How does Canada stack up against other wealthy developed nations?
I was pleased to be convinced by a presentation of Dennis Raphael in the Science for Peace series Vital Discussions of Human Security (scienceforpeace.ca/1165) that health is much more than just an individual responsibility.
Raphael’s lecture, “Economic and Social Security in the 21st Century: How Does Canada Stack Up Against other Wealthy Developed Nations?” illustrated the power of social determinants of health. They are well beyond the control of the individual. Numerous comparative health statistics prove that the social determinants of health have more influence on community health than the “good” behavior of individuals. These social determinants include income security, working conditions, adequate housing, fair income distribution, quality care in early life, access to education and health services, a social safety net, social inclusion, and food security. Some societies give high priority to supporting these prerequisites of health. Others do not. Evidently the worldview—the theory of society that dominates a nation—is a major determinant of this attitude and, in turn, of community health, the sum product of individual health outcomes. Using OECD statistics, Raphael compared the health performance of Canada to other affluent industrial nations.
Ursula Franklin, in “Reflections on Public Health and Peace” (the inaugural Dr. Zofia Pakula lecture at the Dalla Lana School of Public Health, Toronto, November 26, 2012) took me one step further by pointing out that a state of peace is a major determinant of health. We are still aware of the slaughter of World War II, with some 60 million deaths and uncounted health consequences, and we all know that a modern nuclear war would be massively more destructive of human life and health. However, less obvious is the reality that preparations for war are also threats to health by directing the resources of nations away from citizens’ health to the military-industrial complexes. According to the Stockholm International Peace Research Institute, the world’s nations spend 2.5 of their GDP ($1,735 billion) on the military, the USA spending a startling 4.7 of GDP, and Russia 3.9. The resulting massive military establishments, consciously or unconsciously, cultivate national insecurity to consolidate their own hold on local taxes and world wealth. Peace is a crucial prerequisite of community health. War and also preparation for war are negative determinants of public health.
We live in a world in which privatization and globalization have weakened responsible national and local governments. Efficient technocratic rule strives to replace rather slow but responsible democratic institutions. Not infrequently community health bows to the need of profits for transnational corporations, and to the demands for defence against the current “enemy”—either a state or an amorphous, universal and never-ending threat of “terror.” The money follows; weapons trump the social determinants of health. A nation feeling threatened by external forces, real or imagined, may conclude that it cannot afford adequate early childhood support, or fair income distribution, which would influence the physical and mental health of many citizens for a lifetime. War creates the ultimate unhealthy conditions; and the social distortions of war preparations follow closely after. The health disaster of World War II is still echoed today in the suffering citizens and chaotic injustice in Afghanistan, the Congo, Palestine, North Korea, and Sudan, to name a few. In war zones we find the antithesis of community health.
Most affluent industrialized nations, with some notable exceptions, strive to have universal national health care programs, which is to say in most cases the state provides care for people after they become sick. This is expensive and becomes ever more expensive as medical science meets more of our demands. However, a truly healthy nation is perhaps one in which a minimum of illness requires treatment, for good governance by the state actively seeks to provide conditions that reduce the incidence of illness, and in turn lessens demands on the health care system.
Money for defence or health?
Health care professionals do what they can to achieve this by fostering immunizations and many educational outreach programs. Still, the health of a society is a product not solely of available medical services. Rather, community health is a product of the totality of the nation’s social, economic, political, educational, and cultural makeup. The USA, with the world’s largest economy, devotes by far the most money to defence, and arguably has one of the weakest public health systems, in terms of the prerequisites for community health. Canada, proud of its broad Medicare, also falls short on providing many social determinants of health.
The truth about the Canadian record is not a secret:
- Anna Reid, the current president of the Canadian Medical Association, argues that where we live and how we live, our education, and our income level are major determinants of health. As a result of these social determinants, as the gap in income grows, our health outcomes become worse.
- Ed Broadbent, an elder statesman of the NDP, argues that the affluent have something to gain in a society which is more equal; health, security and a more comfortable sense of community are benefits we could all share.
- Bill Clinton, arguing for a more egalitarian America, touched a nerve in the last US election by pointing out that poverty restricts growth.
- Maude Barlow, Council of Canadians national chairperson, argues that we will not have a healthy society until we put social justice and universal social security for all back at the top of our political agenda.
Roy Romanow argues in the preface to A Healthy Society by Dr Ryan Meili:
“Financial stability (GDP) is an important element of societal success, a necessary tool for achieving our goals. It is not, however, the true goal of a society. As Dr. Meili argues … a far more meaningful goal is that of health. Health—that of our neighbors and friends, our families and ourselves— is something we all seek. It’s also a far better measure of success than material wealth.”
Household income continues to be one of the best predictors of future health status. The formula is straightforward: More income equals better health, less income equals worse health. This is true in all age groups and for both women and men.
Historians tell us that we have had two great revolutions in the history of public health. The first was the control of infectious diseases, notwithstanding some recent challenges. The second was the battle against non-communicable diseases. I believe that the third revolution is about moving from an illness model to focusing on all the things that both prevent illness and promote wellbeing.
