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In even the wealthiest countries there are pervasive and stark differences in health by neighbourhood and region, race, socio-economic conditions and opportunities, and other liens of social and economic inequality. Many governments are trying to develop comprehensive policy and programme action to address these health disparities. One at the municipal level is the Greater London Authority in England: it issued a report identifying key issues and priorities for action in August 2007. As foundations for its action plan, the GLA had published a comprehensive review of the evidence base and an overview paper mapping the policy context for strategies and activities to address health inequality.

As Bob Gardner explains in his recent article, Thinking Globally, Acting Locally about Health Reform (in a special edition of Making Waves), it is by understanding and focussing on health disparities on a regional basis, in particular within the structures of Regional Health Authorities, that on-the-ground strategies to reduce health disparities can be developed and implemented. Ontario is in a position to do this now, with the recent establishment of the Local Health Integration Networks. As Bob notes, there have been some interesting and effective examples of initiatives undertaken in other jurisdictions in Canada and internationally where there is a demonstrated commitment to health equity. Bob also points out that a great deal can be learned by sharing promising practices .

If "what is to be done" about health disparities is a question that plagues you, read Bob Gardner's article. We can make a difference by thinking globally and acting locally about health reform.

... that's the only way to describe the urban health landscape in the United States, the richest country in the world and the self-proclaimed leader of the "free" world. I've been in Baltimore for the International Conference on Urban Health and on Thursday afternoon was invited to visit parts of the inner city. I visited Paul's Place, a soup kitchen for homeless and low-income people; and Homeless Health Care. I drove along streets where homeless people wander, and where poor families live in grossly substandard housing, and where thousands of homes are abandoned as the middle and upper-income people have fled to the suburbs.

Perhaps the most terrifying visit was to the University of Maryland's Shock Trauma Centre, which treats about 7,000 gunshot and other victims of violence. This is a state-of-the-art facility with literally millions of dollars in equipment and staff devoted to one goal: Patching up the thousands of poor people who stream through its doors as victims of urban violence. There is a separate emergency room for other patients.

Virtually all the patients to Shock Trauma are poor and have no health insurance. Most of them are black, and almost all are either victims of gang violence, or members of gangs who have been shot or stabbed. Dr. Carnell Cooper and his surgeons have an amazing success rate: 97% of the people who are alive when they enter the facility are patched up and sent on their way.

Dr. Cooper and his team despaired of the revolving door at Shock Trauma: Many patients would come back time and again, since they were discharged back into the terrible urban neighbourhoods where they were assaulted in the first place. The toxic mix of poverty, racism, gang violence, drugs, housing insecurity and a deliberate policy of neglect by almost all levels of government contributes to the steady flow of patients at Shock Trauma.

In recent years, there is a tiny ray of hope. Dr. Cooper has engaged victims of the violence and others in a multi-disciplinary team to tackle some of the devastating social and health conditions that breed the epidemic of violence. They've had remarkable success among the several hundred young people (men and women) that they have worked with. Recidivism is way down - which means less costs to the system, and less damage to the neighbourhoods. He doesn't have the resources to address the most fundamental issues (lack of affordable housing, lack of jobs, shortfalls in education, and so on), but he is making a real difference by simply engaging the victims.

You'd think that politicians and policy-makers would embrace Dr. Cooper and his team, if only because they are saving taxpayers' money, but the pattern of official neglect continues.

In 1918, at the end of the First World War, Dr. Charles Hastings, Toronto's first medical officer of Health, delivered his inaugural address to the American Public Health Association. He directly linked health and democracy:

"Every nation that permits people to remain under the fetters of preventable disease, and permits social conditions to exist that make it impossible for them to be properly fed, clothed and housed, so as to maintain a high degree of resistance and physical fitness, and that endorses a wage that does not afford sufficient revenue for the home, a revenue that will make possible the development of a sound mind and body, is trampling a primary principle of democracy under its feet."

"Health is a prerequisite to the enjoyment of life. We do not only want life, but we want it more abundantly. As Farrand has expressed it: "To make a country really safe for democracy, we must first make it healthy." We have heard much about making the world safe for democracy, but have we a democracy that is safe for the world? This must be assured."

"Will any of the democracies of today stand the test?"

By Dr. Hastings' standard, the Government of the United States of America stands condemned of failing in this most basic test of civilization.

On the final day of the Baltimore conference, we heard from Congressman Elijah Cummings, who put a more contemporary focus on the issue. He noted that the Bush administration is stalling on a bill that would provide basic health care to children (the United States doesn't have a comprehensive health care plan and as many as 50 million Americans are denied access to even the most basic primary care). He spoke of a young boy in Baltimore who died of an infection caused by tooth decay because he was denied access to basic health services.

Congressman Cummings ended with this statement:

"If President Bush can spend $196 billion on Iraq and Afghanistan, then we can afford universal health care."

That's an old tabloid headline, but it's part of the new environmental reality as Toronto declares another extreme heat alert today (August 2).

Extreme heat can be deadly, and there are people who are more vulnerable: the elderly, people with certain illnesses, people taking certain kinds of medication, children. And it's harder for some people to avoid the heat and smog, such as poor people living on the top floor right under the hot roof of a rundown rooming house in the downtown's east end.

The City of Toronto has some practical advice on surviving the extreme heat, but we need to do more than just cope. Last year, the Wellesley Institute released its "Cool Toronto" strategy - a mix of short, medium and long-term policy proposals.

Global climate change is a BIG issue, of course, and its local cousin (what the experts call "urban heat island effect") is equally challenging.

Instead of just sweating and silently cursing the weather, Toronto can take action to cool things down.

Kate Meyers of the Kaiser Permanent Institute for Health Policy has done a comprehensive and insightful review of the research literature on race and health disparities in the US. The goal of her paper is to help develop a clear conceptual and multi-sectoral analytical framework to understand disparities and a platform from which better policy analysis, planning and action can truly impact the problem. She highlights the inter-dependence of a range of factors in four arenas: individuals' social and economic circumstances, including the interrelationships between race and class; communities' physical and cultural environments, not just the importance of built environment in neighbourhoods but also of social capital and community capacities; personal health management and behaviour, but always within a social determinants approach; and health care system financing and delivery. She reviews issues such as cultural competency and diversity and their intersection with the increasing focus on patient-centred care. She emphasizes that how issues are framed shapes the kinds of policy directions considered and adopted and argues, for example, that social justice and quality of care lenses are not mutually exclusive, but are different and we do need to be clear about which frame we are using. She then develops a model in which policy directions and actors can be identified on key issues in each of these four arenas, recognizing that many policy directions can have a cross-sectoral impact. The model is very interesting in graphically portraying the complexity and inter-dependence of the policy landscape for tackling health disparities. However, while this may be due to the American context in which the paper is written, a significant gap is the lack of analysis of the role of governments as over-arching policy, regulatory and funding forces across these arenas. A vital foundation for reducing disparities " and a key focus for community and advocacy groups -- is progressive and integrated state policy that supports targeted interventions addressing the roots of disparities and the most disadvantaged communities, and the necessary cross-sectoral collaboration and coordination across the full range of inter-dependent factors and spheres.