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6. PATHWAYS LINKING CHRONIC DISEASE AND INEQUITY
Key Message: Pathways that lead from inequity to chronic disease are multiple and interdependent.
As we have seen, the factors that influence health are many and complex. Social and economic factors may affect health outcomes through several different mechanisms or pathways. Researchers most often refer to these main processes as materialist, psychosocial, and political/economic pathways. Although direct cause and effect are difficult to establish, correlation between the pathways and population health is clear.
For example, poorer people have higher rates of cardiovascular disease, with one recent study attributing 6,366 Canadian heart disease deaths a year to poverty and nearly $4 billion a year in health care costs to poverty-related heart disease. There is less agreement on how these conditions translate into specific chronic diseases or on the most appropriate interventions.
Researchers observe that material deprivation, social and psychological factors, risk behaviours, and health outcomes are linked and interdependent. They observe that health inequalities result from an accumulation of factors that cluster together. Poverty may reflect an under-investment in social and economic infrastructure. Poverty leads to lack of resources such as access to education, recreation, and employment, which in turn, may lead to a breakdown and fragmentation in the social and economic fabric of society. These social and economic disadvantages include unhealthy child development, disparities in economic development, unemployment, crime, violence, psychological factors such as depression and stress, and a general sense of social and economic exclusion.
Social and economic inequities, in turn, have biological consequences such as lowering immune functions. They increase the prevalence of health risks and unhealthy behaviours like smoking, alcohol and drug abuse, poor diet, and lack of physical exercise that are often precursors of chronic disease. The bi-directional relationship between inequity and disease is demonstrated by the fact that ill health and disability themselves may cause poverty. The disability generated by disease may inhibit employment prospects and deepen poverty, vulnerability, and exclusion. However, while this may often be the case, empirical investigations have not found bi-directionality functioning as a major determining factor in the relationship between inequity and disease. At the same time, intervening social variables like strong social networks and supports also may mitigate some negative impacts of adverse economic circumstances.
The political/economic pathway looks more deeply at the root causes of material and psychosocial inequities and their implications for health. Recently, researchers have suggested that in order to understand these deeper root causes, societal structures, systems, and policies must be analyzed. This includes re-examining various market economies, globalization, and issues of the welfare state that could lead to poverty and chronic disease. Shared social values, as well as historical, cultural, economic, and political structures can profoundly affect the creation of poverty and inequity and determine which groups are disproportionately afflicted. Studies have found evidence that higher levels of social spending are associated with greater life expectancy. This includes investing in structural factors such as education, transportation, affordable housing, libraries, affordable recreational facilities, parks, and uplifting the physical surroundings in neighbourhoods.
Following is a brief description of the materialist, psychosocial, and political/economic pathways. An understanding of these pathways is essential to determining where strategies might intervene and be most effective. Existing data sets do not allow a linking of macro-economic shifts with health outcomes; therefore, we must rely here on more conventional indicators and statistics such as unemployment rates and incidence of low income to assess the likely relationships between inequity and disease in Atlantic Canada.
6.1 MATERIALIST PATHWAY
6.1.1 Poverty and access to resources
The materialist explanation focuses on the ways that social and economic inequities deprive disadvantaged groups of the material necessities for health. It points to ways in which poverty reduces access to the basic resources necessary for good health, including the lack of basic necessities such as food, clean water, shelter, and clothing, as well as lack of opportunities for education, livelihood, transportation, and recreation. There is evidence internationally that higher levels of social spending are associated with greater life expectancy.
The largest body of empirical evidence on equity and disease refers to the influence of poverty and income inequities on health. Low-income Canadians are more likely to have poor health status and to die earlier than other Canadians. Canadians in the lowest-income households are four times more likely to report fair or poor health than those in the highest-income households, and they are twice as likely to have a long-term activity limitation.
A review by the Canadian Heart Health Inequalities Project of studies on health status by income level found that the lowest-income Canadians had almost eight fewer years of life expectancy and significantly more disability than higher-income persons. Canadian men in the lowest 5% of incomes were twice as likely to die before the age of 70 than men in the top 5%. Raphael found that income differences account for 23.7% excess in premature deaths prior to age 75 among Canadians due to cardiovascular disease.
