution and economic regulation might prevent from imploding.
UN High Level Panel
The UN High Level Panel on the post-2015 goals (is there ever one called ‘low-level’?) came up with a number of useful suggestions that could partly forestall such a dystopian ponzi pyramid. These include a call for governments to regulate private finance, reform trade, crack down on illicit capital flows, stem transnational tax evasion, return stolen assets and promote sustainable patterns of production and consumption (4). Such recommendations are meatier than the Panel’s obligatory nudge to donor countries to honour their aid commitments. Been there, done that and, in Canada’s case, we don’t seem to care much. Despite our acknowledged if initially botched leadership on the ‘Muskoka Initiative’ for Maternal/Child Health, we are losing ground on our aid commitments, freezing the level of our disbursements, and restricting contributions to a smaller number of countries. Apart from issues of quantity, there are issues of quality. The 2012 Centre for Global Development’s Quality of ODA Index ranks Canada in the lower half of donors on efficiency and reducing the burdens or transaction costs of aid. We do better on fostering institutions, and are smack in the middle on transparency and learning; a middling assessment at best (5).
Returning to the Panel’s higher-level goals: Good as they are in intent, there is no operational guidance in the report. There is also too much emphasis on corporate social responsibility and partnerships between states and businesses to make global markets more just and equitable, rather than recognizing the pressing need for mandatory and enforceable market rules. It is in how we must move on the Panel’s goals that is of prime importance, which then requires an analysis of why we have these problems in the first place. As a People’s Health Movement commentary laments, none of the prevailing models for post-2015 priorities question, much less challenge, the prevailing paradigm of economic growth (6).
There is even the risk that the UN High Level Panel could reinforce some of the more egregious qualities of the prevailing paradigm. For one, it criticizes the core labour rights of the ILO-led initiative on social protection and ‘decent work’ (7) as too much of a ‘one size fits all.’ It calls, instead, for ‘good jobs’ and for ‘flexibly regulated labour markets’, an invitation to a continual reduction in labour’s power against that of capital. In sync with the World Bank and other economic development agencies, its poverty goal of ‘leave no one behind’ (commendable, depending on where one draws the poverty line) is based on the norm of ‘equality of opportunity.’ While the procedural justice inherent in this norm is important (all should be treated alike), in the game of economics it only becomes fair when all are alike when they start playing. This is patently not the case, not when fewer than 1500 people have more wealth than the combined populations of the continent of Africa and the sub-continent of India (8). Equality of opportunity only becomes fair when it is joined with a parallel commitment to equality of outcome – an ideal but measurable target – that relies on progressive tax/transfer programs within and between governments. Such a norm is unlikely to have much political traction in Canada at the moment, however, where reduced and regressive taxation have been the norm for the past decade or more. The same may be true for most of the austerity-addicted high-income countries and many of the recession-stuck middle-income ones.
What of health?
No one knows exactly how health goals in the post-2015 final list will be defined. Several of the goals from the sustainable development agenda and the high-level panel already deal with key health determinants, albeit imperfectly. The World Health Organization (WHO) is calling for completion of the 2000 health MDG’s unfinished agenda, and a ‘healthy life expectancy’ goal perhaps allowing some broader measurable target. But it seems most keen to bank on a post-2015 health goal of universal health coverage (UHC), a re-born concept still in search of consensus. The WHO defines it as “ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need” (a nod in the direction of the heady days of the Alma Ata Declaration on Primary Health Care), with services “of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship” (9). This sounds reasonable enough, but it ducks the contentious issue of the relationship between public and private sectors in health care financing and provision. With private insurers and providers eager to carve out a larger piece of the annual $6.5 trillion health care ‘market,’ the risk is that the costly chaos now passing for Obamacare in the USA will come to define the global default position.
This is a debate in which Canada could aggressively insert its own comparatively positive experience with a universal, single-payer and mixed provider system. Canada’s national health insurance risk-pool and legislated public administration creates one of the fairest, most efficient and most accessible health care models on record (excepting Cuba). Sure, it has warts: wait-times, gaps in coverage, encroaching privatization. But compared to the American model, and to the dual public/private models dominating Latin America (which most countries in that region are trying to transform into a more public system), the warts on Canada’s system become mere cosmetic pimples.
