healthier societies from analysis to action

clyde hertzmanis Director of the Human Early Learning Partnership, Professor in the University of British Columbia’s Department of Health Care and ology, and Associate Director of the Ce

Healthier Societies: From Analysis to Action

JODY HEYMANN, et al.,

Editors

OXFORD UNIVERSITY PRESS

Healthier Societies

Healthier Societies

From Analysis to Action

Edited by

JODY HEYMANN CLYDE HERTZMAN MORRIS L BARER ROBERT G EVANS

1

2006

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p cm.

Includes bibliographical references and index.

ISBN-13 978-0-19-517920-0 ISBN 0-19-517920-X

1 Social medicine 2 Medical policy—Social aspects 3 Epidemiology.

4 Social change 5 Medical geography I Heymann, Jody, 1959–

RA418.H3955 2005 362.1—dc22 2005040679

1 3 5 7 9 8 6 4 2 Printed in the United States of America

on acid-free paper

branches are many but whose roots are few: the wind comes and uproots them But when our deeds exceed our learning we are like trees whose branches are few but whose roots are many,

so that even if all the winds of the world were to come and blow against them, they would be unable to move them.

—R’Elazar ben Azariah

who influenced the courses of our lives from the earliest stages

By the late 1980s, evidence showed that health status among populations out the twentieth century had persistently differed according to social and eco-nomic status, despite a dramatic change in the major causes of disease and death.Such a finding clearly indicated an important need to further our understanding

through-of the broad and fundamental determinants through-of health In 1987, the PopulationHealth Program was launched to take up this challenge by bringing together amultidisciplinary group of researchers with a diversity of perspectives

The Population Health Program members brought expertise from a broad range

of disciplines, including medicine, epidemiology, geography, anthropology, ology, economics, and policy analysis This combination resulted not only in adiversity of perspectives brought to the study of determinants of health, but it alsocaused researchers to look beyond the barriers of their own disciplines and tothink in new ways

soci-Over the course of fifteen years, the program systematically explored nomic status (SES) gradients and their relationship to health outcomes It is nowwell established that, on average, people with higher levels of income, education,and social position live longer and are healthier than those with lower incomesand lesser social positions Moreover, societies with greater variations in income,education, or social position tend to have higher levels of mortality In the pro-gram’s final five years, program members furthered studies in this area by exam-ining the SES gradient at the level of the individual life course, as well as at thelevels of the neighborhood, community, and society

socioeco-In its effort to develop a comprehensive determinants-of-health framework, theprogram worked to better understand the biological pathways that lead to varia-tions in population health Program members sought to learn how systematic dif-ferences in living circumstances over time can embed themselves in human biology

to create susceptibilities to a wide range of diseases

The program received international recognition for its major contributions inresearch, particularly its work on synthesizing knowledge from a wide range ofdisciplines and developing a model of the determinants of health The programhad a substantial impact on health policy at the local, provincial, and nationallevels

This book pulls together the work and viewpoints of a wide range of programmembers and other colleagues who joined us in this unique research program to

truly understand how to improve population health—from basic science research

to public policy

—Clyde HertzmanDirector, Program in Population Health

1998–2003

The editors and contributors gratefully acknowledge the many years of supportgiven by the Canadian Institute for Advanced Research (CIAR) to the Program inPopulation Health Without the support of the CIAR, the ideas presented in thisbook would not have had a chance to develop and influence thinking in populationhealth around the world

The network, with its national and international membership, would not haveheld together nearly as well without the indispensable help of Michele Wiens Inaddition to playing countless roles in helping to facilitate the network’s collabo-rations, she played key staff roles in communicating among contributors for thisbook Kate Penrose at Harvard University played a similarly invaluable role instaffing this final project and ensuring that this book came to fruition We’re deeplygrateful to both for their help

All good books benefit from a wise and experienced editorial eye, and this bookwas no exception Jeffrey House at Oxford University Press brought his experiencedeye to this project and gave invaluable suggestions Carrie Pedersen generouslygave of her time to finish the project after Jeffrey House retired from Oxford

We are deeply indebted to the many colleagues at each of our institutions whohave commented over the years on the ideas that have gone into this book andwho have debated us, stimulated our thinking, and encouraged us to focus on thebest way to create healthier societies

The seeds for this work were sown early Ce´cile Brault, high school teacher andadvisor, grounded Jody Heymann in the impact of lived inequalities and in theresponsibility we all have to do all we can to address them Tom Robinson, ClydeHertzman’s seventh-grade teacher, taught him the value of critical appraisal MorrisBarer’s father, Ralph David Barer, was truly the first influence on his career track.Geoffrey Robinson, an early colleague of Bob Evans, pioneered the concept ofpopulation pediatrics in Vancouver over thirty years ago, steps ahead of the times.This book is dedicated to them and to many more than we can name who influ-enced the courses of our lives and this work from its earliest stages

About the Editors, xvAbout the Contributors, xviiHealthier Societies: An Introduction, 3

