UNNATURAL CAUSES is inequality making us sick? HEALTH EQUITY research topics and resources to learn more
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Policy & Change

Background: To paraphrase the Institute of Medicine’s (IOM) 2002 report on public health: what can we as a society do to fulfill our ongoing interest in assuring the conditions for people to be healthy?

Decisions that governments and corporations make every day benefit some and burden others. Unfortunately, they often reinforce class, racial and gender inequities that contribute to unequal patterns of illness and premature death. Building a social movement that can advocate effectively for more equitable social and economic policies is critical to changing our economic, physical and social environments so that they promote rather than threaten our health.

In other words, tackling health inequities is unavoidably a matter of politics; of engaging in struggles over how we want our government to allocate resources, regulate corporate power, and implement the principles of democracy.

Tony Iton, MD, director of the Alameda County Public Health Department in California, points out that social policies that produce and reproduce class and racial inequality have, over time, “taken many forms, including racially restrictive covenants on property, economic redlining in banking practices, school segregation, [unfair] housing and urban renewal policies, disinvestment in public transportation, discriminatory zoning practices, law enforcement racial profiling, [discriminatory] incarceration policies, and other deliberate governmental policies and practices.”

But we’ve also made many changes during the last century that have improved health equity by improving peoples’ lives: the eight-hour work day, universal public high school, the right to collective bargaining, social security, civil rights, environmental standards... There’s no reason why we can’t do so again.

Opportunities for change abound. Iton and others suggest a wide range of tangible policy options, including quality universal preschool, improved public school funding, living wage laws, affordable housing, land use and zoning reform, improved public transit, fair immigration policies, criminal justice reform, and, of course, full employment, fair trade and even progressive tax policy.

Some of these policy changes will be driven locally, some on the state level, others on the federal level. In general, they fall within three categories:

• Tackling inequality and improving living standards. These policies aim to close the gap between the rich and the rest of us, and between white people and people of color, such as living wage jobs, more equitable tax policy, affirmative action and family supports.

• Protecting those at the bottom of the pyramid. These policies protect under-resourced households and communities from health threats posed by the chaos and uncertainty of free markets. They promote not only additional programs and services, but more equitable allocation of public resources through needed social investments (such as quality schools, affordable housing, and public transit) so that the means for achievement are more available to those with fewer individual resources.

• Reforming decision-making. These policies aim to open and democratize decision-making processes that too often are dominated by concentrated economic and political power. Successful policy change depends more than anything else on those most affected by injustice working together to set priorities, generate solutions, make their voices heard, and to organize effectively to hold government accountable.

How does one advance “health in all policies”? How can local, state and national public policy action in support of health equity be brought about? What is the legislative agenda? What are the policy and program levers? What does this imply for organizations’ own strategies and structures? How do engaged groups communicate with each other and so avoid having to climb the same learning curve over and over again? How can a comprehensive and sustained health equity focus and movement best be built? Can these initiatives be brought together under one health equity national strategy, umbrella or coalition? Should they?

The articles and media in this “policy and change” section address some of the policies and strategies tackling patterns of advantage and deprivation, of hope and despair, and of health and illness.

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Image Thumbnail Social Determinants of Health: The Canadian Facts E-mail to a friend
Juha Mikkonen and Dennis Raphael

The primary factors that shape the health of Canadians are not medical treatments or lifestyle choices but rather the living conditions they experience. This report considers 14 social determinants of health and outlines why they are important; how Canada is doing in addressing them; and what can be done to improve their quality. The purpose of the document is to provide promote greater awareness of the social determinants of health and the development and implementation of public policies that improve their quality.

Image Thumbnail Social determinants of health: the community as an empowered partner E-mail to a friend
ARTICLE by S. Leonard Syme, Preventing Chronic Disease, January 2004

"While we in public health know the importance of involving community partners in our programs, we also know how difficult it is to do. The challenge of involving the community is especially difficult if one has been trained, as I have been trained, to be an arrogant, elitist prima donna. I am the "expert," after all, and I help people by sharing my expertise..."

