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Globalization and the health of Canadians having a job is the most important thing

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Background: Globalization describes processes of greater integration of the world economy through increased flows of goods, services, capital and people. Globalization has undergone significant transformation since the 1970s, entrenching neoliberal
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  RESEARCH Open Access Globalization and the health of Canadians: ‘ Having a job is the most important thing ’ Ronald Labonté 1* , Elizabeth Cobbett 2 , Michael Orsini 3 , Denise Spitzer 4 , Ted Schrecker 5 and Arne Ruckert 6 Abstract Background:  Globalization describes processes of greater integration of the world economy through increasedflows of goods, services, capital and people. Globalization has undergone significant transformation since the 1970s,entrenching neoliberal economics as the dominant model of global market integration. Although this transformationhas generated some health gains, since the 1990s it has also increased health disparities. Methods:  As part of a larger project examining how contemporary globalization was affecting the health of Canadians,we undertook semi-structured interviews with 147 families living in low-income neighbourhoods in Canada ’ s threelargest cities (Montreal, Toronto and Vancouver). Many of the families were recent immigrants, which was anotherfocus of the study. Drawing on research syntheses undertaken by the Globalization Knowledge Network of the WorldHealth Organization ’ s Commission on Social Determinants of Health, we examined respondents ’  experiences of threeglobalization-related pathways known to influence health: labour markets (and the rise of precarious employment),housing markets (speculative investments and affordability) and social protection measures (changes in scope andredistributive aspects of social spending and taxation). Interviews took place between April 2009 and November 2011. Results:  Families experienced an erosion of labour markets (employment) attributed to outsourcing, discrimination inemployment experienced by new immigrants, increased precarious employment, and high levels of stress and poormental health; costly and poor quality housing, especially for new immigrants; and, despite evidence of declining socialprotection spending, appreciation for state-provided benefits, notably for new immigrants arriving as refugees. Jobinsecurity was the greatest worry for respondents and their families. Questions concerning the impact of theseexperiences on health and living standards produced mixed results, with a majority expressing greater difficulty ‘ making ends meet, ’  some experiencing deterioration in health and yet many also reporting improved living standards.We speculate on reasons for these counter-intuitive results. Conclusions:  Current trends in the three globalization-related pathways in Canada are likely to worsen the health of families similar to those who participated in our study. Keywords:  Canada, Globalization and health, Labour markets, Housing, Social protection, Immigrant health Introduction The impact of globalization on the health of individualsand societies has received significant attention in academiasince the onset of the contemporary phase of globalizationin the early 1970s. The literature examining their relation-ship includes both positive and negative accounts of theeffects of the global integration of finance and productionon population health. The health gains of globalizationostensibly relate to the economic benefits derived from in-creased international trade, investment, and product inte-gration and associated reductions in the prevalence of poverty [1]. Negative health aspects of globalization citedin the literature include threats to public health and gov-ernment ’ s regulatory policy space from multilateral and bi-lateral trade agreements, structural adjustment policies,and growing income and wealth inequalities [2]. These re-flect, in turn, the increasing importance of what a  Lancet  Commission described as  “ transnational activities that in- volve actors with different interests and degrees of power ” ([3] pp.630). A smaller set of studies has focused on the * Correspondence: rlabonte@uottawa.ca 1 Globalization/Health Equity, Professor Faculty of Medicine, Institute of Population Health, University of Ottawa, 1 Stewart Street, ON K1N 6N5Ottawa, CanadaFull list of author information is available at the end of the article © 2015 Labonté et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the srcinal work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article,unless otherwise stated. Labonté  et al. Globalization and Health  (2015) 11:19 DOI 10.1186/s12992-015-0104-1   various links between globalization and social determi-nants of health (SDH), defined broadly as the working andliving conditions that determine people ’ s abilities to leadhealthy lives [4-7]. One of the key insights of the SDH lit- erature is that the health effects of globalization are almostnever uniformly distributed, with disparities in access toSDH widening [8].Building on the recent trend in globalization studies togive greater voice to marginalized groups [9-11], our article offers an in-depth narrative account of how globalizationprocesses are shaping the health experiences and outcomesof disadvantaged Canadians across three cities: Vancouver,Toronto, and Montreal. We explore how relatively poorfamilies