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Abstract

Background

Despite a robust research literature on the importance of promoting health equity and stated commitments by public health authorities to this goal, progress in doing so has been disappointing in Canada. One reason is the failure to mobilize the public in support of this goal. Almost a decade ago, Sir Michael Marmot called for a “social movement” to promote health equity but there are reasons for why such a movement has not taken hold in Canada.

Purpose

We carry out a critical narrative review and case study of Canadian health equity activities that examines the intersection of these activities with definitions of what constitutes a social movement.

Analysis

Employing Harvey’s concept of critical social research as not taking for granted apparent social structure and processes, we look beneath the surface of appearances to ask why health equity activities have generally failed in Canada such that a social movement – as defined in the social movements literature – is required to move forward.

Findings

Social movements engage the public to resist problematic social conditions outside of established governance structures and processes yet for the most part, health equity advocacy in Canada has been limited to those who do so as part of their paid employment or research funding by Canadian governing authorities whose policies create these conditions. As a result of these arrangements, health equity advocacy cannot readily meet the conditions necessary for a social movement: communicating the need for such a movement; identifying those responsible for health inequities; establishing networks supporting such a goal; and cultivating a distinct health equity identity.

Conclusion

We suggest reviewing the structures, processes, and successes and failures of a variety of social movements, e.g., Social Medicine, Environmental, Labour, and Anti-Globalization, among others, to identify lessons and insights that may assist in the development of a health equity social movement in Canada.

Keywords

health equity social movements public health health promotion

All those who have thought about the bad state of things refuse to appeal to the compassion of one group of people for another. But the compassion of the oppressed for the oppressed is indispensable. It is the world’s one hope.

– Bertolt Brecht, 1938/1979¹

Introduction

Health equity is about everyone attaining their best possible health. Whitehead’s work on health equity of 35 years ago still best defines the concept of health equity: “Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided.^{2(p. 67)} For Whitehead there are two key components of health equity: access to the living and working conditions necessary for health and access to required health care. Health equity is a defining theme in contemporary public health literature and the topic of a multitude of research.³ Despite these activities, actual practice in promoting health equity has been a profound failure in Canada.⁴

In this article we argue these failures make necessary a health equity-focused social movement in Canada with a social movement defined as “informal networks, based on shared beliefs and solidarity, which mobilize about conflictual issues, through the frequent use of various forms of protest.”^{5(p. 20)} Social movements arise because the established state of affairs is unsatisfactory and governing authorities are unwilling to address these problems.⁶ There is now a well-established literature on social movements that, for the most part, has not been part of the health equity literature.^7–11 We carry out a critical narrative review and case study of Canadian health equity activities that examines the intersection of these activities with definitions of what constitutes a social movement. We conclude that health equity activities in Canada do not meet the criteria of being a social movement. An inquiry into social movements and their potential for promoting health equity is now required as the health equity scene in Canada is not improving and may be worsening.

We identify how a social movement concerned with health equity in Canada could respond to these deteriorating conditions and the components that would be part of such a social movement. Our analysis contrasts these requirements with the actual landscape of health equity activity. Reasons for their absence are detailed as are means by which these barriers to developing such a social movement could be overcome.

Background

We consider the importance of promoting health equity and how the apparent failure to do so in Canada requires the building of a social movement.

Promoting Health Equity

Whitehead’s definition of health equity provided earlier still best defines the concept of health equity.² Achieving health equity requires providing the conditions necessary for health and access to required health care. Barriers to health equity are a result of systemic societal structures and processes that inequitably distribute economic and social resources and block access to health care. Regarding access to the conditions necessary for health, the absence of health equity is the presence of health inequalities, which being avoidable and unfair, are health inequities.

Whitehead outlines four processes creating these inequities: (1) health-damaging behaviour where the degree of choice of lifestyles is severely restricted; (2) exposure to unhealthy, stressful living and working conditions; (3) inadequate access to essential health and other public services and (4) health-related social mobility whereby sick people move down the social scale.

Whitehead identifies seven means of promoting health equity which clearly involve the making and implementation of public policy: (1) improving living and working conditions; (2) enabling people to adopt healthier lifestyles; (3) committing to decentralizing power and decision making, thereby encouraging people to participate in every stage of the policy-making process; (4) assessing the health impacts of policies and implementing health-equity supportive ones through intersectoral action; (5) concern and control at the international level; (6) making high quality health care accessible to all; and (7) assuring equity policies based on appropriate research, monitoring and evaluation.

