Studying intra-metropolitan health Studying intra-metropolitan health disparities in Canada: How and disparities in Canada: How and

why globalization matterswhy globalization matters

Ted Schrecker, Jennifer Cushon, Ted Schrecker, Jennifer Cushon, Nazeem Muhajarine, Ronald LabontéNazeem Muhajarine, Ronald Labonté

Canadian Public Health Association Canadian Public Health Association Halifax, June 2008Halifax, June 2008

Funded by Canadian InstitutesFunded by Canadian Institutesof Health Research of Health Research

Research TeamResearch Team

Ronald Labonté (principal investigator), Ronald Labonté (principal investigator), University of OttawaUniversity of Ottawa

Toba Bryant, York UniversityToba Bryant, York University

Jody Heymann, McGill UniversityJody Heymann, McGill University Kristin Good, Dalhousie UniversityKristin Good, Dalhousie University

Denise Spitzer, University of OttawaDenise Spitzer, University of Ottawa Michael Orsini, University of OttawaMichael Orsini, University of Ottawa

Aleck Ostry, University of VictoriaAleck Ostry, University of Victoria Nancy Ross, McGill UniversityNancy Ross, McGill University

Dennis Raphael, York UniversityDennis Raphael, York University Michael Sawada, University of OttawaMichael Sawada, University of Ottawa

Carol Amaratunga, University of OttawaCarol Amaratunga, University of Ottawa Jerry Spiegel, Univ. of British ColumbiaJerry Spiegel, Univ. of British Columbia

Elizabeth Kristjansson, University of OttawaElizabeth Kristjansson, University of Ottawa Richard Stren, Univ. of Toronto (emeritus)Richard Stren, Univ. of Toronto (emeritus)

Judith McKenzie, University of GuelphJudith McKenzie, University of Guelph Armine Yalnizyan,Armine Yalnizyan,Canadian Centre for Policy AlternativesCanadian Centre for Policy Alternatives

Nazeem Muhajarine, Univ. of SaskatchewanNazeem Muhajarine, Univ. of Saskatchewan Jennifer Cushon, Univ. of SaskatchewanJennifer Cushon, Univ. of Saskatchewan

Damaris Rose, INRSDamaris Rose, INRS Laura Bisaillon, University of OttawaLaura Bisaillon, University of Ottawa

Ted Schrecker, University of OttawaTed Schrecker, University of Ottawa

Globalization and the Health of Globalization and the Health of Canadians: Mission StatementCanadians: Mission Statement

To improve Canada’s ability to anticipate and respond to the To improve Canada’s ability to anticipate and respond to the effects of globalization on the health of low-income adults in effects of globalization on the health of low-income adults in Canadian metropolitan areas with children under 18. Key Canadian metropolitan areas with children under 18. Key channels of influence include global reorganization of production channels of influence include global reorganization of production and its effects on labour markets; financial markets; and and its effects on labour markets; financial markets; and migration flows. Analysis will include the spatial dimensions of migration flows. Analysis will include the spatial dimensions of globalization’s effects (both positive and negative), and on how globalization’s effects (both positive and negative), and on how globalization enhances or constrains the ability of governments globalization enhances or constrains the ability of governments to develop appropriate policy responses in areas including to develop appropriate policy responses in areas including taxation, regulation, income support and provision of social taxation, regulation, income support and provision of social infrastructure.infrastructure.

1. Why focus on cities?1. Why focus on cities?

80% of Canada’s population lives in metropolitan 80% of Canada’s population lives in metropolitan areas, one-third in our main study areas areas, one-third in our main study areas (Toronto, Montréal, Vancouver), which also(Toronto, Montréal, Vancouver), which also

Receive ~80% of recent immigrantsReceive ~80% of recent immigrants

1. Why focus on cities?1. Why focus on cities?

Cities provide complex “mosaics of risk and Cities provide complex “mosaics of risk and protection” (protection” (Fitzpatrick & LaGory, 2003)Fitzpatrick & LaGory, 2003)

1. Why focus on cities?1. Why focus on cities?

… … and are the and are the stage on which stage on which the forces and the forces and pressures of pressures of globalization play globalization play out and affect out and affect people’s livespeople’s lives

2. Why globalization?2. Why globalization? Arguably the dominant element of today’s Arguably the dominant element of today’s

economic and political environment, in the form economic and political environment, in the form for instance of … for instance of …

““Global supply-chains connecting Global supply-chains connecting cheap workers on one side of thecheap workers on one side of theworld with rich consumers on theworld with rich consumers on theother” (other” (The Economist,The Economist, 2002) 2002)

2. Why globalization?2. Why globalization?

… … with well docu-with well docu-mented effects on mented effects on metropolitan areas (UN metropolitan areas (UN Habitat, 2001). Habitat, 2001). However, However,

http://www.unhabitat.org/pmss/getPage.asp?page=bookView&book=1618

2. Why globalization?2. Why globalization? Few connections have been made between Few connections have been made between

social scientific research on globalization and social scientific research on globalization and social determinants of health (SDH) and the social determinants of health (SDH) and the similarly extensive literature on place and healthsimilarly extensive literature on place and health

