7. DISCUSSION

It is clear from the evidence that the health of populations is dependent on social and economic conditions. A society that has social and economical inclusion has better health than one that excludes large segments of the population from opportunities to lead productive and fulfilling lives. It is also clear from the evidence that social and economic inclusion, in turn, depends on the material well-being of its citizens and on a relatively equitable distribution of resources. Conversely, societies that exclude groups based on income, socioeconomic status, race, or ethnic background are correspondingly more fragmented. They have more crime and violence, higher rates of depression and stress, and are generally less healthy than more equitable societies. As one researcher observes, inequality is not a social and economic investment in growth. Systems that push people down do not value the human talents that can generate a productive economy and result in robust health in the future

The literature recognizes a wide range of pathways between inequity and disease. The effectiveness of any policy will depend on its capacity to identify the optimal points in these processes and pathways where interventions can best reverse the potential for disease onset. As we have seen, pathways to ill health include lack of material resources such as sufficient income, access to education, and employment opportunities; lack of psychosocial supports in the community and workplace; and political and economic policies that increase inequities. While cause and effect relationships are not well understood, sufficient evidence now exists to indicate that these pathways can lead to unhealthy coping behaviours and to chronic disease.

It may appear from the above discussion that much of the evidence relating chronic disease with inequities in Atlantic Canada is negative. However, it must be emphasized here that important successes have already been achieved in this region and that Atlantic Canada has inherent strengths that might help, in part, to reduce the incidence of chronic disease. Research on civic and voluntary work in Atlantic Canada has found strong evidence that social support networks are still more vibrant here than in other parts of the country. The Atlantic Centre of Excellence for Women’s Health has specifically identified support groups in the four Atlantic provinces that are playing a major role in strengthening these community networks.

A report prepared for the Atlantic Centre of Excellence for Women’s Health by GPI Atlantic noted that the strength of family, social, and community supports is also a profound Atlantic region asset that undoubtedly buffers adverse health impacts. These strengths are not measured in our standard economic indicators and are thus always in danger of being neglected and overlooked in the quest for economic growth and material wealth. But there is no doubt that it will serve the region and the health of its population well to nurture, maintain, and strengthen the network of community supports that contributes so much to the quality of life in Atlantic Canada.

The Atlantic region leads the country in high levels of social support. Throughout Canada, and in the four Atlantic provinces, women report higher levels of social support than men. Since 1994, however, Nova Scotians have slipped by comparison with residents of Newfoundland and Labrador and Prince Edward Island in the degree to which they can rely on social supports. In Nova Scotia, the highest levels of social support are in the Pictou-Guysborough-Antigonish-Strait area, with lower levels reported in south and southwest Nova Scotia and in Colchester-Cumberland-East Hants.

In New Brunswick, the Moncton and Miramichi health districts report somewhat lower levels of social support than in the rest of the province. Social support levels are consistently high throughout Newfoundland and Labrador and Prince Edward Island. It has been noted that strong social supports might play an important role in buffering adverse economic conditions, reducing stress, and protecting health in Newfoundland and Labrador. It is recommended that further research explore these strengths in greater depth for their potential to prevent disease throughout Atlantic Canada.

Many healthy city and healthy community projects in various locations have created models of public involvement in policy development. A few of these projects are listed in the Appendix. The People Assessing Their Health (PATH) project helped pioneer this strategy in Atlantic Canada. PATH, which began as a pilot project in three communities in eastern Nova Scotia, was designed to enable more community involvement in decisions regarding health. It created Community Health Impact Assessment Tools (CHIATs) to help community members assess policies and programs in their area for their impact on health. This approach helps ensure that a population health strategy includes the knowledge and wisdom found in local communities. It also acknowledges that participation, empowerment, and capacity building are crucial elements in overcoming health inequities.

