Commentary
Canadian values, social policy and the health of our kids Avram Denburg MD MSc1,2 A Denburg. Canadian values, social policy and the health of our kids. Paediatr Child Health 2016;21(5):242-244. What explains the widening disparities in child health and social circumstance in Canada? And why do we tolerate such inequality? In the present commentary, the author argues that to understand – and ultimately influence – the trajectory of child health and well-being in our country, we must attend to the impact of social policy on the life chances of Canadian children. This, in turn, demands that we probe the fundamental values that guide social policy in modern welfare states and locate Canada’s place in this political spectrum. The author explores the controversial tax policy of income-splitting to contextualize this discussion of values, and argues that our polity increasingly privileges economic liberty above equality or solidarity. Until those best positioned to advocate for children – including paediatricians and child health care providers – begin to engage with social policy, the health and well-being of Canada’s children will remain a tale of two increasingly different worlds. Key Words: Child health; Health policy; Social determinants of health; Social policy; Social values
The child as social paradox
Children in most societies continue to experience a wide array of social ills. Canada’s children are no exception: more of our children are living in poverty than ever before; violence and social dislocation are facts of life for too many Canadian youth (1,2). Infant and under-five mortality rates in Canada are well above average for countries with comparable levels of development (3). Indexes of child well-being place us squarely in the middle of the pack, leagues behind the Netherlands and Scandinavia (4). As child health professionals – arguably those in society most concerned with the health of children and best positioned to improve it – we are complicit in the preservation of this paradox. Yet, most of us appear to be unaware of this fact, or unengaged in understanding and addressing the issues that underlie it.
Seeing the forest for the trees
This is, in part, a consequence of the centrality that health care enjoys in our public discourse about social well-being. Focus on the acute, the medically remediable and the technological has induced myopia in our perception of problems that face Canadian children and our apprehension of solutions to them. It is also a product of the health and social policy choices we make in light of this preoccupation with our health care system. Honest efforts to address child health outcomes at the population level demand we move beyond a focus on health care per se, toward social determinants as the foundation of child health and well being. This does not diminish the importance of a robust, sophisticated and wellresourced child health care system; every child deserves the dignity
Les valeurs canadiennes, les politiques sociales et la santé des enfants Qu’est-ce qui explique les disparités croissantes en matière de santé et de situation sociale des enfants au Canada? Pourquoi tolère-t-on de telles inégalités? Dans le présent commentaire, l’auteur avance que, pour comprendre et influencer la trajectoire de santé et de bien-être des enfants du pays, il faut examiner les répercussions des politiques sociales sur les chances des enfants canadiens dans la vie. Pour ce faire, il faut sonder les valeurs fondamentales qui orientent les modèles de protection sociale dans les États providences modernes et situer la place du Canada au sein de ce spectre politique. L’auteur explore la politique fiscale controversée du fractionnement du revenu pour contextualiser cet exposé sur les valeurs, et avance que nos politiques privilégient de plus en plus la liberté économique au détriment de l’égalité ou de la solidarité. Tant que les personnes les mieux placées pour défendre les enfants, y compris les pédiatres et les dispensateurs de soins aux enfants, ne s’investiront pas dans les politiques sociales, la santé et le bien-être des enfants du Canada demeurera l’histoire de deux mondes de plus en plus éloignés.
and opportunity of access to optimal medical care. However, it does imply that we need to consider, and contend with, forces broader than those conferred by biological heritage or happenstance. This is especially true in light of evolving knowledge of the epigenetic pathways through which social factors interact with biology to condition the propagation of disease and response to treatment for a given child. This awareness compounds the need to consider social circumstance, and the impact of social policies on it, in our efforts to shore-up child health in Canada (5).
