Equity from the Start: The way ahead in Ontario alPHa Toronto October 22, 2009 Michael M. Rachlis MD MSc FRCPC

Outline There are serious inequalities in health status which are related to disparities in the social determinants of health and health care services What could public health do to reduce health inequalities?

Inequalities in health Men live 6 years less than women Women have more chronic, non-fatal conditions Aboriginal men live 7 years less than non- Aboriginals Poor men live 5 years less than rich men Infant mortality is 70% higher in poor neighbourhoods than rich neighbourhoods Northern Ontarians live shorter lives

Source: Wolfson M, Rowe G, Gentleman JF, Tomiak M. Career earnings and death, a longitudinal analysis of older Canadian men. J Gerontol 1993; 48(suppl):

Things might be getting worse Even before the recession, the working poor wages at fallen by 25% The rate of childhod poverty was as high as in 1989 when Canada voted to end it by 2000 Almost all the income and wealth gains in the past ten years have gone to the top 5% and especially the top 1% of income earners

2.8 – – – – – 7.6 Age and sex adjusted Diabetes prevalence rates Toronto Diabetes Prevalence Rates by Neighbourhood 2001 From: R Glazier. Neighbourhood environments and resources for healthy living

Interactions of risk factors Diabetes rates are highest in areas that have lower income levels, higher unemployment rates, higher proportion of visible minorities and higher immigration rates. Areas with high rates of diabetes tend to be found outside of Toronto’s downtown core, in suburban areas, where there is reduced access to healthy resources such as fruit and vegetable stores and where “activity friendliness” is lower (e.g. fewer amenities within walking distance, poorer access to public transit, greater car dependency).

It’s better to be poor downtown Wealthy areas such as Rosedale have low diabetes rates, regardless of the level of access to healthy resources or activity friendliness. Downtown high risk areas such as Regent Park and Parkdale have lower diabetes rates than expected, most likely because of the ability to walk to services, better access to healthy foods, recreational centers and public transit.

“To a great extent, attempts to separate the relative contribution of these factors risks presenting an incomplete picture of the complex inter- relationship between racial and ethnic minority status, socioeconomic differences, and discrimination in the United States.” US Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care 2003

Disparities in health between different groups are responsible for 20% of health care costs Health Disparities Task Group of the Federal Provincial Territorial Advisory Committee on Population Health and Health Security. Health Disparities: Roles of the Health Sector sp/disparities/pdf06/disparities_discussion_paper_e.pdf sp/disparities/pdf06/disparities_discussion_paper_e.pdf

Health inequalities between different groups in Ontario are pervasive and deadly. They rob Ontario of productive citizens and raise the costs of our health care system. The presence of such significant inequalities amidst plenty makes me ashamed for myself and my country.

But the question for Public Health is: So What?

What can local public health do? Most key economic, social, and environmental policies are provincial or federal jurisdiction. Public health cannot force its views on municipalities What can we do with our bully pulpit and “soft power”? How can we partner more effectively?

What can MOHLTC, MCY, or MHP do? Most key economic, social, and environmental policies are under the control of other provincial ministries, the federal government, or international agencies. The provincial government lacks a strategic plan for health and formal coordination structures essential for implementing healthy public policy.

What can MOHLTC, MCY, or MHP do? There isn’t even coordination about funding increases between ministries!?!

What can the Ontario Agency for Health Protection and Promotion do? “To provide scientific and technical advice and support to the health care system and the Government of Ontario in order to protect and promote the health of Ontarians and recue health inequities.” OAHPP First legislative object

What can public health organizations do? How can we be more effective in our advocacy with government and the public? How can we partner more effectively? What are the limits to advocacy when most of us work for the state?

What can public health researchers do? The evidence is already overwhelming How do we make our research more relevant?

“Courage my Friends, ‘Tis Not Too Late to Make a Better World!” TC Douglas (per Tennyson)

Our panellists Dr. Francoise Bouchard, Ontario associate chief medical officer of health, health promotion Janet Gasparini, ED Sudbury Social Planning Council Dr. Heather Manson, Sr. Medical Advisor to the President ON Agency for Health Protection and Promotion and Interim Director Health Promotion Dr. Dennis Raphael, Professor of Health Policy and Management York University A surprise Guest!