The Code Red Project: Engaging Communities in HealthSystem Change in Hamilton, Canada

Patrick F. DeLuca • Steve Buist • Neil Johnston

Accepted: 30 March 2012 / Published online: 4 May 2012� Springer Science+Business Media B.V. 2012

Abstract The communication of determinants of health and health outcomes normally

executed through academic channels often fail to reach lay audiences. In April of 2010, the

results of collaboration between academe and mass media were published in the Hamilton

Spectator, one of Canada’s 10 largest English-language daily newspapers as a 7-day series.

The aim of the collaboration was to describe the disparities in the determinants of health

and health status that exists in the City of Hamilton’s neighbourhoods in a way that could

be easily comprehended by a lay audience. Simple statistics, maps of the City’s neigh-

bourhoods, interviews and stories were woven together to communicate these disparities.

The reaction to the series was overwhelming. It spawned a new position in the municipal

government, was discussed at the Provincial and Federal levels of governments, prompted

the local university to alter plans, relocating a new health care centre to the greatest area of

need as highlighted by the series, and won several local and national awards. The objective

of this manuscript is to describe all aspects of the series, including the specific decisions

made, the methods employed and the aftermath of its publication.

Keywords Health communication � Mass media � Determinants of health �Spatial variation of health and determinants

P. F. DeLuca (&)Centre for Spatial Analysis, School of Geography and Earth Sciences, McMaster University,1280 Main Street West, Hamilton, ON L8S 4L8, Canadae-mail: delucapf@mcmaster.ca

S. BuistWilfrid Laurier University, Brantford Campus, 73 George Street, Brantford,ON N3T 2Y3, Canada

S. BuistThe Hamilton Spectator, 44 Frid Street, Hamilton, ON L8N 3G3, Canada

N. JohnstonDepartment of Medicine, McMaster University, DTC 301, 1280 Main Street West, Hamilton,ON L8S4L8, Canada

123

Soc Indic Res (2012) 108:317–327DOI 10.1007/s11205-012-0068-y

1 Introduction

The population health perspective, or the determinants of health approach (Evans and

Stoddart 1994), has become an integral part of health research and health policy in both

Canada and overseas (for example, Wilkinson 1996). The Canadian Public Health Agency

has created a 12 item list of what determines health that include both individual and

neighbourhood determinants (Public Health Agency of Canada 2003). Included in this list

are physical and social environments, income and social status, education and literacy,

healthy child development, health services, social support networks, personal health

practices and coping skills, biology and genetic endowment, gender, culture and

employment conditions. Each of these determinants has been explored to varying degrees

using a variety of approaches and the results have been reported via the traditional aca-

demic routes (i.e., journals and conferences).

Newspapers remain an important source of information for Canadians about current

events, particularly when the topics are related to science (Cook et al. 2007) and, more

specifically, health research. Indeed, newspapers trail only physicians and pharmacists as

the top source of information for Canadian patients about new drugs (Cassels et al. 2003).

However, Hayes et al. (2007) note that Canadian newspapers seldom mention social

determinants of health in their publications. Mass media can influence conversations and

opinions on health but the degree to which they influence public health policy is unknown

(Hayes et al. 2007). In April of 2010, the results of collaboration between academe and

mass media were published in the Hamilton Spectator, one of Canada’s 10 largest English-

language daily newspapers, with an average daily circulation of approximately 100,000

copies and a weekly combined readership that averages 366,000 adults. The question that

was explored was whether or not there were significant variations in the determinants of

health and health outcomes across the City of Hamilton’s neighbourhoods.

Past research into health issues in Hamilton are numerous (for example, Luginaah et al.

2001; Buzzelli et al. 2003; Finkelstein et al. 2003; Wilson et al. 2004; Law et al. 2005;

Veenstra et al. 2005; Latham and Moffat 2007; Wilson et al. 2009; Merchant et al. 2011).

The primary objective of this effort was to stimulate a community debate about the

variation of both the determinants of health and health status between neighbourhoods

and what could be done to alleviate them. As such, the decision was made to bypass normal

academic vehicles of dissemination and take the results directly to the public through the

mainstream media. This was accomplished with the publication of a seven-day special

investigative series in the Hamilton Spectator entitled ‘‘Code Red’’.