Look to the roots: Values and social policy
A still-deeper look reveals this paradox is rooted in the values that frame and justify social policy choices for children in Canada. Our political institutions, the legislation and policies they promote and the values that guide those decisions, make the biggest difference to the health and well-being of the greatest number of children in our society. It is the type of political and social culture that we create, endorse and sustain that matters most to child health. Scholars of politics from diverse disciplines – including political science, history and philosophy – have given much thought to the connection between values and the evolution of political cultures and institutions across countries. This field of inquiry has much to say about where real-world policies come from, how they affect our collective identity and how they are likely to affect our lives. The relationships between three basic principles determine the boundaries and character of social citizenship in modern welfare states. They are familiar ones, our shared heritage in the wake of the
Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario Correspondence: Dr Avram Denburg, Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8. Telephone 416-813-7742 , fax 416-813-5327, e-mail [email protected] Accepted for publication December 19, 2015 242
©2016 Canadian Paediatric Society. All rights reserved
Paediatr Child Health Vol 21 No 5 June/July 2016
Commentary
French revolution: liberty, equality and solidarity (6). Each of these values pulls against and checks the others. Welfare states – in which government is instrumentally involved in the economic and social conditions impacting its citizens – are built on these values: their differences are borne out in their mix, on the relative emphasis placed on one above the others. These foundational values, expressed in political culture and discourse, determine a great degree about the laws and policies that shape society. Societies premised on equality, similar to several of the Scandinavian countries, emphasize universalism as an organizing principle for policy, and conceive of a strong role for the state in stewarding resources to mitigate inequality. Societies premised on liberty, similar to ours, focus on the needs of those at the margin and leave the rest to the whim of the market. Societies premised on solidarity focus on collective goals and obligations, and seek to minimize risks to social stability through policy, often in the form of worker-based insurance. Many focus on traditional models of the family as the locus for, and beneficiary of, social policy, and are often geared toward the maintenance of existing social patterns (Figure 1) (7).
values in the real world: income-splitting
A discussion of values may appear far removed from real-world concerns about child illness and suffering. Nothing could be further from the truth. Recent political debate over tax policy that would have permitted income-splitting by Canadian families is a controversial case in point. As legislated by Stephen Harper’s Conservative government, income-splitting in Canada represented a roughly $2.2 billion annual tax break, one primarily accruing to middle- and upper-income families (8). It offered comparatively little tax relief for low-income families and none to single parents. The Conservative government framed this policy as a measure to enhance the economic freedom of Canadians, by enabling “people to put more money back in their own pockets” (9). Less loudly trumpeted were the likely opportunity costs. The Conservatives advocated this tax reform despite evidence that supports doing just the opposite. Infant mortality rates in high-income countries correlate strongly with generosity in family policies that support dual-earner families – notably universal childcare, early childhood education and enhanced parental leave. Comparative analysis of family policies in Organization for Economic Cooperation and Development countries demonstrates that an increase of one percentage point in dual-earner support lowers infant mortality by 0.04 deaths per 1000 births (10). So what, aside from naked political calculus, could prompt such a policy? Its motivation stemmed from the values that have increasingly grounded Canadian political institutions and discourse in recent decades. Policies such as income splitting reflect a broader approach to the governance of society that is founded on, and privileges, certain values at the expense of others; in this case, the centrality and ascendancy of the market. Income splitting reinforces this liberal cast, emphasizing regressive taxation and the role of the economy in social citizenship, while eschewing equality and universalism as organizing principles for social policy. Interestingly, in its nod to traditional family structures, income-splitting also echoes the ideological commitments of the conservative and Latin regimes of continental Europe. Despite compelling evidence that improved child health outcomes (gauged by something as fundamental as infant mortality) correlate strongly with universal early childhood programs and policies, the pull of basic ideological commitments to market freedom often wins the day. We are increasingly a society that privileges liberty above equality or solidarity. Liberty is an essential building block of a free and Paediatr Child Health Vol 21 No 5 June/July 2016
Figure 1) Typology of welfare state regimes (reproduced with permis-
sion from reference 7) just society; however, liberty unchecked leads to polarization and social dislocation. If we are serious about protecting and promoting child health, we must involve ourselves with social policy. If we are to influence social policy, we must attend to the values that ground our polity. As one of its first moves, the current Liberal government chose to scrap income splitting. This is a salutary example of federal policy: a values-based decision supported by robust evidence. We should hold all levels of government to this basic, but critical, standard for policymaking.
So what?
I am not arguing that we, as child health professionals, should shirk our traditional duties, nor that our primary focus should be anything other than the welfare of the child in front of us. I do contend, however, that unless we think explicitly and deeply about the values we want our social and political institutions to reflect, we will continue to play at the fringes of child health and well-being in Canada. So what can we do? We can inform ourselves about policies that impact children and families, and the political dynamics that underlie them. We can engage our patients in understanding how these policies impact them specifically. We can advocate – for our patients as individuals, and for children collectively – employing our considerable privilege to influence public debate on the issues that matter to Canada’s youth. We can act bravely to support leaders, policies and institutions that promote the values to which we are committed; and to challenge leaders, policies and institutions that compromise those values. Acknowledgements: The author gratefully acknowledges the Canadian Institutes of Health Research, The Pierre Elliott Trudeau Foundation and the Canadian Child Health Clinician Scientist Program for support during the period of this research.
