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Trevor Hancock: What makes us healthy? Hint: It’s not health care

This is the first of a series of columns about health.

This is the first of a series of columns about health. But even though I trained as a physician, I will not be writing much about health care, because the evidence suggests that it is not all that important as a determinant of our overall health, compared to broader environmental, social, economic and behaviouralfactors.

While it is difficult to be precise, estimates suggest that only 10 to 15 per cent of premature deaths could be prevented by improvements in health care.

This means that as a society we should be investing more in creating social conditions and environments that make people healthy, rather than in increasingly expensive high-tech care.

This is not to argue against the provision of medical care — when I am sick or injured, of course I want good health care.

And as a former family physician, I recognize that good primary and community care are the heart of the system.

But we need to have a conversation about where we get the biggest health return on our investments, be they public or private. Would we get more health by investing more in the broad determinants of our health, rather than in high-tech care?

I am also not going to offer tips about healthy living. Experience has shown that educating people about how to be healthy has limited utility. It didn’t work all that well for smoking; what made a difference was the combination of higher taxation, non-smoking bylaws and regulations, lawsuits and — above all — a change in our social norms so that smoking simply became socially unacceptable.

We need to apply those lessons to our current concerns with physical inactivity, unhealthy eating and unhealthy weights.

Instead, I am going to write about what we in public health call “the causes of the causes,” what predisposes us to smoke, eat too much or be inactive, and even the “causes of the causes of the causes” — what are the underlying social, environmental, economic, political and cultural forces that result in some people, communities and nations being more healthy than others.

My health tips will be about how we create healthy communities and nations, a field of work we call population-health promotion and that Canada helped pioneer in the 1980s and 1990s.

Let me illustrate with a story.

Once upon a time, there was a village by the banks of a river, and every day people would be swept past the village, struggling and drowning. The villagers, being kind people, were upset about this, so they developed a system to rescue people from the river, resuscitate and care for them and return them to their families.

Over time, however, more and more people were found to be struggling in the river, and while the system grew to be very good, it was also very complex and expensive.

So they began to wonder why was it that so many people chose to swim in the river, and they sent out advertisements warning people not to swim in the river and proposed educational programs.

But unfortunately, everybody was so busy rescuing people that nobody had time to go upstream and see who was pushing people into the river in the first place, and stop them doing it.

What I am interested in is going upstream, finding out who or what is making us sick, and stopping it. How do we create the conditions that enable people to make healthy choices?

Sadly, too many people in Canada today are not in a position to make such choices.

But interestingly, if we ask people what makes them healthy, they don’t talk very much about the health-care system. They talk about having healthy food and good housing, being active and engaged, having good relationships with and support from family and friends, being happy at work. At a community level, they talk about having safe streets, good public transport, parks and other amenities. In other words, they intuitively understand population health.

We know in our hearts what we need to do to create a healthier society and healthier communities, but we don’t act on what we know. I hope to help change that.

Dr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.

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