Jody Heymann and Clyde Hertzman

Part I: The Complex Relationship between Social

and Biologic Determinants of Health

1 Interactive Role of Genes and the Environment, 11

John Frank, Geoffrey Lomax, Patricia Baird, and Margaret Lock

2 Biological Pathways Linking the Social Environment,

Development, and Health, 35

Clyde Hertzman and John Frank

3 Global and Local Perspectives on Population Health, 58

Margaret Lock, Vinh-Kim Nguyen, and Christina Zarowsky

4 A Life Course Approach to Health and Human Development, 83

Clyde Hertzman and Chris Power

5 Universal Medical Care and Health Inequalities:

Right Objectives, Insufficient Tools, 107

Noralou P Roos, Marni Brownell, and Verena Menec

Part II: An In-depth Look at Several Determinants of Health

6 Food, Nutrition, and Population Health:

From Scarcity to Social Inequalities, 135

Lise Dubois

7 Work and Health: New Evidence and Enhanced Understandings, 173

Cam Mustard, John N Lavis, and Aleck Ostry

8 Income Inequality as a Determinant of Health, 202

Nancy Ross, Michael Wolfson, George A Kaplan,

James R Dunn, John Lynch, and Claudia Sanmartin

9 Role of Geography in Inequalities in Health and Human Development, 237

James R Dunn, Katherine L Frohlich, Nancy Ross,

Lori J Curtis, and Claudia Sanmartin

Part III: Moving from Research to Policy

10 Social Welfare Models, Labor Markets, and Health Outcomes, 267

Joachim Vogel and To¨res Theorell

11 Changing Trends in Economic Well-being in OECD Countries:

What Measure Is Most Relevant for Health? 296

Lars Osberg and Andrew Sharpe

12 Reallocating Resources acrossPublic Sectors to Improve Population Health, 327

Greg L Stoddart, John D Eyles, John N Lavis, and Paul C Chaulk

13 Taking Different Approaches to Child Policy, 348

Anita L Kozyrskyj, Lori J Curtis, and Clyde Hertzman

14 Where Do We Go from Here? Translating Research to Policy, 381

Alison Earle, Jody Heymann, and John N Lavis

Index, 405

About the Editors

jody heymannis the founding director of the Project on Global Working ilies, the first project devoted to understanding and improving the relationshipbetween working conditions and family health and well-being throughout theworld She is founding chair of the Initiative on Work, Family, and Democracy Aprofessor in the Faculties of Medicine and Arts at McGill University, Heymann isfounding director of the McGill Institute for Health and Social Policy Heymannhas been awarded a Canada Research Chair in Global Health and Social Policy

Fam-Her current and most recent books include Forgotten Families: Ending the Growing Crisis Confronting Children and Working Parents in the Global Economy (OUP, 2005); Unfinished Work (2005); Global Inequalities at Work: Work’s Impact on the Health of Individuals, Families, and Societies (OUP, 2003); and The Widening Gap

(2000)

Heymann has served in an advisory capacity to the World Health Organization(WHO); United Nations Educational, Scientific, and Cultural Organization(UNESCO); the International Labor Organization (ILO); the U.S Senate Com-mittee on Health, Education, Labor, and Pensions; and the U.S Centers for DiseaseControl and Prevention, among other organizations

clyde hertzmanis Director of the Human Early Learning Partnership, Professor

in the University of British Columbia’s Department of Health Care and ology, and Associate Director of the Centre for Health Services and Policy Research.Nationally, he is a Canada Research Chair in Population Health and Human De-velopment and a Fellow of the Canadian Institute for Advanced Research (CIAR)

Epidemi-in the Successful Societies and Experience-based BraEpidemi-in and Biological Developmentprograms Hertzman has played a central role in creating a framework that linkspopulation health to human development, emphasizing the special role of earlychildhood development as a determinant of health His research has contributed

to international, national, provincial, and community initiatives for healthy childdevelopment

morris l barer is the first Scientific Director of the Institute of Health Services

and Policy Research, Canadian Institutes of Health Research He was the foundingDirector of the Centre for Health Services and Policy Research at the University

of British Columbia, where he remains as research faculty He is also a professor

in and director of the Division of Population Health and Health Services Research

in the Department of Health Care and Epidemiology at the University of BritishColumbia His recent research has focused on the determinants of health care costincreases; pharmaceutical policy in Canada; separating fact from fiction in argu-ments about access to care, wait lists, the effects of an aging population; healthcare financing; use of health care services, particularly by seniors; continuity ofcare; and the roles of research evidence and interests in the evolution of healthcare policy

robert g evans is a professor with the Department of Economics at the

Uni-versity of British Columbia He is a Fellow of the Canadian Institute for AdvancedResearch and was director of the Institute’s Population Health Program from 1987

to 1997 He held a National Health Research Scientist award and has received aCanadian Institutes of Health Research Senior Investigator award Major publica-tions include “Strained Mercy: The Economics of Canadian Health Care” (1984)and “Why Are Some People Healthy and Others Not? The Determinants of Health

of Populations” (1994; as senior editor) Evans’s studies of health care systems andpolicies have led to numerous invitations to provide policy advice to the Canadianfederal and provincial governments He has also been a consultant and lecturer onhealth care issues to governments and other public agencies in the United States,Europe, Asia, and the South Pacific Evans has been elected as a Fellow of theRoyal Society of Canada and was awarded the Health Services Research Advance-ment Award

