Summary

Social inclusion and the health of Canadians: Where are the gaps?

Friday March 28, 2003 - Plenary

Dennis Raphael, Associate Professor in the York University School of Health Policy and Management, traced recent attempts to place the social determinants of health within the context of social inclusion and exclusion. He expressed concern about the “profound barriers out there that will make it difficult for us to do this kind of work”.

In Europe, Raphael said, social exclusion is defined in a way that includes unemployment, low income, housing, educational opportunities, discrimination, citizenship, and a variety of other conditions that are recognized as social determinants of health. Research shows that societies with a high incidence of income inequality and poverty tend not to support social infrastructure, so that individual and social exclusion coincide.

Raphael cited 1991 data showing that Canadians were healthier than Americans, with lower mortality rates and less income inequality. Some of the most unequal states—like Louisiana, Mississippi, Alabama and Texas—“are also the jurisdictions that invest very meagerly in social amenities” like libraries, social welfare, public transportation and schools. They do spend more money on prisons, “which of course is good for the Gross Domestic Product”.

But while Canada has done a good job of conceptualizing the social determinants, the country has been less adept at implementation. Insurance companies know that income, early education and food security are the best indicators of health and chronic illness. But health promotion, for the most part, focuses on lifestyle issues, diet and smoking—which ultimately means asking someone to go home and exercise after spending 18 hours each day driving a taxi.

A more comprehensive solution would include policies to improve access to affordable housing and financial resources, as a first step in reducing social exclusion, stress, and the well-documented health problems—including immune system effects, heart disease and high cholesterol—that result. But when Raphael issued a review of published literature that linked health effects to social exclusion, the reaction in some quarters was so strong that he had to publish it on a US Web site.

In general, he said his findings received a positive response from social welfare and social development organizations, anti-poverty organizations, and faith communities. But the public health community, lifestyle-oriented health promoters, and illness-oriented foundations were more “ambivalent and guarded”, and one heart health organization bounced Raphael from its list server. He noted that recent funding decisions in Ontario have emphasized lifestyle-based programs that studiously avoid any acknowledgement of structural inequalities.

Looking ahead, he said researchers should address four key issues rather than looking for more money or new technologies:

• Equitable distribution of income and other resources;
• An adequate, accessible safety net;
• A socially cohesive, caring society;
• Responsive and democratic institutions.

Facilitator/provocateur Louise Bouchard said marginalized populations would be well served by a more global analysis of the structure of society. She said the health sector is gradually moving to supplement biomedical knowledge with an understanding of the social and environmental determinants of health.

The distinction between natural, political and moral inequalities was first articulated by Jean-Jacques Rousseau more than 200 years ago, Bouchard said. But societies are only beginning to recognize that social inequality leads to a higher incidence of physical ailments, disability, impaired quality of life and premature death. The difference is reflected in health statistics for countries with comparable economic performance that take different approaches to health and social policy.

Pat Spadafora, Director of the Sheridan Elder Research Centre in Oakville, ON, said the continuum from social inclusion to exclusion suggests a range of choices for older adults, including whether to be included and whether someone is deciding on their behalf. The World Health Organization defines active aging as a process of “optimizing opportunities for health, participation and security in order to enhance quality of life as people age”. But when the Second World Assembly on Aging convened in Madrid last year, the result was a very general statement of priorities that must now be clarified and implemented by national governments. The need is urgent, Spadafora said, in light of a demographic shift that is described as an “age quake” by the United Nations and a “silver tsunami” in Japan.

The international research agenda put forward by the UN Program on Ageing does include material on social participation and integration and healthy aging. Key concerns include intergenerational relationships, ageism, images of aging, psycho-social determinants of participation and aging, and measures to empower and enable seniors’ participation and contribution to society. Spadafora expressed particular interest in the implications of increased longevity, including the challenge of ensuring that added years are as free as possible from disability. The Sheridan Elder Research Centre is also looking at the built environment as a factor in seniors’ ability to age in place, and at the importance of encouraging and enabling older adults to embrace different kinds of new technology.