Austerity policies pose major threats to the public’s health. In this guest post, Ronald Labonté argues that the austerity agenda in Canada stems not from a crisis in finances, but from a crisis in fair taxation. 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.
The American Jurist, Oliver Wendell Holmes, once wrote that taxes are the price we pay for civilization. By that account we are becoming less civilized with each new budget cycle. We are being told that we have a crisis of public debt and deficit. We do not. We have a crisis in fair taxation for the public goods that sustain health and civility, and a 40 year uncontrolled experiment in global neoliberalism and free market fundamentalism that has seen the starkest rise in income and wealth inequalities in over a century. Canada is just one of scores of national examples.
Canada began its downward taxation spiral in the 1980s. Marginal rates paid by the highest income earners dropped from 43% in 1988 to 29% in 2010. Corporate taxes fell from 49% in 2004 to just 27% in 2010 (Simms 2013). As taxes as a percent of Canadian GDP declined, so did public spending. Canada now ranks 24th of 34 OECD countries in our overall rate of taxation. Since 2006 and the Conservative government, we have lost over $220 billion in federal government tax cuts (Fanelli and Lefebvre 2012). The Great Financial Crisis of 2008, the result of profligate greed on the part of a handful of unregulated financial gamblers, and the trillions spent by governments on bank rescues and stimulus spending to buffer the subsequent Great Recession, have since become a pretext for: not more and fairer taxation, but more tax breaks and government cutbacks.
This is the post financial crisis austerity agenda being rolled out around the world, with between 80% and 90% of the global population now coming under its yoke (Ortiz and Cummins, 2013). Who pays austerity’s heaviest cost in poorer health and wellbeing? The poor, the rural, women, children and the ever growing number of the ‘precariat’ – those whose globalization’s ‘flexibilized’ labour markets offer lower pay, fewer benefits, less security and often only part-time or temporary jobs. Throw in the massive global youth unemployment bulge and we have a recipe for domestic and international conflict, some of which (the Arab spring, rural China, parts of Africa) has already emerged.
Cuts in tax and government spending are good for the economic elites of the world who have seen their fortunes soar since the Great Financial Crisis. Consider that the world’s 1,426 billionaires between them had as much wealth in 2012 as the combined populations of Africa (1 billion people) and India (1.27 billion people), an inequality ratio of 1.5 million to 1 (Forbes 2013). But tax and spending cuts are actually bad for the economy, especially when private investment is drying up and the ‘real economy’ of production and consumption is sluggish, if not sclerotic.
Indeed, public spending has a little known fiscal multiplier effect, which, in high-income countries such as Canada, ranges between 1.6 and 1.7. For every dollar in new government spending there is $1.60 to $1.70 in new economic growth. That is because government spending buys goods and services made by workers and employs civil servants who buy more goods and services. Private companies see things improving and start investing more of their hoarded cash. Some forms of government spending (in health, education, environmental protection, the things that matter in most peoples’ lives) have much higher fiscal multipliers. By contrast, as the Canadian economist Jim Stanford has calculated, for every dollar in new corporate tax cuts, only 10 cents is re-invested in the real economy that employs people (Stanford 2013). The rest goes to dividends, financial reserves or gambling in the still unregulated shadow banking world of derivatives and hedge funds – the highly leveraged ‘casino capitalism’ that brought us the Great Financial Crisis. So a win-win-win (public spending on things people value, healthier citizens and faster economic recovery) becomes a lose-lose-lose (more wealth for those who don’t need it, slower economic growth and new, toxic asset bubbles primed for another burst).
Another comparison: Based on OECD data, if Canada taxed at the average rate of the EU15 countries (40% of GDP), we would raise almost $160 billion more each year in revenue. If we spent on health and social programs at the EU 15 average rate of 30%, we would be pumping $208 billion more each year into the goods, services and income transfers that improve peoples’ health and wellbeing. None of these EU 15 countries are in structural deficit, and several have been outperforming Canada in narrowly measured economic terms for years.
