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Trevor Hancock: Health care a small part of true health

A recent Times Colonist editorial on the importance of prevention in improving health and reducing health care costs is on target (“Prevention key to health costs,” Nov. 9).

A recent Times Colonist editorial on the importance of prevention in improving health and reducing health care costs is on target (“Prevention key to health costs,” Nov. 9). But in focusing on prevention in primary care, its prescription did not go far enough.

As a former family physician and as the co-chairman of B.C.’s Clinical Prevention Policy Review that led to the creation of the Lifetime Prevention Schedule in 2009 (the only systematic policy on clinical prevention in Canada), I would be the first to say that prevention within the health-care system is important.

But as a public-health physician, I must point out that health care — even preventive health care — is a relatively small contributor to the health of the population.

This is because the main determinants of health lie beyond health care, in our communities and in our environmental, social, economic and political systems.

If we want healthy people, we need to improve our living and working conditions so that they support health in society by investing in healthy homes, schools, workplaces (including hospitals) and communities.

And we need to reverse the human-induced decline in the health of our ecosystems that threaten the health of all of us. If we do all this — and more — we can reduce the burden of disease to which the health-care system has to respond.

So what would a true prevention agenda look like? First, we need a societal commitment to focus on human rather than economic development; our purpose in life, surely, is not merely to grow the economy. As a humanist, I like to think our purpose is to help everyone achieve the highest level of human development of which they are capable. That should be the focus of governance and governments at all levels. This would result in very different, and much healthier, public policies.

Yet our provincial and federal governments are focused almost entirely on GDP as a measure of social well-being and progress. But we have clear evidence that beyond a certain point, which we passed long ago, further increases in GDP per capita add little to life expectancy.

The best performance on a range of health and social outcomes is found in high-income countries that have the highest levels of social equity.

Hence, we need to reduce social inequity and the resultant inequalities in health that burden our society.

Next, we need to create living and working conditions that make the healthy choice the easy choice.

• Why, for example, do so many people over-eat? Look at standard portion sizes in North America. They have increased dramatically over the past 50 years or so, and are larger than European portion sizes —- so we are encouraged to over-eat.

• Why are we so inactive? Check out our sedentary work patterns and our car-dependent lifestyles. There is good evidence that suburban sprawl contributes to obesity because suburban environments are not very walkable — to get anywhere that matters, you have to drive.

• Why do people drink too much? Check out recent policy changes in B.C. and elsewhere that make alcohol access easier — with the entirely predictable and evidence-based result that consumption increases (why else would the alcohol industry support this approach?) and health is impaired.

When we consistently make the unhealthy choice the easy choice — even the only choice — why would we be surprised that people make unhealthy choices?

Only when we have created environments supportive of health should we then move on to what too many people see as the first step — exhorting people to change their behaviour, which can easily turn to victim-blaming.

But it is much more than personal behaviour. If we have learned nothing else from our largely successful tobacco-reduction strategy over the past 50 years, it is that we need to use all the tools at our disposal — legislation, taxation, environmental and social change, peer support, education and clinical prevention.

Interestingly, an agenda much like this was agreed to by Canada’s ministers of health in 2010, including B.C.’s minister.

But disappointingly, it was then largely ignored.

It is time to revisit that declaration and commit to a true prevention agenda, if we want to reduce the burden of disease, pain, suffering and premature death that in turn places a burden on our health-care system, on our economy and on society.


Dr. Trevor Hancock is a public-health physician and a professor and senior scholar at the School of Public Health and Social Policy at the University of Victoria.