what the church can do
TRANSCRIPT
Poverty is Making Us Sick:What Faith Communities Can Doto Achieve Health and Social Justice
Dr. Cory Neudorf, Chief MHO Saskatoon Health Region, and
Associate Clinical professor, U of S
Introduction: What does it all mean??
Health Disparity – differences or variations between groups
Health Inequality – implies the need for equality
Health Inequity – implies a value judgement …things are unfairly distributed
E.g. equality does not always imply equity. Perhaps some groups need something more than others (equal service for equal need)
What “determines” Health?
The fundamental conditions and resources for health are:
peace,
shelter,
education,
food,
income,
a stable eco-system,
sustainable resources,
social justice, and equity.
National and International Work on Health Inequalities/Inequities
WHO Commission on the Social Determinants of Health Final Report August 2008 “Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health”
WHO Commission RecommendationsThree principles of action
1. Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age.
2. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.
3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.
National and International Work on Health Inequalities/Inequities
“CPHO Report on the State of Public Health in Canada” May 2008
CPHO Report: Public health in Canada
Source:Dahlgreen, G. & Whitehead, M. (2006). European strategies for tackling social inequities in health: Levelling up Part 2. World Health Organization.
Factors that influence our health
Our health – Life expectancyLife expectancy at birth by neighbourhood income and sex,
urban Canada, 2001
Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs.
Source: Wilkins et al. (2007), Statistics Canada.
Our health – Life expectancy
Source: Indian and Northern Affairs Canada, Basic Departmental Data, 2004.
Life expectancy at birth by sex, Registered Indian and general population, Canada, 1980-2001
Our health – Causes of deathAge-standardized mortality rates for lung cancer by neighbourhood income, female, urban Canada, 1971-2001
Age-standardized mortality rates for ischemic heart disease by neighbourhood income, male, urban Canada, 1971-2001
ASMR – Age-standardized mortality rate.Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs.
Source: Wilkins et al. (2007), Statistics Canada.
Health behaviours
Source: Statistics Canada, Physically Active Canadians.
Percentage of the general population aged 12+ years who were physically active by income, Canada, 2005
Addressing inequalitiesMaking a difference to reduce health inequalities involves these priority areas for action:
Social investment Canada can build on its strong policy foundations to further reduce the gap that contributes to
health inequalities
Community capacity Strong communities are critical. Broad social policy and investments are needed to
compliment and support community efforts
Inter-sectoral action All levels of government, the private and non-governmental sectors, and international
organizations can work together towards integrated, coherent policies and actions to effectively prevent and improve upon health inequalities
Knowledge infrastructure Reducing health inequalities requires building knowledge: better information about specific sub-
populations/regions; a greater understanding of how determinants interact; and stronger insight into how to apply proven practices from other jurisdictions
Leadership Leadership across all sectors is crucial to reducing health inequalities.
