Urban sprawl detrimental to public health

Urban sprawl detrimental to public health

Dr. Trevor Hancock

19 November 2017

703 words

Urban sprawl has to be one of the more damaging things we have done to the Earth – and to ourselves. That was not self-evident at the time it started in the 19th century, but it has been known for several decades, and yet we still are building sprawl. What’s more, we are exporting this destructive form of development to middle and low-income countries.

The limiting factor that kept cities compact for most of civilisation was how far one could reasonably travel and get back in a day. In the days when walking and horse transport – if you could afford one – were the only means of travel, that was not very far. But the advent of railways in the 19th century, followed by trams and buses, meant that people could live further away, and suburbs could develop.

This process began in London with the opening of the Metropolitan Railway in the 1860’s and London’s suburbs developed rapidly with the promise of country life in the city. But it really took off in North America with the advent of the automobile, leading to the car-dependent low-density urban sprawl we see today.

In a 2014 report for the Canadian Council on Urbanism, using 2011 census data, David Gordon and Isaac Shirokoff noted that “Canada is a suburban nation. Two thirds of our country’s population lives in suburbs” – and that rises to 80 percent in the largest metropolitan areas such as Vancouver. Moreover, they found that 90 percent of the population growth in metropolitan areas between 2006 and 2011 occurred in auto dependent suburbs and exurban areas, rather than in central cores or ‘transit suburbs’.

But why is that such a problem for the Earth and for us? The problem is that suburbs are very energy-inefficient and resouce intensive. Low-density housing makes public transport difficult, if not impossible, because there are too few people and it is too expensive. So everyone ends up driving. A 2008 Statistics Canada report, using data from the 2001 census, found that “the farther people live from the city centre, the more time they spend behind the wheel” – and they use a car more often and drive further.

Suburbs are also a problem because single-family dwellings are generally less energy-efficient than apartments or other forms of multi-family dwelling (although older houses in the urban core may be a problem because they have less insulation). And it is more expensive per person to provide infrastructure such as roads, water, sewers and electricity.

The result is that greenhouse gas (GHG) emissions – and other air pollutants due to transportation– are much higher in the suburbs. For example, a 2007 article by Jared VandeWeghe and Christopher Kennedy (the latter now Director of the new civil engineering program at UVic) looked at total residential GHG emissions in Toronto. They found the top ten census tracts, all in the suburbs, have an average annual emission rate almost 4 times that of the bottom ten (9 of them in the central core), largely due to vehicle emissions.

The health impacts of urban sprawl were first explored in depth more than a decade ago in the 2004 book Urban Sprawl and Public Health (one of the three authors, Larry Frank, holds the Bombardier Chair in Sustainable Transportation at UBC). While the health problems related to global warming caused by GHG emissions are global in nature, we certainly are beginning to experience health problems in Canada, and they identified many other health problems of a more local nature resulting from urban sprawl.

These include higher rates of physical inactivity and obesity due to driving rather than active transportation; respiratory and cardiovascular disease due to air pollution; more traffic injuries and deaths resulting from car-dominated transportation; and impacts on mental health and social wellbeing.

In short, continued suburban sprawl is incompatible with the overall health of this and future generations. The answer is obvious, although not simple: Stop suburban sprawl. In Victoria, that means intensifying the more central areas while preventing further suburban development in the Western communities or the Saanich peninsula. It also means holding the line against the further extension of water supply to be the Juan de Fuca electoral district, which is just a cloak for further suburban development.

© Trevor Hancock, 2017



Build telecommute centres, not interchanges

Build telecommute centres, not interchanges

Dr. Trevor Hancock

13 November 2017

701 words

The public health approach to management of disease and injury is very simple. We believe that the best way to manage it is to never have it in the first place. Well, what if we applied that thinking to the infamous Colwood crawl? What if the best approach to the crawl were to prevent it in the first place?

I recall a perhaps apocryphal story from the early days of the ‘information superhighway’ in the 1980s that the US Department of Transportation was willing to allow highway funds to be used for the digital highway. True or not, it is the right idea – one way to deal with congestion is to arrange it so that people don’t need to travel in the first place. Welcome to telecommuting!

