Systematic denial harms our health

Systematic denial harms our health

Dr. Trevor Hancock

18 September 2018

698 words

Two of my recent readings from very different fields have each in their own way underlined how we have failed to come to grips with fundamental challenges that have significant health impacts today, and will have profound impacts for the next generations. We – and by ‘we’ I mean mainly the powerful who run our major public and private institutions – have ignored and denied the evidence for decades, choosing short term economic gain and not caring about long-term human pain.

The two areas are the social determinants of health  – mainly poverty, inequality and social injustice  – and climate change, which I will discuss next week. In each case, the authors make it clear that we have known all along that our current policies are harmful and that better options exist – but governments and their corporate partners have failed to act, or have even actively obstructed action.

The first example is the rather depressing summary of the history of our inaction on the social determinants of health, dating back to at least 1974. This story is told in Andrew MacLeod’s new and very welcome book All Together Healthy. MacLeod is the legislative bureau chief for The Tyeehere in BC and his book is about all the things beyond the health care system that make us healthy; in other words, the subject of my columns.

He recounts a story only too familiar to those of us who work in population and public health. In 1974 the federal Department of Health and Welfare (as it then was) published a short but powerful policy framework; A New Perspective on the Health of Canadians. I have a particular attachment to this report, because it was published just before I moved to Canada to be a family doctor in rural New Brunswick. I read it soon after and it helped change my life and move me towards a career in public health.

Named for the then Minister, Marc Lalonde, the Lalonde Report suggested there are four ‘health fields’: Human biology, lifestyle, the environment and health care. Importantly, the report stated “there is little doubt that future improvements in the level of health of Canadians lie mainly in improving the environment, moderating self-imposed risks and adding to our knowledge of human biology.”

While this approach paid a bit too much attention to lifestyle as personal choices and behaviours, failing to acknowledge the powerful forces in the social and commercial environments that shape choices, such as income and marketing, it nonethelessmarked a crucial turning point by questioning the impact of health care on health. In fact, as MacLeod points out, the report stated the federal government would pay as much attention to these other three fields as it then did to the financing of health care.

Really? Did I miss something? As MacLeod drily remarks, “action did not tend to match the rhetoric” And he goes on to recount the other national reports since then that have also been largely ignored, among them the 1986 Epp report (named for another federal minister), which highlighted among other things the need to address health inequality related to income and a 1990s report from the National Health Forum that repeated the same messages.

The reasons behind this neglect and denial, if not outright suppression, are apparent in the 1974 Lalonde report, which states “ominous counter-forces have been at work to undo progress in raising the health status of Canadians. These counter-forces constitute the dark side of economic progress”. And there you have it in a nutshell; a lot of people make a lot of money by making people sick.

Hence MacLeod’s closing observation that “the federal government under both major parties has known for decades that poor health is closely tied to social inequity”. And yet, he concludes, it as done nothing and in fact “in many cases has taken policy choices that have made matters worse”

If we really want to improve the health of the population, we have to tackle poverty, inequality, and unhealthy business practices. In short, we have to change society and the economy, which is clearly too big a step  – and too threatening – for these who hold power in Canada today.

© Trevor Hancock, 2018


Change the values that shape our systems

Change the values that shape our systems

Dr. Trevor Hancock

10 Sept 2018

701 words

Two weeks I argued that the immense challenge of climate change and other global ecological changes that threaten our health, as well as the high levels of inequality experienced world-wide, are the inevitable result of the societal systems we have created. If “every system is perfectly designed to get the results it gets”, as the Institute for Healthcare Improvement puts it, then to get different results, we need a different system.

Last week I suggested that our economic system is not fit for purpose in the 21stcentury. The new mantra that we can have both a strong economy and a healthy environment is simply not true if the strong economy is based on harming the environment. So the Trudeau and Notley argument that we need the pipeline in order to get the oil from the Alberta tarsands to foreign markets is nonsensical when we consider both the global climate change impact of the tarsands, and the local devastation they create. Their arguments are rooted in a world view, modernism, and an underlying set of values that are also not fit for purpose in the 21stcentury.

Modernism, the dominant world view or paradigm within which we operate, is rooted in two 16thcentury transformations in thought, according to Krishan Kumar, Professor of Social and Political Thought at the University of Kent,  The first was a religious transformation, the Protestant Reformation, with its attendant values relating to work (the Puritan work ethic), which led to modern capitalism. This was accompanied by a Scientific revolution that was based on rationalist thought and the scientific method.