A 10-year study of people living with HIV/AIDS in Vancouver found that low socioeconomic status prior to infection was associated with disease progression and survival chances. Another Vancouver study showed that those engaging in high-risk behaviours had lower incomes than those not taking risks.
In 1999, the San Francisco Department of Public Health analyzed the impact of increasing the living wage to see how this would improve health and increase the educational achievement of children. The health impact showed that a minimum wage of $11 per hour predicted decreases in the risk of premature death for adults aged 24 to 44 by 5%. For the children of these workers, the living wage predicted a 34% increase in high school graduation.
Food insecurity is a problem among those with low income as evidenced seen by a growing use of food banks and child feeding programs. Food insecurity is defined as “the inability to acquire or consume an adequate diet quality or sufficient quantity of food in socially acceptable ways, or the uncertainty that one will be able to do so.” A recent study looked at food insecurity and hunger of 141 low-income single mothers with children in Atlantic Canada. It found that 96.5% of the families experienced food insecurity during the year of the study. Of the families in this sample, 87% were dependent on social assistance.
The above study adds to a growing body of research that suggests that welfare benefits in the Atlantic provinces are not sufficient for families to purchase basic necessities. Many studies use Statistic’s Canada's Low-income Cut Offs (LICOs) as a measure of poverty. The LICOs represent the amount of money a family needs for food, clothing, and shelter. In 2000, the year of the above study, social assistance benefits for a single parent with one child were 72% of the LICOs in Newfoundland and Labrador, 64% in Nova Scotia and New Brunswick, and 63% in Prince Edward Island. Nine health regions in Atlantic Canada had significantly higher proportions of economic families living below the low-income cut-off level in 1996 than the Canadian average. These included three of Newfoundland and Labrador’s five rural health regions and all four rural health regions in New Brunswick. In Nova Scotia, only Cape Breton (NS5) had a higher proportion of economic families living below the low-income cut-off than the national average. Among Atlantic Canada’s 21 health regions, Newfoundland and Labrador’s western region (NF4) had the highest rate of low income in 1996, at 23.2% (Figure 14).
Figure 14. Atlantic regions with higher rates of low income among economic families than the national average, 1996, (%)
Source: Statistics Canada, 1996 Census, 20% sample.
Opportunities for physical activity may also be restricted in low-income communities where residents do not feel safe walking in their neighbourhoods or cannot afford to take advantage of recreational facilities.
6.1.2 Employment
There is much evidence to show that unemployment has detrimental effects on the mental, physical, and social well-being of individuals as well as their families and communities. A study of unemployment and health attributable to the East Coast fishery closures found that the unemployed had very high levels of stress, a predictor of chronic disease. Unemployed people tend to have poorer health than those who are employed. According to Statistics Canada, “unemployed people suffer a disproportionate share of health problems, such as depression, morbidity and reduced life expectancy.” A study in Newfoundland and Labrador found that 67% of HIV-positive persons were unemployed, and 62% had an income less than $15,000 per year.
Marie Jahoda’s seminal study of the 1930s’ depression showed that employment provides far more than income. The following quote from Jahoda illustrates an interconnection between the materialist pathway and the psychosocial pathway described in the next section:
Employment makes the following categories of experience inevitable: it imposes a time structure on the waking day; it compels contacts and shared experiences with others outside the nuclear family; it demonstrates that there are goals and purposes which are beyond the scope of an individual but require a collectivity; it imposes status and social identity through the division of labour in modern employment; it enforces activity.
Conversely, Jahoda demonstrated that unemployment damages mental health because of the psychological deprivation and lack of psychological supports.
The Canadian Institute for Health Information, at its National Consensus Conference on Population Health Indicators, confirmed youth unemployment as a key determinant of health. Unemployment here only refers to those actively looking for work and excludes full-time students. Every year since 1997, unemployment rates have been more than twice as high for those under 25 as for those aged 25 and over. In 2001, 12.8% of Canadian youth were unemployed, compared to 6.1% of those 25 and over. In sum, there is an age inequity here that is concealed by the composite employment statistics.
