Health 101: The Social Determinants of Health 9/10/2012 8:23:00 AM
-Tutorials every other week
-10% deduction per day on late assignments
Contact: Elaine Power ([email protected]
Office hours: KHS 301G
-Monday 10-11, or email to set up appointment (HLTH 101 in subject line)
Course pack of readings: campus bookstore $20
-As Long as the Rivers Flow $19
Tutorial #1: Intros, Code of Conduct, Review of ICE and ICE quiz
Tutorial #2: Small group discussion of As Long as the Rivers Flow
Tutorial #3: Review of common writing problems in book review (led by TA)
Tutorial #4: Debate: Be it resolved that it is time to close Canada’s food banks
Tutorial #5: Small group discussion
-As Long as the Rivers Flow book review
-Version 1, due in class Sept 27 (10%)
-Version 2, due in tutorial #5 (November) (25%)
-Tutorial #1, mini-quiz on ice (4%)
-Tutorial #4, debate participation (2%) + written debate notes (4%)
-Letter to Harper, due November 26 (10%)
-Weekly mini-quizzes on Moodle (5%)
-Final exam (40%)
** Class on 17 Sept will include information about what is expected for your book review.**
You will also be discussing the novel in tutorial #2 and your TA will review common writing
mistakes in tutorial #3.
Version 1 due in class Thursday 27 Sept 2012, 1000 words maximum, 10% of final mark
In version #1, you will be expected to focus on the content of the novel. Version 2 due in tutorial #5, 1250 words maximum, 25% of final mark
In version #2, you will be expected to make connections to the course material.
For tips on how to write a book review, consult one or more of the following websites:
http://leo.stcloudstate.edu/acadwrite/bookrev.html Readings 9/10/2012 8:23:00 AM
• 10 Sept: Introduction to the class
• Picard, A. (2004, 30 September). Bring on the duelling top-10s: Two lists
not to die for. The Globe and Mail.
• Bezruchka, S. (2012, 7 August). If there were a health Olympics, the U.S.
wouldn't even medal, The Seattle Times.
• Video: Introduction to Unnatural Causes.
• 11 Sept: Sociological approaches to social issues, or the problem with
The ICE Model - what it is and an application
• Johnson, A. G. (2008). The Forest and the Trees: Sociology as Life,
Practice, and Promise. Philadelphia: Temple University Press. P1-36.
• The ICE Method of Assessment and Learning
• Freeman, A. (2005, August 12). Easy riders bear high cost of feeling wind
in their hair. The Globe and Mail, p. A3.
• 13 Sept: What is health? How is health experienced? How is it
measured? lay understandings of health, Aboriginal understandings of health
• 17 Sept: Writing a book review & introducing key concepts for social
determinants of health
How to Write a Book Review
Public Health Agency of Canada, Determinants of Health,
Strategic Initiatives and Innovations Directorate. (2011). Reducing Health
Inequalities: A Challenge for Our Times. Ottawa: Public Health Agency of
Download at: http://publications.gc.ca/site/eng/391198/publication.html • 18 Sept: What is ―Public Health‖? Rose‘s ―prevention paradox‖; Ideology
and Public Health
• Baggott, R. (2000). Public Health: Policy and Politics. London: MacMillan
Press Ltd. p. 1-6.
• 20 Sept: History of Public Health & Canadian Contributions to Public
• Picard, A. (2010, 17 June). Invisible success: A century of better health.
The Globe and Mail, www.globeandmail.com, pp. L1, L4.
• See also:
Public Health Agency of Canada, http://www.phac-aspc.gc.ca/ph-sp/
• 24 Sept: Public health and the case of smoking
Voigt, K. (2010). Smoking and Social Justice. Public Health Ethics, 3(2), 91-
• 25 Sept: Overview of research ethics; review of academic integrity &
https://www.indiana.edu/~istd/ • 27 Sept The Whitehall Studies & the Status Syndrome
• Longevity: Nobel‘s greatest prize. (2007, 20 January). The Economist, pg.
Assignment #1 due at the beginning of class: Book Review
#1 of As Long as the Rivers Flow
• 1 Oct Income Inequality as a Determinant of Health
Video: Episode 1 of Unnatural Causes, In Sickness and In Wealth
• 2 Oct Poverty and Income Inequality as a Determinant of Health: The
Reading: Sapolsky, R. (2005). Sick of poverty. Scientific American,
December, p. 94-99.
Video: Stephen Bezruchka, TEDxRainer.
• 4 Oct The Impact of the Economic Downturn on Population Health
• Bezruchka, S. (2009). The effect of economic recession on population
health. Canadian Medical Association Journal, 181(5), 281.
Video: Episode 7, Unnatural Causes, Not Just a Paycheck
• 8 Oct No class. Happy Thanksgiving weekend • 9 Oct Poverty in Canada and the Health Impacts of Childhood Poverty
• Raphael, D. (2011). Poverty in childhood and adverse health outcomes in
adulthood. Maturitas, 69, 22-26.