Moving forward Foster collective will and leadership
If Canadians want to be the healthiest population in the world, addressing health inequalities must become a priority
Working across sectors and jurisdictions, health inequalities can be reduced through: recognizing role of prevention and promotion; developing indicators and measurement tools; recognizing health as a shared responsibility; and engaging leaders
Reduce child poverty Some of the greatest returns on investment are those targeted to the early years Reducing child poverty requires examination of: income redistribution policies and
initiatives required for healthy childhood development; developing better opportunities for children (e.g. housing, education); targeting interventions for children at-risk; and adopting best practices from other jurisdictions
Strengthen communities Communities are where all sectors and players can easily converge to establish
local priorities and develop shared strategies for addressing health inequalities Enhance Canadian communities by: working collaboratively to support community
efforts; improving access to skills/resources; sharing multi-level data; and supporting the replication of proven successful initiatives
Reducing Gaps in Health:A Focus on Socio-Economic Status in Urban CanadaNov. 2008
A collaboration between the
Canadian Population Health Initiative and the
Urban Public Health Network
Saskatoon Analysis of Dissemination Areas by Deprivation Index Quintiles
Pan-Canadian, Regina, Saskatoon and Winnipeg Comparison
Ratio of Age Standardized Hospitalization Rates Between Low and High
SES Groups, Pan-Canadian, Regina, Saskatoon and Winnipeg
2.3
1.9 2.0
3.5
3.8
4.2
4.54.7
8.5
1.6
2.8
1.3
1.8
2.5
3.0
3.9
1.2 1.2 1.3
1.6
1.3 1.4
1.9
3.4
2.7
2.42.3
1.6
1.1
2.4
2.2
1.91.7
2.2
3.4
6.4
3.43.33.4
2.8
2.4
2.0
5.0
2.73.0
3.73.4
2.12.2
1.81.9
1.3
0
2
4
6
8
10
Low birthweight
Injuries inchildren
Landtranprot
accidents
Asthma inchildren
Unintentionalfalls
Injuries Anxietydisorders
Affectivedisorders
ACSC Diabetes MentalHealth
COPD Substance-related
disorders
Rati
o
Pan-Canadian Regina Saskatoon Winnipeg
Source: RQHR presentation on CPHI study
Ratio of Age Standardized Self-Reported Health Percentages Between Low and High SES Groups, Pan-Canadian, Regina, Saskatoon and Winnipeg
0.8
0.9
1.1
1.2
1.2
1.2
1.5
1.8
0.7
0.8
1.1
1.1
1.3
1.6
1.8
2.2
0.8
1.1
1.1
1.5
1.2
1.2
1.6
2.4
0.8
0.8
1.1
1.3
1.4
1.4
1.5
1.8
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Self-rated
health
Influenza
immunization
Overweight or
obese
Activity
limitation
Alcohol binging Physical
inactivity
Risk factors Smoking
Rati
o
Pan-Canadian Regina Saskatoon Winnipeg
Source: RQHR presentation on CPHI study
Saskatoon neighbourhood analysis boundaries, excluding industrial and development areas, 2005
Legend
Affluent neighbourhoods
Rest of Saskatoon
Low income neighbourhoods
Source: Saskatoon Health Region, Public Health Sevices
Health Issue Rate Ratio (% higher)Core : Total Saskatoon
Rate Ratio (% higher)Core : Affluent
Hospitalizations
Suicide Attempts 3.75 (275%) 15.58 (1458%)
Mental Disorders 1.85 (85%) 4.27 (327%)
Injuries and Poisonings 1.54 (54%) 2.46 (146%)
Diabetes 3.98 (298%) 12.86 (1186%)
COPD 1.38 (38%) n/s 1.53 (53%) n/s
Coronary Heart Disease 1.34 (34%) 1.70 (70%)
Stroke 1.33 (33%) n/s 1.82 (82%) n/s
Cancer 0.89 ( no difference) n/s 1.02 (no difference) n/s
Physician Visits
Mental Disorders 1.52 (52%) 2.28 (128%)
Injuries and Poisonings 1.35 (35%) 1.91 (91%)
Diabetes 1.71 (71%) 2.11 (111%)
COPD 1.43 (43%) 2.42 (142%)
Coronary Heart Disease 1.12 (12%) 1.44 (44%)
Stroke 0.88 (no difference) n/s 1.58 (58%)
Cancer 0.77 (no difference) n/s 1.00 (no difference) n/s
Prescription Drug Use
Mental Disorders 1.21 (21%) 1.62 (62%)
Diabetes 1.80 (80%) 2.60 (160%)
Health Issue Rate Ratio (% higher)Core : Total Saskatoon
Rate Ratio (% higher)Core : Affluent
Public Health / Reportable Diseases
Chlamydia 4.32 (332%) 14.89 (1389%)
Gonorrhea 7.76 (676%) n/a
Hepatitis C Notifications 8.04 (704%) 34.60 (3360%)
Complete MMR coverage by age 2 yrs
Core 46.4% Avg. 68% Affluent 94.9%
No MMR by age 2 Core 10.7% Avg. 3.5% Affluent 1.7%
Health Status Indicators
Teen Births 4.21 (321%) 16.49 (1549%)
Infant Mortality Rates 5.48 (448%) 3.23 (123%) n/s
Low Birth Weight 1.46 (46%) 1.10 (10%) n/s
All Cause Mortality 1.04 (no difference) n/s 2.49 (149%)
Health Issue Rate Ratio (% higher)Core : Total Saskatoon
