José Martin-Moreno and Terrence Sullivan
Chronic diseases, including heart disease, cancer, stroke, diabetes and respiratory illnesses, top the global health agenda. The World Health Organization attributes no less than 89 per cent of all Canadian deaths to these diseases, which are known as a "wicked problem" for health authorities because of the overlap of so many disparate disease determinants, originating at so many levels, from individual behaviour to international trade and wealth distribution.
Determinants include genetics, epidemiology, environment, social inequity, health literacy, behavioural risk factors and even the social networks that influence our attitudes on health and lifestyle. Policymakers must expand the scope of action beyond health care to confront the intersection of circumstances where individuals live and work.
Concerted action must be taken at three levels: society, community and individual.
Societal-level action reflects public policy and governmental interventions aimed at modifying the existing legal frameworks and the environment to make healthy individual behaviour easier. Healthy public policy relies on levers at senior tiers of government, including laws, taxation, major social transfers, regulation of commercial products and allocation of resources to health services and health-related government programs. Ideally, actions should be shaped through political consensus to ensure continuity, commitment and long-term follow-up.
Canada has done well here on tobacco control, ratifying the Framework Convention on Tobacco Control in 2004 and implementing a range of tough anti-tobacco legislation at both the federal and provincial levels. Similar actions have not been applied to alcohol, despite an ambitious National Alcohol Strategy released in 2008. Potentially effective recommendations have not been taken at either federal or provincial levels linking prices to strength despite the national strategy and a 2012 report on chronic disease in Ontario recommending progressive pricing. This reveals the inherent tension in national and provincial health policy initiatives, where governments juggle conflicting interests, often working at cross-purposes with their own stated goals.
This tension seems also at work in the Federal, Provincial and Territorial Framework for action to curb childhood obesity. On one hand, there have been promising initiatives, such as the federal child-fitness tax credit and a platform commitment by Ontario to reduce childhood obesity. On the other, food industry interests are still protected by limiting their role to voluntary measures to reduce marketing of unhealthy products to children – illusory promises also made in the past by the tobacco industry. In both of these areas, binding legislation is an important resource that should not be left untapped.
The community level is another sphere that has great potential for affecting the population's health. Social settings should be exploited in order to engage people on health matters through communication, awareness, education, training and outreach. Emerging research has explored the effect that social networks have on health-related behaviours such as smoking, drinking, eating and exercising. Expanded access to exercise facilities and healthy food, support groups to quit smoking, sports teams to foster physical activity, and diet groups to tackle obesity all have the potential to catalyze individual intentions to be healthier into a support network that enables health.
Canada has a long and positive experience with community and workplace outreach programs, evident in places such as Kamloops, B.C., and a range of federal and provincial strategies, such as the Integrated Pan-Canadian Healthy Living Strategy. More can always be done to make health a priority for all citizens, especially by setting explicit targets aimed at reaching the most vulnerable subpopulations: ethnic minorities, immigrants, young people and the poor.
Finally, health services have a direct role to play in measures targeted at the individual. Primary care facilities are the optimal setting for personally tailored health advice, recruitment to disease-screening programs, immunizations and detection and follow-up of risk factors such as obesity. Systematic inclusion of these elements in primary care practices requires fluid, two-way communication between public health experts and primary care practitioners, a Canadian weak point revealed during the SARS crisis.
Patient empowerment can also help individuals manage their condition through lifestyle changes and adherence to treatment regimens. There's room for improvement in this area in Canada, particularly in a time of constraint when patient empowerment can potentially maximize the use of health resources and avert, at least in part, the dilemma faced by health authorities in dedicating resources to one area along the causal pathway of disease instead of another.
On all three levels of policymaking, significant inroads have been made. We have the evidence and the tools to further reduce the burden of chronic disease. Yet, effectively implementing programs requires strong governance, engagement with a wide range of sectors inside and outside of government, and a strong commitment to creating a healthy social and physical environment throughout the population and society.
José Martin-Moreno is a professor of medicine and public health at the University of Valencia and an adviser to the World Health Organization/Europe. Terrence Sullivan is a professor at the University of Toronto's Institute of Health Policy, Management and Evaluation and chair of the board of Public Health Ontario. The authors are part of the symposium Finance & Governance for Health, hosted by the School of Public Policy and Governance, to examine how international evidence and experience can help build a better health-care system for Canadians.