Public Policy Approaches to Health Inequalities

Dennis Raphael, PhD

School of Health Policy and Management

York University, Toronto, Canada

Presentation at the Rammelkamp Center for Education and Research Symposium:

Health Disparities: From Genetics to Health Policy September 27, 2006, Cleveland, Ohio

Overview of Presentation• Health inequalities reflect differences in living

conditions• Living conditions are shaped by public policy decisions

concerned with the distribution of economic and social resources

• Health status – and living conditions – differ profoundly among Americans

• The USA has one of the worse population health profiles among developed nations

• The USA has one of the worse public policy profiles among developed nations

• The solution to health inequalities lies in the political sphere

Ten Tips For Better Health - Donaldson, 1999 1. Don't smoke. If you can, stop. If you can't, cut down.

2. Follow a balanced diet with plenty of fruit and vegetables.

3. Keep physically active.

4. Manage stress by, for example, talking things through and making time to relax.

5. If you drink alcohol, do so in moderation.

6. Cover up in the sun, and protect children from sunburn.

7. Practise safer sex.

8. Take up cancer screening opportunities.

9. Be safe on the roads: follow the Highway Code.

10. Learn the First Aid ABC : airways, breathing, circulation.

Donaldson, L. (1999), Ten tips for better health., London UK: Stationary Office.

I: Health inequalities reflect differences in living

conditions

Bertolt Brecht, 1898-1956. Worker’s Speech to a Doctor

We know what makes us ill. When we are ill we are told That it’s you who will heal us.

When we come to you Our rags are torn off us And you listen all over our naked body.

As to the cause of our illness One glance at our rags would Tell you more.

It is the same cause that wears out our bodies and our clothes.

Disadvantage and Health: Academic Perspectives

It is one of the greatest of contemporary social injustices that people who live in the most disadvantaged circumstances have more illnesses, more disability and shorter lives than those who are more affluent.

-- Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.

0.18 0.20 0.22 0.24 Share of Income Held by Lower 50%

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Working-Aged Male (25-64) Mortality by Median ShareU.S. States and Canadian Provinces

Mortality Rates Standardized to the Canadian Population in 1991

U.S. States with weighted linear fit (from Kaplan et al., 1996)Canadian Provinces with weighted linear fit (slope not significant)

MSLA

AL

CA

TX

FL

NH

MN

PEI

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SASK

ONT

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MAN

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SC

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Source:Ross N., et al. BMJ 2000;320(7239):898-902.

WA

0.15 0.19 0.23 0.27Median Share of Income

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300

400

500

600

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Working Age (25-64) Mortality by Median ShareU.S. and Canadian Metropolitan Areas

U.S. cities (n=282) with weighted linear fit (from Lynch et al. 1998)Canadian cities with weighted linear fit (n=53) (slope not significant)

Mortality Rates Standardized to the Canadian Popluation in 1991

FlorenceSC

JacksonvilleNC

SiouxCityIA

MonroeLA

ChicagoIL

TuscaloosaAL

Prince George

WashingtonDC

Oshawa

NewYorkNY

LosAngelesCA

NewOrleansLA

BryanTX

McallenTX

SiouxCityIA

AppletonWI

PortsmouthNH

PineBluffAR

FlorenceSC

MonroeLA

AugustaGA

Montreal

Vancouver

Toronto

Barrie

Oshawa

Shawinigan

WAWeightedCan&US June 29, 1999 12:53:18 PM

Cleveland

Ross, N. et al. (2005). Metropolitan income inequality and working-age mortality: A cross-sectional analysis using comparable data from five countries Journal of Urban Health, 82, 101-110.

Social determinants of health as a window into living conditions

What are SDOH?• Social determinants of health are the

economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole.

• Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members.

Brunner, E. and Marmot, M. G. (2006), Social organization, stress, and health in Marmot, M. G. and Wilkinson, R. G. (Eds.), Social Determinants of Health, Oxford University Press, Oxford..

A Policy-Oriented Approach to SDOH

• early life• education• employment and

working conditions• food security• health services

• housing• income and income

distribution• social exclusion• social safety net• unemployment

Source: Raphael, D. (2004). Social Determinants of Health: Canadian Perspectives. Toronto: Canadian Scholars Press.

SDOH and Health

• “Measures of social and economic status, including occupation, are extremely powerful predictors of premature heart disease.”