Rate Ratio (% higher)Core : Affluent
Income and Health, selected results
In comparison to high income residents, low income residents in Saskatoon are:
1458% more likely to attempt suicide
1389% more likely to have chlamydia
1186% more likely to be hospitalized for diabetes
3360% more likely to have Hepatitis C
1549% more likely to have a teen birth
448% more likely to have an infant die in the first year
Full immunization 46% vs 95% high income
Response to data
Health workers and general public Shock Denial moving to
reluctant acceptance Anger over degree of
disparity Motivation to change
Inner city Community & workers Less shock Anger and despair Desire to see action Willingness to partner Many ideas for change
SHR response to data
Awareness of need to be responsible in the release of the data
1. Need baseline data on community and staff awareness, attitudes, willingness to change
2. Need to inform affected groups from community to government (Communication strategy)
3. Need to have both a Health System action plan and a Social Determinants of Health Action Plan to announce closely following the data release
4. Ongoing study and evaluation Commitment to keep measuring the issue and effect of
interventions until things change
Survey Data Summary
Baseline survey done to:Measure public and staff awareness of Health
DisparitiesGauge public receptiveness to possible policy
interventions Plan to repeat survey once public
awareness campaign and media coverage has had a chance to further inform people.
Survey Data Summary
5000 respondents in and around Saskatoon with representation from Inner city (including interviews with homeless people and those without telephones), rest of Saskatoon, and rural residents.
Response rate 62%. Representative by age, income, neighborhood, income, cultural status. F slightly > M
Survey Data Summary
80% of people agree that the poor are more likely to suffer from poor health
However, they tend to assume it is only in areas such as suicide attempts, diabetes, HIV/STI’s, while they feel there would be no difference for mental illness, injury, heart disease, breathing problems, stroke and cancer
If health status does differ by income, they believe an “acceptable level” would be: 0% 49% of people 10% 12% of people 25% 17% of people 50% 20% of people >100% 4% of people
Survey Data Summary
91% of people believe something can be done to address this disparity
Over 30 policy options were presented for consideration, and the top three answers were: Strengthen early intervention programs for children and youth 82% Earning supplements to help people move off welfare 82% More disease prevention programs 81%
Option with the least support: More union membership for workers 29%
More support given when options focused on children: More subsidized nutritious food: 62% support More subsidized nutritious food for children: 75% support
Survey Data Summary
When asked how they would propose funding any of these interventions: 10% raise taxes 82% redistribute current taxes
If financial resources are limited: 41% supported transferring funds from treatment to
prevention (59% against) 40% support for transferring funds from health
treatment to health creating services such as education and affordable housing (60% against)
Summary
“Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity. …Reducing health inequities is, …an ethical imperative. Social injustice is killing people on a grand scale.” (Marmot, 2008).
What Can Be Done by our Governments in Canada / Saskatchewan?
Use evidence-based policy options in areas such as: Income Education Employment Housing Health services Aboriginal Cultural Status and governance
..to develop and support an “all of government” approach to reduce the gap in a generation in our country / province
Set targets and goals and measure our progress
Why Should I Support This? Some voiced objections…
Don’t People Get What They Deserve in Life? “Freedom to choose is socially determined (rigged). This model has been tested to
destruction over the last few decades. We are motivated by self-interest, but we are also altruistic, intolerant of unfairness, and made to live in community” Marmot, 2008
Surely this is not a problem in (Canada, Sask., Regina, Saskatoon, etc)? Health Inequity affects us all (social gradient effects, costs of poverty)
Isn’t it a cultural issue? The role of ethnicity disappears once you control for poverty, education, etc.
