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8/8/2019 Minimizing health inequity through the social determinants of urban health: A health geography perspective on air
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Research Paper for Geography 3820H
Minimizing health inequity through the socialdeterminants of urban health: A Health Geography
perspective on air pollution in Toronto
by
Timothy M. Shah
December 2009
Prepared for
Dr. Mark Skinner
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Introduction
The rise of air pollution in urban Canada is an omnipresent reality. Over the years,
epidemiologists, public health experts, sociologists and economists have successfully shown that
air pollution produces multiple negative consequences for society including economic costs,
health care demands and poor environmental conditions (Toronto Public Health, 2004). Many of
these quantitative studies have shown how social deprivation and low income can greatly impact
a communitys exposure to air pollution (see Burra et al. 2009). For example, public health and
environmental research have statistically shown the rise of traffic related emissions in urban
areas across Canada; attributing this rise to increased automobility use and commuting patterns
in urban environments (Toronto Public Health, 2004). Of late, social and health geographers
have become more interested in the uneven geographical distribution of social deprivation and
traffic emissions (Ross et al. 2009). Multiple socio-economic groups constitute an urban area;
certain groups are more socio-economically disadvantaged than others and thus their utilization
of health services might be greater than their healthier urban counterparts.
Understanding a neighbourhoods exposure to poor air quality or air pollution in cities is crucial
for influencing public health interventions and policies. However, as this research paper will
illustrate, in cities like Toronto, air pollution is a ubiquitous phenomenon with pollutants
concentrated around major arterial roads across the city (Chiotti, 2004). Thus, many socio-
economic groups can be exposed to urban air pollution but how these groups access health and
medical resources and cope with such health conditions can be drastically different (Burra et al.
2009). From a health geography lens, it is critical that we examine both differential exposure and
differential susceptibility to air pollution in cities like Toronto. By focusing on differential
susceptibility, public health policies can be more effective at reducing health inequities by
directing resources to those that need it most.
Air pollution and health care inequity are highly complex phenomena that cannot exclusively be
studied through quantitative analyzes. What are now emerging out of health geography are the
social determinants of health concept. This paper will analyze and interpret the social
determinants of urban health and explain why it is critical to study the local and physical urban
environments of Torontos neighbourhoods which might promote or inhibit health. The major
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theoretical construction of this paper attempts to draw on literature that reviews the correlation
between socio-economic status and health inequity.
Torontos Central Local Health and Integration Network (LHIN) is in the midst of creating
health equity strategies to minimize disparities and inequities in health outcomes for the citys
residents (Gardner, 2008). With a variety of strategies in hand, the LHIN can greatly benefit
from learning about how the social determinants of health concept. Specifically, how this
concept can help and better address low socio-economic status groups in coping with health
conditions that result from exposure to air pollution.
This paper will provide recommendations for the LHIN. Public health policy can be better
operationalized if professionals such as health geographers vigorously employ qualitative
research methods to investigate the social determinants of health in Torontos poorer
neighbourhoods. However, health geographers must work with other professionals in a holistic
manner to truly alleviate the existing health inequities prevalent in urban environments such as
Toronto. Therefore, this paper is more interested in socio-economic status (SES) than income, as
SES is more holistic and can inform a better understanding of the present health inequities. This
can ultimately reveal significant findings and direct resources and services to those who need
them most.
Community Profile
Toronto is Canadas largest city, with a population of 2.5 million (Toronto, 2009). With about
632 square kilometers of geographical expanse, the citys total area and population make it the
biggest in the country (Hulchanski, 2007). The city is socioeconomically and ethnically diverse,
concentrated in different parts of the urban core. There has been a 20 percent increase in the
citys population since the 1970s with immigrants presently constituting 50 percent of Torontos
population (Hulchanski, 2007). The city has 527 census tracts with populations ranging from
2,500 to 8000 for each of these tracts (Hulchanski, 2007). Toronto has been selected as the case
study because of its significant city-wide income inequality. Based on 1996 data, the average
census tract household income in quintile one ranged from $18,901 to $42,688 and in quintile
five, the range was between $76,032 and $245,701 (Burra et al. 2009).