To repeat: there is no fiscal crisis. There is a taxation crisis. We are not living with scarcity where everyone must tighten his or her belt. We are living in an era of egregious inequality where increasing amounts of global income are escaping the redistributive bite of the taxman, transfer-priced or squirreled away in the (still burgeoning) number of offshore financial centers (aka ‘tax havens’). Most of these are located within or under the protection of the world’s wealthiest countries, the same ones now hollowing out their tax-gutted welfare states.
Canada’s tax crisis is not exclusive. It can be found in most of the world’s countries, engaged in a revenue race to the bottom in order to attract or retain foreign investors. But over the short-term the austerity this leads to is bad for health and for the economy. Even the IMF is doing a deep re-think over the macroeconomic wisdom of its austerity mantra. Over the long-term the gap it widens between those few who too much and those many with too little imperils a peaceful global future. And without strong market regulations and progressively financed redistributive spending, relying on economic growth in ‘real economy’ of production and consumption to lift the world out of poverty will destroy our planetary life supports long before we come even close.
When are Canadian politicians (and those in most of the world’s countries) going to realize that the neoliberal emperor of free markets, low taxes and minimal government has no clothes?
Fanelli, Carlo and Priscillia Lefebvre. 2012. “The Ottawa and Gatineau Museum Workers’ Strike: Precarious Employment and the Public Sector Squeeze.” Alternate Routes: A Journal of Critical Social Research 23: 121-46.
Forbes. 2013. “Inside the Billionaires List: Facts and Figures.” Forbes. http://www.forbes.com/sites/luisakroll/2013/03/04/inside-the-2013-billionaires-list-facts-and-figures/
Ortiz, Isabel and Matthew Cummins. 2013. “The Age of Austerity: A Review of Public Expenditures and Adjustment Measures in 181 Countries.” Initiative for Policy Dialogue and the South Centre. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2260771.
Simms, David. 2013. “Canada Best Place in G8 to Pay Business Taxes.” Canadian Broadcasting Coporation. http://www.cbc.ca/news/business/taxes/canada-best-place-in-g8-to-pay-business-taxes-1.1380380.
Stanford, Jim. 2013. “The Failure of Corporate Tax Cuts to Stimulate Business Investment.” In The Great Revenue Robbery, ed. R. Swift. Ottawa: Canadians for Tax Fairness.
As a follow-up to last week’s guest post, this week Ted Schrecker outlines the political trajectories which have not only shaped current landscapes of health disparities, but also continue to obstruct avenues towards achieving greater health equity. He challenges us to consider the prospects for national-level inroads and contemplates whether the future lies in more localized efforts. Ted is a Professor of Global Health Policy at Durham University.
It is now 34 years since Margaret Thatcher’s Conservatives came to power in the United Kingdom. How time flies when you’re having fun.
The election of the Conservatives, and that of Ronald Reagan in the following year, transformed not only domestic politics in the two countries but also the global political landscape. The most direct and immediate global impact was the imposition of neoliberal orthodoxy on many low- and middle-income countries by the IMF and World Bank, in order to protect the interests of creditors, including many of the largest US banks, but this was only part of a longer-term recasting of political discourse.
The Thatcher-Reagan transition marked a break with postwar policies that led directly to today’s levels of economic inequality and their consequences for health. Although forces of economic integration (globalisation) were already playing out within the economies of the high-income world, those forces were supported and in some cases driven by state actions and policy choices that could have been made differently. For example, in the United States, although the pre-tax incomes of the one-percenters started growing rapidly as a share of all incomes in the early 1980s, research from Germany’s Institute for the Study of Labour shows that even before the economic crisis of 2008, tax cuts for the rich magnified the effects of market income inequality. As pointed out in an excellent recent article on the history of neoliberalism: “In the end, neoliberalism was very much a state-directed project, but the interests represented by these same states changed, as did the central actors defining policy.”
The Thatcher-Reagan transition also provided signals about the extent to which Anglo-American electorates would tolerate the undoing of postwar understandings of social citizenship. Successor governments were quick to act on those signals. Not Thatcher but the Labour government of Tony Blair introduced tuition fees for British university students and eliminated the 10p income tax rate. Not Reagan but Democratic president Bill Clinton made good in 1996 on a campaign pledge to “end welfare as we know it,” playing to racist and sexist stereotypes while expanding the low-wage female workforce whose precarious living and working conditions were eloquently described a few years later by journalist Barbara Ehrenreich.
