Social Determinants of Health: Ideological, Economic ... - Tamarack

Social Determinants of Health:
Ideological, Economic, and Political
Barriers to Health
Dennis Raphael, PhD
School of Health Policy and Management
York University
Presentation to the University of Waterloo Health Studies
and Gerontology Department Seminar, October 30, 2007

Overview of Presentation I
• What do we know about the
determinants of health?
• How do we know it?
• What should we be doing?
• Why isn't this happening?
• What can be done about it?

Overview of Presentation II
• How does the epistemology (nature of
knowledge) shape our understandings and
actions on the determinants of heath?
• How do the ideologies of epidemiology and
individualism shape our understandings and
actions on the determinants of heath?
• How does the political economy of a society
shape our understandings and actions on
the determinants of heath?

What do we know about the
determinants of health?

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

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.

Ottawa Charter’s Prerequisites of Health
• peace
• shelter
• education
• food
• income
• a stable eco-system
• sustainable resources
• social justice
• equity
Source: World Health Organization, 1986

The Focus of the Canadian SDOH
Conference
• 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.

All policies which have
a direct bearing on
health need to be
coordinated. The list is
long and includes,
among others,
income security,
employment, education,
housing, business,
agriculture,
transportation, justice
and technology.
-- Jake Epp, Achieving Health For All: A Framework for Health
Promotion, Ottawa: Health and Welfare Canada, 1986.

Alberta Government
• The health of all Albertans should be promoted and
improved by taking a global view of all of the
factors that determine and affect people’s health.
This includes basic public health measures,
economic well-being, early childhood development,
education, housing, nutrition, employment status,
quality of the environment, lifestyle choices and
healthy behaviours.
• A Framework for Reform: Report of the Premier’s
Advisory Council on Health, Dec. 2001, p. 41.

Mechanisms and
Pathways

Materialist Approach
• Health inequalities result from the
differential accumulation of exposures
and experiences that have their
sources in the material world.
• Lynch JW, et al. 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, et al Income inequality and mortality: importance to
health of individual income, psychosocial environment, or material
conditions. BMJ 2000;320:1220-1224.

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

Poverty as the
Clustering of
Disadvantage

All conceivable evils are heaped
upon the poor…They are given damp
dwellings, cellar dens that are not
waterproof from below or garrets that
leak from above… They are supplied
bad, tattered, or rotten clothing,
adulterated and indigestible food.
They are exposed to the most
exciting changes of mental condition,
the most violent vibrations between
hope and fear... They are deprived of
all enjoyments except sexual
indulgence and drunkenness and are
worked every day to the point of
complete exhaustion of their mental
and physical energies…
Frederich Engels, 1820-1895. The Condition of the Working Class in England

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.

Percentage of Canadians, Children, and Individuals in Female
Lone-Parent Families Living in Poverty by Province, 2004
70
BC Now Poverty
Leader
Percentage Living in Poverty
60
50
40
30
20
10
18.4
23.1
62.7
57.7
16.5
13.9
14.4
50.2
18.1
32.9
11.7 10.8
39.9
15.8 15.6
54.6
17.4
14.7
15.8
19.2
47.6
16
57.3
20.1
54.2
13.2
14.5
19.2
23.5
62.8
0
NFL NB NS PEI PQ ON MB SK AL BC
All Children Female Lone-Parent Families
Source: Statistics Canada (2006). Persons in Low Income Before Tax, CANSIM Tables.

Low Income Gap for All Families and Unattached Individuals
by Province, 2004
10000
Poor in Alberta and
BC are Really Poor!
Poverty Gap in Dollars
9000
8000
7000
6000
5000
4000
3000
6900
6600 6500
6100
76007600
5700 5500
7400 7200
8400
7600
8000
7300 7200
6600
9200
8700
8900
8000
2000
1000
0
NFL NB NS PEI PQ ON MB SK AB BC
All Families
Unattached Individuals
Source: Statistics Canada (2006). Low Income Gap Before Tax in Dollars, CANSIM Tables.

SDOH (Living Conditions) and Health
Social determinants can affect health in a
number of ways:
• SDOH provides the prerequisites for health, such
as shelter, food, warmth, and the ability to
participate in society;
• SDOH can cause stress and anxiety which can
damage people’s health;
• SDOH limit peoples’ choices and militates
against desirable changes in behaviour.
- Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling
Inequalities in Health: An Agenda for Action.

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..

