Chapter 8 Learning Objectives and Summary

Learning Objectives

• To compare different theoretical perspectives addressing health and healthcare disparities.
• To name and recognize the social determinants of health.
• To identify historical trends in Canadian health and healthcare.
• To list barriers that produce disparities in healthcare access.
• To name the effects of unequal access to healthcare.
• To evaluate the efforts undertaken to equalize access to good health and healthcare in Canada.

Summary

Introduction

The social determinants of health are the living conditions that influence an individual’s health status and are beyond the control of any single individual, including income, education, and access to health services. Most sociologists believe that they play a more significant role in shaping a population’s overall health than genetic tendencies and lifestyle choices.

            Canada’s system of universal healthcare was formalized in 1984 with the introduction of the Canada Health Act. However, access to good health and healthcare remains an issue.

Theoretical Perspectives on Access to Healthcare

From a functionalist standpoint, healthcare is a social institution responsible for safeguarding the well-being of all members of society. It is also a form of social control, as an absence of good health leads to disorganization and deviance. Conflict theorists assume that good health is unequally distributed in society, and those with the most power will enjoy the best health. Problems in the delivery of healthcare result from the capitalist economy. Feminists explore how gender impacts a person’s health. Women are often left off drug trials, natural events such as pregnancy and childbirth are medicalized, and the “second shift” can take a toll on health. Nonetheless, men are, on average, unhealthier than women. Sociologists working from a critical “race” perspective explore how ideas of racial inferiority have been used to justify mistreating some people in medical studies. Finally, symbolic interactionists focus on social interactions and the ways people “perform” ideas of health and healthcare. They are also interested in the relations between sick people, family caregivers, and health professionals.

            Victim blaming occurs when an illness is seen as the ill person’s fault. Alternately, the population health perspective analyzes society as a whole to ask why, in general, certain kinds of people get sick or die more often than others. People who are socially, economically, and politically disadvantaged suffer worse health than their well-off counterparts.

The Social Determinants of Health

Social determinants of health include education, employment and job security, early childhood development, food insecurity, housing, social exclusion, the social safety net, and health services. Additional determinants are income and income distribution, Indigenous status, gender, race, immigration status, and disability.

Changing Trends in Healthcare

Canadians today live longer and enjoy a better quality of life, as a result of vaccinations, better treatments (e.g., chemotherapy and insulin injections), and improved prenatal and postnatal care.

            One widespread trend has been de-institutionalization: a tendency to shorten hospital stays and reduce the number of people in long-term treatment facilities. This started about 50 years ago and has continued rapidly, owing to several factors. First, the cost of hospital care has grown continually. Second, the development of self-administered pharmaceutical drugs for a range of illnesses has allowed many people to remain at home. Third, neoliberal governments were glad to download the costs of treatment to patients. Finally, a concerted attack on mental hospitals made the public sympathetic to de-institutionalizing mentally ill people.

            Many public health measures have increased over the last 30 years, and behaviours like smoking and drunk driving have decreased. Yet people do not equally enjoy improvements in health. Men, Indigenous Peoples, and poorer Canadians have lower life expectancies at birth. Lower life expectancies are found in regions with high rates of smoking, heavy drinking, and obesity; high unemployment; little education; and a large Indigenous population. Proof that social inequality causes bad health is found in the Whitehall Studies on British civil servants. They found that death rates from chronic heart disease were three times higher among low-ranking civil servants than among high-ranking civil servants.

Low-Income People in Canada

People who earn less are more likely to be unhealthy. Diet, exercise, and alcohol and tobacco use all vary by income, which also has a direct impact on other social determinants. Lower-income Canadians have a lower life expectancy, are more likely to have a severe illness and die prematurely, and have a greater chance of having two or more chronic conditions such as heart disease or diabetes. They have less education, inferior food quality, and inadequate housing. They are also less likely to be able to afford prescription medication and less likely to be tested and diagnosed for medical problems early. Children and teenagers in poorer neighbourhoods are more likely to be hospitalized from an unintentional injury. The consistent correlation between income and health is often referred to as the social gradient in health.

            One reason for the disparity is that healthcare costs money. 30 per cent of healthcare costs are not covered by health insurance in Canada, including vision care, dental care, mobility aids, homecare devices, and medication. Another important factor is stress. It can be stressful to be poor, and on average, people with higher levels of stress have a higher susceptibility to illness and disease. Canadians with postsecondary education are healthier on average than those without it, as it is more likely they will find a safe, secure, and reasonably well-paid job, which leads to good health. They are also better able to take preventive measures to promote good health because they know how to navigate the healthcare system effectively. Finally, class discrimination may influence the healthcare low-income Canadians receive.