with children living in conditions of personal andgeographic (neighbourhood) deprivation are being affectedby three globalization-related pathways: labour markets,housing markets, and social protection programs. Wedocument that the re-shaping of working conditions andthe rise of precarious employment (pathway #1) is thedominant pathway by which globalization shapes livedexperiences and health outcomes of low-income familiesliving on the economic margins. While most interview re-spondents did not directly reference social determinants of health when describing challenges to their own health,social conditions loomed large, with lack of jobs as themost commonly cited source of stress and health chal-lenge to them and their families. However, given theway in which different social determinants of healthinteract and reinforce health outcomes, we also explorehow housing affordability (pathway #2) and welfare re-trenchment (pathway #3) reinforce existing inequitiesin access to SDH in Canada. In the current climate of austerity, amidst cutbacks to social protection measuresand affordable housing programs and the rapid ascend-ancy of precarious forms of employment, the need toexamine how the health effects of globalization mani-fest on the margins of society becomes all the morepertinent.In this paper we report on findings from a qualitativestudy of low-income families with young children livingin relatively deprived neighbourhoods in Canada ’ s threelargest cities (Montreal, Toronto and Vancouver), with anemphasis on immigrant families. The focus on low-income families arose from earlier work that identified agrowing gap in the median incomes of families raisingchildren in Canada, with the bottom four deciles all show-ing declines between 1976 and 2006 (the last year forwhich comparable census data are available). The poorestdecile lost almost 70 percent, in contrast to the 30 percentincrease for the richest decile [12], indicative of a largerand global trend in income and wealth inequalities overthis 30-year period. Although government tax/transferprograms drove down child poverty rates in Canada overthis period (from 12.6 percent in 1981 to 9.5 percent in2007), the depth of those remaining in poverty grew [13],and Canada continues to lag in the bottom third of theOECD league table for child poverty [14].The emphasis on immigrant families reflects recentevidence of a more rapid deterioration of the  ‘ healthy immigrant ’  effect (where new immigrants tend to behealthier than those born in the country to which they migrate) and increased inequalities in their access tohousing, economic opportunities and income relative toCanadian-born persons [15-17]. Importantly, the loss of  the healthy immigrant effect is not uniform as racializedpersons and women, report the greatest deterioration intheir health and well-being over time [15,18-20]. We begin with a brief discuss of globalization and itsprimary health-influencing pathways. We then describeour research methods before presenting our findings orga-nized thematically by three pathways: labour markets,housing markets and government social protection pol-icies. We next locate these findings within a broader litera-ture on globalization before some concluding remarks onthe prospects for improving health equity in the presentCanadian political context for the families in our study. Background Globalization increasingly conditions and constrains gov-ernments ’  economic, social and health policy choices [8].Although globalization is not new, most political econo-mists agree that it has undergone substantive transform-ation since the 1970s [21]. Oil price shocks, economicrecessions, and anti-inflationary monetarist policies in theworld ’ s economically dominant countries precipitated adeveloping world debt crisis. This crisis combined witha neoconservative political backlash in the wealthiercountries (primarily the USA, UK, and Germany) andthe collapse of the Soviet Union led to entrenchment of neoliberal economic theory as the dominant globalorthodoxy. Broadly stated, this theory contends that theeconomy is too complex for governments to regulate,and that free markets, sovereign individuals, free trade,strong property rights, and minimal government inter-ference are the best means to enhance human well-being. Although srcinally propounded in the 1940s,neoliberal economics only began its global ascendency with the imposition of structural adjustment programsby the international financial institutions in response tothe 1980s developing world debt crises [22,23], and subsequently through the proliferation of trade and in- vestment liberalization treaties that increasingly imposeconstraints on public policy that go far beyond simply removal of border barriers to trade see e.g. [24-27]. Neoliberal governance entails a restructuring ratherthan a weakening of states [28-30], giving rise to vari- ous national policy responses (c.f. [31,32]). Labonté  et al. Globalization and Health  (2015) 11:19 Page 2 of 16  These broadly sketched global trends formed thebackdrop for an interdisciplinary research program thatset out to study the effects of globalization on thehealth of Canadians (2006 – 2012). Our project adoptedJenkins ’  definition of globalization as transnational eco-nomic integration:  “ a process of greater integration withinthe world economy through movements of goods and ser- vices, capital, technology and (to a lesser extent) labour,which lead increasingly to economic decisions being influ-enced by global conditions ”  ([33] p.1). Key