What the church can do

Poverty is Making Us Sick:What Faith Communities Can Doto Achieve Health and Social Justice

Dr. Cory Neudorf, Chief MHO Saskatoon Health Region, and

Associate Clinical professor, U of S

Introduction: What does it all mean??

Health Disparity – differences or variations between groups

Health Inequality – implies the need for equality

Health Inequity – implies a value judgement …things are unfairly distributed

E.g. equality does not always imply equity. Perhaps some groups need something more than others (equal service for equal need)

What “determines” Health?

The fundamental conditions and resources for health are:

peace,

shelter,

education,

food,

income,

a stable eco-system,

sustainable resources,

social justice, and equity.

National and International Work on Health Inequalities/Inequities

WHO Commission on the Social Determinants of Health Final Report August 2008 “Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health”

WHO Commission RecommendationsThree principles of action

1. Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age.

2. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.

3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.

National and International Work on Health Inequalities/Inequities

“CPHO Report on the State of Public Health in Canada” May 2008

CPHO Report: Public health in Canada

Source:Dahlgreen, G. & Whitehead, M. (2006). European strategies for tackling social inequities in health: Levelling up Part 2. World Health Organization.

Factors that influence our health

Our health – Life expectancyLife expectancy at birth by neighbourhood income and sex,

urban Canada, 2001

Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs.

Source: Wilkins et al. (2007), Statistics Canada.

Our health – Life expectancy

Source: Indian and Northern Affairs Canada, Basic Departmental Data, 2004.

Life expectancy at birth by sex, Registered Indian and general population, Canada, 1980-2001

Our health – Causes of deathAge-standardized mortality rates for lung cancer by neighbourhood income, female, urban Canada, 1971-2001

Age-standardized mortality rates for ischemic heart disease by neighbourhood income, male, urban Canada, 1971-2001

ASMR – Age-standardized mortality rate.Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs.

Source: Wilkins et al. (2007), Statistics Canada.

Health behaviours

Source: Statistics Canada, Physically Active Canadians.

Percentage of the general population aged 12+ years who were physically active by income, Canada, 2005

Addressing inequalitiesMaking a difference to reduce health inequalities involves these priority areas for action:

Social investment Canada can build on its strong policy foundations to further reduce the gap that contributes to

health inequalities

Community capacity Strong communities are critical. Broad social policy and investments are needed to

compliment and support community efforts

Inter-sectoral action All levels of government, the private and non-governmental sectors, and international

organizations can work together towards integrated, coherent policies and actions to effectively prevent and improve upon health inequalities

Knowledge infrastructure Reducing health inequalities requires building knowledge: better information about specific sub-

populations/regions; a greater understanding of how determinants interact; and stronger insight into how to apply proven practices from other jurisdictions

Leadership Leadership across all sectors is crucial to reducing health inequalities.

Moving forward Foster collective will and leadership

If Canadians want to be the healthiest population in the world, addressing health inequalities must become a priority

Working across sectors and jurisdictions, health inequalities can be reduced through: recognizing role of prevention and promotion; developing indicators and measurement tools; recognizing health as a shared responsibility; and engaging leaders

Reduce child poverty Some of the greatest returns on investment are those targeted to the early years Reducing child poverty requires examination of: income redistribution policies and

initiatives required for healthy childhood development; developing better opportunities for children (e.g. housing, education); targeting interventions for children at-risk; and adopting best practices from other jurisdictions

Strengthen communities Communities are where all sectors and players can easily converge to establish

local priorities and develop shared strategies for addressing health inequalities Enhance Canadian communities by: working collaboratively to support community

efforts; improving access to skills/resources; sharing multi-level data; and supporting the replication of proven successful initiatives

Reducing Gaps in Health:A Focus on Socio-Economic Status in Urban CanadaNov. 2008