References
1. Campaign 2000. Child poverty, 25 years later: We can fix this. 2014 report card on child and family poverty in Canada. Toronto, November 2014. (Accessed September 15, 2015). 2. McMurtry R, Curling A. The review of the roots of youth violence. Volume 1: Findings, analysis, and conclusions. Toronto: Queen’s Printer for Ontario, 2008. (Accessed September 16, 2015).
243
Commentary 3. Organization for Economic Cooperation and Development. Infant mortality, OECD Health Data (version April 2014). OECD Family Database. Paris, May 2014. (Accessed September 16, 2015). 4. Organization for Economic Cooperation and Development. Doing better for children. Chapter 2: Comparative child well-being across the OECD. Paris, September 2009. (Accessed September 16, 2015). 5. Denburg A, Daneman D. The link between social inequality and child health outcomes. Healthc Quart 2010;14:21-31. 6. Bernard P. Social cohesion: A critique. Canadian Policy Research Networks Discussion Paper No. F/99. Ottawa, December 1999 [cited 2015 Oct 11]. (Accessed September 20, 2015).
244
7. Saint-Arnaud S, Bernard P. Convergence or resilience? A hierarchical cluster analysis of the welfare regimes in advanced countries. Curr Sociol 2003;51:499-527. 8. Geddes J. The surprising spoils of income-splitting. Maclean’s. (Accessed September 20, 2015). 9. Whittington L. Stephen Harper says Canadians want incomesplitting plan. Toronto Star. 2015 Mar 18 [cited 2015 Oct 11]. (Accessed October 11, 2015). 10. Lundberg O, Yngwe MA, Stjarne MA, et al. The role of welfare state principles and generosity in social policy programmes for public health: An international comparative study. Lancet 2008;372:1633-40.
Paediatr Child Health Vol 21 No 5 June/July 2016
Canadian values, social policy and the health of our kids Avram Denburg MD MSc1,2 A Denburg. Canadian values, social policy and the health of our kids. Paediatr Child Health 2016;21(5):242-244. What explains the widening disparities in child health and social circumstance in Canada? And why do we tolerate such inequality? In the present commentary, the author argues that to understand – and ultimately influence – the trajectory of child health and well-being in our country, we must attend to the impact of social policy on the life chances of Canadian children. This, in turn, demands that we probe the fundamental values that guide social policy in modern welfare states and locate Canada’s place in this political spectrum. The author explores the controversial tax policy of income-splitting to contextualize this discussion of values, and argues that our polity increasingly privileges economic liberty above equality or solidarity. Until those best positioned to advocate for children – including paediatricians and child health care providers – begin to engage with social policy, the health and well-being of Canada’s children will remain a tale of two increasingly different worlds. Key Words: Child health; Health policy; Social determinants of health; Social policy; Social values
The child as social paradox
Children in most societies continue to experience a wide array of social ills. Canada’s children are no exception: more of our children are living in poverty than ever before; violence and social dislocation are facts of life for too many Canadian youth (1,2). Infant and under-five mortality rates in Canada are well above average for countries with comparable levels of development (3). Indexes of child well-being place us squarely in the middle of the pack, leagues behind the Netherlands and Scandinavia (4). As child health professionals – arguably those in society most concerned with the health of children and best positioned to improve it – we are complicit in the preservation of this paradox. Yet, most of us appear to be unaware of this fact, or unengaged in understanding and addressing the issues that underlie it.