All four Atlantic provinces have higher rates of unemployment than the Canadian average (7.2% in 2001): 16.1% in Newfoundland and Labrador, 11.9% in Prince Edward Island, 9.7% in Nova Scotia, and 11.2% in New Brunswick. But these provincial averages again mask sharp intra-provincial differences. With a few exceptions, like industrial Cape Breton’s high unemployment rate and the low unemployment rate in Nova Scotia’s Annapolis Valley, the disparities largely follow an urban-rural split. For example, rural Prince Edward Island has 15% unemployment, compared to 9% in Charlottetown and Summerside. Unemployment in St. John’s is 9.4% while rural Newfoundland and Labrador has unemployment rates in excess of 20%. In Nova Scotia, unemployment in Cape Breton as a whole (18.6%) and in Sydney (19.1%) is 2.5 times higher than in Halifax (7.1%) and the Annapolis Valley (7.5%). Halifax actually has a lower unemployment rate than the Canadian average.
Youth unemployment rates in Atlantic Canada are higher: 24.7% in Newfoundland and Labrador, 17.7% in Nova Scotia, 17.2% in New Brunswick, and 16.3% in Prince Edward Island. It is not surprising that the 1994/95 National Population Health Survey found the highest rates of depression and poor psychological well-being among youth, with mental well-being increasing with age. Remarkably, this is a reversal from the patterns of a generation ago, when seniors were more likely than younger Canadians to be depressed. The fact that low-income rates among the elderly have fallen by half since 1980, while poverty and unemployment among youth have increased sharply, may have contributed to this change in mental health status.
Figure 15. Unemployment rates, New Brunswick health regions, 1996 and 2001, (%)
Source: Statistics Canada, Labour Force Survey, special tabulations.
Note: In southern New Brunswick, with its three large urban centres, unemployment rates fell between 1996 and 2001 to below 10%, as they did in most of Canada. In rural and northern New Brunswick, on the other hand, unemployment rates increased during this period, with the Bathurst region recording 18.2% unemployment in 2001.
6.1.3 Education
Educational attainment is positively associated with both economic status and favourable health outcomes. It is also positively associated with self-rated health status and with healthy lifestyles and health behaviours. For example, obesity rates are inversely proportional to educational attainment. In the 1996/97 National Population Health Survey, only 19% of respondents with less than high school education rated their health as “excellent,” compared with almost 30% of university graduates. Self-rated health, in turn, has been shown to be a reliable predictor of health problems and longevity.
Educational attainment has also been reliably linked to health care utilization. George Kephart in Nova Scotia found that those with no high school degree use 49% more physician services than do those with an undergraduate university degree. And those with just a high school diploma use 12% more than those with a university degree. From a health determinants perspective, education is clearly a good investment that can reduce long-term health care costs.
Atlantic Canada’s major urban centres have a comparable or higher rate of high school graduation than the Canadian average, while many rural areas, with smaller towns and villages, have a lower rate. St. John’s (75%), Halifax (75%), and Fredericton (76%) have higher rates of high school completion than the national average (72%). Industrial Cape Breton is an urban exception, with a high school graduation rate of just 60.5%, well below the Canadian average. Nova Scotia’s Annapolis Valley is a rural exception, with the highest post-secondary graduation rate (53.9%) of any rural health district in Atlantic Canada, and higher than the national average for rural areas (51.5%).
Figure 16 indicates regions with a markedly lower proportion of the population aged 25 to 29 having completed high school than the national average. Rural Newfoundland and Labrador and Prince Edward Island, rural Nova Scotia with the exception of the Annapolis Valley, and northern New Brunswick have comparatively low rates of high school completion. Central Newfoundland (52.6%) has a significantly lower rate of high school completion than the national average (71.8%). In Nova Scotia, the southwest region (Yarmouth-Digby) has the lowest rate of high school completion (55.2%) in the province.
Figure 16. Atlantic health regions with below-average rates of high school completion, 1996, (%)
Source: Statistics Canada, 1996 Census, 20% sample.
Halifax (60%), St. John’s (59%), and Charlottetown/Summerside (57%) also have significantly higher proportions of the population with post-secondary degrees than the Canadian average (51.5%), while rural regions (with the notable exception of the Annapolis Valley) generally have proportionately lower rates of post-secondary graduation.
It is beyond the scope of this paper to examine all of the social and economic determinants of health such as housing, transportation, recreation, and so on. However, we briefly will consider environmental factors. These factors, such as exposure to toxins and lack of clean air and pure water, also contribute to chronic disease. Chernomas has examined changes in society since 1900 when communicable diseases, rather than heart disease and cancer, were the leading causes of death. By 1950, cardiovascular disease and cancer accounted for two-thirds of all deaths, and infectious diseases accounted for less than 10%. Chernomas argues that socially and economically determined production and distribution conditions contributed a great deal to this change. He says that mechanization uses more energy and chemicals in production, which has “transformed food, water, air, and the labour process into mediums for heart disease and cancer.”