elements of thisprocess include: world-scale reorganization of productionacross multiple national borders, which combines trade,foreign direct investment, and outsourcing, to create new and volatile patterns of integrative trade [34]; increasedmobility of both direct investment and financial capitalas a result of financial deregulation and increased cap-ital mobility, changes in the mix of financial institutions,and advances in information and communications tech-nologies; and the emergence of genuinely global labour andproduct markets [35-37]. Drawing on the parallel work of the GlobalizationKnowledge Network of the World Health Organization ’ sCommission on Social Determinants of Health [38,8], we identified three globalization-related pathways that exist-ing evidence suggested influence the health of Canadians:   Labour markets: decline in manufacturing, rise of precarious and non-standard employment, andpolarization of incomes between a minority of knowledge workers and a majority of service andindustrial workers [37,39-41]   Metropolitan land use and housing markets:speculative investments, real estate bubbles, spatialsegregation and problems of affordability [42,43]   Social protection measures: rise of the competitive( ‘ business friendly  ’ ) state and changes in scope andredistributive aspects of social spending, alongsideimpacts of tax competition, neoliberal economicpolicies and expansion of offshore financial centersand capital flight [44-47] The different connections between these three path-ways and health results have been well established in a variety of academic analyses from a social determinantof health perspective [4-6,41,45]. However, this is not to suggest that globalization is the only or even dominantfactor in shaping theses pathways. Housing and labourmarkets and social protection measures are all informedby domestic institutional arrangements and culturalnorms of acceptability within society. While we acknow-ledge the importance of such domestic forces, our ana-lysis focuses on the globalization-related pathways fortwo principal reasons: firstly, a full analysis of both do-mestic and external forces, and how such forces relate toeach other, was outside of the remit of the study. Sec-ond, we assume that many domestic factors are them-selves (indirectly) influenced by external pressures andglobalization processes. This is probably best evidencedby the role of international financial institutions in therestructuring of labour markets and social protectionpolicies, especially in low-income countries; but sincethe global financial crisis this is also increasingly the casein high income countries. Methods The three cities were chosen for reasons beyond their size.They were all experiencing job-loss due to out-sourcing of production to lower-wage countries; housing costs wererising rapidly; all three were major recipients of immigrantpopulations; changes in federal and provincial tax policieswere reducing the percentage of provincial GDP allocatedto social protection spending; and existing studies in allthree cities had established important shifts in the geog-raphy, depth and dynamics of poverty for low-incomefamilies [48-52]. We developed our neighbourhood sample using adeprivation index comprising seven variables from the2006 Canadian census (see Table 1). Census tracts thatscored high on the deprivation scale were selected inconsultation with researchers familiar with neighbourhooddynamics in each of the three cities. Two neighbourhoodswere chosen in each city: one from within traditional urbanboundaries where new immigrant arrivals first settle andareas of high poverty concentration persist; and another inthe peri-urban area. The rationale for the second geo-graphic site was fourfold: (1) such neighbourhoods (notably in Toronto and Vancouver) were becoming repositories of new immigrant and lower middle-class families due tohousing affordability issues; (2) they were most likely tohave experienced de-industrialization given the peripherallocation of factories; (3) they were likely to involve lengthy commuting times for employed persons; and (4) they werelikely to be under-served by public transit and other publicfacilities. The exception to this geographic sampling wasMontreal; as an island, it had no peri-urban equivalent; thetwo neighbourhoods studied are both in the centre.There were neighbourhood differences, as well. Vancouverneighbourhoods had a higher portion of recent immi-grants than those in Toronto and Montreal, reflectingmigration from Asia. The unemployment rates in theMontreal neighbourhoods were double or more thanthose in Vancouver. Vancouver ’ s urban neighbourhoodhad the lowest percentage of population with below high school education. This reflects its high rate of recentmigration and Canada ’ s  ‘ point system ’ , which is biased infavour of immigrants with post-secondary or tertiary educa-tion since educational attainment is accorded a high num-ber of points towards immigration eligibility. Vancouver ’ s Labonté  et al. Globalization and Health  (2015) 11:19 Page 3 of 16  Table 1 Neighbourhood Deprivation Index Characteristics 2006 VANCOUVERDepriv- ationrankingMunicipality - locationdescription% of Populationliving below LICOafter tax% of Children<age 6 living belowLICOafter taxUnemploy-mentrate (15 yrs and over)% below highschool education(15 yrs and over)% Lone-parentfamilies% Recent immigrants(Jan/2001 to May/2006)% of Renterspaying >30% of income on rent & utilities 15 Vancouver - LowerMarpole (urban)30.7 27.4 8.5 9.1 20.2 40.2 38.04 