Chapter 9: Politics, Public Policy and Health Inequalities
Policy is a course of action that is anchored in a set of values regarding appropriate public goals, and a
set of beliefs about the best way of achieving those goals.
Public policy implicitly argues that an issue is no longer a private affair. That issue has consequences for
collective well-being and must be regulated. There is always debate as to whether an issue is private
affair or a public matter. Equally, there is debate about public goals and how they ought to be
achieved. Crucial to remember that public policy is shaped by political, economic and social forces.
Examples include the long-gun registry in Canada and the gun ownership in the U.S.
Yet, policy is inescapable in relation to many aspects of collective life. Since many issues have
implications for collective well-being. Recall that health is a function of a variety of social determinants,
including health care and services. Policy directed to any of these social determinants of health will
invariably impact the health of Canadians.
List of social determinants are: Affordable housing, employment and working conditions, education and
training, health care and services, sports and recreation.
Unionization is a state of harmony or agreement: the act of joining together in a context. There is a
relationship between unionization levels and the health of a population. Research indicates that social
democratic regimes have higher levels of unionization. Also, higher levels of social security and public
health care expenditures and coverage. Implemented full employment strategies, attained high rates of
female employment, showed the lowest levels of income inequality and poverty rates, lowest rates of
infant mortality. In the U.S., unionization and the ability to organize is weakly supported and actively
Rates of Unionization - Sweden – 79% Norway – 54% Canada – 38% U.K. – 29% U.S. – 13%
Housing: Affordable housing policy, CHMC, Tenant Laws
Education: Daycare (national childcare policy), Kindergarten, Commitment to public education, Extra-
curricular programs, Student Loans/Aid, Scholarships
Sports and Recreation: Cricket versus Yachting, $78M vs. $1.6M
Reading - Edwards. As Good As It Gets
Sweden and Norway represent social democratic welfare states, while the US, UK and Canada are liberal
welfare states. Canada is closer to US in its welfare positions compared to France and Germany.
Canada’s social spending has been falling dramatically towards health care and social services.
Increases in life expectancy was due to increases in the following: support for social democratic parties,
proportion of population voting, public health care coverage, proportion of population employed,
female labour force participation, income inequality and national wealth. Chapter 11: Evolution of health care policy
A universal, publicly funded and comprehensive system that serves the needs of all. A fee-for-service
model built on private practice and public payment (In US). Financed through taxes and administered
publicly (In CA). It spreads the risk across the entire population so that insurance is affordable for all.
One purchaser or single-payer (monopsony) means more effective cost control. It also provides
universal coverage for all Canadians. The Canada Health Act insures services to all Canadians.
US has chosen to insure populations. Uncovered population must secure own coverage, often through
the employer. Insurance companies charge higher premiums to those with pre-existing conditions. Such
high premiums exclude those who cannot afford the premiums an absence of cost control.
Insurance companies compete for health care professionals, thus increasing the cost of services and
drugs. CHA (Canadian health association) ensured that virtually all Canadians had access to medical
services. In contrast, public and private commitments to health insurance declined in the US.
Companies reduced health insurance coverage due to rising costs of health benefits. Employees paid
greater share of premiums and costs. Increase in part-time employees without health benefits.
In Canada, provincial public insurance plans develop contracts with private non-profit care institutions
and practitioners to deliver care. This speaks to the values that inform a culture and its social and
political institutions; community versus individualism, limited government and free market.
Political system in US makes change in direction difficult. There are three levels of government, each
with refusal power. There is no party discipline. Also, the PM is the head of the governing party, making
it more difficult for lobbyists to oppose policy supported by government. Where as party discipline in
Canada makes it easier for policy change by the governing party. Change of course is also difficult to
achieve in Canada as the existing system becomes entrenched.
Canada is not as radically different from the US in terms of health of the population. Wait times and
absence of sufficient investment in education and general welfare (housing) pose significant health
challenges to Canadians. In Canada, public financing and public delivery offer good cost control and
good equity. However, suffer from questionable client responsiveness (lack of accountability; wait
Private insurance companies in the US limit the types of treatments clients’ insurance plans cover. This is
a restriction on both the client and the physician. No such restriction exists for Canadian physicians.
