Rachel's Democracy & Health News #874  [Printer-friendly version]
September 28, 2006


[Rachel's introduction: The health of U.S. citizens is abysmally
poor, compared to that of other wealthy, industrialized societies.
When we look for causes, we often don't examine the real fundamentals
--the "social determinants of health." These "social determinants"
are, in turn, created or modified by specific public policies. This
week and next we depart somewhat from our usual journalistic approach
to offer this important new statement on the poor health of U.S.
citizens and the public policies that lie behind the shocking
numbers. The statement is framed as a challenge to the public health
community in the U.S.]

By Dennis Raphael

[Editors' introduction: Dr. Dennis Raphael is a professor in the
School of Health Policy and Management, York University, Toronto. In
recent years he has edited two volumes on the social determinants of
health -- Staying Alive: Critical Perspectives on Health, Illness,
and Health Care (2006), and The Social Determinants of Health:
Canadian Perspectives (2004). He is the author of Inequality is Bad
for Our Hearts; Why Low Income and Social Exclusion are Major Sources
of Heart Disease in Canada (2001). If you have a high-speed internet
connection, you can see and hear Dr. Raphael delivering an
interesting lecture. If you are not familiar with the concept of
"social determinants of health," you might read this short article
in Wikipedia. In manuscript, this article was originally titled,
"Public Policies Drive the Deteriorating Population Health Profile in
the USA."]


International interest in the social determinants of health represents
yet another cycle of recognition of the importance of structural
determinants of health that began in earnest in the 1850's (1, 2).

Yet, recent waves of concern with structural determinants of health
appear to have bypassed the mainstream American public health
community (3-5). Analysis of how early life, education, employment and
working conditions, food security, housing, income and its
distribution, and unemployment and employment security (6) shape
health and creates health inequalities seem especially timely as the
USA presents one of the worse population health profiles among wealthy
developed nations and one of the most undeveloped public policy
environments in support of health (7, 8).

These public policy issues concern income distribution, employment
security and working conditions, and quality of the social
infrastructure in support of health. Despite evidence that the USA has
become a striking outlier among wealthy developed nations in its
population health and public policy profiles, the USA public health
community is taking only cautious steps towards addressing the
structural antecedents of health and disease (4, 9) . And when the
social determinants of health concept is explored the analyses are
typically narrow and strangely depoliticized (10-13). Public policy
antecedents of health determinants such as family, labor, tax, social
assistance, and taxation policy, as examples, are rarely mentioned and
when they are, are done in a rather perfunctory manner (14, 15).
Resignation that progressive public policy change in support of health
in the USA is unlikely is frequently a message conveyed in these
analyses (16-19). What roles could the public health community play in
this effort and how likely is it that these efforts could succeed?

Social Determinants of Health

The renewed focus on social determinants of health (6, 20-25) grew out
of efforts by UK researchers to identify the specific exposures by
which members of different socio-economic groups come to experience
varying degrees of health and illness (26). It is no accident that the
term social determinants of health made its contemporary appearance
during the Thatcher era in a UK volume concerned with policy, social
organization, and health (27). The concept struck a responsive chord
in many wealthy industrialized nations where growing income and wealth
inequalities, the weakening of the welfare state, and increasing
evidence of social exclusion were causes for concern (28-30).

The social determinants of health concept failed to gain much traction
within the USA pubic health community even though the growth in income
and wealth inequalities since the 1980's has been greater than any
other wealthy developed nation (8). Despite sporadic mention of the
concept in various American academic articles (10, 14, 31, 32), the
USA public health community gaze is firmly focused on rather narrow
issues of identifying racial and ethnic disparities, health care
access, and behavioral risk factors rather than structural issues
concerned with the distribution of economic and social resources (4,
33). When the social determinants of health are considered, these are
strangely de-politicized such that their public policy antecedents are
rarely mentioned and certainly not criticized through a consistent
political analyses.

The key exceptions to this trend include the work of Smeeding and
Rainwater who have labored over the years to raise issues of poverty,
income distribution, and service distribution, their public policy
antecedents, and their implications for health (8, 34-36). Similarly,
the recent volume by Hofrichter brought together much of the sparse
literature on the structural determinants of population health in the
USA (37). See also Alesina and Glaeser, (38), Rank (39), Kawachi and
Kennedy (40), Brooks-Gunn (41) and Auerbach and colleagues (42) and
work on income and wealth inequality by numerous non-governmental
organizations (43-46).

