2/28/2002: Re: PROCOR:An article from the BMJ (http://bmj.com)
The emphasis on diet and lifestyle is heart disease is misguided and not
supported by the evidence. The following paper discusses what happens
when
public health services the interests of the elite rather than thoses we
are professing to help. The references are embeded in the text.
Dr. Dennis Raphael
**************************
Public Health Units and Poverty in Ontario: Part of the Solution or Part
of the Problem?
Dennis Raphael
School of Health Policy and Management
York University
Toronto, Canada
Material in this paper was presented at the All-Members Meeting of the
Association of Local Health Authorities, February 1, 2002, Toronto,
Ontario.
Correspondence to: Dr. Dennis Raphael,
School of Health Policy and Management,
Atkinson Faculty of Liberal and Professional Studies,
York University, 4700 Keele Street,
Toronto, Ontario M3J 1P3
Tel: (416) 736-2100, ext. 22134
e-mail: draphael@yorku.ca
Abstract
Despite Canada's extensive reputation as a leader in health promotion
and population health concepts, public health practice remains wedded to
downstream
approaches to addressing health issues. The example of heart health
initiatives in Ontario is used to illustrate how public health units
usually limit their
activities to downstream, lifestyle approaches. This occurs though
there is limited evidence that these approaches are effective and
increasing suggestions
that these approaches serve to harm health by diverting attention away
from societal determinants of health. These practices may result from
the lack of appropriate theory for considering contextual factors that
affect health. It more likely results from an adherence to government
imposed ideological concepts of the nature of health and illness. These
neo-liberal and neo-conservative ideologies frame health as an
individual responsibility and deny the health threatening effects of
governments' regressive social and economic policies.
Public Health Units and Poverty in Ontario: Part of the Solution or Part
of the Problem?
Overview
This paper considers the role public health units in Ontario -- Canada's
largest province --play in addressing poverty as a determinant of
health. These activities are considered in light of the history of
Canadian policy statements on poverty and health and current knowledge
about the relationship between poverty and health. I focus on heart
health issues and initiatives undertaken by Ontario public health units
for a number of reasons. First, I recently worked with a local heart
health network to address the role poverty plays in the incidence of
heart disease. Second, heart health is an important focus of provincial
and local public health efforts in Ontario. Third, I believe that heart
health activities illustrate the disconnect between what is known about
the causes of many public health problems and the activities of many
public health units in Ontario. The analysis and conclusions in this
paper probably have wide applicability to public health practice across
Canada and in many other nations. This would especially be the case in
the United States where health promotion is clearly defined as involving
lifestyle approaches to
promoting health.
Heart health initiatives in Ontario are consistent with the downstream
emphasis towards poverty-related health issues of public health units
across Canada. There is little evidence of the long-term effectiveness
of such efforts and these approaches have unintended side effects that
work against health. The questions raised by my analysis are AWhy does
public health in Ontario focus on downstream activities to the exclusion
of more broadly based upstream concerns? What are the effects upon
policy makers, the media, and the public's understandings of the causes
of illness in Canada of this emphasis?
The reasons for public health' s neglect of upstream issues are
considered. Is it due to the lack of appropriate theory for considering
the role these issues play in health? or Is it that public health has no
alternative but to promulgate ideological views of the causes of illness
advanced by their political masters? Examples of public health units
that identify poverty as an issue to be addressed by policy makers and
the public are provided. Means by which public health units could
address poverty-related issues at their source rather than continuing to
focus on Apicking up the health-related pieces in local communities are
outlined.
Canadian Policy Statements on Income and Health Canada has been seen as
a world leader in the development of health promotion and population
health concepts.. Restrepo, H. E. (1996). introduction. In Health
Promotion: An Anthology, pp. ix-xi. Washington DC: Pan American Health
Organization. These concepts expanded the meaning of health and
suggested new ways of thinking about public policy in support of health.
Ideas about reducing health inequalities, empowering individuals and
communities, and building healthy cities and communities were introduced
by, or quickly made their way into Federal and Provincial policy
documents.. Pinder, L. (1994). The Federal Role in Health Promotion:
Art of the Possible. In A. Pederson, M. O Neill. & I. Rootman (eds.)
Health Promotion in Canada: Provincial, National and International
Perspectives, pp. 92-106. Toronto: W.B. Saunders. Health Canada's
Population Health website provides these key Federal documents.. Health
Canada (2001). The Population Health Approach. Ottawa: Health Canada.
On line at http://www.hc-sc.gc.ca/hppb/phdd/resources/ Poverty has been
identified as a key determinant of health in many of these federal and
provincial statements.. Hamilton, N. & Bhatti, T. (1996). Population
Health Promotion: An Integrated Model of Population Health and Health
Promotion. Ottawa: Health Promotion Development Division, Health
Canada. On-line at http://www.hc-sc.gc.ca/main/hppb/phdd/resource.htm .
Health Canada. (1998).
Taking Action on Population Health: A Position Paper for Health
Promotion and Programs Branch Staff. Ottawa: Health Canada. On-line at
http://www.hc-sc.gc.ca/main/hppb/phdd/resource.htm. . Government of
Ontario. (1994). Wealth and Health, Health and Wealth. Toronto: Queens
Printer for Ontario.
Similarly, Canadian Public Health Association policy statements stress
the importance of various societal determinants of health, including
income..Canadian Public Health Association (2001). CPHA Policy
Statements. Ottawa: CPHA. On line at
http://www.cpha.ca/english/policy/pstatem/polstate.htm. Most recently,
the association passed an action plan to address the incidence of
poverty and its impacts on health.. Canadian Public Health Association.
Reducing Poverty and Its Negative Effects on Health. Resolution Passed
at the 2000 CPHA Annual Meeting, Ottawa. On line at
http://www.cpha.ca/english/policy/resolu/2000s/2000/page2.htm. Canadian
concepts have influenced health policy thinking in Europe, and more
recently, provided US health workers with ideas for improving the health
of Americans.. Auerbach, J.A., Krimgold, B., & Lefkowitz, B. (2000).
Improving Health: It Doesn't Take a
Revolution, Washington, DC: National Policy Association. . Raphael, D.
& Bryant, T. (in press). The Limitations of Population Health as a
Model for a
New Public Health. Health Promotion International. . Minnesota
Department of Health (2001). A Call to Action: Advancing Health for All
Through Social and
Economic Change. St. Paul, MN: Minnesota Department of Health. On line
at http://www.health.state.mn.us/divs/chs/hsd/action.pdf
A summary of government and association positions on poverty and health
are available.. Raphael, D. (in press). Canadian Policy Statements on
Income and Health:Sound and Fury --Signifying Nothing. Canadian Review
of Social Policy.