The Failure to Promote Health Equity in Canada

There is little doubt that public policies in Canada fail to provide the conditions necessary for achieving health equity. The contrast between these nations and Nordic and Continental nations is documented in Bryant’s Handbook of the Social Determinants of Health,¹² Bryant and Raphael’s The Politics of Health in the Canadian Welfare State,¹³ and Raphael’s Social Determinants of Health: Canadian Perspectives.¹⁴

The health equity picture for Canada is bleak. Increases in income and wealth inequality, employment insecurity and precarity, and housing and food insecurity have created a polycrisis of living and working conditions in Canada such that the ongoing functioning of society – sometimes termed social reproduction, that is, sustaining everyday life, care, and the preservation of health – is uncertain.³ The concept of polycrisis characterizes an array of linked crises that are not simply contemporaneous but also interconnected. These barriers to equity are a result of systemic societal structures and processes that result in public policy that creates health inequalities and lack of access to health care, which being avoidable and unfair, are health inequities. A short list of such public policies would include legislation providing very low employment security, low minimum wages, difficulty unionizing, and low social spending across a wide range of areas such as social assistance, disability, employment insurance, support to families, and public pensions.⁴

As examples of their effects upon health, infant mortality rates in Canada are well above those in other wealthy nations.¹⁵ Life expectancy in Canada has not only fallen in rank as compared to many other nations but has also shown absolute declines in life expectancy for three of the past 4 years.^16,17 The quality and equitable distribution of several social determinants of health such as income, employment security, and housing and food security also compare poorly in comparison to these other nations.¹³ On three important aspects of public policy that promote health, redistribution, social spending, and managing the market economy, Canada’s profile falls well behind many other wealthy nations.⁴

Forces Responsible for This Failure

The reasons for the failures to implement health equity in Canada are well documented. Primary among these are the features of what Esping-Andersen identified as the liberal welfare state, a category to which Canada belongs.^18,19 The liberal welfare state provides modest benefits such that the State usually provides assistance only when the market fails to meet citizens’ most basic needs. Their political and social history is one of dominance by business interests resulting in the population relying on the employment marketplace rather than the State as the source of economic and social security.

As a result, liberal welfare states are the least developed in terms of provision of citizen economic and social security.¹³ A key feature is their use of means-tested benefits targeted only to the least well-off. They have historically been distinguished by lower levels of redistribution and social expenditures, and unwillingness to manage the market economy, all contributors to health inequities. These nations have been especially susceptible to the effects of neoliberal restructuring – that is, the retrenchment of the welfare state, deregulation of business practices, and privatization of previously public services – which have only reinforced these tendencies.

Suthakaran and Raphael provide a recent validation of these characteristics with Canada – and other liberal welfare states – comparing poorly with Nordic social democratic and Continental conservative welfare states on indicators of redistribution (as measured by income inequality and poverty rates), social spending (in areas of overall social spending, spending on families, disability, and public pensions) and managing of the workplace (union density, collective agreement coverage, and employment protection).⁴

Indeed, the liberal welfare state’s aversion to these three means of managing health inequities – redistribution, social spending, and managing the market economy – is so strong as to have been labelled as taboos by political scientist Julia Lynch.²⁰ In Canada, these taboos are cemented by the increasing adoption of neoliberal approaches to governance that include privatization, imposition of austerity, and regulatory rollback, lack of media coverage of health equity issues, the strong influence of the corporate and business sectors in public policymaking, and the frequent conflation by the media, public, and health care communities of health with health care.¹³

Not surprisingly, promoting health equity is virtually invisible among Canadian governing agendas at the federal and provincial levels. The later omission – the provincial level – is especially important as health care services and labour, social assistance, and housing policy are the responsibility of provincial authorities. The effects of these processes have become so problematic that they are eliciting increasing use in the academic and popular literature of the term “social murder” to describe the health effects of the Canadian public policy environment.^21,22 Clearly, it is necessary to consider ways of mobilizing the public to demand governing authorities address these issues. Historically, social movements have been identified as one such means of forcing governmental action.^9,10 These are necessary as most contemporary models of public policy fail to recognize many of the barriers to progressive public policy change.

Public Policy Models

Most public policy models portray the public policy process as rational. At the centre of this portrayal is a benevolent government that provides opportunities for civil society input. It weighs the evidence of each potential policy option present and decides on one it deems best for all interests. There is little room for conflict, contention, or politics. The focus tends to be on the activities of cabinet ministers, policy experts, and political elites rather than civil society.^23–25 Social movements challenge these dominant interests and their narratives on issues by presenting alternative policy options.

In contrast to rational public policy models, critical social science models provide analytic tools to examine the role and contributions of social movements in political processes.^24,26 Social movements can partner with opposition political parties to achieve their public policy aims as exemplified by the women’s and environmental movements during the 1970s and 1980s. These are precedents to which a social movement committed to achieving health equity can aspire.