At the same time the public health community gazes on ethnic and
racial disparities, access to health care, and behavioral risk
factors, the public policy environment in support of health
deteriorates (43, 47-49). Much of this has to do with the neo-liberal
and neo-conservative resurgence that began in earnest during the
Reagan presidency which coincided -- and was incompatible -- with
growing international interest in structural approaches to health
promotion (50). Now, 20 years after the Reagan Revolution led to
astounding increases in income and wealth inequality, the dismantling
of much of the American welfare state, and hardening public attitudes
towards governmental provision of services, the public health
community is taking cautious steps towards addressing structural
determinants of health. How likely are these efforts to be successful?

Within most nations, social class, occupational status, and income are
analyzed as key issues that interact with public policy approaches to
resource distribution and service provision to shape health
inequalities and population health (28, 51, 52). Social stratification
interacts with public policy to produce differential exposures to
societal resources that shape health (53, 54). In the USA however,
issues of social class, occupational position, and income take a back
seat to analysis of "racial and ethnic disparities" in health (4).
Indeed, discussion of resource distribution including income and
general social provision as determinants of health is clearly
undeveloped in the USA. Analysis of social stratification and social
class as health determinants is even less so (42, 55-57).The reasons
for this and the impact this focus has on public health researchers
and workers' activities in the service of health are discussed below.

The USA Population Health Profile

The social determinants of health and their public policy antecedents
are especially relevant to the USA as its health profile is especially
poor in relation to other wealthy industrialized nations. For the
following indicators of population health of a nation, a rank of 1 is
best, with increasing rank indicating poorer relative performance as
compared to the wealthy industrialized nations of the Organization for
Economic Cooperation and Development (OECD).

Life Expectancy

In 2002, life expectancy for American males was 74.4 years, and for
women, 79.8 years providing a relative rank of 22nd of 30 wealthy
developed nations for men; and 25th of 30 for women (7). The average
life expectancy increase in the USA of 7.2 years from 1960 to 2002 was
well below the OECD average of 9.2 years giving the USA a rank of 22nd
of 30 nations.

Infant Mortality Rate

In 2002, the USA's 2002 rate of 6.8/1000 gives it a rank of 25th of
the 29 wealthy industrialized nations for which these data are
available (7).

Low Birthweight Rate

In 2003 the USA's low birthweight rate was 7.9 per 100 newborns giving
it a ranking of 25th of 28 wealthy industrialized nations for which
these data were available (7).

Childhood Death by Injury Rate

During the period 1991-1995, 14.1 American children per 100,000 died
from injuries giving the USA a ranking of 23rd of 26 wealthy
industrialized nations (58).

Child Maltreatment Deaths

During the 1990's the incidence of childhood death by maltreatment per
100,000 children in the USA was 2.2 per 100,000 (59). This gave the
USA an overall rank of 26th of 27 wealthy industrialized nations. A
ranking that takes into account "undetermined intent" raises the USA's
rate to 2.4 per 100,000 and a relative ranking of 25th of 27.

Teenage Pregnancy Rate

The USA's rate during the 1990's of 51.1 births to 1000 women below 20
years of age gives it a rank of 28th of 28 wealthy industrialized
nations. These rates are exceptionally high -- 21 points higher than
the nearest nation, the UK.

To summarize, the USA shows a very poor population health profile on a
variety of health indicators. It does poorly on male and female life
expectancy, infant mortality rank, low birthweight rate, deaths from
child injury and child maltreatment.

Poverty as a Health Determinant: USA Rates in International

Poverty is increasingly seen as the greatest threat to human
development and a nation's quality of life (60, 61). The experience of
poverty also results in -- as well as contributes to -- social
exclusion, a process identified by the European Union and the World
Health Organization as the primary threat to the smooth functioning of
developed societies (62, 63). Where does the USA stand on this

Overall National Poverty Rates and Poverty Gaps

Using the internationally agreed-upon convention of poverty as the
percentage of individuals with disposable income less than 50% of the
median income of the population, the USA's overall poverty rate for
the mid 1990's was 16.6% (7). By 2000 it had increased to 17.0% which
was well above the OECD average of 10.2%. The USA's relative rank in
this important rating was 26th of 27 wealthy industrialized nations.
In terms of the gap between the average incomes of those living in
poverty and the median income of the population, the USA's gap of
34.3% is above the OECD average of 27.7%, providing a rank of 23rd of

Child Poverty -- Relative and Absolute Rates

During the late 1990s, the USA's relative child poverty rate of 22.4%
gave it a ranking of 22nd of 23 wealthy industrialized nations (64).
These rates can be compared with those seen for the Nordic nations
(Denmark, 5.1%; Finland, 4.3%; Norway, 3.9%; and Sweden, 2.6%),
Belgium (4.4%); and Luxembourg (4.5%).