Dr Ryan Meili argues that health delivery too often focuses on treatment of immediate causes and ignores more fundamental conditions that lead to poor health. Income, education, employment, housing, the wider environment, and social supports are more important than the actions of physicians, nurses, and other health care providers.
And well before our time, Dr. Rudolf Virchow pointed out in 1848 that “Medicine is a social science, and politics is nothing more than medicine on a grand scale.”
Dennis Raphael told us that when, as younger man, he first discovered these truths he knew that he had to tell the world, the people, the politicians. He saw the need for a great change, a change that would alter the conditions that led to ill health and, in turn, reduce the burden on an expensive health care system. A determined man, now professor in the School of Health Policy and Management at York University. he is still pursuing that objective with determination but with less success than he, or we, would desire. He has edited Poverty in Canada, written more than 170 scientific papers, and other publications, including Social Determinants of Health: The Canadian Facts.
Raphael sets out three models of social welfare in wealthy nations, which he illustrates with comparative OECD statistics. These stats show a correlation between nations’ social welfare attitudes and actions and the measurable health and well being of their citizens.
Three Types of States
Based on the thesis of Apsing Andersen, published in 1990, the three models are labeled: Liberal, Conservative, and Social Democratic. They can be found respectively in Anglo-Saxon, Western European, and Scandinavian countries. Nations in these groups put different emphases on the social determinants of health, and the OECD statistics show the resulting health outcomes. There is a considerable correlation between attitudes and outcomes in these groups. These can be summarized as follows:
- The Liberal welfare states, including Britain, Canada, Australia, and the USA, offer modest benefits (with strict conditions) to citizens demonstrably in desperate need. These Anglo-Saxon states make minimal effort to embrace policies that supply the prerequisites of health to all citizens, children, workers, or retirees. They leave much of the responsibility for personal health and security to the individual. Social mobility in these nations, contrary to popular mythology, is actually low.
- The Conservative (or Corporatist-Statist) states provide support for the youth, unemployed, aged, and other disadvantaged citizens, differentiated on the basis of established or potential levels of earnings. Sometimes thought of as the Bismarkian model, it is the system of support used in Germany, France, Belgium, and other Western European states. Essentially, the system is designed to avoid unrest potentially generated by seriously deprived citizens. However, these states are not hostile to developing policies that support the prerequisites of health. Many of them have a good record of providing employment security, unemployment support, and generous educational support.
- The Social Democratic welfare states, such as Sweden, Norway, and Finland, pursue universal welfare support, based on an assumption of equality of citizen rights. They pursue tax and social policies that foster equality and the development of the maximum health and potential of all citizens through early childhood care, adequate income, free educational opportunities, and the resulting enhanced social mobility. Citizenship brings security and opportunity as rights, and those rights of fellow citizens are endorsed in national policy.
Many of us Canadians have a personal debt of gratitude to the medical professionals and the medicare which makes their services available. However, we should not let that personal appreciation obscure our understanding that community health is a product not only of access to competent medical services. Perhaps more important is our nation’s commitment to the social determinants of health: peace, justice, early and further education, economic security, and a reasonably equitable society with social mobility that maximizes the potential skills of all the members of the community. The latest figures on food bank use do inspire confidence that we are doing a good job.
Among the many charts of OECD statistics Raphael presented, the Infant Mortality rate stands out as an important health indicator. The bearing mother is embedded in the community and the health of the newborn is a direct product of the social determinants of that nation’s health. Using this measure, we see that infant mortality in Canada is the second highest in the liberal group of Anglo-Saxon nations and almost twice as high as the social democratic group (see chart 1).
Canada’s investment in early childhood education also lagged far behind almost everyone in 2010 (chart 2). Poverty rates in families with children (chart 3) also leaves much room for improvement.
Having in the past smugly compared Canadian health services favorably with our big neighbor, I was taken aback to see us embedded in the liberal group of welfare states, stuck among the countries providing the least support to community health. Many of us, missing the larger picture, think that our medicare provides adequate health protection. Critics, and the OECD statistics, prove otherwise.
Even more disturbing, as Ursula Franklin noted, is the trend encouraged by our current government to cut social services, and silence critics, even gave a public rebuke to the UN body which made unflattering comparisons based on the OECD statistics. The same government, having abandoned support for UN peacekeeping, makes a continuing effort to bolster the budget and the profile of the military and its industrial backers to prepare for what they seem to see as inevitable and perpetual war.
Our security is not to be found in an ever larger, more expensive military establishment.
Dennis Raphael and Ursula Franklin give us the truths we need to keep in mind to pursue our health and safety.
Ron Shirtliff is an associate editor of Peace Magazine.
For a video of the Raphael lecture with other bar graphs see: scienceforpeace.ca/1165.
For Dr. Franklin’s lecture: mediacast.ic.utoronto.ca:82/GHD-SI (Windows)
mediacast.ic.utoronto.ca:81/20121126-GHD-SI.mp3 (Mac or Linux)