Poverty and Health
The effects of poverty on health have been known since the 19th
century..Sram, I. & Ashton, J. (1998). Millenium Report to Sir Edwin
Chadwick. British
Medical Journal, 317, 592-596. More recently, interest in the issue was
spurred by the publication in the UK of the Black and the Health Divide
reports.. Black,
D. & Smith, C. (1982). The Black report. Reprinted in P. Townsend, N.
Davidson, & M. Whitehead (Eds) (1992). Inequalities in Health: the
Black Report
and the Health Divide. New York: Penguin. . Townsend, P., Davidson, N.,
& Whitehead, M. (Eds) (1992). Inequalities in health: the Black report
and the health divide. New York: Penguin. These reports documented how
those in the lowest employment groups showed a greater likelihood of
suffering and dying from
a wide range of diseases at every stage of the life cycle. In the USA,
similar documentation is now available of the higher incidence among
lower-income
Americans of a range of illnesses.. US Department of Health and Human
Services (1998). Health, United States, 1998: Socioeconomic status and
health chartbook . On-line at
http://www.cdc.gov/nchs/products/pubs/pubd/hus/2010/98chtbk.htm.
Within Canada, individuals living within the poorest 20% of
neighbourhoods are more likely to die from cancers, heart disease,
diabetes, and respiratory diseases among others than the more well-off..
Wilkins, R., Adams, O., & Brancker, A. (1989).
Changes in mortality by income in urban Canada from 1971 to 1986. Health
Reports, 1 (2), 137-174. In Canada, data on individuals' social status
are not routinely collected at death, so researchers use residence
census tracts to estimate income level. Even with the inevitable
slippage that occurs since some poor people live in well-off
neighbourhoods and vice-versa, it is conservatively estimated that 22%
of premature years of life lost to Canada can be attributed to income
differences. This health cost to Canada of income-related health
inequalities is close to the total impact of heart diseases or cancers.
Health and well-being differences between poor and not-poor Canadian
children are seen in the incidence of illness and death from disease,
hospital stays, accidental injuries, mental health and well-being,
school achievement and drop-out, family violence and child abuse, among
others.. Canadian Institute on
Children's Health (1994). The Health of Canada's Children: A CICH
Profile. Ottawa: Author. . Canadian Institute on Children's Health
(2001). The Health of
Canada's Children: A CICH Profile, 2nd edition. Ottawa: Author. In
fact, poor children show higher incidences of just about any
health-related problem,
however defined.
How can poverty-related health differences be explained? While a variety
of explanations have been advanced, material deprivation arguments
provide the best explanation for understanding the health effects of
poverty.14 . Shaw, M., Dorling, D., Gordon, D. & Davey Smith, G. The
Widening Gap: Health Inequalities
and Policy in Britain. Bristol UK: The Policy Press, 1999. .Pantazis,
C., and Gordon, D., editors. Tackling Inequalities: Where Are We Now and
What Can Be
Done? Bristol UK: Policy Press, 2000. . Gordon, D., Shaw, M., Dorling.,
D., and Davey Smith, G. Inequalities in Health: The Evidence Presented
to the
Independent Inquiry into Inequalities in Health. Bristol UK: The Policy
Press, 1999. . Leon, D. & Walt, G. (eds.) (2001). Poverty, Inequality
and Health: An international perspective. New York: Oxford University
Press.
Material deprivation refers to individuals' exposures to both beneficial
and damaging aspects of the physical world.. Lynch, J. W., Davey Smith,
G., Kaplan, G.A., & House, J. S. (2000). Income inequality and
mortality: importance to health of
individual income, psychosocial environment, or material conditions,.
British
Medical Journal, 320, 1220-1204. Individuals experiencing material
deprivation
have greater exposures to negative events such as hunger and lack of
quality
food, poor quality of housing, inadequate clothing, and poor
environmental
conditions at home and work. In addition, these individuals have less
exposures
to positive resources such as education, books, newspapers, attendance
at
cultural events, opportunities for recreation and other leisure
activities, and
involvement in other stimulating activities that contribute to human
development
and health over the life span.
Associated with material deprivation is the experience of excessive
psychosocial stress. Numerous models have been advanced to explain the
pathways
by which the experience of material deprivation becomes converted into
illness
and disease. These models are especially relevant for understanding how
the
experience of poverty leads to the development of heart disease..
Brunner, E. &
Marmot, M. (1999).Social Organization, Stress, and Health. In M.G.
Marmot & R.G.
Wilkinson (eds.). Social Determinants of Health. Oxford: Oxford
University
Press. . Jarvis, M.J. & Wardle, J. (1999). Social Patterning of
Individual
Health Behaviours: The Case of Cigarette Smoking, In M.G. Marmot & R.G.
Wilkinson (eds.). Social Determinants of Health. Oxford: Oxford
University
Press. . Stansfeld, S. A. & Marmot, M. (2002). Stress and the Heart:
Psychosocial Pathways to Coronary Heart Disease. London UK: BMJ Books.
Concerning the number of children and families experiencing
material
deprivation, there are no shortage of reports and studies that document
the
deteriorating social environment in Ontario during the past decade..
Golden, A.
(1999). Taking Responsibility for Homelessness: An Action Plan for
Toronto.
Toronto: City of Toronto.
. Federation of Canadian Municipalities (2001). Second Report: Quality
of Life
In Canadian Communities. Ottawa: Federation of Canadian Municipalities.
.
Ontario Non-Profit Housing Association & Co-operative Housing Federation
of
Canada (2001). Where=s Home? 2000 Update. Toronto: Ontario Non-Profit
Housing
Association & Co-operative Housing Federation of Canada. . Daily Bread
Food Bank
and North York Harvest (2001). Who=s Hungry Now? Food Recipient
Profiles, 1995,
2000, 2001. Toronto: Daily Bread Food Bank and North York Harvest. .
Raphael,
D., Brown, I., & Bryant, B. et al. (2001). How government policy
decisions
affect seniors= quality of life: findings from a participatory policy
study
carried out in Toronto, Canada, Canadian Journal of Public Health, 92,
190-195..
. Raphael, D., Brown, I., & Wheeler, J. (2000). A City for All Ages:
Fact Or
Fiction? Effects of Government Policy Decisions on Toronto Seniors=
Quality of
Life. Toronto: Centre for Health Promotion, University of Toronto, 2000.
On line
at http://www.utoronto.ca/seniors. . Ontario Campaign 2000 (2001). Child
Poverty
in Ontario: Report Card 2000. Toronto: Ontario Campaign 2000. On-line
at
http://www.campaign2000.ca. Relevant indicators include the explosive
growth in
numbers of children and families living in poverty, living as homeless
or
home-insecure, and using food bank use or other emergency food
supplies. Before
considering public health responses to this policy environment, I
examine a
common public health activity, promoting heart health.
The Case of Heart Disease: Poverty Swamps Lifestyle Effects
At the conclusion of a public presentation I made on the health
related
effects of increasing poverty and income inequality, a Toronto public
health
nurse asked: ADid you know that many of the slides that show
income-related
health effects were about heart disease?@ I learned that the Ontario
Ministry of
Health and Long-Term Care had allocated $17,000,000 over five years to
address
the Arisk factors@ of inactivity, diet, and tobacco use. In response,
heart
health networks had sprung up across the province to promote lifestyle
changes
among residents.
