HIV/ AIDS and Health Determinants: Lessons for Coordinating Policy and Action

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A Discussion Paper for the Ministerial Council on HIV/ AIDS

Please note that the views presented in this document do not necessarily represent the views of Health Canada, the Federal/ Provincial/ Territorial Advisory Committee on AIDS or of any government represented in those groups.

Ce document est aussi disponible en français sous le titre :
Le VIH/ sida et la santé de la population : Leçons pour la coordination de l'action et des politiques

Catalogue No. H39-632/ 2002E
ISBN 0-662-32560-52

Prepared by
Martin Spigelman Research Associates
mspigelman@telus.net

January 2002
The contribution of the Federal/ Provincial/ Territorial Advisory Committee on AIDS to this document is gratefully acknowledged.

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T able of Contents

1. Introduction
   1.1 Purpose and Objectives
   1.2 Methodology
   1.3 Report Organization
2. From Medical Care to Social Care
   2.1 Health Promotion
   2.2 Population Health
   2.3 The Social Determinants
3. The Social Determinants and HIV/ AIDS
   3.1 Reflections on the Literature
   3.2 Wealth and Health
   3.3 Early Childhood Experience
   3.4 Social Support, Social Cohesion and Discrimination
   3. 5 RaceandGender
   3.6 Housing and Homelessness
   3.7 Health Services
4. Conclusions: Making Sense and Making Progress
   4.1 Making Sense
   4.2 Making Progress on Population Health

References
Appendix - Information Sources

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Executive Summary

Today in Canada, the HIV/ AIDS epidemic is settling ever more resolutely in the most vulnerable of communities. The inability to control its spread has made clear how illusory is the belief once confidently held that advanced industrial societies are somehow immune to infectious disease and that medical science and medical care can address every biological threat and health condition.

Canada, therefore, needs to pursue other approaches if it is to prevent HIV/ AIDS and manage the HIV/ AIDS epidemic. The population health model offers one such strategy. It builds on a holistic view of health that recognizes the many factors that influence population health and well being. These social determinants include, for example, poverty, income inequality, racism and discrimination, and early childhood experiences.

Health Canada initiated this literature review in order to consider HIV/ AIDS in a population health context, to identify those social determinants most closely associated with HIV/ AIDS, and to consider policy directions that will strengthen the Canadian response to the epidemic.

Reflections on the Literature

There is a strong body of literature that considers the population health concept. There is very little literature, however, that places HIV/ AIDS in this broad context. This may be due to researchers being more interested in encouraging behavioural change in the short term than in societal shifts that require a longer period of time and sustained effort across sectors.

It may be due also to the researchers having to confront a number of very fundamental methodological challenges. These include, for example, the epidemic s diversity, the need to construct appropriate control or comparison groups, and the need for longitudinal studies that require more patience than the epidemic allows and more resources than are usually available. Analysts invariably have to struggle with the need not to equate the absence of evidence with evidence of absence.

Findings

The literature presents compelling evidence of the relationship between the social determinants of health and HIV/ AIDS. The different social determinants influence a person s vulnerability to HIV infection, the speed with which HIV infection will progress to AIDS and a person s ability to manage and live with HIV/ AIDS.

The most important of these determinants include emotional, physical and sexual abuse during childhood as well as inequities based on income, race and gender. Importantly, racism and discrimination not race, culture or gender themselves leave groups of people particularly vulnerable to HIV infection by excluding them from the social and economic mainstream and by denying them the social supports needed to enhance and preserve life.

These health determinants act at the level of the individual, for example when child abuse and adult homelessness increase the likelihood of a person engaging in high-risk behaviours. They act also at the societal level, for example when economic inequities create short-term needs the need for food and shelter, and even the need for drugs that make long-term health prospects an academic concern.

Making Progress on Population Health

The literature frequently offers recommendations for influencing individual and community behaviour. Distributing condoms and clean needles figures prominently as do special efforts targeted to specific at-risk groups. These are vitally important for managing the epidemic.

However, leaving prevention to behavioural change to condoms reinforces the notion that HIV transmission is narrowly the result of personal shortcomings and group dynamics. Such efforts, while essential in the short term, are not the answer for the long term. Building a population health framework for HIV/ AIDS requires strong, committed, non-partisan leadership at the highest levels in the community and in governments across the country. This leadership must embed the population health concept within a social justice agenda encompassing efforts:

• to reduce the income and other inequities in Canada;
• to invest in the country s children and youth; and
• to ensure that people are not relegated to the margins of society because of mental or other illnesses, disability, sexual orientation, race, culture or gender.

Progress on this social justice agenda will require research and education, cooperation and coordination across agencies and jurisdictions, and efforts to apply the lessons of population health to current strategies for managing the HIV/ AIDS epidemic.

The Canadian Strategy on HIV/ AIDS and the various Ministerial Councils and federal/ provincial/ territorial committees constitute a strong foundation for building a social justice agenda for Canada. What is needed are efforts to build partnerships with those departments that already understand population health, and efforts to reach out to those other government and community agencies that do not. Given the importance of leadership, these efforts should be directed initially at Ministers, Deputy Ministers and senior staff in the hope that their commitment will then permeate their respective organizations.

Building leadership, commitment and a public consensus will require efforts to place epidemiology more clearly into a social justice context. Research is needed to associate the social determinants with longer-term health outcomes and to articulate the potential cost savings and public health benefits that will flow from this approach. There would be value also in reaching out to those governments and commissions currently endeavouring to analyze and reform their health care systems.

Furthermore Health Canada and the Canadian Strategy on HIV/ AIDS could endeavour to enhance the ability of health sector researchers to share their knowledge with a broader and more general audience. These researchers need to communicate their findings and knowledge in ways that are compelling and effective, and through vehicles other than technical journals.

The effort to manage the HIV/ AIDS epidemic cannot stand still while pursuing the social justice agenda. It is important, therefore, to move certain HIV/ AIDS-related activities in directions that reflect the current understanding of population health. This could include, for example, efforts:

• to engage leaders from other policy sectors in the HIV/ AIDS-related committees;
• to address the underlying factors that place people at risk of HIV infection when testing for HIV or when providing support in health clinics and homeless shelters;
• to integrate sexual abuse counselling with HIV prevention efforts and to link the Canadian Strategy on HIV/ AIDS with the National Children s Strategy, the Social Union and other early childhood development efforts;
• to expand harm minimization programs and place addictions in a social and health context rather than in the criminal justice system;
• to provide supports to the children of parents living with HIV/ AIDS so as to ensure that their life chances are not compromised;
• to develop protocols to assist hospitals and health professionals meet the particular needs of marginalized groups; and
• to re-orient thinking and reporting so as to focus on racism and discrimination rather than on race and on those groups who are particularly vulnerable to HIV infection.

Given the nature, threat and potential impact of HIV/ AIDS, there are no practical alternatives to the population health model and a social justice agenda. Governments and society need to regard the HIV/ AIDS epidemic not as a health issue alone and certainly not as a moral issue but as a legal issue, a human rights issue and an equity issue. A nation s health must be treated as a barometer of its commitment to social justice and human rights. Common sense, practical experience and a wealth of research from around the world suggest that societies are investing wisely when they broaden their vision to include a population health and social justice framework.

 

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