Code Red had several objectives. Primarily, the aim was to describe the disparities in

the determinants of health and health status that exists in the City of Hamilton’s neigh-

bourhoods in a way that could be easily comprehended by a lay audience. Second was to

draw the attention of planners and political leaders to the polarisation of the community in

health status that has developed as industrial jobs have slowly disappeared from the city.

Third was to stimulate public debate about the waste of health care resources that occurs

when people have nowhere else to turn for help other than Hospital Emergency rooms.

Fourth, was to stimulate discussion about how fragmentation of health and social services

has led to incoherent accountability for results. A final related objective was to provoke

political debate about a lack of policies and political accountability for Ontario’s health

and social services. The objective of this manuscript is to describe all aspects of Code Red

and its aftermath. The following section describes the study setting. This is followed by the

methods utilized in producing Code Red and then a discussion about its impact in the

community including the strengths and weaknesses of the approach.

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2 The City of Hamilton

The City of Hamilton, Ontario (Fig. 1) is a midsize industrial Canadian city located at the

western end of Lake Ontario (43.3oN, 79.9oW). The city is an amalgamation of five

generally affluent suburban communities (Ancaster, Dundas, Flamborough, Glanbrook,

and Stoney Creek) and a central urban area (the old City of Hamilton), geographically

divided into upper and lower levels by the Niagara Escarpment (Fig. 1). The lower inner

city is ravaged with high levels of poverty as well as environmental damage from heavy

industry located in the north end of the city on Hamilton’s sheltered natural harbour.

The population of the city (n = 505,000) has people from all parts of the socio-eco-

nomic spectrum, and has been recognized as having a significant proportion of families and

individuals living at or beneath Canada’s poverty level. Over the past 50 years, the city has

undergone a demographic transition as wealthier people moved out of older neighbour-

hoods in the lower city, into the newer, less dense suburban communities, and immigrants

and individuals of lower SES moving into lower-cost housing in the inner city (Table 1).

At the same time, industrial jobs have been slowly leaving the city. For example, Stelco(now US Steel), a major steel manufacturer has shrunk from over 25,000 employees in

1980 (McDonald et al. 2000) to approximately 1,500 employees in 2011. In 2006 Hamilton

saw closures to plants such as Camco, Rheem Canada and the Procter & Gamble distri-

bution centre. Several other companies saw a dramatic decrease in their workforce such as

Trebor Cadbury Allan, Siemens Canada (which has since left Hamilton for South Carolina)

and Wentworth Mold.

Fig. 1 The City of Hamilton

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3 Methods

Prior to any data collection and analysis, the study was submitted for consideration by the

Research Ethics Board of St. Joseph’s Healthcare, Hamilton. It was concluded that no

formal review by the Board was required. The study was further reviewed by senior

executives of St. Joseph’s Healthcare and approved provided that the institutions providing

service or patients could not be identified.

Data for the study was obtained from several sources. Emergency room visit data and

hospital admission records for the period of April 1, 2006–March 31, 2008 were collected

from Canadian Institute for Health Information (CIHI) for every patient listing Hamilton as

a home address (approximately 400,000 observations). Each health record included age,

gender of patient, the date of emergency room or hospital visit, the length of stay,

the medical (ICD-10) coding for every procedure performed and a geographic marker

(dissemination area of residence). A conscious decision was made to treat the data in

the simplest fashion possible so as not to confuse a lay audience, therefore, typical data

treatments such as age and sex standardization were not applied, rather denominators for

rates were chosen for children, seniors or the total population. Variables that were derived

from the data obtained from CIHI include: average length of stay for acute hospital care

per hospital admission, average number of days of alternate level care per hospital

admission, hospital admission rate per 1,000 people, urgent hospital admission rate per

1,000 people, rate of respiratory related emergency room visits per 1,000 people, rate of

cardiovascular related emergency room visits per 1,000 people, percentage of emergency

room visits with patients reporting no family physician, emergency room visit rate for

trauma for children under age 16, per 1,000 people, emergency room visit rate for trauma

for persons aged 70 and over per 1,000 people, total emergency room visit rate per 1,000

people, rate of psychiatric related emergency room visits per 1,000 people and low birth

weight babies as a percentage of total births. Death records along with the postal code of

residence at time of death (more than 12,000) were obtained from Service Ontario for

2006–2008. Rather than life expectancy, the average age of death was reported to avoid

complexity for a lay audience. Both local District School Boards (Catholic and Public)

provided data on high school completion by Dissemination Area, from which the dropout