• Social Organization, Stress, and Health, E. Brunner & Michael Marmot. In Social Determinants of Health. M.G. Marmot & R.G. Wilkinson (eds.). Oxford: Oxford University Press, 1999, p. 32.

Materialist Approach

• “Health inequalities result from the differential accumulation of exposures and experiences that have their sources in the material world.”

• Lynch JW, Smith GD, Kaplan GA, House JS. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ 2000;320:1220-1224.

Neo-Materialist Approach

• “The effect of income inequality on health reflects a combination of negative exposures and lack of resources held by individuals, along with systematic underinvestment across a wide range of human, physical, health, and social infrastructure.”

• Lynch JW, Smith GD, Kaplan GA, House JS. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ 2000;320:1220-1224.

Ten Tips for Staying Healthy - Gordon, 1999

1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.2. Don't have poor parents.3. Own a car.4. Don't work in a stressful, low paid manual job.5. Don't live in damp, low quality housing. 6. Be able to afford to go on a foreign holiday and sunbathe.7. Practice not losing your job and don't become unemployed.8. Take up all benefits you are entitled to, if you are unemployed, retired

or sick or disabled.9. Don't live next to a busy major road or near a polluting factory.10. Learn how to fill in the complex housing benefit/ asylum application

forms before you become homeless and destitute.• Source: Gordon, D. Posting on Spirit of 1848 List, April, 1999

II. Living Conditions are Shaped by Public Policy

Decisions

SDOH and their Public Policy Determinants

• early life – income supports, progressive family policy, availability of childcare, support services

• education – support for literacy, public spending, tuition policy

• employment and working conditions – active labour policy, support for collective bargaining, increasing worker control

• food security – income and poverty policy, food policy, housing policy

• health services – public spending, access issues, integration of services

SDOH and their Public Policy Determinants

• housing – income and housing policy, rent controls and supplements, provision of social housing

• income and income distribution – taxation policy, minimum wages, social assistance, social assistance levels, family supports

• social exclusion – anti-discrimination laws and enforcement, ESL and job training, approving foreign credentials, support of a variety of other health determinants

• social safety net – spending on a wide range of welfare state areas

• unemployment – active labour policy, replacement benefits, labour legislation

III. Health status – and living conditions – differ profoundly among

Americans

Living Conditions and Health: Mechanisms

Living conditions affect health in a number of ways:

• Living conditions provide the prerequisites for health, such as shelter, food, warmth, and the ability to participate in society;

• Living conditions can cause stress and anxiety which can damage people’s health;

• Living conditions limit peoples’ choices and militates against desirable changes in behaviour.

- Adapted from Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.

Origins of Disease• A body of evidence is now emerging which

shows that health outcomes in adulthood reflect the accumulating influence of poor socio-economic circumstances throughout life. Adverse socio-economic conditions in early life can produce lasting increases in the risk of cardiovascular disease, respiratory illness, and some cancers late in life.

• Poverty, Social Exclusion, and Minorities, M. Shaw, D. Dorling, & G. Davey Smith. In

Social Determinants of Health. M.G. Marmot & R.G. Wilkinson (eds). Oxford: Oxford

University Press, 1999, p.216

IV. The USA Population Health Profile

Sources: United Nations Human Development Reports (2005), Innocenti Report Cards (2000-2005) and Society at a Glance

(OECD, 2005)

V. The USA Public Policy Profile

Figure 12.2: Average Percentage of Net Replacement Rates over 60 Months of Unemployment, for Four Family Types and Two

Earnings Levels Without and With Socal Assistance, 2002

6

30

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Belgium

Finlan

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New Zea

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Canada

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Without Social Assistance With Social Assistance

Source Organization for Economic Cooperation and Development. (2005). Society at a Glance: OECD Social Indicators 2005 Edition. Paris, France, Figure SS1.1, p.43.

Figure 12.3: Average Net Incomes of Social Assistance Recipients as Percent of Median Equivalent Household Income,

Married Couple with Two Children, 2001

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010203040506070

Austra

lia

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Poland

Czech

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No Housing Related Benefits With Housing-Related Benefits

Source: Organization for Economic Cooperation and Development. (2005). Society at a Glance: OECD Social Indicators 2005 Edition. Paris, France. Figure SS6.1, p.45.