Many workers however, were concluding these efforts were
inadequately
addressing the role societal factors play in the incidence of heart
disease and
were most probably ineffective in supporting and promoting health among
those
most at risk. I was asked to work with a local network to review what
was known
about the causes of heart disease and the means of reducing its
incidence. The
perception of these workers was consistent with the current research
literature.
The results of this collaboration, the report Inequality is Bad of
Our
Hearts: Why Low Income and Social Exclusion are Major Causes of Heart
Disease in
Canada . Raphael, D. (2001). Inequality is Bad for Our Hearts: Why Low
Income
and Social Exclusion Are Major Causes of Heart Disease in Canada.
Toronto:
North York Heart Health Network. concluded that medical and lifestyle
factors
accounted for rather small amounts of variation in the incidence of
cardiovascular disease among Canadians.. Marmot MG, Rose G, Shipley M,
&
Hamilton PJS. Employment Grade and Coronary Heart Disease in British
Civil
Servants. Journal of Epidemiology and Community Health, 1978, 32,
244-249. .
Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, & Chen JJ,
Socioeconomic Factors, Health Behaviors, and Mortality. JAMA, 1998, 279,
1703-1708. . Feldman JJ, Makuc DM, Kleinman JC, & Cornoni-Huntley J.
National
Trends in Educational Differentials in Mortality. American Journal of
Epidemiology, 1989, 129, 919-933. Additionally, cardiovascular disease
was
found to be the illness most associated with poverty among Canadians..
Statistics Canada (2001). Estimates of Premature Deaths (Prior to Age
75) Due to
Cardiovascular Disease Among Canadians. Ottawa: Statistics Canada
Special
Tabulation Of 1996 Mortality by Neighbourhood Income Data for Urban
Canada.
Concerning explanatory mechanisms, it concluded that material
deprivation,
excessive psychosocial stress, and the adoption of unhealthy behaviours
associated with living in poverty created cardiovascular risk burdens
that
accumulated across the life span.. Barker DJ, Osmond C, & Simmonds M.
Weight in
Infancy and Death from Ischemic Heart Disease. Lancet, 1989, 2,
577-580. .
Forsen T, Erikson JG, Tuomilehto J, Osmond C, & Barker DJ. Growth in
Utero and
During Childhood Among Women Who Develop Coronary Heart Disease:
Longitudinal
Study. BMJ, 1999, 319, 1403-1407. . Eriksson JG, Forsen T, Tuomoilehto
J,
Winter PD, Osmond C, & Barker DJ. Catch-up Growth in Childhood and Death
from
Coronary Heart Disease: Longitudinal Study. BMJ,1999, 318, 427-431.
. Eriksson JG, Forsen T, Tuomilehto J, Osmond C & Barker DJ Early
Growth and
Coronary Heart Disease in Later Life: Longitudinal Study. BMJ, 2001,
322,
949-953. And one=s situation during early childhood was especially
important in
predicting the onset of cardiovascular disease. Not only did the
experience of
poverty itself swamp the effects of biomedical and lifestyle factors as
precursors of heart disease, these biomedical and lifestyle factors were
themselves determined by the experience of living in poverty.
These findings were considered in relation to the adverse childhood
and
adult circumstances that are becoming increasingly common among Ontario
families. It was concluded that many current federal, provincial, and
municipal
economic and social policies were a prescription for poor cardiovascular
health
and that attempts to modify lifestyles were unlikely to offset the
negative
health effects resulting from such policy changes. Indeed,
cardiovascular
disease was seen as the ideal example of a disease where material
conditions
were determinants of its incidence.. Davey Smith, G., Grunnell, D., &
Ben-Shlomo, Y. (2001). Life-cpurse approaches to socio-economic
differentials
in cause-specific adult mortality. In Leon, D. & Walt, G. (eds.)
(2001).
Poverty, Inequality and Health: An International perspective. New York:
Oxford
University Press. . Davey Smith, G., Ben-Shlomo, Y., & Lynch, J. (2002).
Life
course approaches to inequalities in coronary heart disease risk. In
Stansfeld,
S. A. & Marmot, M. (2002). Stress and the Heart: Psychosocial Pathways
to
Coronary Heart Disease. London UK: BMJ Books. Numerous policy options
for
addressing these threats to cardiovascular health were presented.
The Case of Heart Disease: Public Health in Action
In contrast to the evidence implicating the important role social
and
economic policies play in influencing heart health, current activities
of heart
health networks across Ontario conform closely to the Ministry-imposed
mandate
of promoting physical activity, healthy diet, and reducing tobacco use.
A few
networks include issues of stress and stressful environments. This
limited
mandate has been enthusiastically picked up by Ontario=s public health
units.
Since the program's inception, public health and community partners
have
been working together in 37 health unit areas across the province
to
promote healthy living, provide behaviour change opportunities,
build
supportive environments and influence healthy policy. The current
Ontario
Heart Health Program (OHHP) structure facilitates an impressive
return for
investment by leveraging involvement of community partners and by
reducing
the burden of illness and treatment costs for chronic disease. The
OHHP
currently offers approximately 500 activities across Ontario..
Uetrect, C.
(Nov. 21, 2001). Concern about Termination of Ontario Heart Health
Program.
Letter to The Honourable Tony Clement, Minister of Health and Long
Term
Care. Toronto: Ontario Public Health Association.
Despite this optimistic statement, there is no evidence available
concerning the effectiveness of the Ontario programs. From other sources
however, doubts concerning these kind of lifestyle approaches= general
ineffectiveness in improving heart health among those most at risk is
accumulating.. O=Loughlin, J.L., Paradis, G., Gray-Donald, K., & Renaud,
L.(1999).The Impact of a Community-based Heart Disease Prevention
Program in a
Low Income, Inner City Neighbourhood. American Journal of Public Health,
89,
1819-1826. . Fitzpatrick, M. (2001). The Tyranny of Health: Doctors
and the
Regulation of Lifestyle. London: Routledge. Additionally, one outcome
of these
activities B though perhaps not an intended one -- has been to
completely
remove from the public consciousness any awareness that societal factors
such as
poverty play important roles in the development of heart and other
diseases. The
pervasiveness of this public blind spot concerning the societal
determinants of
heart disease was seen in a recent survey of Hamilton, Ontario
residents. When
asked an open-ended question about the causes of heart disease and
provided with
the opportunity to give up to seven responses, only one respondent of
601
identified poverty as a cause of heart disease.. Paisley, J., Midgett,
C.,
Brunetti, G., & Tomasik, H. (2001). Heart Health Hamilton-Wentworth
Survey:
Programming Implications. Canadian Journal of Public Health, 92,
443-447.
Public Health in Canada: Poverty as a Downstream Issue
The public health downstream emphasis apparent in Ontario heart
health
initiatives is consistent with recent reviews of public health practice
across
Canada. One review found AMany provinces had no evidence of mandated
programs
that were explicitly health focussed, that addressed broader
determinants of
health, or used multiple strategies.@. Sutcliffe, P., Deber, R. & Pasut,
G.