Kumar identifies a number of  elements that comprise ‘modernism’, but states “fundamentally, it is the economic changes that most dramatically affect industrial society.” Those economic changes include “economic growth as the central defining feature of an industrial . . . economy”. These transformations, and the growth in wealth, resources and power for the nations of the West that resulted led to a belief in the inevitability of progress.

But progress has been confused with economic growth, and two key values that relate to that; acquisitiveness and greed. We want more stuff, and we can never have enough. If you are a billionaire, you still aren’t a multi-billionaire. And if the acquisition of all that wealth (and the power that goes with it) impoverishes others and harms the planet – well, that is just the cost of progress.

The fact that economic growth now threatens the stability of the ecosystems and the sustainability of the natural resources upon which we depend somehow is ignored. This is linked to another key attribute of modernism that Kumar mentions, and which stems from the scientific revolution; “a sense of being superior to and/or apart from nature”. We do not fully understand or accept that the environment is not some ‘nice to have’ fringe benefit of being wealthy, not something that must be sacrificed in the name of progress.

At the heart of our challenges, then, lie two sets of values that we have to change; acquisitiveness, greed and economic growth on the one hand, and our separation from nature on the other. With respect to the first, we need to replace growth with the concepts of adequacy or sufficiency as a guiding principle. In the foreword to the book “Enough is Enough” by Rob Dietz and Dan O’Neill, Herman Daly – the ‘elder statesman’ of steady state economics – suggests that ‘enough’, which means “sufficient for a good life”, “should be the central concept in economics”, while “the current answer of ‘having ever more’ is wrong”. Or as Gandhi said, “Earth provides enough to satisfy every person’s need, but not every person’s greed”.

Dietz and O’Neill propose a number of policies that together “form an agenda for transforming the economic goal from more to enough”. These include limiting the use of materials and energy to sustainable levels, stabilizing population through compassionate and non-coercive means, achieving a fair distribution of income and wealth, and changing the way we measure progress.

Add to that a recognition that we are part of, not apart from, nature and must act accordingly, and we might have a fighting chance of getting to a society based on enough for all.

© Trevor Hancock, 2018


We don’t pay the full cost of goods and services

We don’t pay the full cost of goods and services


Redesigning our systems to help people and the planet

Dr. Trevor Hancock

4 Sept 2018

700 words

Last week I discussed the Institute for Healthcare Improvement’s key principle – that every system is perfectly designed to get the results it gets – and suggested we apply it to society as a whole. Which begs the question: What results do we want? I suggested that we need to create a societal system that is perfectly designed to enable all the people of the world to live good quality lives within the bounds of the Earth and its ecological systems. What might such a system look like?

A good place to start is to change the entire focus of public discourse and public policy from economic development to human and social development. We have come to believe that progress and success means being wealthy and accumulating more stuff – regardless of who gets less while we get more, and regardless of any harm that we do to the Earth and its living systems.

But economic development must be the means, not the end; it must support the goal of maximising human and social capital in an ecologically sustainable and socially just way. A key question, then, is what sort of economic system would do that and how do we get such a system? We need to examine all public and private sector policy decisions, especially economic policies, and ask ‘do they move us towards or away from this goal’?

One key instrument of public policy is taxation. The fundamental principle here is to tax the things society doesn’t want, and not tax the things we do want. Hence the carbon tax, tobacco taxes and so on. In the energy sector, this would mean taxing fossil fuels based on their environmental and human health impact, with the highest taxes going on coal, dirty oil (e.g. the Alberta tarsands) and dirty (fracked) gas.

Cleaner fossil fuels such as non-fracked gas would get lower taxes, and there would be no taxes at all on energy conservation goods and services and clean, green, renewable energy sources. The increased taxes raised from the fossil fuel sector would help drive down demand. Until those taxes dried up, they could be used to support the energy system workforce to transition to the  growing conservation and renewables sector and to fund research on green technologies.

Such an approach could also be used in the area of consumables. We should reward products that have a long life and are designed to be recyclable or repairable, while heavily taxing (or banning) single-use, disposable products. We should give tax breaks for car sharing programs, bikes and public transit, and put higher taxes on larger vehicles. We can also extend this approach to our diets, with higher taxes on unhealthy foods high in sugar, salt and fat and on meat, especially beef, which has a large environmental impact. This would both improve health and protect the environment.