Chernomas explains that animals are fed food filled with chemicals, including growth hormones and hormones that transform their fat into saturated fat, a major contributor to coronary disease. These artificial carcinogens are everywhere in our society. Chemicals are added to our water, air, food, clothing, furniture, medicine, and so on. People who live in poor circumstances are especially vulnerable to these health risks.
Poor neighbourhoods are often located in toxic, industrial areas, where environmental factors, such as exposure to toxins and lack of clean air and pure water, also constitute pathways to disease. A recent study of cardiovascular disease and cancer mortality in Sydney, Nova Scotia, noted the area’s high historical exposure to pollutants. While not conclusive, the study found evidence that “exposures to carcinogens found in Sydney’s ambient environment may have contributed to increased cancer risk.”
6.2 PSYCHOSOCIAL PATHWAY
To understand why lower-income groups have higher rates of chronic disease and premature death regardless of behavioural risk factors, researchers have examined psychosocial factors as key intervening variables. The epidemiological literature now points convincingly to the strong influence of psychosocial factors on health.
Unlike the materialist pathway, which focuses on the material resources necessary to health, the psychosocial pathway investigates the intermediate social and psychological processes that may be precursors to physical disease. It also takes into account the fact that social and economic inequities can produce mental health problems such as depression, anxiety, uncertainty, insecurity, and lack of connection to others, to meaning in life, or to something larger than oneself.
The psychosocial pathway has been used by researchers to explain how ethnic, racial, or immigrant inequities may have poor health outcomes. It also looks at the effect of chronic stress on disadvantaged groups, such as Aboriginal people, visible minorities, single mothers, children, and youth, who are particularly affected by poverty and other inequities. This pathway also includes consideration of early childhood development, occupational groups at risk, the social advantages of educational attainment, and other societal issues such as crime and violence.
The psychosocial pathway particularly highlights the impacts on health of the chronic stresses produced by disadvantaged life circumstances and so works in conjunction with the materialist pathway. Substantial research has found that stress negatively affects health, weakens the immune system, and increases susceptibility to a wide range of illnesses. Stress is thought to affect health mainly in two ways. First, stress leads to changes in health-related behaviours, such as alcohol and tobacco use, substance abuse, or diet. These behaviours lead to worse health directly, through damage to organs of the body, and indirectly, by making one more susceptible to contracting illnesses. For example, the correlation between high stress and smoking is well documented. Statistics Canada’s National Population Health Survey found that among Canadians reporting very low stress rates, just 21% of women and 27% of men are smokers. Among those reporting high stress rates, 45% of women and 46% of men are smokers, with an almost direct linear relationship between stress level and smoking prevalence for both sexes.
The second way stress affects health is identified in the field of psychoneuroimmunology. This has found direct, measurable links between health and the body’s physiological reactions to stress. Stress triggers the release of steroid hormones responsible for a series of physiological responses, typically labeled the “fight-or-flight” response. They do so, for example, by raising the heart rate, blood pressure, and flow of blood to muscles. When these stress responses are persistent, they can lead to illness or make one more susceptible to illness by limiting production of key immune system cells. Studies have found that stress responses affect processes and functions that can lead to or exacerbate serious illnesses such as heart failure and stroke.
Everyone experiences some level of stress in his or her life. However, the disadvantaged experience more unrelenting and chronic stress. The British Whitehall Study found that all workers had high levels of stress at work. However, when senior administrators went home, their blood pressure dropped. When low-level workers went home, their blood pressure remained elevated. It is this chronic nature of stress that causes consequences to accumulate over time and lead to illness.
Work stress has been particularly identified in many studies as an important predictor of hypertension and coronary heart disease. It may derive from low levels of responsibility, lack of control, non-supportive superiors, time pressures, and/or work overload. In one American study, male workers with the highest levels of job strain were found to have four times the risk of heart attack as those with the lowest levels of strain, indicating a risk level equal to that of smoking and high blood cholesterol.