3. Place, health, and3. Place, health, andeconomic inequalityeconomic inequality

Socioeconomic gradients in health status are Socioeconomic gradients in health status are ubiquitous, within Canada and within ubiquitous, within Canada and within metropolitan areas. Here are just two metropolitan areas. Here are just two illustrations: illustrations:

Life expectancy at birth by neighbourhood Life expectancy at birth by neighbourhood income quintile, urban Canadaincome quintile, urban Canada

60

70

80

90

Q5 Q4 Q3 Q2 Q1 Q5 Q4 Q3 Q2 Q1

19711996

Men Women

Source: Statistics Canada data cited in Canadian Population Health Initiative, 2004

Poverty and healthPoverty and healthin Montréalin Montréal

http://www.santepub-mtl.qc.ca/Portrait/Les29/index.html

3. Place, health, and3. Place, health, andeconomic inequalityeconomic inequality

Socioeconomic gradients in health status are Socioeconomic gradients in health status are ubiquitous, within Canada and within ubiquitous, within Canada and within metropolitan areas metropolitan areas

An expanding body of research shows that An expanding body of research shows that ‘place matters’ at both metropolitan and ‘place matters’ at both metropolitan and neighbourhood or small area level, even after neighbourhood or small area level, even after compositional factors are controlled for. compositional factors are controlled for.

Trends like increasing economic segregation Trends like increasing economic segregation and concentration of poverty are clearly evident and concentration of poverty are clearly evident in Canadian cities. Furthermore, in Canadian cities. Furthermore,

3. Place, health, and3. Place, health, andeconomic inequalityeconomic inequality

““[C]urrent measures of simple universally [C]urrent measures of simple universally applied ‘neighbourhood’ exposures may applied ‘neighbourhood’ exposures may severely underestimate the total effect of severely underestimate the total effect of ‘context’” (Cummins et al., 2007), as illustrated ‘context’” (Cummins et al., 2007), as illustrated by the following example (Matthews et al., 2005; by the following example (Matthews et al., 2005; used with permission)used with permission)

4. Major channels of influence: 4. Major channels of influence: globalization globalization → SDH *→ SDH *

Polarization of labour market incomes and Polarization of labour market incomes and opportunities, e.g. deindustrialization, parallel opportunities, e.g. deindustrialization, parallel rise of highly paid producer services and the rise of highly paid producer services and the low-wage, often precarious service sector jobs low-wage, often precarious service sector jobs that meet the needs of the “working rich”that meet the needs of the “working rich”

* In major Canadian metropolitan areas

4. Major channels of influence: 4. Major channels of influence: globalization globalization → SDH *→ SDH *

Changes in public policy landscape: emphasis Changes in public policy landscape: emphasis on competition to attract investment, social on competition to attract investment, social policy retrenchmentpolicy retrenchment

* In major Canadian metropolitan areas

““[R][R]edistribution grew enough in the 1980s to edistribution grew enough in the 1980s to offset 130% of the growth in family market-offset 130% of the growth in family market-income inequality -- more than enough to keep income inequality -- more than enough to keep after-tax income inequality stable. However, in after-tax income inequality stable. However, in the 1990-to-2004 period, redistribution did not the 1990-to-2004 period, redistribution did not grow at the same pace as market-income grow at the same pace as market-income inequality and offset only 19% of the increase in inequality and offset only 19% of the increase in family market-income inequality” family market-income inequality” (Heisz, 2007) (Heisz, 2007)

4. Major channels of influence: 4. Major channels of influence: globalization globalization → SDH *→ SDH *

Metropolitan housing markets and land uses, Metropolitan housing markets and land uses, e.g. as gentrification is driven by globalization’s e.g. as gentrification is driven by globalization’s winners, cities become sites for consumption winners, cities become sites for consumption rather than production and governments rather than production and governments subsidize that reinventionsubsidize that reinvention

* In major Canadian metropolitan areas

4. Major channels of influence: 4. Major channels of influence: globalization globalization → SDH *→ SDH *

Immigration: Immigrants concentrate in large Immigration: Immigrants concentrate in large cities; economic situation of recent immigrants is cities; economic situation of recent immigrants is fragile relative to rest of population, with fragile relative to rest of population, with probable longer-term implications for healthprobable longer-term implications for health

* In major Canadian metropolitan areas

5. Key methodological challenges5. Key methodological challenges

Describing the macro-micro linkages between Describing the macro-micro linkages between globalization and changes in SDH and globalization and changes in SDH and globalization; deciding on the nature of evidence globalization; deciding on the nature of evidence required to convincingly to assert a link with required to convincingly to assert a link with globalization; and establishing the relative globalization; and establishing the relative contributions of globalization and other, contributions of globalization and other, unrelated influencesunrelated influences

