Addressing the social determinants of health

Addressing the social determinants of health

GUEST COMMENTARY Addressing the social determinants of health David Butler-Jones, MD, MHSc, LLD (hon), FRCPC, FACPM, CCFP, is the Chief Public Health...

682KB Sizes 0 Downloads 57 Views

GUEST COMMENTARY

Addressing the social determinants of health David Butler-Jones, MD, MHSc, LLD (hon), FRCPC, FACPM, CCFP, is the Chief Public Health Officer of Canada

“The health of the public is the foundation upon which rests the happiness of the people and the welfare of the state.”—Benjamin Disraeli, British Prime Minister, 1877

A deeper understanding of what makes us healthy One of life’s greatest challenges is re-imagining our place and purpose in the grand scheme of things, even if it means fine-tuning our usual ways of doing business. When I began my career as a clinical physician, public health was one of the last places I saw myself. My passion was clinical medicine. I was, and remain, fascinated by the mystery of clinical diagnosis. I loved being in a position to provide care and support to others. It did not take long, however, to recognize that there was much we could do to keep people out of the emergency room in the first place. If we were only sending people right back into the conditions and environment that contributed to their ill health, what good had we ultimately done? How much more could we, collectively, do for Canadians by looking deeper into those problems? Taking into account what Sir Michael Marmot refers to as the “causes of the causes,” it is hard to argue against the virtue of ensuring everyone has clothes on their backs, adequate shelter, access to nutritious and safe food, a good education, employment, and income. Yet, despite a century of progress and evidence, we often still do not see beyond the surface level the value of those factors that make up the social determinants of health (Fig. 1).

A 30,000-foot view In general, Canadians are the healthiest they have ever been. We are enjoying a higher life expectancy and a lower infant mortality rate on average than at any other time in our country’s history. In fact, Canada is one of the healthiest countries in the world. The bad news is not all health trends are improving. We cannot rate our collective health and well-being by looking only at those who are healthiest nor can we focus only on averages. Those averages mask very important details and differences. As we move forward as a nation, we cannot neglect those that opportunity has left behind; we must recognize that socioeconomic and health inequalities prevent a proportion of our population from achieving their potential health

Figure 1. The social determinants of health. (Reprinted with permission Dahlgreen G, Whitehead M. European strategies for tackling social inequities in health levelling up part 2. World Health Organization; 2006.)

130

Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012

GUEST COMMENTARY

and well-being. Despite progress in many areas, existing health inequalities are, in fact, preventing Canada from becoming as healthy and productive as it could be. Socioeconomic determinants such as education, income, housing, and the environment play a vital role in overall health and in reducing these gaps. The challenge lies in addressing the determinants, as a society, as deeply to their roots as much as possible because they are complex and multifaceted. Poverty is, after all, a constellation of deprivations that includes not just income but also our sense of influence, hope, and control over our own future, and these, in part, rely on a host of social factors.

Made-in-Canada approaches So, how are we doing as a society in eliminating the growing gaps between us? What is being done at the government level and internationally? What examples can we point to that we, as individuals and collectively, can emulate and adapt to address the social determinants of health? In Canada, 100 years ago, there were no public pensions. Senior citizens were more likely to be economically disadvantaged than other citizens. Basic sanitation, food inspection, social work challenges, disease control, and inadequate housing topped health agendas. However, from Disraeli’s time onward, there was recognition that public health is the first public good in health, and it is a shared role of governments to address the well-being of communities. Living conditions began to be seen as important to health, and by the 1970s these conditions became enshrined in Canadian policy. Medicare, unemployment insurance, and affordable housing all formed part of the “foundation,” in Disraeli’s terms, of our health and happiness as a people and the success of our country. The federal Old Age Security pension came about in the 1950s, followed by an income-tested Guaranteed Income Supplement, Spouse’s Allowances, and provincial and territorial supplements. Canada moved from having one of the highest rates of income-disadvantaged seniors among industrialized nations to one of the lowest, contributing to a great extent to health and wellness in this country. Governments, the private sector, not-for-profit organizations, communities, and individuals continue to undertake initiatives across the country to close the gap on health and social inequalities. In this country, one does not need to look far to find examples. Quebec’s Family Policy, ActNow BC, Healthy Child Manitoba, Nova Scotia’s Eskasoni Primary Care Project, Pathways to Education, Breakfast for Learning, and Habitat for Humanity’s provincial and territorial programs are only a few of the initiatives leading the way involving public, private, and voluntary sector organizations. These are some of the promising models we can act on moving forward. We have also seen success with federally funded programs, such as the Aboriginal Head Start in Urban and Northern Communities Program, which supports community-based projects focused on early childhood development for First Nations, Inuit, and Metis children and their families living in urban and northern communities. Recently, the Government of Canada also announced a $21 million investment in 11 new research programs to help improve health equity, and Canada’s Innovation Strategy provides direct support to communities and a base of practical knowledge on effective interventions that will be shared with other communities and partners across Canada. At all levels, governments are working together to create environments supportive of health at the community level, such as child development programs and initiatives to prevent diabetes, hepatitis C, and HIV. At the Public Health Agency of Canada, we reflect the importance of social determinants through our long-term strategy. Internationally, Canada is also proud to be a part of a renewed global focus on addressing the social determinants of health. Canada participated actively in the World Health Organization’s Commission on Social Determinants of Health, which was set up to link knowledge with action, highlighting the fact that health status is a concern to all policy makers.