Figure 12.4: Net Incomes at Statutory Minimum Wages, Married Couple with Two Children as Percentage of Median Household

Income, 2001 in Relation to Poverty Line (- - - - ), 2001

34

46

0102030405060708090

100

Per

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One Full-Time Minimum Wage Earner Two Full-Time Minimum Wage Earners

Source: Organization for Economic Cooperation and Development. (2005). Society at a Glance: OECD Social Indicators 2005 Edition. Paris, France. Figure SS6.2, p.45.

29.2

28.928.5

27.4

27.226.4

26.0

24.824.4

24.3

23.923.0

21.8

21.821.1

20.8

20.1

20.119.8

19.6

18.518.0

17.9

17.816.9

14.8

13.813.2

11.8

6.1

0 5 10 15 20 25 30

DenmarkSwedenFrance

GermanyBelgium

SwitzerlandAustriaFinland

ItalyGreeceNorwayPoland

UKNetherlands

PortugalLuxembourg

Czech RepublicHungaryIcelandSpain

New ZealandAustralia

Slovak RepublicCanada

JapanUSA

IrelandTurkeyMexicoKorea

Figure 12.12: Total Public Expenditure as a % of GDP, 2001

Source: OECD (2004). Social Expenditure Database www.oecd.org/els/social/expenditure

8.07.5

7.47.2

7.16.8

6.76.7

6.46.46.3

6.36.3

6.26.2

6.16.1

5.75.4

5.35.25.2

5.15.0

4.94.8

4.43.9

3.2

0 2 4 6 8

GermanyIceland

SwedenFrance

DenmarkNorwayCanada

CzechBelgium

SwitzerlandPortugal

ItalyJapan

AustraliaUSA

UKNew ZealandNetherlands

SpainFinlandAustriaGreece

HungarySlovakIreland

LuxembourgPolandTurkeyKorea

Figure 12.3: Public Expenditure on Health as % of GDP, 2001

12.711.8

11.711.3

10.7

10.69.2

8.7

8.58.38.3

8.18.07.9

7.97.57.4

7.36.86.7

6.76.4

5.5

5.35.1

4.8

4.74.7

2.71.2

0 5 10 15

GreeceSwitzerland

GermanyItaly

AustriaFrance

SwedenBelgiumPoland

DenmarkSpain

UKHungaryFinland

PortugalLuxembourg

MexicoJapan

NorwaySlovak

Czech RepublicNetherlands

IcelandUSA

TurkeyCanada

New ZealandAustralia

IrelandKorea

Figure 12.4: Public Expenditure on Old Age as % of GDP, 2001

5.55.2

4.84.1

3.93.9

3.83.6

3.33.0

2.8

2.82.7

2.52.5

2.52.4

2.32.3

2.32.12.1

1.81.4

1.10.8

0.70.5

0.4

0 1 2 3 4 5 6

PolandSwedenNorway

NetherlandsDenmark

FinlandSwitzerland

LuxembourgBelgium

CzechNew Zealand

IcelandHungaryAustria

UKPortugal

SpainSlovak

GermanyAustralia

FranceItaly

GreeceIreland

USACanada

JapanKoreaTurkey

Figure 12.5: Public Expenditure on Incapacity-Related Benefits as % of GDP, 2001

3.83.4

3.23.0

2.92.9

2.82.8

2.62.5

2.3

2.22.2

1.91.8

1.61.6

1.51.2

1.21.1

1.1

1.00.9

0.90.6

0.50.4

0.3

0 1 2 3 4

DenmarkLuxembourg

NorwayFinlandAustria

SwedenAustralia

FranceIceland

HungaryBelgium

UKNew Zealand

GermanyGreeceIreland

Czech RepublicSlovak

SwitzerlandPortugal

NetherlandsTurkey

ItalyPoland

CanadaJapanSpainUSA

Mexico

Figure 12.6: Public Expenditure on Family as % of GDP, 2001

4.42

3.75

3.68

3.46

3.01

2.85

2.51

2.19

2.09

2

1.95

1.8

1.67

1.32

1.14

1.13

0.89

0.79

0.61

0.53

0.45

0.3

0 1 2 3 4 5

DenmarkBelgium

NetherlandsGermany

FinlandFrance

SwedenSpain

IrelandAustria

PortugalSwitzerland

NorwayNew Zealand

CanadaAustralia

United KingdomJapan

Slovak RepublicUnited States

Czech RepublicKorea

Figure 12.18: Public Spending on Active Labour Policy as % of GDP, 2003

Table 13.2 National Rankings on a Range of Indicators – Rankings for Each Domain are Only

