minimizing health inequity through the social determinants of urban health: a health geography...

8/8/2019 Minimizing health inequity through the social determinants of urban health: A health geography perspective on air

1/22

Research Paper for Geography 3820H

Minimizing health inequity through the socialdeterminants of urban health: A Health Geography

perspective on air pollution in Toronto

by

Timothy M. Shah

December 2009

Prepared for

Dr. Mark Skinner


2/22

Introduction

The rise of air pollution in urban Canada is an omnipresent reality. Over the years,

epidemiologists, public health experts, sociologists and economists have successfully shown that

air pollution produces multiple negative consequences for society including economic costs,

health care demands and poor environmental conditions (Toronto Public Health, 2004). Many of

these quantitative studies have shown how social deprivation and low income can greatly impact

a communitys exposure to air pollution (see Burra et al. 2009). For example, public health and

environmental research have statistically shown the rise of traffic related emissions in urban

areas across Canada; attributing this rise to increased automobility use and commuting patterns

in urban environments (Toronto Public Health, 2004). Of late, social and health geographers

have become more interested in the uneven geographical distribution of social deprivation and

traffic emissions (Ross et al. 2009). Multiple socio-economic groups constitute an urban area;

certain groups are more socio-economically disadvantaged than others and thus their utilization

of health services might be greater than their healthier urban counterparts.

Understanding a neighbourhoods exposure to poor air quality or air pollution in cities is crucial

for influencing public health interventions and policies. However, as this research paper will

illustrate, in cities like Toronto, air pollution is a ubiquitous phenomenon with pollutants

concentrated around major arterial roads across the city (Chiotti, 2004). Thus, many socio-

economic groups can be exposed to urban air pollution but how these groups access health and

medical resources and cope with such health conditions can be drastically different (Burra et al.

2009). From a health geography lens, it is critical that we examine both differential exposure and

differential susceptibility to air pollution in cities like Toronto. By focusing on differential

susceptibility, public health policies can be more effective at reducing health inequities by

directing resources to those that need it most.

Air pollution and health care inequity are highly complex phenomena that cannot exclusively be

studied through quantitative analyzes. What are now emerging out of health geography are the

social determinants of health concept. This paper will analyze and interpret the social

determinants of urban health and explain why it is critical to study the local and physical urban

environments of Torontos neighbourhoods which might promote or inhibit health. The major

2


3/22

theoretical construction of this paper attempts to draw on literature that reviews the correlation

between socio-economic status and health inequity.

Torontos Central Local Health and Integration Network (LHIN) is in the midst of creating

health equity strategies to minimize disparities and inequities in health outcomes for the citys

residents (Gardner, 2008). With a variety of strategies in hand, the LHIN can greatly benefit

from learning about how the social determinants of health concept. Specifically, how this

concept can help and better address low socio-economic status groups in coping with health

conditions that result from exposure to air pollution.

This paper will provide recommendations for the LHIN. Public health policy can be better

operationalized if professionals such as health geographers vigorously employ qualitative

research methods to investigate the social determinants of health in Torontos poorer

neighbourhoods. However, health geographers must work with other professionals in a holistic

manner to truly alleviate the existing health inequities prevalent in urban environments such as

Toronto. Therefore, this paper is more interested in socio-economic status (SES) than income, as

SES is more holistic and can inform a better understanding of the present health inequities. This

can ultimately reveal significant findings and direct resources and services to those who need

them most.

Community Profile

Toronto is Canadas largest city, with a population of 2.5 million (Toronto, 2009). With about

632 square kilometers of geographical expanse, the citys total area and population make it the

biggest in the country (Hulchanski, 2007). The city is socioeconomically and ethnically diverse,

concentrated in different parts of the urban core. There has been a 20 percent increase in the

citys population since the 1970s with immigrants presently constituting 50 percent of Torontos

population (Hulchanski, 2007). The city has 527 census tracts with populations ranging from

2,500 to 8000 for each of these tracts (Hulchanski, 2007). Toronto has been selected as the case

study because of its significant city-wide income inequality. Based on 1996 data, the average

census tract household income in quintile one ranged from $18,901 to $42,688 and in quintile

five, the range was between $76,032 and $245,701 (Burra et al. 2009).