• 11 Oct The cost of poverty in Canada and the concept of Basic Income
• Goar, C. (2011, 11 January). Anti-poverty success airbrushed out. The
• Anderssen, E. (2010, 19 November). To end poverty, guarantee everyone
in Canada $20,000 a year. But are you willing to trust the poor? , The Globe
and Mail, Download at
• 15 Oct: Guest Speaker: Hon. Hugh Segal, Senator for Kingston-
Frontenace-Leeds, on Eliminating Poverty in Canada
• 16 Oct: Introduction to Food (In)Security and Food Banks **This class is
preparation for your debate in Tutorial #4**
• Poppendieck, J. (1994). Dilemmas of emergency food: A guide for the
perplexed. Agriculture and Human Values, 11(4), 69-76.
• Power, E. (2011, 25 July). Time to Close our Food Banks. The Globe and
• See also: Blog about living on a food bank diet
• 18 Oct: Right to Food and the Special Rapporteur‘s Visit to Canada
Readings: Schutter, O. D. (2012). Visit to Canada from 6 to 16 May 2012 - End-of-
mission statement: United Nations Human Rights, Office of the High
Commissioner for Human Rights.
See also Universal Declaration of Human Rights
especially Article 25
• 22 Oct: Intro to ―Race‖ and Racism as determinants of health for
Indigenous People in Canada
Video: Episode 2 of Unnatural Causes, Race: The Power of an Illusion
• 23 Oct: The Health of Indigenous People in Canada and the Enduring
Legacy of Residential Schools
• Smith, D., Varcoe, C. and Edwards, N. (2005). Turning around the
intergenerational impact of residential schools on Aboriginal people:
Implications for health policy and practice. Canadian Journal of Nursing
Research, 37(4), 39-60.
• Prime Minister Stephen Harper‘s statement of apology. 11 June 2008
• Indian Residential Schools. Agreement in principle: FAQs
• 25 Oct: The Enduring Legacy of Residential Schools
Video: Kuper Island: Return to the healing circle (1997)
• 29 Oct: Guest Speakers: Melissa Webster and Krystle Maki, Anti-poverty
activism and Put Food in the Budget
• 30 Oct: Creating Change: How Change Happens (or doesn‘t)
• 1 Nov: Globalization and Health. Introduction to globalization, global
health, neoliberalism & key players
• Marmot, M. (2005). Social determinants of health inequalities. The Lancet,
• 5 Nov: Global Crises, Global Health
Schrecker, T. (2012). Multiple crises and global health: New and necessary
frontiers of health politics. Global Public Health: An International Journal for
Research, Policy and Practice, 7(6), 557-573.
• 6 Nov: Global Climate Change and Health
no reading for this class
• 8 Nov: The Politics of Global Climate Change
McKibben, B. (2012, 19 July). Global Warming's Terrifying New Math, Rolling
Week 10 • 12 Nov: Globalization, Trade & Health
• Williams, D. & Homedes, N. (2001). The impact of maquiladoras on health
and health policy along the U.S.-Mexico border. Journal of Public Health
Policy, 22(3), 320-337.
• 13 Nov: Globalization, Trade & Health
Film: Maquilapolis (part 1)
• 15 Nov: Globalization, Trade & Health
Film: Maquilapolis (part 2)
• 19 Nov: Structural Violence and HIV/AIDS
• Farmer, P., Nizeye, B., Stulac, S., & Keshavjee, S. (2010). Structural
violence and clinical medicine. In H. Saussy (Ed.), Partner to the Poor: A
Paul Farmer Reader (pp. 376-392). Berkeley: University of California Press.
• 20 Nov: Guest speaker: Mark Brender, Partners in Health Canada
• 22 Nov: Global Health: The Millennium Development Goals
• 26 Nov: Our moral obligations?
No Reading for this class.
• 27 Nov: Catch-up, Review & Questions • 29 Nov: No Class Lecture #1 Lecture and Readings 9/10/2012 8:23:00 AM
The definition of sociology according to Allan G. Johnson: The study of
individuals and society and how they are relevant to each other. ―The one
thing‖ that society offers: we are part of something much bigger than who
we are as individuals. We have to understand what it it is that we‘re
participating in and how we participate in it (p.13).
Sociology: Some sociologists see the discipline as a descriptive one, others
see it as a normative discipline (aka prescriptive).
Concerns how things should be, rather than how they actually are.
Public Health: A normative field of study and profession (aka prescriptive).
Public health‘s goal: to improve health status of the population by reducing
disease and preventable deaths. Recognizes the importance of individual
contributions to injury and disease, but is more interested in understanding
how to reduce or alleviate hazards by addressing the underlying causes (ex.
―upstream‖ - preventing, ―downstream‖ - patching).
Public policies, city design, work of Public Health Units.
Legislation (seatbelts, vaccinations, food safety, clean drinking
water, provision of sewers, pasteurization of milk, helmets.
