When counseling patients on health, physicians often focus on lifestyle changes such as diet, exercise or smoking. This kind of advice can be important for the individual, but does little to change underlying drivers of health like income, education and employment. These factors are the ones that have the greatest impact on whether patients will be able to eat well, move around or butt out.
Taking the next step to address the upstream determinants of health requires the involvement of government, and an understanding that health and wellbeing go beyond health care.
In countries like Finland, the idea of Health in All Policies has been influencing public policy for some time. This approach to policy applies a social determinants of health lens in sectors from education and finance to housing, transportation and social assistance. In the 1970s, the Finnish government launched one of Europe's earliest Health in All Policy projects, and targeted one of the countries unhealthiest regions. Rather than simply chiding the community to "eat less, exercise more," policy makers persuaded local butter, cream, bread and meat producers to reduce the fat and salt contents of their foods, while introducing oil seed crops and berry production as alternative (and healthier) ways to earn a living. Combined with healthier school workplace menus and tough anti-smoking laws, applying a health lens to agricultural, economic and education policies helped reduce cardiovascular disease in 18 to 65 years olds by 73%.
In Canada, Quebec has been an early Health in All Policies leader. In 2002, the province passed its new Public Health Act, legislation that mandates provincial departments and agencies ensure new bills and regulations not harm the health of Quebecers. The routine use of Health Impact Assessments has been the result, and has begun to reach other levels of government. The mayor of Acton Vale, a small town outside of Montreal, requested that a Health Impact Assessment be completed for a proposed residential development project located between a snowmobile trail, a highway and a school. The findings offered concrete guidance on how to prevent accidents with safe street design, reduce noise pollution, encourage active transport and preserve green space.
Beyond Quebec, despite the endorsement of the public health and policy community, a Health in All Policies approach has not found the political will necessary for meaningful change. But the past year offers signs of hope, with governments in Canada from across the political spectrum beginning to see the potential.
Most recently, Newfoundland's Minister of Health and Deputy Premier Stephen Kent, has shown an understanding of the potential of healthy public policy. Before his appointment, Kent was one of three candidates vying for the leadership of the provincial Progressive Conservative Party. Included in his health care platform was a commitment to make health a whole-of-government priority. Kent proposed collaborative teams, including the Department of Natural Resources, the Newfoundland and Labrador Housing Corporation, Child, Youth and Family Services, and Municipal Affairs, to "create a better environment for healthy people." Now as Minister of Health, he has an opportunity to put these plans into action.
In the heart of what is known as conservative country, Edmonton's new mayor, Don Iveson, is bringing a similar approach to municipal government. He recently convened a city-wide symposium on poverty with an explicit focus on the social determinants of health.
While the delivery of health care is traditionally a provincial responsibility, the mayor's symposium identified a number of municipal areas of action. Among the opportunities discussed were "traditional" gaps in health insurance (drug, dental and vision services) as well as gaps in needs further upstream like school textbooks, affordable housing in a city with rising rents and accessible community sports programs.
At the Federal level, former Liberal health critic and physician Carolyn Bennett, has championed a whole-of-government approach to health policy. The New Democrats, and their health critic, Libby Davies, have introduced the first national health policy with an explicit focus on the social determinants of health, including income inequality, housing and food security. While they stop short of the Canadian Medical Association's 'What Makes Us Sick' recommendation to require the federal government to include a health impact assessment as part of the cabinet decision-making process, they endorse the idea that the federal government must address the health impacts of decisions in all sectors.
Canadians understand that health is more than hospitals and doctors, diet and exercise. A Health in All Policies approach offers public leaders an opportunity to turn that understanding into thoughtful action.
This piece was co-written by Danyaal Raza, a Toronto-based family physician.
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