Seeing the forest for the trees
This is, in part, a consequence of the centrality that health care enjoys in our public discourse about social well-being. Focus on the acute, the medically remediable and the technological has induced myopia in our perception of problems that face Canadian children and our apprehension of solutions to them. It is also a product of the health and social policy choices we make in light of this preoccupation with our health care system. Honest efforts to address child health outcomes at the population level demand we move beyond a focus on health care per se, toward social determinants as the foundation of child health and well being. This does not diminish the importance of a robust, sophisticated and wellresourced child health care system; every child deserves the dignity
Les valeurs canadiennes, les politiques sociales et la santé des enfants Qu’est-ce qui explique les disparités croissantes en matière de santé et de situation sociale des enfants au Canada? Pourquoi tolère-t-on de telles inégalités? Dans le présent commentaire, l’auteur avance que, pour comprendre et influencer la trajectoire de santé et de bien-être des enfants du pays, il faut examiner les répercussions des politiques sociales sur les chances des enfants canadiens dans la vie. Pour ce faire, il faut sonder les valeurs fondamentales qui orientent les modèles de protection sociale dans les États providences modernes et situer la place du Canada au sein de ce spectre politique. L’auteur explore la politique fiscale controversée du fractionnement du revenu pour contextualiser cet exposé sur les valeurs, et avance que nos politiques privilégient de plus en plus la liberté économique au détriment de l’égalité ou de la solidarité. Tant que les personnes les mieux placées pour défendre les enfants, y compris les pédiatres et les dispensateurs de soins aux enfants, ne s’investiront pas dans les politiques sociales, la santé et le bien-être des enfants du Canada demeurera l’histoire de deux mondes de plus en plus éloignés.
and opportunity of access to optimal medical care. However, it does imply that we need to consider, and contend with, forces broader than those conferred by biological heritage or happenstance. This is especially true in light of evolving knowledge of the epigenetic pathways through which social factors interact with biology to condition the propagation of disease and response to treatment for a given child. This awareness compounds the need to consider social circumstance, and the impact of social policies on it, in our efforts to shore-up child health in Canada (5).
Look to the roots: Values and social policy
A still-deeper look reveals this paradox is rooted in the values that frame and justify social policy choices for children in Canada. Our political institutions, the legislation and policies they promote and the values that guide those decisions, make the biggest difference to the health and well-being of the greatest number of children in our society. It is the type of political and social culture that we create, endorse and sustain that matters most to child health. Scholars of politics from diverse disciplines – including political science, history and philosophy – have given much thought to the connection between values and the evolution of political cultures and institutions across countries. This field of inquiry has much to say about where real-world policies come from, how they affect our collective identity and how they are likely to affect our lives. The relationships between three basic principles determine the boundaries and character of social citizenship in modern welfare states. They are familiar ones, our shared heritage in the wake of the
Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario Correspondence: Dr Avram Denburg, Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8. Telephone 416-813-7742 , fax 416-813-5327, e-mail [email protected] Accepted for publication December 19, 2015 242
©2016 Canadian Paediatric Society. All rights reserved
Paediatr Child Health Vol 21 No 5 June/July 2016
Commentary
French revolution: liberty, equality and solidarity (6). Each of these values pulls against and checks the others. Welfare states – in which government is instrumentally involved in the economic and social conditions impacting its citizens – are built on these values: their differences are borne out in their mix, on the relative emphasis placed on one above the others. These foundational values, expressed in political culture and discourse, determine a great degree about the laws and policies that shape society. Societies premised on equality, similar to several of the Scandinavian countries, emphasize universalism as an organizing principle for policy, and conceive of a strong role for the state in stewarding resources to mitigate inequality. Societies premised on liberty, similar to ours, focus on the needs of those at the margin and leave the rest to the whim of the market. Societies premised on solidarity focus on collective goals and obligations, and seek to minimize risks to social stability through policy, often in the form of worker-based insurance. Many focus on traditional models of the family as the locus for, and beneficiary of, social policy, and are often geared toward the maintenance of existing social patterns (Figure 1) (7).