(1997). Public Health in Canada: A Comparative Study. Canadian Journal
of Public
Health, 88, 246-249., p. 247 Reasons given by informants for this lack
of focus
included a lack of political commitment and the failure to allocate
resources to
population health issues.
An extensive survey of public health units across Canada found that
half of
98 responding health regions did not have any initiatives addressing
poverty
issues. And among those that did, virtually all were dealing with the
consequences of poverty rather than addressing its causes.
The vast majority of these initiatives focus on the consequences
that
poverty has for individuals and their families...The findings from
this
study suggest that health sector initiatives that address and
attempt to
change the social, economic, and economic conditions within which
poverty
is rooted are very rare.. Williamson, D. (2001). The Role of the
Heath
Sector in Addressing Poverty. Canadian Journal of Public Health,
92,
178-183.,p.182
Working Downstream: Effectiveness
The emphasis on explaining poor health as a function of unhealthy
behaviours resulting from individual choice and exhorting individuals B
especially those on low income B to give up these behaviours is clearly
an
ineffective approach. First, behavioural factors account for a small
proportion
of the likelihood of developing a number of diseases as compared to
societal
factors such as poverty. Second, it adopts a Ablaming the victim@
approach
whereby those with disadvantage are blamed for their own illness when
the
factors responsible their illness are beyond their control. Third,
emphasis on
risk behaviours fails to address underlying issues of why disadvantaged
people
adopt these behaviours. Fourth, from an effectiveness standpoint: It
[individual choice approach] has also been signally unsuccessful in
leading to
the development of effective interventions to achieve behaviour change
in
disadvantaged groups. 56,p.241
An intensive heart health project in a low income neighbourhood in
Montreal
confirms the ineffectiveness and indeed, irrelevance, of downstream,
lifestyle
approaches in low income, high stress communities.47 The
ineffectiveness of
downstream approaches is not limited to heart health issues. An
intensive
prenatal nutrition program in a lower income area of Montreal found that
while
the health of expectant mothers improved as a result of nutrition
supplements
and counselling, there was no impact on incidence of low birth-weight
newborns..
CBC News On Line (2002). Premature Birth Rates a Mystery: Quebec Study.
On line
at
http://cbc.ca/cgi-bin/templates/view.cgi?category=Canada&story=/news/200
1/08/17/babies_010817
Williamson=s comments on the effects of adownstream emphasis of public
health
seems increasingly accurate:
While these initiatives likely play an important role in reducing
the
negative effects that poverty has on health, they do little to
alter the
socioeconomic and political conditions that contribute to the
poverty
experienced by Canadians. Until these broad structural conditions
are
addressed and altered, efforts to improve the health of Canadians
will be
limited. . Williamson, D. L. & Green, L. W. (1999). The role of the
health
sector in addressing poverty as a determinant of health. Poster
Presentation at the Annual Meeting of the Canadian Public Health
Association. Winnipeg, June.
Working Downstream: Unintended Effects
Critical explorations of the unintended effects of health promotion
programs have raised profound questions about the unintended effects of
downstream approaches to public health issues.. Nettleton, S. & Bunton,
R.
(1995). Sociological critiques of health promotion. In R. Bunton, S.
Nettleton,
& R. Burrows (eds.) The Sociology of Health Promotion: Criticval
Analyses of
Consumption, Lifestyle and Risk. New York: Routledge. . Bunton, R.,
Nettleton, N. & Burrows, R. (eds.) (1995). The Sociology of Health
Promotion:
Criticval Analyses of Consumption, Lifestyle and Risk. New York:
Routledge. In
the breakfast program area, it has been suggested that these programs
foster
material dependency and lead to stigmatization of poor children and
families.
It may well also be that these programs perpetuate inequalities rather
than
serving to reduce them.. McIntyre, L., Travers, K., & Dayle, J. (1999).
Children=s feeding programs in Atlantic Canada: Reducing or reproducing
inequities? Canadian Journal of Public Health, 90, 196-201
. Hay, D. (2000). School-Based Feeding Programs: A Good Choice for
Children?
Victoria BC: Information Partnership.
Another consideration is the extent to which downstream approaches
focussed
on lifestyle change foster the ideology of neo-liberalism and
neo-conservatism
in an age of economic globalization. There is now an increasing
literature that
considers why lifestyle programs such as the ones associated with the
Ontario
heart health initiatives are so popular among neo-liberal and
neo-conservative
governments, and the agencies they fund.. Nettleton, S. (1997).
Surveillance,
health promotion and the formation of a risk identity. In M. Sidell, L.
Jones,
J. Katz, & A. Peberdy (eds.) Debates and Dilemmas in Promoting Health,
pp.
314-324. London UK: Open University Press.
Governments advancing such activities can be seen as supporting
health
among citizens at the same time as they weaken the societal structures
that much
more profoundly affect health. The point is succinctly made by
Fitzpatrick in
relation to health promotion initiatives in the UK, but can equally
apply to the
present Ontario provincial government.
In the harsh world of politics, New Labour=s slavish devotion to...
fiscal
rectitude and electoral expediency mean that it has no intention,
either of
raising benefits to the poor, or of doing anything to reduce income
differentials... Under the banner of health inequalities New Labour
has
turned health promotion into a sophisticated instrument for the
regulation,
not only of individual behaviour, but that of whole communities..
Fitzpatrick, M. (2001). The Tyranny of Health: Doctors and the
Regulation
of Lifestyle. London: Routledge. ,p.
What does it mean to say that lifestyle-oriented approaches to
health
promotion are about the control of individuals and communities? It means
that
lifestyle approaches to health promotion serve the interests of the
established
and powerful by defining illness as resulting from individual lifestyle
choices.
Such a view diverts attention from government policies that weaken the
structures that support citizens= health and ends up blaming the victims
of
government policies -- because of their >poor lifestyles= -- for their
own
health misfortunes. The study cited earlier of Hamilton residents=
understandings of the causes of heart disease illustrates this view.
What are low income residents of Hamilton, Ontario -- and
elsewhere -- to
make of the greater incidence of heart disease and other health
misfortunes
among their low income neighbours, friends, and relatives than that seen
among
their more well-off neighbours? Research evidence indicates that the
greater
incidence of disease should be attributed to their lower income status
which in
most cases results from factors outside their personal control. But the
ideology of individualism promulgated by the government and its public
health
agents -- and clearly internalized by respondents -- lead them to blame
themselves for their higher incidence of disease and illness,
subsequently
relieving government policy makers from taking responsibility for their
health
threatening policies. In Ontario, this has involved reducing social
assistance
benefits, eliminating new social housing, and transferring wealth from
the poor
to the wealthy through income tax reduction for the well-off, among
other
policies.