The Promise of Social Movements

An extensive and distinct literature documents a wide range of social movements and evidence of their ability to effect change that builds upon the concepts initially provided by Diani.^6,10,11For Moody-Adams and UNICEF, respectively:

The social movements that have successfully deepened our understanding of justice and compassion and enlarged our sense of the possibilities of human solidarity, have been driven by agents who were hopeful about the possibility of producing moral change, confident in the worth of acting on their moral convictions, and willing to take risks and endure sacrifice in the process. In other words, morally progressive social movements rely on the efforts of agents who possess hope, faith, and courage.^{27 (p.155)}

Social movements are the core of social change. Famous historical efforts include the US civil rights movement, the women’s suffrage movement, the anti-apartheid movement, gay rights and broader LGBTQ movements, decolonization movements, the Arab Spring, Black Lives Matter, Global Citizen, and the MeToo movements. And beyond these global and national processes, subnational and local movements form and evolve constantly.²⁸

Social movements are different from traditional party politics and public policy advocacy, development and implementation in that they develop in opposition to these processes. Box 1 provides key components as provided by Diani²⁹ which are similar to those provided by Tilly, Castaneda, and Wood¹⁰ and Tarrow.⁹

Box 1. Key Components of a Social Movement

1. A social movement is a network of informal interactions between a plurality of individuals, groups and/or organizations.

2. The boundaries of a social movement network are defined by the specific collective identity shared by the actors involved in the interaction.

3. Social movement actors are engaged in political and/or cultural conflicts, meant to promote or oppose social change either at the systemic or non-systemic level.

Source: Diani²⁹

Examples of social movements – which appear consistent with the components provided in Box 1 – are provided in Box 2. In our analysis we consider the intersection of health equity work in Canada to date – its characteristics and effects – with components of these and other social movements.

Box 2. Examples of Social Movements

1. Feminist Movement

2. Civil Rights Movement

3. Black Lives Matter Movement

4. LGBTQ + Movements

5. Labour Movement

6. Environmental Movement

7. Peace Movement

8. Anti-Globalization Movement

9. Idle No More Movement

10. Disability Rights Movement

Source: Yadav³⁰

Components of Social Movements

While there are differing emphases in the varied accounts of what constitutes a social movement, clear similarities between these are apparent. As noted in Box 1, Diani emphasized a network of informal interactions between individuals, groups and/or organisations; a collective identity shared by the actors; and engagement in political and/or cultural conflicts meant to promote or oppose social change.²⁹ For della Porta and Diani, the essential elements are similar in that social movements are characterized by actors being engaged in collective action in conflict with clearly identified opponents through dense, informal networks with which they share a distinct collective identity.⁶ Tilly, Castaneda, and Wood¹¹ identify a social movement as having these components:

1. Social movement campaign: a sustained, organized public effort making collective claims on specific authorities, e.g. national governments;

2. Social movement repertoire: combinations of culturally recognizable forms of popular protests, e.g. marches, rallies, demonstrations; and

3. WUNC displays: the coordinated public performance of Worthiness, Unity, Numbers, and Commitment by members and supporters of the movement.

They describe the WUNC concept as follows:

The term “WUNC” sounds odd, but it represents something quite familiar. WUNC displays can take the form of statements, slogans, or labels that imply worthiness, unity, numbers and commitment: Citizens United for Justice, Mothers for Peace, the 99%, and so on. Collective self-representations often act them out in idioms that local audiences will recognize, for example:

• worthiness: sober demeanor; neat clothing; presence of clergy, dignitaries, and mothers with children.

• unity: matching badges, headbands, banners, or costumes; marching in ranks; singing and chanting.

• numbers: headcounts, signatures on petitions, messages from constituents, filling streets, retweets, repostings, and numbers of likes.

• commitment: braving bad weather; visible participation by the old and disabled; resistance to repression; ostentatious sacrifice, subscription, and/or benefaction.¹¹

Tarrow locates social movements within the concept of contentious politics.¹⁰ While noting that ordinary people do not normally try to exert power through contentious means, he defines contentious politics as follows: “Contentious politics occurs when ordinary people – often in alliance with more influential citizens and with change in public mood – join forces in confrontation with elites, authorities and opponents.”^(p.10) He sees social movements as having four basic properties: (1) collective challenges; (2) common purposes; (3) social solidarity; and (4) sustaining contention. These social movements have four means of mobilization:

• Resources mobilization: the organization of collective action and the creation of organizations and coalitions to sustain it.

• Framing demands around widely held symbols and linguistic devices with the capacity to rally supporters and attract third parties.

• Accessing and creating opportunities, a process that varies in different types or regimes.

• Diffusing collective action to new sites and different actors after a protest has been mounted, including the transnational diffusion of movements.^(p.19)

Tarrow also identifies mechanisms of demobilization which likely have relevance for understanding the failure to have the promotion of health equity becoming a social movement:¹⁰

• Repression, or, more generally, controlling contention, but also, its opposite.

• Facilitation, which satisfies at least some of the claims of contenders, who may also retreat from the struggle.

• Exhaustion, the simple weariness of being in the streets, or, more subtly, irritation with the strains of collective life in a movement.

• Radicalization, the shift of social movement organizations or parts of them, towards increased assertiveness; and

• Institutionalization, the incorporation of some other organizations or parts of them into the routines of organized politics.^(p.30)

In our analysis we consider how these processes have likely played a role in the failure to achieve a health equity social movement in Canada.

