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The Chief Public Health Officer's Report on The State of Public Health in Canada 2008

Moving Forward
– Imagine the Possibilities

It is well documented that the top three causes of premature death in this country are cancers, circulatory diseases and unintentional injuries.116

But there are some things that might surprise Canadians.
If levels of education and income are viewed as rungs on a ladder, there is evidence that shows that every step down from the top brings with it a reduction in health.9, 98, 122, 145 Those not at the highest levels of education and income are less healthy, and collectively lose more years of life to premature death. Evidence suggests that if all Canadians had the same rate of premature death as the most affluent one fifth of Canadians, there would be a 20% reduction in premature mortality across the population.144 This would be equivalent to wiping out all premature deaths from either injuries or cardiovascular diseases.144 However, this is not simply a matter of extremes between those at the highest and lowest incomes, or between the most and least educated. It is a gradient where at every level there is a difference in health status.

This is not to say that lower education and income directly cause early death. There is no evidence to make the claim of clear linear cause and effect in that regard. But what can be said is that, in general, people are less healthy in relation to lower levels of education and income, and much of why and how this occurs is not well understood.

In the last chapter, priority areas for action were discussed. This chapter considers what could be done in regards to Canada’s three most pressing priorities – fostering leadership and collective will, reducing child poverty and strengthening communities.

Imagine if all Canadians and all sectors applied their energy, resources and resolve to address the full range of issues that can affect health.

It is estimated that $1 invested in the early years saves between $3 and $9 in future spending on the health and criminal justice systems, as well as on social assistance.423 Imagine the long-term benefit to taxpayers then, if Canada were to achieve progress on child poverty rates as good or better than world leaders such as Finland, Norway and Sweden.8, 424

Imagine if the extraordinary success of Regent Park’s “Pathways to Education” project was replicated nation-wide.316 While we have some of the highest rates of high school completion in the world, think what Canada could achieve if all young people had the supports they needed to finish a secondary education and the corresponding increase that would bring to the number of youth moving on to college or university. Consider the impact of those highly skilled and educated workers on Canada’s competitiveness and future prosperity, not to mention the likely health benefits to these individuals.

Imagine how much healthier people would be if every Canadian had access to adequate housing. The impacts would be profound for many communities, but in particular for people living on First Nations reserves where half of existing housing falls short of Canada Mortgage and Housing Corporation standards and where, partly as a consequence, tuberculosis rates are eight to ten times higher than the general population.209, 278 Could individual ownership help Canada move in that direction?

What would be the impact if all First Nations and Inuit communities had agreements in place for education and health services that provided them with increased control over their communities’ future?

Imagine the improvements in peoples’ quality of life if, by addressing the factors that influence health, physical and social environments were created in which Canadians could easily make good choices to achieve and maintain the highest state of health possible.425 Far fewer Canadians would be treated for chronic conditions like heart disease, cancer, Type 2 diabetes and emphysema. And waiting lists for hip and knee replacement would be shortened.

None of this is beyond the realm of possibility. In fact, all Canadians pay a high price by failing to address these issues. There are direct costs to the health care system resulting from health inequalities, and these costs will only grow if the causes of health inequalities are not addressed.2 There are also indirect costs, such as lost productivity, that have negative repercussions for the entire economy.2, 98, 426

A time to act

Improvements in quality of life over the past century have helped Canada to become one of the healthiest nations in the world.141, 427 Conditions are ripe to take this a step further by aiming to be the healthiest nation with the smallest gap in health. Employment levels are at an all-time high, Canada also boasts one of the best-educated populations in the world, with a higher proportion of post-secondary graduates than almost any other country.314

Clearly, the necessary means and talent exist to tackle the wide array of health inequalities that prevent individuals from achieving their dreams and goals, and which limit Canada’s ability to achieve its full economic and social potential.

What can be done?

Foster collective will and leadership

If Canadians are serious about wanting to be the healthiest country in the world, addressing health gaps must become a priority.