This process is especially insidious in light of the limited
evidence that
these lifestyle choices -- especially physical inactivity and diet --
are major
causes of illness and disease. Essentially, individuals and communities
encountering health difficulties as a result of governmental policies
are doubly
damaged. First, they expe
supported by the evidence. The following paper discusses what happens
when
public health services the interests of the elite rather than thoses we
are professing to help. The references are embeded in the text.
Dr. Dennis Raphael
**************************
Public Health Units and Poverty in Ontario: Part of the Solution or Part
of the Problem?
Dennis Raphael
School of Health Policy and Management
York University
Toronto, Canada
Material in this paper was presented at the All-Members Meeting of the
Association of Local Health Authorities, February 1, 2002, Toronto,
Ontario.
Correspondence to: Dr. Dennis Raphael,
School of Health Policy and Management,
Atkinson Faculty of Liberal and Professional Studies,
York University, 4700 Keele Street,
Toronto, Ontario M3J 1P3
Tel: (416) 736-2100, ext. 22134
e-mail: draphael@yorku.ca
Abstract
Despite Canada's extensive reputation as a leader in health promotion
and population health concepts, public health practice remains wedded to
downstream
approaches to addressing health issues. The example of heart health
initiatives in Ontario is used to illustrate how public health units
usually limit their
activities to downstream, lifestyle approaches. This occurs though
there is limited evidence that these approaches are effective and
increasing suggestions
that these approaches serve to harm health by diverting attention away
from societal determinants of health. These practices may result from
the lack of appropriate theory for considering contextual factors that
affect health. It more likely results from an adherence to government
imposed ideological concepts of the nature of health and illness. These
neo-liberal and neo-conservative ideologies frame health as an
individual responsibility and deny the health threatening effects of
governments' regressive social and economic policies.
Public Health Units and Poverty in Ontario: Part of the Solution or Part
of the Problem?
Overview
This paper considers the role public health units in Ontario -- Canada's
largest province --play in addressing poverty as a determinant of
health. These activities are considered in light of the history of
Canadian policy statements on poverty and health and current knowledge
about the relationship between poverty and health. I focus on heart
health issues and initiatives undertaken by Ontario public health units
for a number of reasons. First, I recently worked with a local heart
health network to address the role poverty plays in the incidence of
heart disease. Second, heart health is an important focus of provincial
and local public health efforts in Ontario. Third, I believe that heart
health activities illustrate the disconnect between what is known about
the causes of many public health problems and the activities of many
public health units in Ontario. The analysis and conclusions in this
paper probably have wide applicability to public health practice across
Canada and in many other nations. This would especially be the case in
the United States where health promotion is clearly defined as involving
lifestyle approaches to
promoting health.
Heart health initiatives in Ontario are consistent with the downstream
emphasis towards poverty-related health issues of public health units
across Canada. There is little evidence of the long-term effectiveness
of such efforts and these approaches have unintended side effects that
work against health. The questions raised by my analysis are AWhy does
public health in Ontario focus on downstream activities to the exclusion
of more broadly based upstream concerns? What are the effects upon
policy makers, the media, and the public's understandings of the causes
of illness in Canada of this emphasis?
The reasons for public health' s neglect of upstream issues are
considered. Is it due to the lack of appropriate theory for considering
the role these issues play in health? or Is it that public health has no
alternative but to promulgate ideological views of the causes of illness
advanced by their political masters? Examples of public health units
that identify poverty as an issue to be addressed by policy makers and
the public are provided. Means by which public health units could
address poverty-related issues at their source rather than continuing to
focus on Apicking up the health-related pieces in local communities are
outlined.
Canadian Policy Statements on Income and Health Canada has been seen as
a world leader in the development of health promotion and population
health concepts.. Restrepo, H. E. (1996). introduction. In Health
Promotion: An Anthology, pp. ix-xi. Washington DC: Pan American Health
Organization. These concepts expanded the meaning of health and
suggested new ways of thinking about public policy in support of health.
Ideas about reducing health inequalities, empowering individuals and
communities, and building healthy cities and communities were introduced
by, or quickly made their way into Federal and Provincial policy
documents.. Pinder, L. (1994). The Federal Role in Health Promotion:
Art of the Possible. In A. Pederson, M. O Neill. & I. Rootman (eds.)
Health Promotion in Canada: Provincial, National and International
Perspectives, pp. 92-106. Toronto: W.B. Saunders. Health Canada's
Population Health website provides these key Federal documents.. Health
Canada (2001). The Population Health Approach. Ottawa: Health Canada.
On line at http://www.hc-sc.gc.ca/hppb/phdd/resources/ Poverty has been
identified as a key determinant of health in many of these federal and
provincial statements.. Hamilton, N. & Bhatti, T. (1996). Population
Health Promotion: An Integrated Model of Population Health and Health
Promotion. Ottawa: Health Promotion Development Division, Health
Canada. On-line at http://www.hc-sc.gc.ca/main/hppb/phdd/resource.htm .
Health Canada. (1998).
Taking Action on Population Health: A Position Paper for Health
Promotion and Programs Branch Staff. Ottawa: Health Canada. On-line at
http://www.hc-sc.gc.ca/main/hppb/phdd/resource.htm. . Government of
Ontario. (1994). Wealth and Health, Health and Wealth. Toronto: Queens
Printer for Ontario.
Similarly, Canadian Public Health Association policy statements stress
the importance of various societal determinants of health, including
income..Canadian Public Health Association (2001). CPHA Policy
Statements. Ottawa: CPHA. On line at
http://www.cpha.ca/english/policy/pstatem/polstate.htm. Most recently,
the association passed an action plan to address the incidence of
poverty and its impacts on health.. Canadian Public Health Association.
Reducing Poverty and Its Negative Effects on Health. Resolution Passed
at the 2000 CPHA Annual Meeting, Ottawa. On line at
http://www.cpha.ca/english/policy/resolu/2000s/2000/page2.htm. Canadian
concepts have influenced health policy thinking in Europe, and more
recently, provided US health workers with ideas for improving the health
of Americans.. Auerbach, J.A., Krimgold, B., & Lefkowitz, B. (2000).
Improving Health: It Doesn't Take a
Revolution, Washington, DC: National Policy Association. . Raphael, D.
& Bryant, T. (in press). The Limitations of Population Health as a
Model for a
New Public Health. Health Promotion International. . Minnesota
Department of Health (2001). A Call to Action: Advancing Health for All
Through Social and
Economic Change. St. Paul, MN: Minnesota Department of Health. On line
at http://www.health.state.mn.us/divs/chs/hsd/action.pdf
A summary of government and association positions on poverty and health
are available.. Raphael, D. (in press). Canadian Policy Statements on
Income and Health:Sound and Fury --Signifying Nothing. Canadian Review
of Social Policy.