Absolute child poverty rates are generated by applying the USA poverty
standard to other nations adjusting for national currencies and
national purchasing power. The USA poverty standard is set very low
and is usually seen as an indicator of very limited resources
associated with serious material and social deprivation (64). The
USA's rate of 13.9% places it 11th of 19 nations for whom these data
were available. The Nordic nations also have very low absolute poverty
rates (Sweden, 5.3%; Norway, 3%; Denmark, 5.1%; Finland, 6.9%),
Belgium (7.5%), and Luxembourg (1.2%) thereby maintaining their low
rankings on both kinds of poverty indicators.

Recent Analyses from the Luxembourg Income Study (LIS)

How does the very high level of poverty in the USA come about? An
analysis of LIS data by Smeeding provides insights into this process
among 11 wealthy developed nations (36). These nations represent four
Anglo-Saxon nations, Canada, Ireland, United Kingdom, and the USA;
four central European nations, Austria, Belgium, Germany, and the
Netherlands; one Southern European nation, Italy; and two Nordic
nations, Finland and Sweden.

These analyses highlight how public policy determines poverty rates.
Poverty rates are based on the international convention of a poverty
cut-off of less than 50% of median adjusted disposable income for

The USA's overall poverty rate of 17% places it as the highest of
these 11 nations. For USA children living in single parent households
the poverty rate is a striking 41.4%, almost four times the rate for
Swedish children living in this situation and almost six times the
rate for Finnish children. The situation for USA elders does not fare
much better. The USA's elder poverty rate of 28.4% is the second
highest among these nations exceeded only by the strikingly high rate
of 48.3% seen in Ireland. Similarly, the USA's poverty rate for
childless adults is at 18.8%, exceeding every nation.

Have USA rates changed over time? Smeeding compares overall poverty
rates for each nation over a 23 year period from the base year of 1987
to 2000. In 1987, the relative poverty rate for the USA was 17.8%. For
2000 he provides two rates. The 2000 relative rate applies the same
calculation to 2000 as applied in 1987: the poverty line as less than
50% of the median disposable income for all residents. For the USA,
the relative poverty rate in 2000 was 17% showing little change form

The anchored rate refers to the percentage of Americans in 2000 living
below the poverty line as it was calculated in 1987 and adjusted for
increases in the cost of living since that time. In the USA, this
figure is 13.8%. There has been therefore some improvement in the
actual income of those at the bottom, but in relative terms poverty
rates in USA are virtually unchanged from 1987 to 2000.

Poverty rates are shaped by government spending programs.

Market income refers to income derived from gainful employment or
investments and other private sources. Relying upon the market as the
source of income provides rather high overall poverty rates across all
nations. The USA's poverty rate based on market income is lower than
most nations. Social insurance and taxes -- referring to transfers
such as child benefits and children's allowances and changes in
distribution resulting from taxation -- reduces the USA's poverty rate
to 19.3%. The USA's poverty rate associated with the provision of a
few more varied benefits -- called social assistance -- further
reduces the poverty rate to 17.0%.

What is the calculated effect on poverty rates of these government
programs? In the USA, social insurance programs reduce the poverty
rate by 16.5% and all programs reduce it by 26.4% which is the
smallest amount among these nations. In contrast, the overall
reduction rate is 60.9% for the nations included in this analysis.
Indeed, Sweden reduces its poverty rate by 77.4% by such actions.
Belgium, Germany, Austria, and Finland also reduce their overall
poverty rate by at least 70% through government action.

The USA expends a miserly 2.3% of Gross Domestic Product (GDP) on
non-elderly citizens. In contrast, Finland and Sweden spend over 10%
of GDP on citizen benefits. The importance of government expenditures
in reducing poverty is illustrated by an analysis that reveals that
non-elderly cash and near-cash (e.g., housing subsidies, active labor
market subsidies, etc.) predict 61% of the variation among these
nations' non-elderly poverty rates. Nations that spend more money on
these benefits have lower poverty rates. Nations that spend less have
higher poverty rates.

Smeeding also shows that the percentage of low-paid workers is
strongly related to the percentage of non-elderly citizens within a
nation living in poverty (36). The USA has 25% of its workers
identified as earning less than 65% of the median wage and a poverty
rate of 17.8%. In contrast only 5% of Finnish and Swedish workers earn
low wages and their poverty rates are 4.5% and 6% respectively. These
variations in numbers of low paid workers accounts for a strikingly
high 85% of the variation among nations in the number of people living
in poverty. In essence, the single best predictor of the number of
people living in poverty in a nation is the number of people earning
low wages. This begs the question of why so many USA workers are
low-paid, an issue discussed in following sections.