Women in Canada

Women have to deal with unique problems that can impact their health. They are more likely than men to be single parents. Single mothers report higher levels of stress, and stress is bad for health. Women are also less likely to take part in leisure-time physical activity than men, which may be due in part to the distribution of labour in the home. Women are more likely to work in precarious and “high strain” jobs, which can increase their risk of health problems. They are also more likely to work non-standard jobs without employment insurance or stay home with a child. Cultural appearance norms can lead women to develop life-threatening eating disorders.

            There are three gender- or sex-based issues when it comes to healthcare research. The first is that female bodies have historically been left out of relevant clinical research. Second, the researchers that include women in their trials discover that their bodies respond differently to some drugs than men’s bodies do. Finally, women have different health needs than men. They are more likely to experience chronic illness and disease, autoimmune diseases, and pain. Moreover, the lack of data on drug interactions during pregnancy means that many women avoid taking necessary medications while pregnant.

Men in Canada

Men are less likely than women to visit doctors. At the same time, men are more likely to smoke and drink heavily and are less likely to make positive health changes such as improving their diet and exercising. They are also more likely to suffer from workplace accidents. All of this may be the result of constructs of masculinity that emphasize aggressiveness and self-reliance. Finally, men are more likely than women to suffer more extreme forms of social exclusion (such as homelessness) and three times more likely to die from suicide.

Seniors in Canada

Canadian seniors are more vulnerable to chronic illness, disease, and specific injuries, and typically need more healthcare. Many seniors require homecare, especially older seniors and those with a disability. Most rely on friends and family for their homecare needs. However, certain groups may be less likely to receive informal homecare and may also have weak social supports. They include seniors without children or grandchildren, seniors who live in rural or remote areas, and seniors who have recently arrived in Canada. A smaller number of seniors rely on homecare provided by paid employees. But this costs money, and seniors who can’t afford it may have unmet homecare needs. There are also many social factors influencing the health of Canadian seniors. For example, studies have found that social engagement is correlated with well-being. However, low-income seniors are more likely to be isolated and unengaged.

Immigrants in Canada

People wishing to immigrate to Canada must undergo a medical examination to show that they will not pose a danger to public health or be a drain on the medical system. That is largely why Canadian immigrants start off healthy. However, most immigrants report a decrease in good health within a few months, and their health status continues to decline over the following years. One reason is that some immigrants adopt unhealthy “Canadian” habits. Another is that poorer language skills are associated with poorer health. Language skills are important when describing symptoms to a doctor and learning medication instructions. They are also required for social interaction and community involvement. The more social networks an immigrant has, the more likely they are to report being healthy. Where mental health is concerned, employment status is significant, as are alienation, discrimination, feelings of isolation, and exclusion. Certain immigrant populations – including refugees and non-European immigrants – have a higher risk of transitioning to poorer health, and this can be linked to experiences of racism.

            Most refugee claimants are eligible for limited, temporary health insurance, but they still face unique barriers to healthcare. Translation services are covered for mental healthcare, but not for other healthcare needs. Coverage for mental healthcare does not include social workers. Any child born to a refugee claimant is covered by their provincial health plan, but in many provinces the parents have to pay for medications. Moreover, changing coverage for refugee healthcare has left some doctors unclear about whether they can treat refugees. Undocumented or non-status Canadians are not insured through provincial health insurance plans and must pay to receive healthcare. Some undocumented people visit volunteer-run, free clinics, but these clinics are likely to be extremely busy, understaffed, and undersupplied.

Indigenous Peoples in Canada

Indigenous Peoples in Canada fare worse than the average Canadian when it comes to health. They have higher rates of heart disease, type 2 diabetes, tuberculosis, and HIV/AIDS. They are also more likely to drink and smoke and die prematurely, and less likely to report good health.

            Indigenous communities struggle with high levels of poverty, unemployment, and inadequate housing, and these factors contribute to poor health. There are fewer healthcare professionals in remote areas where many Indigenous Peoples live, and where they are present, Indigenous populations often report feeling marginalized. Many Indigenous Canadians who live off-reserve experience residential instability, which is correlated with poor health and can cause difficulties completing an education, setting up healthy routines, and establishing relationships.

            Cultural factors are equally important. One continuing effect of colonization is the erosion of traditional cultural practices. The sudden introduction of modern technology to remote, isolated communities may affect Indigenous Peoples’ health and access to care. Stereotypical views of Indigenous Peoples contribute to poor health results by presuming that they cannot grow and find new ways to thrive. They are also subjected to discrimination while seeking medical care. The ongoing trauma of residential schools, marginalization, and exclusion contribute to elevated rates of mental illness in Indigenous communities, including depression, suicide, and addictions. Suicide is especially common among youth in Inuit communities.