Obviously not every commuter can telecommute, and probably many of those who could would still need to be in their office from time to time. But if on average commuters could telecommute one day a week, that alone would reduce traffic volume by 20 percent. This would also have environmental health benefits; fewer cars means less air pollution and lower emissions of carbon dioxide, thus helping to reduce global warming, with all its anticipated adverse health impacts.

Telecommuting can take one of two main forms; working from home or working from a remote office. The latter could be a satellite office for a Ministry or large business or a shared public or private facility where people from different sectors could work a day or two a week.

From a public health perspective I favour the shared office space for several reasons. Working at home can be very socially isolating, but also would mean equipping every home with office technology, and finding a suitable workspace in the home, thus requiring more equipment and probably shifting costs to the employee.

On the other hand, a neighbourhood telecommute centre could provide several public health and other benefits. First, of course, it becomes a place where people gather, thus building community connections. Add a daycare or other health and social services, perhaps a library, a coffee shop or small café and you have even more benefits. And you get more family and community time too, given that time spent commuting is time not spent with family and in the community.

Tie the centre into local walking and biking trails and bus service and you have the benefits of active transportation. And even if people do drive, they are not driving as far, which reduces pollution and greenhouse gas emissions, and they are not spending as much time commuting. A recent Canadian study, for example, found that “working from home is associated with decreases in overall travel time by 14 minutes and increases in odds of non-motorised travel by 77 percent”.

A recent UK study found that workers reported that a 20-minute increase in commute time was equivalent in terms of their reduced job satisfaction to a 19 percent pay cut. Dr Kiron Chatterjee, who led the research, noted that “An important message for employers is that job satisfaction can be improved if workers have opportunities to reduce the time spent commuting, to work from home, and/or to walk or cycle to work – such commuting opportunities are likely to be good news for employee wellbeing and retention and hence reduced costs to businesses.”

All of which brings me to the infamous McKenzie interchange, a Ministry of Transport version of bypass surgery; drastic, and too late in the disease process. As far as I can see, the effect of the interchange will be to get frustrated commuters to their next stoplight and tailback a few minutes quicker.

It would have been a much better use of public money if they had taken that $90 million or so and invested it in eight or nine $10 million telecommute centres in the Western Communities; the environmental social and health benefits would have been significant.

So before investing more public money on a failed 20th century approach by building more interchanges, the new provincial government should undertake a full and comprehensive impact assessment of telecommuting as well as other solutions such as really good public transit. We would all be healthier for it.

© Trevor Hancock, 2017




Pollution is not inevitable cost of prosperity

Pollution is not inevitable cost of prosperity

Dr. Trevor Hancock

6 November 2017

702 words

In two previous columns I explored the scale of chemical pollution in society and the health and environmental toll it takes, as revealed in the recently released report of the Lancet Commission on Pollution and Health. In this final column in the series, I examine the reasons the Commission believes underlie the neglect of this important issue.

The first is a belief that pollution is just the cost of development, that all countries as they develop have to go through the pollution stage before they become wealthy enough to stop it. The Commission “vigorously challenges that claim as a flawed and obsolete notion”.

Pollution is in fact very costly, both in health terms and in dollars, and thus is a drag on economic development. The Commission notes that the productivity losses due to pollution-related diseases “reduce gross domestic product (GDP) in low-income to middle-income countries by up to 2% per year”, while it is estimated that “welfare losses due to pollution . . . amount to . . . 6.2% of global economic output”.

On the other hand, the report also notes that “an estimated US$30 in benefits . . . for every dollar invested in air pollution control” in the USA, while “the removal of lead from gasoline has returned an estimated $200 billion . . . to the US economy each year since 1980”. Given that we do not even know the health impacts and thus the costs of many pollutants, the benefits of controlling them are likely to be large.

A second reason is that production, use and disposal of chemicals has increasingly been moved to low and middle-income countries, where awareness is less, costs lower, regulations weaker and enforcement more lax. While this may translate into increased profits for the corporations that move their work to these countries, it exposes local people to levels of chemical use and pollution that would not be tolerated in high-income countries.

It seems to me that it should be a matter of national and international ethical corporate behaviour that no high-income country allow its corporations to operate in another country using practices that would not be permitted in their home country. Why should people in middle and low-income countries pay a health price for chemicals that we use and benefit from, and at lower costs than if we produced them here?

