Food Insecurity as Social Determinant of Health: The Case for a Canadian National School Lunch Program

ACEEL HAWA

One can understand human health in a very narrow context; that is to say, healthcare, as a service delivered to patients that has objective measures of efficiency and impact – how good drugs or procedures or advice are and whether they are available in sufficient amounts. If you broaden this definition, one can consider access to care, and whether systemic inequalities create barriers to patients receiving the care they need. Financing of care is another important corollary here; whether state or private structures exist in sufficient capacity to ensure care is available in sufficient quantities and at the needed times. Even more broadly, appropriateness of care can ensure culturally-linked delivery and is connected tightly to sufficient training of healthcare workers and carers. All this however, still only scratches the service of what it means to live a healthy, productive life, and the various elements of one’s living that contribute meaningfully to health outcomes.

As a major part of the post-2015 sustainable development global agenda, the World Health Organization defines the social determinants of health as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” A laundry list of relevant SDOHs have been adapted for the Canadian context and include: “income and income distribution; education; employment status and working conditions; early childhood development; food insecurity; housing; social exclusion and social safety networks.” There also exists an additional subset of SDOHs that comprise various immutable and intrinsic characteristics that intersect with healthcare access and outcomes, including race, gender, indigenous status, sexual identity, disability-status, age cohort, and all other ancillary demographic trends.

This article is tasked with assessing a novel solution to improving health, and has decided that school lunch programs, implemented and financed by national or provincial/territorial remit, ought be considered as a valuable strategy for mitigating food insecurity, reducing the impacts of poverty, and more specifically, improving health outcomes in vulnerable populations during the formative stages of early childhood development.

The first step to understanding this policy lever is to scope the problem. Food security is defined by the Food and Agriculture Organization (FAO) of the United Nations as when “all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life.” In Canada, food insecurity is measured via Statistics Canada’s Canadian Community Health Survey (CCHS), a cross-sectional survey administered to approximately 60,000 Canadians per year. It may come as a major surprise to those enamoured by progressive conceptions of Canada’s social welfare programming, that in 2012 results compiled by Valerie Tarasuk et al., the nation reported over 1.15 million cases of children experiencing food insecurity. This number is contextualized by a staggering 1 in 6 Canadian households having experienced some level of food insecurity – a status that includes “concerns about running out of food before there is more money to buy more, […] inability to afford a balanced diet, […] going hungry, missing meals, and in extreme cases, not eating for a whole day because of a lack of food and money for food.”This is, therefore, a major moral and policy failing for Canadian governments and one that must be addressed.

The next step is to understand what this gap means for healthcare outcomes; the link between food insecurity and human health has been widely studied and understood. Canadian research suggests that hunger experiences can have significant impacts on child health – with depression and asthma incidence being highly correlated – and on adult health – with incidence of chronic conditions like depression, heart disease, and diabetes highly correlated. Along the developmental timescale, childhood undernutrition has strong links to poor cognitive development and underperformance in school. Moreover, food insecurity can drive poor school attendance, reduced social safety nets, and lower attainment in daily activities, which can all themselves reinforce poor health outcomes as SDOHs. One must also be careful in all this not to conflate caloric attainment with nutrition, and therefore not to ignore the nutritional value of the food being consumed. Nutritional adequacy as a concept suggests that is not sufficient to ensure that Canadian children are simply fed the required amount of energy to sustain them, but that the food being consumed is combatting the downstream problems associated with limited and poor diet, namely that it promotes neither deficiency nor imbalance in nutrition.

The next step is to assess inequities and understand how this gap manifests itself across a heterogeneous population; that is to say, are the impacts of this food insecurity felt broadly and evenly across the Canadian population or do they specifically disempower certain groups? The highest rates of food insecurity were found to be located in Canada’s north, with Nunavut as ground zero for the problem resting at 45.2% of households experiencing food insecurity. This self-evidently localizes some of the worst effects to Canada’s First Nations, Inuit, and Métis peoples – though it is another great moral failing that the CCHS survey results do not include Canada’s homeless population, nor residents of its reserve system, where more than half of Canada’s Indigenous peoples live. It would nevertheless be unsurprising if within the available provincial breakdowns, the phenomenon was at its most acute in reserves, homeless shelters, and the low-income neighbourhoods in which a plurality of these most vulnerable groups reside. Moreover and most relevantly to this article’s policy proposal, a report by Statistics Canada suggests that among the most pronounced inequities in this policy area is how food insecurity affects children; children were the age demographic that most disproportionately experienced food insecurity and “[e]ven when the other potentially confounding factors such as household income […] were considered, children still had almost five times the odds of living in a food-insecure household as did seniors.” Policy solutions that are targeted at this community are therefore essential.