Image Thumbnail Social Injustice and Public Health E-mail to a friend
BOOK edited by Barry S. Levy and Victor W. Sidel, 2005

Edited by two past presidents of the American Public Health Association, with chapters written by 48 experts in various aspects of social injustice, this book addresses many aspects of social injustice and their relationship to public health. Social injustice manifests in many ways ranging from various forms of overt discrimination to the wide gaps between the "haves" and the "have-nots" within a country or between richer and poorer countries. It increases the prevalence of risk factors and hazardous exposures, which in turn lead to higher rates of disease, injury, disability, and premature death. This book is organized so that health professionals, students in the health professions, and others will find it of practical value in public health and medical practice, research, education, policy development, and advocacy.

Image Thumbnail Socioeconomic Disparities In Health: Pathways and Policies E-mail to a friend
SCHOLARLY ARTICLE by Nancy E. Adler and Katherine Newman, Health Affairs, 2002

Socioeconomic status (SES) underlies three major determinants of health: health care, environmental exposure, and health behavior. In addition, chronic stress associated with lower SES may also increase morbidity and mortality. Reducing SES disparities in health will require policy initiatives addressing the components of socioeconomic status (income, education, and occupation) as well as the pathways by which these affect health. Lessons for U.S. policy approaches are taken from the Acheson Commission in England, which was charged with reducing health disparities in that country.

Image Thumbnail Socioeconomic gradients in health in international and historical context E-mail to a friend
William H. Dow and David H. Rehkopf

This article places socioeconomic gradients in health into a broader international and historical context. The data presented supports the conclusion that current socioeconomic gradients in health within the United States are neither inevitable nor immutable. This literature reveals periods in the United States with substantially smaller gradients, and identifies many examples of other countries whose different social policy choices appear to have led to superior health levels and equity even with fewer aggregate resources. The article also sheds light on the potential importance of various hypothesized mechanisms in driving major shifts in U.S. population health patterns.  A comparison with Canada suggests that exploring broad social policy differences, such as the weaker social safety net in the United States, may be a promising area for future investigation.

Image Thumbnail South Los Angeles Health Equity Scorecard (pdf) E-mail to a friend
REPORT by A Park, N Watson, and L Galloway-Gilliam, Community Health Councils, Inc., December 2008

To assess the extent to which inequities in the healthcare and physical resource environments determine and shape the health of the South LA community, Community Health Councils collaborated with the Coalition for Health and Justice in a year-long study examining the healthcare and physical environment resources in the area. The resulting Scorecard takes into account multiple public and private policies that influence the resident health through investment—or lack of investment—in economic, education, housing, and healthcare systems. The Scorecard also identifies incremental steps by which South LA can be helped to achieve health equity.

Image Thumbnail Staying Alive: Critical Perspectives on Health, Illness, and Health Care E-mail to a friend
BOOK by Dennis Raphael, Toba Bryant, and Marcia Rioux, 2006

In addition to the traditional approaches of health sciences and the sociology of health, this contributed volume shows the impact that human rights issues and political economy have on health, and takes up these issues as they occur in Canada and the United States within a wider international context. The book also contains chapters on issues of pharmaceutical policy, social exclusion, gender and care, the social construction of illness and disability, and approaches to promoting population health that include insights into the impact of economic forces such as globalization and privatization on health care and other health issues.

Image Thumbnail Strategic Actions for a Just Economy E-mail to a friend

SAJE is an economic justice, community development, and popular education center that has been building economic power for working class people in Los Angeles since 1996. Over the past eleven years, SAJE's winning combination of community organizing, coalition-building, and grassroots policy has gained significant benefits for the community. Accomplishments include creating the nation's first welfare-to-work bank account and, through the Figueroa Corridor Coalition for Economic Justice, negotiating the nation's most comprehensive community benefits agreement.

Image Thumbnail Strategic Alliance for Healthy Food and Activity Environments E-mail to a friend

The Strategic Alliance is a coalition of nutrition and physical activity advocates in California, working to shift the debate on nutrition and physical activity away from a primary focus on personal responsibility and individual choice to one that examines corporate and government practices and the role of the environment in shaping eating and activity behaviors. The Alliance's goal is to benefit the health and wellness of all California residents by promoting environmental solutions and institutional and government policies and practices that support healthy eating and activity.