3


4/22

In 2006, Torontos population had the greatest proportion of people living with low income of

the 36 public health units in Ontario (Toronto Public Health, 2008). In 2005, 24.5 percent of

Torontos population lived below the Statistics Canada low income cut-off (before tax), up from

22.6 percent in 2000 (Toronto Public Health, 2008). Approximately one-third of Torontos

children under six years old lived below the low income cut-off (LICO) rate in 2005 (Toronto

Public Health, 2008). Over 20 percent of Torontonians aged 65 years and older lived below the

LICO in 2005 compared to 9.4 percent in the rest of Ontario and 14.4 percent in Canada

(Toronto Public Health, 2008).

In Toronto, air pollution contributes about 1,700 pre-mature deaths and 6,000 admissions to

hospitals each year (Toronto Public Health, 2004). Whats more, the major source of ambient air

pollutants in Toronto is the transportation sector. This has resulted in an excess of nitrogen

dioxide levels which have exacerbated air quality and reduced the quality of life for Torontos

children and adults (Toronto Public Health, 2004). While nitrogen dioxide levels have declined

in Ontario, these rates have been consistently rising in Toronto (Toronto Public Health, 2004).

For Toronto, air pollution disproportionately causes many lower-income populations to access

ambulatory services for conditions such as asthma and cardiovascular disease (Burra et al. 2009).

To illustrate how air pollution is more symptomatic of socio-economic status and not just

income, Appendix 1 provides a series of maps showing the socio-economic indicators for the

city. These maps include the spatial distribution of income, unemployment, educational

attainment and rented dwellings - all of which reflect the social determinants of health which will

be explained. Figure 1 shows a map of Toronto with the number of families under the low-

income cut-off point. This map sets the context in explaining how income inequality is an

ongoing phenomenon in Toronto. This paper is not meant to write about income inequality, but

address how a variation in urban income for the city can reveal important socio-economic

indicators that the Central LHIN should be more aware of.

4


5/22

Figure 1. Spatial Distribution of families under LICO (Toronto Community Health, 2005)

Air Pollution in Toronto: an Urban Health Issue

Air pollution is an egregious urban health issue of our time. In Toronto, on-road and off-road

vehicles are estimated to generate 38 percent of nitrogen dioxide (NO2), 38 percent of sulphur

dioxide (SO2), 74 percent of carbon dioxide (CO2), 25 percent of particulate matter with

diameters of particulate 10 and 2.5 and 15 percent of volatile organic compounds (VOC)

emissions (Chiotti, 2004). Toronto has the highest summertime levels of fine particulates and the

5


6/22

highest annual mean levels of nitrogen dioxide levels (Chiotti, 2004). Smog alert days have also

been on the rise for the city and this is largely attributed to an increased number of vehicles on

the road (Chiotti, 2004). There were 27 smog alert days in 2002, up from just 3 in the year 2000

(Chiotti, 2004). Since the 1980s, there has been a steady increase in ozone levels in Toronto.

Ozone triggers asthmatic attacks among those suffering chronically from the disease (Toronto

Public Health, 2004). Also over the last two decades, the number of vehicles entering the city

each weekday morning increased by 75 percent (Toronto Public Health, 2004).

An increase in the number of vehicles entering the city has numerous implications. Toronto finds

itself situated in the heart of the Greater Golden Horseshoe. As the region continues to grow in

population, urban sprawl may lead to the worsening of air quality conditions for many

municipalities. It is estimated that 3.5 million people will join the Greater Golden Horseshoe by

2035; this will lead to an expanding transportation sector that is conducive to automobility and

public transit (Chiotti, 2004). However, public transit will have to be given policy weight not

only for reasons of smart growth and providing for densification, but alleviating the pernicious

air pollutant sources derived from motor vehicles. Therefore this is not just a planning issue for

the Ministry of Public Infrastructural Renewal; it is an issue that should be high on the agenda of

the Ministry of Health and Long-Term Care and Torontos Central LHIN.