Nations that transfer less resources to citizens are more likely to
have higher levels of poverty -- and as other evidence shows -- poorer
population health profiles (65-67). Nations that tolerate greater
proportions of low-paid workers have higher poverty rates and the
associated population health consequences. The next sections explore
the nature of these differences in governmental support of citizens
through transfers and programs.

USA Public Policy in Perspective

Health inequalities and population health profiles associated with
these inequalities result from systematic variations in approaches to
public policy (68, 69). Commonly termed the welfare state, this basket
of public policies serves to promote human, social and economic
development, reduce citizen uncertainty, and foster health and
well-being. This political economy of health is well developed in
Europe, much less so in North America (70, 71). It is especially
undeveloped in the USA.

Societal Commitments to Citizens and Governmental Spending

Public commitment to supporting citizens is seen in percentage of
Gross Domestic Product (GDP) transferred to citizens through programs,
services, or cash benefits. Nations may choose to transfer relatively
small amounts, allowing the marketplace to serve as the primary
arbiter of how economic resources are distributed (72). Or a nation
may choose to intervene to control the marketplace and make decisions
concerning these allocations of resources (73). Nations that transfer
a greater proportion of resources are more likely to show better
population health profiles, and relatively less health inequalities
(67). These health and inequality differences emerge through a series
of mechanisms that involve degree of poverty and the material and
social deprivation that are associated with such levels (65).

An especially important indicator is extent of government transfers.
Transfers refer to governments taking fiscal resources that are
generated by the economy and distributing them to the population as
services, monetary supports, or investments in social infrastructure.
Such infrastructure includes education, employment training, social
assistance or welfare payments, family supports, pensions, health and
social services, and other benefits (7).

Among the developed nations of the OECD, the average public
expenditures in 2001 was 21% of Gross Domestic Product (GDP) (74).
There is rather large variation among countries with Denmark (spending
29.2% of GDP) and Sweden (spending 28.9% of GDP) being the highest
public spenders. The USA ranks 26th of 30 wealthy industrialized
nations and spends just 14.8% of GDP on public expenditures. The only
nations that allocate a smaller percentage of GDP to public
expenditure are Ireland (13.8%); Turkey (13.2%); Mexico (11.8%); and
Korea (6.1%).

The USA is the highest spender on total expenditure on health care.
However, it is in the mid-range on public spending for health care as
much of its spending on health care is from private sources. It is in
the other areas of benefits and supports to citizens that the USA
reveals itself as a very frugal public spender. The USA ranks near the
bottom of nations in allocations to old-age related spending,
primarily pensions with a rank of 26th of 30 wealthy industrialized
nations. The USA also ranks among the lowest spenders on incapacity or
disability-related issues for a rank of 25th of 29 wealthy
industrialized nations. And the USA ranks very poorly on family
benefits achieving a rank of 28th of 29 of these wealthy
industrialized nations.

Another way to slice up the expenditure pie is to consider spending on
income support to the working age population and social services as
well as health and pensions. Income support involves family benefits,
wage subsidies, and child support paid by governments to help keep
low-income individuals and families out of poverty. Social services
include counseling, employment supports, and other community services.
Not surprisingly, the USA ranks relatively low on income supports to
the working-aged population and social services. The USA spends just
7.9% of GDP in income supports to the working age population (rank
28th of 30) and 6.7% on social services (rank 20th of 30).

Active Labor Policy

Active labor policy refers to the extent that governments support
training and other policies that foster employment and reduce
unemployment. The USA allocates 0.53% of GDP to such policies. This
provides it with a ranking of 20th of 22 wealthy industrialized
nations for which data was available.

Public Policy and Citizen: Implications for Day-to-Day Life

How do these differing commitments to supporting citizens translate
into differing conditions of day-to-day life? Only a few sets of
issues can be examined here: resources available to the unemployed,
level of social assistance benefits, level of minimum wages, and
levels of pension benefits.

Unemployment Benefits over a Five Year Period for an Average
Production Worker

For most Americans, benefits that would be available over a five year
period would be unemployment insurance which would expire after a year
of benefits. A family with liquid assets would then need to liquidate
these prior to receiving social assistance benefits. For these non-
destitute families, unemployment insurance provides only 6%
replacement income over this period. This ranks the USA 27th of 28
wealthy industrialized nations in its generosity of benefit. If
families did qualify for social assistance, the benefit percentage
would be 30%, providing a ranking of 26th of 28 nations (7).