About the Contributors

patricia bairdis a pediatrician and medical geneticist and has been head of theDepartment of Medical Genetics at the University of British Columbia She hasbeen a member of many national and international bodies, among them the Na-tional Advisory Board on Science and Technology (chaired by the Prime Minister)and the Medical Research Council of Canada She chaired the Federal Royal Com-mission on new reproductive technologies She has served as an advisor to theWHO on genetics in recent years and has published extensively on the policyimplications of new genetic and reproductive technologies

marni brownell is a senior researcher with the Manitoba Centre for HealthPolicy and an assistant professor in the Department of Community Health Sciences

at the University of Manitoba Brownell holds a New Investigator Award with theCanadian Institutes of Health Research and is a core member of the CanadianInstitute for Advanced Research New Investigator Network Her background is indevelopmental psychology, and her research focuses on the social determinants ofchild health

paul c chaulk is president of the Atlantic Evaluation Group and has ten years

of experience covering a broad scope of health research as well as participatorymodels of program and system evaluation In particular, he was the project co-ordinator of the Prince Edward Island System Evaluation Project, which evaluatedthe 1993 health reforms in that province

lori j curtis is a specialist in health economics and econometrics Curtis was

an assistant professor in the Department of Community Health and Epidemiologyand the Department of Economics at Dalhousie University when collaborating onthis project; she was awarded a Clinical Scholar Award by the Faculty of Medicine.Curtis has recently moved to the Applied Research and Analysis Directorate inHealth Canada and is now focusing on health policy research Research areas haveincluded child and maternal health; the relationship between poverty, health, andhealth care utilization; gender, labor force participation, and health; and povertyand inequality

lise dubois is an associate professor in the Department of Epidemiology andCommunity Medicine at the University of Ottawa She is based at the Institute ofPopulation Health at the University of Ottawa, where she holds a Canada ResearchChair in Nutrition and Population Health Her research interest relates to the role

of nutrition as a determinant of social health inequalities in different countries.She works mainly on population-based birth cohort data, analyzing the role ofnutrition in early years on later social and health inequalities

james r dunn is an assistant professor in the Department of Community Health

Sciences at the University of Calgary He holds a New Investigator Award fromthe Canadian Institutes of Health Research and a Health Scholar award from theAlberta Heritage Foundation for Medical Research His background is in the socialgeography of health, and he has research interests in the relationship betweenincome inequality and population health in North American metropolitan areasand housing as a socioeconomic determinant of health

alison earleis a research scientist at the Harvard School of Public Health, whereshe has taught classes on the translation of public health research into public policy.She currently serves as project director for the Work, Family, and DemocracyInitiative, a research effort designed to compare social conditions and public pol-icies influencing the health and well-being of working families globally Her pub-lished research has focused on differences across social classes in the availability ofsocial supports and adequate working conditions, and their impact on children’shealth and developmental outcomes

john d eyles is a professor at McMaster University and is Director of its Institute

of Environment and Health His main research interests include the appraisal,evaluation, and application of scientific evidence in policy settings; individual, com-munity, and policy responses to environmental events; and the relationships be-tween environmental quality (and degradation) and human health, values, and theenvironment Eyles has carried out work for several national and provincial or-ganizations and governments in Canada and has served on several expert panelsand advisory committees and boards

john frankis a physician-epidemiologist with special expertise in prevention InDecember 2000, Frank was appointed Scientific Director of the Canadian Institutes

of Health Research, Institute of Population and Public Health, located at the versity of Toronto Frank’s main area of interest is the biopsychosocial determinants

Uni-of health status at the population level Frank was the founding Director Uni-of search at the Institute for Work & Health in Toronto and is currently a seniorscientist with the institute

Re-katherine l frohlich is an assistant professor at the Universite´ de Montre´al in the

Department of Social and Preventive Medicine Her research interests are the tion of social theory into social epidemiological research and, specifically, how to con-ceptualize, operationalize, and understand the effects of context on disease outcomes

integra-george a kaplan is Professor and Chair of the Department of Epidemiology in

the School of Public Health and a Senior Research Scientist at the Institute forSocial Research He is also Director of the Michigan Initiative on Inequalities inHealth; the Michigan Interdisciplinary Center on Social Inequalities, Mind andBody; and the Center for Social Epidemiology and Population Health, all at the Uni-versity of Michigan Kaplan also directs the newly formed Robert Wood JohnsonFoundation Health and Society Scholars Program at the University of Michigan

anita l kozyrskyj is an associate professor at the Faculty of Pharmacy and

Department of Community Health Sciences at the University of Manitoba Overthe past nine years she has been a health services researcher at the Manitoba Centrefor Health Policy Her research has spanned several areas, from population healthstudies in asthma and other chronic diseases in children to policy research onpharmaceuticals She is Manitoba Director of the Western Regional Training Centre

in Health Services Research Kozyrskyj holds a Canadian Institutes of Health search New Investigator Award

Re-john n lavis is the Canada Research Chair in Knowledge Transfer and Uptake,

Associate Professor in the Department of Clinical Epidemiology and Biostatistics,Member of the Centre for Health Economics and Policy Analysis, and AssociateMember of the Department of Political Science at McMaster University His prin-cipal research interests include knowledge transfer and uptake in public policy-making environments, the politics of health care systems, and the links betweenlabor market experiences and health

margaret lockis Marjorie Bronfman Professor in Social Studies in Medicine inthe Department of Social Studies of Medicine and also in the Department of An-thropology at McGill University She is a Fellow of the Royal Society of Canadaand was awarded the Prix Du Que´bec, domaine Sciences Humaines, the CanadaCouncil for the Arts Molson Prize, and the Canada Council for the Arts Killam

Prize Lock’s prize-winning monographs include Encounters with Aging: Mythologies

of Menopause in Japan and North America (1993) and Twice Dead: Organ plants and the Reinvention of Death.

