healthier societies from analysis to action

Healthier Societies:
From Analysis to Action
JODY HEYMANN, et al.,
Editors
OXFORD UNIVERSITY PRESS
Healthier Societies
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Healthier Societies
From Analysis to Action
Edited by
JODY HEYMANN
CLYDE HERTZMAN
MORRIS L. BARER
ROBERT G. EVANS
1
2006
1
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Library of Congress Cataloging-in-Publication Data
Healthier societies : from analysis to action / Jody Heymann [etal.].
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
135798642
Printed in the United States of America
on acid-free paper
When our learning exceeds our deeds we are like trees whose
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
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To Ce´cile Brault, Tom Robinson, Ralph David Barer, and Geoffrey Robinson,
who influenced the courses of our lives from the earliest stages

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Preface
By the late 1980s, evidence showed that health status among populations through-
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
of the broad and fundamental determinants of health. In 1987, the Population
Health Program was launched to take up this challenge by bringing together a
multidisciplinary 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, soci-
ology, economics, and policy analysis. This combination resulted not only in a
diversity of perspectives brought to the study of determinants of health, but it also
caused researchers to look beyond the barriers of their own disciplines and to
think in new ways.
Over the course of fifteen years, the program systematically explored socioeco-
nomic status (SES) gradients and their relationship to health outcomes. It is now
well established that, on average, people with higher levels of income, education,
and social position live longer and are healthier than those with lower incomes
and 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 the
levels of the neighborhood, community, and society.
In its effort to develop a comprehensive determinants-of-health framework, the
program 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 in

research, particularly its work on synthesizing knowledge from a wide range of
disciplines and developing a model of the determinants of health. The program
had a substantial impact on health policy at the local, provincial, and national
levels.
This book pulls together the work and viewpoints of a wide range of program
members and other colleagues who joined us in this unique research program to
x Preface
truly understand how to improve population health—from basic science research
to public policy.
—Clyde Hertzman
Director, Program in Population Health
1998–2003
Acknowledgments
The editors and contributors gratefully acknowledge the many years of support
given by the Canadian Institute for Advanced Research (CIAR) to the Program in
Population Health. Without the support of the CIAR, the ideas presented in this
book would not have had a chance to develop and influence thinking in population
health around the world.
The network, with its national and international membership, would not have
held together nearly as well without the indispensable help of Michele Wiens. In
addition to playing countless roles in helping to facilitate the network’s collabo-
rations, she played key staff roles in communicating among contributors for this
book. Kate Penrose at Harvard University played a similarly invaluable role in
staffing this final project and ensuring that this book came to fruition. We’re deeply
grateful to both for their help.
All good books benefit from a wise and experienced editorial eye, and this book
was no exception. Jeffrey House at Oxford University Press brought his experienced
eye to this project and gave invaluable suggestions. Carrie Pedersen generously
gave 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 who

have commented over the years on the ideas that have gone into this book and
who have debated us, stimulated our thinking, and encouraged us to focus on the
best way to create healthier societies.
The seeds for this work were sown early. Ce´cile Brault, high school teacher and
advisor, grounded Jody Heymann in the impact of lived inequalities and in the
responsibility we all have to do all we can to address them. Tom Robinson, Clyde
Hertzman’s seventh-grade teacher, taught him the value of critical appraisal. Morris
Barer’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 of
population 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.
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Contents
About the Editors, xv
About the Contributors, xvii
Healthier 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
xiv Contents
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 across
Public 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
xv

About the Editors
jody heymann is the founding director of the Project on Global Working Fam-
ilies, the first project devoted to understanding and improving the relationship
between working conditions and family health and well-being throughout the
world. She is founding chair of the Initiative on Work, Family, and Democracy. A
professor in the Faculties of Medicine and Arts at McGill University, Heymann is
founding director of the McGill Institute for Health and Social Policy. Heymann
has been awarded a Canada Research Chair in Global Health and Social Policy.
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 Disease
Control and Prevention, among other organizations.
clyde hertzman is Director of the Human Early Learning Partnership, Professor
in the University of British Columbia’s Department of Health Care and Epidemi-
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)
in the Successful Societies and Experience-based Brain and Biological Development
programs. Hertzman has played a central role in creating a framework that links
population health to human development, emphasizing the special role of early
childhood development as a determinant of health. His research has contributed
to international, national, provincial, and community initiatives for healthy child
development.
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 founding
Director of the Centre for Health Services and Policy Research at the University
xvi About the Editors
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 British
Columbia. His recent research has focused on the determinants of health care cost
increases; pharmaceutical policy in Canada; separating fact from fiction in argu-
ments about access to care, wait lists, the effects of an aging population; health
care financing; use of health care services, particularly by seniors; continuity of
care; and the roles of research evidence and interests in the evolution of health
care 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 Advanced
Research 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 a
Canadian 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 and
policies have led to numerous invitations to provide policy advice to the Canadian
federal and provincial governments. He has also been a consultant and lecturer on
health 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 the
Royal Society of Canada and was awarded the Health Services Research Advance-
ment Award.
xvii
About the Contributors
patricia baird is a pediatrician and medical geneticist and has been head of the
Department of Medical Genetics at the University of British Columbia. She has