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In 2006, Torontos population had the greatest proportion of people living with low income of
the 36 public health units in Ontario (Toronto Public Health, 2008). In 2005, 24.5 percent of
Torontos population lived below the Statistics Canada low income cut-off (before tax), up from
22.6 percent in 2000 (Toronto Public Health, 2008). Approximately one-third of Torontos
children under six years old lived below the low income cut-off (LICO) rate in 2005 (Toronto
Public Health, 2008). Over 20 percent of Torontonians aged 65 years and older lived below the
LICO in 2005 compared to 9.4 percent in the rest of Ontario and 14.4 percent in Canada
(Toronto Public Health, 2008).
In Toronto, air pollution contributes about 1,700 pre-mature deaths and 6,000 admissions to
hospitals each year (Toronto Public Health, 2004). Whats more, the major source of ambient air
pollutants in Toronto is the transportation sector. This has resulted in an excess of nitrogen
dioxide levels which have exacerbated air quality and reduced the quality of life for Torontos
children and adults (Toronto Public Health, 2004). While nitrogen dioxide levels have declined
in Ontario, these rates have been consistently rising in Toronto (Toronto Public Health, 2004).
For Toronto, air pollution disproportionately causes many lower-income populations to access
ambulatory services for conditions such as asthma and cardiovascular disease (Burra et al. 2009).
To illustrate how air pollution is more symptomatic of socio-economic status and not just
income, Appendix 1 provides a series of maps showing the socio-economic indicators for the
city. These maps include the spatial distribution of income, unemployment, educational
attainment and rented dwellings - all of which reflect the social determinants of health which will
be explained. Figure 1 shows a map of Toronto with the number of families under the low-
income cut-off point. This map sets the context in explaining how income inequality is an
ongoing phenomenon in Toronto. This paper is not meant to write about income inequality, but
address how a variation in urban income for the city can reveal important socio-economic
indicators that the Central LHIN should be more aware of.
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Figure 1. Spatial Distribution of families under LICO (Toronto Community Health, 2005)
Air Pollution in Toronto: an Urban Health Issue
Air pollution is an egregious urban health issue of our time. In Toronto, on-road and off-road
vehicles are estimated to generate 38 percent of nitrogen dioxide (NO2), 38 percent of sulphur
dioxide (SO2), 74 percent of carbon dioxide (CO2), 25 percent of particulate matter with
diameters of particulate 10 and 2.5 and 15 percent of volatile organic compounds (VOC)
emissions (Chiotti, 2004). Toronto has the highest summertime levels of fine particulates and the
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highest annual mean levels of nitrogen dioxide levels (Chiotti, 2004). Smog alert days have also
been on the rise for the city and this is largely attributed to an increased number of vehicles on
the road (Chiotti, 2004). There were 27 smog alert days in 2002, up from just 3 in the year 2000
(Chiotti, 2004). Since the 1980s, there has been a steady increase in ozone levels in Toronto.
Ozone triggers asthmatic attacks among those suffering chronically from the disease (Toronto
Public Health, 2004). Also over the last two decades, the number of vehicles entering the city
each weekday morning increased by 75 percent (Toronto Public Health, 2004).
An increase in the number of vehicles entering the city has numerous implications. Toronto finds
itself situated in the heart of the Greater Golden Horseshoe. As the region continues to grow in
population, urban sprawl may lead to the worsening of air quality conditions for many
municipalities. It is estimated that 3.5 million people will join the Greater Golden Horseshoe by
2035; this will lead to an expanding transportation sector that is conducive to automobility and
public transit (Chiotti, 2004). However, public transit will have to be given policy weight not
only for reasons of smart growth and providing for densification, but alleviating the pernicious
air pollutant sources derived from motor vehicles. Therefore this is not just a planning issue for
the Ministry of Public Infrastructural Renewal; it is an issue that should be high on the agenda of
the Ministry of Health and Long-Term Care and Torontos Central LHIN.
