If providing health care and a social safety net for citizens were an Olympic event, the United States would be in a dead heat for last among developed nations. Recently, I had the opportunity to interview Dr. Dennis Raphael a professor at York University in Toronto Canada. Dr. Raphael has done extensive study and research on social systems and health disparities on a global scale. I reached out to Dr. Raphael specifically for his international perspective and global research analysis because I was interested to see how the United States compared to other developed nations. It appears that my suspicions are worst than I had imagined.
Dr. Raphael goes in great detail and provides a host of resources for anyone who may be researching poverty and health care disparities. We have all heard the Liberal and Conservative view points for or against Obamacare, but what does the rest of the world see when viewing the normal course of business and politics in America?
As Americans, we are always ranking things in order to assign value, worth, and level of importance. One of the biggest revelations for me from this interview was seeing how the United States poverty rates compared to other countries. It’s astonishing! Here is what Dr. Raphael had to say:
SWH: Could you tell SWH readers about your background and your work on poverty and health care inequalities?
DR: I am a professor of health policy and management at York University in Toronto Canada. I was originally trained in child development and educational psychology and have come to have an interest in health policy as it became apparent that the health and well-being of children and families was tightly related to the public policies that are implemented within a society. These public policies affect the health of citizens through what have come to be known as the social determinants of health. These public policies shape social determinants of health such as income and income distribution, employment and working conditions, food security, housing, and the availability of health and social services.
My work and those of others have also demonstrated that these social determinants of health have a much stronger impact on health than does the usual villains of physical inactivity, excess weight, excessive alcohol use, and even tobacco use. These effects are especially great for those living in poverty.
It is very convenient for governments and governmental authorities to blame individuals for their own health shortcomings by pointing to these so-called lifestyle factors rather than the public policies that have much importance in shaping health. My recent work has focused on differences among nations in these public policies and the social determinants of health such as the USA, Canada, and other wealthy developed countries that are members of the Organization for Economic Cooperation and Development.
SWH: How does the United States Model for Health Care and its social safety net compare to Canada and other developed nations?
DR: What has become apparent and is now well accepted in the literature is that the quality and distribution of the social determinants of health in nations such as United States and Canada lag well behind those seen in other wealthy developed countries. The United States is an especially great outlier as it is the only developed nation that does not provide citizens with healthcare as a matter of right. It also has the most unequal distribution of the social determinants of health and, not surprisingly, has the worst population health profile among all wealthy developed nations with the exception of Turkey and Mexico. US poverty rates are the highest outside of Mexico and Turkey.
I’ve also come to the conclusion that the reason for this has much to do with the dominant political ideologies of those who govern these nations. As unbelievable as it may seem for those of us who live in the United States and Canada, most developed nations are led by leaders who take an active interest in developing public policy that promotes the health and well-being of citizens. Most wealthy developed nations provide universal affordable childcare to all members of society, provide workers with legislative guarantees that provide some semblance of job security but also the availability of job training and if unemployment occurs, payments that allow them to live a life with dignity. For the last 20 years, the United States has been an exceptional outlier in providing people with virtually none of these social determinants of health, and the United States is the only nation that does not provide people with guaranteed vacation time, guaranteed supported maternity leave, and of course health care.
Unfortunately for us living in Canada, Canadian leaders have chosen to emulate the American model of public policy over the last two decades rather than the more sophisticated and helpful approaches adopted among European nations. The result is that Canada’s population health profile and the quality and distribution of the social determinants of health is increasingly beginning to look like that of the United States, with the accompanying expected declines in quality of life and overall health of the population. The primary factor that has become apparent is the nations that take seriously the provision of quality social determinants of health to its population are governed by political parties that are identified in the literature as being either Social Democratic or Conservative.
Despite what many people think, the so-called conservative parties of North America are not really conservative as much as “liberal”. This applies to both the Democratic and Republican parties in the USA. Despite the meaning of the word “liberal” in North America which many people think as meaning progressive, the term liberal in political science and political economy actually refers to a form of governance where governments take little if any interest in providing the population with the means of maintaining and promoting health. I’ve written extensively about the distinction between Social Democratic, Conservative, and Liberal welfare states, and I urge readers to take a look at some of these works. In essence, the approach governments have taken in the United States and Canada towards providing the means of their population to maintain health are incredibly undeveloped as compared to the nations of Europe.
SWH: Can you provide a snapshot of major social safety net programs put in place by the Canadian government to address income disparities and to assist vulnerable populations within your country?
DR: The most apparent difference between Canada and the United States in terms of social safety net programs is that in Canada every Canadian is entitled to the provision of healthcare as a matter of right. While this may seem exceptional to Americans, this is also the practice in every other wealthy developed nation that belongs to the Organization for Economic Cooperation and Development. For people like me and others who work in health, it is almost unbelievable that the United States does not provide health care to citizens as a matter of human rights. It should not be surprising that this lack of any kind of coordinated system in the United States leads to the United States having the most expensive and apparently least effective health care system among nations in the developed world. The US also has exceptionally high poverty rates which are particularly ironic considering its overall wealth.
