Rachel's Democracy & Health News #875  [Printer-friendly version]
Octover 5, 2006


[Rachel's introduction: As we saw last week, the health of U.S.
citizens is poor, compared to that of other wealthy, industrialized
societies. In Part 2 of this important essay, Dennis Raphael shows
that U.S. public health policies largely ignore the primary
determinants of health: early life, education, employment and working
conditions, food security, housing, income and its distribution,
social safety net, social exclusion, and unemployment and employment

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."]

The USA Public Health Scene

Numerous writers have considered how the USA population health and
public policy profiles are linked (9, 35, 36, 65, 75). Certainly, the
evidence urges the raising of these issues and seeking their policy
solutions through public health action. It is therefore, fascinating
to interrogate contemporary public health documents such as the
Institute of Medicine's The Future of the Public's Health (22),
Healthy People 2010 (23), and documents from the American Public
Health Association (APHA) (76, 77) for their attention to these
issues. The dominant model is organized around themes of:

a) racial and ethnic disparities with little concern for how broader
determinants of health cause these disparities;

b) access to health care rather than issues of income and other
resource distribution, and

c) a wide gap between knowledge concerning the broader determinants of
health and action to address these determinants in the policy sphere

National Policy Documents and Reports

Like other USA documents, Healthy People 2010 contains a chapter on
the broader determinants of health and its health model is consistent
with a broader health perspective. It has a prominent emphasis on
issues of access to health care which is not surprising given that 17%
or 45 million Americans are without health insurance coverage.

However, closer inspection of the document reveals that the role
played by broader determinants of health is undeveloped. The Leading
Health Indicators "[R]eflect the major health concerns in the United
States at the beginning of the 21st century." These objectives --
physical activity, overweight and obesity, tobacco use, substance
abuse, responsible sexual behavior, mental health, injury and
violence, environmental quality, immunization, and access to health
care -- are firmly planted in the biomedical and behavioural public
health model.

Explicit indicators of poverty or income levels, unemployment or job
security, or any other obvious indicator of broader determinants of
health are absent. Any and all examples of influencing policy are
limited to legislative changes designed to promoting healthy behaviors
or access to health care. There is little recognition of early life,
education, employment and working conditions, food security, housing,
income and its distribution, social safety net, social exclusion, and
unemployment and employment security as primary determinants of

The Institute of Medicine's The Future of the Public's Health has
similar shortcomings (Institute of Medicine, 2002). It has a chapter
on developments in population health, yet these concepts do not
diffuse to the rest of the volume. Virtually all issues to be
addressed are health care-related or behaviorally-focused around diet,
tobacco use, or physical activity. Policy is conceived narrowly as
legislation related to risk behaviors and health protection.

APHA policy statements and numerous "Fact Sheets" reveal an emphasis
on access to health care, the situating of health differences in terms
of racial and ethnic disparities, and attention to modifying
behavioral risk factors for disease and illness (76, 77). They
describe differences in health status among White, African-American,
Hispanics and Latinos, American Indian and Alaskan natives, and Asian
Americans and Pacific Islanders, but highlight findings of unequal
access to, and quality of, health care treatment.

Broadening the Scope

Some public health agencies address broader influence upon health. The
report America's Health: State Health Rankings provides data and
rankings for states on four sets of indicators of which two have a
broad scope (78). Community Environment (violent crime, lack of health
insurance, infectious disease, children in poverty, and occupational
fatalities), and Health Policies (percent of health dollars for public
health, per capita public health spending, and adequacy of prenatal
care) focus on broader health determinants.

A commentary accompanying the report points out that the infant
mortality rate in the USA showed the first increase in 40 years,
ranking the USA 28th internationally. Yet, like many other USA
analyses, the emphasis for action is primarily health care-related
with a consistent, though undeveloped call to address persistent
disparities, particularly among racial/ethnic groups.

A few innovative local public health initiatives address broader
determinants of health. Many of these are state-level initiatives
occurring under the auspices of a Robert Wood Johnson Foundation
program (25). The predominant activity of these is the creation of
data bases and community networks to meet basic public health
functions. Only Minnesota has highlighted broader determinants of
health and the role they play in health inequalities. A Call To
Action: Advancing Health for All Through Social and Economic Change
calls for public policy action to influence the broader determinants
of health (24). However, a new governor has modified the health
department mandate threatening this unique emphasis. A noteworthy
exercise taking place in New York City is the Agenda for a Healthy
New York where an alliance is educating the public with the goal
influencing a range of broader determinants of health (79).

In summary, public health activity in the USA is characterized by a) a
focus on providing access to health care access to its citizens; b)
ethnic and racial disparities in health rather than a range of health
determinants; c) a reluctance to consider the role structural aspects
of society such as the distribution of economic and social resources
play in influencing health; and d) a blind-spot as to the broad public
policy antecedents of these determinants.

The Role of Public Health in Linking Population Health and Public

Clearly, structural analyses of population health have had little
penetration into public health discourse. The increasingly
conservative public policy environment in the USA associated with
reduced assistance payments, reduction of entitlements to the poor,
and growing income and wealth inequalities combines with Americans'
generally negative attitudes towards the roles of governments to make
an activist public health agenda problematic (3, 9, 80).

The focus on racial and ethnic health differences represents a
carryover from the civil rights activities of the 1960s as well as the
intellectual and political barriers to addressing issues of income and
social class (81). The effects of this is remove increasing income and
wealth gap among Americans and issues important to the majority of
Americans such as wages, employment security and working conditions,
as public health issues. The focus on health care represents a
reasoned response to an egregious situation whereby over 45 million
citizens are not insured for health care costs. But again, the effect
of this focus is to divert attention from a variety of health
determinants whose quality is rooted in the public policy processes.