Surrey - Guildford Town Centre (peri-urban)38.0 55.5 7.6 25.6 31.2 47.1 32.4 TORONTODepriv- ationrankingMunicipality - locationdescription% of Populationliving below LICOafter tax% of Children<age6 living below LICOafter taxUnemploy-ment rate(15 yrs and over)% below highschool education(15 yrs and over)% Lone-parentfamilies% Recent immigrants(Jan/2001 to May/2006)% of Renterspaying >30% of income on rent & utilities 13 South Parkdale (urban) 39.1 56.1 9.6 20.3 32.4 20.0 48.66 Black Creek (peri-urban) 44.7 61.4 14.8 40.0 45.9 11.0 27.4 MONTREALDepriv- ationrankingMunicipality - locationdescription% of Populationliving below LICOafter tax% of Children<age6 living belowLICOafter taxUnemploy-ment rate(15 yrs and over)% below highschool education(15 yrs and over)% Lone-parentfamilies% Recent immigrants(Jan/2001 to May/2006)% of Renterspaying >30% of income on rent & utilities 6 Côtes-des-Neiges (CDN) 48.3 71.9 19.8 24.4 22.5 24.8 45.810 Parc-Ex 45.3 71.0 18.7 40.0 21.5 22.3 37.3 L   a  b   on t    é    e  t    al     . G l     o b   al    i    z  a t   i     on an d  H  e  al     t   h     (  2  0 1  5  )  1 1  :  1  9   P   a   g e4   of     1   6    urban neighbourhood also had the lowest percentage of population living below the low-income cutoff (LICO), ameasure of relative poverty based on families spending 20percent more of their income on food, shelter and clothingthan the average family, adjusted for family and community size. Montreal ’ s Côte-des-Neiges (CDN) neighbourhoodtopped the list with almost half of the population and thehighest percentage of young children living below theLICO. Toronto ’ s peri-urban neighbourhood had the lowestpercentage of renters paying more than 30 percent of in-come on rent (much of the housing in this neighbourhoodis subsidized) while the urban neighbourhood had the high-est percentage.Researchers in each of the three cities aimed to recruit25 families in each neighbourhood. Eligibility criteria werethat the families lived within the selected census tract (or very close to the boundaries of that tract), and had at leastone parent and one child 19 years or younger living athome. Recruitment consisted of distribution of a posteradvertising the study through community agencies, localchurches, food banks, elementary schools, housing co-ops, local restaurants, and private businesses. Some re-cruitment also occurred through snowball sampling.Recruitment was generally successful in reaching thetypes of families in which our study was interested. (seeTable 2) In Toronto and Montreal respondent families weregenerally poorer and more likely to be unemployed thanthe 2006 census tract (neighbourhood) averages. This wasnot the case in Vancouver, however, where poverty and un-employment rates in our sample were lower than the 2006averages. Vancouver had higher rates of both full time andpart-time employment, particularly in the urban neighbour-hood, where housing prices would be unaffordable other-wise. Respondents in all six neighbourhoods were morelikely to be immigrants than the 2006 averages, a deliberatepart of our sampling strategy. Most respondents ’  childrenwere under 15 years of age, with many under five. The ma- jority of respondents were female. Interviews took placeduring the day. A striking difference between the three cit-ies is the high educational attainment in the Vancouverurban neighbourhood, the low educational attainment inboth Toronto neighbourhoods and, considering the highunemployment and poverty rates, the comparatively higheducational attainment in both Montreal neighbourhoods.Interviews lasted between 45 and 90 minutes at locationschosen by the participants, with most taking place in re-spondents ’  homes. Vancouver interviews occurred betweenApril and November 2009 (n=50), Montreal interviews be-tween November 2009 and November 2010 (n=47), andToronto interviews between August 2010 and November2011 (n=50). The semi-structured interview schedule wasdesigned to elicit responses that captured participants ’ Table 2 Interviewee Characteristics VANCOUVER (n=50)Municipality - locationdescriptionSex (#) % of families withchildren living belowLICO (before tax) 1 % full timework  2 % part-timework  2 % un-employed 2 % immigrants 3 % with high schooleducation or less 4 Vancouver - LowerMarpole (urban)22 F,3 M12 50 30 4 73 4Surrey - Guildford TownCentre (peri-urban)23 F,2 M32 43 15 9 59 37 TORONTO (n=50)Municipality - locationdescriptionSex (#) % of families withchildren living belowLICO (before tax) 1 % full timework  2 % part-timework  2 % un-employed 2 % immigrants 3 % with high schooleducation or less 4 South Parkdale (urban) 23 F,2 M68 17 15 37 88 56Black Creek (peri-urban) 22 F,3 M50 42 14 22 76 64 MONTREAL (n=47)Municipality - locationdescriptionSex (#) % of families withchildren living belowLICO (before tax) 1 % full timework  2 % part-timework  2 % un-employed 2 % immigrants 3 % with high schooleducation or less 4 Côtes-des-Neiges (CDN) 17 F,5 M77 11 22 39 91 23Parc-Ex 25 F 92 20 0 49 100 28 1 Average number of children/ household before tax 2006 LICOs for municipalities >500,000 population. 2 Employment status based on both respondent and respondent ’ s spouse; % do not equal 100 as some respondents reported being students, stay-at-homeparents, or on disability allowance. 3 Based on both respondent and respondent ’ s country of birth. 4 Respondents only, excludes college, trades certificate/diploma, university. Labonté  et al. Globalization and Health  (2015) 11:19 Page 5 of 16
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