Table 1 Selected socio-economic variables for the amalgamated City of Hamiltona

Communities Averagedwellingvalue

Medianfamilyincome

% Childrenbelow lowincome cut-off

% Recentimmigrants

Governmenttransfers as %of total income

High schooldropout rate per1,000 studentsb

Former Cityof Hamilton

$197 819 $58 283 24.0 3.82 16.2 87.3

Lower city $176 981 $52 118 28.7 4.47 18.0 107.9

Upper city $227 979 $67 206 17.3 2.88 13.6 57.5

Stoney Creek $272 447 $76 377 11.6 2.06 11.6 42.4

Glanbrook $305 495 $81 432 4.1 0.86 10.2 39.0

Ancaster $396 976 $103 651 3.5 1.65 5.8 35.0

Dundas $305 856 $79 350 12.3 0.80 8.8 27.5

Flamborough $367 121 $91 305 3.6 0.73 6.8 41.2

a Source: 2006 Canadian Census, average of census tract valuesb Source: Hamilton-Wentworth District and Hamilton-Wentworth Catholic District School Boards

320 P. F. DeLuca et al.

123

rate per 1,000 students was computed. All of the aforementioned records did not include

any personal information that would allow the identities of individual patients to be

revealed. The observations were geocoded (in the case of postal codes) or aggregated (in

the case of dissemination areas) to the census tract level of geography used by Statistics

Canada to measure a wide variety of social and economic variables within urban regions of

Canada. They have the added benefit in this study of having boundaries that match up well

with the City’s traditional neighbourhood boundaries in the urban core. In total, there are

135 CTs in the amalgamated City of Hamilton but due to data suppression, small popu-

lation sizes or missing data, 5 CTs could not be used for the study. Finally, several

variables relating to various determinants of health were collected from the 2006 Census of

the Canadian population. Variables collected include dwelling value, percentage of female

lone parent, median income per person over age 15, median income per family, people

over 15 living below the poverty line, children living below the poverty line, people aged

25–64 with no High School Diploma, people aged 25–64 with a University Degree, Per-

centage of immigrants, percentage of people aged 65 and older, and percentage of

dwellings occupied by renters.

The data were then entered into a GIS for mapping. It was felt that mapping the data in a

simple fashion would most effectively communicate the data to a lay audience rather than

presenting results of more complex statistical models or mapping techniques like cluster

analysis. For example, rather than mapping rates per 1,000 and visualizing them using

more difficult to understand map classification schemes like natural breaks, the rates were

ranked and mapped using a quintile scheme, such that each category displayed represented

20 % of the census tracts in the city. An easily identifiable green to red colour scheme was

utilized. For the lowest 20 % of the data the colour green was employed to indicate better

parts of the city, this was followed by a lighter shade of green for the next 20 % of the data.

The middle 20 % of the data was beige, followed by pink and then highest 20 % was

coloured red.

4 The Code Red Series of Publications

The Hamilton Spectator published the Code Red series in seven instalments between April

10 and April 17, 2010. Each of the days included multiple maps displaying different

aspects of the collected data, interviews with relevant stakeholders and simple statistics

interwoven into a coherent story about the health of the city. The first story, which served

as an introduction to the readership was entitled ‘‘Mapping the Health of Hamilton’’. Seven

maps along with associated statistics were presented including: average age at death

(Fig. 2), hospital admission rate, cardiovascular disease, respiratory disease, childhood

poverty, lone female head of household and an aggregate map which was a combination of

all of the measures included in the study (Fig. 3). Statistics presented included a 21-year

difference in average age at death across Hamilton neighbourhoods, ranging from a high of

86.3 years to a low of 65.5 years. Also, there was a 22-year difference in the average age

of a patient attending hospital with a cardiovascular-related emergency—from 57 years at

one extreme to 79 years at the other. With respect to acute-care hospital bed use, one

neighbourhood in the lower inner city had a rate of 729 days of acute-care hospital bed use

per 1,000 people between the ages of 16–69. At the other extreme, an affluent suburban

neighbourhood had a rate of 46 days of acute-care bed use per 1,000 people between the

ages of 16 and 69. Other statistics presented included one inner-city neighbourhood having

a rate of children living below the poverty line of 68.5 per cent while there were seven

The Code Red Project 321

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neighbourhoods where the rate of children living below the poverty line was 0 per cent.

