Canada's leadership in addressing the social determinants of health
Canadians in general enjoy very good health and the average lifespan of Canadians has increased by more than 30 years since the early 1900s. Where we live, learn, work and play--the social determinants of health--can have a great impact on how long and how well we live. In other words, the chances of becoming sick and dying early are greatly influenced by social factors such as education, income, nutrition, housing and neighbourhoods. Indeed, the roots of most health inequalities are social.
Canada has long been regarded as an international leader in addressing the broad determinants of health and strengthening community involvement in public health processes. Since confederation in 1867, there has been a movement in Canada lobbying for collective action, initially to tackle unsafe water and sewage disposal systems, overcrowded and slum housing, poverty, malnutrition, and unsafe food and milk.
Universal public schooling in Canada began in the late 19th century and inspections of students in schools by public health nurses started in 1907. Public health confidence increased in the 1920s, with notable initiatives to protect child and maternal health. The Great Depression in the 1930s and the experience of WWII led to the development of universal programs such as Family Allowance that brought a significant measure of security to people's lives.
The first Director-General elected to the World Health Organization (WHO) was Canadian Dr. Brock Chisholm and the Constitution of WHO, drafted in 1946, famously defined health as "a state of complete physical, mental and social well-being." One of WHO's core functions was to promote "the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene" as required to achieve health progress.
By the mid-1960s, it was clear in many parts of the world that the dominant medical and public health models were not meeting the most urgent needs of poor and disadvantaged populations. The landmark 1974 report, New Perspectives on the Health of Canadians (also known as the Lalonde Report) was among the first studies to propose a comprehensive framework for understanding health determinants and to acknowledge the limited role of health care in improving health. By 1986, there was greater emphasis on the key determinants of health, driven by the federal report, Achieving Health for all: A Framework for Health Promotion.
Later that year, WHO, Health Canada, and the Canadian Public Health Association jointly hosted the first International Conference on Health Promotion in Ottawa, at which the Ottawa Charter for Health Promotion was adopted. The Ottawa Charter identified key determinants ("prerequisites") of health: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity. Improvement in health requires a secure foundation in these basic prerequisites and health promotion should aim at making these conditions favourable.
In 1999, federal, provincial and territorial governments in Canada endorsed a population health approach, which focuses on the 'upstream' causes of health outcomes. This population health model aims to address the interrelated conditions and factors that influence people's health over the life course.
Health inequities both within and between countries, however, have continued to increase. There is a gap in life expectancy of more than 40 years between the richest and poorest countries. The Commission on Social Determinants of Health was set up by the WHO in 2005 to consider the evidence on what can be done to promote health equity, and to foster a global movement to achieve it. Canada has been a significant contributor to this work. The Commission calls for closing the health gap in a generation. The three principles of action are:
- Improve the conditions of daily life--the circumstances in which people are born, grow, live, work, and age
- Tackle the inequitable distribution of power, money, and resources--the structural drivers of those conditions of daily life--globally, nationally, and locally
- Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health
In Canada today, the medical care system continues to absorb the majority of health sector resources, with less than 3% of health spending allocated towards health promotion and prevention. In 2008, the Chief Public Health Officer reported on the broad determinants of health and how they contribute to health inequalities. Major health disparities persist between various groups in Canadian society. For instance, the life expectancy of First Nations and Inuit peoples is 5-10 years less when compared to Canadians more generally. Indeed, for each gradient up or down in social and economic standing, there is a corresponding and equivalent positive or negative movement in health status and life expectancy.
Many of the consequences of these health inequalities are avoidable and are costly not only to individuals and families but for the health system and society in general.
For more information
- Commission on Social Determinants of Health, Final Report, World Health Organization, 2008
- The Chief Public Health Officer's Report on the State of Public Health in Canada, 2008, Addressing health inequalities
- Canadian Public Health Association response to the World Health Organization (WHO) Commission's Report, Closing the gap in a generation: Health equity through action on the social determinants of health, 2008