It was never expected to be easy, grappling with a global pandemic as grave as COVID-19. In its early days in Canada, during our spring of silent shock, we powered down our economy, stayed home as much as we could, and hoped that our collective sacrifice would buy our governments and health care systems the time needed to prepare, strategize and not get overwhelmed by another wave.
The shutdown period challenged us in many ways. The social deprivation and break from “normal” made us anxious, depressed, lonely. More broadly, the inability to have everyone shelter down exposed inequities built into our economic, social and health care systems. The unequal and unfair impact of COVID-19 exposed the failure of years of neoliberal austerity that purposely diminished the role of the public service in areas critical to health and well-being. Our governments’ false belief that the private sector would pick up the slack left us unprepared for a pandemic.
The springtime television images of an army coming to rescue ailing elders and staff in long-term care facilities was a tragic symbol of this systemic failure. There were similar damning moments as COVID-19 ripped through migrant worker camps, meat-packing plants and low-income, often racialized communities. These communities were exposed to the greatest risks of a deadly virus without the protections afforded the privileged, those of us with private means.
If we could not protect the most susceptible people from COVID-19, what did that say about us, our governments, our institutions? Why were we not able to plan for a pandemic that was always a question of when, not if?
***
In Ontario, the failure of the provincial government to work coherently and transparently with public health and education officials to reopen schools in the fall led to confusion, contradictory advice, nonsensical rules and questions of political competence. The Alberta government made oddly timed decisions to wage war with doctors, cut health care positions and downplay the seriousness of the virus, with Premier Jason Kenney assuring us in May that, “The average age of death from COVID in Alberta is 83. And I remind the house that the average life expectancy is 82.” In provinces that were initially sheltered from COVID-19, such as Saskatchewan and Manitoba, viral spread began to soar.
Across Canada, cracks in the federation have been showing. Creating a coherent, national response to COVID-19 was very much like herding cats while walking on eggshells. No jurisdictional response was alike. Some provinces, such as B.C., were more proactive, accepting the scientific evidence and expert advice that their public health officials were offering. Others, such as Alberta, Manitoba, Ontario and Quebec, not so much. While the federal government showed policy and fiscal leadership by introducing massive income support programs for individuals and business, it became increasingly clear that getting everyone on the same page was a growing concern.
By mid-November the scenario that some had predicted was quickly becoming reality: COVID-19 was on a rapid growth path in many Canadian jurisdictions. Outbreaks in long-term care facilities returned with a vengeance. “It’s like a nightmare that we’re reliving now which we really shouldn’t have had to, given that we had months to prepare over the summer for a second wave,” Dr. Amit Arya, a palliative care physician, told the Toronto Star in November.
Some health care systems were already nearing capacity, even before flu season kicked in. At the same time that provinces were allowing indoor dining, gym openings, and gatherings too large to contain spread, some were also losing their ability to keep up with contact tracing. Toronto Public Health Officer Dr. Eileen de Villa warned the public toassume COVID-19 is everywhere. Political leadership had been faltering, and public health experts were resorting to pleas for people to take cover. There were warnings of political mishandling of the pandemic.
Reopening the economy without a co-ordinated plan to minimize viral spread was magical thinking. Political delay in following public health advice contributed to a strong second wave, which came with exponential costs to people’s well-being, the health care system and an economy that has no chance of thriving without a healthy public. Some of our governments have failed to recognize, or have forgotten, that health and the economy are inextricably linked.
This is a critically important point. Underlying everything the COVID-19 moment has taught us is the revelation of how shallow our understanding of public health actually is. Until we truly appreciate how public health is different from concepts like individual health, and not the same thing as our universal health care system, we are doomed to repeat our failures.
What comes to mind when you think of public health?
If you’re like most people, the idea of public health probably brings to mind hospitals and physicians, or what you, personally, can do to promote a healthy lifestyle, such as eating nutritious food or not smoking. At the moment, your attention is likely drawn to ventilators, vaccines and other high-profile medical tools of the response to the pandemic.
While all of these things are important elements of health, they exist within a broader context of the social determinants of health—the social, economic, ecological and colonial factors that determine why some people are healthy and others are not. It’s not just about your individual behaviour or the ability of your health care system to treat your ailments, it’s about the root causes of good or bad health. Those root causes are hardwired into our social and economic systems, which are the product of political decisions.
While we have known about the social determinants of health for a long time, political action to address them has been, to say the least, disappointing. This reflects a strong tendency among most people and politicians to think of “health,” “public health,” and “health care” as interchangeable things, such that the solutions to health problems are seen to lie within the health care system.