-Public health benefits the population, not the individual. Wearing a seatbelt
in the car may be inconvenient or an individual who will never get involved
in a car accident, however if people didn‘t follow this rule because it was
‗inconvenient‘ for them, then that would inconvenience the population even
more, because this would create more deaths.
3 questions in preventing death and disease:
1) What is to be prevented? How can exposure be reduced?
2) Who is responsible for taking action to protect public health?
3) How safe should we seek to make the public from hazards in the
workplace, transportation, and areas like playgrounds and the environment?
Walkerton Tragedy: May 2000: E. Coli contaminated water
7 people died, 2500 ill with long term health effects
Privatization of the water-testing facilities
Incompetent staff, with no provincial water regulations 2011 – USA
48,000 people died from preventable deaths because the didn‘t
have access to timely healthcare
Privatization made for the biggest cause of bankruptcy in the US is
1966: When Canada decided to set up a universal healthcare system.
Restrictions on individual liberty:
Paternalism: restricting the individuals freedom to promote his/her
idea of well-being.
Public health paternalism: minor infringements on freedom justified
by the greater good of society.
Social Democratic Ideology: Scandinavian cons.(Results in increased deaths)
-The role of the state as a principal means of social improvement
-Limiting effects of capitalism
-―Positive Freedom‖ to do things – state ensures basic needs (income,
education) enabling citizens to fully participate in society resulting in
higher income taxes and more taxes on the public.
Neo-Liberal Ideology: Supply/Demand
-The role of the market is promoting individual freedom; social good is
secondary. No regulation or governmental decision.
-Limits the role of the state (except in maintaining order and protecting
-―Negative Freedom‖ from interference in my life.
-Interconnectedness of humans, health and environment.
-Destructiveness of economic growth at all costs
-Local, community based actions.
Bias of Public Health: -Duty and moral obligation to promote the health of all and to reduce
inequalities among groups.
Normative Disciplines: Profoundly moral- seeking the essence of who we are
as humans and as society.
Seek to understand human suffering and social injustice and to alleviate it-
need systematic ways to understand problems.
Individualism: A way of thinking that encourages us to explain the world in
terms of what goes on inside individuals and nothing else (p.11).
Society is just a collection of individuals.
Ignores the difference between individuals.
Personal solutions cannot solve societal problems.
Racism: About individuals and not society.
Individuals are not responsible for a world they did not create.
Individuals are responsible for choosing how to participate.
The social system and individuals work in a constant cycle:
We make the social system happen.
Our lives are shaped by socialization & the path of least resistance.
Social Systems: Not ―things‖ - ongoing process
Constantly being created or shaped; they are always changing.
ICE Method of Assessment and Learning:
Ideas: a basic foundation of the structure (alphabet).
Connections: a connection of those ideas (words).
Extensions: beyond the course connecting ideas from other sources and
broadening your knowledge.
―Easy riders bear the cost of feeling the wind in their hair‖.
– The Globe and Mail
A public health law example: motorcycle helmet law- prevents deaths. 3 Ideas: Helmets lower the amount of motorcycle deaths;
3 Connections: Individualism; Neo-liberalism; Role of public health and the
laws promoting public health
3 Extensions: The way in which public health is different between societies
(ex. Canada vs. the USA): Gun control laws; National motto‘s (Can: peace,
order, and good government. USA: life, liberty, and pursuit of happiness). Week #2 Lecture and Readings 9/10/2012 8:23:00 AM
Public Health Agency of Canada, Determinants of Health,
Strategic Initiatives and Innovations Directorate. (2011). Reducing Health
Inequalities: A Challenge for Our Times. Ottawa: Public Health Agency of
Download at: http://publications.gc.ca/site/eng/391198/publication.html
In Canada, which groups are most vulnerable to health inequalities?
People living on low income
Aboriginal peoples (first nations, Inuit, Métis)
Canadians living in rural parts of Canada
Vulnerable men and women
According to the World health organization (Who), there are five main
causes of health inequalities:
1. Different levels of power and resources.
different groups in our
society have different access to resources, power and influence which, in
turn, affects their degree of personal control over their life circumstances.
2. Different levels of exposure to health hazards.
some people are at
greater risk of experiencing factors that can negatively affect their health,
such as poor housing or working conditions that are unsafe, have high
demands or offer little personal control.
3. Different impacts of exposure to health hazards.
everyone is exposed to the same health risks, their health may not be
affected in the same way.
4. Different impacts of being sick.
illness and chronic disease can have
a harsher impact on some groups in our society.
5. Different experiences in early childhood.
disadvantage early in our
lives can accumulate and lead to poor health throughout adulthood and old
The WHO recommends the following actions to reduce health inequalities: -improve living and working conditions. enhance supports for early childhood
development and education, and ensure social protection for workers, the
unemployed, the elderly and people living with disabilities.
-tackle the inequitable distribution of power, money and resources. Promote
gender equity, political empowerment and human rights.