Methods

We carry out a critical narrative review and case study of Canadian health equity activities that examines the intersection of these activities with definitions of what constitutes a social movement.^26,31 Employing Harvey’s concept of critical social research as not taking for granted apparent social structure and processes, we look beneath the surface of appearances to ask why health equity activities have generally failed in Canada such that a social movement – as defined in the social movements literature – is required to move forward.²⁶ Interestingly, despite each of ours 25+ years of experience of researching health equity issues in Canada, we were not familiar with the social movements literature as we had not seen its application in the Canadian literature on health equity. We did find a short, curated list on social movements by the National Collaborating Centre for the Determinants of Health.³² However, this document had never been cited in the academic literature according to Google Scholar.^TM

We first read three highly referenced volumes on social movements to identify the components of a social movement: della Porta and Diani’s Social Movements: An Introduction,⁶ Tarrow’s Power in Movement¹⁰ and Tilly, Castaneda, and Wood’s Social Movements, 1768–2018.¹¹ We then reviewed Canadian developments in promoting health equity since the 1974 Lalonde Report³³ through the search terms of “health equity” and “Canada” using Google Scholar.¹ Just about all of the returns of this search were familiar to us as each of us had been working in this area for over two decades.

We anticipated that much of the health equity work in Canada would proclaim commitment to addressing the broader social determinants of health but in practice would show healthy doses of lifestyle drift and failure to influence the broader societal structures that perpetuate health inequities in Canadian society.³⁴ To help guide our inquiry we identified three sensitizing concepts that provided a focus for our efforts.³⁵ In essence, sensitizing concepts serve as an antennae tuned to certain concepts which in the present case were (1) Canada’s success in achieving health equity; (2) the promise and components of social movements; and (3) barriers to both health equity and a social movement to achieve health equity, but we remained open to identifying other emerging themes.³⁵

After reading the volumes on social movements and reviewing health equity developments in Canada, we asked four questions: (1) What are the components of a social movement?; (2) What constitutes health equity activities in Canada?; (3) To what extent do these activities meet the definition of a social movement?; and (4) If they do not, what needs to be done?

Findings

As detailed earlier, a social movement arises as a result of perceived unacceptable circumstances. It is outside traditional approaches to advocacy, policy development and implementation and usually identifies a perceived adversary. It involves the public through a network of informal interactions between a plurality of individuals, groups and/or organizations. Those within a social movement share a collective identity. Finally, social movement actors engage in political and/or cultural conflicts in order to promote or oppose social change either at the systemic or non-systemic level.

We first detail health equity activities in Canada and why their lack of success requires the formation of a health equity social movement. We then detail the components of such a social movement and why Canadian health equity activities do not meet the criteria of such a movement. We conclude with what would need to be done to form a health equity social movement.

Health Equity Activities in Canada

Canada has a perceived reputation as being a health equity leader. Its production of the 1974 Lalonde Report³³ and the 1986 Epp Report³⁶ and federal provision of health equity research and pilot activity funding since then is consistent with such a view.³⁷ The federal government website contains details of its perceived commitment to promoting health equity that includes funding for a number of National Collaborating Centres for Public Health.³⁸ The Academic Leads/Scientific Directors and a sample of Advisory Committee Members of these Centres are presented as an Appendix. These individuals are certainly well qualified, but as will be explored below, are likely inhibited from critiquing the authorities that, while they are funding their health equity-related activities, are at the same time creating health equity-threatening public policies.

• Indigenous Health at the University of Northern British Columbia, in Prince George

• Determinants of Health at St Francis Xavier University, in Antigonish, Nova Scotia

• Healthy Public Policy at the Institut national de santé publique du Québec, in Montréal

• Environmental Health at the BC Centre for Disease Control, in Vancouver

• Infectious Diseases at the University of Manitoba, in Winnipeg

• Methods and Tools at McMaster University, in Hamilton, Ontario

There is also an extensive library of reports on health inequalities in Canada from the Canadian Population Health Initiative,³⁹ Canadian Institute of Population and Public Health,⁴⁰ Canadian Institute for Health Information,³⁷ the National Collaborating Centre on Determinants of Health,⁴¹ National Collaborating Centre for Healthy Public Policy,⁴² Statistics Canada,⁴³ as well as a Health Inequalities Data Tool.⁴⁴ Ontario, Canada’s largest province, has one of the most detailed statements about promoting health equity through the activities of public health units that are funded primarily through provincial funding.⁴⁵

Public health practice results in decreased health inequities such that everyone has equal opportunities for optimal health and can attain their full health potential without disadvantage due to social position or other socially determined circumstances.

Program outcomes

• The board of health achieves timely and effective detection and identification of health inequities, associated risk factors, and emerging trends.

• Community partners and the public are aware of local health inequities, their causes, and impacts.

• There is an increased awareness on the part of community partners of the impact of social determinants of health on health outcomes and increased support for actions to decrease health inequities.