Social Assistance or Welfare

The OECD identifies as social assistance and welfare support as
"benefits of last resort." On average, USA social assistance benefits
for a married couple with two children provide 22% of median average
income. This places these benefits as 28% less than the <50% of median
income-indicator of poverty. As compared to the other nations for
which these data are provided, the USA ranks 20th of 23 nations in
providing these benefits of last resort (7).

Minimum Wages

Percentage of low-paid workers is the best predictor of percentage of
citizens living in poverty. How does the USA compare to other nations
in having minimum wages that keep people out of poverty? For an
American two-child family with one full-time minimum wage earner, the
wages received places the family at 34% of the median household
income, well below the commonly accepted poverty cut-off of 50% of
median poverty level (7). For a two-parent family with two children
working full-time at minimum wages, the level of median income
achieved is 46% of the poverty level. The USA's ranking for single
parent working family is 12th of 15 wealthy industrialized nations.
For the two-parent working family, the USA rank is 14th of 15.


The Social Security System provides benefits to individuals upon
retirement. The OECD provides data on the value of pension benefits
provided by each nation as a function of the gross earnings of an
average production worker (7). For a worker earning 50% of an average
production worker, the USA's pension provides a rate of 61% of these
earnings. For an American earning the average production worker's
income, the rate is 51%. The rates for average-waged workers are very
low by international comparison giving the USA a rank of 25th of 30
wealthy industrialized nations. For very low-paid workers, the USA
achieves an even lower rank of 28th of 30.

[To be continued next week.]


1. Engels F. The condition of the working class in England. New York:
Penguin Classics; 1845/1987.

2. Virchow R. Report on the Typhus Epidemic in Upper Silesia. In:
Rather LD, editor. Collected Essays on Public Health and
Epidemiology,. Canton MA: Science History Publications; 1848. p.

3. Hofrichter R. The politics of health inequities: Contested terrain.
In: Health and Social Justice: A Reader on Ideology, and Inequity in
the Distribution of Disease. San Francisco: Jossey Bass; 2003.

4. Raphael D, Bryant T. The State's role in promoting population
health: Public health concerns in Canada, USA, UK, and Sweden. Health
Policy 2006;79:39-55.

5. Raphael D, Bryant T. The limitations of population health as a
model for a new public health. Health Promotion International

6. Raphael D, editor. Social Determinants of Health: Canadian
Perspectives. Toronto: Canadian Scholars Press; 2004.

7. Organization for Economic Cooperation and Development. Society at a
Glance: OECD Social Indicators 2005 Edition. Paris, France; 2005.

8. Smeeding T. Public Policy and Economic Inequality: The United
States in Comparative Perspective. Syracuse NY: Maxwell School of
Citizenship and Public Affairs, Syracuse University; 2004.

9. Raphael D. A society in decline: The social, economic, and
political determinants of health inequalities in the USA. In:
Hofrichter R, editor. Health and Social Justice: A Reader on Politics,
Ideology, and Inequity in the Distribution of Disease. San Francisco:
Jossey Bass; 2003.

10. Berkman LF, Lochner KA. Social determinants of health: Meeting at
the crossroads. Health Affairs 2002;21(2):291.

11. Huckabee M. A vision for a healthier America: What the states can
do. Health Affairs 2006;25(4):1005-1008.

12. Benjamin GC. Putting the public in public health: New approaches.
Health Affairs 2006;25(4):1040-1043.

13. McGinnis JM. Can public health And medicine partner In the public
interest? Health Affairs 2006;25(4):1044.

14. Gostin LO, Powers M. What does social justice require for the
public's health? Public health ethics and policy imperatives. Health
Affairs 2006;25(4):1053.

15. Fielding JE, Briss PA. Promoting evidence-based public health
policy: Can we have better evidence and more action? Health Affairs

16. Mechanic D. Disadvantage, Inequality and Social Policy. Health
Affairs 2002;21(2):48-59.

17. Mechanic D. Rediscovery Of the 'Public' In public health. Health
Affairs 2006;25(4):1178-1179.

18. Mechanic D. Policy challenges In addressing racial disparities and
improving population health. Health Affairs 2005;24(2):335-338.

19. Mechanic D. Disadvantage, inequality, and social policy. Health
Affairs 2002;21(2):48.

20. Marmot M, Wilkinson R. Social Determinants of Health. 2nd ed.
Oxford, UK: Oxford University Press; 2006.

21. World Health Organization. WHO to Establish Commission on Social
Determinants of Health. In. Geneva: WHO; 2004.

22. Institute of Medicine. The Future of the Public's Health in the
21st Century. Washington DC: National Academies Press; 2002.