Image Thumbnail Strategic Review of Health Inequalities in England Post 2010 E-mail to a friend

Professor Sir Michael Marmot has been asked by the British government to Chair an independent Review to propose the most effective strategies for reducing health inequalities in England from 2010. This review is a response to the recommendation of the WHO Commission on Social Determinants of Health that national governments develop and implement strategies and policies suited to their particular national context aimed at improving health equity.

Image Thumbnail Strong Medicine for a Healthier America E-mail to a friend
American Journal of Preventive Medicine

A supplement to the latest issue of the American Journal of Preventive Medicine (AJPM), funded by the Robert Wood Johnson Foundation, includes six articles and a broad array of commentaries that provide a fundamental understanding of the fact that where, we live, learn, work and play has as much to do with our health as the health care we receive.

The authors–including Risa Lavizzo-Mourey, David R. Williams, Michael G. Marmot and more–address factors beginning with early childhood education, to homes and communities, to the economic rationale for improving the lives of disadvantaged Americans. Together, the collection provides an in-depth look at why some Americans are so much healthier than others and why Americans are not the healthiest people in the world.

Image Thumbnail Tackling Health Inequities Through Public Health Practice: Theory to Action E-mail to a friend
BOOK edited by Richard Hofrichter and Rajiv Bhatia

Social justice has always been a core value driving public health. Today, much of the etiology of avoidable disease is rooted in inequitable social conditions brought on by disparities in wealth and power and reproduced through ongoing forms of oppression, exploitation, and marginalization.

Tackling Health Inequities raises questions and provides a starting point for health practitioners ready to reorient public health practice to address the fundamental causes of health inequities. This reorientation involves restructuring the organization, culture and daily work of public health. Tackling Health Inequities is meant to inspire readers to imagine or envision public health practice and their role in ways that question contemporary thinking and assumptions, as emerging trends, social conditions, and policies generate increasing inequities in health.

Image Thumbnail Tackling the Root Causes of Health Disparities Through Community Capacity Building (pdf) E-mail to a friend
ARTICLE by Anthony Iton. Chapter in Tackling Health Inequities Through Public Health Practice: A Handbook for Action

Iton explains how legacies of structural poverty, instituional racism, and other systemic injustices shape the environment in which all public health efforts take place. Thus, to successfully address a community's health, public health workers and policy officials need to take such factors into account, and design their interventions based on the particular strengths and needs of each community, and build partnerships as much as possible with community members, advocates, activists and other stakeholders. Successful public health action depend ultimately on the empowerment of the community itself.

Image Thumbnail Take Back Your Time E-mail to a friend

Take Back Your Time is a campaign to pass The Minimum Leave Protection, Family Bonding and Personal Well-Being Act of 2007. This amendment to the Fair Labor Standards Act would guarantee that anyone who's worked at a job for a year would get three weeks of vacation. On the site, you can download a handbook and other resources for mobilizing around this goal.

Image Thumbnail Taking Action (pdf) E-mail to a friend

A one-page handout with a few ideas you can use to get started and encourage others to become involved in working towards health equity.

Image Thumbnail Targeting Childhood Development to Make the Nation Healthy Again E-mail to a friend
PRESENTATION by Stephen Bezruchka, MD, January 19, 2007

With characteristic humor and clear, accessible style, Dr. Bezruchka illustrates how the US falls behind less affluent countries in health indicators and argues for better policies to address early childhood development and improve national health.

The page contains a text summary of the presentation, or you can listen to the audio while following along with his slides by clicking "audio slides" under Dr. Bezruchka's photo on the right side of the page.

Image Thumbnail The Built Environment: Designing Communities to Promote Physical Activity in Children E-mail to a friend
POLICY STATEMENT from the American Academy of Pediatrics

This first-ever policy statement on health and place from the AAP argues that pediatricians working with community partners should participate in establishing communities designed for activity and health.

