excellent. Thanks for sharing. I look forward to the book.
Ana Natale-Pereira, MD, MPH
Assistant Professor of Medicine
Division of Academic Medicine, Geriatrics, and Community Programs
30 Bergen Street ADMC-6-614
Newark, New Jersey 07102
Office: 973-972-8994 or 1744
Fax: 973-972-8799
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"Life is not measured by the number of breaths we take, but by the
number of moments that take our breath away"
(annonymous)
>>> [log in to unmask] 05/15/08 10:00 AM >>>
This foreword to SDOH: Canadian Perspectives, 2nd edition (forthcoming
October, 2008) was written by Dr. Carolyn Bennett, Liberal MP for St.
Pauls in Toronto..
FOREWORD
When Tommy Douglas brought our first universal publicly funded health
system to the province of Saskachewan, he passionately argued that
medicare must not only ensure that people get the health care they need
when they need it, but it must implement public policies for keeping
people well not just patching them up once they get sick.
Unfortunately since that time medicare has been pulled towards a
commitment to the ?service contract? of health care delivery.
Thankfully,
in Canada we have had Dennis Raphael sounding the alarm that just
focussing on the ?repair shop? is not only counter to our Canadian
values
of social justice, it will ultimately put the sustainability of our
cherished health care system at risk. His scholarship and dogged
advocacy
on the need to address the broadest possible approach to social
determinants of health has been a powerful antidote to the ?tyranny of
the
acute?.
It has been said that Canada led thinking on ?population health? with
the
Lalonde Report of 1974, ?New Perspectives on the Health of Canadians?.
In
1986 the Ottawa Charter identified 5 action areas for Health Promotion,
the fourth of which ?Building healthy public policy? called for: ?
complementary approaches, including legislation, fiscal measures,
taxation
and organisational change. Health promotion policy requires the
identification of obstacles to the adoption of healthy public policies
in
non-health sectors and the development of ways to remove them.?.
Since then, a tremendous amount of research has shown that health is
influenced by a wide range of policies and interventions that go beyond
health care. Interestingly, the Canadian Institute for Advanced
Research
estimates that only 25% of the health of the population is attributable
to
the health care system, while 15% is due to biology and genetic
factors,
10% results from the physical environment and 50% is attributable to
the
social and economic environments. Health can no longer be the sole
responsibility of the Ministers of Health.
Throughout this volume there is a profound sense of frustration that
despite the increasing discussions and evidence on the importance of
dealing with the social determinants of health, Canadian public
policymakers have been embarrassingly resistant to these concepts.
I believe that as long as citizens think of the ?sickness care system?
whenever they hear the word ?health? we are going to have real trouble
in
our efforts reorienting public policy to the social determinants of
health. Surely the production of health through poverty elimination or
workplace hazards reduction must fit side by side with a system
mandated
to operate emergency rooms and to reduce wait times for surgical
services?
Canadians must understand that upfront investment in the social
determinants of health today will prevent larger amounts of money being
spent on treatment and rehabilitation later on.
Dr. Halfan Mahler has said that ?Health is Politics? and that ?If you
want
to move healthy public policies forward, you have to have political
dynamite?. SARS, Kasheshewan, Hurricane Katrina or the heat wave in
France
in 2004 that killed over 14,000 have been important teachable moments.
I
believe we have done a terrible job of explaining the ?pay now or pay a
lot more later? economic arguments for investing in health to citizens
?.
? A stitch in time saves nine?, ? penny wise and pound foolish? are
axioms
we were all raised on. But the ?tyranny of the acute? means that
putting
new drugs on the formulary and a new gamma knife for the world class
surgeon becomes the squeaky wheel and active measures on the social
determinants of health take a back seat again and again. In Canada we
have
also suffered because the social determinants of health criss-cross
many
government departments and all jurisdictions. We have been unable to
break
through the ?gridlock? of jurisdictional squabbles and vertical
ministerial accountability for these complex challenges.
I think citizens do understand the social responsibility ? health as a
fundamental human need and therefore a basic human right and our moral
obligation to do the right thing. But if they or a loved one is waiting
on
a wait-list, they expect their politicians to immediately respond and
fix-it. The medical model still rules.
There is no question that the political will to ?do the right thing?
dramatically improves with an educated public. Health literacy means
that
citizens can be pulling healthy public policy from their governments
and
politicians. I am a big believer in bottom-up solutions and the
importance
of improving the methodologies for true civic efficacy.
