When public policy fails

Canadian health agencies continue to develop diabetes prevention and management strategies that primarily focus on “lifestyle”: poor diet, excess weight, and lack of physical activity.  But the exclusive focus on “lifestyle” ignores the important role played by the social determinants of health.  A recent paper entitled A toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics: the experiences of poor Canadians with Type 2 diabetes outlines a number of key issues and concerns with this approach:

– While there is a general understanding that social and economic factors play a large role in shaping health, this has not changed how we respond to specific diseases, such as diabetes.

– Canadians with diabetes who live in poverty are still at high risk, despite access to universal health care.

– Low income contributes to many “lifestyle” risks:  poor diet, few opportunities for physical activity, high stress, and inadequate housing.

– The result is that mortality rates for Canadians living in poverty who have diabetes has exploded over the past few decades, while mortality rates have remained stable or even declined for the better off.

– These increases in diabetes mortality began in the mid-1980’s, alongside inflation-adjusted declines in minimum wages and absolute declines in social assistance levels.

– These trends suggest that diabetes prevention programs would be most effective if they focused on poverty, and the barriers to healthy lifestyles.

Clearly, there is a continued disconnect between health care services and public policy that supports the health of individuals.  When research, analysis, and recommendations are done, they often support the a superficial recommendation to adopt “healthy lifestyles”, rather than public policy that would get at the deeper issues of material and social deprivation that create barriers to healthy lifestyles for those living in poverty.

The public discourse over “lifestyle” must be systematically challenged by everyone in the health care sector, in order to address this disconnect in public policy.  Doctors for Fair Taxation is an excellent example of the health care sector lending their voice to the issue of income inequality. The Registered Nurses’ Association of Ontario also regularly advocates on issues related to social determinants of health such as poverty and food security.   Ontario’s 74 Community Health Centres ground their work in the social determinants of health and are vocal advocates at the community and provincial level. However, until a consistent and collective voice for change is heard, the disconnect between policy and reality will continue.

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  1. Lori Kleinsmith

    Thank you for sharing this, Ron. We do need to use current, highly academic evidence such as this to substantiate our policy advocacy work, but must also figure out how to diffuse the ideas into public discourse so that shifts can occur. Would love to hear examples from others as to how this is being done.

  2. kathy hardill

    nice piece, lori – i agree, of course – and would add to your examples of folks tackling this issue health providers against poverty whose website is

    in the 19th century rudolf virchow famously said “all diseases have two causes – one pathophysiological, the other political” – highlighting the fact that the insights into the root causes of morbidity and mortality are not new – i do not have the same faith in conventional political processes that if simply enough health care sector people “systematically challenge” the notions that the causes of illness are most importantly to be found in the unhealthy choices of the masses, things will change

    you are talking about fundamental redistribution of wealth – a high impact health intervention that would drastically reduce chronic illness and health system costs – but the basic values of capitalism (which most health sector individuals support!) preclude this –

    essentially the only thing that will be effective is mass and unrelenting direct action – not something health sector employees nor bureaucrats are renowned for – even the CHC system, which i hold dear, tends for the most part to act very conservatively and tends to be most reluctant to speak out against the provincial government that funds it – so when we have organized around raising provincial social assistance rates, CHCs have felt it risky to publicly lend their voices to a direct attack on their funder, and frankly many of those 70 plus CHCs are in fact quite medical modelled and do not value time spent away from direct patient care – CHCs that have health promoters who can do upstream work are lucky, but it is by no means typical.

    I have challenged the public discourse on “healthy lifestyles” for 25 years, and i love it when others do as well. Having said that, the redistribution of wealth demands radical political action, not the collective voice of well meaning, well paid health system bureaucrats and health care professionals like you and i. I’m not sure what a “direct attack on health inequalities” noted in the referenced abstract means, but perhaps it is getting at what must be done beyond talking.

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