5. CULTURAL, SOCIAL, AND ECONOMIC CONTEXT

Key Message: Inequities in society affect the whole population, not just the poor.

5.1 CULTURAL AND SOCIAL CONTEXT

Evidence from literally hundreds of studies confirms that social and economic conditions are root causes of communicable, noncommunicable, and mental diseases. Atlantic Canada has seen the demise or decline of several key industries associated with the “old economy” (e.g., mining, steel making, logging, and fishing) and is therefore in the midst of major societal shifts that are likely to impact health in significant ways. These changes currently manifest in sharp intra-provincial differences. For example, Cape Breton has suffered from the loss of key industries like mining and fishing resulting in unemployment and deepening poverty. While the pathways between these macro-economic changes and health outcomes are not well understood, results from the 2000/01 Canadian Community Health Survey show, as we have seen, that Cape Bretoners have generally poor health and currently live more years with disabilities than residents of any of the other 138 health districts in Canada, while the health profile of Halifax in many ways more closely resembles that of central Canada.

In the past 25 years, Atlantic Canada has seen rapid and dramatic economic and social changes, which could have direct and indirect health impacts. For example:

• The dismantling of trade barriers in an increasingly competitive global economy has had domestic impacts on firm structure, real wages, income disparities, work hours, the environment, and other health determinants.
• An economy based increasingly on knowledge and information, rather than plant and equipment, has affected educational and health disparities.
• Unbridled energy and natural resource consumption has had impacts on climate, fish stocks, forests, farmland, and water resources that were unanticipated 25 years ago.
• The shift from family farms and local food sources to industrial agriculture, highly processed foods, and long-distance transportation of food may have affected the nutritional value of food and produced unintended health impacts.
• Women have doubled their employment and labour force participation rates, with impacts on gender roles, children, family structure, increased unpaid work, time stress rates, and free time.
• An era of increasing social spending, taxation, and government deficits has been replaced by fiscal restraint, government surpluses, and tax cuts that have affected family well-being as well as access to health services and social supports.

The Atlantic provinces reflect trends affecting contemporary culture worldwide. However, as Conrad and Hiller suggest:

While reform, retrenchment, and restructuring have been the mantra of the new world order, Atlantic Canada has embraced them more out of necessity than conviction. Few can dispute that the dismantling of the interventionist state has taken a heavy toll in a region where private institutions are ill positioned to take up the slack. Toll highways, home-based care, food banks, call centres, and corporate sponsorship of education and research may represent a brave new world to those converted to the religion of the marketplace, but many Atlantic Canadians regret the abandonment of the noble dream that made human welfare rather than corporate profits the measure of a civil society.

The impact of these changes on health is not yet well understood. In fact, there has been frank acknowledgement on the part of many researchers of the inadequacy of knowledge about the nature of the changes themselves and particularly about the reasons for the increasing co-variance of income, education, age, and other factors with health status.

5.2 IMPORTANCE OF GEOGRAPHICAL AREA

There is evidence that “place,” with its particular regional, historical, and cultural factors, may influence the health of the entire population despite individual incomes. The fact that geographic locations influence health is well established in the research. This research often assumes that areas differ because of the characteristics of the individuals who live there. However, research is now looking at how the context of place also affects health. A new groundbreaking textbook, Neighborhoods and Health, demonstrates how the physical and social characteristics of a neighbourhood shape the health of its residents. Research has linked neighbourhood characteristics with mortality rates, general physical health, and psychological well-being, even after controlling for individual risk factors and income. Noting that multiple dimensions of poor health cluster in disadvantaged neighbourhoods, it asks: What is it about these neighbourhoods, above and beyond the attributes of individuals who live there, that might contribute to health outcomes?

Recently, this line of inquiry has broadened to include the health of the entire population living in generally disadvantaged regions. With few exceptions, studies find that individual health is associated with community socioeconomic level over and above individual socioeconomic position. Although effects are most pronounced for the poor, individuals at all income levels living in poor communities tend to have worse health than those living in areas with higher overall income. For example, one study in England found that both low- and high-income people living in deprived wards tended to have poor health. It also found, however, that in less deprived wards, the socioeconomic disparities in health were greater. That is, those with higher incomes had better health than those with lower incomes. Another study, examining ages 30 to 64 in a mixed economic area, found worse health associated with individuals with household incomes of less than $15,000. However, those in the $15,000 to $49,000 range also had adverse health effects. The study did not find adverse health effects for individuals with family incomes over $50,000.

The research implies that there are things about areas themselves that are important to the health of their residents. Explanations for these observations include social and economic factors such as levels of poverty, income distribution, racial segregation, social networks, and social and political organization. Other hypotheses include aspects of the physical environment such as air and water quality and housing conditions. We will look at some of these explanations in the next section.

Understanding the specific contextual factors in particular areas is a first step in discovering the root causes of chronic disease. In turn, this understanding can have implications for disease prevention and health policy. As Diez Roux points out:

Neighborhood differences are not “naturally” determined but rather result from social and economic processes influenced by specific policies. As such, they are eminently modifiable and susceptible to intervention. In addition, the improvement of neighborhood environments is likely to have a multitude of benefits for people and society as a whole.

