Kaity Doiron is a student in the public health program at the University of Lethbridge who has been doing her practicum placement at Parkland Institute. Her research focus has been to look at the Alberta public policy implications of the internationally accepted principles of public health and the Social Determinants of Health. This blog is a summary of her research findings over the past four months.
A health care system—even the best health care system in the world—will be only one of the ingredients that determine whether your life will be long or short, healthy or sick, full of fulfillment, or empty with despair.”
- Honourable Roy Romanow
Income inequality is a leading problem for developed nations—one that has profound negative impacts on health and the economy. The World Health Organization explains the prevalence of health inequity as an “unequal distribution of health-damaging experiences that is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.” The World Health Organization, the United Nations, and the Public Health Agency of Canada have been urging action on the socio-environmental determinants of health for decades. The barrier to understanding the prerequisites for health is not evidence; the evidence has been absolute for decades. What is missing is the will of those in power to ensure that these prerequisites for health are accessible to the public. Our current biomedical emphasis on health fails to understand the significance of the cause of our issues, not just the symptoms.
Premier Rachel Notley’s recent announcement of “compassionate belt tightening” in the forthcoming Alberta budget foreshadows that while health care and education may be spared, cuts elsewhere will have the potential to intensify the epidemic of health inequities across our entire population. If we demand action based on evidence, we will find that the struggle we are experiencing to improve population health, to curb health care costs, and to maintain our provincial economic edge can all be remedied through the structural and intersectional actions on the Social Determinants of Health.
Social Determinants of Health
The 1978 Alma Ata Declaration, a pinnacle milestone of international health care, affirmed that health was not simply the presence or absence of disease but the complete mental, physical, and social well being of humans. This declaration made it clear that health is a human right and needs to be addressed by “social and economic sectors in addition to the health sector.” These outside forces have come to be known as the Social Determinants of Health (SDOH).
The SDOH are the circumstances in which we grow, work, live, and age. They are shaped by the distribution of power and privilege. SDOH disproportionately affect specific marginalized populations based on social categories. The National Collaborating Center for Determinants of Health explains, “Indigenous and racialized peoples generally experience higher rates of poverty, precarious and under employment, discrimination and systemic disadvantages within housing, education, and public health systems.” The unnecessary disadvantages attributed to specific social groups directly and indirectly create unfair, unjust and avoidable differences in health, which is how the World Health Organization defines inequity.
Health inequity and income inequality in the developed world
The Parkland Insitute fact sheet Sick of Inequality warns that when income gaps become too large, everyone is at risk of negative consequences. Social problems emerge at greater frequency, people experience poorer health, live shorter lives, and business and the economy suffers. Without thoughtful redistribution, issues of inequality will urge modern governments to do more with less.
Social epidemiologists Richard Wilkinson and Kate Picket compile over 40 years of research in their book The Spirit Level: Why equality is better for everyone, to describe the correlation between income inequality and health inequity. As shown in Figure 1, they found a strong link between life expectancy and income is recognized until individual national income per person reaches $25,000, after which GDP becomes irrelevant. What actually determines health is inequality.
Figure 2 shows the relationship between developed countries and levels of inequality and social problems (criminal activity, teen pregnancy, levels of incarceration, trust within the community, depression, HIV and AIDS, etc.). Countries with higher rates of inequality, such as the United States, have consequently higher rates of social problems. Spain and Portugal are highlighted as test comparisons based on their similar proximity and GDP. Portugal experiences greater social problems as a result of inequality when compared to its counterpart, Spain. Sweden and Japan have different structures of redistribution, but both benefit from increased health by prioritizing equality.
Within populations inequality creates a social gradient of ill health where at each decreasing level of income there are increasing health inequities. The highest income earners have the best health, and at each level beneath them populations suffer at intensifying intervals. However, even the highest level of income earners have been shown to experience negative effects in unequal societies. When developed countries are compared to one another, the less equitable countries experience poorer health outcomes at every income level.
Canada is not immune to these trends; Canada has some of the lowest ratings for three key measures of health status, and suffers from the same social gradient of health that Wilkinson and Picket warn of. Health inequities, which are a result of avoidable inequalities, cost us.
Figure 3 shows hospitalizations categorized by illness condition and socio-economic status. In each category of hospitalization the lowest socio-economic status category accesses services at a significantly higher rate than its counterparts. The three most significant inequities brought on by socio-economic status include mental health, injuries, and ambulatory care sensitive conditions (asthma, grand mal seizures, heart failure, etc.). Our emphasis on treatment of these symptoms of inequality, opposed to the social and economic root causes, result in an over burden on our health care system.