Trans-geoffrey lomaxis Research Director with the California Environmental HealthTracking Program He is currently involved in the planning and implementation

of a statewide population health surveillance system He has been conducting vironmental and occupational health research since 1985 His doctoral researchinvolved an evaluation of the scientific, ethical, legal, and policy issues related toworkplace biomonitoring and genetic testing.

en-john lynchis an associate professor in the Department of Epidemiology, School

of Public Health, at the University of Michigan He has joint appointments at theCenter for Human Growth and Development, the Institute for Social Research,and the Center for Research on Ethnicity, Culture, and Health His main area ofresearch interest is in the life course processes that help generate trends in popu-lation health and social inequalities in health

verena menecis an associate professor in the Department of Community HealthSciences and the Director of the Centre on Aging at the University of Manitoba.She holds a Tier 2 Canada Research Chair in Healthy Aging Her main researchinterests are in the areas of healthy aging and the relationship between healthservices use and population health, particularly among senior populations

cam mustard is a professor in the Department of Public Health Sciences at theUniversity of Toronto and President and Senior Scientist at the Institute for Workand Health He was Associate Director and Fellow of the Population Health Pro-gram of the Canadian Institute for Advanced Research and a recipient of a Ca-nadian Institutes of Health Research Scientist award Mustard has active researchinterests in the areas of labor market experiences and health, the distributionalequity of publicly funded health and health care programs, and the epidemiology

of socioeconomic health inequalities across the human life course

vinh -kim nguyen, a practicing HIV specialist and medical anthropologist, has

been involved in a number of projects to expand access to antiretroviral drugs inWest Africa for the past ten years His research concerns the broader social andpolitical problematic of access to treatment He is Associate Professor of FamilyMedicine at McGill University and is also affiliated with the Departments of An-thropology and Social Studies of Medicine

lars osbergis currently McCulloch Professor of Economics at Dalhousie versity His major fields of research interest have been the extent and causes ofpoverty and economic inequality, with particular emphasis in recent years on socialpolicy, social cohesion, and the implications of unemployment and structuralchange in labor markets Among other professional responsibilities, he has been a

Uni-president of the Canadian Economics Association and a member of the ExecutiveCouncil of the International Association for Research in Income and Wealth.

aleck ostryis an assistant professor in the Department of Healthcare and demiology and Center for Health Services and Policy Research at the University

Epi-of British Columbia He is a current recipient Epi-of a Canadian Institutes Epi-of HealthResearch New Investigator Award as well as a Michael Smith Foundation for HealthResearch Scholar Award Ostry teaches courses and conducts research on the socialdeterminants of health He specializes in research on work and stress

chris poweris Professor of Epidemiology and Public Health at the Institute ofChild Health in London, UK She has conducted extensive research on life courseepidemiology and social inequalities in health Currently her research focuses onpathways from childhood circumstances, particularly socioeconomic conditions,through cognitive development, growth and obesity, to adult disease

noralou p roos is a professor in the Department of Community Health Sciences

at the University of Manitoba and was founding director of the Manitoba Centrefor Health Policy Roos held a National Career Scientist Award and now holds theCanada Research Chair in Population Health Roos has been a member of the PrimeMinister’s National Forum on Health Her research focuses on using population-wide data on health, education, and social assistance to understand the determi-nants of health and human development

nancy ross is Assistant Professor of Geography at McGill University and anassociate of the Health Analysis and Measurement Group at Statistics Canada Ross

is a New Investigator with the Canadian Institutes of Health Research, with search interests in the contribution of social environmental conditions to healthoutcomes Along with colleagues, she has studied the income inequality and mor-tality relationship in comparative contexts

re-claudia sanmartinis a senior analyst in the Health Analysis and MeasurementGroup at Statistics Canada Sanmartin is focusing on issues related to access tohealth care services in Canada, including waiting times and the effects of incomeinequality on health Sanmartin was awardedthe Canadian Institute for AdvancedResearch doctoral stipend in population health

andrew sharpe is founder and Executive Director of the Ottawa-based Centrefor the Study of Living Standards (CSLS) Established in 1995, CSLS is a national,

independent, nonprofit research organization Its main objectives are to studytrends and determinants of productivity, living standards, and economic well-beingand to develop policy recommendations to improve the lives of Canadians Sharpe’searlier positions include Head of Research at the Canadian Labour Market andProductivity Centre and Chief, Business Sector Analysis at the Department of Fi-nance.

greg l stoddart is a professor in the Department of Clinical Epidemiology and

Biostatistics, a member of the Centre for Health Economics and Policy Analysis, and

an associate member of the Department of Economics at McMaster University Hehas published widely on both the economics of health care and the economics ofhealth, and he is currently participating in the development of the Program in PolicyDecision-Making at McMaster, a new research program that seeks to better under-stand the public policy decision-making process and the factors that influence it

to ¨ res theorell is a professor of psychosocial medicine at the Karolinska

Insti-tute and director of the National InstiInsti-tute for Psychosocial Factors and Health inStockholm, Sweden He has a background in internal medicine, occupational med-icine, and social medicine and has done research in stress physiology and stressepidemiology

joachim vogelis a professor in the Department of Sociology at the University

of Umea˚, Sweden, as well as senior expert on social indicators, social welfare ysis, and social reporting at Statistics Sweden He was founder and director for theSwedish annual social welfare surveys located at Statistics Sweden, as well as theofficial Swedish system of social reporting His recent research concerns compar-ative research of welfare regimes and welfare delivery in Europe; social reports onthe living conditions of the elderly, youth, and immigrants; and studies of incomeand material living standards in Europe

