Michael Wolfson is a former Assistant Chief Statistician at Statistics Canada and a current member of the University of Ottawa’s Center for Health Law, Policy and Ethics.
For the first time, a new study has assessed life expectancy across neighborhoods in Canada’s largest cities – the first in Canada to drill down beyond provincial and city boundaries to census tracts, the smallest geography that can support life expectancy estimates.
The results are disturbing.
Together with my colleagues, we examined 3,348 census tracts in the 15 largest cities in Canada, as well as those with reliable data in the largest cities in the United States. Variations in life expectancy between geographic areas are widely observed and are generally related to socio-economic factors such as income poverty and median household income. While overall life expectancy in Canada was about three years longer among the cities studied, we found differences of up to 20 years between one census tract and another, all in one major city.
Of Canada’s 15 largest cities, Victoria had the widest life expectancy, while Oshawa had the lowest. Victoria, St. Catharines, Ont., and Winnipeg had the largest associations between life expectancy and the poverty income ratio and median family income, while Vancouver and Toronto had the weakest associations.
Our results showed significant differences in life expectancy among cities in the same province. These findings are particularly salient in light of the frequent claims that health care is a provincial jurisdiction and thus their responsibility. The implication of these findings is that something about rural communities also has important effects on life expectancy and health inequalities.
Perhaps surprisingly, we also found that life expectancy between censuses in Canada’s largest cities could be as wide as in the six largest cities in the United States, where the variation was as much as about 20 years. However, there was a big difference when it came to income poverty: the US cities showed a much stronger relationship between life expectancy and poverty than in Canada’s six largest cities.
This is a mystery. On the one hand, the largest cities in both countries show similarly large variations in life expectancy by census tract. In contrast, income poverty explained much more of these health inequalities in the urban United States than in Canada.
What could be driving these health disparities in Canada, if not the usual socio-economic measures?
While Canada supposedly has “universal” health care (despite large gaps in dental, pharmaceutical, and long-term care) that is certainly much more universal than in the United States, this cannot be a strong explanation. There were differences in inequality in Canadian life expectancy between cities in the same province.
Another possibility is that Canada is significantly more egalitarian than the United States (although less egalitarian than some other OECD countries), which is reflected not only in terms of income inequality, but also in educational outcomes. Furthermore, and despite America’s rhetoric of being the land of opportunity, Canadians experience twice as much movement up (and down) the income ladder from one generation to the next as in America. And while there is increasing attention in the United States to “deaths of despair,” there is growing evidence that chronic stress is a more common cause of shorter life expectancy.
But something other than differences in national inequality must be at work. The significantly stronger relationship in each of the six largest US cities between life expectancy and the poverty rate can be attributed to greater racial segregation in US cities. While Canada also suffers from racial and other forms of discrimination, recent analyzes point to something more general: there is greater socioeconomic segregation in American neighborhoods, including but not exclusively by race.
In part, these wider differences in social and economic segregation may be due to very different municipal structures. In the United States, wealthy suburbs can “opt out” of supporting poorer neighborhoods in the same city by creating their own local governments and school boards. Conversely, recent waves of municipal and school board mergers in Canada’s largest cities mean that local public goods such as schools are distributed more equitably, with far fewer elected local authorities.
The results of our study raise important questions. Although Canada’s largest cities appear to have significantly reduced the link between income poverty and life expectancy relative to their American counterparts, why are the differences within them as large as in the United States? Even though health care is a provincial and regional responsibility, why can these patterns differ so much from one city to another within the same province? Is the merger of local governments and school boards the “hidden gem” of public health policy?
Now that we have the data, addressing these questions could reframe the discourse on health and health policy in Canada.
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