Another example of a highly successful initiative is the Community Action Program for Children (CAPC), one of three programs funded by Health Canada (with the Canada Prenatal Nutrition Program and Aboriginal Head Start) to help families improve the health and well-being of children under the age of 6. The CAPC funds local groups within communities to provide services for low-income families, single parents, or isolated families. The programs directly address at least four major determinants of health including healthy child development, personal health practices and social skills, social support networks, and social environment. Over 40 community-based organizations offering CAPC programs are located throughout the Atlantic provinces. Results from one of the largest qualitative research evaluations ever conducted in Canada show that 87% of the parents participating in the CAPC in Atlantic Canada reported a positive change in their lives, and 75% of the children had observable changes in their development.

All four Atlantic provinces have made new commitments to health promotion and chronic disease prevention. Newfoundland and Labrador has initiated a comprehensive Strategic Social Plan to integrate social, economic, and health goals for the first time. Nova Scotia has created a new Office of Health Promotion under the direction of a minister and is in the process of developing a Chronic Disease Prevention Strategy through the Department of Health. New Brunswick’s 2002 report, Health Renewal: A Report from the Premier’s Health Quality Council, recommends a shift from a treatment to a wellness focus in policy and program formation. And Prince Edward Island, as part of the government’s five-year Strategic Plan, has developed a “Wellness Plan,” that acknowledges social determinants of health such as income, education, gender, and early childhood development.

The descriptive data presented in this report can serve as a first step toward understanding specific aspects of inequity in the Atlantic region. The next step is to examine specific high-risk areas in more detail and to tailor policies where needs are greatest. We have long known that national and provincial averages conceal major rural-urban and other intra-provincial differences in health status. Although basic patterns are clear, a deeper analysis of all variables is needed to clarify root causes of chronic diseases. The recently released Canadian Community Health Survey data now enable the correlation of health status and health outcomes at the health district level with census, demographic, and labour force data on income disparity, low income, unemployment, and a wide range of other variables.

7.1 POLICY IMPLICATIONS

Key Message: Social and economic factors are modifiable. Effective strategies must address the root causes of social inequities in society.

The physical and mental, communicable and non-communicable disease patterns in the Atlantic provinces are cause for concern. Coherent and effective strategies to reduce health inequities in Atlantic Canada must be based on an understanding of existing regional inequities, social and economic risk conditions, and particular chronic disease patterns in this region. Such strategies must be specific to the social and economic circumstances and cultural conditions of the Atlantic provinces. Again, the good news is that the detailed intra-provincial data available for the first time in the 2000/01 Canadian Community Health Survey will encourage new research that provides policy makers with the information they need to target interventions where needs are greatest.

Over the years, all levels of government in Canada have adopted a wide range of income, employment, health, education, housing, and social policies designed to alleviate poverty and reduce socioeconomic inequality. While these programs have achieved marginal improvements in many areas, they have had limited success in changing the underlying social and economic inequities and patterns leading to chronic disease in this country. According to one analyst, this is because there has been no integrated, comprehensive agenda and because only a few programs have improved health as their explicit aim.

The current public debate on reforming health care in Canada, for example, overlooks the substantial role that poverty and inequality reduction could potentially play in reducing health care costs. Commissions to examine health and health care have acknowledged the social determinants of health but have not translated this recognition into policy recommendations designed to improve population health.

The next step is to develop coordinated, comprehensive plans for the Atlantic provinces that address all of the social determinants of health and recognize the interactions among them. Fortunately, there are many good local, national, and international examples of societies that have adopted such a comprehensive approach and instituted far-reaching social and economic policies designed to improve population health. The United Kingdom’s Acheson Report and Sweden’s New Public Health Policy, as well as Canadian initiatives like the Newfoundland and Labrador Strategic Social Plan and Quebec’s new anti-poverty law can serve as models for Atlantic Canada. Sweden’s new public health policy, for example, is coordinated by a central body; organized around the social determinants of health rather than health outcomes; focused on wellness rather than disease; aimed to work toward broad, popular support and consensus; and coordinates the entire Swedish governmental policy with a view to improving public health as an explicit national goal.

