Is The Living Wage a Public Health Issue?

By Ted Bruce

While browsing on-line news recently, I stumbled across an article about protests by American fast food workers and their poverty level wages.

The newly calculated 2012 living wage rate for Metro Vancouver stands at $19.62 per hour. Photo Source: A Living Wage for Families (

The newly calculated 2012 living wage rate for Metro Vancouver stands at $19.62 per hour. Photo Source: A Living Wage for Families (

I was reminded of calls for a living wage in BC. Living wage proponents everywhere are starting to gain more attention exactly because of the dynamics described in the article. People are working full time or even at 2 jobs and still may be unable to meet their basic living expenses. I was also struck by the similarity in the arguments by those opposed to living wage policies such as the belief that raising wages is not affordable. Although the article does a good job of debunking that myth (I love the comment on how big corporations are subsidized by food stamps for the poor), it is important for public health advocates to have a fundamental grasp of the living wage. Public health has consistently called for a variety of healthy public policies such as affordable child care. Public policies can directly affect the calculation of the living wage rate and thus the cost of a living wage to employers in any given community. When public health calls for social and income related policies that promote population health, they are in some respects contributing to the debate on the living wage. To learn more about the living wage visit: The living wage discussion raises the broader issue of the corporate determinants of health. This is a topic that is becoming more important as governments downsize and the role and power of corporations in our society increases. PHABC will soon be announcing an initiative on the corporate determinants of health so we can better understand how to advocate within this sector. Stay tuned for a blog by John Millar, PHABC’s Vice President in an upcoming blog on this topic.

Ted Bruce is the Past President of the PHABC

When the Doctor Comes Calling – For Poverty Reduction

By Ted Bruce

Two recent reports offer very compelling arguments to address the social determinants of health as a societal priority. They also point to the important role public health plays as an advocate for healthy public policy more generally.

The first, published in the British Medical Journal, is yet another piece of evidence that addressing socioeconomic conditions is good for health and an investment in social initiatives may be more effective at improving health than expenditures on health services.

As the study points out: “Although most health reform efforts to improve health status focus on health expenditures, it may be that additional attention on social services is also needed. This approach is consistent with public-health frameworks, which have frequently highlighted the social over the biological and medical determinants of health”.

Many public health advocates in BC have longed encouraged the Ministry of Health and health care leaders to argue for a more comprehensive approach to health care reform that would tackle poverty reduction and end the never ending increase in health care expenditures. Naturally, most health care leaders are reluctant to take this view when they feel the pressures and demands on the health care system. But it does not have to be an either/or approach. What is needed is a cross government or intersectoral approach where at least there is a common understanding of what priorities are needed and every sector makes its contribution. This approach was applied to the government’s now defunct “ACT Now” health promotion initiative aimed at the behavioural risk factors associated with chronic disease. And it is what has been called for in regard to tackling poverty in the province.

It is clear from this study that intersectoral approaches are critical if we are to get the investments in place that will produce the results we need. In fact, it may be the only way forward to improve health and contain health care costs. We can all learn more about how to approach intersectoral work later this year as the theme of this year’s PHABC Annual Conference is on this very topic. ( .

cma reportBut when it comes to getting upstream of illness and truly tackling the root causes of the health inequities that drive so much of our health care expenditures, health care leaders have tended to stay silent – but not so much anymore as evidenced by the report and position now taken by the Canadian Medical Association (CMA).

Most health care providers see the impact of poverty on health every day in their practices, but generally they feel helpless to act on it. Naturally there is a tendency to think governments will show the leadership to tackle these serious social problems. Or they defer to the efforts of their public health counterparts to “fight the good fight”. But the need for action by government is so pronounced that health inequities and their root social causes are now entering the mainstream of advocacy by organized medicine.

While certain groups of physicians have been active in advocating for social justice and poverty reduction, this effort by CMA represents a major shift in thinking about the role of medicine in creating a new paradigm for health. As more partners like the CMA join the call of public health advocates for a broad approach to poverty reduction, food security and social housing, we will see the intersectoral approaches that are necessary to reduce health inequities – and ultimately slow down the rate of growth in health care expenditures.

