Towards an epidemiological understanding of the effects of long-term institutional changes on population health: A case study of Canada versus the USA

• Published in: Social science & medicine (1982) Vol. 64; no. 3; pp. 589 - 603
• Main Authors: Siddiqi, Arjumand, Hertzman, Clyde
• Format: Journal Article
• Language: English
• Published: Oxford Elsevier Ltd 01.02.2007; Elsevier; Pergamon Press Inc
• Series: Social Science & Medicine
• Subjects: Biological and medical sciences; Canada; Comparative analysis; Comparative studies; Economic Development; Epidemiologic Studies; Epidemiology; Expenditure; Female; General aspects; Health; Health care; Health Care Costs; Health Care Utilization; Health Problems; Health Status; Historical analysis; Historical perspectives; Humans; Income Distribution; Income inequality; Income inequality Canada USA Social epidemiology Historical analysis Structural determinants Institutional determinants; Institutional determinants; Institutions; Life Expectancy; Male; Medical sciences; Miscellaneous; Outcome Assessment (Health Care); Policy; Population; Public Health; Public health. Hygiene; Public health. Hygiene-occupational medicine; Social Class; Social epidemiology; Social structure; Socioeconomic conditions; Socioeconomic factors; Structural determinants; U.S.A; United States; United States of America; USA; Well Being; Canada; United States; North America; America; United States > US; Income inequality; Canada; USA; Historical analysis; Structural determinants; Social epidemiology; Institutional determinants; Human; Income; Change; Institution; Epidemiology; Long term; Health status; Health policy; Population; Social medicine; Economic aspect; Comparative study; Public health; Inequality
• ISSN: 0277-9536; 1873-5347
• DOI: 10.1016/j.socscimed.2006.09.034

This paper uses a comparative case study of Canada and the USA to argue that, in order to fully understand the associations between population health and the socioeconomic environment we must begin to place importance on the dynamic aspect of these factors—examining them as they evolve over time. In particular, for institutional and policy shifts that often unfold over decades, population health must attend to these big, slow moving processes by adopting a historical perspective to the knowledge base. We compare Canada and the USA on basic health outcomes and a range of determinants of health for which routine data have been collected for all or most of the period between 1950 and the present. During the analysis that follows, we are able to establish that, at the level of society (i) greater economic well being and spending on health care does not yield better health outcomes, that (ii) public provision and income redistribution trump economic success where population health is concerned, and (iii) that the gradual development of public provision represents the buildup of social infrastructure that has long-lasting effects on health status. Our case study shows what can be gleaned from a comparative perspective and a long-term view. The long view allows us to detect the gradual divergence in health status between these two societies and to trace potential institutional causes that would otherwise go unnoticed. The perspective introduced here, and in particular the comparison of Canada and the USA, provides strong support for the use of cross-national comparative work, and a historical perspective on the investigation of societies that successfully support population health.