Richard Lessard, Director of Public Health for the City of Montréal, presented study results that linked key measures of health and wellness to levels of income, employment and education in different parts of the newly-amalgamated municipality. His data also compared demographic characteristics and health outcomes for Montréal with those of several other major Canadian cities—Toronto, Vancouver, Ottawa , Winnipeg and Calgary. He reported that:

• Montréal has a smaller proportion of immigrants than Toronto and Vancouver, but far more single-parent families than other major centres.

• Montréalers are less likely to hold a post-secondary diploma and more likely to be unemployed than their counterparts in other cities.

• Montréal has a higher poverty index, a far lower rate of home ownership, and less equitable distribution of income than other cities.

• Inner city neighbourhoods in the southwest, east and east-central parts of the city have social assistance rates that are up to four times higher than those in the more privileged western areas. The rate of single-parent families varies from 16 to 36%, while the proportion of children under five living in poverty varies from 22 to 58%. Teen pregnancy rates per thousand population vary from 16 to 42 by city regions, and from eight to 64 across the smaller territories served by different Centres locales de services communautaires (Local Community Service Centres). In some CLSC regions, up to 57% of residents have no high school diploma.

• Rates for different types of disease increase dramatically for the two lower income quintiles. Breast cancer rates are higher in the wealthier western neighbourhoods, but death rates are lower, indicating that the more privileged communities receive better screening and/or treatment. When the researchers noted differences in the rate of hip and knee replacements, they checked with orthopedic surgeons and learned that they often decide against operating on patients whose co-morbidities will lead to longer hospital stays. Rates of heart surgery correspond more closely to the actual risk, indicating an element of discretion in medical decisions that has a direct bearing on equity.

• Rates of cardiovascular disease have declined over time, but the overall reduction varied from 12% in the highest income quintile to 5% in the lowest. Child mortality rates have dropped across the board, but are still highest in the lowest quintiles.

• Between 1979-83 and 1994-98, life expectancy increased from 68.5 to 70.4 in the lowest quintile, and from 78.7 to 81.5 in the highest—so while there were improvements in all income groups, the disparity between quintiles actually increased.

Lessard said it’s important for public health practitioners to ask what they’ve done wrong, and why inequalities persist. One part of the challenge is to tailor public health interventions to the profiles of individual neighbourhoods: the response to persistent poverty is different than the services required for a “trampoline neighbourhood”, where people move in when they lose their jobs and return to a more privileged setting when they can.

“The honest answer is that we don’t know what’s working and what isn’t,” he said. But superficially, at least, public health can find its target audience by starting with the two lowest income quintiles.

A participant recalled her experience working with the 50,000 people—including older workers, immigrant workers, and women—who lost their jobs when 300 plants closed down in the Toronto area. She said changes in federal labour adjustment supports made it difficult to deliver the job upgrading and language training that people needed to re-enter the work force. Before the introduction of the revamped Employment Insurance program, laid-off workers were re-employed at a 68% higher wage rate. Now, the participant said one-third are re-employed, one-third are disabled, and one-third are dead. There was little support for an effort to look at the social determinants involved, and limited attention from researchers has meant that no one knows what happened to a whole group of people.

Another audience member identified seniors with severe mobility problems as a largely invisible population that is in danger of total social exclusion. In some sense, she said older adults in this group are victims of good intentions—home care may be a great success, but the result is that seniors at home have no opportunity to participate in society.

A participant said the language of social exclusion and inclusion fails to fully capture the experience of some immigrant women, for whom inclusion in an oppressive situation presents major problems. She also cautioned against assuming that immigrant women are waiting passively for social policies to bring them out of their marginalization, noting that many of them have a history of organizing and actively resisting oppression. She invited participants to join a gathering at the British High Commission over the lunch hour to bear witness against “the ultimate act of social exclusion, which is war”.

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For more information about the conference, contact:
 
Sarah Zgraggen
The Willow Group
Tel: (613) 722-8796;
Fax: (613) 729-6206;
e-mail: szgraggen@thewillowgroup.com