How do we know it?

Infant Mortality, Canada 1996
Q1-Richest
Q2
Q3
Q4
Q5-Poorest
per 1,000
0 1 2 3 4 5 6 7 8
Source: Wilkins et al., 2002, Health Reports

Life Expectancy, Males,
Canada 1996
72 73 74 75 76 77 78 79
Yrs
Q1-Richest
Q2
Q3
Q4
Q5-Poorest
Source: Wilkins et al., 2002, Health Reports

Life Expectancy, Females,
Canada, 1996
80 80.5 81 81.5 82 82.5 83
Yrs
Q1-Richest
Q2
Q3
Q4
Q5-Poorest
Source: Wilkins et al., 2002, Health Reports

Increased Risk of Diabetes in Ontario Among
Low Income Residents, 1997/97
Males
Females
Diabetes Prevalence Ratio
5
4
3
2
1
0
1.4
3.8
1.5
2.3
Low Low-Middle Upper-
Middle
Income Level
2
1.2 1
1
High
Source: Hux J, Booth G, Laupacis A. The ICES Practice Atlas: Diabetes in Ontario.
Institute for Clinical Evaluative Sciences and the Canadian Diabetes Association; 2002.

Diabetes Mortality, Urban Canada,
ASMR x 100,000
Males, 1996
22
20
18
16
14
12
10
8
6
4
2
0
1971 1976 1981 1986 1991 1996
Source: Wilkins et al., 2002, Health Reports
Q1 - Richest
Neighbourhoods
Q2
Q3
Q4
Q5 - Poorest
Neighbourhoods

Diabetes, males
ASMR x 100,000
26
24
22
20
18
16
14
12
10
8
6
4
2
0
1971 1976 1981 1986 1991 1996 2001
Q1 - Richest
Q2
Q3
Q4
Q5 - Poorest

Diabetes Mortality, Urban Canada,
ASMR x 100,000
Females, 1996
22
20
18
16
14
12
10
8
6
4
2
0
1971 1976 1981 1986 1991 1996
Q1 - Richest
Neighbourhoods
Q2
Q3
Q4
Q5 - Poorest
Source: Wilkins et al., 2002, Health Reports
Q5 - Poorest
Neighbourhoods

Diabetes, females
ASMR x 100,000
26
24
22
20
18
16
14
12
10
8
6
4
2
0
1971 1976 1981 1986 1991 1996 2001
Q1 - Richest
Q2
Q3
Q4
Q5 - Poorest

Functional Health:
The results of testing on children
for eight basic attributes: vision,
hearing, speech, mobility,
dexterity, cognition, emotion, and
pain and discomfort.

14
Annual Family Income and Percentage of
Children with “Lower Functional Health”
13.4
12
10
8
8.6
8.1 8.3
6
5.1
4
2
0
80,000
Source: Prepared by the Canadian Council on Social Development using the National Longitudinal
Survey of Children and Youth, 1994-1995

Heart Attack Admission Rates by Area
Income, Ontario, 1994 - 1997
14000
12000
11837
13935
13115
10000
8000
8090
6000
4000
4614
2000
0
Highest Income
Quintile
2nd Quintle Middle Quintile 4th Quintile Lowest Income
Quintile
Source: Alter, D. A. et al. (1999). Effects of socioeconomic status o access to invasive cardiac
procedures and on mortality after acute myocardial infarction. NEJM, 341, 1360-1367.

Report of Fair or Poor Self-Rated Health:
Odds Ratios for Individual and Area Factors, Ontario, 1996
0 1 2 3 4 5
Age 40-64
Age 65+
Female
Individual low income
Individual medium income
No regular exercise
1.07
1.62
2.19
2.33
3.44
3.89
Smoker
Less than secondary education
Medium area inequality
High area inequality
Low area median income
Medium area median income
1.38
1.43
1.11
1.18
1.07
1.18
Source: Xi et al. (2005). “Income inequality and health in Ontario”, CJPH, 96, 206-211

Poor Scores (

The Story Behind the Story I
How does the epistemology (the nature
of knowledge) shape our understandings
and actions on the determinants of
heath?

Three Forms of Knowledge (Park, 1993)
• Instrumental (or positivist) knowledge is developed
through traditional scientific approaches. It is
concerned with controlling physical and social
environments.
• Interactive (or lived) knowledge is derived from
sharing lived experiences. It is concerned with
understanding and the connections among human
beings.
• Critical knowledge is derived from reflection and action
on what is right and just. It is concerned with raising
consciousness about the causes of problems and
means of alleviating them.