This leads to a third key issue: “the opposition of powerful vested interests has been a perennial barrier to control of pollution, especially industrial, vehicular, and chemical pollution”. The Lancet Commission is blunt in stating that these industries “impugn the science linking pollution to disease, manufacture doubt about the effectiveness of interventions, and paralyse governmental efforts to establish standards, impose pollution taxes, and enforce laws and regulations.”

In his introductory chapter to a section on ‘Contaminants in the Age of the Anthropocene”, part of a just released Encyclopedia of the Anthropocene, Dr. Pierre Mineau – a Saltspring Island-based environmental scientist – supports this analysis. But importantly, he also reminds us that “we all share in the responsibility for not insisting that better systems be put in place to prevent either misguided introductions [of chemicals] or slow and inadequate controls” on their use. And, he might have added, we can try to avoid using them in our homes and communities.

On the positive side, the Lancet Commission concludes, we know what we need to do and how to do it. And importantly, if we apply these methods in middle and low-income countries, we can help them “avoid many of the harmful consequences of pollution, leapfrog the worst of the human and ecological disasters that have plagued industrial development in the past, and improve the health and wellbeing of their people.”

As with so many other health and environment issues, we see here a decades-long refusal to take seriously the concerns of public health professionals and environmental activists, who time and again are left saying ‘we told you so’. It does not give us great comfort. It is time we all insisted that governments put the wellbeing of people and the environment on which they depend – not just here, but around the globe – ahead of the wellbeing of corporations and their shareholders.

© Trevor Hancock, 2017


Pollution and health: A neglected issue

Pollution and health: A neglected issue

Dr. Trevor Hancock

30 October 2017

702 words

Perhaps the most startling claim made by the Lancet Commission on Pollution and Health, in its October 19th report, is that “despite its substantial effects on human health, the economy, and the environment, pollution has been neglected” and its health effects “underestimated in calculations of the global burden of disease”. Considering all the attention that pollution issues have garnered over the years, that seems, on the face of it, a rather preposterous claim.

Yet dig a little deeper and the reason for that claim becomes apparent. In essence, while pollution certainly gets a lot of public and media attention, for the most part that has not translated into public policy that effectively curbs pollution. On the contrary, “in many parts of the world, pollution is getting worse”, particularly air, chemical and soil pollution in rapidly developing low and middle-income countries. Meanwhile the health and environmental consequences have been largely ignored, accepted as the cost of doing business, the price of development.

Contrary to previous estimates, which have found a lower burden of disease and premature death due to pollution, the Commission – which included three Canadians, including Professor Bruce Lanphear at SFU – concludes that “diseases caused by pollution were responsible for an estimated 9 million premature deaths in 2015 – 16% of all deaths worldwide”. To give some sense of proportion, the commission points out this is “three times more deaths than from AIDS, tuberculosis, and malaria combined and 15 times more than from all wars and other forms of violence”.

But these are ‘only’ deaths; on top of this we need to include all the illness and disability associated with pollution. The costs are enormous; the productivity losses are estimated to be up to 1.7 percent of annual health care spending in high-income countries and 7 percent in some rapidly developing middle-income countries.

And yet all this is an underestimate. Of the three main categories of pollutants, the Commission argues, only one group has been sufficiently well studied that the health effects are well understood and included in their estimate. This category includes in particular the links between indoor and outdoor air pollution and a number of conditions such as heart disease, chronic lung disease and cancer.

The big culprit here, according to the Commission, is combustion of fossil fuel and – in low income countries – biomass. This accounts for “85 percent of airborne

particulate pollution and for almost all pollution by oxides of sulphur and nitrogen” with the biggest problem being coal (which is why we need to close down the coal industry and drastically reduce fossil fuel use).

The second category is pollutants where we have some evidence of links to health problems and growing evidence of causation, but not enough to quantify the burden of disease. This includes associations between soil pollution with heavy metals and toxic chemicals at mines and industrial sites, and between fine particulate air pollution and conditions such as diabetes, and some diseases of the central nervous system.

The third category is, in many ways, the most troubling. It includes “new and emerging pollutants” such as certain pesticides (e.g. neonicotinoids and glyphosate), nano-particles, pharmaceutical wastes and substances that disrupt endocrines (hormones) or the developing neurological system. Moreover, some of these are widely dispersed in the environment and in our own bodies and the bodies of many other species, the phenomenon of ecotoxicity I referred to last week.