-measure and understand the problem and assess the impact of action.
collaborate at the national and international levels to evaluate the impact of
policy and action on health inequalities. Train policy-makers and health
practitioners, and increase public understanding through awareness
-enhance health promotion and disease prevention policies to meet the
needs of disadvantaged populations including:
-improving access to health services;
-Reducing risks and boost protective factors such as coping skills; and
-creating environments in which the healthy choice is the easy choice–for
“We cannot rate our collective health and well-being by looking only
at those who are healthiest. We must also consider those left
– dr. david Butler-Jones, chief Public health officer of canada
Hamburger method vs Hamburger soup method (Danielle Lorenz)
See also links for parts 2-5 in this series about essay writing (links at bottom
of page listed above)
Hamburger Soup Method (or a more complex hamburger):
-more flexibility and more complexity
-you do not have to stick to 5 paragraphs but basic structure is the same as
the hamburger method
introduction – this includes an introductory statement, a thesis
statement and a mapping statement body paragraphs – each one should start with a topic sentence
conclusion –including a concluding statement
As Long as the Rivers Flow: Essay, Due: October. 27th
Fictional book, why he chose to make this fiction, think about metaphor
Give interpretation - what is the message trying to be developed
Aim for 1000 words
get the reader‘s attention so that the reader wants to keep reading:
use a quote, memorable statement, shocking statistic (residential
schools in Canada)
Google authors name (National Post article) + reference it
avoid sweeping generalizations!!
Clearly states your topic PLUS an arguable opinion
-Takes a position
-Answer What?, How?, and Why? in developing your thesis
What will you argue? Say what you are going to say in the upcoming essay.
State your main arguments in the order in which they will appear.
-Prove your thesis statement – give evidence from the book
-Can be more than 3 paragraphs! stick to one main idea per paragraph
-Begin each paragraph with a topic sentence
Transition from last paragraph
Introduce topic for current paragraph
Link this topic to your thesis Conclusion:
-Say what you said
-Re-state your thesis in different words
-Sum up your arguments
-Make a strong and memorable concluding statement
-There is no one ―right way‖ to write an essay
-Different styles, arguments, thesis statements can earn high grades
-Will be looking for creativity, originality, freshness
-Will post some examples from last year (remember it was a different
-Leave yourself lots of time. Start early. Leave your essay for a day before
-Make an outline.
-Use short, strong, concise sentences.
-Introduction and conclusion are really really important – make them strong!
-PROOFREAD. Check for spelling, grammatical errors, coherence & flow.
-Read it aloud. Have someone else proofread for you. Make sure it makes
-Use active not passive voice
-Can use first person – but use it appropriately. Personal opinion without
evidence is weak.
-Do not use contractions (don‘t, can‘t)
-Use plain, strong language. Avoid flowery or pretentious language.
-Do not use the thesaurus to blindly substitute words!
Difference Between Essay #1 and Essay #2:
-Essay #1 – concentrate on the book and what the book is about (the ―I‖
-Essay #2 – make connections to the course (the ―C‖ from ICE) – what does
the book have to do with health & social determinants? -An ―A‖ on your first essay does not mean you will get an ―A‖ on the second
-Your second essay will likely be very different than the first
-Use APA style
-Essay #1 –references other than the novel not required
-Essay #2 – expect you to reference course materials, lecture notes, other
-Direct quotes from the novel MUST include quotation marks around the
quote and a page number.
-Cite page numbers in your arguments, even if not direct quotes.
-Will post a grading rubric on Moodle
-Your essay will be randomly assigned to a TA
-We strive to mark consistently
-Requests for re-marking – must make your case in writing to the TA who
marked your paper. Your grade may decrease upon remarking.
Cover Page for Essay:
-YOUR TA‘s NAME!
-Your tutorial section
Rose‘s Key Message:
-―a large number of people exposed to a small risk may generate many
more cases than a small number exposed to a high risk‖
-causes of individual cases may not be the same as causes of population
rates of disease
Example: -consider serum levels of cholesterol, a known highly treatable risk factor for
coronary heart disease (CHD)
-treatment: (1) diet, exercise, weight loss; (2) pharmaceuticals
-for the individual, cholesterol between 5.2 and 6.2 mmol/L is considered
―borderline high‖. A cholesterol level in an individual above 6.2 mmol/L
doubles the risk of CHD.
Are individual risks and population risks the same? NO.
