In 1986 a World Health Organization (WHO) statement stated that in order to reach a state of health “an individual or group must be able to realize aspirations and satisfy needs, and to change or cope with the environment.” Health is affected by the inequalities in the social determinants of health. The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. In 2003, a WHO working group identified ten social determinants of health: social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food and transport. There is a strong and widespread consensus that income and social status are the most important determinants of health across populations. The lower people are on the socioeconomic hierarchy the higher their risk of developing chronic diseases, and the shorter their life expectancy. Income level interacts with other determinants to create differences in life experiences – quality of early life, education, employment and working conditions, food security, housing, social exclusion, etc. – and differences in health status.
Inequity and inequality are not interchangeable. Inequity is unfair, avoidable differences arising from poor governance, corruption or cultural exclusion. It is the result of human failure giving rise to avoidable deaths and disease. Health equity is the absence of systemic disparities in health (or in the major social determinants of health). In the past, health inequalities were not considered inequities, and thus did not deserve attention (for if differences are not unfair differences or unjust differences, then they can be minimized and shrugged off). There is a new reference framework – consider every health inequality or disparity as a health inequity until it can be proven it is not – by grounding thinking in the human right to health or wellness.
The World Conference on Social Determinants of Health brought together Member States and stakeholders to share experiences on policies and strategies aimed at reducing health inequities. The World Conference in October 2011 developed the Rio Political Determinants of Health, a political statement of commitment for the implementation of the social determinants of health approach to reduce health inequities and to build support for the implementation of action on social determinants of health. The meeting identified nine broad areas, or social determinants themes. Two of the themes identify that the type of health care system is important. One theme identifies that globalization affects health and the social determinants of health through changes in social stratification, differential exposure to vulnerability, health system characteristics. The other theme identifies that health systems as important determinants of health, and, in particular, the way health systems are designed operated and financed act as a powerful determinant of health.1 In November 2013 WHO launched the Economics of Social Determinants of Health project to describe and discuss the potential for economic rationales to make the case for social determinants of health interventions, and to summarize economic evidence in key public policy areas.
The health care systems in Canada and the US are important determinants of health. In 1968, the Canada Health Act set out to develop relatively uniform level of resources dedicated to health care across Canada. The Canada Health Act contains five principles: public administration, comprehensiveness, universality, portability of benefits, and accessibility. Three of the five variables that define the architecture have a pan-Canadian dimension – who pays, what is covered and who decides. But the other two factors, namely, where care is delivered, and by whom are decided by the provinces. In the US the Affordable Care Act (Obamacare) was signed into law to reform he healthcare industry by President Barack Obama on March 23, 2010. The goal of Obamacare is to give more Americans access to affordable, quality healthcare insurance, and to reduce the growth of healthcare spending in the US. The Affordable Care Act expands the affordability, quality, and availability of private and public health insurance through consumer protections, regulations, subsidies, taxes, insurance exchanges and other reforms. States have either implemented a state run health insurance exchange, or let the federal government run the health insurance exchange for them. Neither system was an attempt at social engineering.
The profound improvements in health in industrialized countries are primarily not due to advances in medicine or health care, but rather in the kind of societies in which we live, and are due to improvements in general living conditions. There is a growing body of evidence about what makes people healthy. This evidence suggests that the contribution of medicine and health care is quite limited, and that spending more on health care will not result in significant further improvements in population health. It appears that lifestyle behaviours – smoking, diet and physical activity account for small variations of incidence in heart disease, cancer and diabetes. It is now apparent that social determinants of health are more important to the health of Canadians and Americans than biomedical and life style factors.
There was a time when the middle class – really anyone who falls between the rich and the working poor – occupied a wide and comfortable place in society. It meant a stable job, a house with a yard, a two car garage, a perhaps a nice pension. Where did the middle class come from? During the 1950s the gradually expanding economy created prosperity throughout North America. The 1950s are considered the decade that eliminated poverty for the great majority of Canadian and US citizens. The decade was associated with the shift from suburban areas to suburbs, with the supply of housing increasing 27%. With a shorter workweek and increased disposable income the middle class adopted conservative values. The problem during the last four decades is the middle class has not grown (household incomes peaked in 1973). The existing middle class is now earning less compared to those higher up on the wealth scale, and they are working harder for what they get.
The economic system that created the middle class and eliminated poverty in Canada and the US differs from the economic system of trickle down economics that has evolved over the past 30 years. While the actual gap between the rich and the rest is far greater in the US, the inequality is growing faster in Canada than the US. The US has the most unequal society of any industrialized country, so saying “things are better in Canada than the US” does not represent a great achievement considering how low the benchmark is set. The growth in inequality is being driven by an accumulation of wealth among the very top income earners, while the middle class lower income earners continue to stagnate. The great equalizers – universal health care, education, and pensions are under threat, as cash-strapped governments look to trim budgets. Today the middle class is under tremendous pressure – many believe the deck is stacked against them.2
Hope and optimism of the future is key to health and well-being. A study by Wilkinson and Pickett, researchers from the United Kingdom, claim that societies like Japan and Norway, where the middle class is prominent and the pendulum swing from excessively wealthy to poor was far less, has the greatest health, longevity well-being and the least anxiety and depression. Living in a society that tolerates large gaps between the rich and the poor is bad for your health. In a big gap society those lower down the ladder experience more chronic stress that those towards the top.3
A big part of wellness is having meaning in one’s life and the sense that one is contributing to the world whether it be making a difference in the lives of friends and family, ecology or vocation. This has a great deal to do with attitude. Not surprisingly, much stress in in society can be attributed to economic inequality. In fact, economic inequality may have an effect on our overall health than any other single factor. Research has shown economic inequality to be a primary cause of illness.
Health is a resource for everyday life. Health is a positive concept emphasizing social and personal resources as well as physical capabilities. The inequities of health are measured by the spread in life expectancies between poor and rich neighborhoods, and the need to disseminate knowledge and learning to all local authorities and their partners. These social determinants of health are the social, economic and environmental conditions that influence the health of individuals and populations. They include the conditions of daily life and the structural influences upon them, themselves shaped by the distribution of money, power and resources at global, national and local levels. They determine the extent to which a person has the right physical, social and personal resources to achieve their full potential.4
In addition to an individual’s income affecting whether he or she stays healthy or become’s ill, research is finding that the overall health of all members of a society is more determined by the distribution of income rather than by the overall wealth of the society.5 The healthiest (and happiest) countries in the world are not the richest, rather the countries where wealth is shared widely and more equally. These differences create health inequities. Removing barriers to health creates health equity – allowing everyone to reach their full health potential and not be disadvantaged from attaining this potential as a result of their class, socioeconomic status or other socially determined circumstance. This includes removing barriers to those with disabilities and creating opportunities to access good healthcare. Removing barriers to good health requiress addressing the income gap between the wealthy and the rest of society.
1 “Rio Political Declaration on Social Determinants of Health.” http://www.who.int/sdhconference/declaration/en/
2 Horsman, Greg. Occupy Wall Street Success (1 Dec 2012) http://questioningandskepticism.com/2012/12/01/occupy-wall-street-success/
3 Rabin, Mitchell. “The Stress of Inequality and its Powerful Effect on Health.” <http://www.naturalnews.com/031674_inequality_health.html>.
4 “The Social Determinants of Health.” <http://www.local.gov.uk/web/guest/health/-/journal_content/56/10171/3510325/ARTICLE-TEMPLATE>.
5 Wilkinson, R.G Unhealthy Societies:the Afflictions of Inequality. New York: Routledge, 1996.