Ted Profile– Ted Bruce is the Past President of the PHABC

Further reading:

12 Great Public Health Achievements – Acting on the Social Determinants of Health | by the Canadian Public Health Assocation

“Recognition that health is influenced by many factors outside the health care system has strengthened public health’s commitment and leadership in activities that address the broad determinants of health, such as income, education, early childhood development and social connections.” Read more…

Canadian Milestones: Acting on the Social Determinants of Health |  by the Canadian Public Health Assocation

Government Must Be Accountable for the Costs of Poverty

By Ted Bruce

A report on the rising poverty rate among new immigrants to Canada ran side by side with an article on BC’s version of austerity as the government moves to deal with a declining economic situation.

The report on poverty notes that the failure to address this rising poverty sets up a “tinderbox” of discontent. A similar message has been repeatedly stated by the public health community. There is ample evidence as demonstrated by epidemiologists Richard Wilkinson and Kate Picket and documented so well in their book The Spirit Level that societies with high levels of economic inequality perform very poorly. And it is clear that the public wants government to address poverty as is shown by the recent polling done by the BC Healthy Living Alliance.

Is government’s “austerity” response the solution? Governments that essentially ignore poverty reduction policies say that they can’t afford them or that policies related to job creation will be the best solution to the problem. The economists can debate this but there is ample evidence that the cost of poverty is greater than the cost of the investments that could alleviate it. The study by the Canadian Centre for Policy Alternatives (supported by PHABC) provides a startling analysis of the costs of not acting.

But even if politicians believe their austerity and trickle down growth paradigm is correct, they have an obligation to demonstrate that it works. So why not set some timelines and targets as has been called for by public health organizations like PHABC and the Health Officers Council of BC? If our elected officials believe they are building a better society for citizens through their policies, it is not asking too much for them to show us they can reduce poverty. Let’s measure it and report on it. That is not asking for too much.

Ted Bruce is the past-president of the PHABC


Literacy: A foundational element of a poverty reduction strategy

By Ted Bruce

Books-1-iconIn the current election we see almost random program promises to address issues related to poverty. These are necessary but not sufficient to make a substantial change. A comprehensive poverty reduction strategy is about a lot more than small increases in welfare rates or small increments in early childhood services for children. That is why the PHABC position calls for a COMPREHENSIVE approach. What are needed is a bold vision and an all of society approach led by a dedicated minister and a plan with target and timelines. Without a comprehensive plan some fundamental elements of success will be missed.

Take literacy for example. One seldom hears literacy discussed as part of a poverty reduction strategy although it is almost foundational to creating sustainable change. Without strengthening literacy in society we do not get upstream of one of the critical areas of disadvantage for many adults in our society. The fact sheets about literacy, health literacy and poverty highlight (see links below) highlight the importance of tackling literacy as a poverty reduction strategy. Its time we stopped a piecemeal approach to poverty reduction and truly invested in a bold approach – one that is comprehensive and sustainable. It will pay for itself many times over.

Fact Sheet: Literacy and Poverty | Decoda Literacy Solutions | March 2013

Fact Sheet: Health Literacy | Decoda Literacy Solutions | March 2013

Health Officers Council release report on health inequities in BC

By Dr. Victoria Lee

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Today, the Health Officers Council of BC (HOC) released an updated report on Health Inequities in BC.  Analyses of life expectancy in British Columbia (BC) by income groups between the periods of 2002‐6 and 2006‐10 found a disturbing trend: the gap in life expectancy between Local Health Areas (LHAs) with the highest socio‐economic status (SES) and those with the lowest SES has widened dramatically.  We know that poverty is bad for our health.  People living in the lowest SES areas are more likely to suffer from health risks and complications of illness, while less likely to be able to access care.