Now, let’s put it all together. We know that food insecurity is broadly prevalent in Canadian society, disproportionately impacts vulnerable subgroups and children in particular, and has inextricable links to health outcomes from a SDOH perspective, again with pronounced and multidimensional impacts on children. This represents, therefore, a substantive call for action. Enter: school lunch programs.

Writing in The Tyee, Katie Hyslop reminds us that “as a variety of media organizations have noted, Canada is the only country in the G7 group of leading economies or the 34-nation Organization for Economic Cooperation and Development (OECD) without a national school food program.” Moreover, Lynn McIntyre, writing in Policy Options, argues that “Canada’s response to food insecurity has remained community-based, ad hoc, and largely focused on the provision of free or subsidized food”; the decentralized nature of our current system means the country is dependent on loose coalitions of community groups, public health agencies, and district school boards to provide children with consistent and nutritious meals. This stands in stark contrast to the United States, whose National School Lunch Program (NSLP) reached reaches 92% of US students and is utilized by 56% of that group.

What would a “Canadian National School Lunch Program” policy look like? The specific programmatic nuances of such programs have been expounded on in a myriad of research papers within this academic niche, and suffice it to say there are an exhaustive list of variants (for example, should a program by opt-in or opt-out). A reductive examination would suggest that a few consensus items exist: namely that the program provide low cost or free meals to qualifying students, disbursed via schools, with funding progressively earmarked to districts with the highest need and lowest ability to meet those needs. A more rigorous breakdown of delivery, quality, financing, governance, and ethics is beyond the scope of this paper.

This article will conclude with three caveats in this regard. First, the cost of such a policy may prove the most substantive impediment to its implementation; the NSLP itself costs around $8.7 billion per year to service more than 30.5 million children daily. This being said, economies of scale suggest that the government’s purchasing power likely presents the most cost efficient way possible of ensuring children get fed, and moreover, some evidence suggests downstream health economics cost savings (manifested in reduced service need, higher level of educational and income attainment, etc.) of the NSLP in the USA, suggesting that maybe the financial case isn’t as clear cut as the red ink would suggest. It will therefore be essential for civil society to be an advocate on this issue to shape a countering narrative in which this can become an important area of focus for policymakers reticent to increase the budget deficit.

Second, the proposed school lunch programs cannot and should not exist in a vacuum. To work best, they will require (a) protecting the affordability of healthy, staple foods like milk and vegetables through subsidy, waiver, price control, or tax incentive; (b) substantial government commitment to anti-poverty policymaking; and (c) the establishment of a strong and enforceable monitoring regime to watch for gaps in the program’s delivery, be it geographic, financial, or governance-related. Each of these complementary areas of focus would require significant time to unpack and assess, but are worth mentioning given the cross-cutting interconnectedness of this policy area, and social determinants of health writ large.

Third and finally, in necessary complement to the previous points, advocates must be careful not to treat anti-poverty policies as a panacea to these food insecurity challenges. While it is undoubtedly true that income and socio-economic status are some of the most significant predictors of household food insecurity, to problematize the issue as simply an unfortunate byproduct of poverty is to link it to a larger, more lethargic and divisive debate that has raged throughout the Canadian polity for decades – that is to say, talking about food insecurity in the context of poverty politicizes what ought be a technocratic issue and may ensure the problem languishes as a footnote in larger economic policymaking rather than receive the full and concerted approach it deserves.

For Canada to pride itself on its healthcare system, it needs to provide more than just the barebones – a spectrum of services, policies, and programmes to address the upstream factors contributing to human health and well-being is essential, especially when the state has thus far failed to ensure adequacy and equity of outcomes for its most vulnerable populations. A national or provincial school lunch framework is both a moral necessity and policy victory.

 

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