We have extrapolated some key elements from these models for Health Canada’s Population and Public Health Branch, Atlantic Regional Office, to consider as potential next steps in the development of strategic policies designed to reduce inequities and improve population health in Atlantic Canada. What follows is certainly not an exhaustive list, but it offers some rudiments of a potential framework for forward movement. This framework should include long-, intermediate-, and short-term objectives; the creation of structures and processes to coordinate policy; the development of analytical tools and research priorities; and the involvement of communities in implementing programs and policies.

7.2 RECOMMENDATIONS FOR ACTION

Recommendation 1: New population health strategies must reflect an understanding of the social and economic conditions that support and sustain population health.

The evidence supports the necessity of social and economic inclusion for the well-being and health of the population. This must be the primary goal of any new population health initiative in Atlantic Canada. Strategic investments that result in a more equitable distribution of public and private resources will likely have the most impact on reducing health inequities and improving public health. Strategies should also build on strengths that already exist in Atlantic Canada.

The root causes of inequities and chronic disease must be addressed rather than the more limiting and less effective focus on individual behaviours. Working with individual diseases in isolation ignores their common basis in the social and economic determinants of disease. Future work must be based on a comprehensive framework that integrates the three chronic disease areas – communicable, noncommunicable, and mental health.

Strategies must begin to shift the focus from disease to assets, strengths, health, well-being, and quality of life.

Innovative changes and policies designed to reduce inequities and improve health in this region may reverberate in other parts of the country and beyond. Socioeconomic inequities in health affect every country to varying degrees. Many nations are contemplating solutions and policy interventions, and some are implementing social and economic reforms. All, however, are still looking for answers. It is remarkable that a social and health experiment in a small area of Finland called North Karelia is referenced globally by population health analysts. Just as Nova Scotia has become renowned as a leader in recycling, there is no reason why the Atlantic provinces cannot become known for effective population health policies that address the root social causes of health and illness.

Recommendation 2: New population health strategies must be based on common values and coordinated around a central vision.

The strategies must be guided by commitments to the population health principles of equity, sustainability, and social justice; to a holistic approach; to intersectoral action; to the use of multiple strategies; and to the empowerment and participation of communities and ordinary citizens in improving population health. Modeling the social and economic systems of this region on these values could have a profound effect on the well-being and health of individuals and communities in Atlantic Canada.

Atlantic Canadians have long valued social justice, cultural diversity, civic participation, social equality, fairness, compassion, and social solidarity. For example, in 1998, the New Brunswick government initiated a broad public consultation to discover what the population thought of its social policies. The resulting report, Report on Social Policy Renewal, stated that New Brunswickers recognized that social development and economic development go together. Respondents stated that they:

… would like the two fields to be more integrated, and focus more on improving the quality of life for individuals and families ... The state must develop an approach based on real needs of the population ... If this condition is met, community-based organizations and natural helpers can establish various types of partnerships between the government and the community … To create real partnerships and promote the growth of the social economy, the population should get more involved in developing programs, and the government should support community projects.

Recommendation 3: New population health strategies must include a multilevel and multisectoral approach.

The strategies must aim to incorporate the common values into public policy making at all levels so that a broad social and economic commitment to “healthy public policy” and multisectoral action guides all policy decisions. Working cooperatively is crucial in order to gather collective strength; guide long-term, nonpartisan strategies; define priorities; avoid duplication; and coordinate approaches. The federal government and the provincial governments of Atlantic Canada need to cooperate on their strategies for population health, social justice, and healthy communities. Government accountability must go beyond the four-year agenda mandated by elections and incorporate long-term goals.