23. U.S. Department of Health and Human Services. Healthy people 2010:
Understanding and improving health. Washington DC: U.S. Department of
Health and Human Services; 2000.

24. Minnesota Department of Health. A Call to Action: Advancing Health
for All Through Social and Economic Change. In. St. Paul, MN:
Minnesota Department of Health; 2001.

25. Turning Point. States of change: Stories of transofromation in
public health. Seattle, WA: Robert Woods Johnson Foundation; 2004.

26. Townsend P, Davidson N, Whitehead M, editors. Inequalities in
Health: the Black Report and the Health Divide. New York: Penguin;

27. Tarlov A. Social determinants of health: The sociobiological
translation. In: Blane D, Brunner E, Wilkinson R, editors. Health and
Social Organization: Towards a Health Policy for the 21st Century.
London UK: Routledge; 1996.

28. Mackenbach J, Bakker M. Tackling socioeconomic inequalities in
health: Analysis of European experiences. Lancet 2003;362:1409-1414.

29. Scarth T, editor. Hell and High Water: An Assessment of Paul
Martin's Record and Implications for the Future. Ottawa: Canadian
Centre for Policy Alternatives; 2004.

30. Madanipour A, Cars G, Allen J. Social Exclusion in European
Cities. London: Jessica Kingsley; 1998.

31. Lurie N. What the Federal Government can do About the Nonmedical
Determinants of Health. Health Affairs 2002;21(2):94-106.

32. McGinnis JM, Williams-Russo P, Knickman JR. The Case for More
Active Policy Attention to Health Promotion. Health Affairs

33. Nettleton S. Surveillance, health promotion and the formation of a
risk identity. In: Sidell M, Jones L, Katz J, Peberdy A, editors.
Debates and Dilemmas in Promoting Health. London, UK: Open University
Press; 1997. p. 314-324.

34. Rainwater L, Smeeding T. Doing Poorly: The Real Income of American
Children in a Comparative Perspective. In: Luxembourg Income Study;

35. Rainwater L, Smeeding TM. Poor Kids in a Rich Country: America's
Children in Comparative Perspective. New York: Russell Sage
Foundation; 2003.

36. Smeeding T. Poor People in Rich Nations:The United States in
Comparative Perspective. Syracuse: Luxembourg Income Study Working
Paper #419. Syracuse University, Syracuse, New York; 2005.

37. Hofrichter R, editor. Health and Social Justice: A Reader on
Politics, Ideology, and Inequity in the Distribution of Disease. San
Francisco: Jossey Bass; 2003.

38. Alesina A, Glaeser EL. Fighting poverty in the US and Europe: A
world of difference. Toronto: Oxford University Press; 2004.

39. Rank MR. One Nation, Underprivileged: Why American Poverty Affects
Us All. New York: Oxford University Press; 2004.

40. Kawachi I, Kennedy B. The Health of Nations: Why Inequality Is
Harmful to Your Health. New York: New Press; 2002.

41. Brooks-Gunn J, Duncan GJ, Britto PR. Are SES Gradients for
Children Similar to Those for Adults? Achievement and Health of
Children in the United States. In: Keating DP, Hertzman C, editors.
Developmental Health and the Wealth of Nations: Social, Biological and
Educational Dynamics. New York: Guilford Press; 1998.

42. Auerbach JA, Krimgold B, editors. Income, Socioeconomic Status,
and Health: Exploring the Relationships. Washington, DC: National
Policy Association; 2001.

43. Collins C, Hartman C, Sklar H. Divided Decade: Economic Disparity
at the Century's Turn. Boston: United for a Fair Economy; 1999.

44. Association of Community Organizations for Reform. ACORN'S Living
Wage Web Site. In; 2003.

45. Bernstein J, Brocht C, Spade-Aguilar M. How much is enough: Basic
family budgets for working families. Washington DC: Economic Policy
Institute; 2000.

46. Mishel L, Bernstein J, Boushey B. The State of Working America
2002/2003. Ithaca: Cornell University Press; 2003.

47. Heymann J. The Work, Family, and Equity Index: Where does the
United States Stand Globally? Boston: The Project on Global Working
Families; 2004.

48. Brink S, Zeeman A. Measuring Social Well-Being: An Index of Social
Health for Canada: Human Resources Development Canada, Applied
Research Branch,; 1997. Report No.: Report R-97-9E.

49. Deaton A, Paxson C. Mortality, Income, and Income Inequality Over
Time in Britain and the United States: National Bureau of Economic
Research; 2001 October. Report No.: NBER Working Paper No.w8534.