We also know that tackling poverty head on can shift the trends that we’re observing in BC.   BC is one of the two provinces in Canada that does not have a provincial poverty reduction plan in progress or development.  We can start to reverse the trends by developing and implementing a provincial poverty reduction plan with critical milestones, indicators and evidence-based strategies.

Read the full HOC report ‘Health Inequities in BC 2013

Dr. Victoria Lee is the Co-chair of the Population Health Committee, Health Officers’ Council.

‘Health as if everybody counted’ – a great online resource

The Population Health Network at the University of Ottawa has created a “network of networks” linking researchers, decision-makers and practitioners across the country. They host weekly “fireside chats” to share research findings and the application of those findings ( On this website is a blog (Health as if Everybody Counted) by Ted Schrecker, a scientist and Associate Professor in the University of Ottawa’s Department of Epidemiology and Community Medicine, and a principal scientist at the University’s Institute of Population Health.

A recent blog is entitled “Our big fat complicated population health problem, Part 2: It may be worse than we thought”. This and his previous blogs will be of interest to public health practitioners, and other visitors to our Health Voices website. By following the link to the blog, you can read a variety of entries that may also be of interest (e.g., A new frontier for action on health equity, related to transportation policy).  I really enjoy Ted’s blogs and recommend them to you.

Marjorie MacDonald is the President of Public Health Association of BC

Embrace the wisdom of investing in children

By Dr. Brian O’Connor

In a recent blog (‘It Doesn’t Have to Be this Way’, March 27th), Trevor Hancock, in a tribute to Clyde Hertzman, reviewed the policy platform of the Human Early Living Partnership (HELP) as contained in the 15×15 document.  Much of this speaks to the importance of ensuring adequate incomes for families and some of the key aspects of a poverty reduction plan.

One of Clyde’s colleagues at HELP, Professor Paul Kershaw, has put a unique twist on early child development and the need for adequate resources for families in terms of income, time and services.  Young people and young families have unique challenges in today’s social environment that present huge impediments in terms of the ability of children to develop optimally.  Professor Kershaw refers to the young families of today as the squeezed generation or GenSqueeze (  His thesis is that today’s young families, quite unlike their predecessors (boomer, gen x, etc.) are severely under resourced in terms of

1) the time they have available for optimal parenting

2) the lack of supportive services – the consequences of a paucity of sound social policies in support of today’s families such as universal, quality, affordable for all, day care – Professor Kershaw proposes a $10/day solution, a solution also promoted by the Coalition of Child Care Advocates of BC ( and

3 ) income issues arising from discrepancies in wages and the cost of living over time leading to two working parent families with very long hours

Professor Kershaw has contrasted the social policy supports that as Canadian society, we have put in place for seniors as an example while at the same time we have not been as generous in our support for young people and young families.   While he is not trying to pit one generation against another, he does point out that our social spending on seniors comes to $45,000 per Canadian over 65, while a similar young family today is afforded social policy spending of only $12,000 per Canadian under 45.   He does not support reapportioning  spending  (maintain funding to existing social programs) but adding a mere $1000 per Canadian in additional spending which will as an investment bear vast return in mitigated costs from things such as reduction in costs from crime, education, avoidable absenteeism and improvements in human capital, and competitiveness.

It is interesting that our society has not fully embraced the wisdom of investing in children, the future of our province, by ensuring optimal early child development for all BC’s children.  While our universal Medicare program is a defining national characteristic and the support we provide seniors is never questioned, we can hear the negativity that arises when one proposes $10/day child care – “why do I have to pay for their child’s day care?”

So Professor Kershaw comes at the poverty reduction question in a slightly different way.  But it is anchored in the recognition that optimal child care development if not addressed through policy options that provide more resources, will perpetuate the continuum of poverty, poor child outcomes and increased health inequity.