In light of the likely significant but as yet unquantified health effects of the second and third categories, the Commission believes that its estimate of 9 million deaths “could thus be the tip of a much larger iceberg”. So why is this significant health problem neglected? Why does any government in its right mind allow its population to be exposed to these pollutants at levels that are known to harm health?

I will explore the roots of this neglect in my next column, but sadly, I think that part of the reason is that, as the Commission notes, “Pollution disproportionately kills the poor and the vulnerable. Nearly 92% of pollution-related deaths occur in low-income and middle-income countries”. You can’t help but think that the cynical and sinister calculus is that these lives are cheap, and they don’t matter.

© Trevor Hancock, 2017

Protecting health in our chemical society

Protecting health in our chemical society

Dr. Trevor Hancock

23 October 2017

701 words

Last week The Lancet – one of the world’s leading medical journals – published another in its series of Commission reports on various aspects of Planetary Health, this time on pollution and health. Next week I will delve into the report in some detail, but first I want to go back 36 years, to when I was the co-author of a major report for the Local Board of Health for Toronto on the health impacts of our chemical society. We sought to document the overall health, social, environmental and economic impacts of our widespread use of chemicals, and suggest actions we should take to reduce or eliminate those impacts.

Our report – Our Chemical Society – defined a chemical society as “one which believes its quality of life is, in large measure, dependent upon, and directly related to, the widespread production and use of chemicals”. We noted that at that time there were 60 – 100,000 chemicals in commercial use. Of these, 34,000 were on the US EPA’s 1978 Toxic Effects List, very few of which had been adequately tested.

Harmful or potentially harmful chemicals are pervasive in our lives. Some are intended to be inhaled, consumed or applied to our bodies, including food additives and synthetics, tobacco and alchohol, pharmaceutical drugs, cosmetics and toiletries, including scents and air fresheners. But many others are not, but get into our environments and ultimately our bodies anyway; they are in the paints, solvents and fabrics we use and and the materials with which we build and furnish our homes, schools and workplaces. Some, of course – the pesticides and herbicides – were designed to be toxic to various life-forms.

Much of this exposure has occurred since the end of the Second World War, after which the chemical industry really took off. One consequence is a phenomenon known as ‘ecotoxicity’; the widespread contamination of ecosystems and food chains with low levels of muliple persistent organic pollutants and heavy metals. As a result we – and all other species – carry a body burden of dozens, even hundred of these chemicals, with health consequences that are largely unkown – and probably unknowable, because of their potential interactions.

In the face of this onslaught we recommended taking a much tougher line on controlling chemicals, suggesting that “it is better to ban a product subsequently found to be safe than to permit the use of a product subsequently found to be harmful”. Because once a chemical is out in the environment, you can’t take it back or remove it – only nature can. Thus we suggested reversing the onus of proof; no longer treating chemicals as if they were human, and thus innocent until proven guilty, but guilty until proven innocent.

To tackle the vast backlog of safety testing, we suggested introducing the concept of social utility, prioritising for testing those chemicals judged to be likely to have high utility and putting others – such as yet another scented product – at the back of the line, and thus not on the market. We argued for stronger controls on the advertising and marketing of chemicals, and we urged people and organisations to try to be as chemical-free as possible. In addition, we urged the passage of an Environmental Bill of Rights, greater public involvement and transparency in the regulation of chemicals and even a Select Committee or a Royal Commission to investigate the situation.

Fast forward 36 years and not much has changed – certainly none of what we recommended has happened. The Lancet Commission reports that “pollution has been neglected” and its health effects under-estimated, noting that “more than 140,000 new chemicals and pesticides have been synthesised since 1950”. Of these, the 5000 chemicals produced in the highest volume “have become widely dispersed in the environment and are responsible for nearly universal human exposure”.

Moreover, “fewer than half of these high-production volume chemicals have undergone any testing for safety or toxicity” – note that is ANY testing! It is as if we are subjects in an unauthorised experiment to which we have never given consent. Why have governments allowed this to happen? Why does human health count for so little? We should be outraged, and we should insist that governments placed human wellbeing ahead of corporate profit and the economy.

© Trevor Hancock, 2017

Seeking common vision and common action

Seeking common vision and common action

Dr. Trevor Hancock

15 October 2017

702 words

There is an emerging community-based movement in the capital region – and elsewhere around the world – that recognises that ecological, social and economic conditions and human wellbeing are not separate issues but are inextricably linked. Here in Victoria a number of related initiatives have sprung up, mostly in just the past couple of years, that are working to address these intersecting issues holistically, but in somewhat different ways.

