OVERVIEW
For most Canadians real income decreased during the 1990s, and by 1996 the level of child poverty had set record levels.1 At the same time the rich got richer,2 the cause of which is not obscure: 'The growing gap between rich and poor has not been ordained by extraterrestrial beings. It has been created by the policies of governments.'3 Are economic inequality and its effects issues to be addressed by public health? Should we '...broaden the parameters of the health policy debate to include economic and social issues'4? My answer is 'yes' to both questions. The economic inequality issue is the focus of my presentation but public health responses to many social issues could be viewed within the framework presented.
The role of public health
I define public health as: The science and art of preventing disease, prolonging life and promoting the health of the population through organized efforts of society. This needs to be explicitly stated because it is easy for us, and the lay public, to think that public health is primarily concerned with what a Toronto health worker calls the 3 R's of Rats, Rabies, and Rubella. With few exceptions, current provincial public health practice pays little attention to economic and social issues.5
The indisputable existence of health inequalities
Evidence of income-related health inequalities in the United Kingdom was highlighted in the Black and the Health Divide Reports.6 In Canada, the most cogent presentation of these effects is the Health of Canada's Children Report7 that documents the profound variation in health and well-being between poor and non-poor children. For a sense of the magnitude of these kinds of effects, Statistics Canada data conservatively attribute 22% of mortality differences among Canadians to income differentials.8
Income-related health inequalities occur for incidence of mortality and morbidity, accidents and injuries, levels of mental health and well-being, school achievement and drop-out, family violence and child abuse. What is the public health explanation and response to these findings?
Much of the public health discourse around health inequalities focuses on health impacts of poverty,9 and indeed, poverty is an important issue in Canada. The National Council on Welfare reported that by 1996, the poverty rate in Canada rose to 17.6%, and child poverty reached a 17-year peak.10 A poverty analysis often leads to a public health focus on needs of 'risk groups' and programs to reach these groups. Programs teach skills and provide information and support to change faulty lifestyles. They may involve home visits, provision of nutrition supplements, or any other resource that the group is seen as lacking. Recent analyses, however, challenge the 'risk group' metaphor. Health inequalities exist across the socioeconomic gradient, not just between poor and non-poor. More importantly, the mechanisms by which these socioeconomic gradients in health occur seem to involve the basic structures and functioning of a society - and population responses to these - not simply that individuals lack resources to be remedied with a health initiative.
In Unhealthy Societies: The Afflictions of Inequality, Wilkinson' brings together work that indicates economic inequality is the major public health issue facing Western nations. In his analysis, increasing economic inequality decreases social cohesion, increases individual malaise, and produces the conditions by which increased mortality and morbidity occur.
Inequality affects everybody, not just the poor
For Wilkinson, economic inequality affects those on the top of the economic ladder as well as those at the bottom. As a society begins to 'disintegrate', a result of increasing polarisation and alienation, there is decline in civil commitment, personal civility, and population health and wellbeing. To illustrate, the well-off increasingly opt out of the public discourse. They send their children to private schools, lobby for two-tiered medical systems, hire security guards for their property; all of which heightens societal disintegration.
Canada's well-off grow wealthier, but become subject to the same threats that the less well-off experience, that is, deteriorating health and educational systems, increased crime and violence, and greater danger on the roads - among others. All of these situations are associated with a lack of personal control, which is an important determinant of health. 12
Public health responses and a proposal for a new public health in Canada Public health responses to issues take three forms.13 In the medical approach, emphasis is on high risk groups, screening of one sort or another, and health care delivery. The behavioural approach focuses on high risk attitudes and behaviours. Programs educate and support individuals to change behaviours. Policies such as tobacco legislation, mandated food labelling and school health programs support these shifts.
The socio-environmental approach integrates the proceeding within a focus on high risk conditions, many of which reflect political decisions made by governments. If we add the premise that a society that tolerates high levels of economic inequality is a highrisk society, we end up with a proposal for public health's role in these and other issues.
Public health should emphasize the 3 P's of Participation, Policy, and Political Action. The three P's were first mentioned to me by a colleague at the Toronto Public Health Department, as her rejoinder to the traditional public health focus upon Rats, Rabies, and Rubella. This insight was her's, the analysis that follows is mine.
Participation
Neighbourhood cohesion and involvement is a determinant of community and personal well-being.14 Cohesion and participation are clearly determinants of health in health promotion theory.15,16 Putnam's17 study on civil society in Italy and Wilkinson's 'Unhealthy Societies'' provide empirical validation of the roles of cohesion and participation in promoting health and well-being. Participation by itself is no solution to faulty government policy-making, but it is a means of ameliorating some of its effects.'16
Public health can support community development and participation by working closely with community organizations and members to promote health. Public health is richly resourced compared to community health centres, recreation centres, and many smaller community agencies. Public health can be a source of information, serve a coordinating function, and when necessary, act as an advocate when the agencies that are so important to community cohesion and participation are threatened by faulty and ill-thought-out government policies.
Policy development and implementation
Governments make decisions that affect the health of citizens. If we define policy as 'a principle or course of action chosen to guide decision-making,'ls public health has a responsibility to develop and advocate for policies that promote health and reduce health inequalities.