Epidemiological research has conclusively proven that exposure to air pollution can exacerbate
asthma conditions, induce heart attacks, reduce overall lung function, trigger cardiovascular
diseases and bring about chronic obstructive pulmonary disease (COPD), just to name a few
(Toronto Public Health, 2004). As the academic literature will explain, it has been corroborated
that lower socio-economic groups are at much higher risk to these health conditions because of
their exposure to air pollution (Lin et al. 2003).
Review of Literature
Urban sprawl invariably intensifies air pollution. Citizens living around the boundaries of
Toronto can find themselves making longer commutes to their urban workplace using major
arterial roads like the Don Valley Parkway and Highway 404. These arterial roads are only
becoming more popular as the city grows. Finkelstein et al. (2004) showed using cox
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Investigating whether these individuals are aware of these ostensible risks would help their
community produce vivid illustrations of the health risks that they can contract or exacerbate
such as asthma, chronic obstructive pulmonary disease and cardiovascular disease. As Raphael et
al. (2008) explained, allowing community members to understand these health and social issues
such as crime, mental illness and high levels of stress, will help people better understand their
health and well-being.
There are two other studies that have explored the connection between social deprivation and
traffic emissions. The first is a study on social disadvantage, air pollution and asthma physician
visits in Toronto. Burra et al. (2009) look at the five income quintile groups in Toronto that are
dispersed over 450 census tracts. They explain that given the large population at risk, increased
ambulatory consultations likely represent another facet of the public health impact and societal
burden of exposure to urban air pollutants (Burra et al. 2009). Their first conclusion is that
groups with lower socio-economic status are at much higher risk of asthma morbidity than
groups in higher income quintiles.
There is approximately a three-fold difference in ambulatory asthma visit rates in the lowest vs.
highest income quintiles (Burra et al. 2009). For males aged 1-17 years, the mean daily visit rate
is 5.96 per 10,000 for the lowest income quintile and 2.17 for the highest income quintile (Burra
et al. 2009). Excess physician visits associated with air pollution constitute a substantial societal
cost. The Ontario Medical Association estimates that the annual cost of air pollution on the
provincial health care system is $1 billion (Toronto Public Health, 2004). Burra et al. (2009)
explain that a one inter-quartile increase in the concentration of nitrogen dioxide is associated
with 88,700 extra visits over the 10-year study period. Air pollution also induces cardiovascular
disease (CVD) which also has revealing disparities. One study of Toronto showed that the
absolute difference in CVD premature mortality rates was 42 per 10,000 for males in the lowest
income quintile compared to the highest income quintile (Toronto Public Health, 2008).
This study portends that even in a society where access to universal health care is made possible,
there are vulnerable populations who utilize ambulatory care and hospital services more than
others. While this study provides a laudable statistical analysis to illustrate the differences in
asthma morbidity and ambulatory care utilization between income quintiles, as health
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geographers, we need to explore why these disparities exist in the first place. There must be
more of an informed understanding of the context in which lower socio-economic groups live in.
As previously mentioned, housing conditions are worth investigating but also the nutritional food
status, domestic violence and psycho-social stress levels of the households in these deprived
neighbourhoods.