Improving population health through the elimination of existing inequities requires a collaborative and coordinated approach on the part of all policy departments, as many potential policies that affect health lie outside the traditional domain of the health sector. Therefore, the health sector should play an influencing, rather than a leading, role. A multisectoral approach will recognize, for example, that macro-economic, taxation, minimum wage, and social assistance policies affect the health of the population. For that reason, Raphael and other researchers point to the importance of actions that raise incomes and access to resources, increase social relationships and supports, decrease chronic stress, and change economic and social policies that undermine health. Dugger recommends that the solution to inequality is “institutional reconstruction” that eliminates the system of inequality, rather than programs that “smooth off the rough edges.” He suggests that understanding inequity begins with the study of social and economic processes and institutions.

In addition to cooperation at the government level, strategies also must involve the professional, business, labour, volunteer, and community sectors in decision making and implementation.

Recommendation 4: New population health strategies must strengthen assessment, data collection, research, and evaluation to measure progress towards greater equity.

Toward these ends the strategies must:

• encourage data collection on population health issues that link health indicators with measures of socioeconomic status, race/ethnicity, and other elements of equity and inequity
• expand health indicators to encompass the full range of social and economic determinants of health
• encourage participatory, action-oriented, qualitative research
• involve community in setting indicators and research agendas
• develop an Atlantic Canada Research Strategy that will avoid duplication, gather and coordinate existing knowledge, and focus on cooperation, rather than competition, among research groups
• evaluate what has been successful and support these initiatives on a long-term basis
• develop mechanisms to translate knowledge into policy.

It will be difficult to make genuine progress towards greater social and economic equity and improved population health while these issues are invisible in the core measures of progress used to assess social and economic well-being and prosperity. Current measures, based on economic growth statistics, assess how much production and income are generated but provide no information on how that income is distributed or shared. While the Gross Domestic Product statistics are released monthly, Statistics Canada provides information on the income gap much less frequently, with the latest available statistics generally three years old.

If equity, and its impact on population health, is to assume its rightful place on the policy agenda, then it must be measured and reported regularly as part of our core measures of progress in order to assess whether inequities are growing or narrowing. Income gaps can be measured both by quintiles and using the GINI coefficient, with information provided on regional and local inequities, including changes over time. The gender wage gap can also be monitored, along with specific information on the status of vulnerable and marginalized groups. Statistics on assets and debts can similarly measure changes in wealth distribution. A first step in this direction is the more frequent provision of data on equity by Statistics Canada.

Recommendation 5: New population health strategies must give extra help to vulnerable groups and regions with the greatest needs, taking care to avoid creating further stigma and discrimination.

Inequity issues are societal issues and are not limited to issues of different groups. Therefore, strategies that relate to the root causes of disparity will have the most beneficial effect. However, since vulnerable groups and regions suffer directly from inequities, they need special interventions. It is important to recognize and respect the inherent wisdom and value to society within these groups and regions and to avoid considering them as “problems.” In developing strategies, capacity must be developed so that vulnerable groups, regions, and communities can identify and determine their own needs and solutions, which the government can then support.

In particular, regional policy interventions can be targeted where needs are greatest, such as in Cape Breton, northern New Brunswick, Labrador, rural areas, and African-Canadian and Aboriginal communities, where current inequities produce particularly adverse health outcomes. Intra-provincial comparisons within Atlantic Canada demonstrate quite clearly that poor health outcomes tend to be clustered in particular geographical areas. Cape Breton and the Campbellton area in northern New Brunswick, for example, have lower average incomes, higher rates of unemployment, higher proportions of single mothers, higher rates of low income, and poorer health status than Halifax or Fredericton.

On the other hand, simplistic generalizations on income and health will miss key patterns in the relationship between inequity and disease. Labrador, for example, overall exhibits the anomaly of relatively high incomes, low rates of low income, and few single mothers. Yet, it has the lowest life expectancy of any region in Atlantic Canada – an outcome that may be related to its high proportion of Aboriginal people. The island of Newfoundland has the lowest average incomes and the highest rates of unemployment in the country, but, as we have seen, has low stress and high rates of mental well-being, self-rated health, and functional health – outcomes that may be related to strong social networks. It is essential to study the effect of intervening social and economic variables in deepening or mitigating inequities and adverse economic circumstances.