Canada provides other aspects of the social safety net that are not available to Americans. In Canada the so-called RAND formula stipulates that once a union is certified in the workplace, all employees must belong to that union. In the United States the so-called “right to work laws” actually weaken unions and the economic and social security Americans obtain and as a result, Americans have some of the lowest wages among the Organization for Economic Cooperation and Development and the highest poverty rates among virtually all wealthy developed nations. Only 7% of Americans belong to unions and as a result their job security and working conditions, as well as their wages, are among the lowest of those working in wealthy developed nations.
In contrast, in the Scandinavian nations over 80% of people belong to unions and an even greater proportion of them work under collective agreements. Even in the conservative nations of Continental Europe, when unions themselves have lower membership than in Scandinavia, virtually all workers are covered by collective agreements. As a result, they experience greater job security, more employment and training opportunities, and generally greater security which translates into better health, and their poverty rates are the lowest among wealthy developed nations.
In Canada, 31% of workers belong to a union and while this figure is low in comparison to other nations, it is of course rather high as compared the United States.
Other social safety net programs that Canadians have access to are guaranteed maternity leave that is supported through the employment insurance system. Women who have been employed are entitled to close to 60% of their average salary during the 12 months that constitutes maternity leave in Canada. In the United States there are no such provisions. Even then, provisions are stronger in many European countries where women are entitled to close to 100% of their average salary during their maternity leave. And even then there are nations in Europe when men are entitled to paid maternity leave.
SWH: Over the course of your work, have you done any comparisons of the Canadian and USA social security systems to those of other industrialized nations, and what were your findings?
DR: I have written numerous articles that have compared the differing situations between the United States, Canada and other members of the Organization for Economic Cooperation and Development. Two of these articles recently appeared in the journal Health Promotion International and these titles are appended at the end of this interview. In addition, I recently published a book entitled Tackling Health Inequalities: Lessons from International Experiences. This book consists of a number of case studies of differing wealthy developed nations and includes a chapter on the United States in addition to ones on the United Kingdom, Canada, Australia, Finland, Norway, and Sweden. I urge readers to take a look at these documents and to consider the United States situation in relation to that seen in other wealthy developed nations.
To summarize the findings succinctly, United States is an incredible outlier in its approach to providing citizens with the conditions necessary for health. Canada does somewhat better and for many Canadians the comparison to United States gives cause for much satisfaction. However, when the Canadian situation is compared to the situation in other wealthy developed nations Canadians have much less to be happy about and there are many individuals, groups, and professional associations that are trying to move the public policy picture in Canada to that of these other wealthy developed nations and away from the United States model.
SWH: In your opinion, how has austerity measures implemented by various governments in developed nations contributed to or helped alleviate health inequalities of its citizens?
DR: In a nutshell, the austerity measures implemented by developed nations have served to contribute to the health inequalities that are apparent among the citizens. I direct your readers’ attention to three books in particular: To Live and Die in America, Class, Power, Health and Health Care by Robert Chernomas and Ian Hudson (2013), Social Murder and Other Shortcomings of Conservative Economics by Robert Chernomas and Ian Hudson (2007), and The Body Economic: Why Austerity Kills: Recessions, Budget Battles, and the Politics of Life and Death by David Stuckler and Sanjay Basu (2013).
SWH: Do you have any current projects and/or publications that you are working on or recently released, and how does someone find more of your research?
DR: In addition to my recent book Tackling Health Inequalities: Lessons from International Experiences that was published in 2012, I have written numerous articles that document how public policy is related to the health and quality of life of citizens in wealthy developed nations such as United States and Canada. More recently I’ve been examining how differing ways of thinking about health among public health departments lead to different directions in approaching their mandate. I’ve also written extensively about the mainstream media and how these media think about health and means of promoting public education that can lead citizens to think differently about health and become more involved in the public policy process in order to create the conditions necessary for health. People can see some of these recent articles by going to this link, and I’ve also produced a primer that should be of interest to all readers entitled Social Determinants of Health: The Canadian Facts. This can be obtained online at http://thecanadianfacts.org.
Thank you for the opportunity to contribute to this ongoing discussion that is of such importance for those of us living in North America.
Raphael, D. (2012). Tackling Health inequalities: Lessons from International Experiences. Toronto: Canadian Scholars’ Press.
Bryant. T., Raphael, D., and Rioux, M. (2010). Staying Alive: Critical Perspectives on Health, Illness and Health care, 2nd edition. Toronto: Canadian Scholars’ Press.
Raphael, D. (2013). The political economy of health promotion: Part 1, national commitments to provision of the prerequisites of health. Health Promotion International, 28, 95-111.
Raphael, D. (2013). The political economy of health promotion: Part 2, national provision of the prerequisites of health. Health Promotion International, 28, 112-132.
Raphael, D. (2011). Mainstream media and the social determinants of health in Canada: Is it time to call it a day? Health Promotion International, 26, (2), 220-229.
Photo Credit: Picture of Family Courtesy of www.mlive.com