Another relevant study published in the Social Science and Medicine Journal (2009) looked at
the double burden of deprivation and ambient air pollution at the neighbourhood scale in
Montreal. Using geographical information systems (GIS) as a quantitative method, the authors
create a spatial model of predicting mean annual concentrations of NO2 across Montreal. Using
Pearson correlation coefficients, they examined a series of neighbourhood level indicators of
deprivation and levels of ambient NO2. Ross et al. (2009) find that the association with
particulate pollution was stronger for both cardiopulmonary and lung cancer mortality among
individuals with lower levels of education. The neighbourhoods with lower SES had higher
proportions of unemployed adults, visible minorities, and lower levels of educational attainment
(Ross et al. 2009). These neighbourhoods according to Ross et al. were positively associated
with higher exposure to ambient levels of NO2. This is yet another study with findings that
suggest that social determinants of health like educational attainment can be correlated with
higher exposure to ambient levels of air pollution. The lack of qualitative analysis in these
studies does not tell us why this is the case.
A study conducted in Vancouver found a strong association between exposure to particulate
matter and mortality in populations with lower educational attainment and income relative to
those with higher levels (Lin et al. 2003). As the authors write, the study did not investigate
how such indicators would help unravel various pathways (material, behavioural) through which
SES may influence the relation between health outcomes and exposure (Lin et al. 2003).
Vancouver is another example of an urban centre that faces challenges with air pollution. While
the city has made some notable improvements with sustainability and public transportation (see
Brugmann, 2009), its air pollution conundrum continues to disproportionately affect lower
income groups.
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The point of using this study along with Montreal is to show that air pollution is a multifaceted
issue crossing environmental, epidemiological and geographical boundaries. These studies do
present the uneven geographical distributions of social deprivation and traffic emissions, but they
do not investigate the social determinants of urban health- undoubtedly the major causes of
health conditions in the first place.
A review of air pollution and SES in Rome will conclude this section. It is the findings in this
study that challenge the conventional belief that only lower socio-economic groups are exposed
to air pollution. Tasco et al. (2007) explain that in Rome, people with high SES are paradoxically
more exposed to traffic-related pollution than lower SES. This finding is not in line with the
preceding examples which corroborated that people with lower SES are more exposed to air
pollution. In Rome, daily particulate matter affects a large sector of the population. However, the
people of high social class are not affected by the negative effects of air pollution to the extent of
citizens in other social class categories (Tasco et al. 2007). Thus, this should lead health
geographers to focus not just on differential exposure to air pollution among social groups, but
also differential susceptibility.
How does exposure increase susceptibility? Higher susceptibility to disease in more
disadvantaged people is influenced by socio-economic circumstances acting at different stages of
the life course in a complex accumulation of risks (Tasco et al. 2007). Lower SES households
might have higher levels of stress, violence and poor nutritional value. Consequently, individuals
who have high hypertension levels of stress and poor health status such as obesity may be less
able to cope with the effects of air pollution on the heart (Tasco et al. 2007). The authors also
found that air pollution is stronger in individuals with increased baseline systemic inflammation
and oxidative stress.
Figure 2. Map of metropolitan area of Rome showing the areas where specific measures
have been adopted to limit traffic and air pollution (Tasco et al. 2007).
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While the focus of this paper is on Toronto, I show this map because it provides a good
illustration of city zoning in Rome. In the 1980s, heavy use of automobiles created egregious
congestion and air pollution in the urban core of Rome. As a policy strategy, the city decided to
create a limited traffic zone to minimize the number of cars allowed in the core of the city. In
spite of this strategy, this part of the city still has the highest number of traffic emissions (Tasco
et al. 2007). A small portion of the citys population live in the central part of the city, and the
social class distribution in the city centre is skewed towards high social class. Further, the
percentage of households in the high emission categories for all of the traffic pollutants increases
with increasing income and SES (Tasco et al. 2007). Last, households of higher social class are
more likely to be located in areas with high traffic emissions and this disparity is stronger when
SES rather than income is considered (Tasco et al. 2007).