Working across sectors and jurisdictions, there is reason to believe health inequalities can be reduced while advancing other social goals such as reducing crime and fostering civic participation. Through collective will and leadership Canada can achieve this goal by:

  • building recognition of the importance of preventing disease and injury, and of promoting health. While a strong and accessible health care system will always be vitally important, prevention is preferable to treatment and has the potential to yield a significant return on investment.328 Public health is about more than being ready to respond in times of health emergencies – it is about keeping the population healthy at all times so that the impact of health emergencies can be kept to a minimum;
  • identifying the appropriate indicators and creating the tools required to measure and monitor progress, as well as addressing knowledge and data gaps that prevent effective measurement. By establishing a point of comparison, it will be possible to assess Canada’s progress, or lack thereof, in responding to health inequalities – over time and in relation to other countries;
  • cultivating a whole-of-society response. Canadians’ health is a shared responsibility and individuals, communities, public, private and not-for-profit sectors all have a role to play; and
  • engaging leaders at all levels and across all sectors of society to act as champions, helping people to think about the contribution they can make to ensuring that all Canadians have the opportunity to achieve the best possible health.

Reduce child poverty

There is a growing body of evidence that some of the greatest returns on taxpayers’ investments are those targeted to Canada’s youngest citizens.429 Every dollar spent in ensuring a healthy start in the early years will reduce the long-term costs associated with health care, addictions, crime, unemployment and welfare.430 As well, it will ensure Canadian children become better educated, well adjusted and more productive adults.431

Canada has had success in reducing poverty among seniors in recent decades.8, 123 We have the ability to achieve the same kind of progress with children. This requires further examination of:

  • income redistribution policies, programs and initiatives so that all families have the resources needed for healthy child development;
  • opportunities for healthy early learning and childhood development, housing and infrastructure, post-secondary education, employment and employment supports;
  • targeted interventions aimed at supporting children living in low-income families;
  • collective contributions that can be made to alleviate child poverty; and
  • best practices and lessons learned from other jurisdictions with proven success in reducing child poverty rates.

Strengthen communities

People living closest to the problem are often closest to the solution.432 This has been proven repeatedly by innovative projects ranging from the Eskasoni primary care initiative that offers culturally appropriate approaches to Aboriginal health and Toronto’s mobile health clinic meeting the needs of immigrant women living in a major urban centre, to the food security programs that feed hungry school children all across Canada, and bringing unemployed youth in Montreal together with isolated seniors.

The community is where all sectors converge and where it is often easiest for the various players to come to the table to establish local priorities and develop shared strategies to address inequalities.432 Communities are also in a position to mitigate the health impacts of factors like low income and poor access to education, and can play a pivotal role in creating environments that are supportive of healthy choices for all citizens.

Every effort must be made to build on the existing knowledge, experience, energy and investments already in place in Canadian communities to reduce inequalities in both health and the factors that influence health, including:

  • working collaboratively to support community efforts to create sustainable conditions that enable and promote good health;
  • making it easier for communities to access the skills and resources for local programs;
  • developing and sharing community-generated and national-level data from which non-governmental and community groups can draw; and
  • supporting and sharing research and knowledge to encourage the replication of successful initiatives across the country that can spur further innovations and improvements in inequalities in health.
A commitment to change

“The journey of a thousand miles begins with one step”

— Lao Tzu .

Ultimately, public health comes down to us. Some might call it cliché, but the reality is that as individuals, community members and decision-makers we all have a part to play in either improving or risking public health. Understanding the issues and connections may, at the very least, help us avoid being part of the problem. This includes the inequalities that exist in the health of our population, in our own lives and those of our family members, in our schools and workplaces, and within our neighbourhoods and communities.

A society is only as healthy as its least healthy members. None of us is immune to Canada’s health problems and the inequalities that limit our potential as a nation. In this report, I have presented many examples of policies and programs, both large and small, that are making real differences in the lives of Canadians and that are working to reduce inequalities in our health. As we each take ownership of this issue to the best of our capabilities, we can help to ensure that all Canadians have the opportunity to be as completely healthy as possible. We can do this by, for instance, taking part in our democratic processes, getting actively involved in our communities, promoting healthy choices and reaching out to individuals and groups in need of support. Volunteering, interestingly, in addition to the good work we may do, is associated with better health for the volunteer as well. Why? Health is more than merely the absence of disease or the presence of physical well-being. It is about having those basic, solid foundations for life and society in place, and ensuring we have community, connections, friendship, control over our lives and influence over our own destinies.

As I said at the beginning of this report, our health is influenced by the type of society we choose to create. We all have a role to play in creating the physical, economic, social and cultural conditions that are the foundation of good health. And what we do, even in small ways, can make a difference.

By paying attention to and addressing these underlying determinants of health, not only do we level the playing field for all Canadians, we effectively support the functioning of society and Canada’s competitiveness as a nation. As fewer are left behind more will prosper.

Dr. David Butler-Jones