Beyond Empathy to System Change: Four Poems on Health by Bertolt Brecht.

Bertolt Brecht's poem "A Worker's Speech to a Doctor" is frequently cited as a means to raise awareness among health workers of the health effects of living and working conditions. Less cited is his Call to Arms trilogy of poems, which calls for class-based action to transform the capitalist economic system that sickens and kills so many. In this article, we show how "A Worker's Speech to a Doctor," with its plea for empathy for the ill, contrasts with the more activist and often militant tone of the Call to Arms trilogy: "Call to a Sick Communist," "The Sick Communist's Answer to the Comrades," and "Call to the Doctors and Nurses." We also show that, while "A Worker's Speech to a Doctor" has been applied in the training of health workers, its accusatorial tone towards health workers' complicity in the system the poem is critiquing risks alienating such workers. In contrast, the Call to Arms trilogy seeks common ground, inviting these same workers into the broader political and social fight against injustice. While we contend that the description of the sick worker as a "Communist" risks estranging these health workers, our analysis of the Call to Arms poems nevertheless indicates that their use can contribute to moving health workers' educational discourse beyond a laudable but fleeting elicitation of empathy for the ill towards a structural critique and deeper systemic understanding in order to prompt action by health workers to reform or even replace the capitalist economic system that sickens and kills so many.

Defining health through a critical materialist political economy lens.

It has been recognized since antiquity that the organization of society and how it distributes resources are the primary determinants of health. Yet most definitions of health in the academic and practice literatures limit their focus to the individual's experience of health and functional abilities, neglecting the structures and processes of societies in which the individual is embedded. We draw upon developments in the critical health communication and critical materialist political economy of health literatures to provide a definition of health that directs attention to the role that economic and political systems play in either equitably or inequitably distributing the resources necessary for health. Since these distributions interact with the individual's unique biological and psychological dispositions and situations to produce health, it is important to identify their sources and means of making their distributions more equitable. Because it is through communication that humans interpret society, themselves, and others, a concise definition of health that draws attention to these societal features and their roles on a day-to-day basis in promoting or threatening health is essential.

1845 or 2023? Friedrich Engels's insights into the health effects of Victorian-era and contemporary Canadian capitalism.

The Condition of the Working Class in England (hereafter, CWCE) by Friedrich Engels is a masterpiece of urban research not only for its explicit descriptions of the living and working conditions of members of the Victorian-era working class and their effects on health but also its insights into the sources of these conditions through a political economy analysis. For Engels, the capitalist economic system, with the support of the state apparatus, prematurely sickened and killed men, women and children in its unrestrained pursuit of profits. Our reading of CWCE in 2023 concludes that Engels identified virtually every social determinant of health now found in contemporary discourse with his insights into how their quality and distribution shape health clearly relevant to present-day Canada. Revisiting CWCE directs our attention to how the same economic and political forces that sickened and killed members of the English working class in 1845 now do so in present-day Canada. Engels's insights also suggest means of responding to these forces. We place these findings within Derrida's concept of spectre and Rainey and Hanson's concept of trace to show how ideas from the past can inform the present.

Does unionization and working under collective agreements promote health?

Health promoters recognize the social determinants of health (SDOH) shape health outcomes yet generally neglect how unionization and collective agreements (CAs) shape these SDOH. This is surprising since extensive evidence indicates unions and CAs influence wages and benefits, job security, working conditions and income inequality, which go on to affect additional SDOH of food and housing security, child development and social exclusion. We argue unions and CAs should be a health promotion focus by examining how they influence the SDOH and health outcomes in wealthy developed nations in four ways. First, we consider how union density (UD) and CA coverage (CAC) are associated with differences between wealthy western nations in percentage of low-waged workers, extent of income inequality, and low birthweight and infant mortality rates. Second, we bring together literature that shows greater UD and CAC within national sub-jurisdictions are associated over time with more equitable distribution of the SDOH and better health outcomes. Third, we document-also using available literature-how within nations, union membership and working under a CA shape the SDOH one experiences. Fourth, we carry out a Canadian case study-applying a political economy lens-to examine how power relations, working through economic and political systems, determine extent of unionization and CAC and the inclination of health promoters to consider these issues. Implications for health promoters are considered.

Resisting the Effects of Neoliberalism on Public Policy Comment on "Implementing Universal and Targeted Policies for Health Equity: Lessons From Australia".

Fisher and colleagues carefully review the extent to which health equity goals of availability, affordability, and acceptability have been achieved in the areas of national broadband network policy and land-use policy, in addition to the more traditional areas of primary healthcare and Indigenous health in Australia. They consider the effectiveness of policies identified as either universal, proportionate-universal, targeted or residualist in these areas. In this commentary we suggest future areas of inquiry that can help inform the findings of their excellent study. These include the impacts of Australia being a liberal welfare state and how acceptance of neoliberal approaches to governance makes the achieving of health equity in these four policy areas difficult.