• Boards of health implement strategies to reduce health inequities.

• Community partners implement strategies to reduce health inequities.

• Priority populations are meaningfully engaged in the planning of public health interventions.

• Indigenous communities are engaged in a way that is meaningful for them.

In practice however, these units, like other agencies’ health equity practice, frequently focus on so-called lifestyle behaviours.³⁴

Federal and provincial government authorities, however, are not required to follow the recommendations of these federal and provincial documents, National Collaborating Centres, public health units, or the findings of the research and projects they fund. Indeed, the contrasts between the materials produced by these Canadian activities and the actual public policies that distribute economic and social resources and provide access to health care enacted by governmental authorities are striking.^3,4,46–48

This is not to deny some of the good work being done at the municipal level and recently summarized by the National Collaborating Centre for Healthy Public Policy.⁴² These activities promote community involvement in and improve immediate living circumstances for the most excluded through public policy. But these efforts cannot withstand the strong influence on economic and social policy exercised by provincial and federal governments which do not promote health equity. While they may form the nucleus of a social movement, they exhibit many of the characteristics detailed below that make such an occurrence unlikely.

It appears then that the current state of health equity in Canada is unacceptable. The social movement literature suggests the need for a social movement addressing health inequities. Why then are Canadian health equity activities not a social movement that could produce health equity promoting public policies? To consider this, we return to the components of a social movement and consider the health equity scene in Canada. We consider in turn each of the basic components of a social movement as outlined by della Porta and Diani,⁶ Tilly, Castaneda, and Wood,¹⁰ and Tarrow.⁹

Components of a Social Movement

For della Porta and Diani, there are three components of a social movement.⁶

A Network of Informal Interactions Between a Plurality of Individuals, Groups and/or Organizations

To our knowledge there are no ongoing interactions between the National Collaborating Centres, public health units, health equity researchers and practitioners. And even if there were, these networks would include only federal or provincial employees in the case of public health units, employees of agencies funded by these governing authorities, or researchers funded by governing agencies. Brassolotto, Raphael, and Baldeo and Raphael and Brassolotto provide evidence of collaborations between local public health units and other municipal groups, but again for the most part, these did not include the public.^49,50

A Specific Collective Identity Shared by the Actors Involved in the Interaction

To our mind there is no shared collective identity among those promoting health equity. Much of this may be due to differing understandings among these actors of what are the causes of health inequities and the means to address them. For some, health inequity is about problematic personal behaviours, for others the living and working conditions that lead to health inequities.⁵¹

And even among this latter group, the causes of these problematic living and working conditions may be seen as either misguided public policies, the influence of powerful players that distort public policy such as the corporate sector, the need to manage the contemporary form of the capitalist economic system, or even the necessity to move beyond capitalism towards a socialist economy. The Canadian public has little awareness of the importance of health equity as a result of lack of media reporting, political parties avoiding these issues, and little systematic outreach by public health authorities.^52–56

Engagement in Political and/or Cultural Conflicts, Meant to Promote or Oppose Social Change Either at the Systemic or non-Systemic Level

That virtually all those concerned with promoting health equity through research and public health activity are either funded or paid employees respectively, of the very governing institutions that create the conditions leading to health inequity excludes the presence of political or cultural conflicts making it difficult for them to call for systemic change.

Tilly, Castaneda, and Wood add concrete aspects of a social movement which clearly do not describe health equity activities: a sustained, organized public effort making collective claims on specific authorities; recognizable forms of protests, and WUNC displays: the coordinated public performance of Worthiness, Unity, Numbers, and Commitment by members and supporters of the movement.¹⁰ This is not surprising considering health equity advocates for the most part are upper-middle class researchers and public health professionals whose employment would preclude any such activities.

Moreover, these advocates usually do not apply a critical perspective to their activities. They operate within the constraints of a political system that discourages critical advocacy and protects vested interests at the expense of achieving health equity. Moreover, rarely do they engage local communities in activities to promote health equity. Health equity activities are even a further distance from Tarrow’s concept of a social movement that would involve contentious politics in confrontation with elites, authorities and opponents.¹⁰ Health equity activities also do not share their four basic properties: (1) collective challenges; (2) common purposes; (3) social solidarity; and (4) sustaining contention.

As a result of these realities, our analysis suggests that the promotion of health equity in Canada is nowhere close to being or becoming a social movement. Not surprisingly, the public continues to remain oblivious to the causes and need to respond to health inequities thereby creating no need for Canadian governing authorities to respond to the health inequity crisis. How such a social movement could come about is considered in the following sections.

What Needs to Be Done

Over the past few decades there have been the beginnings of a health equity social movement. One such initiative involved several public health units in Ontario, Canada’s most populous province, creating a video that attempted to draw public attention to the broader factors that shape health and the public policies necessary to achieve these.⁵⁷ The Sudbury and District Health Unit created the video animation Let’s Start a Conversation about Health and Not Talk about Health Care at All. One of its goals was to involve the public in advocating for health equity promoting public policy. Without provincial support, an additional 17 local PHUs (of 36) adapted it for local use. A study of their use of the video found that of the 17 PHUs, all intended to use it to enhance service delivery and promote community collaboration.⁵⁷ In addition, 15 saw it being used to promote public policy advocacy and 14 to promote public education. There is little evidence that these efforts are continuing.

