Living conditions sicken and kill us faster than lifestyle choices.
It is now widely known, at least among the research and public health communities, that the primary factors that shape health are not the so-called “lifestyle” factors of diet, physical activity and tobacco use, but rather the living conditions — or social determinants of health — individuals experience throughout their life course (see the Code Red Series in the Spectator).
For example, material and social deprivation — or in common parlance, poverty — during early childhood are strong predictors of the incidence of cardiovascular disease, adult-onset diabetes, respiratory disease and some cancers during adulthood. Even low birth weight — itself related to mothers living in poverty — is a significant predictor, even better than “lifestyle” factors, of cardiovascular disease and adult-onset diabetes in later life.
But it is not just these major killers that are related to adverse living conditions. Remarkably, deprivation over the life course is strongly related to the incidence of such diverse afflictions as Alzheimer’s disease, arthritis, emphysema, kidney and lung disease, osteoporosis, lupus and mental health problems such as depression and suicide. Unemployment and poor working conditions are important predictors of the incidence of cardiovascular disease. And it is not just the poor — but also the middle class — who are subject to experiencing health-threatening living conditions and the associated stress that causes disease.
Yet, if we followed advice from major disease associations such as the Heart and Stroke Foundation, the Canadian Diabetes Association, the Canadian Cancer Society and others, we would have no sense that these living conditions play any direct role in the incidence of the major life-ending diseases. Additionally, Canadians are assured that these major diseases and a host of other afflictions can be averted through the adoption of “healthy lifestyle choices.” Even more importantly, Canadians are assured the solutions to illness will come from medical and behavioural research rather than public policies that improve the quality of life of Canadians. The table below identifies some of the disease associations that should be concerning themselves with Canadians’ living conditions.
Not only does traditional disease association messaging ignore the direct role of adverse social determinants of health, it usually downplays how social determinants of health even allow such “healthy lifestyle choices” to be made by those most vulnerable to these diseases. Even more telling is the lack of consistent research evidence that these “healthy lifestyle choices” are even reliable predictors of the onset of these diseases. Canadians are rightly confused: Eating fruits and vegetables are sometimes found to be related to cardiovascular disease but not cancer, sometimes cancer, but not cardiovascular disease, sometimes both, sometimes neither.
Disease association authorities need to be told by the public in general and by their donors in particular to pay attention to these findings. And even when the social determinants of health are not the primary causes of disease — such as the case of genetically determined diseases — Huntington’s disease or muscular dystrophy are two examples — the quality of the social determinants of health profoundly shapes the lives of those afflicted and their families.
When experiencing the presence of a life-threatening or disabling disease — regardless of the causes — Canadian individuals and families are increasingly faced with deteriorating quality health and social services, lack of financial supports and difficulty achieving secure and wellpaying employment, among others. At the very minimum, disease associations should recognize that deteriorating social determinants of health are not good for families facing the presence of the illnesses with which these organizations are concerned. Ideally, they would call upon policymakers to improve the quality of life of the most vulnerable Canadians. Until they do so, donors should carefully consider where their money can best be used.
Dennis Raphael, PhD, is a professor of health policy and management at York University in Toronto. He is author of Social Determinants of Health: The Canadian Facts, which can be downloaded at no cost from http://thecanadianfacts.org.
Major disease associations that must be encouraged to adopt a broader social determinants of health perspective
Alzheimer Society of Canada*
Amyotrophic Lateral Sclerosis Society of Canada
The Arthritis Society*
The Brain Injury Association of Canada*
Canadian Breast Cancer Foundation
Canadian Cancer Society*
Canadian Cystic Fibrosis Foundation
Canadian Diabetes Association*
Canadian Foundation for AIDS Research*
Canadian Hospice Palliative Care Association
Canadian Liver Foundation*
Canadian Lung Association*
Canadian Mental Health Association*
Canadian Orthopedic Foundation
Crohn’s and Colitis Foundation of Canada
Easter Seals Canada
The Foundation Fighting Blindness — Canada
Heart and Stroke Foundation of Canada*
Huntington Society of Canada
Kidney Cancer Canada
The Kidney Foundation of Canada*
The Mood Disorders Society of Canada*
Muscular Dystrophy Canada
Multiple Sclerosis Society of Canada
Ovarian Cancer Canada
Parkinson Society Canada
SMARTRISK (Injury Prevention)*
Spina Bifida and Hydrocephalus Association of Canada
•Illnesses strongly associated with adverse living conditions