Certain Canadian commentators are bringing forth a strange critique of public health, suggesting that physicians and public health experts, charged with caring for the health of Canadians, should not concern themselves with the root causes of illness and stick to a narrow range of health interventions.
Fortunately, Canadian health experts have a broader and more complete understanding of how and why people get sick. They aren’t satisfied with simply pulling drowning kids out of the river; though this is obviously important, they also look upstream to ask why kids are falling in the river in the first place. Decades of studies have shown conclusively that income and its distribution, education, employment, housing, food security and the wider environment have far greater impact on health outcomes than health care. I see this borne out daily in the lives of patients whose life circumstances have limited their ability to be enjoy full health.
These upstream factors touch on all aspects of public policy. Our health is determined by political choices. If we want the best for Canadians, shouldn’t our political choices be determined by health?
There is a growing international movement, supported by the World Health Organization, toward “Health in all Policies,” an approach that has been adopted by governments around the world. Here in Canada, Quebec has such a policy, and Newfoundland and Labrador is currently exploring this model.
The notion that is facing the greatest scrutiny is one that has been expressed most clearly in the British Medical Journal: “The more equally wealth is distributed the better the health of that society.” There are three key ways in which wealth inequality can lead to worse health outcomes. The first, and most obvious, is poverty. In a less equal society, more people live in relative disadvantage, and are less able to afford safe housing and nutritious food or to access educational and economic opportunities. Their health suffers as a result, with people living in poverty often having life expectancies 20 or more years shorter than wealthier citizens. In my inner-city neighbourhood in Saskatoon, that manifests in rates of diabetes, heart disease, STIs, infant and overall mortality many times greater than the rest of the city.
The second way that inequality affects health is not confined to the most disadvantaged. As Wilkinson and Pickett described in their 2009 book, The Spirit Level, and further elaborate in a 2015 article for Social Science and Medicine, significant evidence suggests that people living in less equal countries suffer from worse physical and mental health, even if they are at or near the top of the socioeconomic scale. Something about greater inequality — be it higher levels of crime, greater strain on the social safety net, or even higher levels of stress — appears to harm the health of all but the very wealthiest members of a society.
Thirdly, new evidence suggests that it’s not only the people in unequal countries that are sicker; it’s their markets as well. The OECD reported in 2014 that income inequality is at its highest level in 30 years, with economic growth slowed by as much as ten percent in some countries as a result. An IMF study from the same year showed that redistributive policies can improve economic performance in the long term. Many experts, including economists at TD bank, are consequently calling for action on income inequality. Greater levels of inequality damage the economy, worsening the material conditions of all who participate in the economy, and with them their health and wellbeing. Given that inequality has grown significantly in Canada, with the richest 20% now holding 67.4% of wealth in this country, this is an issue of great concern.
This understanding of the connection between inequality and health is growing among the general public. A series of town halls hosted by the Canadian Medical Association on the health of Canadians resulted in a report titled “What Makes Us Sick”, showing that Canadians recognize the influence of income, housing and education on their health.
With Canadians increasingly waking up to the need for an upstream approach to health and politics, those who actively oppose social investment and greater equality are sure to take aim at the notion of health as a guiding principle in public policy.
This is beyond unfortunate, as addressing the upstream determinants of health can both improve the economy and the ability of that economy to provide for the wellbeing of Canadians. That’s a hopeful and compelling idea, and, to some, a dangerous one. The fact that it’s receiving so much press attention suggests it’s an idea whose time has come.
Ryan Meili is an expert advisor with EvidenceNetwork.ca, a family physician in Saskatoon and founder of Upstream: Institute for A Healthy Society. @ryanmeili