            Addressing the social determinants of health is crucial to improving the health of Indigenous Peoples. Solutions that are generated by Indigenous communities are thought to be most effective, and we cannot overlook the significance of culture and historical injustices. The TRC noted that it is necessary to change the way we approach health broadly, to include more Indigenous Peoples working in the healthcare field, to appreciate and respect Indigenous approaches to health, and to improve training for healthcare workers.

LGBTQ+ People in Canada

Many researchers have sought to understand the ways that sexual orientation or gender identity is a social determinant of health. Some have suggested that heteronormativity and gender-normativity might influence the quality of healthcare. Transphobia is another barrier to medical care in Canada. This may encompass direct discrimination (e.g., verbal abuse) or subtle forms of discrimination (e.g., gendered washrooms). Many trans people also experience erasure, or the systematic failure to notice and confirm trans identities. Transphobia and erasure create ill health results for trans people: they have a high rate of STIs and HIV and a high prevalence of mental health issues. Similarly, stigmatization may make people uncomfortable disclosing their sexual orientation to their doctor and result in avoidance of the healthcare system.

            People who are subject to social marginalization experience stress, which is bad for health, and many LGBTQ+ Canadians experience a long-term form of social stigmatization. Discrimination may also show up in a lack of research into LGBTQ+-related health issues.

People with Disabilities in Canada

Disabilities can have an immediate impact on health, but the level of government support for people with disabilities is also important. Canada lacks effective programs that provide support to people with disabilities, leading to increased vulnerability and affecting the accessibility and quality of healthcare. For people with physical disabilities, the arrangement of the doctor’s office can act as an obstacle, and so can the attitudes and expertise of healthcare providers. Some doctors do not take enough account of the disability, while others credit everything to it.

            The health status of people with intellectual disabilities is also poorer than that of the average Canadian. Many factors, including recognizing signs of ill health and communicating health problems to others, act as barriers to accessing healthcare. They face many of the same obstacles to accessing health care as people with physical disabilities, as well as unique challenges such as the failure of care providers to adjust the environment (e.g., by providing easy-read material) and legal requirements about consent. Healthcare providers must make suitable adjustments to ensure their patients are fully aware of their choices and the risks associated with treatment so they can properly consent to a treatment plan.

Consequences of Health Inequality

Everyone suffers to some degree when there are sick people in our society. Sick people are more likely to be absent from work, often fail to contribute to their household, and draw resources away from other household activities. If they become unemployed, they may need social assistance and other social services. Sick people also put pressure on the healthcare system. 

            Today, no one doubts that social inequality is at the root of some of the world’s most pressing health and healthcare issues. One central concern has been the role for-profit health services should play in Canada’s universal system, especially in underserviced areas. Some medical school initiatives are designed for underserviced areas in Canada, including northern, remote, Indigenous, and francophone communities. Telehealth is a growing industry that has the potential to reduce doctor and hospital visits and ensure that emergencies are dealt with quickly and accurately. However, despite efforts to improve access to healthcare, 15.8 per cent of Canadians aged 12 and older did not have a family doctor in 2016, and Indigenous Peoples, as well as people living in poorer or more rural provinces, were more likely to be without a doctor.

            A significant concern about access to healthcare is “waiting time.” Our society cannot afford to provide immediate, high-quality care to everyone who needs it, so healthcare providers need to work on improving people’s expectations as much as on decreasing wait times. This may mean developing a better social organization of waiting, such as by giving every person in a queue a case manager.

Strategies of Resistance

One crucial way in which the Government of Canada seeks to equalize access to good health and healthcare is by understanding it better. Health Canada funds a vast number of research initiatives across the country. It also has programs that are specifically targeted to Indigenous Peoples in Canada. These programs include guides and information on environmental health both in the community and in natural environments, and their family health programs work to address problems particular to Indigenous Peoples.

            The All Nations Healing Hospital is an example of healthcare delivery that addresses the unique needs of the Prairie Indigenous populations. Besides acute and emergency care, the All Nations Healing Hospital offers programs in diabetes management and prevention, nutrition, addictions counselling, and residential school survivors counselling. The hospital addresses the cultural needs of its clientele with traditional ceremonies and the involvement of Elders. It also has programs designed especially for Indigenous women.

            Finally, all over Canada, there are individuals engaged in efforts to equalize access to good health and healthcare. It is crucial that we continue to work with and support initiatives that make healthcare more equitable.