Can we infer one from the other??? NO
(Data from 361, 622 men worldwide, MRFIT)
Figure shows 3 things: 1)most common distribution of serum cholesterol at initial exam = 5-5.5
2)broken curved line incidence of fatal heart attack rises steeply as chol ↑
3)6-yr death rate was 7.3/1000 - highest % of fatal heart attack occurred
around & slightly above the centre of the chol distribution
only 8% of the total of fatal heart attacks attributable to
cholesterol occurred in the high chol group
39% of fatal heart attacks attributable to chol occurred in men with
chol levels between 5 and 6 mmol/l
at the high levels of cholesterol, personal or individual risk is high -
but not many people have high levels of cholesterol, so not many
fatal heart attacks attributable to cholesterol at the population level
involve people with the highest levels of cholesterol
-must find a way to lower risk of large numbers of people who, more often
than not, will not benefit from the change
-conflict between collective interest, requiring community-wide change, and
individual interest people may not want to bother, but public health will
improve only if they do
It is common to find that the burden of ill health comes more from the many
who are exposed to low inconspicuous risk than from the few who face an
obvious problem. This sets a limit to the effectiveness of an individual (high
risk) approach to prevention.
Geoffrey Rose‘s Prevention Paradox:
A preventive measure which brings much benefit to the population offers
little to each participating individual. (Seatbelt example).
What is Health?:
-―Official‖ (expert) definitions of health
Negative definitions (disease oriented)
o Biomedical model
Positive definitions (holistic) o Social models (e.g., WHO, Health Canada, Antonovsky)
-―Lay‖ (ordinary people) understandings of health
-Aboriginal understandings of health
-Why it matters - measuring health
-Roots in the Greek word ―holos‖ which means ―whole‖
-Hippocrates (400BC) - described health as ―a condition in which the
functions of the body and soul are in harmony with the outside world‖
―Negative‖ understandings of Health:
-Absence of disease or illness; ―normality‖ (healthy because I‘m not sick or
injured). Looks at what you don‘t have rather than what you do have.
Absence of Disease:
-bio-medical understanding of health
―an objective, biophysical, phenomenon characterized by altered
functioning of the body as a biological organism‖ (p. 62)
may or may not be accompanied by feelings of distress, pain,
Problems with dominant biomedical model of health:
-mechanistic, reductionist, technical approach - body separate from mind,
-more attention to disease (and curing it) than health (and promoting it)
-doesn‘t take into account the person
Health as absence of illness:
The subjective feeling of pain or discomfort; may or may not
Self-rated assessments of health correlate well with objective
measures of health (correlates well with the objective measures of
health). Doctors & their patients define & understand health differently:
-Disease: professional/medical diagnosis – medically defined, objective
-Illness: person‘s sense of being unwell – subjective experience of ill health
Social, Holistic or Positive Models of Health:
-health as a positive state
-health is more than just the absence of disease
-focus on what facilitates health
-consider the whole person
-biological processes located within the broader context World Health Organization‘s (WHO) definition of health:
―state of complete physical, mental and social well-being, and not merely
the absence of disease or infirmity‖
Public Health Agency of Canada definitions:
-―health as a capacity or resource, not a state; being able to pursue one‘s
goals, to acquire skills and education, and to grow‖
-―the capacity of people to adapt to, respond to, or control life‘s challenges
Aaron Antonovsky: American-Israeli, survived the Holocaust
-searched to understand the factors contributing to good health, the origins
of good health
-core concepts: salutogenesis, sense of coherence How do we survive (and thrive) in the midst of constant stress and disease?:
Antonovsky‘s term for the origins of positive health
latin salus = health; genesis = origins
-salutogenic model of health
Antonovsky‘s conceptual model to guide our identification and
understanding of the factors that protect and enhance good health
Sense of Coherence (SOC):
―The extent to which one has a pervasive, enduring though dynamic, feeling
of confidence that one‘s environment is predictable and that things will work
out as well as can reasonably be expected.‖
-Having a sense of hope for the future is a determinant of health
extent to which events are perceived as making logical sense, that
they are ordered, consistent, and structured
extent to which a person feels they can cope
how much one feels that life makes sense, and challenges are
worthy of commitment
-Antonovsky showed that those with a high SOC more likely to feel less
stress & tension
-development of strong or weak SOC related to a person‘s natural coping
style, upbringing, education, financial assets, social support
-SOC highest in highest social classes
―Lay‖ understandings of Health:
-consequence of ordinary people‘s attempts to make sense of the numerous
sources of information to which they have access
-pragmatic, enabling us to cope with the complexity of health -vary systematically according to social position (class, gender); also vary by
age and culture
-do not necessarily line up with medical diagnoses of disease
-can be positive or negative
-a state of being (absence of illness) Feeling happy, relaxed, great
-something to be had (reserve of physical health; potential to resist illness)
-a state of doing (well-being; happiness, relaxation)
-being able to carry out everyday responsibilities
Health from Aboriginal Perspectives:
-incorporates spiritual, intellectual, physical, emotional dimensions of life
-exists on multiple levels - individual, family, community, nation
-encompasses cultural, social, economic & political spheres
Aboriginal Medicine Wheel: How do we measure health?:
-Life expectancy/longevity (mortality) – most common
-Infant mortality rates (IMR)
-Subjective experience of symptoms, self-perceptions of health
-Ability to carry out normal daily activities
-Contact with the health system
-what exactly is health?