Price regulation of pharmaceuticals make them more accessible because price differentials are 50%
lower for medicines in Canada. No competition for patented products. Accounts for why Canada
Compare public investment in health rather than health care. Grounded in questionable relationship
between medicine and health (social determinants of health). There is a strong correlation between
social spending and health status. Chapter 7: Social Class and Health Inequalities
The Canada Health Act guarantees access to health care for all Canadians. Does a universal health care
system neutralize social class as a significant determinant of health? That would have to assume that the
interventions of the medical system are the primary determinant of health. Health is also influenced by
individual behavior (“lifestyle” choices) or “risk factors”.
Social class organizes people in terms of relative disadvantage and it represents a means through which
patterns of privilege and reward are distributed. It influences the choices or alternatives that are
available to members. Social class corresponds roughly to occupation (income and/or status).
Socio-economic status (SES) – income, education and occupation. Social class exceeds SES – Wealth,
Power and Prestige. SES has been called the ‘magic bullet’ via its influence on health and well-being.
Health can be directly influenced by a combination of “knowledge, money, power, prestige, and social
connections” that are directed to that objective. Important to recognize that social selection (poor
health) impacts SES. That is, poor health restricts income and education. In this way, social class
influences life chances, including health outcomes. Privileged classes “benefit from greater health
education and awareness, access to prevention, and the capacity to avoid risk factors”
SES is associated with mortality, morbidity, and mental health. Difference between density and
overcrowding. Overcrowding is where the infrastructure/amenities are incommensurate with the
High levels of SES inequality will therefore translate into high levels of health inequality. Life expectancy
is a key indicator of population health. High SES translates to greater life expectancy, longer disability-
free life expectancy.
Infant mortality (another key indicator) is 5x higher amongst low income vs middle income in Saskatoon.
Suicide rates 16x higher. Much greater rates of hospitalization amongst low income people.
Poverty almost guarantees poor health. “Markers of poverty that are written on physical bodies include
poor posture…broken and/or missing discoloured teeth, scars” The very poor are made to feel ashamed
of their predicament and blameworthy.
Poor mental health is also more likely to be reported amongst the lower income groups. For example,
depression is highest among the lowest income earners. Amongst highly developed countries, greater
income inequality correlates with higher prevalence of major depressive disorder.
The health benefits of education exceed the income benefits that it brings. Education is positively
correlated with health, including mental health. “Education develops habits, skills, resources, and
abilities that enable people to achieve a better life.”
Both structural conditions (housing, employment, physical environment, etc) and psychosocial variables
(perceptions of inequality, health behaviors, and cognitive processes) account for population health. Social Capital and Income Inequality
Although economic capital and cultural capital tend to be private goods. Social capital is a public good
created as a by-product of social relationships. Social capital is the collective equivalent of the social
network of individuals. In the same way that an individual benefits from a rich social network, so too
does the community benefit from being richly integrated.
Social capital – features of social organization, such as civic participation, norms of reciprocity, and trust
in others that facilitate cooperation for mutual benefit.
Civic engagement – the extent to which citizens involve themselves in their communities, as most often
measured by their membership in groups and associations.
Church, school, political and sports groups; labour unions; professional or academic societies, and
What’s the relationship between voting (voter turnout) and social capital? Criticism of urban life is that
anonymity and plurality makes for reduced social capital.
Social capital tends to be in shorter supply amongst younger age groups, those with less than high
school education and African Americans. Low levels of social capital correlates with distrust, crime, and
corruption. Lack of civic engagement: disinterest in politics; lack of voting.
Positive relationship between income inequality and disinvestment in social capital.
Social trust and civic engagement, combined with little support for progressive social policies, negatively
correlated with morbidity and mortality. Infant mortality; coronary heart disease; accidents. Like most
types of public goods, social capital tends to under produced if left to the market.
For community members, access to its benefits are unrestricted. High social capital potentially benefits
everyone, even those who are unwilling or unable to be active in the life of the community. Comparable
to the “herd effect”
Conversely, the stock of individual resources in a community cannot compensate for an absence of
“Societies that permit large disparities in income to develop also tend to be the ones that underinvest in
human capital (e.g., education), health care, and other factors that promote health”. Social capital is not
a solution for the variety of social ills, but it makes for improved access to collective resources and life
chances. Immigration and Ethnicity
Readings explore the ways in which the immigrant experience is a social determinant of health. More
than one in five Canadian is foreign born.
Good health is a condition of immigration (medical testing is used to screen immigrants). Also, healthier
(younger, better educated) self-select as immigrants. Typical immigrant arrives in better health than
Canadian average. Makes less use of the health care system. That means recent immigrants likely to be
amongst the healthiest in the Canadian population.