Several of these initiatives came together last month at one of the Conversations for a One Planet Region that I have been organising this past year. The Conversations are just that, an attempt to get the conversation started here on what it would mean – and what it would be like – to live in a region that only had an ecological footprint equivalent to our fair share of the Earth’s resources. Since we currently use the equivalent of 5 planets’ worth, this would be an 80 percent reduction; how do we do that while maintaining a high quality of life and good health for all?

Greater Victoria Acting Together (GVAT) is “a broad-based coalition of local groups and community organizations” working to advance the common good. Its focus is on “relational learning and capacity building”, through which it seeks to build respect and trust across sectors and give civil society a greater voice.

Creatively United for the Planet works to celebrate those who are making a difference in our region, “showcasing local change-makers and grassroots solutions for a better world”. They do so through community events (such as the Earth Day Festival), sharing engaging stories and videos and – coming soon – through a series of community TV programs on Shaw.

Cities for Everyone “supports more affordable housing and transportation in order to provide security, freedom and opportunity for people with all incomes and abilities”; it has a strong focus on more ecologically sustainable urban development in order to achieve this purpose.

Then there is Common Vision, Common Action. This past weeekend I was involved in a most unusual non-partisan policy conference, (full disclosure: I was a member of the organising committee). The conference brought together 100 or so participants to establish “a regional agenda for social and ecological justice”. While not explicitly about health, it was very much about how to improve the wellbeing of all the people who live here, while at the same time ensuring the ‘health’ of the natural systems of which we are a part and upon which we depend.

While the conference was non-partisan it was very much political, in that it sought to create a common platform and “a framework for advocacy and action among residents, community organizations, candidates and local governments from now until the 2018 municipal elections and beyond”.

The conference began, in a spirit of reconciliation, by focusing on the Indigenous peoples who lived here for thousands of years before European colonisation began a couple of hundred years ago. Joan Morris, a member of the Songhees Nation, talked about the pain, suffering and loss that Indigenous people had experienced as a result of colonialism, and that continues to this day.

She was followed by Paul Cheoketen Wagner, a wonderful storyteller and activist from the W̱SÁNEĆ (Saanich) Nation. In his very moving remarks he told us we must seek and demonstrate leadership that values all of life, human and non-human, and that we need to love and protect this place as we would love and protect our own children.

In the policy discussions that followed, the participants sought to express these values and sentiments across a range of issues that are largely within the realm of or subject to the influence of local government: Land use and housing, transportation, food and water systems, ecological areas and parks, education, energy systems, arts and culture, and systems of governance, inclusivity and economics.

The result is a draft plarform that proposes a wide range of policy initiatives – and advocacy actions directed to the provincial and federal governments where the local power is absent – that people of good will can work from and run on; people who cherish this place, the planet itself and the wellbeing of all the people who live here and all the life on our planet.

© Trevor Hancock, 2017


Should we try social prescribing?

Should we try social prescribing?

Dr. Trevor Hancock

9 October 2017

701 words

A central theme of my columns is that health is determined by a wide range of factors, most of which are not within the realm of the health sector. Which means that most of the interventions that will help us be healthy are outside the health care system. One of those interventions, first promoted by the UK Department of Health in 2006 and now being developed in England, is social prescribing.

In a report earlier this year, The King’s Fund – a well-respected independent charity working to improve health and care in England – describes social prescribing as a service that provides a “means of enabling GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services”. Given that in the UK about 1 in 5 patients consult their family physician for what are mainly social problems, it makes sense to refer them to social rather than medical care and support.

In the 1970s I worked as a family physician in a community health centre with many marginalised and vulnerable people; many of the problems I saw were not medical problems, and could not be solved with medical interventions. The people I saw were precisely the sort of people The King’s Fund suggested are most likely to benefit from social prescribing: Those with “mild or long-term mental health problems, vulnerable groups, people who are socially isolated, and those who frequently attend either primary or secondary health care”.

The basic idea of social prescribing is very simple: Given that a broad range of environmental, social and economic factors affect health, and that many voluntary and community sector organisations are working to support people in these areas, how do we connect people in need to these organisation and their programs? The types of services that people need, the King’s Fund report notes, include “volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice and a range of sports”.