-how do you define health? how do you experience health? is that different
from your parents? your grandparents? how might (did) your understanding
of health change if you became disabled (or more disabled)? diagnosed with
a chronic disease? a life-threatening disease?
Historical Roots of Public Health:
Louis Villermé, 1782-1863
-Demonstrated a near perfect fit between neighbourhood mortality & relative
poverty; protested against child labour in manufacturing.
-First to show that if you were poorer, (or your neighbourhood was poor)
you would die much earlier.
-Believed social policy could be an important determinant of health;
recommended improving school & working conditions to improve health.
Friedrich Engels, 1820-1895
-No regulations for working conditions, horrible conditions for living in and
-All conceivable evils are heaped upon the poor…They are given damp
dwellings, cellar dens that are not waterproof from below or garrets that leak
from above… They are supplied bad, tattered, or rotten clothing, adulterated
and indigestible food. They are exposed to the most exciting changes of
mental condition, the most violent vibrations between hope and fear... They
are deprived of all enjoyments except sexual indulgence and drunkenness
and are worked every day to the point of complete exhaustion of their
mental and physical energies… Engels Examined:
environmental toxins in houses
infectious disease caused by poor housing conditions (tuberculosis,
lack of medical care
mortality by social class
The organization of economic production (capitalism) forced working-class
people to live and work under circumstances that inevitably caused sickness
and early death. In the trade-off between capitalists‘ profits and workers‘
health, workers always lost. Only a little bit over 100 years ago, the Gov.
started putting restrictions on working environments and conditions.
Rudolf Virchow, 1821-1902
-Founder of ―social medicine‖ Interested in the effects of social and
political forces and how they affect health.
-tried to develop a ―unified theory‖ of how physical and social/political forces
caused disease and suffering
-1847, investigated a typhus epidemic in Upper Silesia; thousands dying
“It is rather certain that hunger and typhus are not produced apart from
each other but that the latter has spread so extensively only through
hunger” (Virchow, letter to his father, 1848)
-overall material conditions of life created the conditions in which either
health or illness flourished
-disease, disability and early death generated through poverty and political
local autonomy in government,
agricultural cooperatives, a more progressive taxation structure (tax higher on the rich, and
lower on the poor)
Edwin Chadwick, 1800-1890
-author of The Sanitary Conditions of the Labouring Population of Great
Britain -> clean water, sewers & adequate housing required to prevent the
spread of infectious disease -> first Public Health Act, 1848
John Snow, 1813-1858
-Leader in the adoption of anaesthesia and medical hygiene
-Founder of epidemiology
-Author of On the Mode of Communication of Cholera, 1849
-believed in the German theory of cholera
-during 1854 epidemic of cholera in London, he spoke to residents; wanting
to know where they accessed their water from, finding all infected residents
had accessed their water from the same Broad St water pump.
-used maps and statistics - beginning of the field of epidemiology
connected the quality of the source of water and cholera cases
Focus of public health throughout most of the 20th century:
-Sanitation; clean water, sewersmany diseases are carried through sewage
-Food regulation and inspection
-Health education, esp. mothers & children
Top Ten Public Health Achievements of the 20th Century (UNC
School of Public Health):
2. motor vehicle safety
3. safer workplaces
4. control of infectious disease
5. decline in deaths from CHD & stroke
6. safer food
7. healthier mothers & babies
8. family planning 9. fluoridation of drinking water
10. recognition of tobacco as a health hazard
Canadian Public Health Association’s Top 12 Public Health
Achievements in past 100 years:
1. Smoking rates down dramatically
2. Vaccination - measles, smallpox, polio virtually gone
3. Motor vehicle deaths reduced by 50% since 1970s
4. Improved conditions for workers
5. Control of infectious diseases such as tuberculosis, cholera, typhus
6. Sharp declines in deaths from heart disease & strokes
7. Food regulation & inspection has reduced food-borne disease
8. Improved maternal & child health: a century ago, 1 in 7 children died
before age 2; death in childbirth common
9. Family planning & women‘s reproductive rights
10. Reduced air/water pollution
11. Social programs - Medicare, old age pensions, child benefits
12. Recognition of the importance of the SDOH
Significance of the LaLonde Report (1974):
-first official Canadian recognition that health depends on more than
the health care system
Goal of the Canadian Government (1974):
-to give as much attention to human biology, the environment and
lifestyle as the financing of health care
-―not only to add years to our life but also life to our years, so that all
can enjoy the opportunities offered by increased economic and social
a condition in which everyone has fair treatment and an impartial
share of society‘s benefits; a fair distribution of advantages/disadvantages
collectivists -> equality of outcomes & economic egalitarianism
achieved through income or property redistribution
neo-liberals -> equality of opportunity achieved through the market Week #3 Lecture and Readings 9/10/2012 8:23:00 AM
For Monday‘s class: Voigt, K. (2010). Smoking and Social Justice. Public
Health Ethics, 3(2), 91-106.