Yet, 11 of 16 women indicated that their health had worsened after living in Canada. Consistent with
finding that as period of residence increases for immigrants, so does the prevalence of chronic
conditions and disability. Health status advantage decreases or even disappears over time (after 10
years or so, begins to converge with the Canadian norm). Some of the decline attributed to the adoption
of mainstream beliefs, attitudes, and lifestyle behaviors (dietary changes; alcohol consumption).
Other determinants include language and cultural barriers to the provision and utilization of services.
Increasing proportion of new immigrants are allophones. Eng/Fr language proficiency is more strongly
associated with better health for immigrants.
Plus discrimination and marginalization in employment, housing, work conditions, income, and social
situations. Lack of recognition of education and past work experience. Education level often not
commensurate with income. Forced to obtain additional educational training. Immigrants (esp, visible
minorities) likely to experience social exclusion on the basis of their status (socio-economic).
Denigration of education and experience, combined with loss of social network, often resulted in
depression, resentment and anger. Therefore they experience high levels of stress and may not possess
adequate coping resources. Contributes to lower health status and higher health risk at different stages
in the life-course. Reports of crying, depression and overwhelming “body aches” are symptoms of well-
being attributable to immigrant experience. In other words, the immigrant experience seems to
contribute to a worsening of health.
Explains, in part, why immigrants tend to gravitate to areas where other similar immigrants live. It
translates into a form of social capital. Sexuality and Health
LGBT comprise in excess of 2 million Canadians. Somewhere between 5-10% of the population. Might
even be higher as Canada attracts increasing numbers of LGBT immigrants. Due to legislated human
rights for queer people: rights relating to protection from discrimination, pensions, adoption, the
recognition of partners as next-of-kin, and marriage. Yet, there are virtually no education/training
programs in relation to cultural competence of LGBT populations. “Treat everyone the same”. Among
those 18-59, 21.8% of homosexuals and bisexuals reported unmet health care needs.
Popular opinion assumes HIV/AIDS as only health issue for LGBT communities. Some see LGBTs as
suffering from mental illness. The most common health illnesses among LGBT are depression, anxiety,
suicidal and substance abuse. All related to stress, discrimination and the threat of violence. The threat
of violence is especially pronounced for the gay man or the lesbian who is masculine. For trans people,
the risk is even greater (seen to be breaching gender norms). Verbal assault is almost common place.
One report suggests 78% of lesbians and gay men experience verbal assault.
Good health care is much more than infrastructure, technology, technical and clinical competence.
Depends significantly on quality of interpersonal communication and dynamic between provider and
client. Physicians in positions of authority: diagnostic knowledge, clinical expertise and social esteem.
Often reflects a gap such as gender, class, caste, ethnicity, sexuality. That gap (power differential) is
most apparent when practitioners are men and clients are women. “You are already one down because
you need something. You are in a supplicant position. Physicians have the power. You need something
they have, even if it is just comfort or a diagnosis or a referral”. Lesbians and gay men are at greater risk
than general population for receiving missed diagnosis and for potentially poorer treatment outcomes.
Less collaborative relationship. “Is your weight a concern to you?” Empowering Information Exchange;
attend to clients’ knowledge needs, ccommunicate relevant health information, explain rationale behind
diagnosis and treatment recommendations Negotiated Action; secured input in relation to treatment,
seeks to understand client’s principles. Instead we often find domination, Withholding Information;
“Left in the dark about their health”, refusal to explain and clarify. Frightening diagnosis cavalierly
delivered, often speculative and then told to come back weeks or months later. Defensive Dismissals;
self-diagnoses unwelcome, dismissive of patient knowledge and understanding of one’s own body,
treated as threat to authority rather than seen as client knowing something about their situation. Sexist
Comments; demeaning expressions and flirtations, sexual harassment. Body Sculpting; presumptions
around what a woman’s body ought to look like and suggested interventions to make change, estrogen
to increase “feminine presentation” Reproductive Regulation; regulate birthrate among particular
female populations, low income and women of color. Bodily Transgression; aggressive handling,
unpleasant examinations, sexual abuse, ranging from fondling to sexual intercourse.
Damaging to health and well-being which can lead to abandoning of health care seeking. The ideology of
heterosexuality often prevents lesbian women and gay men from exercising their full rights as citizens to
health provisions as guaranteed by the Canada Health Act. Employment and Occupational Health and Safety
Work typically dominates much of one’s adult life. Therefore, career and working conditions will
necessarily have an impact on health and well-being.
What are some dimensions of work that might impact health and well-being? Global competition and
mobility of capital has significantly influe