Epidemiological research has conclusively proven that exposure to air pollution can exacerbate

asthma conditions, induce heart attacks, reduce overall lung function, trigger cardiovascular

diseases and bring about chronic obstructive pulmonary disease (COPD), just to name a few

(Toronto Public Health, 2004). As the academic literature will explain, it has been corroborated

that lower socio-economic groups are at much higher risk to these health conditions because of

their exposure to air pollution (Lin et al. 2003).

Review of Literature

Urban sprawl invariably intensifies air pollution. Citizens living around the boundaries of

Toronto can find themselves making longer commutes to their urban workplace using major

arterial roads like the Don Valley Parkway and Highway 404. These arterial roads are only

becoming more popular as the city grows. Finkelstein et al. (2004) showed using cox

6


7/22


8/22

Investigating whether these individuals are aware of these ostensible risks would help their

community produce vivid illustrations of the health risks that they can contract or exacerbate

such as asthma, chronic obstructive pulmonary disease and cardiovascular disease. As Raphael et

al. (2008) explained, allowing community members to understand these health and social issues

such as crime, mental illness and high levels of stress, will help people better understand their

health and well-being.

There are two other studies that have explored the connection between social deprivation and

traffic emissions. The first is a study on social disadvantage, air pollution and asthma physician

visits in Toronto. Burra et al. (2009) look at the five income quintile groups in Toronto that are

dispersed over 450 census tracts. They explain that given the large population at risk, increased

ambulatory consultations likely represent another facet of the public health impact and societal

burden of exposure to urban air pollutants (Burra et al. 2009). Their first conclusion is that

groups with lower socio-economic status are at much higher risk of asthma morbidity than

groups in higher income quintiles.

There is approximately a three-fold difference in ambulatory asthma visit rates in the lowest vs.

highest income quintiles (Burra et al. 2009). For males aged 1-17 years, the mean daily visit rate

is 5.96 per 10,000 for the lowest income quintile and 2.17 for the highest income quintile (Burra

et al. 2009). Excess physician visits associated with air pollution constitute a substantial societal

cost. The Ontario Medical Association estimates that the annual cost of air pollution on the

provincial health care system is $1 billion (Toronto Public Health, 2004). Burra et al. (2009)

explain that a one inter-quartile increase in the concentration of nitrogen dioxide is associated

with 88,700 extra visits over the 10-year study period. Air pollution also induces cardiovascular

disease (CVD) which also has revealing disparities. One study of Toronto showed that the

absolute difference in CVD premature mortality rates was 42 per 10,000 for males in the lowest

income quintile compared to the highest income quintile (Toronto Public Health, 2008).

This study portends that even in a society where access to universal health care is made possible,

there are vulnerable populations who utilize ambulatory care and hospital services more than

others. While this study provides a laudable statistical analysis to illustrate the differences in

asthma morbidity and ambulatory care utilization between income quintiles, as health

8


9/22

geographers, we need to explore why these disparities exist in the first place. There must be

more of an informed understanding of the context in which lower socio-economic groups live in.

As previously mentioned, housing conditions are worth investigating but also the nutritional food

status, domestic violence and psycho-social stress levels of the households in these deprived

neighbourhoods.

Another relevant study published in the Social Science and Medicine Journal (2009) looked at

the double burden of deprivation and ambient air pollution at the neighbourhood scale in

Montreal. Using geographical information systems (GIS) as a quantitative method, the authors

create a spatial model of predicting mean annual concentrations of NO2 across Montreal. Using

Pearson correlation coefficients, they examined a series of neighbourhood level indicators of

deprivation and levels of ambient NO2. Ross et al. (2009) find that the association with

particulate pollution was stronger for both cardiopulmonary and lung cancer mortality among

individuals with lower levels of education. The neighbourhoods with lower SES had higher

proportions of unemployed adults, visible minorities, and lower levels of educational attainment

(Ross et al. 2009). These neighbourhoods according to Ross et al. were positively associated

with higher exposure to ambient levels of NO2. This is yet another study with findings that

suggest that social determinants of health like educational attainment can be correlated with

higher exposure to ambient levels of air pollution. The lack of qualitative analysis in these

studies does not tell us why this is the case.