50. World Health Organization. Ottawa Charter for Health Promotion.
In. Geneva, Switzerland: World Health Organization European Office;

51. Raphael D, Macdonald J, Labonte R, Colman R, Hayward K, Torgerson
R. Researching income and income distribution as a determinant of
health in Canada: Gaps between theoretical knowledge, research
practice, and policy implementation. Health Policy 2004;72:217-232.

52. Mackenbach J, Bakker M, editors. Reducing Inequalities in Health:
A European Perspective. London UK: Routledge; 2002.

53. Diderichsen F, Evans T, Whitehead M. The Social Basis of
Disparities in Health. In: Evans T, Whitehead M, Diderichsen F, Bhuiya
A, Wirth M, editors. Challenging Inequalities in Health: From Ethics
to Action. New York: Oxford University Press; 2001.

54. Muntaner C, Borrell C, Kunst A, Chung H, Benach J, Ibrahim S.
Social class inequalities in health: Does welfare state regime matter?
In: Raphael D, Bryant T, Rioux M, editors. Staying Alive: Critical
perspectives on Health, Illness, and Care. Toronto: Canadian Scholars
Press; 2006.

55. Muntaner C. Commentary: Social Capital, Social Class, and the Slow
Progress of Psychosocial Epidemiology. International Journal of
Epidemiology 2004;33(4):1-7.

56. Navarro V. The politics of health inequlities research in the
United States. International Journal of Health Services

57. Oliver MN, Muntaner C. Researching health inequities among African
Americans: The imperative to understand social class. International
Journal of Health Services 2005;35(3):485-498.

58. Innocenti Research Centre. A league table of child deaths by
injury in rich nations. 2001.

59. Innocenti Research Centre. A League Table of Child Maltreatment
Deaths in Rich Nations. Florence: Innocenti Research Centre; 2003.

60. Esping-Andersen G. A child-centred social investment strategy. In:
Esping-Andersen G, editor. Why we need a new welfare state. Oxford UK:
Oxford University Press; 2002. p. 26-67.

61. Esping-Andersen G. Towards the good society, once again? In:
Esping-Andersen G, editor. Why we need a new welfare state. Oxford UK:
Oxford University Press; 2002. p. 1-25.

62. Percy-Smith J, editor. Policy Responses to Social Exclusion:
Towards Inclusion? Buckingham UK: Open University Press; 2000.

63. Galabuzi GE. Social exclusion. In: Raphael D, editor. Social
determinants of health: Canadian perspectives. Toronto: Canadian
Scholars Press.; 2004.

64. Innocenti Research Centre. A league table of child poverty in rich
nations. Florence Italy: Innocenti Research Centre; 2000.

65. Navarro V, Borrell C, Benach J, Muntaner C, Quiroga A, Rodrigues-
Sanz M, et al. The importance of the political and the social in
explaining mortality differentials among the countries of the OECD,
1950-1998. In: Navarro V, editor. The Political and Social Contexts of
Health. Amityville NY: Baywood Press; 2004.

66. Coburn D. Beyond the income inequality hypothesis: Globalization,
neo-liberalism, and health inequalities. Social Science & Medicine

67. Coburn D. Health and Health Care: A Political Economy Perspective.
In: Raphael D, Bryant T, Rioux M, editors. Staying Alive: Critical
Perspectives on Health, Illness, and Health Care. Toronto: Canadian
Scholars Press; 2006. p. 59-84.

68. Navarro V, editor. The Political Economy of Social Inequalities:
Consequences for Health and Quality of Life. Amityville, NY: Baywood
Press; 2002.

69. Navarro V, Muntaner C, editors. Political and Economic
Determinants of Population Health and Well-being: Controversies and
Developments. Amityville NY: Baywood Press; 2004.

70. Bambra C. The worlds of welfare: illusory and gender blind? Social
Policy and Society 2004;3(3):201-211.

71. Bambra C, Fox D, Scott-Samuel A. Towards a politics of health.
Health Promot. Int. 2005;20(2):187-193.

72. Saint-Arnaud S, Bernard P. Convergence or resilience? A
hierarchial cluster analysis of the welfare regimes in advanced
countries. Current Sociology 2003;51(5):499-527.

73. Brady D. The politics of poverty: Left political institutions, the
welfare state, and poverty. Social Forces 2003;82:557-588.

74. Organization for Economic Cooperation and Development. Society at
a Glance: OECD Social Indicators 2002 Edition. Paris, France; 2003.