Download at http://dx.doi.org/10.1093/phe/phq006
Questions to help guide your reading will be posted on Moodle
For Thursdays class: Longevity: Nobel‘s greatest prize. (2007, 20
January). The Economist, pg. 88.
Epp Report, 1986 Achieving Health for All: A Framework for Health
-Named for the Minister of National Health and Welfare, Jake Epp
-Official recognition that
disadvantaged groups are sicker, die sooner & have more disability
community support impt for coping & health
Three challenges in improving Canadians‘ health:
1. Reducing health inequities
2. Increasing prevention efforts
3. Enhancing people‘s capacity to cope
The Epp Report proposed that health promotion become a cornerstone of the
Canadian health system, and the primary way to meet the three challenges
- Health promotion: ―the process of enabling people to increase control over,
and to improve, their health‖
Ottawa Charter for Health Promotion (1986):
-Birth of the ―new‖ public health
emphasis on health inequities; broad social factors affecting health
& politics; community involvement not just ―experts‖
-Prerequisites for health:
Peace, shelter, education, food, income, a stable eco-system,
sustainable resources, social justice and equity Health Promotion Actions:
Advocating for health & for the conditions that promote health
Enabling all people to meet their fullest health potential
Mediating between competing interests & coordinating action among
Health Promotion Strategies:
-Build healthy public policy (sidewalks, bike lanes)
-Create supportive environments (natural & built environment)
-Strengthen community action
-Develop personal skills
-Reorient health services towards health promotion
-Relatively new term; no agreed-upon definition
-A concept? Or a field of study of health determinants?
-Same as public health? or different?
-―Population health is an approach to health that aims to
a) improve the health of the entire population and to
b) reduce health inequities among population groups. In order to
reach these objectives, it looks at and acts upon the broad range of
factors and conditions that have a strong influence on our health.‖
-―An underlying assumption of a population health approach is that
reductions in health inequities require reductions in material and social
inequities.‖ (we must lessen the gab between the richest and the poorest)
Health Canada‘s Key determinants of health:
1) Income and social status
2) Social support networks
3) Education and literacy
4) Employment/working conditions
5) Social environments
6) Physical environments
7) Personal health practices and coping skills 8) Healthy child development
9) Biology d genetic endowment
10) Health services
Health inequality refers to differences in the health status of
individuals and groups. The reasons for these differences range from biology
and genetics to broad social and economic factors.
Health inequity refers to health inequalities that are generally
considered to be unfair or unjust and modifiable. For example, Canadians
who live in remote or northern regions do not have the same access to
nutritious foods, such as fruits and veggies as other Canadians.
Health equity is the absence of unfair systems and policies that case
health inequalities. Health equity seeks to reduce inequalities. And to
increase access to opportunities for all.
-Single largest cause of preventable premature death in industrialized
-Associated with higher rates of cancer (lung, larynx, mouth); heart
disease; stroke; lung disease; hypertension; peripheral vascular disease
-estimated 100 million premature deaths worldwide in the 20 thcentury
Risk of lung cancer (2006 European Study)
0.2% for men who never smoked (0.4% for women)
5.5% for male former smokers (2.6% for women)
15.9% for current male smokers (9.5% for women)
24.4% for male heavy smokers (more than 5 cigarettes/day) (18.5%
Smoking rates in Canada
-Peaked in 1965 when 49% of Canadians over the age of 15 smoked
(M: 61%; F: 38%)
-1999: 25% of Canadians over age 15 smoked; 28% of those age 15-
19 smoked -2010: 17% of Canadians over age 15 smoked (4.7 million people) (M:
20%; F: 14%); 12 % of those age 15-19 smoked
-Rates higher among Aboriginal people, lower-income & less-educated
Why have rates gone down? Cultural norms, laws
-Comprehensive, multi-faceted public health efforts have enabled
people to quit
-requires individual action, but the personal, social, political, &
economic context matters
Strategies to Reduce Exposure to Smoke:
-Smoking bans & restrictions (strong evidence of effectiveness)
E.g., in Ontario: smoking is banned in all workplaces & enclosed
spaces open to the public (except private homes & hotel rooms).