Another inner-city neighbourhood has nearly one-third (31.8 per cent) of the families

headed by a single mother.

The second day was entitled ‘‘The Cost of Disparity’’ and laid out the costs behind

emergency room usage and tied this to the fact that many individuals in the poorest parts

of the city do not have family doctors and made use of the emergency rooms at the local

hospitals instead. The Code Red series was also able to calculate hospitalization and

emergency room usage costs at the neighbourhood level for the 2-year data period.

Using cost provided by Ontario’s Ministry of Health and Long-Term Care, hospitalization,

emergency room and ambulance use costs ranged from $2,080 per person in the highest use

neighbourhood to $138 per person in the lowest. Emergency room visit rates ranged from

1,291 per 1,000 people in the highest neighbourhood to 97 ER visits per 1,000 people in the

lowest neighbourhood, a difference of 13 times from best to worst. Maps for this day

included percentage of emergency room visits with patients reporting no family physician

(Fig. 4), and total emergency room visits.

Day 3 of Code Red was entitled ‘‘The Early Years—Starting Out’’ and included an

interview with a Nurse Practitioner who works with prospective mothers in the poorest

parts of the city, and two maps, one showing rates of low birth weight and the second, High

School dropout rates. The latter showed that one inner-city neighbourhood had a rate of

267 high school dropouts per 1,000 students while one affluent suburban neighbourhood

had a dropout rate of three per 1,000 students, an 89-fold difference.

Fig. 2 Average age at death by census tract

322 P. F. DeLuca et al.

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The following day’s piece was entitled ‘‘The Earning Years—Home and Job’’ and

served to highlight the disparities that exist in the city with regards to dwelling values and

education. The average dwelling value in one inner-city neighbourhood near the steel mills

in the north end of the city was approximately $87,000, according to the 2006 census,

while in one affluent suburban neighbourhood the average dwelling value was nearly

$500,000. With respect to education, there was one inner-city neighbourhood where 40 per

cent of the adults didn’t have a high school diploma. Maps pertaining to both dwelling

value and people who do not have a high school diploma were also included, as well as a

discussion pertaining to the disappearance of many of the manufacturing jobs that were

once common in the city. In their place are high technology positions that require uni-

versity education, which many of the people living in the inner city do not have.

The fifth day presented information relating to ‘‘The Later Years—Aging and Health’’.

Aside from maps (people aged 65 and over and average number of days awaiting place-

ment in long-term care) and statistics, this day featured an interview with the son of a

hospitalized elderly patient who at the time of publication, had been in the hospital for 154

consecutive days (at a cost of $1,299 per day).

The penultimate chapter was entitled ‘‘Healthy Mind, Healthy Body’’ and revolved

around mental illness and poverty. For psychiatric-related emergency room visits (Fig. 5),

the rates ranged from 88 per 1,000 people per neighbourhood at one extreme to 2.6 per

1,000 people per neighbourhood at the other extreme, a difference of 34 times. Twenty-five

of the top 27 neighbourhoods with the highest rates of psychiatric-related emergency room

visits were located in the lower central city of Hamilton, where poverty rates are the

highest.

Fig. 3 Overall rankings by census tract

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The final day, entitled ‘‘What’s Next? Finding Answers’’ presented six short articles

written by individuals including the Chair of the City’s Poverty Roundtable, the Associate

Medical Officer of Health and the President and CEO of the City’s largest Hospital

Corporation. Also included in this final instalment of the series were ten suggestions for

intervention that could alleviate the problems highlighted in Code Red.

5 The Reaction to Code Red

Using local news or newspapers as a medium for communication changes the way in which

information is perceived, and if executed properly, can communicate effectively to lay

audiences. A deliberate decision was made during this project’s development to dissem-

inate the findings directly to the public through the local newspaper to reach a broader

audience. The objective was to increase community awareness and spark a public debate

on potential solutions. From a public policy and community outreach standpoint, Code Red

is viewed as the most important journalism project ever conceived and carried out at the

Hamilton Spectator and has been recognized elsewhere as a significant effort. For example,

the series has been cited in Canada’s House of Commons and Ontario’s Provincial

Legislature. The study’s findings subsequently became an election issue in the municipal

election that followed 6 months after its publication, with the sole candidate having Code

Red on his platform winning the Mayoral seat on the council. Additionally, the City of

Hamilton created a new staff position specifically in response to Code Red to implement a

Fig. 4 Percentage of emergency room visits with patients reporting no family physician

324 P. F. DeLuca et al.

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neighbourhood development strategy to address some of the issues raised by the series’

findings. The municipal government has also offered $650,000 to any company who will

locate a full service grocery store in the downtown areas of the city to address the shortage

of locations to purchase higher quality food.

