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Health Studies
HLTH 101
Elaine Power

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) Texts: Course pack of readings: campus bookstore $20 -As Long as the Rivers Flow $19 Tutorials: 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 Assignments: -As Long as the Rivers Flow book review th -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%) th -Letter to Harper, due November 26 (10%) -Weekly mini-quizzes on Moodle (5%) -Final exam (40%) Book Review: ** 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: Readings 9/10/2012 8:23:00 AM Week 1 • 10 Sept: Introduction to the class Reading: • 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 individualism; The ICE Model - what it is and an application Readings: • 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 Week 2 • 17 Sept: Writing a book review & introducing key concepts for social determinants of health Reading: How to Write a Book Review See: Public Health Agency of Canada, Determinants of Health, See: Strategic Initiatives and Innovations Directorate. (2011). Reducing Health Inequalities: A Challenge for Our Times. Ottawa: Public Health Agency of Canada. Download at: • 18 Sept: What is ―Public Health‖? Rose‘s ―prevention paradox‖; Ideology and Public Health Reading: • 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 Health Reading: • Picard, A. (2010, 17 June). Invisible success: A century of better health. The Globe and Mail,, pp. L1, L4. Download at: century-of-better-public-health-in-canada/article4322199/ and achievements-in-the-past-100-years/article563401/ • See also: Public Health Agency of Canada, Week 3 • 24 Sept: Public health and the case of smoking Reading: Voigt, K. (2010). Smoking and Social Justice. Public Health Ethics, 3(2), 91- 106. Download at • 25 Sept: Overview of research ethics; review of academic integrity & academic misconduct Reading: See: • 27 Sept The Whitehall Studies & the Status Syndrome Reading: • Longevity: Nobel‘s greatest prize. (2007, 20 January). The Economist, pg. 88. Download at: Assignment #1 due at the beginning of class: Book Review #1 of As Long as the Rivers Flow Week 4 • 1 Oct Income Inequality as a Determinant of Health No Reading Video: Episode 1 of Unnatural Causes, In Sickness and In Wealth • 2 Oct Poverty and Income Inequality as a Determinant of Health: The Spirit Level Reading: Sapolsky, R. (2005). Sick of poverty. Scientific American, December, p. 94-99. Download at: erican1205-92.html Video: Stephen Bezruchka, TEDxRainer. • 4 Oct The Impact of the Economic Downturn on Population Health Reading: • Bezruchka, S. (2009). The effect of economic recession on population health. Canadian Medical Association Journal, 181(5), 281. Download at Video: Episode 7, Unnatural Causes, Not Just a Paycheck Week 5 • 8 Oct No class. Happy Thanksgiving weekend • 9 Oct Poverty in Canada and the Health Impacts of Childhood Poverty Reading: • 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 Readings: • Goar, C. (2011, 11 January). Anti-poverty success airbrushed out. The Toronto Star. • 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 everyone-in-canada-20000-a-year-but-are-you-willing-to-trust-the- poor/article560885/ Week 6 • 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** Readings: • 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 Mail. close-canadas-food-banks/article2106989/ • 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. Download at: 159&LangID=E See also Universal Declaration of Human Rights especially Article 25 Week 7 • 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 No Reading • 23 Oct: The Health of Indigenous People in Canada and the Enduring Legacy of Residential Schools Reading: • 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. See also: • 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) Week 8 • 29 Oct: Guest Speakers: Melissa Webster and Krystle Maki, Anti-poverty activism and Put Food in the Budget See: • 30 Oct: Creating Change: How Change Happens (or doesn‘t) Reading: • 1 Nov: Globalization and Health. Introduction to globalization, global health, neoliberalism & key players Reading: • Marmot, M. (2005). Social determinants of health inequalities. The Lancet, 365, 1099-1104. Download at: Week 9 • 5 Nov: Global Crises, Global Health Reading: 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. Download at: • 6 Nov: Global Climate Change and Health no reading for this class • 8 Nov: The Politics of Global Climate Change Reading: McKibben, B. (2012, 19 July). Global Warming's Terrifying New Math, Rolling Stone. Download at 20120719?link=mostpopular1 Week 10 • 12 Nov: Globalization, Trade & Health Reading: • 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. Download at: • 13 Nov: Globalization, Trade & Health Film: Maquilapolis (part 1) • 15 Nov: Globalization, Trade & Health Film: Maquilapolis (part 2) Week 11 • 19 Nov: Structural Violence and HIV/AIDS Reading: • 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 See: and • 22 Nov: Global Health: The Millennium Development Goals Week 12 • 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 health expenses. 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 private property). -―Negative Freedom‖ from interference in my life. Environmental/Green Ideology: -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 Readings Public Health Agency of Canada, Determinants of Health, See: Strategic Initiatives and Innovations Directorate. (2011). Reducing Health Inequalities: A Challenge for Our Times. Ottawa: Public Health Agency of Canada. Download at: 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  Immigrant groups  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.