Illegal to smoke in a car if travelling with children
Strategies to Reduce Initiation:
-Increase the unit price for tobacco products through taxation (strong
evidence of effectiveness)
-Mass media campaigns (strong evidence of effectiveness when used in
combination with other strategies, such as price increases and school-based
-Prohibition of sale to minors
-Restrictions on advertising and promotion (e.g., bans on sponsorship of
events, transit and outdoor advertising, cartoon characters)
-Illegal for packages to be visible where sold
Strategies to increase cessation:
-Mass media campaigns
-Plain packaging & cigarette package labeling
Health Care Interventions:
-Tobacco use treatment (nicotine replacement therapy)
-Reduced cost of cessation therapies (e.g., nicotine replacement therapy;
cessation groups) -Patient phone support
-Support and counselling from health care providers
WHO: tobacco use is unlike other threats to global health. Infectious
diseases do not employ multinational
Tobacco Industry: Deceit & Denial:
-Throughout the 20 thcentury, the tobacco industry argued:
nicotine was not addictive
link between cancer & smoking was not proven
the industry did not seek to recruit young people to smoke
40 million pages of tobacco industry documents made public in 1998:
-efforts to manipulate scientific research
-artificial ―debates‖ about health impacts of smoking
-attacks on epidemiologists
-recruitment of young smokers as critical to viability
-targeting of women
-industry involvement in illegal activities including cigarette smuggling, anti-
competitive practices, price fixing
-efforts to undermine tobacco control policy & unfavorable initiatives
-lobbying to influence national legislation
-campaigns to circumvent tobacco advertising bans
-use of various methods to maximize the addictive qualities of cigarettes
In 2006, a US District Court found major tobacco companies guilty of a 50-
year conspiracy to deceive and defraud the public about the health risks of
-Judge Gladys Kessler: ―In short, (the) defendants have marketed and sold
their products with zeal, with deception, with a single minded focus on their
financial success, and without regard for the human tragedy or social costs
that success exacted.”
-provinces are suing tobacco companies for health-care costs related to
smoking -average age when smokers begin their habit: 13
-9/10 smokers start smoking before age 18
-considered as addictive as heroin
Opponents of tobacco control legislation emphasize that smoking is an
activity that smokers ―freely‖ engage in and that the risks associated with it
are assumed ―willingly‖ by them. Proponents of tobacco control respond that
the addictive nature of nicotine undermines the voluntariness and autonomy
of smoking decisions, especially when, as we know many smokers become
addicted as adolescents.
Unequal Contexts of ―Choice‖
-less info about health risks (in lower income countries)
-advertising that is targeted to low income groups and higher density of
-different smoking norms; different social meaning of smoking
-means of coping with stress when other coping methods are unavailable
-lack of availability of NRT in lower income countries
How might public health tobacco control strategies be harmful? (p. 96-97)
-higher prices for tobacco takes money away for other things
-increased stigmatization & marginalization
-The policies that aim to improve the living conditions of the disadvantaged
can also be seen as tobacco control policies.
Professor Sir Michael Marmot
Professor of Epidemiology and Public Health, University College
Forefront of research in health inequalities for 30 years
Principal investigator of the Whitehall Studies of British civil
Chair of the WHO Commission on the Social Determinants of Health
(2005-2008) Whitehall I & Whitehall II
Two longitudinal, epidemiological studies of civil servants in the UK
Prospective survey design
o a group of healthy people enrolled in a study & followed over
time to watch for disease development; very powerful
research design; requires large #‘s & long follow-up time;
very expensive, but very powerful
o they follow you to discover what kind of diseases they
develop in later life
o hard to argue with this data
Over 18,000 men aged 40-64 screened between 1967-1969
Classified into 4 grades of employment: administrative, professional
& executive; clerical; other
Exam & health history
Death certificates obtained after 10 years
Predicted that heart disease would result in the individuals with the
highest ranked (or highest stress level) jobs
3-fold difference in mortality between lowest & highest employment
Higher cardiovascular disease mortality among those in ―other‖
group who did not smoke vs administrators who smoked > 20
cigarettes per day
Known risk factors explain only 1/4-1/3 of the differences
General pattern holds for all causes of death, not just
Height inversely related to mortality -> suggests early life
How might ones adult height be influenced by early life? Nutrition (diet)
if you are malnureshed in childhood, you will grow to be shorter,
even if your genetics indicate that you should be tall. Whitehall II:
Over 10,000 people, one third women, aged 35-55, screened
More measurements; included social support, personality measures
Gradients between grades persistent for mortality; similar for
Gradients similar for women as for men
Similar social gradients found for:
o heart disease, some cancers, chronic lung disease,
gastrointestinal disease, depression, suicide, sickness
absence, back pain, general feelings of ill-health
Four main findings:
1) people at the bottom had a higher risk of heart attack than people at the
2) there is a gradient in health
3) gradient applies to all major causes of death
4) classic risk factors (smoking, blood pressure, cholesterol, weight,
inactivity) explain only 1/4-1/3 of the prevalence of heart disease
early life influences;
differences in health behaviours;
social circumstances (housing, social support);
work environment (control; skill level; variety)
How to account for gradients in such different diseases?
o stress hormone that dampens immune system function
o levels rise as rank decreases
o lack of control over work increases BP, heart rate, stress
some combination? other factors Conclusion: we need to pay more attention to job design, social
environments, and the consequences of income inequality - to improve
overall health, we need to decrease social hierarchies and improve people‘s
control over their lives. Decreasing the gap will increase health of the public.
―The Status Syndrome‖ (Marmot):
-the higher the status in the pecking order, the healthier people are - (Nobel
-health follows a gradient that reflects income, education, occupation, early
-above a material threshold, health is more in