A similarity in the studies is that they all use SES as a criterion. SES is more comprehensive than
income because SES constitutes the distribution of educational attainment, unemployment rates,
family size, occupational categories and the proportion of dwellings rented and owned (see
Appendix 1). However, this study, while predominantly quantitative, uses SES to examine the
disparities in health conditions like hypertensive disease, COPD, conduction disorders,
cardiovascular diseases and so on and so forth. The data shows a huge disparity in hypertensive
disease among low and high SES. The distribution of hypertensive disease for low SES is 20.5
percent whereas for the highest SES group it is 14.6 percent (Tasco et al. 2007). This disparity
reveals that low SES households have higher levels of stress which brings about hypertensive
disease and consequently reduces overall health and well-being. Combined, this makes people of
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this SES group more susceptible to air pollution. This study unlike the others, show that the main
explanation for the strong effect modification by SES is differential susceptibility.
Social Determinants of Urban Health
This section will discuss the social determinants of health concept emphasizing how its
interdisciplinarity can be useful for alleviating some of the present health inequities in Toronto.
The social determinants of urban health are indispensable for fair and equitable public health
policy changes. Unfortunately, the use of social determinants has been neglected by the health
sciences, public health and governmental health authorities in Canada (Raphael et al. 2008). As
shown in the literature review, public health analyses have focused too much on the use of
quantitative approaches to understanding health and its determinants. In Canada, there has been a
tendency towards viewing these sources of health and illness as emanating from individual
dispositions and actions rather than resulting from the influence of societal structures (Raphael et
al. 2008). Raphael et al. claim that this is a reflection of positivist science.
The quantitative analyses are useful in informing the distribution of health care service resources
and examining the effects of characteristics of place on health (Gatrell & Elliot, 2009). In terms
of actually alleviating some of these disparities, public health experts and geographers must
carefully look at the various neighbourhoods or census tracts in Toronto to investigate how
healthy they really are. As shown in the maps in Appendix 1, many of these Toronto
neighbourhoods have material deprivation including lack of income and wealth, lower levels of
educational attainment, poor quality housing and unemployment. This can lead one to conclude
that some of these neighbourhoods might have poor health as a result of a poor physical
environment. Social capital, which are the social networks, connections and institutional links
are all significant determinants of an individual or neighbourhoods overall health (Frohlich et al.
2006). Individual social networks, which are the social connections and relations they have with
friends and family, are also predictor of all-cause and cause-specific, mortality or of poor health
(Gatrell & Elliot, 2009).
If people have feelings of distrust and insecurity in their neighbourhoods, or have poor relations
and connections with neighbours, then they may be more stressed and suffer from diseases such
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as hypertensive disease. Political scientist Robert Putnam and geographer Nancy Ross have
shown that components of social capital like community organizational life, engagement with
public affairs and informal sociability are critical for increasing human health and welfare for
any neighbourhood irrespective of socio-economic class (Jackson, 2003). With more social
contact in neighbourhoods, people can interact, socialize and express greater happiness within
their physical surrounding (Jackson, 2003). Poor social capital can intensify illnesses and
respiratory conditions and increase over susceptibility to air pollution.
As Tasco et al. (2007) has shown, lower socio-economic status citizens have higher
susceptibility to disease due to risk factors such as violence, low educational attainment,
psychosocial stress and exposure to environmental hazards. Rented dwellings, unemployment
rates, lower income, educational attainment and access to social networks are all determinants of
health for a given neighbourhood in Toronto. These determinants are proxies for opportunities,
resources and constraints; all of which influence health outcomes.
The findings from the Rome study can be applied to Torontos geographical parameters. It is
difficult to directly make assumptions that lower socio-economic status groups are more exposed
to air pollution than higher SES groups. These groups are living in close proximity to one
another and are not totally segregated. However, some households can have much higher rates of
disease than others.