Poverty and Health
The effects of poverty on health have been known since the 19th
century..Sram, I. & Ashton, J. (1998). Millenium Report to Sir Edwin
Chadwick. British
Medical Journal, 317, 592-596. More recently, interest in the issue was
spurred by the publication in the UK of the Black and the Health Divide
reports.. Black,
D. & Smith, C. (1982). The Black report. Reprinted in P. Townsend, N.
Davidson, & M. Whitehead (Eds) (1992). Inequalities in Health: the
Black Report
and the Health Divide. New York: Penguin. . Townsend, P., Davidson, N.,
& Whitehead, M. (Eds) (1992). Inequalities in health: the Black report
and the health divide. New York: Penguin. These reports documented how
those in the lowest employment groups showed a greater likelihood of
suffering and dying from
a wide range of diseases at every stage of the life cycle. In the USA,
similar documentation is now available of the higher incidence among
lower-income
Americans of a range of illnesses.. US Department of Health and Human
Services (1998). Health, United States, 1998: Socioeconomic status and
health chartbook . On-line at
http://www.cdc.gov/nchs/products/pubs/pubd/hus/2010/98chtbk.htm.
Within Canada, individuals living within the poorest 20% of
neighbourhoods are more likely to die from cancers, heart disease,
diabetes, and respiratory diseases among others than the more well-off..
Wilkins, R., Adams, O., & Brancker, A. (1989).
Changes in mortality by income in urban Canada from 1971 to 1986. Health
Reports, 1 (2), 137-174. In Canada, data on individuals' social status
are not routinely collected at death, so researchers use residence
census tracts to estimate income level. Even with the inevitable
slippage that occurs since some poor people live in well-off
neighbourhoods and vice-versa, it is conservatively estimated that 22%
of premature years of life lost to Canada can be attributed to income
differences. This health cost to Canada of income-related health
inequalities is close to the total impact of heart diseases or cancers.
Health and well-being differences between poor and not-poor Canadian
children are seen in the incidence of illness and death from disease,
hospital stays, accidental injuries, mental health and well-being,
school achievement and drop-out, family violence and child abuse, among
others.. Canadian Institute on
Children's Health (1994). The Health of Canada's Children: A CICH
Profile. Ottawa: Author. . Canadian Institute on Children's Health
(2001). The Health of
Canada's Children: A CICH Profile, 2nd edition. Ottawa: Author. In
fact, poor children show higher incidences of just about any
health-related problem,
however defined.
How can poverty-related health differences be explained? While a variety
of explanations have been advanced, material deprivation arguments
provide the best explanation for understanding the health effects of
poverty.14 . Shaw, M., Dorling, D., Gordon, D. & Davey Smith, G. The
Widening Gap: Health Inequalities
and Policy in Britain. Bristol UK: The Policy Press, 1999. .Pantazis,
C., and Gordon, D., editors. Tackling Inequalities: Where Are We Now and
What Can Be
Done? Bristol UK: Policy Press, 2000. . Gordon, D., Shaw, M., Dorling.,
D., and Davey Smith, G. Inequalities in Health: The Evidence Presented
to the
Independent Inquiry into Inequalities in Health. Bristol UK: The Policy
Press, 1999. . Leon, D. & Walt, G. (eds.) (2001). Poverty, Inequality
and Health: An international perspective. New York: Oxford University
Press.
Material deprivation refers to individuals' exposures to both beneficial
and damaging aspects of the physical world.. Lynch, J. W., Davey Smith,
G., Kaplan, G.A., & House, J. S. (2000). Income inequality and
mortality: importance to health of
individual income, psychosocial environment, or material conditions,.
British
Medical Journal, 320, 1220-1204. Individuals experiencing material
deprivation
have greater exposures to negative events such as hunger and lack of
quality
food, poor quality of housing, inadequate clothing, and poor
environmental
conditions at home and work. In addition, these individuals have less
exposures
to positive resources such as education, books, newspapers, attendance
at
cultural events, opportunities for recreation and other leisure
activities, and
involvement in other stimulating activities that contribute to human
development
and health over the life span.
Associated with material deprivation is the experience of excessive
psychosocial stress. Numerous models have been advanced to explain the
pathways
by which the experience of material deprivation becomes converted into
illness
and disease. These models are especially relevant for understanding how
the
experience of poverty leads to the development of heart disease..
Brunner, E. &
Marmot, M. (1999).Social Organization, Stress, and Health. In M.G.
Marmot & R.G.
Wilkinson (eds.). Social Determinants of Health. Oxford: Oxford
University
Press. . Jarvis, M.J. & Wardle, J. (1999). Social Patterning of
Individual
Health Behaviours: The Case of Cigarette Smoking, In M.G. Marmot & R.G.
Wilkinson (eds.). Social Determinants of Health. Oxford: Oxford
University
Press. . Stansfeld, S. A. & Marmot, M. (2002). Stress and the Heart:
Psychosocial Pathways to Coronary Heart Disease. London UK: BMJ Books.
Concerning the number of children and families experiencing
material
deprivation, there are no shortage of reports and studies that document
the
deteriorating social environment in Ontario during the past decade..
Golden, A.
(1999). Taking Responsibility for Homelessness: An Action Plan for
Toronto.
Toronto: City of Toronto.
. Federation of Canadian Municipalities (2001). Second Report: Quality
of Life
In Canadian Communities. Ottawa: Federation of Canadian Municipalities.
.
Ontario Non-Profit Housing Association & Co-operative Housing Federation
of
Canada (2001). Where=s Home? 2000 Update. Toronto: Ontario Non-Profit
Housing
Association & Co-operative Housing Federation of Canada. . Daily Bread
Food Bank
and North York Harvest (2001). Who=s Hungry Now? Food Recipient
Profiles, 1995,
2000, 2001. Toronto: Daily Bread Food Bank and North York Harvest. .
Raphael,
D., Brown, I., & Bryant, B. et al. (2001). How government policy
decisions
affect seniors= quality of life: findings from a participatory policy
study
carried out in Toronto, Canada, Canadian Journal of Public Health, 92,
190-195..
. Raphael, D., Brown, I., & Wheeler, J. (2000). A City for All Ages:
Fact Or
Fiction? Effects of Government Policy Decisions on Toronto Seniors=
Quality of
Life. Toronto: Centre for Health Promotion, University of Toronto, 2000.
On line
at http://www.utoronto.ca/seniors. . Ontario Campaign 2000 (2001). Child
Poverty
in Ontario: Report Card 2000. Toronto: Ontario Campaign 2000. On-line
at
http://www.campaign2000.ca. Relevant indicators include the explosive
growth in
numbers of children and families living in poverty, living as homeless
or
home-insecure, and using food bank use or other emergency food
supplies. Before
considering public health responses to this policy environment, I
examine a
common public health activity, promoting heart health.
The Case of Heart Disease: Poverty Swamps Lifestyle Effects
At the conclusion of a public presentation I made on the health
related
effects of increasing poverty and income inequality, a Toronto public
health
nurse asked: ADid you know that many of the slides that show
income-related
health effects were about heart disease?@ I learned that the Ontario
Ministry of
Health and Long-Term Care had allocated $17,000,000 over five years to
address
the Arisk factors@ of inactivity, diet, and tobacco use. In response,
heart
health networks had sprung up across the province to promote lifestyle
changes
among residents.