But that health care system reflects our neglect of the social determinants of health, because it’s there to treat the problems after they occur, not to prevent them in the first place. It is, more accurately, a sick care system.
Nowhere is that reality more evident than in the age of COVID-19. The virus has shown us, in no uncertain terms, that health and its social determinants cannot be separated. The pandemic has magnified inequities along axes such as income, employment circumstances, gender, race and ethnicity.
As famously stated by the World Health Organization Commission on Social Determinants of Health in its 2008 final report, those health inequities are in no sense natural—they are “the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.”
In Canada, we have failed to implement, and adequately fund, public universal systems of child care and elder care; to protect public institutions, such as schools, from corporatization and privatization; to update our outdated income support programs so that they better align with current workforce and economic realities; and to commit to reconciliation with Indigenous peoples.
Indeed, the inequitable impact of the pandemic reflects these political failures; fixing them must be part of the recovery. It is time for a coherent, integrated approach to public health.
***
An important challenge, which has become glaringly obvious during this pandemic, is our poor understanding and appreciation of public health, which is routinely conflated with publicly funded health care.
On the one hand, public health is a tiny but mighty component of the health care system. It focuses not only on communicable disease control, but also disease and injury prevention, health promotion, keeping track of the health status of the population and population groups, and emergency preparedness. Outside of a crisis situation, much of the work of public health practitioners (public health physicians, public health nurses, public health inspectors, health promoters, epidemiologists, etc.) remains hidden from public view.
In times of crisis, as during a pandemic, politicians are expected to seek expert guidance from public health practitioners to inform policy decisions. That was the standard proposed in the wake of the SARS outbreak of 2002 and 2003: politics should take a back seat to scientific evidence and expertise. Variation in the extent to which this has played out across the country sheds light on some important challenges to our pandemic response.
Perhaps the most significant example of this variation has been in the ability of chief medical officers of health to issue clear directives unencumbered by provincial politics. Political interference manifests itself in wishy-washy, rudderless plans that try to “balance” health and the economy, as though they were separate.
What happened in the first and second waves of COVID-19 in 2020 was in part the result of the weakening of the public health arm of the health care system. Political decisions have limited the scope of public health practice by combining it with primary and community care as well as through inadequate government funding. The Canadian Institute for Health Information (CIHI) has estimated that public health activities receive about 5% of all health care spending on average, and considerably less in many provinces.
However, that is not the whole story. While the pandemic has placed public health in the spotlight, it has reinforced a very narrow version of public health. More broadly, and usefully, public health can be thought of as the art and science of preventing disease and promoting health through organized societal efforts. Public health embraces values and priorities such as:
- collectivity, with its focus on populations, which are not reducible to an aggregate of individuals;
- social justice, with its concern about social inequities that cause health inequities; and
- upstream thinking, which focuses on the root causes of health problems.
Lying beneath the weakening of public health practice, which one can think of as the tip of the iceberg, is an erosion of these deeper values and priorities. The implications for “the public” in public health are profound. The erosion manifests as cuts to the public sector, solutions packaged in individualized terms, and a deepening political polarization that erodes societal assets such as trust.
Significantly, nothing about this broader version of public health requires that we limit ourselves to the health care system. Indeed, the only way to ensure a just recovery from this pandemic, and to be ready for the next one, is to find ways to operationalize this broader version of public health.
The way forward
COVID-19 has made structural change to public health policy a critical priority, as we’ve heard from Chief Public Health Officer Dr. Theresa Tam. The lack of understanding about the interconnectedness of health, the economy, public well-being and public policy must be redressed. Federal leadership is essential, but so is provincial and municipal co-operation. Incoherent or siloed strategies have proven inadequate to the task.
Here’s our three-step plan.
1. Identify the contours of an integrated, coherent vision of public health.
This is the easy part, since several visions have already been articulated. Three in particular come to mind.
One is the Ottawa Charter for Health Promotion of 1986, which was ahead of its time in characterizing health as a resource for everyday life, and for identifying “prerequisites for health,” including peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. Strengthening health and health equity, according to the charter, requires efforts to build healthy public policy, create supportive environments for health, strengthen community action (including activism), develop personal skills, and reorient health services so they are more attuned to prevention and health promotion.
More than 20 years later, the World Health Organization Commission on Social Determinants of Health identified three overarching recommendations to improve population health and health equity, a goal it described as “closing the gap in a generation.” Those overarching recommendations were to improve daily living conditions; to tackle the inequitable distribution of money, power and resources; and to measure the problem and assess the impact of action.