The Canadian Institute for Health Information (CIHI) projected that Canada could achieve a significant reduction in health services (and the costs associated with their delivery) if it were able to lift the lowest socio-economic group up to the health indicators of the highest socio-economic group. The health benefits included a 45.3% decrease in chronic obstructive pulmonary disease, a 13.5% decrease in motor vehicle collisions, and a 15% decrease in infant mortality.
The impact of inequality on population health in Canada is not a new phenomenon within the medical sector. A 2013 motion submitted by the Canadian Medical Association urged the government of Canada to recognize income inequality as a major determinant of health:
The issue of income inequality is an important one for Canada’s physicians. As physicians, we are not the experts in housing, in early childhood development, income equality and so on. But we are the experts in recognizing the impact of these factors on the health of our patients.
In Alberta we see health disparities intensifying as income declines at every level of income group. The government of Alberta tracks these social gradients of health in life expectancy relative to income, and these findings suggest that the lowest income earners lose 16–17 years of life when compared to the highest income earners. Trends in health also indicate that those who experience higher levels of material deprivation reported increasingly lower self-rated health at each lower level of income. Both of these health trends indicate that income inequality is deteriorating health status in both real and perceived ways relative to the income groups above and below them.
In 2012, Alberta made an economic appeal to address the inequity of Alberta’s lowest income earners in a province-wide poverty elimination strategy, Poverty Costs: An economic case for a preventative poverty reduction strategy in Alberta. The report estimated that $9.5 billion in health care costs, intergenerational effects, loss of opportunity and crime could be saved through poverty elimination. The conclusions from this report are very clear: “investing in poverty prevention would be much less costly in the long run than spending to alleviate poverty in perpetuity." Plans continued to develop in 2015 under Premier Alison Redford, but, unfortunately, to date there has been no commitment to implementation, leaving this economic and social strategy in limbo.
Since Premier Notley took office in 2015, more efforts to reduce poverty have surfaced. The Child Benefit program aims to lift 19,000 households out of poverty; increases in minimum wage target populations at risk, such as women, immigrants, and single parents who find themselves in precarious work; and increases in funding for affordable housing all act as important steps in reducing poverty.
With over 5,000 Albertans experiencing homelessness, and one in five Albertans still earning less than $15 an hour, the crucial question is no longer whether we should help vulnerable populations escape poverty, it is more a question of how. As Nancy Edwards, director of Canadian Institute for Health Research’s Institute of Population and Public Health suggests, “It is time to view population and public health as an economic asset."
The role of public health
Public health is a branch of health care that coincides with the Alma Ata Declaration in working with the social and economic barriers of health in order to raise the standard of living for all. With rising inequality in the most developed parts of the world we need to redefine our strategy on addressing health in our community. Health care is a component, but it does not address the causes of ill health.
In order to improve health statuses, public health initiatives address health inequities through systematic and structural approaches that involve policy decisions and the will of the government. Many public health policies attempt to target vulnerable populations in order to address health inequities within disadvantaged populations (welfare systems, food stamps, subsidized housing, etc.). When implemented alone, these policies sometimes inadvertently reinforce social status within social hierarchies, which can perpetuate the social and health inequities they were set to address. However, when these policies are combined with macro level policies that reach across social and economic spheres—through universal health care, minimum income projects, or province-wide school breakfast programs, for example—health inequities are more consistently addressed. Alberta’s 2017 health budget includes population health as a key strategy to improve health status, yet allocates only 3% of the budget to this branch.
Alberta is rich in resources, but the concentration of wealth within the richest 1% is creating an epidemic of health inequity across our entire population. Despite Premier Notley’s call for “compassionate belt tightening,” Alberta’s debt level does not justify disproven forms of disguised austerity. Alberta’s actual projected net-debt-to-GDP ratio for 2017–2018 is the lowest in Canada, which begs the question: why are we defaulting to funding cuts?
The power to curb health care costs and improve health of Albertans will be a political process that starts with intervention on disadvantaged populations from political leaders that have the power and the will to commit to long-term social investment. The epidemic of income inequality in Alberta will continue to spread if there is not real change in our future. If we chose to commit to income equity, we are choosing to commit to health for all.