Canada gives great advice but fails to take it...
C ontroversies over public and private roles in health care financing and delivery aren’t the only ones worth exploring. There’s plenty to debate in the worlds of health promotion and disease prevention. Here’s a brief review of one of the most important.
Prevention. Politicians talk about it. Health professionals offer wise counsel, vaccines, screening and sometimes, medications. Manufacturers want to be able to make health claims to help market their products. The pharmaceutical industry is constantly on the lookout for vaccines and new drugs (or new uses for old drugs) with the potential to prevent a wide range of childhood and adult ailments. In fact nearly everyone is in the prevention game – even grandmothers offer sage (and sometimes not so sage) advice about how to stay healthy. And yet, when it comes to realizing the true potential of disease prevention and health promotion, we’re still light years away from actually implementing what the evidence suggests might work best.
And so, here it is the first week of 2008 and our thoughts, rather predictably, turn to the resolutions many of us have just made and will likely break before the month is out. Many will vow to quit smoking, lose weight, eat healthier foods and exercise more. All good ideas, widely understood to protect health and prevent disease. And yet quite a bit of important research suggests that all this focus on individual good behaviour may just be missing the boat. It’s a case of seeing trees rather than the whole forest.
Here’s the key point. The most potent levers for improving the health of Canadians are neither in the hands of individuals nor their health professionals. The real movers and shakers are our politicians and government workers. It is the laws they enact, the policies they set, and the regulations they enforce that have the greatest impact. And so, while health services play a role (and for certain individuals at certain times in their lives, a positively crucial role), it is a fairly minor role. Instead, what really makes a difference to the overall health of the population is the quality of our social, economic and physical environments. And these critical environments are, in large measure, determined by municipal, provincial and especially federal policies over, for example, taxation, pensions, education, transportation, child care, housing and environmental protection. Scandanavia, with its far more extensive social safety net and much greater emphasis on equity, gets this. We don’t.
Our failure is a bit embarrassing considering that Canada led the world in bringing forward these key ideas about the broad determinants of health, beginning in 1974 with the publication of the Lalonde Report: A new perspective on the health of Canadians and winning more accolades in 1986 with the release of Jake Epp’s A Framework for Health Promotion. Much subsequent research and theoretical development have refined our understanding about what these concepts actually mean– notably a wide ranging volume edited by Robert Evans, Morris Barer, and Ted Marmor about a decade ago and more recently, an important book by Dennis Raphael looking at how poverty affects health and our quality of life.
A key concept in this arena is how high levels of income inequality are not just damaging to the cohesive nature of our society but also to our health status.
The mediating factors appear to be related to the negative impact of higher stress on individual human biology, such that inferior social status confers heightened risk for all kinds of different illnesses. It is a fact that the mailroom clerk or factory worker who has little control over the pace or content of his work and low social standing is more likely to die prematurely of heart disease than the senior executive, even when controlling for risk factors like smoking, cholesterol levels, and high blood pressure. Perhaps more surprising is the fact that such differences occur at every level of occupation up the corporate ladder, with those in technical and professional occupations dying sooner than senior executives but later than those in clerical positions who in turn have lower mortality rates than the general labourer. This is also a relative finding – thus although similar step-like gradients are consistently found throughout the world within countries, there are also huge differences between countries. For example, in the United Kingdom, the healthiest and wealthiest die later than their compatriots but sooner than the sickest and poorest in Sweden. It isn’t a giant leap to propose that Sweden’s extensive social programs and more egalitarian society might have something to do with these results. As one further clue, a child in Canada is almost 4 times more likely be poor than one in Sweden.
For at least fifteen years, Dr. Fraser Mustard, founder and past president of the Canadian Institute for Advanced Research and Mary Gordon, founder and president of Roots of Empathy and an established leader in programming for children, have tried to influence key decision makers in Canada by bringing to their attention important research about the critical early years of children. This research forms the basis for clear-cut policy change, ranging from programs to help infants and their parents form secure attachments, to offering high quality daycare and kindergarten programs. The late Dan Offord made similar efforts to spread the word about how to improve children’s mental health and to clarify the payoffs and the penalties if we fail to act on what we know about resilience and how child-rearing, school and recreational practices can help to foster it.
How has Canada responded to these pieces of research-inspired advice? It’s disturbing to say that, as a general rule our leaders have moved in directions precisely opposite to those recommended by the evidence. Canada’s progress on the agenda for children has been truly dismal. As just one example, most provinces today still claw back the benefits from the key federal program aimed at helping poor children. Implementation of programs for early childhood development has been discouragingly slow – with some key retrograde moves, including the replacement of a federal cost-sharing scheme to create high quality daycare throughout the country with an ill-conceived $1200 cash payout to parents of pre-schoolers. Except in Quebec, no province is offering low-fee, high quality universal child care. Programs for kids with mental illness are also very much a patchwork, hit-or-miss affair. A recent comprehensive review by Dr. Gillian Doherty concluded that universal programs are a better investment of public funds than initiatives targeted at kids that “everyone knows will have difficulties.” Who believes such advice will receive acceptance in Ottawa? Both Dr. Offord before he died, and Dr. Mustard have had to look offshore to find more receptive audiences for their messages.
On the economic front, income inequality in Canada has worsened enormously since the Lalonde Report was published, despite more than three decades of generally positive economic growth. Have you ever wondered why your adult children have trouble making ends meet even though they work full time, sometimes at multiple jobs or why wages in the service economy are so slow to grow? All is explained when you follow the money.
Since about 1980, almost all of the economic growth in Canada (as measured by our GDP) ended up in the hands of the top earners in our population; the top 0.1 percent saw their annual share of income more than double from 2.5 percent to over 5 percent, while those at the very, very top (0.01 percent of our population) more than tripled their take from 0.5 percent to 1.8 percent. This latter tiny fraction of our population works out to only about 3,300 people, the ultra rich, the super elites.No wonder our youth and young families are struggling to make ends meet. The corporate kleptocracy made off with all the goodies; it should come as no surprise that CEO payouts have risen astronomically over the same period. The excuse given is the need to compete for leadership talent in the global marketplace and indeed similar trends in compensation have been found in the UK, Australia, and the US. But ask yourself : why doesn’t this pattern hold true in Japan or France? Both are major trading nations deeply engaged in global competition and yet income shares for the top 0.1 percent of their respective populations have held pretty steady at around 2 percent since 1945. So the next time some corporate leader urges Canada to become more productive, we should all be asking why? Who is going to benefit?
It’s time to confess that the key argument against rebuilding a more generous welfare state has always been an ideological one. Opponents claim that the high tax rates needed to support such a program would slow economic growth and affect our ability to compete in the world markets. The actual evidence comparing relatively low-tax, high income English-speaking countries (Australia, Canada, Ireland, New Zealand, the UK and the US) with high tax, high income Nordic countries (Denmark, Finland, Norway and Sweden) suggests the opposite is true. Social spending in the English-speaking countries is only 17 percent of GDP compared with 27 percent in Nordic countries. And yet, the latter show far lower poverty rates, and much higher spending on research and development.
So who is to blame for ignoring the evidence and moving us away from sound public policy that would benefit our health (and our pocketbooks)? As Evans points out “Governments in every country are primarily, and pretty much the only institutions for redistributing income and in-kind benefits down the income spectrum.” So there’s your answer. And it’s not a new one, either. Sir Francis Bacon knew it when he gave this advice: “Above all things, good policy is to be used, that the treasure and moneys, in a state, be not gathered into a few hands,…..money is like muck, not good unless it be spread.”
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