A study conducted in Vancouver found a strong association between exposure to particulate

matter and mortality in populations with lower educational attainment and income relative to

those with higher levels (Lin et al. 2003). As the authors write, the study did not investigate

how such indicators would help unravel various pathways (material, behavioural) through which

SES may influence the relation between health outcomes and exposure (Lin et al. 2003).

Vancouver is another example of an urban centre that faces challenges with air pollution. While

the city has made some notable improvements with sustainability and public transportation (see

Brugmann, 2009), its air pollution conundrum continues to disproportionately affect lower

income groups.

9


10/22

The point of using this study along with Montreal is to show that air pollution is a multifaceted

issue crossing environmental, epidemiological and geographical boundaries. These studies do

present the uneven geographical distributions of social deprivation and traffic emissions, but they

do not investigate the social determinants of urban health- undoubtedly the major causes of

health conditions in the first place.

A review of air pollution and SES in Rome will conclude this section. It is the findings in this

study that challenge the conventional belief that only lower socio-economic groups are exposed

to air pollution. Tasco et al. (2007) explain that in Rome, people with high SES are paradoxically

more exposed to traffic-related pollution than lower SES. This finding is not in line with the

preceding examples which corroborated that people with lower SES are more exposed to air

pollution. In Rome, daily particulate matter affects a large sector of the population. However, the

people of high social class are not affected by the negative effects of air pollution to the extent of

citizens in other social class categories (Tasco et al. 2007). Thus, this should lead health

geographers to focus not just on differential exposure to air pollution among social groups, but

also differential susceptibility.

How does exposure increase susceptibility? Higher susceptibility to disease in more

disadvantaged people is influenced by socio-economic circumstances acting at different stages of

the life course in a complex accumulation of risks (Tasco et al. 2007). Lower SES households

might have higher levels of stress, violence and poor nutritional value. Consequently, individuals

who have high hypertension levels of stress and poor health status such as obesity may be less

able to cope with the effects of air pollution on the heart (Tasco et al. 2007). The authors also

found that air pollution is stronger in individuals with increased baseline systemic inflammation

and oxidative stress.

Figure 2. Map of metropolitan area of Rome showing the areas where specific measures

have been adopted to limit traffic and air pollution (Tasco et al. 2007).

10


11/22

While the focus of this paper is on Toronto, I show this map because it provides a good

illustration of city zoning in Rome. In the 1980s, heavy use of automobiles created egregious

congestion and air pollution in the urban core of Rome. As a policy strategy, the city decided to

create a limited traffic zone to minimize the number of cars allowed in the core of the city. In

spite of this strategy, this part of the city still has the highest number of traffic emissions (Tasco

et al. 2007). A small portion of the citys population live in the central part of the city, and the

social class distribution in the city centre is skewed towards high social class. Further, the

percentage of households in the high emission categories for all of the traffic pollutants increases

with increasing income and SES (Tasco et al. 2007). Last, households of higher social class are

more likely to be located in areas with high traffic emissions and this disparity is stronger when

SES rather than income is considered (Tasco et al. 2007).

A similarity in the studies is that they all use SES as a criterion. SES is more comprehensive than

income because SES constitutes the distribution of educational attainment, unemployment rates,

family size, occupational categories and the proportion of dwellings rented and owned (see

Appendix 1). However, this study, while predominantly quantitative, uses SES to examine the

disparities in health conditions like hypertensive disease, COPD, conduction disorders,

cardiovascular diseases and so on and so forth. The data shows a huge disparity in hypertensive

disease among low and high SES. The distribution of hypertensive disease for low SES is 20.5

percent whereas for the highest SES group it is 14.6 percent (Tasco et al. 2007). This disparity

reveals that low SES households have higher levels of stress which brings about hypertensive

disease and consequently reduces overall health and well-being. Combined, this makes people of

11


12/22

this SES group more susceptible to air pollution. This study unlike the others, show that the main

explanation for the strong effect modification by SES is differential susceptibility.