anal-michael wolfsonis Assistant Chief Statistician of Analysis and Development atStatistics Canada This position includes responsibility for analytical activities gen-erally at Statistics Canada, for health statistics, and for specific analytical and mod-eling programs In addition to his federal public service responsibilities, Wolfsonhas been a Fellow of the Canadian Institute for Advanced Research His recentresearch interests include income distribution, tax/transfer and pension policy anal-ysis, microsimulation approaches to socioeconomic accounting and to evolutionaryeconomic theory, design of health information systems, and analysis of the deter-minants of health

christina zarowskyis a physician with a specialization in public health; she isalso a medical anthropologist She leads International Development Research Cen-tre’s (IDRC) new Governance, Equity, and Health program initiative, which ex-amines public health and health systems issues from a governance lens Zarowsky’sareas of research include determinants of population health, the politics of hu-manitarian aid, trauma and social reconstruction among Somali refugees, and theinterfaces among community, professional, and government perspectives on healthcare.

Healthier Societies

Healthier Societies: An Introduction

Jody Heymann and Clyde Hertzman

Failure to Address Social Underpinnings of Health

At an emergency room, an ambulance, with sirens blaring, drives into the bay.Inside is a fifty-year-old man who has had a heart attack at work As rapidly aspossible, emergency medical technicians (EMTs) swing the man out of the back

of the van He has gone into full cardiac arrest, and the emergency medical staffknows that every minute counts in his prognosis One EMT is pounding on hischest while the other is rapidly rolling the gurney into the emergency room (ER)

An ER resident immediately intubates the man Obtaining an airway but still notfinding a pulse, the resident grabs a defibrillator The nurse readies the crash cartwith epinephrine and atropine

In the meantime, other ER staff members have begun attending to a old boy who was raced to the ER by his father because he is clearly having greattrouble breathing Instead of a calm eighteen or twenty times a minute, the boy’srespirations are fast, nearly forty per minute His wheezing is severe enough thatthe ER staff can hear the whistling sound without a stethoscope Whenever he tries

nine-year-to get a good breath in, his chest wall retracts far nine-year-toward his back Within moments,the boy is receiving oxygen by mask, nebulized beta-agonists, and intravenoussteroids

It is only much later, when the boy is upstairs in the pediatric wing of thehospital and the staff members are doing a postmortem on the man who didn’tsurvive, that more of the details come out The fifty-year-old man had been a “set-up” for a heart attack: He had been obese, with high blood pressure, and he hadnever dared to walk in his burned-out neighborhood The nine-year-old lives in atenement filled with cockroaches, in a neighborhood congested with smog Hisfather, who had just lost his job, had been chain smoking on the day of the boy’s

ER admittance No one had addressed the social conditions that had placed thisfifty-year-old or this nine-year-old at such high risk

We all want to live in a society where talented ER staff will be available if we

or our loved ones need them We want to have the best care available when weget sick But we also all know we’d be better off if the illnesses and injuries neverhappened We wouldn’t hesitate to say that the nine-year-old would have been

better off if he had never had an acute exacerbation of his asthma or that the year-old probably would have lived longer and been better off if the heart attackhadn’t occurred Yet experiences like the boy’s and the man’s are common Asindividuals and as nations, we spend far more time and resources treating illnessesand injuries than we do addressing the conditions that give rise to them Moreover,

fifty-in most countries there remafifty-ins far more political pressure to fifty-invest fifty-in medicalcare services for those who are already sick and injured than to invest in theprograms and policies that will prevent those illnesses and injuries

Why the Emphasis on Medical Care?

Although extensive research has demonstrated that social determinants make adifference, at some level, most of us don’t truly believe it—not instinctively, notdown to our bones We often do not understand how social conditions can affect

biology, and we’ve been thoroughly enough ingrained with the notion of the biology

of illness that all explanations starting and finishing with biology seem more sible than any others

plau-Another possible reason for our dependence on medical care is that we, as adults,think it’s too late to take steps that would help prevent our own health problems.Sure, we all would choose to have our children grow up in a society that invested

in the determinants of health and thereby increased our children’s likelihood ofliving many years free of illness and injury But what about life as an adult? Wehave already been exposed to many things Hasn’t the die been cast? If our child-hood experiences mean that we are already going to have serious health problems,wouldn’t it be better for us, as adults, to live in a country that invests almostentirely in medical care?

In addition, we have no idea how to move policy makers The current politicalsystems know how to make medical care happen There are departments in federal,state, and provincial governments to address health care Strong lobbies exist, largeamounts of money are already being spent, and the momentum is strong forincreasing investment in medical care In contrast, uncertainty surrounds the pros-pects for increasing expenditures that would address the social determinants ofhealth

Healthier Societies: An Overview

This book is designed to address the knowledge gaps behind the barriers to proaching health from a societal perspective In part I the authors address thefollowing questions: To what extent is health determined by biological factors? To

ap-what extent is it determined by social factors? And more fundamentally, how dobiological and social factors interact?