Social prescribing involves a primary care practitioner referring a patient to a ‘link worker’ in the community/social care sector. These workers, who may be paid or volunteers, interview the patient and link them to a suitable community or voluntary sector program. Some of these programs fall into the area of local governments, involving a variety of recreational activities.

There are two main reasons for undertaking social prescribing: Improving health and reducing costs. So does it work? Well, there is some evidence that it might, with some studies showing improved health and wellbeing, and even some reductions in use of primary, emergency and specialty care. But whether or not it is cost-effective remains to be seen, partly because most of the studies have only looked at the experience over 12 months or so, while the benefits are likely to accrue over the longer term.

So while there is emerging evidence that it seems to work, it is too early – and the research to date has been too weak – to give a definitive answer. But there are enough interesting examples and information to suggest it may be worth trying here in BC, given the new government’s commitment to support and expand community health centres (CHCs) – or what should perhaps be thought of as community health and social care centres. This provides an opportunity to implement social prescribing, at least on a pilot basis.

There are a few key issues to address. First, social prescribing itself requires funding and support for the link workers or navigators. Second, the agencies and especially the community organisations and NGOs that provide the services will likely need increased funding and support to meet the increased demand that can be expected. Third, any implementation needs to be set up with a strong evaluative component, and it needs to be evaluated over a number of years.

Finally, and perhaps most important, this needs to be seen as a replacement for, and not an addition to healthcare expenditure. If indeed social prescribing succeeds in reducing demand for health care, the resulting savings need to be transferred out of the health care system and into the social care system that are providing these benefits. After all, much of what determines health lies beyond health care, and funding should reflect that reality.

© Trevor Hancock, 2017


Creating mentally healthy communities

Creating mentally healthy communities

Dr. Trevor Hancock

2 October 2017

700 words

The communities in which we live are both physical places and social spaces, and both affect mental wellbeing. A report released by the California–based Prevention Institute in September delves into this issue. (In the interests of transparency, I volunteer on their Executive Advisory Board, although not involved in the preparation of this report.)

Beginning with a framework that identifies factors in the community most related to medical conditions that show the greatest disparity (and thus are related to environmental, social and economic conditions and the behaviours they shape), the Institute looked at how those factors relate to mental health. They found seven factors in the broad categories of ‘People’ (our social spaces), ‘Place’ and ‘Equitable opportunity’ that “have a particularly strong impact on mental wellbeing”.

There are three social factors – Social networks and trust, Participation and willingness to act for the common good, and Norms and culture; three aspects of the physical environment – Look, feel and safety, Housing, and Arts and cultural expression; and one in the area of equitable opportunity – Living wages & local wealth. Since I dealt with poverty last week, I will focus here on the ‘People’ and ‘Place’ factors.

The report notes the considerable body of evidence that “strong social networks and connections correspond with significant increases in mental and physical health”, as well as less violence and addiction and even improvements in academic and economic performance. These strong and positive social connections must be built in families, networks of friends and in schools, workplaces and places of worship – even through connection with pets and therapy animals.

A related strategy is to build community capacity to participate and act together to improve things; there is a positive and reciprocal relationship between community and individual empowerment and there is good evidence that empowerment has significant health impacts. This can include efforts to build a more participatory democratic system. Evidence from Brazilian cities such as Porto Alegre and Belo Horizonte has linked participatory budgeting with improvements in housing, utilities such as water and sanitation, health centres and cultural and recreational facilities, all of which are themselves determinants of health.

The third social factor – which is related to the first two – is to change the community’s culture and social norms. We have seen this with respect to smoking and to drinking and driving, both of which are now much less socially acceptable than they were a few decades ago.

Now we see efforts to change the social norms around bullying in school and on the internet, gender and racial discrimination and harassment in the workplace, domestic violence and other issues that have led to significant mental health impacts. The report notes “Positive social norms that foster inclusion and respect for all persons can enhance individual self-esteem and wellbeing”.

The physical environment also has an impact on mental wellbeing. Unattractive, poorly-maintained neighbourhoods are more common in disadvantaged groups. People living there are less likely to have good-looking schools, good parks nearby, shade trees, attractive streetscapes or public art. Moreover, access to attractive, safe, walkable neighbourhoods and parks facilitates physical activity, which in turn improves mental health.