In some cases, this health region analysis may lead to very specific policy interventions. Cape Breton and western Newfoundland, for example, have the lowest rates of mammogram screening in Atlantic Canada and also the highest breast cancer mortality. Practical health policies that seek to reduce inequities can use this sub-provincial information to target interventions that reduce such health risks and improve access to essential preventive services. Where deeper systemic disadvantages are revealed, as in Labrador and northern New Brunswick, for example, more far-reaching, coordinated, multisectoral, economic, and social policy initiatives will be needed to narrow the gap and improve the health profiles of these disadvantaged regions.

The Atlantic provinces can take concerted action to reduce low-income rates among single mothers, Aboriginal people, the disabled, and other vulnerable groups. It has been done before in Canada. In the early 1980s, low-income rates among the elderly were unacceptably high. Concerted social action succeeded in cutting low-income rates among Canadian seniors from 34% in 1980 to 19% in 1997, and from 31% to 15% among Atlantic Canadian seniors during the same period. Low-income rates among Canadian seniors have fallen further in recent years and are now 9.5% for elderly women and 4.4% for elderly men. If low-income rates can be deliberately and successfully reduced for such a large demographic group, then there is no obstacle to reducing low-income rates among other vulnerable groups with similar determination and success.

Dramatic improvements demonstrated in the psychological well-being and rates of depression among seniors demonstrate the health impacts of such action. Higher rates of youth poverty have correspondingly shifted the profile of poor psychological well-being to younger groups. Actions such as those described above can therefore be based on successful models already developed. They can highlight and reduce inequities in a targeted way, improve the health of Atlantic Canadians, and create a working model for other jurisdictions in Canada and beyond.

7.3 SPECIFIC PUBLIC POLICY INITIATIVES

Beyond the coordinated and comprehensive population health strategies described above, it is also possible to take very specific and innovative policy initiatives that can reduce inequities and improve population health. A few suggestions are provided here. Specific strategies can be initiated at the federal, provincial, municipal, and community levels and can work within and across jurisdictions.

7.3.1 Federal level

The federal government, for example, can:

• Engage researchers, policy makers, and nongovernmental organizations in areas both within and outside the traditional health field, such as economics, environment, urban and rural development, labour, and other disciplines to examine the role played by social and economic factors in creating health and well-being in the population.
• Play a role creating background papers with the long-term view of developing major policy papers such as the United Kingdom’s Independent Inquiry Into Inequalities in Health, and Minnesota’s A Call to Action: Advancing Health for All Through Social and Economic Change. These papers can also address key areas outside the traditional health sphere to examine how agriculture, workplace structures, urban and rural renewal, housing, economic policies, and other areas influence health.
• Identify and research specific processes and policies from countries and areas that have coordinated strategies in place, e.g., United Kingdom, Sweden, and Minnesota.
• Encourage research into the effects that systemic structures have on food, air, water, labour, and other processes underlying inequities and health. Recent federal changes in transfer grants, employment insurance, and pensions could also be the focus of health impact analyses.”
• Create intersectoral fora for dialogue to discover how each sector influences and affects the others.
• Influence a shift in focus from an almost exclusive preoccupation with illness and lack of health, where mortality and morbidity statistics have conventionally been used in health research, to a greater emphasis on research into the determinants of positive health and well-being.