In the first chapter, Frank and colleagues deconstruct the simplistic view thatgenetic research will lead to uniquely effective means of prevention and treatmentand demonstrate the extensive role the social environment plays in determiningthe effect of genetic predispositions on both common and serious diseases Afterchapter 1 demonstrates the large role social conditions play even in the expression

of genes, chapter 2 dives deeply into the pathways through which social ments affect biology

environ-In this second chapter, Hertzman and Frank examine what is known about theways in which social, economic, and psychological environments affect the devel-opment of the brain, central nervous system, and other organ systems, as well ashow development of neurological and other physiological systems in turn influ-ences the body’s immune responses, clotting, and hormonal responses—defensemechanisms that ultimately determine the extent of morbidity and mortality hu-man beings suffer

Whereas the first two chapters of the book focus on universal findings, chapter

3 contextualizes our understanding of the relationship between the social and ological factors that affect health by demonstrating the enormous degree of localvariability in health that occurs even when similar preconditions exist Lock,Nguyen, and Zarowsky make the case that a wide range of local factors influencesthe ways in which similar biologic and social conditions contribute to ill health

bi-An understanding of the ways in which various factors influence health couldnot be complete if it were just a picture taken at one point in time The real ways

in which social factors and biological factors influence health is through theirinteraction over time In chapter 4, Hertzman and Power examine latency models,pathway-dependent relationships, and cumulative effects to highlight the manyinsights that a life course approach to the social determinants of health can provide.This first section of the book ends with an examination of the consequences of

a preoccupation with medical care as the biological solution to health inequalities

In chapter 5, Roos, Brownell, and Menec demonstrate the extent to which universalmedical care systems ensure that those who are poorest, and also burdened withthe most disease, receive the most care At the same time, they make abundantlyclear with more than a decade of data that investments in health care alone willneither improve population health as markedly as socioeconomic changes nor ad-equately reduce inequalities in health

In part II, the authors examine four case studies that help us see the ways inwhich social change can dramatically affect adults’ health, as well as launch chil-dren’s lives onto healthy trajectories This section’s authors analyze in detail thecases of nutrition, working conditions, social inequalities, and geographic dispar-ities

In chapter 6, Dubois provides a historical overview of the relationship betweennutrition and population health She details how the problems of malnutritionhave evolved in industrialized countries to a complex mixture of food insecurity,food poverty, ill nutrition, and obesity Importantly, she provides a nuanced un-derstanding of how nutrition works on a population level, and not merely on thelevel of individual choice.

In chapter 7, Mustard, Lavis, and Ostry write about the evolving relationshipbetween work and health in industrialized countries They begin by providing anunderstanding of the extent to which workplaces have become safer, with respect

to physical hazards, and cleaner, with respect to known chemical toxins, yet arehaving profoundly negative health effects because of the extent to which they areincreasingly unstable environments, with employees facing greater threats of ter-mination, job loss, and increasing inequalities—and are plagued more and morewith high demands that cannot be met

Chapter 8 provides a detailed discussion of what is known about the relationshipbetween inequalities and health Ross and colleagues note that inequality is a par-ticularly important determinant of health in the United States and Great Britain,which have weak employment security, inadequate unemployment protection, andlimited social safety nets In contrast, the level of inequalities in cities and provincesplays a lesser role in determining health in Canada and in Sweden because of thegreater safety nets

This chapter naturally transitions into the discussion in chapter 9 of the role ofgeography in determining how inequalities affect health and human development.Dunn and colleagues examine the wide range of factors that are associated withgeography, from the extent to which housing is heterogeneous, to the availability

of child and elder care, to the quality of public transportation

Yet even when we are convinced that social factors are as important as biologicalones in determining health, and even when we believe that their impact is enor-mous in both adulthood and childhood, the challenge of changing public policiesand programs remains The third section of the book takes a serious look at whatwould be involved in translating into action research findings like those described

in parts I and II Many books conclude, almost as an afterthought, with a section

on what societies should do Few, however, address the question of how to get itdone This is the goal of the final section

In chapter 10, Vogel and Theorell build on the discussions in chapters 8 and 9about how national-level social policies can moderate the impact of inequalities

on health Specifically, they look at a range of social welfare and labor policy models

in Europe and analyze how the choices that different countries have made withrespect to their public policies have directly affected health

In chapter 11, Osberg and Sharpe take on the question: How would we measurenations’ economic success if we really cared about the impact of economic policies

on health? They develop a new measure of economic well-being that includes the

factors most salient to health and apply it to a wide range of countries, strating how it performs notably differently from the commonly used measure ofgross domestic product (GDP).

demon-Chapter 12 examines a unique public policy experiment that occurred in ada Prince Edward Island took the rare step of making a commitment to shareresources across public sectors in order to maximize population health In thischapter, Stoddart and colleagues look at the successes and the challenges that arosewhen this province sought to improve population health by improving social con-ditions rather than just by increasing medical care

Can-Chapter 13 examines three case studies in child policy Kozyrskyj, Curtis, andHertzman examine what can be learned from a study of the extent to which na-tional children’s policies in Canada, the United States, and Norway were influenced

by research on the determinants of child health and well-being

In concluding, the final chapter seeks to answer, Where do we go from here?