Some policies straightforwardly relate to 'lifestyle' aspects such as tobacco regulation, emission controls, and mandated school physical activity, but theory and research suggest broader policies relevant to the health of the population. The Ottawa Charter for Health Promotion19 includes shelter, education, food, and income as basic prerequisites for health. Seedhouse2 sees the foundations of health as meeting basic needs of housing, nutrition, employment, support through the provision of information and education, and the promotion of civic-mindedness.
Some public health authorities act on these issues. The cities of Toronto, Ontario and Birmingham, England have implemented fair hiring policies, as well as policies that recognize the importance of city services, daycare, and supports to community members with ill or disabled relatives.
Political action
Political action does not mean endorsing this or that party, but acting on the recognition that 'the policies, activities, and methods of a government,' that is politics,18 have profound national, provincial, or municipal health effects. This recognition calls for public health to take on an ombudsman role, to be responsible for carrying out and making public 'health impact analyses' of government policies. Most provinces have an ombudsman in regards to government services; public health should take on health analyses of government policies.
Recent Ontario provincial policies that cry out for such health impact analyses include the freezing of social housing construction and ending of rent controls; institution of drug co-payment plans for seniors; a 22% cut in welfare payments combined with massive income tax cuts to the well-off; the attempt, since overturned by the courts, to eliminate pay equity settlements to women in femaledominated service agencies; and proposed legislation that allows privatization of water services.
At the municipal level, health impact analyses could assess the effects of user fees for libraries, recreation and park services, and increases in public transportation fares. Certainly, recent federal changes in transfer grants, unemployment insurance, and pensions could also be the focus of health impact analyses.
CONCLUSION
Based on research on the impact of the broader determinants of health, including economic inequality, on the health of Canadians, there is a need for institutions at the national, provincial, and municipal levels that will:
1. Assure that government and institutional actions are assessed for their impacts on the health of the citizenry (political action);
2. Advise governments and institutions on policies and actions that will enhance the health of the citizenry (policy development); and
3. Support communities and work to enhance community participation and cohesion (participation).
This should be the mandate and role of Public Health.
[Reference]
REFERENCES
[Reference]
1. Statistics Canada. The Daily: 1996 Census, Sources of Income Earnings, and Total Income. Ottawa: Author, May 13, 1998.
2. Statistics Canada. The Daily: Family Incomes, Lower Income Families Lost Ground While Higher Income Families Registered Gains. Ottawa: Author, December 22, 1997.
3. Montague P. Economic inequality and health. Rachel's Environment dr Health Weekly 1996 #497. Annapolis, IN: Environmental Research Foundation. [http://www.monitor.net/rachel/r497.html].
4. Canadian Public Health Association. Health Impacts of Social and Economic Conditions: Implications for Public Policy. Ottawa: Author, 1997.
[Reference]
5. Sutcliffe PA, Deber, R, Pasut G. Public health in Canada: A comparative study. Can J Public Health 1997;88(4): 246-49.
6. Townsend P, Davidson N, Whitehead M (Eds). Inequalities in Health: The Black Report and the Health Divide. New York: Penguin, 1992.
7. Canadian Institute on Children's Health. The Health of Canada's Children: A CICH Profile. Ottawa: Author, 1994.
[Reference]
8. Wilkins R, Adams O, Brancker A. Changes in mortality by income in urban Canada from 1971 to 1986. Health Rep 1989;2:137-74.
9. Reutter L. Poverty and health: Implications for publie health. Can JPublic Health 1995;86(3):149-51.
10. National Council on Welfare. Poverty Profile: 1996. Ottawa: Author, 1998.
11. Wilkinson R. Unhealthy Societies: The Afflictions of Inequality. New York, NY: Routledge, 1996. 12. Wallerstein N. Powerlessness, empowerment, and health: Implications for health promotion programs. Am J Health Prom 1992;6(3):197-205. 13. Labonte R. Health Promotion and Empowerment: Practice Frameworks. Toronto: Centre for Health Promotion and ParticipAction, 1993.
[Reference]
14. Raphael D, Renwick R, Brown I, Rootman I. Quality of life indicators and health: Current status and emerging conceptions. Social Indicators Research 1996;39:65-88.
15. Raeburn J, Rootman I. People-centred Health
Promotion. New York: John Wiley and Sons, 1997. 16. Minkler M. Community Organizing and Community Building for Health. New Brunswick: Rutgers University Press, 1997. 17. Putnam R. Making Democracy Work: Civic Traditions in Modern Italy. Princeton: Princeton University Press, 1993.
[Reference]
18. Webster N. New College Dictionary. Chicago: Consolidated Books, 1990.
19. World Health Organization. Ottawa Charter on Health Promotion. Geneva: Author, 1986. 20. Seedhouse D. Health Promotion: Philosophy, Prejudice, and Practice. New York: Wiley, 1997.
[Author Affiliation]
Associate Professor, Department of Public Health Sciences, University of Toronto
Correspondence: Dr. Dennis Raphael, Department of Public Health Sciences, University of Toronto, McMurrich Building, Toronto, ON, M5S lAB, Tel: 416-978-7567, E-mail: d.raphael@utoronto.ca