Image Thumbnail The Economic Burden of Health Inequalities in the United States E-mail to a friend

This study, commissioned by the Joint Center for Political and Economic Studies and carried out by leading researchers from Johns Hopkins University and the University of Maryland, provides important insight into how much of a financial burden racial disparities are putting on our health care system and society at large. The researchers examined the direct costs associated with the provision of care to a sicker and more disadvantaged population, as well as the indirect costs of health inequities such as lost productivity, lost wages, absenteeism, family leave, and premature death.

Image Thumbnail The Exodus of Public Health What History Can Tell Us About the Future E-mail to a friend
American Journal of Public Health

The authors trace the shifting definitions of the American public health profession's mission as a social reform and science-based endeavor. Its authority coalesced in the late nineteenth and early twentieth centuries as public health identified itself with housing, sanitation, and labor reform efforts. The field ceded that authority to medicine and other professions as it jettisoned its social mission in favor of a science-based identity. Understanding the potential for achieving progressive social change as it moves forward will require careful consideration of the industrial, structural, and intellectual forces that oppose radical reform and the identification of constituencies with which professionals can align to bring science to bear on the most pressing challenges of the day.

Image Thumbnail The Health of Canada's Children. Part III: Public Policy and the Social Determinants of Children's Health E-mail to a friend
Dennis Raphael in the Journal of Paediatrics & Child Health

The health of Canada’s children does not compare well with other wealthy industrialized nations. Significant inequalities in health exist among Canadian children, and many of these inequalities are due to variations in Canadian children’s life circumstances – the social determinants of health. This article describes the social determinants of children’s health and explains how the quality of these social determinants is shaped, in large part, by public policy decisions. Policy directions that would improve the quality of the social determinants of children’s health are presented and barriers to their implementation are considered.

Image Thumbnail The Health of Canada's Children. Part IV: Toward the Future E-mail to a friend
Dennis Raphael in the Journal of Paediatrics & Child Health

Canadian children’s health is influenced, in large part, by the living circumstances that they experience. These living circumstances – also known as the social determinants of health – are shaped by public policy decisions made by governmental authorities. While public policy should be focused on providing all Canadian children with the living circumstances necessary for health, it appears that Canada is far from achieving this goal. Instead, there are programs directed at Canada’s most severely disadvantaged families and children. While vital, these programs appear to achieve less than that which would be achieved if governmental action was designed to strengthen the social determinants of health for all children. Considering the governmental actions that would achieve this goal are well known – with rather little evidence of policy implementation – it is essential to understand the processes by which public policy is made. An important physician role – in addition to providing responsive health care services – is to become forceful advocates for public policy in the service of health. It is in the latter sphere that physician involvement may yield the strongest benefits for promoting children’s health.

Image Thumbnail The Last Mile E-mail to a friend

We all want to live a long, happy life. So how can we improve outcomes and change unequal social conditions? Play this fill-in-the-blank game to spell out a vision for the long term and learn about policy ideas along the way.

Image Thumbnail The Need to Combine Social and Health Policy E-mail to a friend
EDITORIAL by Madeline Drexler, Boston Globe, November 18, 2008

In this short piece, journalist Drexler makes a case for the incoming president to make a serious commitment to improving national health by looking beyond health care to policies that shape employment, housing, transportation, agriculture, taxation, and other social issues.

Image Thumbnail The Perfect Neighborhood E-mail to a friend

What comes to mind when you think of a healthy neighborhood? What does it take to make a neighborhood more healthy? Find out why conditions in some communities might be less favorable to health than others and what can be done to change them.

Image Thumbnail The Political Economy of Health Promotion: Part 1 - National Commitments to Provision of the Prerequisites of Health E-mail to a friend
ARTICLE by Dennis Raphael, Health Promotion International, Dec 2011

Part 1 of two-part article published in Dec 2011 issues of Health Promotion International. Part 1 of this article examines how health promotion rhetoric specifically concerned with provision of the prerequisites of health differs among nations identified as being either liberal, social democratic, conservative or Latin welfare states.

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