5. Key methodological challenges5. Key methodological challenges

From among a huge universe of policies that From among a huge universe of policies that have been adopted in multiple jurisdictions, have been adopted in multiple jurisdictions, developing an inventory of most effective policy developing an inventory of most effective policy responses, keeping in mind that they can either responses, keeping in mind that they can either address the underlying dynamics of globalization address the underlying dynamics of globalization or mitigate/magnify them or mitigate/magnify them

5. Key methodological challenges5. Key methodological challenges

Effective and appropriate use and integration of Effective and appropriate use and integration of a plurality of methods (quantitative and a plurality of methods (quantitative and qualitative) and disciplinary perspectives, while qualitative) and disciplinary perspectives, while keeping a transdisciplinary team focussed on keeping a transdisciplinary team focussed on key research questionskey research questions

6. Initial hypotheses6. Initial hypotheses

Global reorganization of production and social Global reorganization of production and social policy retrenchment are increasing economic policy retrenchment are increasing economic polarization and undermining already tenuous polarization and undermining already tenuous social protection mechanisms in Canada social protection mechanisms in Canada

6. Initial hypotheses6. Initial hypotheses

It may be less important to isolate the distinctive It may be less important to isolate the distinctive contributions of globalization and domestic contributions of globalization and domestic public policy (and it may in practice be public policy (and it may in practice be impossible to separate the two, because of how impossible to separate the two, because of how globalization affects distributions of income and globalization affects distributions of income and wealth and therefore political allegiances) …wealth and therefore political allegiances) …

6. Initial hypotheses6. Initial hypotheses

……than to consider that current trends may signal than to consider that current trends may signal the start of a longer period of polarization the start of a longer period of polarization accompanied and reinforced by the dismantling accompanied and reinforced by the dismantling of infrastructure, built up over two generations, of infrastructure, built up over two generations, that has been crucial to improving the health that has been crucial to improving the health status of Canadians (status of Canadians (cf.cf. Siddiqi & Hertzman Siddiqi & Hertzman 2007) and, within limits, reducing health 2007) and, within limits, reducing health disparitiesdisparities

6. Initial hypotheses6. Initial hypotheses

If this is the case, disparities in access to SDH If this is the case, disparities in access to SDH within Canada’s major metropolitan areas are within Canada’s major metropolitan areas are likely to increase in the absence of equity-likely to increase in the absence of equity-oriented policy responses from all levels of oriented policy responses from all levels of government, but government, but

A major mismatch in all likelihood exists A major mismatch in all likelihood exists between the fiscal and policy capacity of between the fiscal and policy capacity of metropolitan governments and the scale of these metropolitan governments and the scale of these challenges challenges

ReferencesReferences

The EconomistThe Economist (2002, December 7). A moving story. (2002, December 7). A moving story. The Economist,The Economist, 65-66. 65-66.

Cummins, S., Curtis, S., Diez-Roux, A. V., & Macintyre, S. (2007). Cummins, S., Curtis, S., Diez-Roux, A. V., & Macintyre, S. (2007). Understanding and Understanding and representing 'place' in health research: A relational approach. representing 'place' in health research: A relational approach. Social Science & Medicine, Social Science & Medicine, 65,65, 1825-1838. 1825-1838.

Fitzpatrick, K. & LaGory, M. (2003). "Placing" Health in an Urban Sociology: Cities as Fitzpatrick, K. & LaGory, M. (2003). "Placing" Health in an Urban Sociology: Cities as Mosaics of Risk and Protection. Mosaics of Risk and Protection. City & Community, 2,City & Community, 2, 33-46. 33-46.

Heisz, A. (2007). Heisz, A. (2007). Income Inequality and Redistribution in Canada: 1976 to 2004Income Inequality and Redistribution in Canada: 1976 to 2004 (Analytical (Analytical Studies Branch Research Paper 298). Ottawa: Statistics Canada.Studies Branch Research Paper 298). Ottawa: Statistics Canada.

Matthews, S. A., Detwiler, J. E., & Burton, L. M. (2005). Geo-ethnography: Coupling Matthews, S. A., Detwiler, J. E., & Burton, L. M. (2005). Geo-ethnography: Coupling Geographic Information Analysis Techniques with Ethnographic Methods in Urban Geographic Information Analysis Techniques with Ethnographic Methods in Urban Research. Research. Cartographica: The International Journal for Geographic Information and Cartographica: The International Journal for Geographic Information and Geovisualization, 40,Geovisualization, 40, 75-90. 75-90.

Siddiqi, A. & Hertzman, C. (2007). Towards an epidemiological understanding of the Siddiqi, A. & Hertzman, C. (2007). Towards an epidemiological understanding of the effects of long-term institutional changes on population health: A case study of Canada effects of long-term institutional changes on population health: A case study of Canada versus the USA. versus the USA. Social Science & Medicine, 64,Social Science & Medicine, 64, 589-603. 589-603.

UN Habitat (2001). UN Habitat (2001). Cities in a Globalizing World: Global Report on Human Settlements Cities in a Globalizing World: Global Report on Human Settlements 20012001. London: Earthscan.. London: Earthscan.