In chapter 14, Earle, Heymann, and Lavis provide a conceptual framework forunderstanding the process of translating research into action The chapter thenanalyzes a wide range of historical experiences in which social science research hasinfluenced the public policymaking process in the United States, the United King-dom, Canada, the Netherlands, and Sweden The book concludes with recommen-dations for researchers and policy makers for the best ways to increase their ef-fectiveness at creating healthier societies

Part I

The Complex

Relationship between Social and Biologic Determinants of

Health

Interactive Role of Genes and the

Environment

John Frank, Geoffrey Lomax, Patricia Baird,

and Margaret Lock

Enthusiasm for discovering genetic correlates of health and disease is currentlywidespread This enthusiasm is encouraged by a combination of recent researchinitiatives, such as the Human Genome Project, and the flurry of media reportsannouncing that yet another gene–disease association has been identified Implicit

in all these activities, and explicit in many, is the notion that one can attributehealth and disease to genetic determinants and that understanding the genome willlead, inexorably, to improvements in population health.1The new insights provided

by advances in human genetics are exciting because genes hold the codes for ecules that carry out biological processes Thus, genetic research provides a mo-lecular level of analysis for the study of diseases and their causation For example,powerful new genetic research techniques allow the researcher to document themolecular changes that occur when a benign cell is transformed into a malignant(cancerous) one This level of information is proving invaluable in the management

mol-of lung and colon cancer (Fong et al 1999; Dubois 2000)

Information at the molecular genetic level has greatly informed disease diagnosisand management of individuals with inherited conditions due to single genes (i.e.,those known as Mendelian conditions) However, these breakthroughs will becounterproductive if they distract attention from other forms of disease causa-tion—especially social structure, physical environmental influences, and lifestylefactors,2which are of great importance for the common diseases of industrializedlife, all of which are “genetically complex” in that they are the product of manygenes interacting with the environment over entire lifetimes (Willet 2002; Ridley2003; Shostak 2003)

The tendency toward an emphasis on clinical interventions in the new geneticsleaves us skeptical that elucidating genetic determinants of disease will imminently

lead to improvements in population health Our skepticism arises from experiencesuggesting that interventions involving broad-based genetic screening are pro-foundly difficult to implement and have a limited impact on population health.Further, we are concerned that a disproportionate emphasis on genetic determi-nants leads us to overlook the importance of population health research—researchand policies directed toward the full complement of social, environmental, andlifestyle determinants of health.

Enthusiasm for research linking gene expression to health and disease is standable As a branch of risk-factor epidemiology, it lends itself to relatively tightlycontrolled study, and genetic correlates are more easily grasped than the complexnotion of a web of physical, chemical, biological, social, economic, and personalfactors interacting over the life course to cause disease Yet modern epidemiologistshave for decades used the metaphor of “webs of causation” in explaining theorigins of human health at the population level (MacMahon and Pugh 1970) It

under-is important, therefore, that powerful and intuitively appealing genetic mechanunder-isms

be viewed as only part of this web It is also critical that genetic technologies beapplied and used wisely, and their limitations recognized, so that they are not madethe object of unrealistic expectations If the potential of genetic technology is over-estimated, it may be applied inappropriately, with resultant harm or, at minimum,with waste of scarce health care resources (Baird 2000)

We argue that knowledge of the actual determinants of human health at thepopulation level—and especially the role of social structure, environment, andlifestyle—should lead to rather modest expectations of a “genetic silver bullet”approach to improving population health status This argument, in turn, has twomain themes:

1 Most common diseases in technologically advanced societies are rial in origin, meaning that they are the product of complex interactionsbetween our genetic endowment and the world around us, acting over thecourse of a human lifetime

multifacto-2 There are profound difficulties in attempting to actually implement based genetic screening and intervention programs at the population level,

broad-of the sort that would be required if the new genetic knowledge were toradically alter disease frequency in entire societies

The Multifactorial Nature of Human Disease

A key observation about rates of disease, as well as indicators of health, is thatthey are astonishingly variable across populations Consider the so-called chronicdiseases, such as cancer and heart disease, that are the principal causes of death indeveloped nations Schottenfeld and Fraumeni (1996) have documented ten- to

twentyfold differentials in site-specific cancer incidence rates around the globe,particularly for the most common cancer sites in Westernized populations withhigh life expectancy: breast, colon, prostate, lung, and bladder In some cases weknow a great deal about why these rates differ; for example, lung cancer’s rela-tionship to smoking, at both the population and individual levels of analyses, iscommon knowledge However, even with tumors for which we cannot currentlyexplain more than a fraction of cases by known causal exposures in the environ-ment, such as breast and colon cancers, occurrence rates may vary by more thantenfold (Schottenfeld and Fraumeni 1996) This is true even from region to regionwithin those wealthier nations that have sophisticated cancer surveillance registrysystems that produce reliable statistics at the level of the subnational region.What might proponents of genetic disease determination say about such differ-entials? They would look for varying genetic characteristics across these differentlyaffected populations, for example, in tumor suppressor/promoter gene frequencyand/or expression On the other hand, the public or population health scientistwould point to the dozens of published migrant studies in the past few decades asevidence of the clear environmental influence on these disease rates (Marmot et

al 1975; Marmot and Syme 1976; McCredie et al 1990; Ziegler et al 1993)

Geographic Variation in Disease Occurrence and

Migrant Studies

Researchers who conduct migrant studies take advantage of immigration to pare the disease experience of the immigrant groups with that of both their coun-tries of origin and destination Many of these studies have shown that, over time,immigrants shed the chronic disease patterns of their countries of origin and take

com-on those of their country of destinaticom-on For instance, significant changes inchronic disease rates, including cancer incidence, occur within a generation or two

of migration from low-incidence settings to high-incidence settings, and vice versa(Schwab 1998) Genetic differences could not possibly provide the primary expla-nation for this phenomenon, since genes do not change that quickly in populations.Furthermore, the gene pool of most migrants studied generally changes very littleover the first few generations after migration, due to persistent intramarriage withinthe migrant community after arrival in the new homeland