Social Determinants of Urban Health

This section will discuss the social determinants of health concept emphasizing how its

interdisciplinarity can be useful for alleviating some of the present health inequities in Toronto.

The social determinants of urban health are indispensable for fair and equitable public health

policy changes. Unfortunately, the use of social determinants has been neglected by the health

sciences, public health and governmental health authorities in Canada (Raphael et al. 2008). As

shown in the literature review, public health analyses have focused too much on the use of

quantitative approaches to understanding health and its determinants. In Canada, there has been a

tendency towards viewing these sources of health and illness as emanating from individual

dispositions and actions rather than resulting from the influence of societal structures (Raphael et

al. 2008). Raphael et al. claim that this is a reflection of positivist science.

The quantitative analyses are useful in informing the distribution of health care service resources

and examining the effects of characteristics of place on health (Gatrell & Elliot, 2009). In terms

of actually alleviating some of these disparities, public health experts and geographers must

carefully look at the various neighbourhoods or census tracts in Toronto to investigate how

healthy they really are. As shown in the maps in Appendix 1, many of these Toronto

neighbourhoods have material deprivation including lack of income and wealth, lower levels of

educational attainment, poor quality housing and unemployment. This can lead one to conclude

that some of these neighbourhoods might have poor health as a result of a poor physical

environment. Social capital, which are the social networks, connections and institutional links

are all significant determinants of an individual or neighbourhoods overall health (Frohlich et al.

2006). Individual social networks, which are the social connections and relations they have with

friends and family, are also predictor of all-cause and cause-specific, mortality or of poor health

(Gatrell & Elliot, 2009).

If people have feelings of distrust and insecurity in their neighbourhoods, or have poor relations

and connections with neighbours, then they may be more stressed and suffer from diseases such

12


13/22

as hypertensive disease. Political scientist Robert Putnam and geographer Nancy Ross have

shown that components of social capital like community organizational life, engagement with

public affairs and informal sociability are critical for increasing human health and welfare for

any neighbourhood irrespective of socio-economic class (Jackson, 2003). With more social

contact in neighbourhoods, people can interact, socialize and express greater happiness within

their physical surrounding (Jackson, 2003). Poor social capital can intensify illnesses and

respiratory conditions and increase over susceptibility to air pollution.

As Tasco et al. (2007) has shown, lower socio-economic status citizens have higher

susceptibility to disease due to risk factors such as violence, low educational attainment,

psychosocial stress and exposure to environmental hazards. Rented dwellings, unemployment

rates, lower income, educational attainment and access to social networks are all determinants of

health for a given neighbourhood in Toronto. These determinants are proxies for opportunities,

resources and constraints; all of which influence health outcomes.

The findings from the Rome study can be applied to Torontos geographical parameters. It is

difficult to directly make assumptions that lower socio-economic status groups are more exposed

to air pollution than higher SES groups. These groups are living in close proximity to one

another and are not totally segregated. However, some households can have much higher rates of

disease than others.

13


14/22

Recommendations for the Toronto Central LHIN

The proposed health equity vision for the Toronto Central LHIN is to create and sustain a

healthcare system in Toronto where all have equitable access to a full range of high-quality

healthcare and support, and systemic and avoidable health disparities are steadily reduced

(Gardner, 2008). Thehealth equity vision also includes the LHIN collaborating with other health

service providers to reduce inequitable access to health care, target critical barriers and

disadvantaged communities, and encourage innovation and system transformation to enhance

equity (Gardner, 2008). An overarching theme from this health equity vision is preventative

health measures. Appropriately, the LHIN will build equity into crucial directions for health

reform such as chronic disease prevention and management. In an attempt to understand the

real local problems, the LHIN will concentrate comprehensive and multi-disciplinary services in

the most health disadvantaged populations and neighbourhoods (Gardner, 2008).

