I am back on the “balcony of personal reflection,” and today I am joined by Louise Simard. Our conversation is instigated by an article we read on April 11, 2014  written by respected Globe and Mail healthcare reporter André Picard. The article noted the following: “Good health is the bedrock on which social progress is built. A nation of healthy people can do those things that make life worthwhile, and as the level of health increases so does the potential for happiness.” Those words were from an opening to a report titled, A New Perspective on the Health of Canadians. That was April 1974, over 41 years ago”.

Without warning the Ghost of Health Hope emerges…

“I am pleased you are discussing André’s piece, I hope others are reading it as well. I have to agree with him, the Lalonde report would be equally relevant if published today. Do you know why that is? It’s because so very few of its recommendations have been implemented. André went on to point out that in 1974, $10-billion was spent on healthcare. This year, a staggering $211-billion will be expended. Over the past 40 years, approximately $1.8-trillion will have been spent on Canadian healthcare. Of that $1.8-trillion, roughly 2 percent of the total healthcare spending has been allocated to prevention. Is the Canadian society any healthier in 2014 than it was in 1974?” 

Louise looks over at me and says: “It is true. For over 41 years, we the policy makers, operational leaders and front-line providers have talked the talk, but we haven’t walked the walk!” We have long known that the social and environmental determinants of health have a direct impact on the health of a society. But the Lalonde report is only one example of ‘the talk.’ Another report, Achieving Health for All: A Framework for Health Promotion (1986) emphasized the need to reduce social inequities amongst income groups as a way of improving the health of Canadians. 

In the 90’s and early 2000’s governments were re-organizing healthcare systems to achieve more integration and coordination in service delivery. And some jurisdictions, (such as Saskatchewan’s Wellness initiative [1992] and Prince Edward Island’s Health and Community Services Act), set a goal of promoting a population health perspective. These two provinces worked to develop stronger primary care based on the social determinants of health.

Alberta and Saskatchewan both instituted health boards with broad powers and established needs (population) based funding. This was intended to allow for a wide range of services, including significant programming on the social determinants. And in the early 90’s Saskatchewan established a Provincial Health Council to recommend strategies to incorporate the social determinants into health policy. The Provincial Health Council was disbanded a few years later. 

And again, in 1994, a meeting of the Ministers of Health in Canada resulted in the preparation of a paper named Strategies for Population Health: Investing in the Health of Canadians. The paper identified the determinants of health to be: 

1. Income and Social Status
2. Physical Environment
3. Social Support Networks
4. Personal Health Practices and Coping Skills
5. Education
6. Employment and Working Conditions
7. Biology, Genetic Endowment (today we would include “Epigenetics”)
8. Health Services
9. Healthy Child Development

Interestingly, health services, or healthcare, is only one determinant and not the most important one.

And more talk in 1996, a convention on Population Health Promotion: Bringing Our Visions Together was held in Saskatoon. It was attended by representatives from both provincial and federal governments. At that conference Greg L. Stoddart presented a paper, Toward An Understanding of the Determinants of Health - Together. His paper pointed out the considerable published evidence on the correlation between social and environmental determinants and the health status of an individual, or of a socio-economic group. Stoddart went on to say that large social class gradients in life expectancy by income, education and occupational class can be linked to specific diseases. Stoddart says:

The gradient story emphasizes, however, that it is not just a contrast between the very rich and the very poor, but something that is happening systematically, to us all, throughout all levels of the social hierarchy. A socio-economic gradient in health means that groups at every rung of the social ladder are healthier than those at the rung immediately below them (p.15, Population Health Promotion: Bringing Our Visions Together).

The effect goes across the entire socio-economic spectrum. Consequently, a disease-specific approach, or simply treating the illness, does not help us understand the underlying cause of disease among different groups.

I then asked Louise: “I’ve heard a lot lately in the news about early childhood experience as a determinant of adult health. In fact the Royal College of Physicians and Surgeons of Canada has just spoken out on this issue (Toronto Star, November 12, 2014). Adverse childhood experiences (ACE’s) can negatively impact adult health.”

Louise responds: “The explosion in brain research today answers, at least partially, some of the questions about the underlying cause of disease. Brain development is affected by what we are born with (our genes) and what we experience (our environments). We now know that our genes and environments interact, and experiences can switch genes ‘on’ or ‘off.’ This interaction during childhood lays the foundation for brain development and lifelong learning, behaviour and health. Early experiences literally shape the brain’s architecture. That structure can be strong, if early experiences are stimulating and positive, or it can be fragile, if they are not (p10, Fall 2012, Issue 8 “Apple,” Alberta Health Services).

The research on early brain and biological development (EBBD) establishes a connection between early adverse childhood experiences and later disease in adulthood. For example, adverse childhood experiences (ACE’s) such as poverty, neglect, prolonged toxic stress, addiction of a parent, parental depression, abuse in the family, chemicals and environmental stresses, and other adverse experiences can affect a person’s susceptibility to diseases such as cardiac disease, obesity, diabetes and addictions. The research also claims ACE’s can result in a change in gene expression and intergenerational transmission of the change in gene expression. This latter finding has profound implications for society, governments, communities, families and individuals.

The evidence of social gradients and EBBD advance the position that the health of an individual is, in general, influenced more by socio-economic status and/or life experiences than health care services with its downstream strategies. The common thread in these two bodies of research is that upstream strategies that focus on the determinants of health can result in positive outcomes and can mitigate negative effects of adverse experiences, and as a result have a more positive influence on health and productivity.