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Recommendations for the Toronto Central LHIN
The proposed health equity vision for the Toronto Central LHIN is to create and sustain a
healthcare system in Toronto where all have equitable access to a full range of high-quality
healthcare and support, and systemic and avoidable health disparities are steadily reduced
(Gardner, 2008). Thehealth equity vision also includes the LHIN collaborating with other health
service providers to reduce inequitable access to health care, target critical barriers and
disadvantaged communities, and encourage innovation and system transformation to enhance
equity (Gardner, 2008). An overarching theme from this health equity vision is preventative
health measures. Appropriately, the LHIN will build equity into crucial directions for health
reform such as chronic disease prevention and management. In an attempt to understand the
real local problems, the LHIN will concentrate comprehensive and multi-disciplinary services in
the most health disadvantaged populations and neighbourhoods (Gardner, 2008).
All of these endeavours will help alleviate some of the health disparities that currently exist in
Toronto. The LHIN might be able to benefit from incorporating the social determinants of urban
health into their health equity vision. To begin, funding from the LHIN should be set aside for
something I call an interdisciplinary research fund. The rationale is to pay and bring together
epidemiologists, health geographers, public health researchers and environmental health experts
to go into these poorer neighbourhoods in Toronto and conduct research. These researchers
would collectively investigate, through qualitative methods why these people are suffering from
health conditions and why they might be utilizing health services and ambulatory care more than
others.
This would draw an interdisciplinary focus on health and place allowing professionals to
understand what shapes an environment in which people live. This would get at the social
determinants of whether people feel safe, mentally and physically healthy, and feel well
protected from both air pollution and violence in their own neighbourhoods. Environmental
health experts may notice the lack of open and green space in the neighbourhood which can
suggest that there is a weak formation of strong social ties between neighbours (Jackson, 2003).
This research fund can lead to discoveries that suggest these Toronto neighbourhoods lack open
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space, parks and green areas which prohibit sociability and interaction and thus make the
residents feel more unsafe, insecure and less healthy.
Looking at neighbourhoods holistically focuses on the physical features of the environment, the
socio-economic dimensions and the services in which people access such as social services,
counselling, and English as a second language classes (Raphael et al. 2008) All of these findings
can help in providing a better public health understanding and associated resources.
The professionals who study these neighbourhoods would be obliged to publicize the findings
from critical analyses of the social determinants of health and disease. Whats important is that
the use of qualitative approaches to individual and neighbourhood health, can produce vivid
illustrations of the importance of these issues such as asthma prevalence, crime, feelings of
safety and trust, housing conditions, mental illness and stress, for peoples health and well-being
(Raphael et al. 2008). Over time, these health research professionals working under the
interdisciplinary research initiative can help shift the publics and policymakers focus on the
dominant biomedical and lifestyle paradigms to a social determinants of health perspective by
collecting and presenting stories about the impacts social determinants have on peoples lives
(Raphael et al. 2008). This research would also allow for public participation or taking a
community-based research and action approach which can lead to citizens raising public policy
issues that are most salient to them (Raphael et al.2008).
What we have learned from the studies of Burra et al and Ross et al is that citizens that inhabit
these poorer neighbourhoods are at much higher risks of suffering from air pollution. Lower
income quintile groups have higher utilization rates of health and ambulatory care services. The
LHIN should make note of these relationships. Being more pro-active by exploring the health of
these neighbourhoods can improve overall health equity. I recommend a interdisciplinary
approach because having diverse professionals working on this matter can convince the
provincial government that resources and funding are desperately needed in these
neighbourhoods to reduce individuals susceptibility to air pollution diseases. The findings from
such research would create multiple avenues of revenue going towards a good cause that must be
adequately addressed given the forthcoming challenges of population growth and climate
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change. The seniors are an example of a demographic group that would benefit from such a
research fund. Vulnerable populations like seniors are highly susceptible to air pollution and
have historically and contemporarily suffered from severe respiratory illnesses (Toronto Public
Health, 2004).
The senior population continues to age in both urban and rural environments. Their susceptibility
to air pollution alone should create an impetus for the LHIN to develop the interdisciplinary
research fund to address such a significant issue of our time. With an aging senior population,
more pressures will be placed on health care providers and hospital services (Skinner, 2008).