Interventions need to keep cultural issues in mind in their design and implementation, but systematic discrimination is the underlying issue we need to address
Throwing money at people isn’t going to solve anything. Aren’t we always going to have poverty? It’s not only about assistance rates. Complex problems need elegant solutions.
Supporting approaches that help transition people in need to greater stability and self-reliance will greatly reduce poverty rates…as it has in other jurisdictions.
What Can the Church do to Reduce the Gap?
Why Should the Church be Interested in the Community’s Health?
The church: is a major “intersectoral partner” in the effort to
improve health at both the individual and community level
Serves as an important social support mechanism for many people
has a mandate in achieving a balance between evangelism and social justice (ref. John Stott)
Why Should the Christian be Interested in the Community’s Health?
A follower of Jesus Christ must use his actions as their guide (WWJD)
Christ clearly cared about individuals’ physical, emotional, and spiritual health
Christ gave many admonitions to his followers to care about and influence societal issues such as poverty, justice, equity, gender equality, war, etc.
God’s View on Poverty
2000+ verses in the Bible relating to how God feels about poverty and justice
What can I do?
Give (globally and locally) Pray Live responsibly Volunteer Be aware Share God’s passion for the poor Advocate
Ideas for local action
In all these areas, do things individually, in a small group, as a congregation, denomination, and as the Church (collectively with other congregations from many denominations) in your city,
What Can I / We do?
Give (globally and locally) to organizations working in low income areas, or
working to deliver programs for those in need (and not just to “Christian” organizations and causes)
support changes in government programming aimed at reducing the gap, even if it affects your taxes!
Support fundraising initiatives (capital needs) in areas such as affordable housing, improved health promotion & disease prevention, and primary care in areas of need, etc
What Can I / We do?
Pray For justice For spiritual renewal For people/groups in need, and individuals you
encounter For God’s Kingdom to come “on earth as it is in
heaven” For a heart that feels what God feels for the poor
What Can I / We do?
Live responsiblyFor sustainability, and in order to afford to
help others in greater needSpend Wisely – where do you shop? Do you
(indirectly or directly) encourage local business re: ethical practises, fair trade, involvement in being part of the local solutions by supporting them if they do?
What Can I / We do?
VolunteerYour time, and your skills, to agencies
working to reduce the gapBe a mentor or find ways to invest in others
using your area of education, work, or interest
What Can I / We do?
Be aware Learn about health disparity and the social
determinants of health – globally, and here at home Share your findings with others at home, in your
neighborhood, at your workplace, your place of worship
Challenge stereotypes and misconceptions when you hear them, and inform others about workable solutions
What Can I / We do?
Share God’s passion for the poorHow much thought/time do we spend on this
issue compared to the time God devotes to it in the Bible? Compared to other issues we think important and the relative time devoted to those in the Bible?
Take the “Micah challenge” as God requires of us in Micah 6:8 “do justice, love mercy, walk humbly with your God”
What Can I / We do?
Advocate Write letters to decision makers, demonstrate, talk to
your friends and neighbours about the need to change
Meet with your city councillor, MLA, MP and express your concerns and your support for change
Talk to those in your sphere of influence about the issues and possible solutions
Support Saskatoon’s Action Plan on Poverty
Ideas for local action
Adopt a capital project in the community to support (e.g. Station 20 west, a new primary care clinic for the inner city, a comprehensive clinic for HIV positive people and their families
Use your space for clinics and services during the week Support micro loan cooperatives (micro finance) for women
starting small businesses out of their homes in the inner city Encourage members (especially youth) to do a “mission
year” (and perhaps start Mission Year Saskatoon!) or Urban Promise Saskatoon
“Speak” (www.speak.org.uk) advocacy and prayer
Conclusion
The current economic crisis is no reason to delay our response. In fact, our challenge is not to draw back from our ambitions, but to make them more urgent!
UK Prime Minister Gordon Brown, Nov 2008