From April 2010 through March 2012, the authors delivered more than two-dozen

speeches and presentations to various community groups, hospitals, university classes and

government agencies in Hamilton and across southern Ontario. In addition, The Spectator

in conjunction with the local cable television station, hosted two Open Forum sessions

related to Code Red that were broadcast with both sessions attracting standing-room only

crowds to the Spectator auditorium. In the wake of the original Code Red series, there have

been 184 subsequent articles, opinion pieces and letters to the editor published in the

Hamilton Spectator that have made reference to the Code Red series, as long as 23 months

after publication of the series. One of those opinion pieces, co-authored by the Dean of

McMaster University’s Faculty of Health Sciences, and the Chair of McMaster’s

Department of Family Medicine, indicated that the findings of the Code Red series were

the main reason that the University had decided to abandon a long-standing plan to build a

new health campus and medical centre in the west end of the city, and locate it instead

in Hamilton’s downtown, where there is a greater need for health services. In a similar

fashion, McMaster University’s Children’s Hospital decided to relocate a new 100 million

dollar Children’s Treatment Centre in the north end of the city, noting that the chosen site

Fig. 5 Rate of psychiatric-related emergency room visits per 1,000 people

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is surrounded by neighbourhoods identified by the Code Red series as having the highest

rates of poverty.

The series has positively impacted education in the city as well. Several courses offered

at McMaster University in 2010–2011 and 2011–2012 used the Code Red series and its

findings as part of their curricula. The local community college (Mohawk College) has

received a 1.5 million dollar donation so that scholarships can be established for students

who come from the poorest neighbourhoods as identified in the series. At the elementary

and secondary school level of education, a donor has contributed monetary rewards for

students from ‘‘Code Red schools’’ to participate in a Science Fair, held annually by both

local school boards.

The series won a number of important journalism awards both locally and nationally.

Locally, it won an Ontario Newspaper Award for feature writing, a National Newspaper

Award in the Special Projects category, top prize at the Canadian Association of Journalists

awards, and the series was a finalist for the Michener Award, which recognizes the best

public service journalism in Canada. In addition, Code Red was the first Canadian winner

of the Hillman Prize, offered by the US-based Hillman Foundation, which recognizes the

best journalism dedicated to social justice issues.

Finally, in October 2010, the Code Red series and its findings were presented to the 9th

International Conference on Urban Health in New York City, which featured more than

700 presentations from scientific researchers spanning the globe. Specifically, one oral

presentation was given (‘‘Low birth weight babies and social determinants of health:

A Canadian example,’’) and one poster was presented entitled ‘‘Connections between

health, poverty and social determinants at the neighbourhood level: A case study of

Hamilton, Ontario, Canada’’. It is a rare achievement to have a newspaper series cross into

the world of scientific academia.

As has been evidenced, Code Red had (and continues to have) a profound effect on the

community. In general, it can be attributed to the overall approach employed in publishing

the series. One of the great strengths of the study is that metrics provided were very simple

for both policy makers and a lay audience to understand. Additionally, the visualization

through mapping added a sense of place to the study, which people were able to identify

with. Perhaps the greatest cause of concern with the study was the effect that the labelling

of the neighbourhoods might have on the populations that reside there. The authors were

certainly sensitive to that, however, it was felt that the positive outcomes for the com-

munity outweighed the potential stigma that might be attached to these neighbourhoods.

6 Conclusion

Code Red documented the disparities in the determinants of health and health status in the

City of Hamilton that has developed as the industrial jobs disappeared from the inner city.

It drew the attention policy makers, with the Hamilton creating a new senior position to

tackle the issue of poverty in the inner city. It identified, with interviews and costs cal-

culated from figures provided by the Ministry of Health, the waste that occurs in a

Provincial Health Care system when it becomes the resource of last resort after the failure

of incoherent social welfare programs. The maps, simple statistics, and stories all woven

together provide an effective means of communicating health information to the public,

and using this initiative as a template can serve as a model for other jurisdictions in

Ontario, Canada and the other countries in the world.

326 P. F. DeLuca et al.

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