All of these endeavours will help alleviate some of the health disparities that currently exist in

Toronto. The LHIN might be able to benefit from incorporating the social determinants of urban

health into their health equity vision. To begin, funding from the LHIN should be set aside for

something I call an interdisciplinary research fund. The rationale is to pay and bring together

epidemiologists, health geographers, public health researchers and environmental health experts

to go into these poorer neighbourhoods in Toronto and conduct research. These researchers

would collectively investigate, through qualitative methods why these people are suffering from

health conditions and why they might be utilizing health services and ambulatory care more than

others.

This would draw an interdisciplinary focus on health and place allowing professionals to

understand what shapes an environment in which people live. This would get at the social

determinants of whether people feel safe, mentally and physically healthy, and feel well

protected from both air pollution and violence in their own neighbourhoods. Environmental

health experts may notice the lack of open and green space in the neighbourhood which can

suggest that there is a weak formation of strong social ties between neighbours (Jackson, 2003).

This research fund can lead to discoveries that suggest these Toronto neighbourhoods lack open

14


15/22

space, parks and green areas which prohibit sociability and interaction and thus make the

residents feel more unsafe, insecure and less healthy.

Looking at neighbourhoods holistically focuses on the physical features of the environment, the

socio-economic dimensions and the services in which people access such as social services,

counselling, and English as a second language classes (Raphael et al. 2008) All of these findings

can help in providing a better public health understanding and associated resources.

The professionals who study these neighbourhoods would be obliged to publicize the findings

from critical analyses of the social determinants of health and disease. Whats important is that

the use of qualitative approaches to individual and neighbourhood health, can produce vivid

illustrations of the importance of these issues such as asthma prevalence, crime, feelings of

safety and trust, housing conditions, mental illness and stress, for peoples health and well-being

(Raphael et al. 2008). Over time, these health research professionals working under the

interdisciplinary research initiative can help shift the publics and policymakers focus on the

dominant biomedical and lifestyle paradigms to a social determinants of health perspective by

collecting and presenting stories about the impacts social determinants have on peoples lives

(Raphael et al. 2008). This research would also allow for public participation or taking a

community-based research and action approach which can lead to citizens raising public policy

issues that are most salient to them (Raphael et al.2008).

What we have learned from the studies of Burra et al and Ross et al is that citizens that inhabit

these poorer neighbourhoods are at much higher risks of suffering from air pollution. Lower

income quintile groups have higher utilization rates of health and ambulatory care services. The

LHIN should make note of these relationships. Being more pro-active by exploring the health of

these neighbourhoods can improve overall health equity. I recommend a interdisciplinary

approach because having diverse professionals working on this matter can convince the

provincial government that resources and funding are desperately needed in these

neighbourhoods to reduce individuals susceptibility to air pollution diseases. The findings from

such research would create multiple avenues of revenue going towards a good cause that must be

adequately addressed given the forthcoming challenges of population growth and climate

15


16/22

change. The seniors are an example of a demographic group that would benefit from such a

research fund. Vulnerable populations like seniors are highly susceptible to air pollution and

have historically and contemporarily suffered from severe respiratory illnesses (Toronto Public

Health, 2004).

The senior population continues to age in both urban and rural environments. Their susceptibility

to air pollution alone should create an impetus for the LHIN to develop the interdisciplinary

research fund to address such a significant issue of our time. With an aging senior population,

more pressures will be placed on health care providers and hospital services (Skinner, 2008).

Seniors will access health services for all sorts of treatments and medical resources. A good

practical and preventative approach to help alleviate the current and forthcoming pressures on

health care providers would be to support an interdisciplinary research fund. Allowing these

professional researchers to collaborate and investigate the social determinants of health in these

Toronto neighbourhoods would be highly advantageous for health policy.

