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Social determinants of health in Canada: a treadmill of progress


I Introduction
II A brief history
III All doom and gloom?
IV The treadmill
V Getting off the treadmill

--submitted by Karin Davis

I Introduction

The research has been painstakingly and diligently completed. The reports have been written ad nauseam. There is no doubt that our health and well-being is significantly determined by our social and living conditions. The health disparities that we see among Canadians have been inextricably linked to determinants such as income, education, social exclusion and housing.
Individuals and organizations work tirelessly across the country addressing these issues by delivering skills training and early childhood development programs, building affordable housing complexes, and promoting diversity and social inclusion. Though for many who have worked in the field for decades, there is a sense that the strides gained are minimal, particularly when compared to the knowledge that exists and the recommendations that have been made to remedy the situation.

Though the OHPE Bulletin focuses on issues related health promotion and social determinants of health on a weekly basis, it is important to periodically take a step back to collectively review where we’ve been, how well we’re doing and how to address the barriers that keep us from progressing.
II A brief history

The notion that social conditions determine ones health is not new. In fact, it can be dated back the work of both Rudolf Virchow in Germany and Frederick Engles in England in late eighteenth and early nineteenth century.

In Canada, the first report of note was published in 1974 by Marc Lalonde, then Minister of National Health & Welfare. This report, although rudimentary in nature, did acknowledge that environmental factors do play a role in determining ones level of health. The report provided 74 recommendations, the last one in the long list being “a renewed commitment toward the health goals of the World Health Organization and the Pan American Health Organization.”
The following decade was full of promise. It saw Jake Epp, then Minister of National Health & Welfare release his report Achieving Health for All: A Framework for Health Promotion where he concluded that “health promotion implies a commitment to dealing with the challenges of reducing inequities, extending the scope of prevention, and helping people to cope with their circumstances. It means fostering public participation, strengthening community health services and coordinating healthy public policy. Moreover, it means creating environments conducive to health, in which people are better able to take care of themselves, and to offer each other support in solving and managing collective health problems.” In 1986, the World Health Organization convened its first international conference on health promotion, which saw the development of the Ottawa Charter of Health Promotion which declared eight prerequisites to heath: peace, shelter, education, food, income, a stable eco-system, sustainable resources, and social justice and equality.
Hopes were high on November 24, 1989 when then leader of the New Democratic Party, Ed Broadbent introduced a motion to eliminate child poverty by 2000 which resulted in an all-party resolution being passed unanimously by the House of Commons.
Fast forward through the next two decades, and there continue to be similar reports with similar recommendations released by both the Canadian Population Health Initiative (CPHI) and Health Canada in 2004. Most recently, in 2007, the Standing Senate Committee of Social Affairs, Science and Technology established a Subcommittee on Population Health. After nearly two years of research and consultations, they released their report A Healthy, Productive, Canada: A Determinant of Health Approach. This report, like many before, concluded “there has been inadequate policy development reflecting what we have learned about population health. In fact, Canada has fallen behind countries such as the United Kingdom and Sweden in applying the population health knowledge base that has been largely developed here.”

So 37 years after the release of the Lalonde Report, with a plethora of evidence, the problem lies in the significant disconnect between the recommendations and action.

III All doom and gloom?

This is not to say that there haven’t been any significant gains in this area. Progress has been seen within the sector. More professionals grasp the concept of the social determinants of health, more organizations are embracing a broader perspective of health, and initiatives have been developed to address the issues and advocate for change, and the academic arena has provided us with a plentiful amount of data. Community based health initiatives have been developed right across the country, and are revered by health and social service professionals and politicians alike. Even the media is more in tune with the social determinants of health now than it was twenty years ago.

There has also been increasing momentum on the political front, at least provincially. In 2002, Quebec was the first province to implement an anti-poverty strategy and have poverty reduction entrenched in law. In 2004, it released an action plan and dedicated $2.5 billion over five years to implement the changes that it hopes will reduce poverty by 2013.

Other provinces are also making headway. Anti-poverty strategies have been adopted by the provincial governments in Newfoundland and Labrador, Nova Scotia, Manitoba, and Ontario. The Ontario strategy, better known as 25 in 5, was adopted in December 2008 and is now Bill 152 Poverty Reduction Act 2009. And In Prince Edward Island, New Brunswick and British Columbia, groups are working feverishly to complete their strategies and bring them forth to government for adoption.

Those who dedicated their careers to educating others about and addressing the social determinants of health deserve accolades and kudos for paving an often less than popular path.

IV The treadmill

Yet, despite all these advances – the most significant ones occurring at community levels – structural and sustainable change addressing the social determinants of health through the implementation of public policies remains elusive in Canada. Even with regard to the progress within provincial political arenas, only a cautious optimism should be held. Manitoba’s poverty reduction strategy became Bill 226 Social Inclusion and Anti-poverty Act in 2008 - but did not survive past its second reading in the Provincial Legislature, and did not become law.
Ontario’s Poverty Reduction Act calls for a 25% reduction in child poverty in five years – which is now only 31 months away.  While the provincial government has announced a review of social assistance within the province, Premier McGuinty has also allowed social assistance rates to drop below the rate of inflation for the first time since 2006, as well as ending the Special Diet Allowance for people on Ontario Works and the Ontario Disability Support Program.

At a national level, despite the best efforts of advocates, we continue to be without a national strategy on poverty reduction or child care.

V Getting off the treadmill
The challenge for the next generation of advocates is to continue the work of determining what barriers exist in addressing the social determinants of health, why they exist and how to overcome them. Not a simple task by any means, but current experts in the field have developed a foundation upon which to work.

One major barrier is political ideology. During the recent federal election, Campaign 2000, a national anti-poverty coalition, analyzed each of the four parties’ campaign platforms to determine their positions on poverty reduction. They were pleased to find that three out of the four parties were committed to and had a plan for poverty reduction. The one party that was not committed? The one that now holds the balance of power.

Yet, as we’ve seen in Ontario, commitment of a government to reduce poverty does not guarantee their actions will follow. How do we keep our politicians accountable?

David Langille, Dennis Raphael, Ann Curry-Stevens and other experts in the field contend that there are a number of barriers at play including the prevalence of individualism, the power of corporations, the invisibility of the issues within the media, the lack of knowledge of the general public, and the apathy and perceived lack of power by the general public.

The complexity of these issues can be overwhelming, but those in the field must find ways to address these barriers. A social movement is required that educates the general public, not only about the social determinants of health, but about political ideology and processes, the benefit that addressing the social determinants of health would have on the economy and the importance and value of civic engagement.
As Raphael suggests, “Canada has a rich history of concerted public pressure that can lead to positive policy change.”