However we have a formidable enemy in the sales department of modern
media. Simple messages and simple solutions fit on a bumper sticker
and
in a 7 second sound bite. Every day I am reminded of the quote of
H.L.Mencken ? ?For every complex human problem there is a neat simple
solution, it?s just that it?s wrong?. I believe that we must fiercely
defend the complex solutions for the complex problems that are facing
health and health care, but I believe we have to find simpler messages,
plain language if we are going to have citizens onside.
The WHO Commission on Social Determinants of Health, which is headed by
Sir Michael Marmot, is examining the ?social determinants of health?
and
?health inequities? but he is now brilliantly talking about the
?causes?
and the ?causes of the causes? that better explain the huge gaps in
health
outcomes.
Lately I have found that the following short health literacy quiz has
been
helpful in putting the public back into public health and replacing
?health care? with ?systems for health?.
HEALTH 101
1. Do you think we should have
a) strong fence at the top of the cliff or
b) state of the art fleet of ambulances and paramedics waiting at the
bottom?
2. Would you prefer
a) clean air or
b) enough puffers and respirators for all?
3. Would you prefer that wait times be reduced by
a) a falls program to reduce preventable hip fractures, or
b) private orthopaedic hospitals and more surgeons?
4. Should we invest in
a) early learning, child care, literacy, the early identification of
learning disabilities and bullying programs or
b) increase the budget for young offenders? incarceration?
5. Should we
a) assume that the grey tsunami will bankrupt our health care system or
b) include our aging population in the planning of strategies to keep
them
well?
6. Is the best approach to food security
a) food banks and vouchers, or
b) income security, affordable housing, community gardens and
community
kitchens and a national food policy?
7. Pick the one which is not correct
Pandemic Preparedness should focus on
A) Tamiflu for all
B) Working with the vets to keep avian flu a disease of birds
C) Making sure people wash their hands especially the doctors and
nurses
D) Research on vaccines
E) Community care plans for our most vulnerable
8. Should governments boast about
a) how much they spent on the sickness care system or
b) the health of their citizens, leaving no-one behind?
.
The profound structural change needed to secure investments in the
social
determinants of health in our complex federal system will only occur if
we
succeed in raising public awareness and developing political will. As
you
know, politicians tend to follow where the public goes, so helping the
public understand the issues and demand change from governments will be
crucial. For me, a major challenge in Canada is to make the public
understand, believe and take ownership that ill-health, poverty and
social
exclusion are unacceptable in one of the richest countries of the
world.
Progress towards a healthier world thus requires broad participation,
sustained advocacy and strong political action .
I firmly believe that this book provides an imperative for Canada to
move
from the description of the problem and the prescription of solutions
to
implementation of systematic and meaningful strategies and
interventions
to improve the health of our citizens and eliminate the inequity
particularly amongst our First Peoples.
Population health is ultimately a question of what kind of society we
wish
to live in. The aim of population health is for human health to be
seen
as one of the most important overall objectives of public policy.
This is about advocacy, leadership and action. It is about the civic
literacy of putting health back into health care. Dennis Raphael has
articulated a vision. The other contributors have shown us that real
solutions are out there in trenches. We need the political will to
harvest those solutions into better public policy, across government
departments and across the squabbling jurisdictions.
I was there that Friday night in November 2002 at York University in
Toronto for the opening of the conference Social determinants of Health
across the life-span. I remember hearing John Frank and Dennis Raphael
speaking so passionately about these things that seem so sensible and
doable.
This book updates the progress to date in the scholarship and evidence
of
the interventions that can improve the overall health of the population
and reduce health disparities ? which will allow tens of thousands, and
maybe even millions, of Canadians to lead longer lives in better
health.
This in turn will result in increased productivity, because a healthy
population is a major contributor to a vibrant economy; reduced
expenditures on health and social problems; and overall social
stability
and well-being for Canadians. Perhaps even more importantly, a focus
on
interventions to deal with the social determinants of health will
translate into a fairer and more equitable society.
Disraeli said that ?The care of the public health is the first duty of
a
statesman. Unfortunately in our present political system, statesmen, as
defined by James Freeman Clarke, are rare ? ?A politician thinks of the
next election, a statesman the next generation.? If this book were
compulsory reading for all elected officials and public servants, we
could
achieve not only a healthier, more equitable society but also the added
dividend of more statesmen!
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