Provided for the Top 12 Nations in Each Category

Health Health Determinants#

Education and Skills

Environ-ment

Society Economy Innovation

Canada 10 9 3 8 11 12 5

Denmark* 12 2 5 6 1 10 7

Finland* 7 4 1 3 6 10

Norway* 4 3 2 3 4 1 1

Sweden* 2 1 3 1 3 3 1

Iceland 1 11 7 4

Australia+ 7 7 11

Ireland+ 2

N Zealand+ 7 7 12 3

UK+ 6

USA+ 10 3 3

Austriax 2 10

Belgiumx 7 12

Francex 10 7

Germanyx 10 5

Italyx 7

Netherlandsx 11 6 7 8 2 8 7

Spainx 5

Switzerlandx 3 5 10 3 7 3 7

Japan- 5 11 12 10

Korea- 8 6

* Social Democratic political economies x Conservative political economies + Liberal political economies - Asian hybrid economies Source: Adapted from: Conference Board of Canada (2006). Performance and Potential 2005-2006: The World and Canada, Trends Reshaping Our Future. Ottawa: Conference Board of Canada. # Data from Conference Board of Canada. (2003). Defining the Canadian Advantage. Ottawa: Conference Board of Canada.

VI. The solution to health inequalities lies in the

political sphere

Key Tenets of Neo-liberalism

• Markets are the most efficient allocators of resources in production and distribution;

• Societies are composed of autonomous individuals (producers and consumers) motivated chiefly by material or economic considerations;

• Competition is the major market vehicle for innovations

• “There is no such thing as society.”• Source: Coburn, D. (2000). Income inequality, social cohesion

and the health status of populations: The role of neo-liberalism. Social Science & Medicine, 51(1), 135-146.

Sources: 1947-79: Analysis of U.S. Census Bureau data in Economic Policy Institute, The State of Working America 1994-95 (M.E. Sharpe: 1994) p. 37. 1979-2001: U.S. Census Bureau, Historical Income Tables, Table F-3

Source: Center on Budget and Policy Priorities, The New, Definitive CBO Data on Income and Tax Trends, Sept. 23, 2003, citing Congressional Budget Office data.

The Wealth Gap in the USADistribution of Net Worth, 2001

59.0%24.0%

16.7%0.3%

Top 5% ofAmericans

Next 15% ofAmericans

Middle 40%of Americans

Bottom 40%of Americans

Source: Wolff, EN (2004, May). Changes in household wealth in the 1980s and 1990s in the US (Working Paper No. 407.) New York: The Levy Economics Institute of Bard College

Source: Lynch, J. (2000). Income inequality and health: Expanding the debate. Social Science and Medicine, 51, 1001-1005, Figure 1, p. 1003.

Source: Coburn, D. (2004). Beyond the income inequality hypothesis: Globalization, neo-liberalism, and health inequalities. Social Science & Medicine, 58, 41-56, Figure 2, p.44.

Source: Rainwater L, Smeeding TM. Poor Kids in a Rich Country: America's Children in Comparative Perspective. New York: Russell Sage Foundation; 2003.

Degree of Proportional Representation

% of GDP in Transfers

Source: Alesina, A. & Glaeser, E. L. (2004). Fighting Poverty in the US and Europe: A World of Difference. Toronto: Oxford University Press

Social expenditures and child poverty—the U.S. is a noticeable outlier, Economic Policy Institute, July 23, 2004

Figure 13.4: Union Density, Collective Agreement Coverage and Child Poverty, Early 00's (coverage rates) and Late 90's

(poverty rates)

1314

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Union Density Collective Bargaining Coverage Child Poverty Rate

Source: Organization for Economic Cooperation and Development (2006). Trade Union Members and Union Density. Available at http://www.oecd.org/dataoecd/8/24/31781139.xls and Innocenti Research Centre. A League Table of Child Poverty in Rich Nations (Florence: Innocenti Research Centre, 1999), Figure 1, p.4.

Source: Alesina, A. & Glaeser, E. L. (2004). Fighting Poverty in the US and Europe: A World of Difference. Toronto: Oxford University Press

Evidence: USA

Evidence: Canada

Evidence: UK

And, finally…

Rudolph Virchow, 1821-1902

Disease is not something personal and special, but only a manifestation of life under modified (pathological) conditions. If medicine is to fulfil her great task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society?

Dennis Raphael

draphael@yorku.ca

This presentation and other presentations and related papers are available at:

http://www.atkinson.yorku.ca/draphael