Many workers however, were concluding these efforts were
inadequately
addressing the role societal factors play in the incidence of heart
disease and
were most probably ineffective in supporting and promoting health among
those
most at risk. I was asked to work with a local network to review what
was known
about the causes of heart disease and the means of reducing its
incidence. The
perception of these workers was consistent with the current research
literature.
The results of this collaboration, the report Inequality is Bad of
Our
Hearts: Why Low Income and Social Exclusion are Major Causes of Heart
Disease in
Canada . Raphael, D. (2001). Inequality is Bad for Our Hearts: Why Low
Income
and Social Exclusion Are Major Causes of Heart Disease in Canada.
Toronto:
North York Heart Health Network. concluded that medical and lifestyle
factors
accounted for rather small amounts of variation in the incidence of
cardiovascular disease among Canadians.. Marmot MG, Rose G, Shipley M,
&
Hamilton PJS. Employment Grade and Coronary Heart Disease in British
Civil
Servants. Journal of Epidemiology and Community Health, 1978, 32,
244-249. .
Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, & Chen JJ,
Socioeconomic Factors, Health Behaviors, and Mortality. JAMA, 1998, 279,
1703-1708. . Feldman JJ, Makuc DM, Kleinman JC, & Cornoni-Huntley J.
National
Trends in Educational Differentials in Mortality. American Journal of
Epidemiology, 1989, 129, 919-933. Additionally, cardiovascular disease
was
found to be the illness most associated with poverty among Canadians..
Statistics Canada (2001). Estimates of Premature Deaths (Prior to Age
75) Due to
Cardiovascular Disease Among Canadians. Ottawa: Statistics Canada
Special
Tabulation Of 1996 Mortality by Neighbourhood Income Data for Urban
Canada.
Concerning explanatory mechanisms, it concluded that material
deprivation,
excessive psychosocial stress, and the adoption of unhealthy behaviours
associated with living in poverty created cardiovascular risk burdens
that
accumulated across the life span.. Barker DJ, Osmond C, & Simmonds M.
Weight in
Infancy and Death from Ischemic Heart Disease. Lancet, 1989, 2,
577-580. .
Forsen T, Erikson JG, Tuomilehto J, Osmond C, & Barker DJ. Growth in
Utero and
During Childhood Among Women Who Develop Coronary Heart Disease:
Longitudinal
Study. BMJ, 1999, 319, 1403-1407. . Eriksson JG, Forsen T, Tuomoilehto
J,
Winter PD, Osmond C, & Barker DJ. Catch-up Growth in Childhood and Death
from
Coronary Heart Disease: Longitudinal Study. BMJ,1999, 318, 427-431.
. Eriksson JG, Forsen T, Tuomilehto J, Osmond C & Barker DJ Early
Growth and
Coronary Heart Disease in Later Life: Longitudinal Study. BMJ, 2001,
322,
949-953. And one=s situation during early childhood was especially
important in
predicting the onset of cardiovascular disease. Not only did the
experience of
poverty itself swamp the effects of biomedical and lifestyle factors as
precursors of heart disease, these biomedical and lifestyle factors were
themselves determined by the experience of living in poverty.
These findings were considered in relation to the adverse childhood
and
adult circumstances that are becoming increasingly common among Ontario
families. It was concluded that many current federal, provincial, and
municipal
economic and social policies were a prescription for poor cardiovascular
health
and that attempts to modify lifestyles were unlikely to offset the
negative
health effects resulting from such policy changes. Indeed,
cardiovascular
disease was seen as the ideal example of a disease where material
conditions
were determinants of its incidence.. Davey Smith, G., Grunnell, D., &
Ben-Shlomo, Y. (2001). Life-cpurse approaches to socio-economic
differentials
in cause-specific adult mortality. In Leon, D. & Walt, G. (eds.)
(2001).
Poverty, Inequality and Health: An International perspective. New York:
Oxford
University Press. . Davey Smith, G., Ben-Shlomo, Y., & Lynch, J. (2002).
Life
course approaches to inequalities in coronary heart disease risk. In
Stansfeld,
S. A. & Marmot, M. (2002). Stress and the Heart: Psychosocial Pathways
to
Coronary Heart Disease. London UK: BMJ Books. Numerous policy options
for
addressing these threats to cardiovascular health were presented.
The Case of Heart Disease: Public Health in Action
In contrast to the evidence implicating the important role social
and
economic policies play in influencing heart health, current activities
of heart
health networks across Ontario conform closely to the Ministry-imposed
mandate
of promoting physical activity, healthy diet, and reducing tobacco use.
A few
networks include issues of stress and stressful environments. This
limited
mandate has been enthusiastically picked up by Ontario=s public health
units.
Since the program's inception, public health and community partners
have
been working together in 37 health unit areas across the province
to
promote healthy living, provide behaviour change opportunities,
build
supportive environments and influence healthy policy. The current
Ontario
Heart Health Program (OHHP) structure facilitates an impressive
return for
investment by leveraging involvement of community partners and by
reducing
the burden of illness and treatment costs for chronic disease. The
OHHP
currently offers approximately 500 activities across Ontario..
Uetrect, C.
(Nov. 21, 2001). Concern about Termination of Ontario Heart Health
Program.
Letter to The Honourable Tony Clement, Minister of Health and Long
Term
Care. Toronto: Ontario Public Health Association.
Despite this optimistic statement, there is no evidence available
concerning the effectiveness of the Ontario programs. From other sources
however, doubts concerning these kind of lifestyle approaches= general
ineffectiveness in improving heart health among those most at risk is
accumulating.. O=Loughlin, J.L., Paradis, G., Gray-Donald, K., & Renaud,
L.(1999).The Impact of a Community-based Heart Disease Prevention
Program in a
Low Income, Inner City Neighbourhood. American Journal of Public Health,
89,
1819-1826. . Fitzpatrick, M. (2001). The Tyranny of Health: Doctors
and the
Regulation of Lifestyle. London: Routledge. Additionally, one outcome
of these
activities B though perhaps not an intended one -- has been to
completely
remove from the public consciousness any awareness that societal factors
such as
poverty play important roles in the development of heart and other
diseases. The
pervasiveness of this public blind spot concerning the societal
determinants of
heart disease was seen in a recent survey of Hamilton, Ontario
residents. When
asked an open-ended question about the causes of heart disease and
provided with
the opportunity to give up to seven responses, only one respondent of
601
identified poverty as a cause of heart disease.. Paisley, J., Midgett,
C.,
Brunetti, G., & Tomasik, H. (2001). Heart Health Hamilton-Wentworth
Survey:
Programming Implications. Canadian Journal of Public Health, 92,
443-447.
Public Health in Canada: Poverty as a Downstream Issue
The public health downstream emphasis apparent in Ontario heart
health
initiatives is consistent with recent reviews of public health practice
across
Canada. One review found AMany provinces had no evidence of mandated
programs
that were explicitly health focussed, that addressed broader
determinants of
health, or used multiple strategies.@. Sutcliffe, P., Deber, R. & Pasut,
G.
