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Wednesday, December 15, 2010

Social Determinants of Health - Dennis Raphael Responds

Dennis Raphael, Professor of Health Policy and Management, York University

The Time to Act is Now
Despite Canada’s history of developing health promotion and population health concepts and research findings, this report notes that Canada falls well behind other wealthy industrialized nations in having these ideas implemented in the form of public policy that strengthens the determinants of health. Canada’s incidence of poverty, the degree of social and health inequalities between the rich and poor, and its investments in social programs that support the health of the general population and especially the health of the most vulnerable fall well behind other wealthy nations. The report places these findings within a context that identifies how the determinants of health – or more simply living conditions – are the primary determinants of Canadians’ health. If we are to improve the health of Canadians, then we must improve their living conditions.  And as the Canadian Public Health Association has noted, the most effective means of improving the determinants of health is through advocacy for health promoting public policy.[i] Carrying out such activities through public policy action has not been a priority for most Canadian governments which instead have been focused on economic recovery, reducing deficits and debts, and maintaining the health care system.

The evidence that living conditions are the primary determinants of health is extensive and compelling, not least when it comes to the health of children.[ii] Adverse living conditions not only shape the health of children but threaten the foundations of health such that the eventual onset of type II diabetes and cardiovascular disease during adulthood is firmly related to such childhood adversity. And preventing these health problems benefits not only the ones affected but also the entire society in terms of increasing productivity and reducing health care and social services costs. Improving the situation of families with children involves instituting the kinds of public policies that have been implemented in other wealthy nations as described in Appendix 2 of this report.  Canada is richer than most of these nations and has no excuse for not doing so. But we must not limit our efforts to strengthening the determinants of health of children. The largest groups of low income Canadians – with their attendant adverse determinants of health – are unattached non-elderly males and females. Public policy must be directed to improving the determinants of health for all Canadians, right across the economic spectrum.

Public policies that strengthen the determinants of health are of two kinds.  The first kind is investing in the population through provision of benefits, supports, and services.  Sometimes this involves spending on programs that benefit virtually all Canadians such as early child education and care, employment training, and provision of community-based health care and social services.  Other times this spending involves provision of adequate benefits to those who are unable to work because of illness, disability, or unemployment due to the loss of jobs in a changing economy. Recent scholarship indicates that Canada is among the lowest-spending nations in providing the determinants of health.[iii] This is surprising as evidence from the Organisation for Economic Cooperation and Development as well as the Conference Board of Canada demonstrates that such spending is not inconsistent with economic productivity and innovations but is very consistent with improved health and quality of life.[iv]

The second kind of public policy that strengthens the determinants of health is that which provides rights and privileges to Canadians that are taken for granted in many wealthy developed nations.  This involves the institution of collective employment bargaining, sometimes through the facilitation of workplace unionization, other times through employer provision of employment security and benefits. Wealthy developed nations that have strengthened the determinants of health have done so by reaching out to their citizens to ensure that meeting citizen needs – which are also determinants of health -- such as income, housing, and employment, does not fall by the wayside against the needs of those who manage the economy.  Such balance is possible and can be seen not only in the Scandinavian nations but also in the Continental nations of Europe. Put simply, democratic processes that involve Canadians from all across the economic spectrum are good for developing health promoting public policy.

Part of the reason that Canadian governments have not instituted such far reaching public policy activities is the lack of awareness on the part of Canadians about the determinants of health.  Without such awareness such public policy activities may not be positively received by voters, which is an important consideration. There are numerous reasons for this lack of awareness but much of it stems from the lack of media reporting on the determinants of health. Hopefully, this report and others that have been produced will educate governments, institutions, and the general public as to what needs to be done to improve their and their families’ and neighbours’ health.[v] The Health Council of Canada is to be commended for undertaking this task of kick-starting Canadian public policy that will improve the health of Canadians.
* Read Dr. Raphael's article, The health of Canada's children. Part I: Canadian children's health in comparative perspective 

Dennis Raphael, PhD, is a Professor of Health Policy and Management at York University in Toronto. Dr. Raphael is editor of "Social Determinants of Health: Canadian Perspectives", co-editor of "Staying Alive: Critical Perspectives on Health, Illness, and Health Care" and author of "Poverty and Policy in Canada: Implications for Health and Quality of Life", all published by Canadian Scholars' Press. "Health Promotion and Quality of Life in Canada: Essential Readings", an edited collection was released in January 2010 and "About Canada: Health and Illness" was released in September of 2010 by Fernwood Publishers. 

[i] Canadian Public Health Association. (1996). Action Statement for Health Promotion in Canada. Ottawa: CPHA
[ii] Raphael, D.  (2010). The Health of Canada’s Children. Parts I-IV. Paediatrics and Child Health, 15, January-April 2010. Available at
[iii] Raphael, D. (2010).  The Political Economy of Health Promotion. Presentation at the Meeting of the International Union of Health Promotion and Education. Available at
[iv] Organisation for Economic Cooperation and Development. (2004). OECD Employment Outlook 2004. Paris: OECD; Conference Board of Canada. (2010). How Canada Performs: A Report Card on Canada. Ottawa: Conference Board of Canada.
[v] Mikonnen, J. and Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. Available at

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