If you woke up this morning and put your feet on the floor in Moosenee, Iona, Bella Coola or Longlac, then the chances are that your health is poorer than if you were greeting the day in any major Canadian city. Overall, rural folk have lower life expectancy, more injury, chronic disease and mental health concerns, higher rates of smoking, alcoholism and drug misuse and poorer perceptions of their own mental and physical health than Canadian urban dwellers. There are inequalities in health outcomes between rural and urban residents, as well as among other subpopulation groups in Canada. I argue for a more nuanced look at the unfairness of inequalities and what we can do collectively to find ways to address them.
Given the general health benefits that we tend to assume with country living , being further removed from the pollution, fast-food and the fast pace of urban life, why are rural areas so hazardous to health? This is an important, although not easy, question to answer. The links between income, income inequality and health have been demonstrated. People with higher incomes generally enjoy better health, and people in more income- equal societies are generally healthier and live longer, as well. Rural Canadians certainly face unique challenges in obtaining and maintaining steady income and this has an influence on their mental and physical health. However, the Public Health Agency of Canada has identified eleven other broad categories of factors that determine our health. These include social support networks; education and literacy; employment/working conditions; social environments; physical or built environments; personal health practices and coping skills; healthy child development; biology and genetic endowment; health services; gender; and culture. By considering this myriad of determinants, it is not difficult to understand why health outcomes might vary by place of residence.
All Canadians should have the freedom to be able to choose where to live, but should rural people accept some health limitations simply because of geography? Generally, people in rural and remote areas know they will likely have to travel further to get access to certain kinds of health care, and they know the services available to them in their own communities may be limited (for example, in the number or variety of health care professionals available, the types of specialized programs and services and the frequency and variety of possible health promotion activities or interventions). Rural people may also more often choose to drive off-road vehicles or own and operate firearms, for example, and these are personal choices that may be linked to potential health hazards. These are inequalities, but I do not believe that they are all situations that necessarily need to be addressed by public programs and services.
The rural experience of inequality in Canada goes beyond differences in access to tertiary level health care or the free and personal choices people make. Some rural residents eat a poor diet because healthy food is either not affordable, or in the case of some traditional foods, no longer available. This is unjust. Some rural people have higher rates of heart disease, cancer and diabetes because of dramatic changes that have occurred in their diet and activities of daily living, changes that are directly related to colonialism, environmental degradation or a more globalized economy. This is unjust. Some rural people suffer from depression or addictions because of social isolation or lack of meaningful livelihood. Cod fishers, pulp workers, coal miners, hunters and gatherers, small farmers – these people are experiencing many health inequalities but some of them are particularly unjust and it is these we should be focusing on.
In Canada, rural people suffer more injuries than in urban places, but simply comparing injury rates between urban and rural populations isn’t the most important analysis. Instead, we should ask, are unnecessary injuries happening because children are unsafely exposed to machinery on farms, for example? Are occupational health and safety training measures sufficiently available to commercial fishers? Are health promotion interventions appropriately provided in rural schools? Are necessary emergency preparedness procedures in place to at least provide some kind of minimal response if traumatic injury occurs in rural areas? A simple rural-urban difference in injury may not necessarily be unjust, but differences in these kinds of situations, programs or services would be.
The distinctions I am making may seem obvious to many readers, but when the term “inequality” is used, it may focus our gaze on “unequal” situations rather than focusing on a more nuanced understanding of equality as it relates to justice, fairness or equity. These concepts are critical in any discussion of equality. Concerns for social justice and equity have been taken up in Canada and globally for many decades. I would encourage more reference to this material, and in general, more of this kind of nuance in our discussions of inequalities in Canada.
Dr. Colleen Davison is Adjunct Assistant Professor, Community Health and Epidemiology and Global Development Studies at Queen’s University.