Scientific (positivistic) Knowledge is
Privileged above others
• Quantitative (a problem)
• Individualized (a larger problem)
• Non-normative (an even larger problem)
• De-politicized (a profound problem)
• See Raphael, D., & Bryant, T. (2002). The
limitations of population health as a model for a
new public health. Health Promotion
International, 17, 189-199.

What does de-politicized mean when talking
about health promotion or population health?
• Assuming that individuals’ behaviours,
health, and well-being exist independently
of the society in which they live
• Neglect of political and economic forces
shaping the distribution of resources
• Emphasis on knowledge dissemination,
translation, or exchange rather than
building social and political movements in
the service of health

The philosophers
have only
interpreted the
world in various
ways; the point,
however, is to
change it.
Karl Marx, 1818–1883

What should we be doing?

Carrying out the action areas of the Ottawa
Charter would be a good beginning ☺…
• build healthy public policy
• create supportive environments for
health
• Strengthen community action for health
• develop personal skills
• and re-orient health services

Federal

All policies which have
a direct bearing on
health need to be
coordinated. The list is
long and includes,
among others,
income security,
employment, education,
housing, business,
agriculture,
transportation, justice
and technology.
-- Jake Epp, Achieving Health For All: A Framework for Health
Promotion, Ottawa: Health and Welfare Canada, 1986.

1998

2003

2004

2004

2005

2007

Provincial

Local
(NGOs)

Why isn't this happening?
(to the extent that most
provinces have not identified
improving living conditions as
a significant public health
priority)

Alberta’s Plan:
Take Action on Health Now
A wellness program will set targets for better
health. Albertans will be encouraged to follow
healthier lifestyles, such as increasing their level of
physical activity and reducing their use of tobacco.
The program will aim for better health in the
general population, including lower rates of
diabetes, heart disease and injury. A public
information and health promotion campaign will be
launched in the fall of 2002.
Source: Building a better public health care system, the Alberta
government’s response to the Premier’s Advisory Council on Health
Report, January 2002

Ontario Forms a Ministry of Health Promotion
The Ministry will help Ontarians lead healthier
lives by delivering programs that promote
healthy choices and healthy lifestyles. To do this
the Ministry will work closely with partners,
stakeholders and all levels of government.

The Story Behind the Story II
How do the ideologies of epidemiology
and individualism shape our
understandings and actions on the
determinants of heath?

Individualism in Health
• With exceptions, few decision makers examine the
relationship of inequalities in health status to racism or
social, political, and economic inequality. None suggest
the need for major political and economic
transformations to eliminate health inequities.
• Many analysts and policymakers instead focus on
symptoms and treatments, microanalysis of individual
risk factors, and changing people’s behavior and
lifestyles, not conditions or places.
• They present options primarily through a biomedical
model and remedial solutions, mostly associated with
health care, rarely stressing social transformation
(Hofrichter, 2003, p. 25).

Individualism…
• Individualism, a powerful philosophy and practice in North
American, limits the public space for social movement
activism.
• By transforming public issues into private matters of lifestyle,
self-empowerment, and assertiveness, individualism
precludes organized efforts to spur social change. It fits
perfectly with a declining welfare state and also influences
responses to health inequities.
• From this perspective, each person is self interested and
possessed of a fixed, competitive human nature. Everyone
has choice and the potential for upward mobility through
hard work—ignoring how we develop through the process of
living in society (Tesh, 1988).
• Individualism presumes that individuals exist in parallel with
society instead of being formed by society (Hofrichter, 2003,
p. 28).

Mass Media
• The mass media almost always cover health as a
personal issue, with emphasis on individual
behavior, choice, and habits.
• Risks become personal risks, and health issues
become medical issues. News coverage rarely
presents stories about community health.
Options, mainly posed in relation to fragmented
policy, shun institutional critique (Lindbladh and
others, 1998).
• Stories on health, as Lawrence Wallack suggests
in Chapter 27 “communicate personal
responsibility rather than social accountability” (p.
29).

