Under-Served: Health Determinants of Indigenous, Inner-City, and Migrant Populations in Canada. Akshaya Neil Arya, A. N., & Thomas Piggott (Editors). Canadian Scholars, 2018, 424 pages

Under-Served brings together multiple perspectives (academics, healthcare providers, and policymakers) to examine factors — including the social determinants of health, and family and community contexts — that influence the health and healthcare of what has been categorized by the authors as under-served populations in Canada: Indigenous Peoples, migrants including refugees, and special populations (people experiencing homelessness or poverty, people who use opioids, people who are incarcerated, and LGBTQ+ people). Needless to say, all of these social categories are of interest to social work insofar as their social status is potentially precarious.

This book is definitely aimed at a medical and public health audience for whom there is a need to broaden training to include an awareness of how political, social, and cultural contexts affect health practices and both individual and population health.

The book repeats what is already known in public health: health and health inequities are the result of living and working conditions, the health system, and behavioural and individual factors. For example, health results from access to resources and opportunities, including but not limited to healthcare services. From a theoretical perspective, Dennis Raphael (Chapter 2, pp. 23–38) also recalls the need to focus on the causes of the causes: life circumstances are themselves shaped by political ideologies, social organization, and economic policies. It is these elements that are categorized as social structure, within which Raphael (and other authors) does not forget to include two other types of historical state powers — colonialism and racism. Raphael does not, however, fully explain how these powers and their deleterious consequences have evolved over time, or how their entanglement with capitalist ideology and liberal economies produces social inequalities.

Among chapters of special interests, Hanna Gros’s, on mental health in prisons (Chapter 18, pp. 246–252), is especially welcome, because this area of research and practice is often overlooked, even in social work. Gros raises important issues such as human rights, isolation, and family issues.

Lesley Cooper et al. (Chapter 24, pp. 327–340) remind us of the importance of taking into account one’s own cultural values, social position, and power in the care relationship with marginalized populations, such as Indigenous Peoples. Thus, the authors discuss the necessity for students and health professionals to reflect on various issues related to power and systems of privilege (e.g., White and male privilege), values and perspectives, and oppressive behaviours that can impact the care relationship. It seems obvious that these contextual elements plus principles of social justice and equity are already, and hopefully, part of social work education. The question here is: to what extent are these elements systematically and universally taken into account in social work education and practice?

In Chapter 25 (pp. 341–351), Ryan Meili and Thomas Piggott remind us that, often, the dominant discourse about health is limited to healthcare, medicine, technology, and biomedical- and hospital-centred logic. Indeed, it is this approach that the Canadian political system — both federal and provincial — advocates, as we saw during the COVID-19 pandemic. Meili and Piggott remind us that health services play only a minor role in terms of public health. In this, health professionals need to understand that it is social factors (e.g., income, education) that determine behaviour and ultimately health. Thus, the determinants of health are structural, and the political system should be changed, think Meili and Piggott (p. 348). So the observation is made and consists of repeating what we have known for a long time, but that is too often set aside: the structural level is the main source of inequalities. The authors focus on making the care relationship fairer and more equitable, which is already a relevant step.

This book is therefore important for several reasons. One of them is to make some marginalized social categories of the population more visible. It shows that ideological factors shape the role that the state plays in relation to who can access what. Ideology therefore shapes the redistribution of and access to wealth. The fundamental question is: at what level should action be taken to reduce social inequalities in health? Answering this question should consider the historical links between public health, medicine, and the state — a discussion that does not appear in the book. It is therefore not surprising to note that, as Anne Andermann points out (Chapter 26, pp. 352–363), the health sector contributes to the production of health inequalities, when it should rather promote health equity. It is indeed a famous paradox but a reality: the health system in Canada does contribute to health inequalities. We see it over and again, and especially now, during the COVID-19 pandemic.

Andermann makes the same observation. Health workers can contribute to making changes toward health equity starting from the individual level (via a quality care relationship) to the community level (through an identification of health needs and through partnership). The question on ways to create structural change toward more equitable policies and more supportive environments for health — through activism or advocacy — remains less clear and much more challenging. In this regard, Philip Berger et al. (Chapter 27, pp. 364–370) describe a campaign led by doctors to protest against federal cuts to refugee healthcare. Other ways to advocate, inform the public, and act against similar injustice can be undertaken by participating in social media, traditional media, art, or debates.

As suggested by Neil Arya (Chapter 28, pp. 371–378), “societal attitudes and policies can transform rapidly” (p. 376). Yet, social change toward equity and inclusion remains a challenge in Canada. That being said, reducing social inequalities requires, among other things, reforming certain policies and privileges. Some of these are discussed by the authors; others are not. For example, the authors do not discuss the high salaries of medical doctors and the indexation of their wages, which represents a significant proportion of the annual increase in the budget dedicated to the healthcare system, as is the case in Quebec. Would medical doctors give up certain privileges? Other issues that are not really discussed here include the persistence of medical fee-for-service financing, the privatisation of the healthcare system, and healthcare coverage that is not fully universal.

Some authors raise the need to integrate the social sciences in these domains, but do not say more. Not much is said either about the necessity and relevance of inter-professional collaboration in these areas, even though the book is partially a transdisciplinary initiative. The book does not theorize explicitly or in detail social interventions that could be interesting for social workers.

Finally, two things are regrettable: firstly, the absence of an article on climate change and how it might worsen conditions of vulnerability in Canada, and the role of health and social services professionals in this context. The second is the absence of authors from the French-speaking academic or institutional environments. This latter absence seems paradoxical, when we know that linguistic minorities are also to be seen as potentially vulnerable social categories.