One would think that the plethora of evidence pertaining to the effects of social and environmental determinants on population health and individual health, and the research on the intergenerational transfer of a change in gene expression, should command attention from healthcare professionals, communities and governments at every level.”

I then ask Louise: “So why haven’t we moved more aggressively on broader, more comprehensive initiatives to implement policies that focus on the social and environmental determinants of health? What are the barriers that have stood in the way of progress?”

Louise continues, “We usually talk about the determinants of health in the context of population health or vulnerable populations (aboriginal populations or populations living in poverty). As a result, the majority of society fails to identify with the problem. It is not their problem, it’s someone else’s. However, this new research on EBBD and ACE’s is useful in that it makes it personal for all of us and illustrates that, regardless of who we are, our health is influenced by life experiences. And negative life experiences can be minimized or mitigated through programs that support individuals, families and communities. When the research on social gradients or EBBD is brought down to the “personal” level, we should be more successful in capturing the public’s attention.

So, if we reframed the healthcare discussion, we could succeed in changing our focus on health. But if we neglect to reframe our discussion, we will remain focused on the medical/acute care model and continue to tinker with waiting lists, more “lean” approaches and other fixes. The vast majority of our funding and healthcare training will continue to be focussed on treating illness as opposed to promoting good health. This outdated model will continue to hamper any progress towards improving health status, or sustainability of the health system, or improving productivity within society. Twenty years from now we will still be tinkering with the same fixes.”

I raise the concern, “But skeptics say it is impossible to reframe this discussion in the current political system, where sound bites and sensationalism is the main method of communication. We see media focusing on acute care issues within healthcare since it attracts the most attention from the public. Turf protection amongst health workers and institutions in the health care industry makes it difficult to divert money from acute care to community services.”

In a foggy puff, the Ghost, having listened to us patiently, interjects:

“Two very serious barriers to change are economic and politically vested interests blocking any significant redistribution of wealth within the country, and the four year election cycle just isn’t conducive to long-term planning.”

And then vanishes into a mist.

“A valid point,” Louise replies. “If we are going to convince the ‘powers’ of the economic benefits of upstream initiatives, a good first step would be to strengthen understanding about the determinants of health. We can do this by transferring knowledge of the empirical findings around the determinants and EBBD to the public and to all levels of government. The knowledge transfer requires a consistent and compelling message about the economic and other benefits to society, individuals and families.

Collectively, we have the power to make healthcare accountable. How can we continue to fail our citizens by treating the determinants as a second cousin to acute care? How can we continue to fail by not making upstream strategies a priority? After more than 40 years of being all talk, it is time for visionary leadership, strong action and courage! So Hugh, tell me, how do we make this happen?”

I reply, “‘We’, the principal actors in the system: governments, regulatory agencies, organizations, boards and senior managers, professional groups, etc., have either legal or moral authority to demand and promote action on the determinants of health. Some have both. But what is lacking at this time are questions that can be used to surface the assumptions we hold. If we do not explore our assumptions we will continue to be held hostage by our indifference, and ultimately limit any true improvement potential. “

Exposing our assumptions through questions can be uncomfortable, but let’s try.

The Role of All Health System Players

1. Do we play it safe with easily attainable goals? If so, why?
2. Do we demonstrate or support social determinants of health as a noble idea through action? If not, why?
3. Do we reflect upon our actions, and determine whether our behaviour is aligned with our commitment to the social determinants of health?

The Role of Governments

1. To what extent do legislation, high-level policy documents, accountability frameworks, and funding mechanisms incorporate social determinant health targets and expectations? Has government indicated this is a core value and aspiration? Are these expectations enshrined in effective legislation, regulation and policy?
2. Do governments communicate to regulation, licensure and accreditation authorities the importance of making social determinants of health a core expectation and requirement?
3. Do government Ministries and departments talk to each other? Is the right language being used to create a holistic conversation on the broader determinants of health?

Professional Cultures and Values

1. What is the hierarchy of values among professionals? Does the promotion of a “sickness model” trump everything else?  
2. How do professionals perceive their obligations and commitments to the social determinants of health?

The Ghost of Healthcare Hope re-emerges, and this time has a silvery glow and expresses hope…

“On behalf of all citizens, I hope for the following:

First, champions and opinion leaders stepping forward with strong, committed and determined leadership is essential. These leaders set the tone and encourage their members to rise above the special interests of their group and embrace a new approach, even if it means less of the pie for them.

Second, meaningful value-based consultation begins with the public and stakeholders.

Third, public understanding of the benefits is strengthened… If the public is onside, short-term progress can be made, and long-term sustainability of new initiatives becomes possible.

Fourth, develop a clear vision with clearly defined goals and a consistent message. The message should show the benefits to families and communities, to government and to society as a whole through enhanced quality of life for citizens, less disease and increased productivity.

Fifth, evaluation of value should be in place immediately once there is a commitment to new programming. Evaluation is critical to long-term sustainability of the policies.

Sixth, policies applied fairly and with flexibility across the full spectrum of services. Health care workers need to understand the rationale and see fair, nonpartisan implementation of policies.

Seventh, collaboration, throughout and between all levels, with national, provincial, territorial, and municipal governments including community organizations, schools, universities and industry. (See Stoddart, “Toward An understanding of the Determinants of Health--Together”)

Eighth, an overarching action plan with an overarching body that has the “clout” to apply a determinants lens to all initiatives and policies.

Ninth, the federal government has an important role to play to promote and encourage the knowledge transfer and targeted financial support for the implementation of a determinants approach.”

See essays in this series.

See essays from series 2

See essays from series 1

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