Both Blair and Clinton were rewarded with stratospheric wealth after leaving public office; there may or may not be a connection.
Fast-forwarding through the effects of the financial crisis and subsequent recession, which are now familiar, it should now be evident that public finance is a public health issue. (More about this in my next posting.) “Changed priorities” – the phrase taken from a road sign in my neighbourhood – are essential if health disparities are to be reduced.
What are the prospects? One possibility is that finance capital, transnational corporations and wealthy households are too powerful domestically, or too mobile, to leave governments with much room to manoeuvre. Globalisation has doubtless reduced the policy space available, but it is difficult to see that (for example) a mansion tax and a return to the 50p tax rate would lead to an economic implosion. Perhaps more important is the possibility that an electorally decisive plurality of the population now share Thatcherite worldviews and allegiances, even if the rest of us do not. (Does anyone else find the normalisation of “climbing the property ladder” – the expression and the activity – as objectionable as I do?)
This is partly a generational effect. Alex Himelfarb, who retired as Canada’s most senior public servant, recently wrote: “North Americans under 40 have never really known anything other than neo-liberal politics and governments that seem to be backing away, so many will understandably see small government and low taxes as the only option.” On this side of the Atlantic, such diffusion of neoliberal norms appears to be what Johan Mackenbach had in mind when he wrote in 2010: “[I]t is unlikely that a majority of the English electorate would have supported the substantial redistribution of income and wealth that would have been necessary” to avoid the persistence and growth of health disparities during 13 years of Labour government.
Mackenbach’s reference to a majority reflects a widespread misunderstanding of electoral arithmetic and institutions; only under extraordinary conditions is support from a majority of any electorate needed for the success and survival of a policy, or a government. If we substitute a more accurate term, he may well be correct. Thomas Mulcair, the leader of Canada’s centre-left New Democratic Party (NDP), appeared to adopt Mackenbach’s view when he rebuked a byelection candidate who has called for higher taxes on the rich by saying that “no increases in personal taxes will be in any way shape or form part of our political offer in 2015.” (Canadians, like British voters, head to the polls in 2015.) Since the NDP marks the leftward end of Canada’s political spectrum, hopes for ending a retreat from redistributive policy that has been well documented by Canada’s national statistical agency and the OECD are now a dead issue for the near future. Dead as well, as a consequence, are prospects for tackling health inequity in Canada through national-level initiatives.
Mackenbach has identified the core political question about the prospects for reducing health equity by acting on social determinants of health. Five years ago, the WHO Commission on Social Determinants of Health articulated the aspiration of closing the health disparities gap in a generation. The policies of the Coalition threaten to widen the gap, for example by imposing spending cuts that will disproportionately affect England’s disadvantaged regions while debilitating the National Health Service. If changed priorities are not ahead, then the best that we can probably hope for in jurisdictions like Canada and England is that ambitious localised interventions will reduce the speed at which the health gap grows.
A note to readers: Unfortunately, a couple of sources cited in this posting may be protected by paywalls. If you have difficulty accessing them, please contact me at email@example.com and I will try to arrange access.
In this guest post, Dr. Laura Bisaillon critiques the inner workings of the Canadian immigration system. She explores whether mandatory HIV testing is justified for prospective immigrants and challenges us to consider how broader socio-political relations shape such practices.
What logic prevails that sees prospective immigrants and refugees to Canada submitted to a test that would be unlawful to impose on Canadians or permanent residents except by court order? Exploring answers to this troubling question is part of the puzzle that I unravelled in a recently completed social scientific study of the Canadian immigration system and analysis of state decision-making about the admissibility of applicants with HIV within this system. During 18 months of multilingual fieldwork in Montreal, Ottawa and Toronto, I met with over 60 people who described their experiences relating to mandatory HIV testing in the Canadian immigration process. This included HIV-positive applicant immigrants and refugees, nurses and other health providers, and lawyers and civil servants, among other actors.