Public Understandings

Barriers to Action:
Public Officials

The Political Economy of
Determinants of Health
Concepts and Action

Public Health and Public Policy:
Making it Happen I
Eleven public health objectives are as follows:
1. Participation and influence in society
2. Economic and social security
3. Secure and favourable conditions during childhood
and adolescence
4. Healthier working life
5. Healthy and safe environments and products
6. Health and medical care that more actively
promotes good health

Public Health and Public Policy:
Making it Happen II
7. Effective protection against communicable
diseases
8. Safe sexuality and good reproductive health
9. Increased physical activity
10. Good eating habits and safe food
11. Reduced use of tobacco and alcohol, a
society free from illicit drugs and doping and
a reduction in the harmful effects of
excessive gambling

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.

Figure 13.4: Union Density, Collective Agreement Coverage
and Child Poverty, Early 00's (coverage rates) and Late 90's
(poverty rates)
Union and Bargaining
Coverage
100
90
80
70
60
50
40
30
20
10
0
Denmark
Finland
Norway
Sweden
92.5
81
4.2
Switzerland
Belgium
Luxembourg
Netherlands
Germany
Austria
Spain
Portugal
Italy
14.9
28
32
Australia
Canada
United Kingdom
New Zealand
USA
13 14
Union Density Collective Bargaining Coverage Child Poverty Rate
21.9
25
20
15
10
5
0
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.

And back in Canada…

Source: Innocenti
Research Centre.
(2005). Child poverty
in rich countries, 2005,
Innocenti report card
No.6. Florence:
Innocenti Research
Centre.
Most data are from the
years 1998-2000.

Figure 3.5: Average Income by Income Quintile, All Family
Units, Canada, 1995-2004
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
142,700
119,700
43,600 47,500
12,400 12,900
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Lowest Quintile Second Quintile Middle Quintile
Fourth Quintile
Highest Quintile

United Nations Report, 1998
UN lashes out at Canada
for failure to end poverty
Helen Branswell
Times–Colonist Newspaper,
Victoria, B.C., December 5,
1998. pg. E.10

United Nations Report, 2006
Canada failing to care for
poor, disadvantaged: UN
report
CBC News, May 22, 2006
http://www.cbc.ca/story/world/national/2006/05/22/unreportcanada.html

What can be done?

Figure 13.3: Policy Priorities of Canadian Food Banks
Increase Social Assistance Benefits
Raise the Minimum Wage
Facilitate Affordable Rental Housing
Improve Rates and Access to EI
Increase Disability Supports
Improve Income Supports for Seniors
Expand Job Training Opportunities
Provide Affordable Childcare
Increase National Child Benefit
Lower Tuition, Increase Student Grants
Other Policies
Expand Settlement Services
0 10 20 30 40 50 60 70 80
Percentage of Food Banks Recommending Action

Table 1. Federal Party Positions on Issues Identified by Campaign 2000 as Essential to Eliminating
Child Poverty
“Yes” indicates party position meets Campaign 2000 policy recommendation
“Partial” indicates party position partially meets Campaign 2000 policy recommendation
“No” indicates party makes no commitment that meets Campaign 2000 policy recommendation
ISSUE CPC LIB NDP BLOC
Increase Canada Child Tax Benefit to $4,900/child
by 2007 & end clawback from families on social assistance No No Yes No*
Commit to key principles (quality, universal, accessible
& developmental programming) for child care system No Yes Yes No*
Introduce legislation to secure early learning & child care
as permanent social program No No Yes No*
Increase federal funding for a national public system of
Early Learning & Child Care No Yes Yes Yes
Commit to increase social housing & increase funding
by $2 B/year No Partial Yes Yes
Raise the federal minimum wage to $10/hour No No Yes No*
Restore eligibility for Employment Insurance No No Yes Yes
Increase funding for post-secondary education No Partial Partial Yes

Figure 13.4: Union Density, Collective Agreement Coverage
and Child Poverty, Early 00's (coverage rates) and Late 90's
(poverty rates)
Union and Bargaining
Coverage
100
90
80
70
60
50
40
30
20
10
0
Denmark
Finland
Norway
Sweden
92.5
81
4.2
Switzerland
Belgium
Luxembourg
Netherlands
Germany
Austria
Spain
Portugal
Italy
14.9
28
32
Australia
Canada
United Kingdom
New Zealand
USA
13 14
Union Density Collective Bargaining Coverage Child Poverty Rate
21.9
25
20
15
10
5
0
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.