A collaboration between the

Canadian Population Health Initiative and the

Urban Public Health Network

Saskatoon Analysis of Dissemination Areas by Deprivation Index Quintiles

Pan-Canadian, Regina, Saskatoon and Winnipeg Comparison

Ratio of Age Standardized Hospitalization Rates Between Low and High

SES Groups, Pan-Canadian, Regina, Saskatoon and Winnipeg

2.3

1.9 2.0

3.5

3.8

4.2

4.54.7

8.5

1.6

2.8

1.3

1.8

2.5

3.0

3.9

1.2 1.2 1.3

1.6

1.3 1.4

1.9

3.4

2.7

2.42.3

1.6

1.1

2.4

2.2

1.91.7

2.2

3.4

6.4

3.43.33.4

2.8

2.4

2.0

5.0

2.73.0

3.73.4

2.12.2

1.81.9

1.3

0

2

4

6

8

10

Low birthweight

Injuries inchildren

Landtranprot

accidents

Asthma inchildren

Unintentionalfalls

Injuries Anxietydisorders

Affectivedisorders

ACSC Diabetes MentalHealth

COPD Substance-related

disorders

Rati

o

Pan-Canadian Regina Saskatoon Winnipeg

Source: RQHR presentation on CPHI study

Ratio of Age Standardized Self-Reported Health Percentages Between Low and High SES Groups, Pan-Canadian, Regina, Saskatoon and Winnipeg

0.8

0.9

1.1

1.2

1.2

1.2

1.5

1.8

0.7

0.8

1.1

1.1

1.3

1.6

1.8

2.2

0.8

1.1

1.1

1.5

1.2

1.2

1.6

2.4

0.8

0.8

1.1

1.3

1.4

1.4

1.5

1.8

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Self-rated

health

Influenza

immunization

Overweight or

obese

Activity

limitation

Alcohol binging Physical

inactivity

Risk factors Smoking

Rati

o

Pan-Canadian Regina Saskatoon Winnipeg

Source: RQHR presentation on CPHI study

Saskatoon neighbourhood analysis boundaries, excluding industrial and development areas, 2005

Legend

Affluent neighbourhoods

Rest of Saskatoon

Low income neighbourhoods

Source: Saskatoon Health Region, Public Health Sevices

Health Issue Rate Ratio (% higher)Core : Total Saskatoon

Rate Ratio (% higher)Core : Affluent

Hospitalizations

Suicide Attempts 3.75 (275%) 15.58 (1458%)

Mental Disorders 1.85 (85%) 4.27 (327%)

Injuries and Poisonings 1.54 (54%) 2.46 (146%)

Diabetes 3.98 (298%) 12.86 (1186%)

COPD 1.38 (38%) n/s 1.53 (53%) n/s

Coronary Heart Disease 1.34 (34%) 1.70 (70%)

Stroke 1.33 (33%) n/s 1.82 (82%) n/s

Cancer 0.89 ( no difference) n/s 1.02 (no difference) n/s

Physician Visits


Injuries and Poisonings 1.35 (35%) 1.91 (91%)

Diabetes 1.71 (71%) 2.11 (111%)

COPD 1.43 (43%) 2.42 (142%)

Coronary Heart Disease 1.12 (12%) 1.44 (44%)

Stroke 0.88 (no difference) n/s 1.58 (58%)

Cancer 0.77 (no difference) n/s 1.00 (no difference) n/s

Prescription Drug Use


Diabetes 1.80 (80%) 2.60 (160%)



Public Health / Reportable Diseases

Chlamydia 4.32 (332%) 14.89 (1389%)

Gonorrhea 7.76 (676%) n/a

Hepatitis C Notifications 8.04 (704%) 34.60 (3360%)

Complete MMR coverage by age 2 yrs

Core 46.4% Avg. 68% Affluent 94.9%

No MMR by age 2 Core 10.7% Avg. 3.5% Affluent 1.7%

Health Status Indicators

Teen Births 4.21 (321%) 16.49 (1549%)