When I present my research findings, I find that audiences are generally unaware that the Canadian state obliges applicants to submit to HIV testing as a pre-condition for applying to immigrate. Since 2002, Canada has required HIV testing of all persons aged 15 years and above who request Canadian permanent resident status (such as immigrant and refugee persons) and temporary resident status (such as migrant workers, students, and long-term visitors from certain countries; generally countries of the Global South). Citizenship and Immigration Canada manages testing within the immigration medical examination, and tuberculosis and syphilis are the two other conditions for which diagnostics are mandatory. It is not entirely surprising that the general population is unaware of HIV testing or other details of the immigration process. The immigration system is a large and opaque system that is organized as a perplexing and hard to navigate bureaucratic institution. These features make it difficult, time consuming and expensive for people to grasp and traverse. Canadian-born Canadians do not have to interact with the immigration system as immigrant hopefuls, and so its workings remain largely out of view and beyond the likelihood of critical assessment.
HIV testing is normalized as a good and necessary practice within biomedical ways of knowing and thinking about the world. The dominance of this position makes any problematizing of HIV testing difficult, and it also elides the socio-political and embodied contexts in which HIV testing happens. Approximately a half million Canadian immigration medical examinations are conducted annually worldwide. The vast majority of these take place outside of Canada, and the Canadian government actually knows little about the empirical conditions in which HIV testing occurs in these overseas locations. Findings from my research reveal problems, exclusions, and inequities within the practices associated with immigration HIV testing. Testing and practices to which it gives rise are routinized as something that ‘just must happen’ to people who aspire to be Canadians.
Empirical research findings show that there are practices associated with Canadian immigration HIV testing that are problematic. Problems occur for applicants with HIV, for contract physicians conducting HIV testing, and for the immigration system more broadly. For example, prospective immigrants are not necessarily aware they are being tested for HIV; there is a general absence of or inadequate personalized care at diagnosis with HIV; and, persons with HIV report not understanding that the immigration medical encounter is actually a filter where physicians are working within relations that are not therapeutic or in their subjective best interests.
The point is, mandatory immigration HIV testing makes Canada, as a nation—and HIV as a health condition—stand out as exceptional. Testing as a pre-condition for immigration is not inevitable. Unlike Canada, the vast majority of countries within the Organisation for Economic Co-operation and Development do not operate a policy designed to screen out applicants with HIV or that excludes persons who already take antiretroviral medication from the possibility of immigrating. Refugees and spouses are immigrant applicants who are not inadmissible on health grounds. Despite that in Canada HIV is increasingly compared to diabetes for its chronicity and manageability, this is true only under specific conditions, and, furthermore, refugees and immigrants interviewed for this research do not experience HIV according to such classification. Empirical findings show that in practice, HIV is, in fact, ‘othered’ and made exceptional within the Canadian immigration program. The addition of HIV testing in the immigration medical examination was the first change to the exam in about fifty years. No other condition attracts the degree of institutional scrutiny and surveillance that HIV does within the Canadian immigration process.
What role is there for the citizenry, health providers, and other actors? I suggest that legal reform work on the Canadian immigration system, with a specific focus on the place of HIV within this system, is a high priority. Research evidence such as the results generated through my study can provide an important empirical basis for this work. Second, persons who work with immigrant and refugee applicants with HIV are well placed to query the latter people about their experiences with immigration medical examination HIV testing as it occurs in Canada and overseas. Individual citizens and health providers can report irregularities and problems to Canadian-based civil society organizations with specific expertise in assessing and acting on unjust practices as these are directed to persons living with HIV, including the Canadian HIV/AIDS Legal Network (http://www.aidslaw.ca/EN/) and the HIV and AIDS Legal Clinic Ontario (http://www.halco.org/). Last, we might bear in mind that the rationale for what we are asked to do in our work is not always readily evident, and sometimes what we are asked to accomplish is not defensible. In the case discussed here, it is not clear that mandatory HIV testing within the Canadian immigration medical examination is justified. By seeing our immediate workplaces and practices as parts of broader, complex socio-political relations, we are challenged to rethink how and in whose interests these places and practices work.