Brian O’Connor is the Co-Chair of the Population Health Committee, Health Officers Council of BC

Additional Reading:

15 by 15: A comprehensive policy framework for early human capital investment in BC | Human Early Learning Project | 2009

Poverty is Bad for Your Health – Backgrounder and Q&A info series | PHABC 2012

It Doesn’t Have To Be This Way!

By Dr. Trevor Hancock in memory of Clyde Hertzman (March 24th 1953 – February 8th 2013)

Clyde was the Founder and Director of the Human Early Learning Project at UBC, a brilliant, vibrant and engaging man and a good friend. His work was of national and international importance and he is sorely missed both professionally and personally.

At the Celebration of Clyde’s life at the Chan Centre on Sunday March 17th, the incomparable Bob Evans summed up Clyde’s work in these seven words – “It doesn’t have to be this way!” I think the hundreds of people gathered to honour Clyde and celebrate his life recognized Clyde in these words and saw this as a wonderful summing up of a rich life. Clyde was passionately committed to making a difference in the lives of children and the health of the population, and to fighting injustice. His legacy must be our commitment to continue his work.

So at a time when we face an election in BC, we need to demand more than a rhetorical commitment from the contending parties to do something about child development, about the health and well being and level of potential of every child in BC. We need to demand a serious commitment, with serious resources, to implement the policies and programs that flow from Clyde’s life and work.

Here are some key points, taken from the HELP website:
“Key to reducing vulnerability in the early years is a universal platform of supports and services available to all children. This platform needs to be accompanied by additional targeted services for highly vulnerable children and children in low SES ranges or geographical areas. Key also is the elimination, as far as possible, of barriers to access.”

“. . . the standard of living has declined for the generation raising young kids today . . . Doubling of housing costs and stalling household incomes for adults who devote more time to the labour market than any previous generation, result in massive social and economic change. The generation raising kids today is squeezed for time at home; they are squeezed for income because of the cost of housing, and they are squeezed for services like child care that will help them balance successfully raising a family with earning a living. The generation raising young kids does not access its share of economic growth. UNICEF and the OECD rank Canada among the very worst industrialized countries when it comes to investing in families with preschool age children.”

“HELP’s research team has developed a comprehensive policy framework that is built on a foundation of scientific evidence about the importance of the early years. This framework includes three major policy thrusts: benefits for all new parents in the first 18 months of their child’s life; high quality, accessible child care services for all who need them; flexible working hours to allow parents to balance the demands of work and home life.”

In the 2009 report “15 by 15: A Comprehensive Policy Framework for Early Human Capital Investment in BC” HELP makes a number of recommendations for action in BC:

  • Build on maternity and parental leave to enrich the benefit value, and to extend the total duration from 12 to 18 months, reserving additional months for fathers.
  • Build on existing employment standards to support mothers and fathers with children over 18 months to work full-time for pay, but redefine full-time to accommodate shorter annual working hour norms without exacerbating gender inequalities in the labour market.
  • Build on income support policies to mitigate poverty among families with children.
  • Build on pregnancy, health and parenting supports to ensure monthly developmental monitoring opportunities for children from birth through age 18 months, as their parents are on leave.
  • Build on early education and care services to provide a seamless transition for families as the parental leave period ends in order to make quality services for children age 19 months to kindergarten affordable and available on a full- or part-time basis, as parents choose.

The report also points out that “Over a 60 year period, the benefits to society [of Implementing these changes] outweigh the costs by more than 6/1”. So we can best honour Clyde’s legacy by agreeing that indeed it doesn’t have to be the way it is now, by insisting that it can be this way instead, and that BC’s next government must fully implement these policies to improve the health, wellbeing and level of human development of ALL of BC’s children.