Emerging Themes in Social Determinants of Health Theory and Research.

Since 1996, we have been working to have Canadian governmental authorities implement health-promoting public policy that would improve the quality and equitable distribution of the social determinants of health, with rather little to show for our efforts. In this commentary, we identify seven emerging themes that can help explain our failures and point the way forward.

Desperately seeking reductions in health inequalities in Canada: Polemics and anger mobilization as the way forward?

Progress in reducing health inequalities through public policy action is difficult in nations identified as liberal welfare states. In Canada, as elsewhere, researchers and advocates provide governing authorities with empirical findings on the sources of health inequalities and document the lived experiences of those encountering these adverse health outcomes with the hope of provoking public policy action. However, critical analysis of the societal structures and processes that make improving the sources of health inequalities difficult-the quality and distribution of living and working conditions, that is the social determinants of health-identifies limitations in these approaches. Within this latter critical tradition, we consider-using household food insecurity in Canada as an illustration-how polemics and anger mobilization, usually absent in health inequalities research and advocacy-could force Canadian governing authorities to reduce health inequalities through public policy action. We explore the potential of using high valence terms such as structural violence, social death and social murder, which make explicit the adverse outcomes of health-threatening public policy to force government action. We conclude by outlining the potential benefits and threats posed by polemics and anger mobilization as means of promoting health equity.

A bibliometric analysis of Health Promotion International content regarding unions, unionization and collective agreements.

A recent article brought together the health benefits of unionization and working under collective agreements. It was noted how Canadian health promotion texts, reports and statements made no mention of unionization and working under collective agreements as promoting health. This was seen as a significant omission and reasons for this were considered. In this article this analysis is extended to consider how contributors to the flagship health promotion journal Health Promotion International (HPI) conceptualize unions, unionization and working under collective agreements as promoting health. Of 2443 articles published in HPI since its inception, 87 or 3.6% make mention of unions, unionization, collective agreements or collective bargaining, with most saying little about their promoting health. Instead, 20 make cursory references to unions or merely see them as providing support and engagement opportunities for individuals. Forty-five depict unions or union members as involved in a health promotion programme or activity carried out by the authors or by government agencies. Only 33 articles explicitly mention unions, unionization or collective agreements as potentially health promoting, representing 1.3% of total HPI content since 1986. We conclude that the health promoting possibilities of unionization and working under collective agreements is a neglected area amongst HPI contributors. Reasons for this are explored and an Organisation for Economic Cooperation and Development report on the importance of collective bargaining is drawn upon to identify areas for health promotion research and action.

The reemergence of Engels' concept of social murder in response to growing social and health inequalities.

In 1845, Friedrich Engels identified how the living and working conditions experienced by English workers sent them prematurely to the grave, arguing that those responsible for these conditions -- ruling authorities and the bourgeoisie -- were committing social murder. The concept remained, for the most part, dormant in academic journals through the 1900s. Since 2000, there has been a revival of the social murder concept with its growth especially evident in the UK over the last decade as a result of the Grenfell Tower Fire and the effects of austerity imposed by successive Conservative governments. The purpose of this paper is to document the reemergence of the concept of social murder in academic journal articles. To do so we conducted a scoping review of content applying the social murder concept since 1900 in relation to health and well-being. We identified two primary concepts of social murder: social murder as resulting from capitalist exploitation and social murder as resulting from bad public policy across the domains of working conditions, living conditions, poverty, housing, race, health inequalities, crime and violence, neoliberalism, gender, food, social assistance, deregulation and austerity. We consider reasons for the reemergence of Engels' social murder concept and the role it can play in resisting the forces responsible for the living and working conditions that kill.

Assuming policy responsibility for health equity: local public health action in Ontario, Canada.

In Canada's liberal welfare state the public is given little exposure by governmental authorities to the importance of promoting health equity through public policy action on the social determinants of health (SDoH). Not surprisingly, Canada lags in implementing health equity-enhancing public policy. In Ontario, Canada's most populous province, a local public health unit (PHU) took on the task of promoting health equity by developing the video animation Let's Start a Conversation about Health and Not Talk about Health Care at All. In the wake of this work, an additional 17 local PHUs (of 36) adapted it for local use. By placing these activities within Nutbeam's and de Leeuw's concepts of critical health literacy as an essential component of health promotion, we examine how these PHUs came to adopt the video, their intended uses, and supports and barriers encountered. These efforts by local PHUs to promote health equity through action on the SDoH have implications for those in jurisdictions where State attention to these issues is lacking.

Canada considers a basic income guarantee: can it achieve health for all?