In this guest post, Ronald Labonté discusses a recent report from the Fraser Institute which compares the healthcare systems of Sweden and Canada. While the report aims to promote the privatization of the Canadian healthcare system, Labonté argues that its conclusions are ideologically driven and that the evidence it draws on must be considered in the wider sociopolitical context of both countries. 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.
The May 22, 2013 report from the Fraser Institute comparing Swedish and Canadian health systems is interesting, provocative and another example where ideology trumps evidence.
The Fraser Institute is a well-known Canadian conservative think tank that emphasizes small government, market fundamentalism and individual choice in its policy arguments. This does not detract from its report’s findings that Sweden’s health system generally performs better and for a lower expenditure of its GDP than does Canada; or that Sweden allows some private insurance to co-exist with its public system (between 2% and 4% of Swedes opt for such coverage), some small co-payments in its public system (with exclusions for those who find it difficult to pay), and a few privately managed hospitals. On this evidence, the report robustly concludes that Canada should therefore increase private provision of hospital and surgical services, allow private insurance to compete with its public system, and to introduce co-payments (user fees) for all health care.
In doing so, the report ignores that Canada already has a large private health insurance system for non-publicly insured health care. Its private health care expenditure (about 30% of total spending) far exceeds that paid by Swedish citizens (about 15%), partly because Sweden provides free or heavily subsidized dental care and prescription pharmaceuticals, which most of Canada does not. The report also ignores the context in which Sweden’s small medical and hospital co-payment policy exists: a high tax/transfer and high public spending social welfare state, still far outperforming Canada in health, poverty, unemployment and other key social indicators. In this context small out of pocket payments do not pose the same barrier to health care access that they might if transferred to a country like Canada, which ranks very low in the OECD league table for tax/transfers and social spending. One cannot cherry-pick an ideologically convenient public policy out of a total social welfare package.
Finally, that Sweden spends significantly less of its GDP on health care than Canada while outperforming on many health system and health outcome measures, may well be related to its physicians being salaried and much primary care being delivered by nurses. Though noting this, the Fraser Institute report simply concludes that these policies ‘will not work in Canada’ due to ‘a lack of physicians and an independent practitioner model of delivery.’ Whether Canada has a substantial lack of physicians is moot; but the report is silent on the nurse-centered, team-oriented approach to primary care that helps keep Sweden’s health care costs low and which would obviate much of the claimed doctor shortage in Canada. Although shifting some of the budgetary measures for hospitals (from global to activity based financing) may merit consideration, how increasing private sector provision, private financing and user fees would reduce Canada’s annual health care spending, and not launch us further along the American pathway of excess costs for limited returns, is never explained. In sum, the Fraser Institute’s recent report may make for some interesting reading, but with eyes critically wide open.
In this guest post, Ted Schrecker critically discusses the results of a recently published public health study in Canada. Illustrated are the hazardous implications of de-contextualized conceptualizations of health.
In early April 2012, a flurry of news reports described a study of major health risks shortening the lives of people in the Canadian province of Ontario. A typical report described “bad lifestyle choices” as together taking as much as seven years off Ontarians’ life expectancies.
As is often the case, the reality is more complicated. The study, led by Ottawa researcher Douglas Manuel, was based on self-reports from 117,674 interviews in three successive surveys conducted by Canada’s national statistical agency (Statistics Canada) and record linkage of 99,929 of the respondents with their provincial health insurance records. “The primary risk factors of interest were smoking, alcohol consumption, fruit and vegetable consumption, leisure physical activity and stress.” A procedure known as a multivariable Cox proportional hazards model was used to estimate the life expectancy reductions associated with these “behavioural risks,” to use the language of the study report. I’ll return to the problematic nature of this language.
In the full text of the report, the authors are commendably candid about limitations related to possible under-reporting of health risks in the survey on which the report was based – limitations, in many cases, related to the simplistic nature of the survey questions. For instance, the survey asked only about leisure time physical activity, not about activity related to work or quotidian errand-running. The conclusion that Ontarians’ combined exposure reduced overall life expectancy in the province by 7.5 years is no doubt statistically robust, given the data on which it was based. Unfortunately, it’s also a ‘so what’ kind of conclusion. The authors of the report are remarkably unreflective about their focus on proximate risk factors, ignoring the contextual influences that shape individuals’ opportunities to lead healthy lives.