There is also considerable evidence that lack of social supports can contribute to illness. People who are socially isolated tend to be less healthy and more likely to die prematurely than those who have strong social relationships. Strong social support has also been shown to improve resilience and aid recovery from illness. Conversely, lack of social support from family, friends, and communities is linked to higher rates of cardiovascular disease, premature death, depression, and chronic disability. According to Health Canada:
Families and friends provide needed emotional support in times of stress, and help provide the basic prerequisites of health such as food, housing and clothing. The caring and respect that occur in social networks, as well as the resulting sense of well-being, seem to act as a buffer against social problems. Indeed, some experts in the field believe that the health effect of social relationships may be as important as established risk factors such as smoking and high blood pressure.
Figure 17. Atlantic health districts with a notably higher percentage of the population aged 12 and over with high blood pressure, for both genders, compared to Canada, 2000/01, (%)
Source: Statistics Canada, Canadian Community Health Survey 2000/01, health file, available at www.statcan.ca/english/freepub/82-221-XIE/00502/hlthstatus/conditions2.htm#high (extracted December 30, 2002).
A Montreal-based study concluded that HIV-positive gay men were more able to use safe sex practices when they had social support, belonged to a peer group, and had high self-esteem. The effect of mourning on spouses who had lost their partners was examined in a group of 12,522 pairs between 1964 and 1987. During this period, 1,453 men (12%) and 3,294 women (26%) lost their spouses. Of those, 30% of the bereaved men and 15% of the bereaved women died between 7 and 12 months following their spouse’s death.
Wilkinson observes the deterioration in social relations that occurs when social hierarchy becomes more unequal:
In effect, coping with the social environment has been every bit as taxing as the material environment in human development, and this is why such intensely social risk factors as social affiliation, low social status and emotional development early in life, have been identified by modern epidemiology as key influences on population health in developed societies.
While some of these indicators may be quantified, other researchers have given greater weight to individuals’ subjective experiences of relative deprivation and to the emotional responses that arise when they compare themselves with others in their culture. The comparison itself may not be conscious, but will manifest in stress, hopelessness, anger, and feelings of inadequacy and exclusion, all of which may have health consequences.
Hopelessness has been identified as a strong, independent predictor of cardiovascular disease morbidity and mortality in studies of both American and Finnish populations. Hostility, aggression, cynicism, and isolation have also been related to heart disease risk; suppressed anger has been linked to cancer and high blood pressure; and repressed emotionality has been found to predict both cancer and heart disease. Those emotional states are closely linked to social and economic inequities.
More than one in four Canadians experience “quite a lot” of life stress, with more women experiencing high levels of stress than men (26.8% compared to 25.3%). In the 2000/01 Canadian Community Health Survey, all four Atlantic provinces registered a lower rate of stress than the rest of Canada. As in previous population health surveys, residents of Newfoundland and Labrador in 2000/01 registered the lowest stress levels in the country, with Prince Edward Islanders recording the second-lowest levels.
In 1985 and 1991, there was a clear east-west stress gradient in the country, with higher levels of stress reported in Ontario and the West, and all four Atlantic provinces ranking well below national levels. But throughout the 1990s, both Nova Scotia and New Brunswick gradually moved towards national levels.
But the provincial averages conceal some sharp disparities. Women in Charlottetown and Summerside, for example, have far higher rates of stress than men in those towns. And the proportion of residents experiencing high levels of stress in Cape Breton, the Annapolis Valley, the Sussex/Saint John area in southern New Brunswick, and the Campbellton region in northern New Brunswick approaches national levels. The Edmundston region in western New Brunswick is the only health region in Atlantic Canada that substantially exceeds national stress levels. The lowest levels of stress are in rural Newfoundland and Labrador and Prince Edward Island.
More detailed analysis of specific regions within the Atlantic provinces is needed to determine how both material and psychosocial pathways are contributing to the incidence of communicable, noncommunicable, and mental health chronic diseases.
6.3 POLITICAL/ECONOMIC PATHWAY
The social, economic, and political spheres are interconnected and embedded within each other. A growing body of research now suggests that existing inequities are the result of historical, cultural, economic, and political processes and that these inequities cannot be effectively reduced without understanding their systemic roots. These researchers therefore suggest that broad societal structures including various market economies, globalization, and the welfare state must be analyzed in order to understand the deeper root causes of inequities in health status. According to one analyst:
It is absolutely essential for states and individuals to locate that delicate balance between ... a world of high-tech, instantaneous communication, idolatry of markets and investment and “Darwinian brutality” ... and ... a world with a heartfelt sense of belonging, rootedness, community and identity.