High-quality migrant studies demonstrating these patterns abound in the demiological literature, but they appear to have been largely overlooked by geneticresearchers A well-executed epidemiological migrant study of disease occurrence

epi-is analogous to, but constitutes a depi-istinct improvement upon, the “twins rearedapart” study design used by many genetic researchers to help disentangle geneticfrom environmental influences on health and function (Plomin et al 1990; Reiss

et al 1991; Cooper 2001) In both study designs, genetics is held constant, while

Table 1.1 Selected migrant studies of chronic disease

Ziegler

et al 1993

Population-based case–

control study ofChinese, Japanese,and Filipinos aged20–55 migrating toSan Francisco–Oak-land, Los Angeles,and Oahu

A sixfold gradient inbreast cancer risk

by migration terns was observed

pat-Migrants with 8 ormore years in theWest had a relativerisk of breast cancer1.8 times the risk ofmigrants with 2–7years

McCredie

et al 1990

Breast cancer rates in

migrants to NewSouth Wales(NSW), Australia,from various Euro-pean countries,compared withnative-born women

The relative risk forItalians changedfrom 0.5 to 1 over

a 17-year period

The risk for Welshchanged from 2.75

to 1.5 over thesame period

Rates in groups withpreviously higherand lower relativerisks moved towardrisk levels of theirnew homeland aftermigration

McCredie

et al 1990

Colon cancer in

mi-grant males and males to NSW fromItaly and Greece,compared with na-tive born

fe-The relative risk forGreeks and Italianschanged from 0.2

to approximately0.8 over a 17-yearperiod The changewas less in Italianwomen: 0.2 to 0.6

Immigrant patternswere converging onnative patterns

Mortality from

coro-nary heart disease(CHD) among Jap-anese from Japan,Hawaii, and Cali-fornia

Age-adjusted lence rates for defi-nite CHD were: Ja-pan, 5.3; Hawaii,5.2; and California,10.8/1,000

preva-Japanese in Californiawere converging onthe native Califor-nia experience

Sources: Reprinted, with permission, from Ziegler et al 1993; McCredie et al 1990; Marmot et al 1975;

and Marmot and Syme 1976.

environment is changed In migratory studies, substantial variation in mental conditions is guaranteed by the constraint that study subjects have movedfrom one country to another In twin studies, all that can be guaranteed is thatthe twins have not lived together; they may, in fact, live in the same region or indifferent regions where the disease rates of interest are similar Thus, well-designedmigratory studies may be a more reliable source of information on the influence

environ-of environmental factors, “holding genetics constant,” than are studies environ-of twinsreared apart

Table 1.1 summarizes some influential migrant studies conducted over recent

decades regarding coronary heart disease (CHD) and the industrialized world’smajor cancers These studies demonstrated large increases in the rates of diseasewithin two generations of immigration to high-risk countries from low-risk coun-tries and, occasionally, the reverse pattern in those moving from high- to low-risksettings.

The point of this table is that the most widespread, serious diseases of modernlife, all of them conditions more common among older adults, seem to be extraor-dinarily sensitive to environmental influences And there is abundant evidence that

environment in this case includes both physical and chemical exposures, as well as

social-psychological experiences An illustrative example of the role of the ronment is explored next in this chapter The practical public health implication

envi-is obvious: Some adverse environmental effects, such as nutrition, acculturation,and “lifestyle” are clearly reversible, since migrants to high-risk areas are protectedfrom adverse consequences of such environmental exposures only one generationbefore migration and a few thousand miles away

Finnish Height Study

It is often thought that the extent of genetic determination of a trait—its bility—is clear-cut, quantifiable, and fixed But this is not the case, in that heri-tability differs from environment to environment Heritability can be expressed in

herita-a stherita-atisticherita-al index (rherita-anging from herita-a vherita-alue of 0 to herita-a vherita-alue of 1) reflecting the portion of the variation in the characteristic or condition that is genetically trans-mitted among individuals in a defined population It can be derived from a variety

pro-of study designs, including studies pro-of monozygotic (identical) and dizygotic ternal) twins An elegant Finnish study of height clearly demonstrated that complexgene–environment interactions make the heritability of even a “simple” humantrait, such as height, highly context sensitive

(fra-The Finnish researchers used an established national twin registry with 33,534pairs of adult twins, born before 1958 and both still alive in 1974 (Silventoinen et

al 2000) Using data from two mailed questionnaires on height and factors mining zygosity (e.g., appearance, gender), 3,466 identical and 7,450 fraternal pairs

deter-of twins’ data were analyzed The results showed a clear time trend in the bility of height across the following four birth cohorts: those born before 1928;between 1929 and 1938; between 1939 and 1946; and between 1947 and 1957 Theheritability of height steadily increased during this period of gradually improvingliving conditions in Finland, from 0.76 to 0.81 in men and from 0.66 to 0.82 inwomen This finding fits with global data showing that in developing countrieswith widespread malnutrition and infectious diseases associated with suboptimalchild growth, heritability of height is generally lower—for example, 0.56 in oneWest African study (Solomon, Thompson, and Rissanen 1983) Thus, the degree