Increased Risk of Diabetes in Ontario Among Low Income Residents, 1997/97

1.51.2 1

3.8

2.32

11.4

0

1

2

3

4

5

Low Low-Middle Upper-Middle High

Income Level

Dia

bet

es P

reva

len

ce R

atio Males Females

Diabetes Prevalence in Ontario by Neighbourhood Income Quintile, 1999

7.05 6.785.76

5.12

7.76

0123456789

Q1 (Lowest) Q2 Q3 (Middle) Q4 Q5 (Highest)

Neighbourhoood Classified by Mean Income

Dia

bet

es P

reva

len

ce R

ate

Diabetes, Males

0

2

4

6

8

10

12

14

16

18

20

22

1971 1976 1981 1986 1991 1996

Q1 - Richest

Q2

Q3

Q4

Q5 - Poorest

ASMR x 100,000

Diabetes, Females

0

2

4

6

8

10

12

14

16

18

20

22

1971 1976 1981 1986 1991 1996

Q1 - Richest

Q2

Q3

Q4

Q5 - Poorest

ASMR x 100,000

Critical Periods of the Life Course• Foetal development• Birth• Nutrition, growth and health in adulthood• Educational Career• Leaving parental home• Entering labour market• Establishing social and sexual relationships• Job loss or insecurity• Parenthood• Episodes of illness• Labour market exit• Chronic sickness• Loss of full independence -- Shaw et al., The Widening Gap, 1999, p. 106.

Ten Tips For Better Health - Donaldson, 1999

1. Don't smoke. If you can, stop. If you can't, cut down.

2. Follow a balanced diet with plenty of fruit and vegetables.

3. Keep physically active.

4. Manage stress by, for example, talking things through and making time to relax.

5. If you drink alcohol, do so in moderation.

6. Cover up in the sun, and protect children from sunburn.

7. Practise safer sex.

8. Take up cancer screening opportunities.

9. Be safe on the roads: follow the Highway Code.

10. Learn the First Aid ABC : airways, breathing, circulation.

Ten Tips for Staying Healthy - Dave Gordon, 1999.

1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.

2. Don't have poor parents.

3. Own a car.

4. Don't work in a stressful, low paid manual job.

5. Don't live in damp, low quality housing.

6. Be able to afford to go on a foreign holiday and sunbathe.

7. Practice not losing your job and don't become unemployed.

8. Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled.

9. Don't live next to a busy major road or near a polluting factory.

10. Learn how to fill in the complex housing benefit/ asylum application forms before you become homeless and destitute.

Avoiding the Life-Style Trap

• Lifestyle choices are heavily structured by life circumstances

• Lifestyle choices by themselves account for modest proportions of health status

• Lifestyle choices are difficult to change without considering life contexts

• Lifestyle choice emphases can have unintended side-effects that work against health

Political economy is a study of

the natural laws governing the

production and distribution of

wealth.

0.18 0.20 0.22 0.24

Median Share of Income

300

425

550

675

800

Rat

e p

er 1

00,0

00 P

op

ula

tio

nWorking-Aged Male (25-64) Mortality by Median Share

U.S. States and Canadian Provinces

Mortality Rates Standardized to the Canadian Population in 1991

U.S. States with weighted linear fit (from Kaplan et al., 1996)

Canadian Provinces with weighted linear fit (slope not significant)MS

LA

AL

CA

TX

FL

NH

MN

PEI

NFLDNB

SASK

ONT

ALTABC

MAN

QUE NS

SC

ME

0.15 0.19 0.23 0.27Median Share of Income

200

300

400

500

600

Rat

e pe

r 10

0,00

0 P

opul

atio

nWorking Age (25-64) Mortality by Median Share

U.S. and Canadian Metropolitan AreasU.S. cities (n=282) with weighted linear fit (from Lynch et al. 1998)

Canadian cities with weighted linear fit (n=53) (slope not significant)

Mortality Rates Standardized to the Canadian Popluation in 1991

NewYorkNY

LosAngelesCA

NewOrleansLA

BryanTX

McallenTX

SiouxCityIA

AppletonWI

PortsmouthNH

PineBluffAR

FlorenceSC

MonroeLA

AugustaGA

MontrealVancouver

Toronto

Barrie

Oshawa

Shawinigan

USA, Canada, and Sweden Rankings on Compared to Other Industrialized Nations

(Ranking, 1 is best)Measure USA Canada SwedenIncome Inequality (1990) 18 of 18 11 3Child Poverty (1990) 17 of 17 14 2Infant Mortality (1996) 24 of 29 17 2Youth Suicide (1992-1995 15 of 22 16 10High School Drop-Outs (1996) 17 of 17 16 10Youth Homicide (1992-1995 ) 22 of 22 19 5Wages (1996) 13 of 23 15 6Unemployment (1996) 2 of 10 7 8Elderly Poverty (1990) 15 of 17 4 5Life Expectancy (1996) 20 of 29 4 3

Low Income

0

5

10

15

20

25

30

35

40

45

1971 1986 1991 1996

Q1-RichestQ2Q3Q4Q5-Poorest

%

Canadian Policy Directions It has become obvious that people on the low end of the

income scale are cut off from the ongoing economic growth that most Canadians are enjoying. It is also obvious that in these times of economic prosperity and government surpluses that most governments are not yet prepared to address these problems seriously, nor are they prepared to ensure a reasonable level of support for low-income people either inside or outside of the paid labour force.

-- Poverty Profile, 1998. Ottawa: National Council of Welfare Reports, Autumn, 2000.

Critical Analysis I: Reasons for Resistance

Lack of Epidemiological TheoryHealth officials and reporters seem unaware of recent developments in social epidemiological theory and population health research findings.

Commitment to Ideology of Individualism in Health, Illness and Health PromotionAssists the neo-liberal and neo-conservative agendas of blaming individuals for their health problems, absolving governments of blame for their health threatening policies that create poverty, inequality, and social exclusion.

Critical Analysis II: Side Effects of the Biomedical and Lifestyle Heart

Health Approach

Removes the issue of the social determinants of cardiovascular disease and diabetes right off the public policy agenda.

Low income people made to feel that they are responsible for their own poor health (victim blaming).

Health workers and the media become complicit in the process of ‘poor bashing’: Ignoring facts and repeating stereotypes about people who are poor.

Critical Analysis III: The Holy Trinity

As with any area of medical or scientific research,the selection of ‘factors” to be studied cannot beimmune from prevailing social values andideologies. ... It is also evident that so calledlifestyle or behavioural factors (such as the holytrinity of risks - diet, smoking and exercise)receive a disproportionate amount ofattention. As we have seen, the identification andconfirmation of risk factors is often subject tocontroversy and the evidence about causal linksis not unequivocal.  

Nettleton, S. (1997). Surveillance, Health Promotion and the Formationof a Risk Identity in Debates and Dilemmas in Promoting Health.London UK: MacMillan.

Dennis RaphaelSchool of Health Policy and

ManagementYork UniversityToronto, Canada

416-736-2100, ext. 22134

draphael@yorku.ca