Seniors will access health services for all sorts of treatments and medical resources. A good
practical and preventative approach to help alleviate the current and forthcoming pressures on
health care providers would be to support an interdisciplinary research fund. Allowing these
professional researchers to collaborate and investigate the social determinants of health in these
Toronto neighbourhoods would be highly advantageous for health policy.
As previously mentioned, the transportation sector in Toronto is expanding with public transit
infrastructure revitalization. This could help reduce the number of vehicles on the road which
would reduce overall air pollution. However, there is no guarantee that this would be a holistic
solution. Preventative health measures can undoubtedly help maintain the health and well-being
of citizens thereby reducing the health costs that would have otherwise been incurred by the
system. Providing more greenery and open space for example, can help boost interaction and
informal sociability among poorer neighbourhoods. Such a preventative measure has
environmental and health benefits. Accessible green space is important to human welfare at the
neighbourhood scale (Jackson, 2003).
These preventative measures would make the Toronto Central LHINs future health strategies
more inclusive and comprehensive, thus increasing its chances on accessing more funding from
the province. In sum, concerted public health and community efforts can profoundly influence
the development of policies that determine the extent of health inequalities and the overall state
of population health within a city like Toronto (Raphael et al. 2008).
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Conclusion
Air pollution is a growing urban health issue of the 21st century. This paper attempted to show
that when examining air pollution and socio-economic status, it is critical to review not just
differential exposure to pollutants, but the differential susceptibility to pollutants in urban areas.
Many of the studies presented in this paper conclusively demonstrated that lower SES is
correlated with higher rates of diseases as a result of air pollution exposure. Respiratory diseases
including COPD, asthma, cardiovascular disease and heart conditions are all symptomatic of
socio-economic status. The social determinants of health concept was thus used to highlight
some of the tools that the Toronto Central LHIN could use to significantly improve its health
equity strategies. Again, an interdisciplinary research fund combining the expertise of numerous
professionals could reveal significant findings in these Toronto neighbourhoods that ostensibly
have higher rates of exposure to air pollution. Collaboration across professions is essential topreventative health care.
With Toronto being situated in the heart of the growing Greater Golden Horseshoe, population
growth is bound to put more pressures on the existing health infrastructure. While there have
been and continue to be improvements in public transit infrastructure, vehicle emissions in
aggregate will still pose health and environmental problems for the city due to population
growth. Thus, to truly implement equitable and preventative health policy measures, I strongly
advise that the LHIN consider examining the social determinants of urban health as a holistic
strategy. With an interdisciplinary focus, the LHIN will be able to produce better results from
geographical, epidemiological and environmental health analyses which can alleviate pressures
on existing health service providers. This will ultimately lead to a better understanding of the
significant disease susceptibility issues for the City of Toronto, and find practical ways to resolve
them, leading to better health and well-being for all.
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Appendix 1. Maps of Socio-economic status indicators in Toronto.
Appendix 1 is a series of maps showing the socio-economic indicators for the city. These maps
include the spatial distribution of income, unemployment, educational attainment and rented
dwellings - all of which reflect the social determinants of health. I use these maps because they
illustrate the health disparities that emerged from the literature. All of these indicators are critical
for geographers to understand. We can assume that areas that are high in unemployment, low
educational attainment and have a vast percentage of rented dwellings are inhabited by more
vulnerable populations who are thus susceptible to air pollution. Inferences can be made if
professionals and researchers like geographers investigate these issues by visiting such
neighbourhoods of the city.
Spatial Distribution of persons age 25-64 with no high school education (Toronto, 2006).
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Spatial Distribution of Toronto Population with University Degree (Toronto, 2004)
Spatial Distribution Labour Force Participation in Toronto (Toronto, 2004)
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Spatial Distribution of Unemployment in Toronto (Toronto, 2008)
Spatial Distribution of Rented Dwellings in Toronto (Toronto, 2004)
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