The 'P' word: Poverty (and other determinants of health)

I noticed a much more explicit focus on poverty in my discussions about health and well-being  in North America. Perhaps it’s just the circles I’m moving in but it feels there’s much more  reference to the links between ‘health equity’ and the wider social determinants of health.

Liz Weaver (from the Tamarack Institute) uses this powerful quote from David Shipler to highlight the case in point:

“Every problem magnifies the impact of the others, and all are so tightly interlocked that one reversal can produce a chain reaction with results far distant from the original causes. A rundown apartment can exacerbate a child’s asthma, which leads to a call for an ambulance, which generates a medical bill that cannot be paid, which ruins a credit record, which hikes the interest rate on an auto loan, which forces the purchase of an unreliable used car, which jeopardizes a mother’s punctuality at work, which limits her promotions and earning capacity, which confines her to poor housing.”

David Shipler, The Working Poor:  Invisible In America (2004)

I also found this simple yet illuminating story on the Canadian Public Health Agency website which highlights the complex set of factors or conditions that determine the level of health we have;

"Why is Jason in the hospital?
Because he has a bad infection in his leg.
But why does he have an infection?
Because he has a cut on his leg and it got infected.
But why does he have a cut on his leg?
Because he was playing in the junk yard next to his apartment building and there was some sharp, jagged steel there that he fell on.
But why was he playing in a junk yard?
Because his neighbourhood is kind of run down. A lot of kids play there and there is no one to supervise them.
But why does he live in that neighbourhood?
Because his parents can't afford a nicer place to live.
But why can't his parents afford a nicer place to live?
Because his Dad is unemployed and his Mom is sick.
But why is his Dad unemployed?
Because he doesn't have much education and he can't find a job.
But why ...?"

This story highlights some of the key determinants of health which are:

·         Income and Social Status

·         Social Support Networks

·         Education and Literacy

·         Employment/Working Conditions

·         Social Environments

·         Physical Environments

·         Personal Health Practices and Coping Skills

·         Healthy Child Development

·         Biology and Genetic Endowment

·         Health Services

·         Gender

·         Culture

Community Health Champions (CHCs), and those in similar roles, can help address some of these determinants. Whilst the Altogether Better programme was funded to deliver health outcomes around healthy eating, physical activity and mental health, we have an increasing amount of evidence that CHCs can help to improve social networks and  provide social support creating better social environments. They can help with health practices, self management and coping skills and help improve health literacy by improving knowledge and understanding of issues affecting health in its broadest sense. Some CHCs report feeling having a renewed sense of purpose and increased self esteem  and confidence since becoming involved in our projects. Many have developed new knowledge and skills and an increasing number have gone on to complete further training, education and even obtain paid jobs. All factors which contribute to (and I would argue are essential to) improved well-being

There was also much talk in my discussions  with people about the need for health improvement initiatives to be as much about addressing the material circumstances in which people live – as about addressing community health needs. Where we live and work and raise our children has a huge impact on health. If people are living in circumstances where they are worried about paying the bills, being able to feed their children, having a roof over their head - then any talk of behaviour change related to eating more fruit and taking a little more exercise - are likely to have little impact until these broader, more basic, needs are addressed.

 Increased empowerment and giving people a 'voice' and a say in their communities and neighbourhoods can  be mechanisms for addressing the material and environmental circustances in which people live. The Be Active Together Project, Seattle's Neighborhood Matching Fund and Vibrant Communities in Canada are partly about trying to address these needs - based on the notion that improved environments / communities = improved well-being. They are also about identifying and mobilising community assets (e.g. people, skills, organisations)  to improve communties and the places people call home.

This short film from Sudbury & District Health Unit makes valuable viewing for anyone interested in learning more...

 Let's start a conversation about health...and not mention health care at all.

 The Unnatural Causes series is also essential viewing for anyone interested in the social determinants of health and the impact of place and where we live on health and well-being.