As a whole, the Atlantic provinces are poorer than the rest of Canada, which may contribute to the elevated levels of some chronic diseases in the region. In fact, the regional disparity is widening. In 1990, for example, the average Nova Scotia and Newfoundland and Labrador household had 82 cents in disposable income for every $1 in Ontario. By 1998, the average disposable income had dropped sharply to 73 cents in Nova Scotia and 72 cents in Newfoundland and Labrador, for every $1 in Ontario.

The wealth gap between rich and poor provinces has also widened in the last 20 years, with the Atlantic region registering declining shares of national wealth. In 1984, the four Atlantic provinces together had 5.4% of the nation’s wealth. By 1999, they had just 4.4%, despite having 7.6% of households in the country. In 1984, average personal wealth in Atlantic Canada was 61.6% of that in Ontario. In 1999, it was just 52.8% of that in Ontario. Today, the average wealth (assets minus debts) in Atlantic Canada is less than half that in British Columbia and about 56% of that in Ontario (Figure 12).

Figure 12. Average wealth of households by region, 1999, (1999 constant $)

Source: Statistics Canada, Survey of Financial Security, cited in Kerstetter, Rags and Riches.

Note: The Prairies here include Alberta, which has considerably higher average wealth than Manitoba or Saskatchewan, and is therefore also listed separately.

5.3 INCOME DISTRIBUTION

The way income is distributed within society affects the society as a whole. In fact, a growing body of evidence indicates that the distribution of income in a society may be an important determinant of population health. The income difference, between rich and poor, male and female, Atlantic Canadians and other Canadians, and among regions within the Atlantic provinces, can signal inequities in economic status that, in turn, impact health. Poorer regions within Canada and within provinces, as we have seen, have poorer health. Statistical evidence further indicates that inequalities in health have grown in parallel with inequalities in income and that relative economic disadvantage has negative health implications.

According to the editor of the British Medical Journal:

What matters in determining mortality and health in a society is less the overall wealth of the society and more how evenly wealth is distributed. The more equally wealth is distributed, the better the health of that society.

Studies have found that some wealthy countries, like the United States, which have a large gap between the incomes of the rich and the poor, also have lower levels of health than less wealthy but more egalitarian societies like the Nordic countries. Research has found that in the United States, mortality attributable to income inequality equals the combined total mortality from lung cancer, HIV/AIDS, unintentional injuries, diabetes, suicide, and homicide.

People live longer and have better health not in the wealthiest countries, but in countries such as Japan and Sweden, where income inequality is the smallest. Societies with a smaller gap between the rich and the poor also have lower rates of unemployment, less crime, improved education and living standards, and a more inclusive society. They also spend less on health care per capita and more on social infrastructure.

Researchers have pointed out that Canadians should take this as a warning. In Canada, the gap between the rich and the poor has been widening despite strong economic growth as measured by the Gross Domestic Product (GDP). In 1973, the top 10 % of Canadian families earned an average market income 21 times higher than those at the bottom 10 %. By 1996, that figure had risen to 314 times higher. In 1999, the wealthiest 10% held 53% of all personal wealth in the country.

In the 1990s, the real incomes of poor and middle-income Canadians, including those in Atlantic Canada, fell sharply, while those of the wealthiest 20% increased. In Atlantic Canada, the richest 10% of households now owns 49% of the region’s wealth. The richer 50% of Atlantic households controls 92.2% of the region’s wealth, leaving 7.8% for the poorer 50%. A higher percentage of Atlantic households (7.8%) have negative wealth, or debts that exceed assets, than in any other region.

The provincial statistics also conceal marked income disparities within each of the Atlantic provinces. According to the 1996 Census, average incomes in the Halifax region were almost as high as in Canada (98% of the Canadian average) but were more than $6,000 or 34% higher than in Cape Breton. Similarly, incomes in St. John’s were about $5,000 higher than in the rest of Newfoundland and Labrador, and in southern New Brunswick they were similarly higher than in northern New Brunswick. This income disparity has detrimental consequences for the society as a whole.

The distribution of wealth in Prince Edward Island is different from that in the other Atlantic provinces in that nearly 40% of all assets on the Island is tied up in equity in a business. This compares to just 9.4% in Newfoundland and Labrador, 9.1% in Nova Scotia, and 21.5% in New Brunswick. As a percentage of all households, more than twice as many Islanders have equity in a business (23.3%), as in the other Atlantic provinces (12% in Newfoundland and Labrador, 11% in Nova Scotia, and 11.5% in New Brunswick). While data from Statistics Canada’s Survey of Financial Security are not available to explain this disparity, it seems likely that a significant percentage of Prince Edward Island family units have their wealth tied up in family farms and related businesses.

Figure 13. Average wealth by decile, Atlantic Canada, 1999, ($)

Source: Statistics Canada, Survey of Financial Security, cited in Kerstetter, Rags and Riches.

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