 even when 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 age. 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 campaigns. -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 everyone. “We cannot rate our collective health and well-being by looking only at those who are healthiest. We must also consider those left behind.” – dr. david Butler-Jones, chief Public health officer of canada Hamburger method vs Hamburger soup method (Danielle Lorenz) university-vs-high-school/ See also links for parts 2-5 in this series about essay writing (links at bottom of page listed above) Lecture 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 Introduction: 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!! Thesis Statement: Clearly states your topic PLUS an arguable opinion -Takes a position -Answer What?, How?, and Why? in developing your thesis  how-to-form-a-proper-thesis-statement/  ment.htm Mapping Statement: 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. Body Paragraphs: -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 Remember… -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 novel!) Tips: -Leave yourself lots of time. Start early. Leave your essay for a day before you proofread. -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 sense! -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‖ from ICE) -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 essay. -Your second essay will likely be very different than the first Referencing: -Use APA style  -Essay #1 –references other than the novel not required -Essay #2 – expect you to reference course materials, lecture notes, other materials -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. Marking: -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 name -YOUR TA‘s NAME! -Your tutorial section -Word Count 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 -prevention paradox 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. Question: 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 mmol/l. 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 Implication: -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 Rose‘s Conclusion: 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 ―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 Disease:  ―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, discomfort Problems with dominant biomedical model of health: -mechanistic, reductionist, technical approach - body separate from mind, emotions, spirit/soul -more attention to disease (and curing it) than health (and promoting it) -doesn‘t take into account the person Health as absence of illness: Illness:  The subjective feeling of pain or discomfort; may or may not accompany disease  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 pathology -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 and changes‖ 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?: -salutogenesis  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 Three Components: -Comprehensibility  extent to which events are perceived as making logical sense, that they are ordered, consistent, and structured -Manageability  extent to which a person feels they can cope -Meaningfulness  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 Examples -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: -holistic -incorporates spiritual, intellectual, physical, emotional dimensions of life -inter-generational -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) -Diseases (morbidity) -Subjective experience of symptoms, self-perceptions of health -Ability to carry out normal daily activities -Fitness -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 working in -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  occupational diseases  infectious disease caused by poor housing conditions (tuberculosis, typhus)  nutrition  alcoholism  lack of medical care  accidents  mortality by social class Concluding… 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) Concluding… -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 disenfranchisement Recommended:  increased employment,  better wages,  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, sewersmany diseases are carried through sewage -Immunizations -Food regulation and inspection -Health education, esp. mothers & children Top Ten Public Health Achievements of the 20th Century (UNC School of Public Health): 1. vaccination 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 justice‖ Social Justice 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 Reading For Monday‘s class: Voigt, K. (2010). Smoking and Social Justice. Public Health Ethics, 3(2), 91-106. Download at 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. Download at: Lecture Epp Report, 1986 Achieving Health for All: A Framework for Health Promotion -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 various sectors 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 Population Health: -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 11) Gender 12) Culture 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. Tobacco Use: -Single largest cause of preventable premature death in industrialized countries -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% for women) 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 education) -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: -Price increases -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 smoking -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.” In Canada: -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 Opposing Proponents: 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 advertising -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. Whitehall Studies Professor Sir Michael Marmot  Professor of Epidemiology and Public Health, University College London  Forefront of research in health inequalities for 30 years  Principal investigator of the Whitehall Studies of British civil servants  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 Whitehall I:  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 Results:  3-fold difference in mortality between lowest & highest employment grades  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 cardiovascular disease  Height inversely related to mortality -> suggests early life influences  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 between 1985-1987  More measurements; included social support, personality measures Results:  Gradients between grades persistent for mortality; similar for morbidity  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 top 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 Possible Explanations  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?  cortisol? 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 hormones  self-esteem?  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 article) -health follows a gradient that reflects income, education, occupation, early childhood influences -above a material threshold, health is more in
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