Understanding how the material and psychosocial pathways can lead to chronic disease is necessary in order to develop effective prevention strategies. As we have seen, lack of sufficient resources to lead a healthy life puts especially vulnerable groups at risk for a broad range of chronic diseases – communicable, noncommunicable, and mental. As Lynch points out, material conditions structure day-to-day existence, but political-economic processes determine these conditions. Policies that can generate inequality exist before their effects are felt at the individual level.
The general consensus in the population health literature is that addressing only one risk factor at a time will probably not be effective. Addressing a cluster of risk factors may be more helpful. However, these factors are not root causes. They are inequities that lead to stress and physical and mental suffering and then to ill health and chronic disease. Intervening in the materialist or psychosocial pathway – for example, supporting children’s feeding programs – can be very helpful in relieving that suffering. It might also be an investment in the children’s futures, as well as not letting them go hungry. These types of programs are therefore very useful. However, in order to change child hunger, it is important to relate to its root cause. For example, why do children need a feeding program in the first place? What is causing these children to be hungry? Are existing policies having negative health impacts?
The political/economic pathway suggests that, in order to change an inequitable situation, analysts must examine the processes of exclusion. In addition, it is necessary to look at how those processes work. Coburn argues that population health improvements depend on an understanding of the market-based ideology that underlies the dominant current ideologies. Since social supports are recognized as a key determinant of health, a market ideology that values everyone being independent may adversely affect population health. Researchers observe that incomes are mainly the result of both market-driven distributions and government-sponsored redistributions of income. Therefore, any reduction of inequities depends on active government intervention. According to Coburn:
Degrees of inequality are clearly influenced by international, national and local political policies, which are amenable to change. We can either ignore these processes or seek to understand and begin to change them.
Muntaner and Lynch contend that a society using the market as its primary guide and doctrine creates greater income inequalities, reduces social cohesion, and lowers health status. It has this effect partly through undermining the welfare state, which, in that view, interferes with the normal functioning of the market. However, analysts show that globalization has not decreased poverty. With the rise of globalization, inequality is increasing in most countries but appears to be tempered in countries with stronger welfare policies and less market-oriented systems. Davey Smith points out that:
Cross nationally, higher levels of both social expenditure and taxation as a proportion of gross domestic product are associated with longer life expectancy, lower maternal mortality, and a smaller proportion of low birthweight deliveries.
These and other wide-ranging analyses of the more systemic root causes of chronic disease reveal that Canadians traditionally value cultural diversity, social justice, and the welfare state. They traditionally resist pressures from powerful market economies. Since the mid-1970s, analysts show a change in these guiding values and in actual state practices in Canada. Values have shifted from the notion of shared risk and social rights to the notion of individual risks and responsibilities and consumer rights. That shift may have significant implications for the health of Canadians.
The growing reliance on market mechanisms for employment, redistribution, fiscal management, and privatization has contributed to service reductions in the health sphere and to growing socioeconomic gaps among Canadians. Welfare recipients are seen to be abusing the system, and federal supports are seen as corrupting individual initiative and thus are subject to justifiable cuts. In this view, policies are justified because, by giving the rich more disposable income, particularly through tax cuts and keeping wages for workers low, higher profits and incomes for the wealthy will lead to more investment, better allocation of resources, and therefore more jobs and well-being for everyone. The alternative view is that this redistributed wealth will not go into the local or national economy but to international stock markets.
James Dunn in a recent paper, Are Widening Income Inequalities Making Canada Less Healthy?, warned that if governments do not reinvest in public programs, Canada’s stock of “human capital” and its health will decline. He argues that there is no trade-off between health and economic prosperity and that policies can be framed to improve health and economic productivity at the same time. From that perspective, Dunn recommends policy principles that can be applied to a wide variety of disease prevention and health promotion strategies in many sectors.
As sociologist John Gray says:
It is true that restraints on global free trade may not enhance productivity, but maximum productivity achieved at the cost of social desolation and human misery is an anomalous and dangerous idea.
These ideas are the subject of considerable debate, but have profound implications for social and economic inclusion and equity, and ultimately for health outcomes.
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