values in the real world: income-splitting
A discussion of values may appear far removed from real-world concerns about child illness and suffering. Nothing could be further from the truth. Recent political debate over tax policy that would have permitted income-splitting by Canadian families is a controversial case in point. As legislated by Stephen Harper’s Conservative government, income-splitting in Canada represented a roughly $2.2 billion annual tax break, one primarily accruing to middle- and upper-income families (8). It offered comparatively little tax relief for low-income families and none to single parents. The Conservative government framed this policy as a measure to enhance the economic freedom of Canadians, by enabling “people to put more money back in their own pockets” (9). Less loudly trumpeted were the likely opportunity costs. The Conservatives advocated this tax reform despite evidence that supports doing just the opposite. Infant mortality rates in high-income countries correlate strongly with generosity in family policies that support dual-earner families – notably universal childcare, early childhood education and enhanced parental leave. Comparative analysis of family policies in Organization for Economic Cooperation and Development countries demonstrates that an increase of one percentage point in dual-earner support lowers infant mortality by 0.04 deaths per 1000 births (10). So what, aside from naked political calculus, could prompt such a policy? Its motivation stemmed from the values that have increasingly grounded Canadian political institutions and discourse in recent decades. Policies such as income splitting reflect a broader approach to the governance of society that is founded on, and privileges, certain values at the expense of others; in this case, the centrality and ascendancy of the market. Income splitting reinforces this liberal cast, emphasizing regressive taxation and the role of the economy in social citizenship, while eschewing equality and universalism as organizing principles for social policy. Interestingly, in its nod to traditional family structures, income-splitting also echoes the ideological commitments of the conservative and Latin regimes of continental Europe. Despite compelling evidence that improved child health outcomes (gauged by something as fundamental as infant mortality) correlate strongly with universal early childhood programs and policies, the pull of basic ideological commitments to market freedom often wins the day. We are increasingly a society that privileges liberty above equality or solidarity. Liberty is an essential building block of a free and Paediatr Child Health Vol 21 No 5 June/July 2016
Figure 1) Typology of welfare state regimes (reproduced with permis-
sion from reference 7) just society; however, liberty unchecked leads to polarization and social dislocation. If we are serious about protecting and promoting child health, we must involve ourselves with social policy. If we are to influence social policy, we must attend to the values that ground our polity. As one of its first moves, the current Liberal government chose to scrap income splitting. This is a salutary example of federal policy: a values-based decision supported by robust evidence. We should hold all levels of government to this basic, but critical, standard for policymaking.
So what?
I am not arguing that we, as child health professionals, should shirk our traditional duties, nor that our primary focus should be anything other than the welfare of the child in front of us. I do contend, however, that unless we think explicitly and deeply about the values we want our social and political institutions to reflect, we will continue to play at the fringes of child health and well-being in Canada. So what can we do? We can inform ourselves about policies that impact children and families, and the political dynamics that underlie them. We can engage our patients in understanding how these policies impact them specifically. We can advocate – for our patients as individuals, and for children collectively – employing our considerable privilege to influence public debate on the issues that matter to Canada’s youth. We can act bravely to support leaders, policies and institutions that promote the values to which we are committed; and to challenge leaders, policies and institutions that compromise those values. Acknowledgements: The author gratefully acknowledges the Canadian Institutes of Health Research, The Pierre Elliott Trudeau Foundation and the Canadian Child Health Clinician Scientist Program for support during the period of this research.
References
1. Campaign 2000. Child poverty, 25 years later: We can fix this. 2014 report card on child and family poverty in Canada. Toronto, November 2014. (Accessed September 15, 2015). 2. McMurtry R, Curling A. The review of the roots of youth violence. Volume 1: Findings, analysis, and conclusions. Toronto: Queen’s Printer for Ontario, 2008. (Accessed September 16, 2015).
243
Commentary 3. Organization for Economic Cooperation and Development. Infant mortality, OECD Health Data (version April 2014). OECD Family Database. Paris, May 2014. (Accessed September 16, 2015). 4. Organization for Economic Cooperation and Development. Doing better for children. Chapter 2: Comparative child well-being across the OECD. Paris, September 2009. (Accessed September 16, 2015). 5. Denburg A, Daneman D. The link between social inequality and child health outcomes. Healthc Quart 2010;14:21-31. 6. Bernard P. Social cohesion: A critique. Canadian Policy Research Networks Discussion Paper No. F/99. Ottawa, December 1999 [cited 2015 Oct 11]. (Accessed September 20, 2015).
244
7. Saint-Arnaud S, Bernard P. Convergence or resilience? A hierarchical cluster analysis of the welfare regimes in advanced countries. Curr Sociol 2003;51:499-527. 8. Geddes J. The surprising spoils of income-splitting. Maclean’s. (Accessed September 20, 2015). 9. Whittington L. Stephen Harper says Canadians want incomesplitting plan. Toronto Star. 2015 Mar 18 [cited 2015 Oct 11]. (Accessed October 11, 2015). 10. Lundberg O, Yngwe MA, Stjarne MA, et al. The role of welfare state principles and generosity in social policy programmes for public health: An international comparative study. Lancet 2008;372:1633-40.
Paediatr Child Health Vol 21 No 5 June/July 2016