It’s not as if the world just found out about the limitations of risk factor epidemiology, as Courtney McNamara noted in a previous posting. She emphasized Link and Phelan’s excellent work on “social conditions as fundamental causes of disease,” and in its 2008 report the Commission on Social Determinants of Health went to great lengths to foreground the “structural determinants and conditions of daily life” that “are responsible for a major part of health inequities between and within countries.”
None of these insights was incorporated into an interactive life expectancy calculator, based on the study findings, that invites Ontarians to respond to a set of questions that are then used to generate an estimate of how long they can expect to live. Participants are asked such questions as how many servings of fruit or vegetables they ate in the past week; how many were potatoes; and whether any carrots were involved. Other questions relate to leisure-time physical activity, and a strictly dichotomous question (like that in the original survey) asks whether most days are stressful.
Now, if you are paying market rent for housing while living on the sub-poverty social assistance income provided by the province of Ontario, having first exhausted almost all your assets as a condition for eligibility, eating the healthy diet defined by the provincial health ministry is an arithmetic impossibility in much of Ontario. Under these circumstances, hearing a $170k/year researcher and his team tell you that you should eat your carrots and have less stress in your life is not especially helpful. If you are trapped in a low-wage service sector job, or have lost your factory job because the employer locked you out after you refused a 50 percent pay cut and then moved production to a lower-wage jurisdiction, which recently happened to workers at the Electro-Motive plant in London, Ontario, hearing a $170k/year researcher and his team tell you that you should eat your carrots and have less stress in your life is not especially helpful. (Were I in such a situation, class warfare is the first phrase that would come to mind.) And after chasing across town on the bus to shop the specials that are their only chance at a healthy diet, or turning as a last resort to the food banksthat have become an established feature of life in the province (not a lot of carrots there), how many Ontarians living on the margins have time or safe opportunities for “leisure physical activity”?
The researchers’ isolation from the conditions of daily life is revealed with special clarity by their treatment of stress as a variable somehow within the control of those experiencing it. (In The Status Syndrome, Michael Marmot is eloquent on the weaknesses of this presumption.) Before giving one more interview or writing one more grant proposal, all those involved with studies like the one just released in Ontario should read, carefully, Barbara Ehrenreich’s account of life in the low-wage service sector. Nickel-and-Dimed is available both as a book with multiple secondhand sellers and as a feature in Harper’s Magazine, so readily accessible. This view of stress is of course even more pernicious in contexts outside Canada: for example Spain, where unemployment is now over 23 percent in the aftermath of a financial crisis that began in the United States, or the United Kingdom, where housing benefit caps are driving poor families out of central London or into homelessness even as tax rates on the ultra-rich are coming down.
At stake here is a vital instance of what Kristin Shrader-Frechette and Earl McCoy have called a methodological value judgment. Perhaps without being aware of it, Dr. Manuel and his team chose an approach that reinforces the neoliberal tendency to privatize risk and responsibility. Conditions like poverty and ill health are ascribed to the choices and failings of individuals who have little control over macro-scale processes like financial crises and the relocation of production to lower wage jurisdictions, rather than situated with reference to radical inequalities in the opportunity to lead a healthy life. The Commission on Social Determinants of Health understood the pernicious nature of this approach, implicating “poor social policies and programmes, unfair economic arrangements, and bad politics” as pathways to health inequity and structuring one of its three overarching recommendations around “the inequitable distribution of power, money, and resources.”
The most widely agreed-upon axiom of medical ethics is: first, do no harm. Studies and derivative knowledge transfer exercises that neglect structural influences on health fail this basic test, for they are far from harmless.
In this guest post,Kate Jongbloed presents housing instability as social determinant of HIV/AIDS in Canada. Kate draws on others’ arguments that the absence of a national housing policy is to blame for fueling housing instability, with severe implications for the HIV epidemic. Kate is the web coordinator for HealthyHousing.ca, a Canada-wide online resource on HIV and housing. She blogs weekly for Plan Canada’s Because I am a Girl campaign to engage young Canadian girls in global gender issues. See Kate’s full bio here.