Infant Mortality Rates 5.48 (448%) 3.23 (123%) n/s

Low Birth Weight 1.46 (46%) 1.10 (10%) n/s

All Cause Mortality 1.04 (no difference) n/s 2.49 (149%)



Income and Health, selected results

In comparison to high income residents, low income residents in Saskatoon are:

1458% more likely to attempt suicide

1389% more likely to have chlamydia

1186% more likely to be hospitalized for diabetes

3360% more likely to have Hepatitis C

1549% more likely to have a teen birth

448% more likely to have an infant die in the first year

Full immunization 46% vs 95% high income

Response to data

Health workers and general public Shock Denial moving to

reluctant acceptance Anger over degree of

disparity Motivation to change

Inner city Community & workers Less shock Anger and despair Desire to see action Willingness to partner Many ideas for change

SHR response to data

Awareness of need to be responsible in the release of the data

1. Need baseline data on community and staff awareness, attitudes, willingness to change

2. Need to inform affected groups from community to government (Communication strategy)

3. Need to have both a Health System action plan and a Social Determinants of Health Action Plan to announce closely following the data release

4. Ongoing study and evaluation Commitment to keep measuring the issue and effect of

interventions until things change

Survey Data Summary

Baseline survey done to:Measure public and staff awareness of Health

DisparitiesGauge public receptiveness to possible policy

interventions Plan to repeat survey once public

awareness campaign and media coverage has had a chance to further inform people.

Survey Data Summary

5000 respondents in and around Saskatoon with representation from Inner city (including interviews with homeless people and those without telephones), rest of Saskatoon, and rural residents.

Response rate 62%. Representative by age, income, neighborhood, income, cultural status. F slightly > M

Survey Data Summary

80% of people agree that the poor are more likely to suffer from poor health

However, they tend to assume it is only in areas such as suicide attempts, diabetes, HIV/STI’s, while they feel there would be no difference for mental illness, injury, heart disease, breathing problems, stroke and cancer

If health status does differ by income, they believe an “acceptable level” would be: 0% 49% of people 10% 12% of people 25% 17% of people 50% 20% of people >100% 4% of people

Survey Data Summary

91% of people believe something can be done to address this disparity

Over 30 policy options were presented for consideration, and the top three answers were: Strengthen early intervention programs for children and youth 82% Earning supplements to help people move off welfare 82% More disease prevention programs 81%

Option with the least support: More union membership for workers 29%

More support given when options focused on children: More subsidized nutritious food: 62% support More subsidized nutritious food for children: 75% support

Survey Data Summary

When asked how they would propose funding any of these interventions: 10% raise taxes 82% redistribute current taxes

If financial resources are limited: 41% supported transferring funds from treatment to

prevention (59% against) 40% support for transferring funds from health

treatment to health creating services such as education and affordable housing (60% against)

Summary

“Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity. …Reducing health inequities is, …an ethical imperative. Social injustice is killing people on a grand scale.” (Marmot, 2008).

What Can Be Done by our Governments in Canada / Saskatchewan?

Use evidence-based policy options in areas such as: Income Education Employment Housing Health services Aboriginal Cultural Status and governance

..to develop and support an “all of government” approach to reduce the gap in a generation in our country / province

Set targets and goals and measure our progress

Why Should I Support This? Some voiced objections…

Don’t People Get What They Deserve in Life? “Freedom to choose is socially determined (rigged). This model has been tested to

destruction over the last few decades. We are motivated by self-interest, but we are also altruistic, intolerant of unfairness, and made to live in community” Marmot, 2008

Surely this is not a problem in (Canada, Sask., Regina, Saskatoon, etc)? Health Inequity affects us all (social gradient effects, costs of poverty)

Isn’t it a cultural issue? The role of ethnicity disappears once you control for poverty, education, etc.