As previously mentioned, the transportation sector in Toronto is expanding with public transit

infrastructure revitalization. This could help reduce the number of vehicles on the road which

would reduce overall air pollution. However, there is no guarantee that this would be a holistic

solution. Preventative health measures can undoubtedly help maintain the health and well-being

of citizens thereby reducing the health costs that would have otherwise been incurred by the

system. Providing more greenery and open space for example, can help boost interaction and

informal sociability among poorer neighbourhoods. Such a preventative measure has

environmental and health benefits. Accessible green space is important to human welfare at the

neighbourhood scale (Jackson, 2003).

These preventative measures would make the Toronto Central LHINs future health strategies

more inclusive and comprehensive, thus increasing its chances on accessing more funding from

the province. In sum, concerted public health and community efforts can profoundly influence

the development of policies that determine the extent of health inequalities and the overall state

of population health within a city like Toronto (Raphael et al. 2008).

16


17/22

Conclusion

Air pollution is a growing urban health issue of the 21st century. This paper attempted to show

that when examining air pollution and socio-economic status, it is critical to review not just

differential exposure to pollutants, but the differential susceptibility to pollutants in urban areas.

Many of the studies presented in this paper conclusively demonstrated that lower SES is

correlated with higher rates of diseases as a result of air pollution exposure. Respiratory diseases

including COPD, asthma, cardiovascular disease and heart conditions are all symptomatic of

socio-economic status. The social determinants of health concept was thus used to highlight

some of the tools that the Toronto Central LHIN could use to significantly improve its health

equity strategies. Again, an interdisciplinary research fund combining the expertise of numerous

professionals could reveal significant findings in these Toronto neighbourhoods that ostensibly

have higher rates of exposure to air pollution. Collaboration across professions is essential topreventative health care.

With Toronto being situated in the heart of the growing Greater Golden Horseshoe, population

growth is bound to put more pressures on the existing health infrastructure. While there have

been and continue to be improvements in public transit infrastructure, vehicle emissions in

aggregate will still pose health and environmental problems for the city due to population

growth. Thus, to truly implement equitable and preventative health policy measures, I strongly

advise that the LHIN consider examining the social determinants of urban health as a holistic

strategy. With an interdisciplinary focus, the LHIN will be able to produce better results from

geographical, epidemiological and environmental health analyses which can alleviate pressures

on existing health service providers. This will ultimately lead to a better understanding of the

significant disease susceptibility issues for the City of Toronto, and find practical ways to resolve

them, leading to better health and well-being for all.

References

Brugman, J., 2009. Welcome to the Urban Revolution: How Cities are Changing the World.

Toronto: The Penguin Group.

17


18/22

Burra, T.A., Moineddin, R., Agha, M.M., Glazier, R.H., 2009. Social disadvantages, air

pollution, and asthma physician visits in Toronto, Canada. Environmental Research,

109, 567-574.

Chiotti, Q., 2004. Torontos Environment, A Discussion on Urban Sprawl and Atmospheric

Impacts. A Special Report by Quentin Chiotti, The Pollution Probe. Published on-line

at http://www.pollutionprobe.org/Reports/torontosenvironment.pdf.

Frohlich, K.L., Ross, N., Richmond, C., 2006. Health disparities in Canada today: Some

evidence and a theoretical framework. Health Policy, 79, 132-143.

Finkelstein, M.M., Jerrett, M., Sears M. R., 2004. Traffic Air Pollution and Mortality Rate

Advancement Periods. American Journal of Epidemiology, 160, 173-177.

Gardner, B., 2008.Health Equity Discussion Paper. Toronto Central LHIN.Published on-line at:

http://www.torontocentrallhin.on.ca/uploadedFiles/Home_Page/Report_and_Publications

/Health%20Equity%20Discussion%20Paper%20v1.0.pdf

Gatrell, A.C., Elliot, S.D., 2009. Geographies of Health: An Introduction, 2nd edition. Wiley-

Blackwell Publishing, Malden.

Health Canada, 2007. People, place and health.Health Policy Research Bulletin, Issue 14,

(November), published on-line at www.healthcanada.gc.ca/hpr-bulletin.