Unpleasant environments convey the message that ‘you don’t matter’, which makes peole feel neglected and worthless, less empowered and less able to take action on these issues. Arguably, people living in such neighbourhoods actually need extra investment in higher quality, better maintained built environments to make up for the deficits in the determinants of mental health that they experience in many facets of their lives.

Then there are the homes we live in. Being homeless is of course a major threat to mental wellbeing, but poor housing quality is also a threat to both mental and physical health, as is insecure tenure. We also need to look at how housing design supports – or fails to support – social connection; high-rise buildings are generally worse performers here.

Finally, there is good evidence that “music, dance, and all forms of artwork foster mental wellbeing”, as well as community solidarity; the report suggests ensuring that people have access to the spaces and resources needed for artistic expression.

Like Rome, mentally healthy communities cannot be built in a day – but they can be built.

© Trevor Hancock, 2017


Good mental health needs a good start in life

Good mental health needs a good start in life

Dr. Trevor Hancock

25 September 2017

699 words

Not only is poor mental health very costly to manage, it also represents a large burden of human suffering and loss of human potential and – to the extent it is preventable – a tragic societal failure. So it is good to see that – finally – we are beginning to pay some attention to improving the mental wellbeing of the population.

The evidence is clear that good mental health begins in infancy and childhood; a good start in life can create more positive and resilient young people, better able to handle adversity when it occurs.This evidence must be used to inform and guide the work of the new Ministry of Mental Health and Addictions, the health care system, the government as a whole and indeed the whole of society.

There are in essence two key approaches: First, creating supportive environments that protect people from known risk factors and provide a positive, mentally healthy situation. Second, providing resources and programs that enable people – especially children – to become resilient, with the skills they need to manage life’s ups and downs. In practice, these two approaches interact and need to complement each other.

One of the key strategies, as with health in general, is to reduce the level of poverty in our society. A 2010 Statistics Canada report noted that Canadians in the lowest income group are 3 to 4 times more likely than those in the highest income group to report low levels (poor to fair) of mental health. Living in poverty is a very stressful situation, and so not surprisingly is associated with higher levels of anxiety and depression, among other things. The effects of poverty are compounded in Indigenous and some other communities by the legacies of colonialism, racism and discrimination, making these important upstream mental health risk factors to combat.

In a 2007 background document, the Ontario Division of the Canadian Mental Health Association (CMHA) noted “losing stabilizing resources, such as income, employment, and housing, for an extended period of time can increase the risk factors for mental illness”, especially for those who may already be pre-disposed to mental health problems. Because of the importance of poverty reduction, CMHA Ontario “has been calling for poverty reduction strategies that increase access to economic and community supports for vulnerable populations”. CMHA BC has also recently welcomed the poverty reduction measures brought in by the new BC government.

Infants and children are particularly vulnerable to the adverse effects of poverty and colonialism on the family and community environments in which they develop. A 2016 report from the UK’s Faculty of Public Health noted that poverty in the early years leads to poor cognitive performance, while in adolescence “it increases risks of depression, substance abuse, and early sexual and criminal activity”. It is not hard to see how these impacts can lead to the perpetuation of the cycle of poverty.

Efforts to buffer the effects of poverty and colonialism, even while working to reduce them, begin in infancy, indeed, even before birth. High-risk or vulnerable parents (e.g young, poor and single mothers, or parents with mental health or addiction problems) should be identified and provided with supportive services, both to improve their health in pregnancy and to help them develop better parenting and coping skills. A study from the University of Ireland found that “high quality early childhood enrichment provided through preschool results in enduring gains in children’s social and emotional wellbeing, cognitive skills, problem behaviours and school readiness”, especially among more disadvantaged children.

But while it might seem intuitive that high-risk families are the ones who need to be reached, it is well-established in public health that the majority of cases for most conditions do not occur in the high-risk population but in the far more numerous moderate and low risk populations. So all families need to be reached, assessed and offered services, with those found to be at risk provided with more focused, intensive and tailored support, proportionate to their need, an approach known in the UK as proportionate universalism.

So any government that is genuinely interested in ensuring the long-term mental wellbeing of our society needs to invest in poverty reduction, support for parents, especially the most vulnerable, and early child development.

© Trevor Hancock, 2017