Interventions need to keep cultural issues in mind in their design and implementation, but systematic discrimination is the underlying issue we need to address

Throwing money at people isn’t going to solve anything. Aren’t we always going to have poverty? It’s not only about assistance rates. Complex problems need elegant solutions.

Supporting approaches that help transition people in need to greater stability and self-reliance will greatly reduce poverty rates…as it has in other jurisdictions.

What Can the Church do to Reduce the Gap?

Why Should the Church be Interested in the Community’s Health?

The church: is a major “intersectoral partner” in the effort to

improve health at both the individual and community level

Serves as an important social support mechanism for many people

has a mandate in achieving a balance between evangelism and social justice (ref. John Stott)

Why Should the Christian be Interested in the Community’s Health?

A follower of Jesus Christ must use his actions as their guide (WWJD)

Christ clearly cared about individuals’ physical, emotional, and spiritual health

Christ gave many admonitions to his followers to care about and influence societal issues such as poverty, justice, equity, gender equality, war, etc.

God’s View on Poverty

2000+ verses in the Bible relating to how God feels about poverty and justice

What can I do?

Give (globally and locally) Pray Live responsibly Volunteer Be aware Share God’s passion for the poor Advocate

Ideas for local action

In all these areas, do things individually, in a small group, as a congregation, denomination, and as the Church (collectively with other congregations from many denominations) in your city,

What Can I / We do?

Give (globally and locally) to organizations working in low income areas, or

working to deliver programs for those in need (and not just to “Christian” organizations and causes)

support changes in government programming aimed at reducing the gap, even if it affects your taxes!

Support fundraising initiatives (capital needs) in areas such as affordable housing, improved health promotion & disease prevention, and primary care in areas of need, etc

What Can I / We do?

Pray For justice For spiritual renewal For people/groups in need, and individuals you

encounter For God’s Kingdom to come “on earth as it is in

heaven” For a heart that feels what God feels for the poor

What Can I / We do?

Live responsiblyFor sustainability, and in order to afford to

help others in greater needSpend Wisely – where do you shop? Do you

(indirectly or directly) encourage local business re: ethical practises, fair trade, involvement in being part of the local solutions by supporting them if they do?

What Can I / We do?

VolunteerYour time, and your skills, to agencies

working to reduce the gapBe a mentor or find ways to invest in others

using your area of education, work, or interest

What Can I / We do?

Be aware Learn about health disparity and the social

determinants of health – globally, and here at home Share your findings with others at home, in your

neighborhood, at your workplace, your place of worship

Challenge stereotypes and misconceptions when you hear them, and inform others about workable solutions

What Can I / We do?

Share God’s passion for the poorHow much thought/time do we spend on this

issue compared to the time God devotes to it in the Bible? Compared to other issues we think important and the relative time devoted to those in the Bible?

Take the “Micah challenge” as God requires of us in Micah 6:8 “do justice, love mercy, walk humbly with your God”

What Can I / We do?

Advocate Write letters to decision makers, demonstrate, talk to

your friends and neighbours about the need to change

Meet with your city councillor, MLA, MP and express your concerns and your support for change

Talk to those in your sphere of influence about the issues and possible solutions

Support Saskatoon’s Action Plan on Poverty

Ideas for local action

Adopt a capital project in the community to support (e.g. Station 20 west, a new primary care clinic for the inner city, a comprehensive clinic for HIV positive people and their families

Use your space for clinics and services during the week Support micro loan cooperatives (micro finance) for women

starting small businesses out of their homes in the inner city Encourage members (especially youth) to do a “mission

year” (and perhaps start Mission Year Saskatoon!) or Urban Promise Saskatoon

“Speak” (www.speak.org.uk) advocacy and prayer

Conclusion

The current economic crisis is no reason to delay our response. In fact, our challenge is not to draw back from our ambitions, but to make them more urgent!

UK Prime Minister Gordon Brown, Nov 2008

Documents

What the church can do