7.3.2 Provincial level

Provincial governments, for example, can:

• Analyze and create briefs on the impact of local policies and power structures upon health and social and economic inclusion. For example, policies reducing social assistance rates, eliminating new social housing and rent control, and providing transfers of money from the poor to the wealthy through income tax reductions can be examined for their health effects.
• Identify and look specifically at existing policies designed to help people move out of poverty, meet basic needs, and elevate their standard of living.
• Identify and look specifically at existing policies designed to help people move out of poverty, meet basic needs, and elevate their standard of living.
• Develop cost-specific information on particular issues, such as how much affordable housing is needed and how much money must be allocated to this area.
• Identify geographical areas that have particular strengths (to serve as local models and best practices) and areas that have particular inequities.
• Develop preliminary socioeconomic and health profiles of these areas in order to understand both the existing assets and the root causes of difficulties. This would involve looking specifically at factors such as local environment, income, career opportunities, employment, school effectiveness, community assets, social supports, and other determinants of health at the community level and seeing how these factors influence health and inclusion.
• Specifically identify ongoing and previously successful programs in the region that can be encouraged and supported.
• Build and strengthen the capacity of institutions and the public to identify and address population health issues. This can encourage joint action on the ground that can provide practical input and increased debate in policy discussions.
• Explore modes of civic engagement, provide tools and resources to identify and address population health issues at the community level, research community-based innovations designed to increase self-reliance, bring together interests, and help initiate dialogues to improve community health.

7.3.3 Municipal level

Municipalities, for example, can:

• Create health impact analyses, for example, to assess the effects of user fees for libraries, recreation and park services, and increases in public transportation fares.
• Bring together leaders in different municipal departments whose resources can quickly be deployed to improve population health. One example of this intersectoral approach is the way a depressed neighbourhood in San Francisco worked quickly to decrease inequities. A neighbourhood forum identified major chronic health issues, including exposures to chemicals and indoor mould, lack of access to affordable and healthy foods, and violence. To deal with some of these issues, the local transit authority created a shuttle bus between the neighbourhood and grocery stores; the parks department published a guide to recreational services specifically oriented to the neighbourhood; and the city improved key services such as street lighting, city-sponsored cheque cashing, areas for community gardens, “green” school yards, and so on.
• Involve specific community groups. For example, in the same San Francisco neighbourhood cited above, a youth group, ENVISION Youth, was inspired to research barriers to accessing healthy food in its neighbourhood. The group surveyed corner stores, researched supermarket and food production practices and the role of fast food establishments in school and hospital economics, conducted healthy snack taste tests, held community meetings to share its research findings, and developed strategies to influence storeowners to stock fresh food and local producers to create farmers’ markets.

7.3.4 Community health board level

Community health boards, for example, can:

• Create local target areas as pilot projects that have the potential to expand to other local areas. For example, the United Kingdom has created “Health Action Zones” (HAZs), and areas in the United States have created “Environmental Justice Neighbourhoods” (San Francisco). These are pilot programs for community renewal.
• Develop tools and processes for working with geographical and/or vulnerable groups to improve community health. Existing local examples include the community-based work of the Population and Public Health Branch, Atlantic Regional Office, Health Canada; the Coastal Communities Network; the Halifax Inner City Initiative; the Community GPI Atlantic projects in Glace Bay and Kings County, Nova Scotia; the Atlantic Centre of Excellence for Women’s Health; and the Atlantic Health Promotion Research Centre.
• Conduct rapid health impact assessments (HIAs) on particular issues of importance to the community. For example, an HIA might examine whether a carpet-free policy in public housing would improve indoor air quality and health or it might examine the likely effect of proposed zoning or other policy changes on health.
• Conduct community fora to identify what the community wants to do, what it needs in terms of information and research, and what resources are needed to improve community health and well-being. These fora can also identify community assets and strengths.
• Evaluate programs for potential use in other areas of the region.

In sum, the complex problem of reducing social and economic inequities in order to reduce chronic disease, whether communicable, noncommunicable, or involving mental health issues, requires complex solutions. These solutions need to be coordinated and involve all parties working together toward common goals based on common values. It is possible to work together to create a physically, mentally, socially, and economically healthy society. And by working together, it is possible to create a society that is uplifting, sustainable, and inspiring for future generations.

[Previous] [Table of Contents] [Next]

"Our mission is to promote and protect the health of Canadians through leadership, partnership, innovation and action in public health."

Important Notices