In 2013 Dennis Raphael attempted to form a Canadian Social Determinants of Health Alliance by bringing together a range of agencies and organizations to provide a united voice to engage the public with promoting health equity. There was an enthusiastic response from agencies and individuals were identified to manage geographically determined networks (see Box 3). Unfortunately, attempts to receive funding were unsuccessful and the initiative stalled.

In 2013 Saskatoon physician Ryan Meili formed Upstream: Institute for a Healthy Society to highlight health equity issues.⁵⁸ Meili invited the organizations in Box 3 to join Upstream, but most were unwilling due to unfamiliarity with Meili. Upstream was taken over by the Canadian Centre for Policy Alternatives (CCPA) in 2020.⁵⁹ CCPA appears to have limited success in meeting its goals of informing the public about health equity issues. Its last blog entry is dated December 4, 2023.

Box 3. Organizations and Individuals Receptive to a Social Determinants of Health Alliance, Circa 2013

Organizations

Alberta Health Services

Association of Local Public Health Associations

Association of Ontario Health Centre

Canada Without Poverty

Canadian Association for School Health

Canadian Association for Spiritual Care

Canadian Association of Community Health Centres

Canadian Association of Social Workers

Canadian Centre for Policy Alternatives

Canadian Council on Social Development

Canadian Medical Association

Canadian Mental Health Association-Toronto Branch

Canadian Public Health Association

Centre for Effective Practice

Child and Youth Health Network for Eastern Ontario

Community-Campus Partnerships for Health

ERDCO (Ethno-racial People with Disabilities Coalition of Ontario)

Hamilton Spectator

Health Providers Against Poverty

House of Friendship, Kitchener

Interfaith Social Assistance Reform Coalition

KFL&A Public Health Unit

Mamow-ki-ken-da-ma-win - North-South Partnership for Children

Medical Reform Group

National Collaborating Centre for Determinants of Health

Ontario Healthy Community Coalition

Ontario Women’s Health Network

People’s Health Movement Canada

Public Health Association of BC

Saskatoon Health Region

SPC of Cambridge and North Dumfries

Wellesley Institute

Individuals

Anne Andermann, McGill University

Toba Bryant, Ontario Tech University

Benita Cohen, University of Manitoba

James Frankish, University of British Columbia

Martha Traverso-Yepez, Memorial University

Elizabeth McGibbon, St Francis Xavier University

Carlos Quinonez, University of Toronto

Dennis Raphael, York University

Kyle Whitfield, University of Alberta

There have been additional false starts to building a healthy equity social movement. Box 4 details initiatives by the Health Council of Canada, the Canadian Medical Association, the National Collaboration Centre for Determinants of Health and the New Democratic Party, among others. Interestingly, many of their reports are not publicly available.

Box 4.

Initiatives that Failed to Develop into a Health Equity Social Movement

Initiative	Details
A Social Justice Approach to Addressing the Social Determinants of Health (personal communication)	In 2005, original planners aimed to have the National Collaborating Centre for the Determinants of Health create a broad movement to promote social justice in health. The plan was vetoed by governing authorities in favor of a focus on assisting traditional public health units.
Wellesley Institute⁶⁰	The Wellesley Institute was formed as a non-partisan research and policy think tank that works to improve health and health equity in the Greater Toronto Area through action on the social determinants of health. It has a team of 20 professionals focused on “catalyzing action” through its 3-year strategic plan. It has an active program producing numerous quality reports and analysis, again with rather little to show for it in public policy action.
Code Red Series - Hamilton Spectator,⁶¹	The Code Red series published in the Hamilton Spectator newspaper in 2010 started a conversation on health inequalities in Hamilton with a focus on social determinants of health. Code Red met its original objectives of increasing community awareness and creating public debate about health inequalities. The Spectator continues to be the only Canadian outlet consistently carrying health equity stories.
Stepping It Up: Moving the Focus from Health Care in Canada to a Healthier Canada.⁶²	The last report by the Health Council of Canada aimed to shift the health focus to broader determinants of health. The report was ignored by the media and placed on the shelf.
Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health.⁶³	Canada participated in the Commission on Social Determinants of Health by managing two research hubs – Early Child Development and Globalization – and having former Minister of Health and Welfare Monique Begin as a Commissioner. Participation had no noticeable effect upon public policy in Canada.
Social Determinants of Health: The Canadian Facts.^64,65	These documents aimed to spread the social determinants of health concept to varied professional communities, students, the media, and the public. The first two goals were clearly met with over 1,000,000 downloads, primarily by professionals and students. Penetration into public consciousness and translation into public policy has not occurred.
A Nursing Call to Action: The Health of our Nation, the Future of Our Health System.⁶⁶	The Canadian Nursing Association’s National Expert Commission had the goal of meeting the changing and pressing health needs of Canadians in the 21st century. Like the Health Council of Canada’s report it was ignored by the media and placed on the shelf.
Health Care: Now is the Time.⁶⁷	A cross-country consultation was carried out by the federal NDP. Its report focused on the social determinants of health and was placed on the NDP website. Upon the calling of the 2017 election, the report was removed and its content was not part of that or any subsequent NDP election campaigns.
What Makes us Sick?⁶⁸	A cross-country consultation resulted in a report highlighting the importance of the social determinants of health. Like the Health Council of Canada’s report it was ignored by the media and placed on the shelf.