been 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 the
WHO on genetics in recent years and has published extensively on the policy
implications of new genetic and reproductive technologies.
marni brownell is a senior researcher with the Manitoba Centre for Health
Policy and an assistant professor in the Department of Community Health Sciences
at the University of Manitoba. Brownell holds a New Investigator Award with the
Canadian Institutes of Health Research and is a core member of the Canadian
Institute for Advanced Research New Investigator Network. Her background is in
developmental psychology, and her research focuses on the social determinants of
child 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 participatory
models of program and system evaluation. In particular, he was the project co-
ordinator of the Prince Edward Island System Evaluation Project, which evaluated
the 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 Epidemiology
and the Department of Economics at Dalhousie University when collaborating on
this project; she was awarded a Clinical Scholar Award by the Faculty of Medicine.
Curtis has recently moved to the Applied Research and Analysis Directorate in
Health Canada and is now focusing on health policy research. Research areas have
included child and maternal health; the relationship between poverty, health, and
health care utilization; gender, labor force participation, and health; and poverty
and inequality.
xviii About the Contributors
lise dubois is an associate professor in the Department of Epidemiology and
Community Medicine at the University of Ottawa. She is based at the Institute of

Population Health at the University of Ottawa, where she holds a Canada Research
Chair 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 of
nutrition 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 from
the Canadian Institutes of Health Research and a Health Scholar award from the
Alberta Heritage Foundation for Medical Research. His background is in the social
geography of health, and he has research interests in the relationship between
income inequality and population health in North American metropolitan areas
and housing as a socioeconomic determinant of health.
alison earle is a research scientist at the Harvard School of Public Health, where
she has taught classes on the translation of public health research into public policy.
She currently serves as project director for the Work, Family, and Democracy
Initiative, 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 of
social supports and adequate working conditions, and their impact on children’s
health 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 the
environment. Eyles has carried out work for several national and provincial or-
ganizations and governments in Canada and has served on several expert panels
and advisory committees and boards.
john frank is a physician-epidemiologist with special expertise in prevention. In
December 2000, Frank was appointed Scientific Director of the Canadian Institutes

of Health Research, Institute of Population and Public Health, located at the Uni-
versity of Toronto. Frank’s main area of interest is the biopsychosocial determinants
of health status at the population level. Frank was the founding Director of Re-
search at the Institute for Work & Health in Toronto and is currently a senior
scientist with the institute.
About the Contributors xix
katherine l. frohlich is anassistantprofessor atthe Universite´ de Montre´alinthe
Department of Social and Preventive Medicine. Her research interests are the integra-
tion of social theory into social epidemiological research and, specifically, how to con-
ceptualize, operationalize, and understand theeffects of context on disease outcomes.
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 for
Social Research. He is also Director of the Michigan Initiative on Inequalities in
Health; the Michigan Interdisciplinary Center on Social Inequalities, Mind and
Body; and the Center for Social Epidemiology and Population Health, all at the Uni-
versity of Michigan. Kaplan also directs the newly formed Robert Wood Johnson
Foundation 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. Over
the past nine years she has been a health services researcher at the Manitoba Centre
for Health Policy. Her research has spanned several areas, from population health
studies in asthma and other chronic diseases in children to policy research on
pharmaceuticals. She is Manitoba Director of the Western Regional Training Centre
in Health Services Research. Kozyrskyj holds a Canadian Institutes of Health Re-
search New Investigator Award.
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 Associate
Member 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 between
labor market experiences and health.
margaret lock is Marjorie Bronfman Professor in Social Studies in Medicine in
the 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 Canada
and was awarded the Prix Du Que´bec, domaine Sciences Humaines, the Canada
Council 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 Trans-
plants and the Reinvention of Death.
geoffrey lomax is Research Director with the California Environmental Health
Tracking Program. He is currently involved in the planning and implementation
xx About the Contributors
of a statewide population health surveillance system. He has been conducting en-
vironmental and occupational health research since 1985. His doctoral research
involved an evaluation of the scientific, ethical, legal, and policy issues related to
workplace biomonitoring and genetic testing.
john lynch is an associate professor in the Department of Epidemiology, School
of Public Health, at the University of Michigan. He has joint appointments at the
Center for Human Growth and Development, the Institute for Social Research,
and the Center for Research on Ethnicity, Culture, and Health. His main area of
research interest is in the life course processes that help generate trends in popu-
lation health and social inequalities in health.
verena menec is an associate professor in the Department of Community Health
Sciences 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 research
interests are in the areas of healthy aging and the relationship between health
services use and population health, particularly among senior populations.
cam mustard is a professor in the Department of Public Health Sciences at the
University of Toronto and President and Senior Scientist at the Institute for Work