There is little doubt that the implementation of a Basic Income Guarantee (BIG) in Canada and other liberal welfare states would alleviate some of the most egregious examples of absolute poverty that contribute to poor health such as lack of adequate food and shelter and inability to meet basic household and personal needs. BIG would likely improve the health of the most disadvantaged by moving them closer to the relative poverty line. Yet, advocacy for and implementation of BIG carries potential dangers. Since health improves with every step up the income ladder, simply moving people closer to the relative poverty line without providing additional universal benefits and supports common to most other developed nations would limit its health promotion potential. In addition, governing authorities in liberal political economies can use BIG to justify continuing imbalances in economic and political power that skews the distribution of the social determinants of health. In addition, implementation of BIG -- despite its more progressive advocates calls for maintaining or enhancing of existing social programs - can serve as justification for reducing or removing these programs, thereby threatening health.

Narrative review of affinities and differences between the social determinants of oral and general health in Canada: establishing a common agenda.

BACKGROUND: This article overviews Canadian work on the social determinants of oral and general health noting their affinities and differences. METHODS: A literature search identified Canadian journal articles addressing the social determinants of oral health and/or oral health inequalities. Analysis identified affinities and differences with six themes in the general social determinants of health literature. RESULTS: While most Canadian social determinants activity focuses on physical and mental health there is a growing literature on oral health-literature reviews, empirical studies and policy analyses-with many affinities to the broader literature. In addition, since Canada provides physical and mental health services on a universal basis, but does not do so for dental care, there is a special concern with the reasons behind, and the health effects-oral, physical and mental-of the absence of publicly financed dental care. CONCLUSIONS: The affinities between the social determinants of oral health and the broader social determinants of health literature suggests the value of establishing a common research and action agenda. This would involve collaborative research into common social determinants of oral and general health and combined policy advocacy efforts to improve Canadians' living and working conditions as means of achieving health for all.

Governmental Illegitimacy and Incompetency in Canada and Other Liberal Nations: Implications for Health.

The welfare state literature on developing nations is concerned with how governmental illegitimacy and incompetency are the sources of inequality, exploitation, exclusion, and domination of significant proportions of their citizenry. These dimensions clearly contribute to the problematic health outcomes in these nations. In contrast, developed nations are assumed to grapple with less contentious issues of stratification, decommodification, and the relative role of the state, market, and family in providing economic and social security, also important pathways to health. There is an explicit assumption that governing authorities in developed nations are legitimate and competent such that their citizens are not systematically subjected to inequality, exploitation, exclusion, and domination by elites. In this article, we argue that these concepts should also be the focus of welfare state analysis in developed liberal welfare states such as Canada. Such an analysis would expose how public policy is increasingly being made in the service of powerful economic elites rather than the majority, thereby threatening health. It would also serve to identify means of responding to these developments.

Understanding the Promotion of Health Equity at the Local Level Requires Far More than Quantitative Analyses of Yes-No Survey Data Comment on "Health Promotion at Local Level in Norway: The Use of Public Health Coordinators and Health Overviews to Promote Fair Distribution Among Social Groups".

Health promotion is a complex activity that requires analytic methods that recognize the contested nature of it definition, the barriers and supports for such activities, and its embeddedness within the politics of distribution. In this commentary I critique a recent study of municipalities' implementation of the Norwegian Public Health Act that employed analysis of "yes" or "no" responses from a large survey. I suggest the complexity of health promotion activities can be best captured through qualitative methods employing open-ended questions and thematic analysis of responses. To illustrate the limitations of the study, I provide details of how these methods were employed to study local public health unit (PHU) activity promoting health equity in Ontario, Canada.

Labonté Identifies Key Issues for Health Promoters in the New World Order Comment on "Health Promotion in an Age of Normative Equity and Rampant Inequality".

For over 35 years Ronald Labonté has been critically analyzing the state of health promotion in Canada and the world. In 1981, he identified the shortcomings of the groundbreaking Lalonde Report by warning of the seductive appeal of so-called lifestyle approaches to health. Since then, he has left a trail of critical work identifying the barriers to - and opportunities for -health promotion work. More recently, he has shown how the rise of economic globalization and acceptance of neo-liberal ideology has come to threaten the health of those in both developed and developing nations. In his recent commentary, Labonté shows how the United Nations' 2015 Sustainable Development Goals (SDGs) can offer a new direction for health promoters in these difficult times.

New hypotheses regarding the Danish health puzzle.

AIMS: Nordic welfare states have achieved admirable population health profiles as a result of public policies that provide economic and social security across the life course. Denmark has been an exception to this rule, as its life expectancies and infant mortality rates since the mid-1970s have lagged behind the other Nordic nations and, in the case of life expectancy, behind most Organisation for Economic Co-operation and Development nations. METHODS: In this review paper, we identify a number of new hypotheses for why this may be the case. RESULTS: These hypotheses concern the health effects of neo-liberal restructuring of the economy and its institutions, the institution of flexi-security in Denmark's labour market and the influence of Denmark's tobacco and alcohol industries. Also of note is that Denmark experienced higher unemployment rates during its initial period of health stagnation, as well as its treatment of non-Western immigrants and high wealth inequality and, until recently, the fact that Denmark did not systematically address the issue of health inequalities. CONCLUSIONS: These hypotheses may serve as covering explanations for the usually provided accounts of elevated behavioural risks and psychosocial stress as being responsible for Denmark's health profile.