These three forms of initiatives, public health communication, forming an alliance of interested parties, and spreading the Upstream message continue to have promise for building a social movement for health equity, but without funding and ongoing commitment by these organizations to challenge the status quo, such initiatives appear to be unlikely in the near future.

As a glimpse of hope, the Ontario Health Coalition is focused on preserving public health care – has met many of the requirements of a social movement.⁶⁹ It has identified governments as moving towards privatization of health care, it has established dense formal and informal networks, it carries out sustained and visible protests and mobilization campaigns and has members who hold a shared pro-public health care identity. Unfortunately, to date they have not been able to stop the Ontario Conservative government from increasing funding of for-profit health care but perhaps have slowed these efforts. The Ontario Health Coalition is distinguished from the broader Canadian Health Coalition by being more grass-roots focused with greater activity and visibility typical of a social movement as described earlier.

Discussion

We were able to apply our sensitizing concepts to document (1) Canada’s success in achieving health equity; (2) the promise and components of social movements; and (3) barriers to both health equity and a social movement to achieve health. No apparent additional concepts emerged from our analysis. For those aware of the importance of achieving health equity, the current situation is unacceptable. Yet the prospects for building a social movement in support of promoting health equity remains problematic. Virtually all the components of a social movement are lacking.

There is no network of informal interactions between individuals, groups and/or organizations nor a collective identity shared by the actors involved in the interaction. The public has not been engaged and for the most part remains ignorant of the concept of health equity and how the absence of a social movement is related to adverse health outcomes associated with health-threatening living and working conditions and lack of access for many to health care.

In addition, social movement actors are assumed to be engaged in political and/or cultural conflicts to promote social change. Virtually all those engaged in health equity research and practice are employed or funded by the very governmental authorities responsible for the lack of health equity. They cannot be expected to threaten their positions and livelihood by engaging in conflictual relationships with employers and funders. The rise of right-wing populism also serves as a damper on messaging about promoting social justice through health equity promoting public policies. The rush to privatize many components of the health care system is also diverting attention from health equity advocates from broader health equity issues associated with the quality and equitable distribution of the social determinants of health.

Even among those so engaged, it may sometimes appear to be a “labour of Sisyphus” as repeated efforts are met with failure.⁷⁰ We have certainly seen health equity actors in Canada subjected to Tarrow’s mechanisms of demobilizations of Repression – the inhibition of critique within public health agencies;^47,71 Facilitation – satisfaction of some claims leading to retreat such as funding of community research projects; Exhaustion – as efforts repeatedly fail; Radicalization – health equity researchers shifting to work on labour or social justice issues outside of the health equity frame;⁷² and Institutionalization – working on health equity issues in useful but ignored agencies such as the National Collaboration Centres or agencies such as the Wellesley Institute or Canadian Centre for Policy Alternatives.

There are some distinctive aspects of Canadian governance that readers should be aware. While there is a federal Minister of Health, a Public Health Agency of Canada and a Canadian Institute for Health Research, the delivery of health care and education as well as labor legislation and social services and assistance are, according to the Canadian constitution, provincial responsibilities. Increasingly, these provincial governments are highly individualistic, attempting to rationalize away public policies that would improve the quality and equitable distribution of the social determinants of health. This would not necessarily preclude the possibility of a health equity social movement, but it does indicate that Canada is much more fragmented in its governance than many other modern welfare states making a single target for action difficult to achieve.

The situation is further complicated by the lack of any political party – in power or in opposition – raising the issue of health equity as a political goal. This is the case across the entire political range from the ostensibly social democratic New Democratic Party to the business-oriented Liberal and Conservative parties. Interestingly, the marginal Green Party of Ontario maintains commitments to address health equity likely due to the national Green Party having been founded by public health physician and advocate Trevor Hancock.⁷³ In any event, none of these ideas appear to have engaged the Canadian public or mainstream and alternative media.