and 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 research
interests in the areas of labor market experiences and health, the distributional
equity 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 in
West Africa for the past ten years. His research concerns the broader social and
political problematic of access to treatment. He is Associate Professor of Family
Medicine at McGill University and is also affiliated with the Departments of An-
thropology and Social Studies of Medicine.
lars osberg is currently McCulloch Professor of Economics at Dalhousie Uni-
versity. His major fields of research interest have been the extent and causes of
poverty and economic inequality, with particular emphasis in recent years on social
policy, social cohesion, and the implications of unemployment and structural
change in labor markets. Among other professional responsibilities, he has been a
About the Contributors xxi
president of the Canadian Economics Association and a member of the Executive
Council of the International Association for Research in Income and Wealth.
aleck ostry is an assistant professor in the Department of Healthcare and Epi-
demiology and Center for Health Services and Policy Research at the University
of British Columbia. He is a current recipient of a Canadian Institutes of Health
Research New Investigator Award as well as a Michael Smith Foundation for Health
Research Scholar Award. Ostry teaches courses and conducts research on the social
determinants of health. He specializes in research on work and stress.
chris power is Professor of Epidemiology and Public Health at the Institute of
Child Health in London, UK. She has conducted extensive research on life course
epidemiology and social inequalities in health. Currently her research focuses on
pathways 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 Centre
for Health Policy. Roos held a National Career Scientist Award and now holds the
Canada Research Chair in Population Health. Roos has been a member of the Prime
Minister’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 an
associate of the Health Analysis and Measurement Group at Statistics Canada. Ross
is a New Investigator with the Canadian Institutes of Health Research, with re-
search interests in the contribution of social environmental conditions to health
outcomes. Along with colleagues, she has studied the income inequality and mor-
tality relationship in comparative contexts.
claudia sanmartin is a senior analyst in the Health Analysis and Measurement
Group at Statistics Canada. Sanmartin is focusing on issues related to access to
health care services in Canada, including waiting times and the effects of income
inequality on health. Sanmartin was awardedthe Canadian Institute for Advanced
Research doctoral stipend in population health.
andrew sharpe is founder and Executive Director of the Ottawa-based Centre
for the Study of Living Standards (CSLS). Established in 1995, CSLS is a national,
xxii About the Contributors
independent, nonprofit research organization. Its main objectives are to study
trends and determinants of productivity, living standards, and economic well-being
and to develop policy recommendations to improve the lives of Canadians. Sharpe’s
earlier positions include Head of Research at the Canadian Labour Market and
Productivity 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. He
has published widely on both the economics of health care and the economics of
health, and he is currently participating in the development of the Program in Policy
Decision-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 Institute for Psychosocial Factors and Health in
Stockholm, Sweden. He has a background in internal medicine, occupational med-
icine, and social medicine and has done research in stress physiology and stress
epidemiology.
joachim vogel is a professor in the Department of Sociology at the University
of Umea˚, Sweden, as well as senior expert on social indicators, social welfare anal-
ysis, and social reporting at Statistics Sweden. He was founder and director for the
Swedish annual social welfare surveys located at Statistics Sweden, as well as the
official Swedish system of social reporting. His recent research concerns compar-
ative research of welfare regimes and welfare delivery in Europe; social reports on
the living conditions of the elderly, youth, and immigrants; and studies of income
and material living standards in Europe.
michael wolfson is Assistant Chief Statistician of Analysis and Development at
Statistics 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, Wolfson
has been a Fellow of the Canadian Institute for Advanced Research. His recent
research interests include income distribution, tax/transfer and pension policy anal-
ysis, microsimulation approaches to socioeconomic accounting and to evolutionary
economic theory, design of health information systems, and analysis of the deter-
minants of health.
About the Contributors xxiii
christina zarowsky is a physician with a specialization in public health; she is
also 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’s
areas of research include determinants of population health, the politics of hu-
manitarian aid, trauma and social reconstruction among Somali refugees, and the
interfaces among community, professional, and government perspectives on health
care.