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Public Policy Matters to Your Health More Than Lifestyle Choices: Dr. Ryan Meili

A Healthy Society

The following article is excerpted from A Healthy Society: How a Focus on Health Can Revive Canadian Democracy, by Dr. Ryan Meili. Leaders and Legacies will run a multi-part series based on this book in the coming days.

People care about health. It’s part of our assumed common ground, a truly shared value that transcends class, colour, and political ideology. Our conversations are replete with references to health. If you ask expectant parents if they’re having a boy or a girl, the answer is inevitably, “We don’t care, as long as it’s healthy.” When neighbours and friends are ill, we go out of our way to help them. If people fall on hard times, a common encouragement is, “At least you have your health.” We speak of healthy relationships, healthy attitudes, healthy economies, and healthy appetites. We toast one another’s health. These familiar expressions reflect our unconscious preoccupation with our common vulnerabilities, hopes, and fears: we know, deeply, that health — physical, mental, and social — is a necessary condition for the full enjoyment of life.

This focus on health is reflected in public life as well as private, particularly in the heated political debates around health care and health spending. Health care and health are very different things, but health care is the policy area most obviously linked to health, and the attention given to it is an identifiable surrogate for this deeper preoccupation. With rare exceptions, health care is the number one issue of importance in Canadian polling, an unusual constant in the tumultuous sea of public opinion.

Accordingly, health care spending takes up the largest portion of provincial budgets. There have been many who have complained about this, saying that an inordinate focus on health takes away from other important areas such as education, justice, and infrastructure spending. In a way they’re right — our focus on health care at the expense of other important aspects of public life is disproportionate. But the problem is not that we care too much about health, it’s that we are doing so in an incomplete and reactive fashion. Our approach tends to be palliative rather than preventative; we focus too much on what to do when our health fails, not on how to make sure the conditions are in place for more people to thrive, to stay healthy. If we truly want a healthy society, we need to build a political movement with health as its focus.

Ryan Meili

The notion that health and illness are determined by life circumstances is not new, and in recent years it has become a staple of health theory and teaching. In one of the first lectures of medical school, students are asked what the greatest factors are in deciding whether someone will be healthy or ill. Lifestyle choices — like the so-called holy trinity2 of diet, exercise, and smoking cessation — are a common response. Others will talk about access to health services, while others reference genetics or culture. After this discussion, the students are shown the list of health determinants from the Canadian Institute for Health Information. In order of impact, the factors that make the biggest difference in people’s health are:

  1. income status
  2. education
  3. social support networks
  4. employment and working conditions
  5. early childhood development
  6. physical environment
  7. personal health practices and coping skills
  8. biological and genetic factors
  9. health services
  10. gender
  11. culture
  12. mass media technology (i.e., television viewing and physical inactivity). 

Invariably, this list is met with a degree of surprise. As aspiring doctors, the students think they are getting into the business of making people healthy. Then they see that the services offered by the health professions barely crack the top ten factors.

The lesson to be drawn from the list of determinants, and the one that is stressed to students, is that the most important factors that determine people’s health are social, and the most effective solutions are political. Health services — the response to ill health — have much less effect on ultimate health outcomes than social determinants such as income and education, housing and nutrition. Gender, culture, and biology, the more immutable of the determinants, also figure near the bottom. What the students learn is that, while they can indeed have the power to heal, they cannot act alone. The response to illness is not limited to one profession or sector: it must be societal.

The question, then, is where does it make the most sense to focus our political efforts? In other words, which determinants of health are most directly affected by public policy? The social determinants of health are income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety net, health services, Aboriginal status, gender, race, and disability.

As you can see, these are all areas where public policy can change a person’s situation or experience to either improve or worsen health. When we address inadequate housing, when we stop gender discrimination and racism, when we ensure people have access to work that is safe and fair and that our children receive the care and attention they need to grow, then we can dramatically improve health outcomes. So what’s holding us back?

— Dr. Ryan Meili is a family doctor at the West Side Community Clinic in Saskatoon and head of the Division of Social Accountability at the College of Medicine at the University of Saskatchewan. 

Next: Lessons Learned in Saskatchewan

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