Understanding action on the social determinants of health: a critical realist analysis of in-depth interviews with staff of nine Ontario public health units.

BACKGROUND: Addressing the social determinants of health (SDH) is identified as a role for local public health units (PHUs) in the province of Ontario. Despite this authorization to do so there is wide variation in PHU practice. In this article we consider the factors that shape local PHU action on the SDH through a critical realist analysis. METHODS: Interviews with Medical Officers of Health (MOHs) and lead staff from nine PHUs in Ontario identify the structures and powers that allow PHUs to address the SDH as well as the many factors that either activate or inhibit these structures and powers. RESULTS: We found that personal backgrounds and attitudes of MOHs and leading staff people as well as local jurisdictional characteristics shape whether and how PHUs carry out SDH-related activities. CONCLUSIONS: Action on the SDH is a result of a complex interplay of micro-, meso- and macro-level factors that requires recognition of the contested nature of public health, presence of Ministry of Health mandates, local jurisdictional characteristics, and politics. The most effective way to assure PHU action on the SDH is for the Ministry of Health and Long-Term Care to mandate such activities and develop accountability mechanisms that assure implementation.

Beyond policy analysis: the raw politics behind opposition to healthy public policy.

Despite evidence that public policy that equitably distributes the prerequisites/social determinants of health (PrH/SDH) is a worthy goal, progress in achieving such healthy public policy (HPP) has been uneven. This has especially been the case in nations where the business sector dominates the making of public policy. In response, various models of the policy process have been developed to create what Kickbusch calls a health political science to correct this situation. In this article I examine an aspect of health political science that is frequently neglected: the raw politics of power and influence. Using Canada as an example, I argue that aspects of HPP related to the distribution of key PrH/SDH are embedded within issues of power, influence, and competing interests such that key sectors of society oppose and are successful in blocking such HPP. By identifying these opponents and understanding why and how they block HPP, these barriers can be surmounted. These efforts to identify opponents of HPP that provide an equitable distribution of the PrH/SDH will be especially necessary where a nation's political economy is dominated by the business and corporate sector.

Ideological and organizational components of differing public health strategies for addressing the social determinants of health.

Despite a history of conceptual contributions to reducing health inequalities by addressing the social determinants of health (SDH), Canadian governmental authorities have struggled to put these concepts into action. Ontario's-Canada's most populous province-public health scene shows a similar pattern. In statements and reports, governmental ministries, professional associations and local public health units (PHUs) recognize the importance of these issues, yet there has been varying implementation of these concepts into public health activity. The purpose of this study was to gain insight into the key features responsible for differences in SDH-related activities among local PHUs. We interviewed Medical Officers of Health (MOH) and key staff members from nine local PHUs in Ontario varying in SDH activity as to their understandings of the SDH, public health's role in addressing the SDH, and their units' SDH-related activities. We also reviewed their unit's documents and their organizational structures in relation to acting on the SDH. Three clusters of PHUs are identified based on their SDH-related activities: service-delivery-oriented; intersectoral and community-based; and public policy/public education-focused. The two key factors that differentiate PHUs are specific ideological commitments held by MOHs and staff and the organizational structures established to carry out SDH-related activities. The ideological commitments and the organizational structures of the most active PHUs showed congruence with frameworks adopted by national jurisdictions known for addressing health inequalities. These include a structural analysis of the SDH and a centralized organizational structure that coordinates SDH-related activities.

Challenges to promoting health in the modern welfare state: the case of the Nordic nations.

AIMS: Finland, Norway, and Sweden are leaders in promoting health through public policy action. Much of this has to do with the close correspondence between key health promotion concepts and elements of the Nordic welfare state that promote equity through universalist strategies and programs that provide citizens with economic and social security. The purpose of this article is to identify the threats to the Nordic welfare states related to immigration, economic globalization, and welfare state fatigue. METHODS: Through a critical analysis of relevant literature and data this article provides evidence of the state of the Nordic welfare state and some of these challenges to the Nordic welfare state and its health promotion efforts. RESULTS: There is evidence of declining support for the unconditional Nordic welfare state, increases in income inequality and poverty, and a weakening of the programs and supports that have associated with the excellent health profile of the Nordic nations. This is especially the case for Sweden. CONCLUSIONS: It is argued that the Nordic welfare states' accomplishments must be celebrated and used as a basis for maintaining the public policies shown to be successful in promoting the health of its citizens.