Faced with these difficulties we are now engaged on a project to examine a wide range of social movements across the globe in an effort to distill lessons from them that may be of use to health equity advocates in Canada. As one example the Social Medicine concept has been rather successful in Latin America and appears in many aspects to constitute a social movement concerned with health equity that has shown some success.⁷⁴ It thrived by building public support that led to influence upon political choices related to provision of economic and social security in many nations. In some cases, social medicine movement contributed to political regime change: Chilean president Salvador Allende was both a medical doctor and strong proponent of social medicine and Che Guevara was first trained as a medical doctor.

Other social movements have not fared as well. While still highly visible, the Environmental Movement has failed to stem the movement to a catastrophic tipping point where the future of the Earth is at risk.⁷⁵ The Anti-Globalization Movement has accomplished little in terms of resisting the adverse effects of neoliberal-inspired economic globalization.⁷⁶ Nevertheless, there are lessons to be learned from these social movements for those working towards health equity in Canada and elsewhere.

Conclusion

The health equity scene in Canada is so problematic as to call for a social movement to demand governmental action to improve the living and working conditions that shape health and access to health care. To date health equity activities in Canada have done little to promote health equity. Past initiatives showed promise but proved ineffective. Together with colleagues we are embarking on a year-long project to systematically review the structures, processes, and successes and failures of a variety of social movements – Health Equity, Health Care, Social Medicine, Environmental, Social Justice, Labour, Political, Disability Rights, and Anti-Globalization – to identify lessons and insights that may assist in the development of a health equity social movement in Canada. Findings will be presented in a volume to be published by Policy Press.

The assumption would be that formation of a social movement promoting health equity could – through political parties’ fear of electoral failure – force Canadian political parties once in power to take appropriate action. Admittedly, despite the plethora of health equity work in Canada, there has not been to date any political party activity organized around discussions of health equity. Having such discussions take place may be the most important reason for pursuing the idea of a health equity social movement.

The growing recognition of the Canadian polycrisis in living and working conditions with their adverse health effects may spur such efforts.⁷⁷ But as has been seen in the USA, deteriorating living and working conditions can also drive the rise of reactionary right wing politics in which case formation of a health equity social movement would be even more important.⁷⁸

Footnotes

ORCID iDs

Dennis Raphael

Toba Bryant

Ethical Considerations

As no human subjects were involved in this work, ethical approval and informed consent were not necessary.

Author Contributions

Both authors conceived the project and collected relevant information. DR wrote the first draft of the paper and both authors contributed to subsequent revisions. All authors read and approved the final manuscript. DR is the guarantor.

Funding

The authors received no support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors report no conflicting interests.

Data Availability Statement

All data used in this study are from publications provided in the reference section.*

Note

Author Biographies

Dennis Raphael, PhD, is Professor at the School of Health Policy and Management at York University in Toronto. Dr. Raphael is editor of Social Determinants of Health: Canadian Perspectives (4th ed.), Tackling Health Inequalities: Lessons from International Experiences, and Immigration, Public Policy, and Health: Newcomer Experiences in Developed Nations. He is author of Poverty in Canada: Implications for Health and Quality of Life (3rd ed.) and About Canada: Health and Illness (3rd ed.) and co-author of The Politics of Health in the Canadian Welfare State and co-editor of Staying Alive: Critical Perspectives on Health, Illness and Health Care (3rd ed.).

Toba Bryant, PhD, is Associate Professor in the Faculty of Health Sciences at Ontario Tech University in Oshawa, Canada. Dr. Bryant is author of Health Policy in Canada (3rd ed.), first editor of Staying Alive: Critical Perspectives on Health, Illness and Health Care (3rd ed.), co-author of The Politics of Health in the Canadian Welfare State and editor of the contributed volume Handbook on the Social Determinants of Health. She is also general editor of the academic journal, Critical Issues: An International and Interdisciplinary Journal. Dr. Bryant has authored numerous book chapters and journal articles on the social determinants of health, public policy change, and housing as a social determinant of health.

Academic Leads/Scientific Directors and Advisory Board Members,National Collaborating Centres

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Why Promoting Health Equity in Canada Requires a Social Movement

Abstract

Background

Purpose

Analysis

Findings

Conclusion

Keywords

Introduction

Background

Promoting Health Equity

The Failure to Promote Health Equity in Canada

Forces Responsible for This Failure

Public Policy Models

The Promise of Social Movements

Box 1. Key Components of a Social Movement

Box 2. Examples of Social Movements

Components of Social Movements

Methods

Findings

Health Equity Activities in Canada

Components of a Social Movement

A Network of Informal Interactions Between a Plurality of Individuals, Groups and/or Organizations

A Specific Collective Identity Shared by the Actors Involved in the Interaction

Engagement in Political and/or Cultural Conflicts, Meant to Promote or Oppose Social Change Either at the Systemic or non-Systemic Level

What Needs to Be Done

Box 3. Organizations and Individuals Receptive to a Social Determinants of Health Alliance, Circa 2013

Discussion

Conclusion

Footnotes

ORCID iDs

Ethical Considerations

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

Note

Author Biographies

Academic Leads/Scientific Directors and Advisory Board Members,National Collaborating Centres

References