Housing instability and HIV are parallel epidemics – what puts an individual at risk for one also increases their risk of the other.
Rent Versus Own
Canada ranks high on most measures of global development and health, but is not fulfilling its international obligations to providing the right to shelter for its citizens. The issue is primarily one of renters versus owners.
The cult of home ownership, the “Canadian Dream,” is supported by government incentives, and as a result we have a very high percentage of homeowners compared to most other countries. At the same time, renting is stigmatized and the gap in income between owners and renters is growing. With the absence of a national housing strategy and a steadily declining role in housing, the Canadian government has failed to implement policy that will reduce this gap and support housing options for renters as well as buyers, serving low and moderate income households (Shapcott).
The result is high rates of homelessness and hidden homelessness in Canada, a fact that has severe implications for the health of all Canadians.
Health and Housing
The impact poor housing conditions are well documented: they cause negative physical and mental health outcomes. Unstable housing, especially at the extreme of homelessness, is also associated with lower life expectancies and higher death rates. On the flip side, unhealthy individuals find themselves disadvantaged in the housing market (Bryant).
Housing stability plays a crucial role in both HIV treatment and prevention. Both the material benefit and meaning derived from housing play a role in preventing new infections and supporting those living with HIV.
Drug Use: Individuals with substance use issues are highly vulnerable to HIV infection and often lead very chaotic lives. Housing can help to stabilize drug use, reducing unsafe injections and providing a safe place to store clean needles between injections. (See Dickson-Gomez et al.)
Safe Sex: “Particularly important for understanding relationships between housing and HIV is the extent to which access to housing structures intimate relations,” say Aidala and Sumartojo. For example, women in sex work who have a safe place to conduct business can increase control over condom use and reduce the danger of a bad date.
Unstable Housing and Homelessness: Unstable housing has been independently associated with both HIV and Hepatitis C infection. Some researchers have also found a dose response relationship between HIV and the housing continuum (Elifson et al; Coady et al). Others have noticed that the longer someone has spent on the street, the more vulnerable they are to infection (Rosenthal et al; German et al; Rice et al).
HIV Treatment and Care
Lack of stable housing is a major obstacle to treatment and care of HIV positive individuals, but the challenges of living with the disease can also make housing situations tenuous.
“The type of housing you live in, the amount of money you spend each month for your housing, and how often you have to move directly affect your health when you are living with HIV…if you have stable housing, you will be healthier, less stressed and enjoy a better quality of life,” says Tucker.
Loss of Housing: Episodic illness may make it difficult for an individual to work to make rent or keep up with mortgage payments. Disability insurance or social assistance is often insufficient to meet housing needs. Co-occurring conditions, including substance use and mental health issues, can lead to eviction.
Stigma and Discrimination: HIV status can make searching for housing challenging when faced with stigma from landlords and neighbours. Using disability income to pay for housing may prompt questions from a landlord and living in housing specially designated for people with HIV can lead to unwanted disclosure.
Accessibility: People with HIV may need special facilities, such as wheelchair accessibility or support from home care workers. Proximity to doctors and pharmacists is also particularly important.
Healthy Environments: Living on the street or in shelters can increase exposure to infections, such as pneumonia and tuberculosis. During periods of sickness, lack of housing can mean having nowhere to recouperate, such as if shelters require residents to leave during the day. This increases reliance on hospital services.
Treatment Adherence: Safe, secure and adequate housing provides stability and structure that can make storing and taking medications more straightforward, as well as make it easier to attend regular doctor’s appointments.
For people vulnerable to or living with HIV, housing is a matter of life and death. The stability that a roof provides can help prevent HIV infection and improve quality of life for people living with HIV. Canada’s housing policy choices are daily determinants of the health of those living with HIV and those at risk of infection.
Shapcott calls for a National Housing Strategy – Canada is one of the few countries in the world without one – that includes ensuring adequate rental units available; improvements in social welfare to decrease inequality between renters and owners; and subsidized construction of rental units. Without a national housing strategy, reduction in the growing gap between renters and owners, and an investment in rental housing, Canada will continue to violate citizens’ rights to both health and housing.