(1997). Public Health in Canada: A Comparative Study. Canadian Journal
of Public
Health, 88, 246-249., p. 247 Reasons given by informants for this lack
of focus
included a lack of political commitment and the failure to allocate
resources to
population health issues.
An extensive survey of public health units across Canada found that
half of
98 responding health regions did not have any initiatives addressing
poverty
issues. And among those that did, virtually all were dealing with the
consequences of poverty rather than addressing its causes.
The vast majority of these initiatives focus on the consequences
that
poverty has for individuals and their families...The findings from
this
study suggest that health sector initiatives that address and
attempt to
change the social, economic, and economic conditions within which
poverty
is rooted are very rare.. Williamson, D. (2001). The Role of the
Heath
Sector in Addressing Poverty. Canadian Journal of Public Health,
92,
178-183.,p.182
Working Downstream: Effectiveness
The emphasis on explaining poor health as a function of unhealthy
behaviours resulting from individual choice and exhorting individuals B
especially those on low income B to give up these behaviours is clearly
an
ineffective approach. First, behavioural factors account for a small
proportion
of the likelihood of developing a number of diseases as compared to
societal
factors such as poverty. Second, it adopts a Ablaming the victim@
approach
whereby those with disadvantage are blamed for their own illness when
the
factors responsible their illness are beyond their control. Third,
emphasis on
risk behaviours fails to address underlying issues of why disadvantaged
people
adopt these behaviours. Fourth, from an effectiveness standpoint: It
[individual choice approach] has also been signally unsuccessful in
leading to
the development of effective interventions to achieve behaviour change
in
disadvantaged groups. 56,p.241
An intensive heart health project in a low income neighbourhood in
Montreal
confirms the ineffectiveness and indeed, irrelevance, of downstream,
lifestyle
approaches in low income, high stress communities.47 The
ineffectiveness of
downstream approaches is not limited to heart health issues. An
intensive
prenatal nutrition program in a lower income area of Montreal found that
while
the health of expectant mothers improved as a result of nutrition
supplements
and counselling, there was no impact on incidence of low birth-weight
newborns..
CBC News On Line (2002). Premature Birth Rates a Mystery: Quebec Study.
On line
at
http://cbc.ca/cgi-bin/templates/view.cgi?category=Canada&story=/news/200
1/08/17/babies_010817
Williamson=s comments on the effects of adownstream emphasis of public
health
seems increasingly accurate:
While these initiatives likely play an important role in reducing
the
negative effects that poverty has on health, they do little to
alter the
socioeconomic and political conditions that contribute to the
poverty
experienced by Canadians. Until these broad structural conditions
are
addressed and altered, efforts to improve the health of Canadians
will be
limited. . Williamson, D. L. & Green, L. W. (1999). The role of the
health
sector in addressing poverty as a determinant of health. Poster
Presentation at the Annual Meeting of the Canadian Public Health
Association. Winnipeg, June.
Working Downstream: Unintended Effects
Critical explorations of the unintended effects of health promotion
programs have raised profound questions about the unintended effects of
downstream approaches to public health issues.. Nettleton, S. & Bunton,
R.
(1995). Sociological critiques of health promotion. In R. Bunton, S.
Nettleton,
& R. Burrows (eds.) The Sociology of Health Promotion: Criticval
Analyses of
Consumption, Lifestyle and Risk. New York: Routledge. . Bunton, R.,
Nettleton, N. & Burrows, R. (eds.) (1995). The Sociology of Health
Promotion:
Criticval Analyses of Consumption, Lifestyle and Risk. New York:
Routledge. In
the breakfast program area, it has been suggested that these programs
foster
material dependency and lead to stigmatization of poor children and
families.
It may well also be that these programs perpetuate inequalities rather
than
serving to reduce them.. McIntyre, L., Travers, K., & Dayle, J. (1999).
Children=s feeding programs in Atlantic Canada: Reducing or reproducing
inequities? Canadian Journal of Public Health, 90, 196-201
. Hay, D. (2000). School-Based Feeding Programs: A Good Choice for
Children?
Victoria BC: Information Partnership.
Another consideration is the extent to which downstream approaches
focussed
on lifestyle change foster the ideology of neo-liberalism and
neo-conservatism
in an age of economic globalization. There is now an increasing
literature that
considers why lifestyle programs such as the ones associated with the
Ontario
heart health initiatives are so popular among neo-liberal and
neo-conservative
governments, and the agencies they fund.. Nettleton, S. (1997).
Surveillance,
health promotion and the formation of a risk identity. In M. Sidell, L.
Jones,
J. Katz, & A. Peberdy (eds.) Debates and Dilemmas in Promoting Health,
pp.
314-324. London UK: Open University Press.
Governments advancing such activities can be seen as supporting
health
among citizens at the same time as they weaken the societal structures
that much
more profoundly affect health. The point is succinctly made by
Fitzpatrick in
relation to health promotion initiatives in the UK, but can equally
apply to the
present Ontario provincial government.
In the harsh world of politics, New Labour=s slavish devotion to...
fiscal
rectitude and electoral expediency mean that it has no intention,
either of
raising benefits to the poor, or of doing anything to reduce income
differentials... Under the banner of health inequalities New Labour
has
turned health promotion into a sophisticated instrument for the
regulation,
not only of individual behaviour, but that of whole communities..
Fitzpatrick, M. (2001). The Tyranny of Health: Doctors and the
Regulation
of Lifestyle. London: Routledge. ,p.
What does it mean to say that lifestyle-oriented approaches to
health
promotion are about the control of individuals and communities? It means
that
lifestyle approaches to health promotion serve the interests of the
established
and powerful by defining illness as resulting from individual lifestyle
choices.
Such a view diverts attention from government policies that weaken the
structures that support citizens= health and ends up blaming the victims
of
government policies -- because of their >poor lifestyles= -- for their
own
health misfortunes. The study cited earlier of Hamilton residents=
understandings of the causes of heart disease illustrates this view.
What are low income residents of Hamilton, Ontario -- and
elsewhere -- to
make of the greater incidence of heart disease and other health
misfortunes
among their low income neighbours, friends, and relatives than that seen
among
their more well-off neighbours? Research evidence indicates that the
greater
incidence of disease should be attributed to their lower income status
which in
most cases results from factors outside their personal control. But the
ideology of individualism promulgated by the government and its public
health
agents -- and clearly internalized by respondents -- lead them to blame
themselves for their higher incidence of disease and illness,
subsequently
relieving government policy makers from taking responsibility for their
health
threatening policies. In Ontario, this has involved reducing social
assistance
benefits, eliminating new social housing, and transferring wealth from
the poor
to the wealthy through income tax reduction for the well-off, among
other
policies.
This process is especially insidious in light of the limited
evidence that
these lifestyle choices -- especially physical inactivity and diet --
are major
causes of illness and disease. Essentially, individuals and communities
encountering health difficulties as a result of governmental policies
are doubly
damaged. First, they expe
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