– Dr. Trevor Hancock is a Professor and Senior Scholar, School of Public Health and Social Policy, University of Victoria

Further Reading:

HELP Fact Sheets and Briefs:

HELP Maps:

15 by 15: A comprehensive policy framework for early human capital investment in BC | Human Early Learning Project | 2009

2013 Speech from the Throne is another missed opportunity

By Ted Bruce

Tuesday’s provincial Speech from the Throne sets out a vision for revenue generation for the future, relying heavily on the natural resources of the Province. But is falls very short of a vision for the health of British Columbians. There is an understandable concern with the economy and the deficit and debt of the Province. However, it fails to recognize that a central and ever increasing pressure on government finances is the cost of health care, which now eats up close to 50% of the provincial budget. It seems we have become addicted to finding money to pay for the demand for health care interventions without taking on the long term challenge of moderating the growth in expenditures by creating a sustainable health system founded on prevention.

Tuesday’s Speech from the Throne is another missed opportunity.

What could have been said if a prevention lens was applied to the Government’s intentions?

There was considerable emphasis on jobs especially in the construction and trades. This demands an increase in injury prevention. Does public health have the capacity to deal with the type of industrial growth envisioned in the Speech? We are making improvements in tackling injuries, but injuries especially among young people are a major contributor to hospitalizations and health care use. Investments in injury prevention are needed – and they pay off.

The Speech highlights how BC is a new home and refuge for many people seeking opportunity in a new country. And yet there is little recognition that many new Canadians come to this province healthier than many Canadians. Unfortunately they lose some of this benefit as they adopt unhealthy lifestyles promoted by the relentless advertising machine of the junk food industry. This is an added problem for new Canadians; for many their income situation also has long term consequences for their health, and especially that of their children. We know many immigrants experience income insecurity while working for minimum wage and struggling to find child care so they can enter the workforce. The socioeconomic inequity they experience compared to other Canadians puts them at risk for health problems. How can we protect the healthy immigrant effect? We need to strengthen public health’s effort to promote healthy living and put in place and enforce regulatory measures to protect the health of the public, especially that of children. That is a prevention agenda for new Canadian families. And we need to ensure a strong social safety net for all Canadians that will mitigate and reduce socioeconomic inequities.

Progress is being made on preventable deaths and the Speech mentions cancer prevention. The case of cancer prevention is an informative one. It demonstrates we can, through prevention, make huge strides in reducing death and illness. But groups such as the Canadian Cancer Society BC and Yukon Division who, along with PHABC and a number of other health organizations initiated the BC Healthy Living Alliance, have documented some of the additional resources needed in the prevention area for some key chronic diseases. This represents a vision for the future. Unfortunately, the Speech from the Throne simply makes minor reference to what is one of the greatest public health achievements in history rather than setting us on a path to a healthier future based on investments in prevention.

The Speech from the Throne recognizes the important role of early childhood education and child care, stating that there will be new initiatives in these areas. That is good news for public health because we know these investments are foundational to the long term health of young people and families. But we also know that piecemeal approaches are not particularly effective. We have learned this from public health experiences such as tobacco reduction where a comprehensive approach was required, involving a range of strategies including health education, regulation and pricing.  The reduction of health inequities requires no less of a comprehensive effort. Rather than small incremental changes in early childhood and child care, a full health inequity strategy is needed, one that includes initiatives aimed at income security, food security, early childhood supports and affordable housing. Almost every other province in Canada has recognized this in adopting comprehensive poverty reduction strategies, and it requires a bold vision and political will to move forward in BC.

From a health perspective, it is a vision for the future that seems to be missing in this Speech from the Throne.

– Ted Bruce is the past-president of the Public Health Association of BC

Further reading:

2013 Speech from the Throne | BC Government | February 12, 2013

Throne Speech childcare pledges too vague, advocacy groups say | The Globe and Mail, February 13 2013

B.C. throne speech repackages old announcements, lacks courage and vision | | By Iglika Ivanova (CCPA), February 13 2013

Canada’s failing grade for poverty and inequality is bad news for health

By Dr. Trevor Hancock*

It is no surprise to we who work in population and public health that Canada in general and BC in particular has a poor record when it comes to poverty and inequality. And we understand only too well – and see on a regular basis – that poverty not only sucks but that it also sickens, depresses, injures, maims and kills. We also have seen that inequality in a community can be corrosive, widening the gap between the advantaged and the disadvantaged to the point that a sense of community is lost – as French philosopher Raymond Aron put it, “when inequality becomes too great, the idea of community becomes impossible”.