Hulchanski, D., 2007. The Three Cities within Toronto. Toronto: Centre for Urban and

Community Studies, University of Toronto. Published on-line at:

www.urbancenter.utoronto.ca/redirects/rb41mediarelease.html

Jackson, L.E., 2003. The relationship of urban design to human health and condition. Landscape

and Urban Planning, 64, 191-200.

Jerrett, M., Burnett, R.T., Kanaroglou, P., Eyles, J., 2001. A GIS- environmental justice analysis

of particulate air pollution in Hamilton, Canada. Environmental Planning, 33, 955-973.

Leung D.Y.M., Ledford, D.K., 2009. Asthma disparities in urban environments. Journal of

Allergy Clinical Immunology, 123, 1199-1206.

Lin, M., Chen, Y., Villeneuve, P.J., Burnett, R.T., Lemyre, L., Hertzman, C., McGrail, K.M.,

Krewski, D., 2004. Gaseous Air Pollutants and Asthma Hospitalization of Children with

18


19/22

Low Household Income in Vancouver, British Columbia, Canada. American Journal of

Epidemiology, 159, 294-303.

Macintyre, S., Ellaway, A., Cummins, S., 2002. Place effects on health: how can we

conceptualise, operationalise and measure them? Social Science & Medicine, 55,

125-139.

Macintyre, S., McKay, L., Ellaway, A., 2005. Are rich people or poor people more likely to

be ill? Lay perceptions, by social class and neighbourhood, of inequalities in health.

Social Science & Medicine, 60, 313-317.

Masuda, J.R., Zupancic, T., Poland, B., Cole, D.C., 2008. Environmental health and vulnerable

populations in Canada: mapping an integrated equity-focused research agenda. The

Canadian Geographer, 52, 427-450.

Raphael, D., Curry-Stevens, A., Bryant, T., 2008. Barries to addressing the social determinants

of health: Insights from the Canadian experience. Health Policy, 88, 222-235.

Skinner, M.W., Rosenberg, M.W., Lovell, S.A., Dunn, J.R., Everitt, J.C., Hanlon, N. andRathwell, T.C., 2008. Services for seniors in small town Canada: the paradox ofcommunity. Canadian Journal of Nursing Research, 40(1), 80-101.

Tasco, C., Forastiere, F., Stafoggia, M., Piccitto, S., Agabiti, N., Cesaroni, G., Perucci, C.A.,

2007. Socioeconomic status, Particulate Air Pollution, and Daily Mortality: Differential

Exposure of Differential Susceptibility. American Journal of Industrial Medicine, 50,208-216.

Toronto Public Health., 2004.Air Pollution Burden of Illness in Toronto. City of Toronto.

Published on-line at:

http://www.toronto.ca/health/hphe/air_and_health.htm

Toronto Public Health., 2008. The Unequal City: Income and Health Inequalities in Toronto.

City of Toronto. Published on-line at:

http://www.toronto.ca/health/map/pdf/unequalcity_20081016.pdf

19


20/22

Appendix 1. Maps of Socio-economic status indicators in Toronto.

Appendix 1 is a series of maps showing the socio-economic indicators for the city. These maps

include the spatial distribution of income, unemployment, educational attainment and rented

dwellings - all of which reflect the social determinants of health. I use these maps because they

illustrate the health disparities that emerged from the literature. All of these indicators are critical

for geographers to understand. We can assume that areas that are high in unemployment, low

educational attainment and have a vast percentage of rented dwellings are inhabited by more

vulnerable populations who are thus susceptible to air pollution. Inferences can be made if

professionals and researchers like geographers investigate these issues by visiting such

neighbourhoods of the city.

Spatial Distribution of persons age 25-64 with no high school education (Toronto, 2006).

20


21/22

Spatial Distribution of Toronto Population with University Degree (Toronto, 2004)

Spatial Distribution Labour Force Participation in Toronto (Toronto, 2004)

21


22/22

Spatial Distribution of Unemployment in Toronto (Toronto, 2008)

Spatial Distribution of Rented Dwellings in Toronto (Toronto, 2004)

22

minimizing health inequity through the social determinants of urban health: a health geography...

Documents