PLANETARY HEALTH WEEKLY

February 16, 2023

In his book, “American Exceptionalism”, Seymour Martin Lipsett wrote that “”it is impossible to understand a country without seeing how it varies from others.  Those who know only one country know no country.”

We ended the last blog pointing out the importance of political choices a society makes that strongly influence its health using as examples U.S. states and whether they have liberal or conservative politics.  What are the outcomes of political choices in Canada? 

We find that incomes in the bottom half of Canadian households are higher than in the U.S.  While richer US households have more income than Canadians, median Canadian income is higher than in the U.S.  Canadians are generally better off than Americans; and as pointed out, healthier.  Canadians have a life expectancy that is 5.5 years greater than the U.S. for 2021.  That is equivalent to eradicating heart disease and cancer as causes of death in the U.S. If that happened they would be about as healthy as Canadians. 

We have stressed the importance of income inequality as a determinant of a population’s health. The relationship is seen among U.S. states.  More unequal states have higher mortality.  If we take a measure of health as age-adjusted mortality rates, and look at the relationship with the proportion of income received by the less well-off 50% of households for U.S. states in 1990, there is a strong relationship that is highly statistically significant.

If we throw the ten Canadian provinces into this graph the relationship looks like this.

Here the circle diameters are proportional to population size.  Notice that the ten Canadian provinces in red cluster at the low mortality, low income inequality spectrum.  The green slope remains very statistically significant for the U.S. states.  With only ten data points, the less steep slope for the Canadian provinces is not statistically significant at the p<0.05 level.  That means there might be a one in 20 chance of this occurring randomly.  There are only four U.S. states that cluster with the ten Canadian provinces. It would appear that the income inequality health relationship is weaker in Canada.  Why might that be? 

The United States functions on the cafeteria plan.  If you want something you have to buy it.  Not much is given to those who aren’t already rich.  The bottom 90% have to struggle to pay for schooling, housing, transportation, healthcare, and much much else.  In Canada schooling is heavily subsidized.  There are few private universities.  Medical care is free at the point of delivery by physicians and in hospitals.  There remains a monthly Canada Child Benefit payment which may be supplemented by provinces.  Thus Canadian income can go for non-essential items such as vacations.  There are statutory vacation laws in Canada while the United States remains a no-vacation nation.  Much more redistribution in the way of social expenditures happens in Canada compared to America.

There is also a strong relationship between income inequality and homicide rates.  Similar to the above demonstration if we look at homicide rates among Canadian provinces and U.S. states we find higher American income inequality resulting in more homicides.  Martin Daly at McMaster University (in Hamilton, Ontario) has done many such studies summarized in his 2016 book “Killing the Competition: Economic Inequality and Homicide”.

Mass shootings are almost a daily occurrence in the United States these days.  Studies show they are more likely to occur in areas with high income inequality and the presence of high incomes.  One mechanism might be the stress from living in such an environment that makes some people take it out on others.  From 1998 to 2019 there were over 800 mass shooting fatalities in the U.S. but less than 15 in Canada.  Violent political rhetoric fans these shootings in the U.S.  Something is seriously wrong there.  Canadian media is not as divisive.  Fox News stopped broadcasting in Canada because of low viewership.

Another way to see this comes from a study showing the income inequality health relationship is robust for American labour market income, but inconsistent for Canadian cities. 

Another study found income inequality associated with higher mortality among native-born Canadians but not immigrants.  The longer immigrants stay in Canada the more they are affected by income inequality.  Canada has many immigrants.  Twenty percent of those living in Canada were born outside of the country.  Tolerance for the foreign-born is quite high in Canada in comparison to the United States.

Happiness and well-being measures are higher in Canada than America despite the U.S. Declaration giving everyone the right to pursue happiness.  Happiness is declining in the U.S. in comparison to Canada.

There is less obesity and less pain in Canada compared to the United States.  Canada scores much better in the UNICEF Innocenti Reports of child welfare in rich nations.   Canada has apologized to the First Nations.  I’m doubtful it will happen in the U.S. 

This is not meant to paint Canada as a utopia.  Health inequities remain.  Poorer people have poorer health.  Mortality outcomes for Nunavut are worse than in any U.S. state.   Much needs to be done in both nations. 

Dr. Stephen Bezruchka