Reducing Health Inequalities
We consider that without a shift of
resources to the less well off, both in
and out of work, little will be
accomplished in terms of a reduction of
health inequalities by interventions
addressing particular downstream’
influences.
-- Report of the Acheson Independent Inquiry
into Inequalities in Health 1998 p 33

The Story Behind the Story III
How does the political economy of a
society shape our understandings and
actions on the determinants of heath?

What is the Central Institution in
Canadian Society?
• The state?
•The market?
• The family?

Source: Saint-Arnaud, S., & Bernard, P. (2003). Convergence or resilience? A
hierarchial cluster analysis of the welfare regimes in advanced countries. Current
Sociology, 51(5), 499-527.

Esping-Andersen Typology of
Welfare States I
• Social Democratic (e.g., Sweden, Norway, Denmark,
Finland), Liberal (UK, USA, Canada, Australia), and
Conservative (Germany, France, Italy, Portugal)
welfare states form a continuum of government
support to citizens.
• These supports range from high government
intervention welfare systems in the Social Democratic
countries to residual welfare systems as seen in
Liberal political economies.
• Conservative nations (e.g., Germany, France, Italy fall
midway in their provisions.
• Source: Esping-Andersen, G. (1999). Social Foundations of
Post-Industrial Economies. New York: Oxford University Press.

Esping-Andersen Typology of
Welfare States II
• The Liberal welfare state sees means-tested
assistance, modest universal transfers, and modest
social-insurance plans.
• Means-testing refers to benefits in the Liberal welfare
state being primarily geared to low-income groups.
• Social assistance is limited by traditional, liberal workethic
attitudes that stigmatize the needy and attribute
failure to individual, rather than, societal failures.
• Liberal nations limit welfare benefits since it is
believed generous benefits lead to a preference for
welfare dependency rather than gainful employment.
• Source: Esping-Andersen, G. (1999). Social Foundations of Post-
Industrial Economies. New York: Oxford University Press.

Anglo-Saxon Liberal Regimes
• Anglo-Saxon liberal political economies had the
lowest health care expenditures and the lowest
coverage by public medical care.
• Had greater incidence of low wage earnings,
higher income inequalities, and the highest poverty
rates.
• These economies derived the greatest proportion
of income from capital investment rather than
wages.
• These economies had the lowest improvement
rates in infant mortality rates from 1960 to1996.
• Source: Navarro, V., & Shi, L. (2002). The Political Context of Social Inequalities and
Health. In V. Navarro (Ed.), The Political Economy of Social Inequalities: Consequences
for Health and Quality of Life. Amityville, NY: Baywood

Figure 12.4: Public Expenditure on Old Age as % of GDP, 2001
0 5 10 15
Greece
Switzerland
Germany
Italy
Austria
France
Sweden
Belgium
Poland
Denmark
Spain
UK
Hungary
Finland
Portugal
Luxembourg
Mexico
Japan
Norway
Slovak
Czech Republic
Netherlands
Iceland
USA
Turkey
Canada
New Zealand
Australia
Ireland
Korea
1.2
2.7
5.5
5.3
5.1
4.8
4.7
4.7
9.2
8.7
8.5
8.3
8.3
8.1
8.0
7.9
7.9
7.5
7.4
7.3
6.8
6.7
6.7
6.4
12.7
11.8
11.7
11.3
10.7
10.6

Figure 12.5: Public Expenditure on Incapacity-Related Benefits
as % of GDP, 2001
0 1 2 3 4 5 6
Poland
Sweden
Norway
Netherlands
Denmark
Finland
Switzerland
Luxembourg
Belgium
Czech
New Zealand
Iceland
Hungary
Austria
UK
Portugal
Spain
Slovak
Germany
Australia
France
Italy
Greece
Ireland
USA
Canada
Japan
Korea
Turkey
0.8
0.7
0.5
0.4
1.4
1.1
1.8
3.3
3.0
2.8
2.8
2.7
2.5
2.5
2.5
2.4
2.3
2.3
2.3
2.1
2.1
4.1
3.9
3.9
3.8
3.6
4.8
5.2
5.5

Figure 12.6: Public Expenditure on Family as % of GDP, 2001
0 1 2 3 4
Denmark
Luxembourg
Norway
Finland
Austria
Sweden
Australia
France
Iceland
Hungary
Belgium
UK
New Zealand
Germany
Greece
Ireland
Czech Republic
Slovak
Switzerland
Portugal
Netherlands
Turkey
Italy
Poland
Canada
Japan
Spain
USA
Mexico
0.6
0.5
0.4
0.3
1.2
1.2
1.1
1.1
1.0
0.9
0.9
1.9
1.8
1.6
1.6
1.5
2.6
2.5
2.3
2.2
2.2
3.2
3.0
2.9
2.9
2.8
2.8
3.4
3.8