BC in particular has gained an unenviable reputation as the capital of child poverty in Canada and organisations such as the PHABC and the Health Officers Council have been vocal in calling for action to reduce child poverty and improve health. In doing so, we have joined with the ‘usual suspects’ – our colleagues and partners in the social development world, those working for a more just society and so on. But it is heartening and comforting to see that people in the business world also see these issues and understand their importance.

Which brings me to the “Society” report released this week from the Conference Board of Canada on Canada’s performance as a society. For those not familiar with the Conference Board, it is an independent, non-partisan, not-for-profit applied research organization catering largely to Canada’s business community and to governments. They have for some years been exploring the issue of population health and the social determinants of health, and they recognize both the implications of this issue for business and the role that business can play in addressing the social determinants of health. Now, the Conference Board has examined Canada’s progress in “providing a high and sustainable quality of life for all Canadians”. In their report they point to Canada’s poor performance on poverty in the working age population, child poverty, income inequality and gender equity as “troubling for a wealthy country”.

The Conference Board notes that the goal that it sets out for Canada (as noted above) “requires much more than economic success. By ‘high quality of life,’ we mean communities that:

  • ensure the active participation of individuals within society, including its most vulnerable citizens (such as youth and people with disabilities)
  • minimize the extremes of inequality between its poorest and richest citizens
  • are free from fear of social unrest and violence.”

Using OECD data, the Conference Board finds that Canada rates a ‘B’ overall for its social performance and comes 7th out of 17 countries examined, trailing the Nordic countries, the Netherlands and Austria, but ahead of countries such as the UK, Australia, Japan and the USA – which comes dead last. Canada has had a B grade throughout the last two decades, which the Board notes “means it is not living up to its reputation or its potential”.

The Board measures social performance “using 17 indicators across three dimensions: Self-sufficiency, equity and social cohesion”; it is particularly in the area of equity that Canada performs so poorly. Specifically, Canada gets a ‘D’ grade for its rate of working age poverty (“the working-age poverty rate rose from 9.4 per cent to 11.1 per cent” between the mid-1990s and the late 2000s) and a ‘C’ for child poverty (“the child poverty rate increased from 12.8 per cent to 15.1 per cent”), the gender income gap and income inequality. Only in elderly poverty did Canada get an ‘A’, but even here “The elderly poverty rate increased from 2.9 per cent to 6.7 per cent” in that same time period.

Noting that the rising rate of child poverty is “particularly disappointing”, the Board quotes the OECD as follows:

“Failure to tackle the poverty and exclusion facing millions of families and their children is not only socially reprehensible, but it will also weigh heavily on countries’ capacity to sustain economic growth in years to come.”

All this leads the Conference Board to conclude that “The self-image of Canada as kinder and gentler is based largely on a narrow Canada–U.S. comparison”. . . .  and that self-satisfaction is,

“not justified when Canada’s social performance is compared with its peer countries. Six countries rank above Canada overall, and Canada’s “D” grade on working-age poverty and “C” grades on child poverty and income inequality, are troubling for a wealthy country.”

Turning finally to BC, it used to be that BC had a mechanism for doing its own reports on performance. But the Progress Board, established by Premier Gordon Campbell, was later abolished by him shortly after it had the temerity to point out BC’s poor performance on many of the same social development measures as those used by the Conference Board. But given that BC has had the highest rate of child poverty in Canada for much of the past decade, and that until very recently its minimum wage had not increased for a decade, slipping from the highest to one of the lowest rates in the country, it is safe to assume that BC trails Canada in the areas highlighted as problematic by the Conference Board, with predictable, harmful and expensive consequences for health.

 * Dr. Trevor Hancock is a Professor and Senior Scholar in the School of Public Health and Social Policy at the University of Victoria