More recently, in 2015, the Truth and Reconciliation Commission released its final report and recommendations following a multi-year process of information gathering and public discussions concerning Canadian government policies of cultural genocide, which have caused unacceptable social and economic conditions for Indigenous peoples in Canada. The social and ensuing health inequities that continue, which provide a dramatic example of the social determinants of health, may only be addressed through a foundation of reconciliation, defined as commitment by all Canadians to an ongoing process of establishing and maintaining respectful relationships.
It goes without saying that these goals go well beyond the scope and mandate of the health sector. They demand a broader approach to leverage the legal, constitutional and collective mechanisms that we have at our disposal.
A health-in-all-policies approach offers one avenue, since it provides a way to operationalize the fundamental understanding that the primary determinants of health, well-being and health equity reflect public policy decisions outside of the health sector.
For example, under a health-in-all-policies approach income tax policy would be guided by the extensive knowledge of the negative consequences for health of poverty and income inequality. Education policy would recognize universal public education for what it is—a backbone of a healthy and equitable society. The inadequacies of federal and provincial jurisdictional mechanisms would be embraced by a commitment to Indigenous self-governance. And so on.
2. Co-ordinate the wider public health vision across political jurisdictions.
Having identified the contours of an integrated vision for public health, governments must co-ordinate their leadership in advancing the vision in all parts of Canada.
The federal government’s economic support mobilization during the pandemic has been significant. The structural change—and challenge—now is to transition those activities from an integrated emergency protection response to an integrated, longer-term investment in the social determinants of health.
There are hints that we are moving in this direction. The federal government’s structural supports have shifted into medium-term solutions, such as a more flexible (and thus respectful) system of employment insurance. In the last federal throne speech, the Trudeau government hinted at potentially significant advances to strengthen child care and long-term care. This would be in line with the government’s 2019 mandate letters, which referenced well-being budgeting, that is, making sure that program spending and taxation decisions support people’s well-being.
In our federated country, co-ordinated leadership demands provincial co-operation, the absence of which has been made clear in the pandemic. Once again, we have a working guide in the form of the Declaration on Promotion and Prevention, signed by Canada’s federal, provincial and territorial health ministers in 2010.
Health portfolios across the country are overwhelmingly focused on treatment-oriented health care, yet ministers from different political parties committed in the declaration to principles of prevention, health promotion and social determinants of health. Imagine how different the pandemic experience might have been had that declaration been translated into governance structures that prioritize well-being.
Provincial co-ordination, with federal leadership, could institutionalize and protect public health elements of the health care system, such as independence for chief medical officers of health, and adequate and sustained funding for core public health activities (e.g., health surveillance, protection and prevention). Importantly, however, the “system” it supports would not stop there. It would transcend our public policy environment, as demanded by the social determinants of health.
3. Work from the ground up to uncouple “health” from “health care.”
Underpinning the success of the first two steps, a third step is to work from the ground up to break down the pernicious conflation of health, health care and public health—and to help people make a connection between health and its social determinants. In addition to popular discourse about health, which is dominated by a focus on health care and individual lifestyle behaviours, this challenge exists—disconcertingly—within public health itself.
For example, while the SARS epidemic of the early 2000s helped spur an explosion of post-secondary education programs in public health, in an effort to build workforce capacity, concern has more recently been expressed that these programs tend to privilege certain kinds of research methods and theories. So-called quantitative methods are prioritized over qualitative and participatory approaches, for example. Likewise, behavioural theories, where the unit of focus is the individual, crowd out learning and application of critical social theories that foreground issues of power. In some cases, educational programs omit pressing issues entirely, such as ecological determinants of health.
COVID-19 reminds us that we have not devoted enough attention to broad-based science literacy and critical thinking. These are essential to rebounding from the current pandemic and ensuring preparedness, not only for the next pandemic but for other, equally pressing emergencies—with equal if not greater consequences for health—such as climate change.
***
These steps—articulating the contours of an integrated version of public health, putting in place co-ordinated leadership to advance the vision, and creating the necessary foundation where health is uncoupled from health care—are required for meaningful improvements to health and well-being for all.
The integrated, coherent version of public health we have advocated here is very different from what most people think of when they think of “public health.” That is the structural change required. Anything less dooms us to repeat the failures of 2020.
Lindsay McLaren is Professor in the Department of Community Health Sciences and the O’Brien Institute for Public Health at the University of Calgary. Trish Hennessy is Director of thinkupstream.ca, a project of the Canadian Centre for Policy Alternatives.