There are no shortage of suggestions on how public health researchers
and workers could begin to address the structural issues that shape
the presence of health inequalities and the USA population health
profile (37, 42, 82). It is not my intention to repeat these here.
What is obvious is that for the most part these suggestions have not
been taken up to any discernible degree by the public health community
in the USA. Why might this be the case?

In a series of interviews with prominent health researchers and policy
advocates across the USA, I investigated the reasons for public health
neglect of these broader issues. No surprises emerged from these
analyses. The rise of neo-liberal and neo-conservative forces --
reflecting both a breakdown of the post-war consensus among
government, business, and labor and the legacies of the Reagan
Revolution -- have served to actively suppress virtually all public
health activity related to addressing broader determinants of health.
This is especially the case for issues related to income and as noted
by Navarro,(56) social class as an object of inquiry and analyses has
always been the subject of derision by academic researchers,
policymakers, and elected officials.

Difficulties in addressing broader determinants of health and their
public policy antecedents is not a problem of evidence, it is a
problem of political will on the parts of public health researchers
and workers and their governmental masters. This analysis suggests
three key roles public health workers and researchers could play in
raising these issues: education, motivation, and activation in support
of the social determinants of health. These activities would help
build the political supports by which public policy in support of the
social determinants of health could be implemented. Each is considered
in turn.


In the USA the general public health community and the American public
-- remain woefully uninformed about, and stubbornly resistant to the
concept and implications of the social determinants of health. At a
minimum public health researchers and workers could carry out -- and
publicize the findings from -- critical analysis of the social
determinants of health and their role in influencing health. There is
no shortage of areas in which these activities could take place:
social determinants of health such as poverty, housing and food
insecurity, and social exclusion appear to be the primary antecedents
of just about every affliction known to humankind. My short list of
such afflictions includes coronary heart disease, type II diabetes,
arthritis, stroke, many forms of cancer, respiratory disease,
HIV/AIDS, Alzheimers, asthma, injuries, death from injuries, mental
illness, suicide, emergency room visits, school drop-out, delinquency
and crime, unemployment, alienation, distress, and depression.
Examples of such analyses and critiques of the dominant paradigms are
available (83, 84).


Public health researchers and workers can shift public, professional,
and policymakers' focus on the dominant biomedical and lifestyle
health paradigms to a social determinants of health perspective by
collecting and presenting stories about the impact social determinants
of health have on people's lives. Ethnographic and qualitative
approaches to individual and community health produce vivid
illustrations of the importance of these issues for people's health
and well-being (85). There is some indication that policymakers -- and
certainly the media -- may be responsive to such forms of evidence
(86). In addition, community-based activities allow community members
to provide their own critical reflections on society, power and
inequality (87-89). These approaches allow the voices of those most
influenced by the social determinants of health to be heard and hold
out the possibility of their concern being translated into community
and political activity on their part and policy action on the part of
health and government officials.


The final role is the role that is the most important but potentially
the most difficult: supporting political action in support of health.
There is increasing evidence that the quality of any number of social
determinants of health within a jurisdiction is shaped by the
political ideology of governing parties (35). Nations with a larger
left-cabinet share from 1946 to the 1990s had the lowest child poverty
rates and highest social expenditures; nations with less left-share
had the highest poverty rates and lowest social expenditures (36).
Poverty rates and government action in support of health -- the extent
of government transfers -- is higher when popular vote is more
directly translated into political representation through proportional
representation (38).

The USA has never had members of a left political party in federal
government. The USA does not have a viable left party (90, 91) and
some argue the Democratic Party does not qualify as a center party
applying international baselines. Similarly, the strength of the labor
movement is a strong determinant of both public policy and population
health (92). The USA has the lowest union membership density (13%) and
lowest collective agreement coverage (14%) of any wealthy
industrialized nation (93). Strengthening workers' rights to organize
and improve wages, benefits, and employment security is clearly a
public health issue that requires action in the political sphere (94,
95). The implications are clear: population health will be improved by
support of political parties, governments, and policymakers that
propose public policies in favor of health. Public health in the USA
would be well-served by diverting at least a small portion of current
focus and activities towards these broader issues. Some beginnings
have been made in this direction in the USA (24, 79, 96-98) and
certainly numerous examples from outside the USA are available (28,
52, 99-101).


A political approach to addressing health inequalities and promoting
population health recognizes the public policy conditions necessary
for health. These conditions include equitable distribution of wealth
and progressive tax policies that create a large middle class, strong
programs that support children, families, and women, and economies
that support full employment. While the USA has become an outlier
among wealthy industrialized nations in its public policy approaches
in favor of health, American history shows that there have been
periods of progressive activity and legislative action in support of
its citizens (102). There is also increasing recognition that the USA
model of public policy is inappropriate for meeting the challenges of
a post-industrial economy (103). Political reversals are possible in
democracies. The United Kingdom emerged from two decades of neo-
liberal conservative rule to elect a labor government in 1997
committed to reducing health inequalities. New Zealand took a similar
neo-liberal course during the 1990s, but has now reversed direction.
Ideologies are malleable and national social policies can be changed.

The best means of promoting population health and reducing health
inequalities through a social determinants of health perspective
involves citizens being informed about the political and economic
forces that shape the health of a society. Once so empowered, they can
consider political and other means of influencing these forces. This
is not a role that public health researchers and workers have
considered their own. It appears rather a daunting task, but one that
hold the best hope of promoting the health of citizens in the USA. Is
this possible?


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 a Healthy
New York. 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. 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.