75. Navarro V, Schmitt J. Economic efficiency versus social equality?
The U.S. liberal model versus the European social model.

76. American Public Health Association. Leave no one behind:
Elimimating racial and ethnic disparities in health and life
expectancy. Washington DC: American Public Health Association; 2004.

77. American Public Health Association. Disparities in Health Fact
Sheets. Washington, DC: American Public Health Association; 2004.

78. United Health Foundation. America's Health: State Health Rankings.
Minnetonka, MN: United Health Foundation; 2004.

79. Public Health Association of New York City. Agenda for Public
Health. In: Public Health Association of New York City; 2005.

80. Bryant T. Politics, public policy and population health. In:
Raphael D, Bryant T, Rioux M, editors. Staying Alive: Critical
Perspectives on Health, Illness, and Health Care. Toronto: Canadian
Scholars Press; 2006. p. 193-216.

81. Navarro V. The Politics of Health Policy: The US Reforms
1980-1994. Cambridge MA: Blackwell Publishers; 1994.

82. Auerbach JA, Krimgold B, Lefkowitz B. Improving Health: It Doesn't
Take a Revolution. Washington, DC: National Policy Association; 2000.
Report No.: NPA report # 298.

83. Raphael D. Social justice is good for our hearts: why societal
factors -- not lifestyles -- are major causes of heart disease in
Canada and elsewhere. In. Toronto, Canada: Centre for Social Justice
Foundation for Research and Education (CSJ); 2002.

84. Raphael D, Anstice S, Raine K. The social determinants of the
incidence and management of Type 2 Diabetes Mellitus: Are we prepared
to rethink our questions and redirect our research activities?
Leadership in Health Services 2003;16:10-20.

85. Popay J, Williams GH, editors. Researching the People's Health,
Routledge. London UK: Routledge; 1994.

86. Bryant T. Role of knowledge in public health and health promotion
policy change. Health Promotion International 2002;17(1):89-98.

87. Park P. What is participatory research? A theoretical and
methodological perspective. In: Park P, Brydon-Miller M, Hall B,
Jackson T, editors. Voices of change: Participatory research in the
United States and Canada. Toronto: Ontario Institute for Studies in
Education Press; 1993. p. 1-19.

88. Minkler M, Wallerstein N, Hall B. Community Based Participatory
Research for Health. San Francisco: Jossey Bass; 2002.

89. Minkler M. Community-Based Research Partnerships: Challenges and
Opportunities. Journal of Urban Health 2005;82(Supplement 2):ii3-

90. Lipset M. Continental Divide: The Values and Institutions of the
United States and Canada. New York: Routledge; 1990.

91. Lipset M, Marks G. It Didn't Happen Here: Why Socialism Failed in
the United States. New York: W. W. Norton; 2000.

92. Navarro V, Shi L. The Political Context of Social Inequalities and
Health. In: Navarro V, editor. The Political Economy of Social
Inequalities: Consequences for Health and Quality of Life. Amityville,
NY: Baywood; 2002.

93. Organisation for Economic Co-operation and Development. OECD
Employment Outlook 2004. Paris: Organisation for Economic Co-operation
and Development; 2004.

94. Zweig M. The working class majority: America's best kept secret.
Ithaca: Cornell University Press; 2000.

95. Zweig M, editor. What's Class Got to Do with It?: American Society
in the Twenty-First Century. Ithaca NY: Cornell University Press;

96. National Association of County and City Health Officials. Tackling
health inequities through public health practice: A handbook for
action. Washington DC: National Association of County and City Health
Officials; 2006.

97. Minnesota Department of Health. Healthy Minnesotans: Public Health
Improvement Goals 2004. Minneapolis: Minnesota Department of Health,;

98. Office of Minority Health M. Populations of Color in Minnesota:
Health Status Report. Minneapolis: Minnesota Department of Health;

99. Hayward K, Colman R. The Tides of Change: Addressing Inequity and
Chronic Disease in Atlantic Canada. Halifax NS: Atlantic Regional
Office, Health Canada; 2003.

100. Public Health Agency of Canada. Turning the Tide: Why Acting on
Inequity Can Help Reduce Chronic Disease. 2005. Halifax, NS: Public
Health Agency of Canada; 2006.

101. European Committee for Health Promotion Development. Reducing
Inequalities in Health: Proposals for Health Promotion Policy and
Action. In: World Health Organization; 2000.

102. Phillips K. Wealth and Democracy. New York: Broadway Books; 2002.

103. Rifkin J. The European Dream: How Europe's Vision of the Future
is Quietly Eclipsing the American Dream. New York: Tarcher; 2004.