Educate

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?
Rudolph Virchow, 1821-1902

Motivate

Activate

Figure 13.3: Policy Priorities of Canadian Food Banks
Increase Social Assistance Benefits
Raise the Minimum Wage
Facilitate Affordable Rental Housing
Improve Rates and Access to EI
Increase Disability Supports
Improve Income Supports for Seniors
Expand Job Training Opportunities
Provide Affordable Childcare
Increase National Child Benefit
Lower Tuition, Increase Student Grants
Other Policies
Expand Settlement Services
0 10 20 30 40 50 60 70 80
Percentage of Food Banks Recommending Action

Figure 13.4: Union Density, Collective Agreement Coverage
and Child Poverty, Early 00's (coverage rates) and Late 90's
(poverty rates)
Union and Bargaining
Coverage
100
90
80
70
60
50
40
30
20
10
0
Denmark
Finland
Norway
Sweden
Switzerland
Belgium
Luxembourg
Netherlands
Germany
Austria
Spain
Portugal
Italy
Australia
Canada
United Kingdom
New Zealand
USA
Union Density Collective Bargaining Coverage Child Poverty Rate
13 14
21.9
25
20
15
10
5
0
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.

Resources
• Canadian Centre for Policy Alternatives
• Centre for Social Justice
• Canadian Council on Social Development
• Campaign 2000
• National Council of Welfare
• Canadian Labour Congress
• National Anti-Poverty Coalition
• Caledon Institute
• Canadian Policy Research Networks
• Public Health Agency – Health Canada

A Canada with Scandinavian-Style
Equality is Achievable
• It’s not as if we need to obliterate capitalism. Properly
regulated, taxed, and forced to operate in the public
interest, business firms can fit constructively into a just
society. The wealth that their workers produce can be
more fairly distributed.
• This is evident in several parts of Europe, notably in the
Scandinavian nations, where capitalism still thrives.
Norway, Sweden, Denmark, and Finland may not have
developed idyllic societies -- but their economies are far
more equitable than Canada’s and far less blighted by
poverty, hunger, and homelessness.
• Business firms operate freely and profitably in these
countries, but under constraints that make them good
corporate citizens…
• Source: Ed Finn, CCPA Monitor, March 1, 2006.

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

Table 1. Federal Party Positions on Issues Identified by Campaign 2000 as Essential to Eliminating
Child Poverty
“Yes” indicates party position meets Campaign 2000 policy recommendation
“Partial” indicates party position partially meets Campaign 2000 policy recommendation
“No” indicates party makes no commitment that meets Campaign 2000 policy recommendation
ISSUE CPC LIB NDP BLOC
Increase Canada Child Tax Benefit to $4,900/child
by 2007 & end clawback from families on social assistance No No Yes No*
Commit to key principles (quality, universal, accessible
& developmental programming) for child care system No Yes Yes No*
Introduce legislation to secure early learning & child care
as permanent social program No No Yes No*
Increase federal funding for a national public system of
Early Learning & Child Care No Yes Yes Yes
Commit to increase social housing & increase funding
by $2 B/year No Partial Yes Yes
Raise the federal minimum wage to $10/hour No No Yes No*
Restore eligibility for Employment Insurance No No Yes Yes
Increase funding for post-secondary education No Partial Partial Yes

The Best Hope
• The best means therefore of promoting health and
improving population health involves Canadians – and
others -- being informed about the political and
economic forces that shape the health of a society.
Once so empowered, they can consider political and
other means of influencing these forces.
• Health promoters and population health researchers
need to “get political” and recognize the importance of
political and social action in support of health.
• This seems a rather daunting task, but one that hold
the best hope of promoting the health of citizens in
Canada and elsewhere (Bryant, Raphael, & Rioux,
2006).

And, finally…

And I always thought: the
very simplest words
Must be enough. When I
say what things are like
Everyone's heart must be
torn to shreds.
That you'll go down if you
don't stand up for yourself
Surely you see that.
Bertolt Brecht, 1898-1956. And I Always Thought.

Dennis Raphael
draphael@yorku.ca
This presentation and other presentations
and related papers are available at:
http://www.atkinson.yorku.ca/draphael