The imperialism of the immediate Yet, the major roadblock preventing us from pushing the agenda forward is one, fundamentally, of attitude. Unless more of us deepen our focus on the margins, our future is less optimistic. Immediate concerns raise the spectre of, in essence, losing the notion of the preventive dose. Short-term imperatives still need a counterpoint. The statistics back that philosophy. Although, for example, in Canada, the number of years lost to premature death has been declining overall, Canadians living in northern regions lose many more years to premature death than the national average. This is in large Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012

131

Butler-Jones

Figure 2. Age-adjusted prevalence of chronic conditions among First Nations adults compared with the general Canadian adult population. (Reprinted with permission from First Nations Regional Longitudinal Health Survey [RHS]).

part caused mainly by unintentional injuries, suicides, and self-inflicted injuries. Additionally, some 11% of the Canadian population still live in poverty (Fig. 2). The gap between those with the highest and lowest incomes is also widening because incomes of the richest 20% of the population are increasing faster than the incomes of the poorest 20%. One in 10 households with children, particularly young children, do not always have enough food. A total of 13.7% of Canadians report being unable to access acceptable housing. About nine million Canadians perform below the literacy level considered the minimum necessary to succeed in today’s economy and society. The percentage is even higher for certain groups, including seniors, immigrants, and Aboriginal peoples. A deeper understanding of the roots of these conditions will go a long way to influencing, individually, what our future may look like. What about acting on the problem? What can each of us do to improve these situations? I would argue that today conditions are ripe for Canadians to aim to be the healthiest nation with the smallest gap in health between the most and least advantaged individuals.

Re-imagining our place and purpose When it comes to what really can be referred to as a shared responsibility to act on the social determinants, I often use the acronym PACEM as a way to remember. It’s Latin for peace, but it really is about Partnership, Advocacy, Cheerleading, Enabling, and Mitigation—partnership in terms of finding those who have a shared view willing to work together to identify and respond to issues and acting through those relationships; advocacy in terms of identifying the issues, bringing forward practical options that policy makers, governments, and others can draw on to make a difference; cheerleading in terms of supporting what works and stopping what does not, keeping the bigger picture of health for all in mind; enabling through encouraging best practices and applying them in our own situations by not putting up barriers to personal initiative; and mitigation by picking up the pieces when needed and starting again. Individual choice, family, and community self-determination are critical for good health. Good evidence and supports, so that healthier choices are easier and accessible options, allow individuals to thrive. At the basic levels of public health in Canada, we recognize problems, see what the underlying causes are, and work with the people closest to those problems to support and adapt solutions. Every point beyond that community stage, whether provincial, municipal, territorial, or interdepartmental – at every stage, vertically and horizontally, we need to bring another layer of value. We 132

Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012

GUEST COMMENTARY

need to not so much sacrifice our jurisdictions but rather share them. As Samuel Johnson said several centuries ago, “It is amazing what you can accomplish when no one has to take the credit.” There is a role for everyone—it is not just about government or about doing for others, it is about the positive synergy of individual and collective responsibility and applying the right incentives and practices to achieve the most positive outcomes. The actions that are the most effective, the least intrusive, and with the fewest side effects are crucial; after all, there is no such thing as expertise we do not need. In dealing with the social determinants of health, everything is connected. It is the uptake of this transformative philosophy that will determine our way forward. Regardless of our expertise, we share the same economic and demographic challenges. We see the same risks in many social, economic, and geographic issues, and we see how working upstream to improve public health has so many benefits downstream on the economy, on productivity, on the health care system, and in so many other ways. The big picture surrounding us is evolving with increasing clarity at national and international levels. Even if it involves re-imagining what we do and how we do it, fully understanding and addressing global challenges through the prism of social determinants is more than a noble goal. It is about our shared vision and commitment to act in concert to address the health needs of all Canadians. It is how communities work together to look after one another, and it is just good public policy.

Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012

133