Then there are the perverse incentives in the system, which may have seemed like a good idea at the time, but now take us in the wrong direction, such as tax breaks and subsidies to the fossil fuel industry. These would need to be removed and transferred to the clean energy industry.

Another set of perverse incentives are associated with suburban sprawl; a 2013 report from the University of Ottawa’s Sustainable Prosperity project notes that “current price structures encourage sprawl while obscuring significant costs”.In Halifax, for example, the true costs to the city for the higher infrastructure needs of suburban living were roughly 2.5 times greater per person than for urban living. Other hidden costs include the much higher energy consumption of an auto-dependent community and associated poor air quality, congestion and long commutes. Clearly, we can’t afford suburban sprawl – and yet we keep building it.

No doubt people will object that all this will make the cost of living higher. It probably will, so we must also use the taxation system to ensure that life does not become unaffordable for people living on lower incomes. But we need to stop living in a fool’s paradise where everything is cheap and disposable, because we are not in fact paying the true costs of our goods and services.

I will return to this topic next week.

© Trevor Hancock, 2018


A system perfectly designed to harm the planet

A system perfectly designed to harm the planet

Dr. Trevor Hancock

28 August 2018

700 words

The Institute for Healthcare Improvement (IHI) in the USA is a leader in improving the quality of care and the effectiveness of the health care system and its approaches are also widely used in Canada. The guiding principle underlying all that IHI does is that “every system is perfectly designed to get the results it gets”.

The principle comes to us from systems and management science and organisational development. When applied to health care, it is used to try to understand what leads to poor quality and ineffective care and medical error. Then it is used to figure out what changes in the system are needed to prevent those problems and to ensure quality care. It is a principle that we should apply more broadly to our society and the global ecological changes we are creating, especially climate change.

There is mounting evidence that the planet is heating up – and quicker than expected. In fact there have been a number of worrying observations and studies about climate change in just the past month. One study in Nature Communications projects temperatures in the North China Plain within the next few decades that “may limit habitability in the most populous region, of the most populous country on Earth”.

Other reports have documented the unprecedented break up of Arctic ice and glaciers and the melting of permafrost in Siberia and Alaska. The latter could release not only vast quantities of carbon dioxide but also methane, a greenhouse gas that is some 25 times more potent that CO2, creating a worrying self-reinforcing cycle; more warming releases more methane and CO2, which creates more warming.

Loss of Arctic sea ice and permafrost thawingare two of the 15 ‘tipping elements’ scientists from the Stockholm Resilience Centre discuss in an article in the Proceedings of the National Academy of Science.  These ‘tipping elements’, which also include Amazon and Boreal forest dieback, may combine to create what they call a ‘tipping cascade’, a “domino-like cascade that could take the Earth System to even higher temperatures”. They caution that this could lead to “conditions that would be inhospitable to current human societies and to many other contemporary species”.

Moreover, a report from the Breakthrough Institute in Melbourne suggests the scientific community has been overly conservative in its approach: “the bulk of climate research has tended to underplay these risks, and exhibited a preference for conservative projections and scholarly reticence”. However, the report states, such an approach “is now becoming dangerously misleading with the acceleration of climate impacts globally . . . [because] what were lower probability, higher-impact events are now becoming more likely”.

So if we apply the IHI principle, we must conclude that our current social, economic, political and cultural system is perfectly designed to bring us not only the economic growth and increasing wealth we seek (mostly for the select few, with increasing inequality for many), but the global ecological consequences: Climate change, resource depletion, pollution, species extinction and other global ecological changes.

Moreover, it seems our political system is perfectly designed to fail to come to grips with these problems. We have seen the USA pull out of the Paris Accord and actually work to promote coal use. In Canada Justin Trudeau’s government has taken over the Kinder Morgan pipeline, which will support expanded production of Alberta’s dirty tarsands oil, while Ontario’s new government and other provinces fight back against the carbon tax. Sadly, our political system consistently favours short-term economic and political gains over long-term human and ecological wellbeing.

This cannot continue; we should not undertake what amounts to an experiment to see what might trigger disastrous tipping cascades – but that is exactly what we are doing. We need to step back and understand what aspects of the current system lead us to make the wrong long-term decisions. Then we need to figure out what it would take to create a societal system that is perfectly designed to enable all the people of the world to live good quality lives within the boundaries of the Earth’s ecological systems.

This is the most important challenge we face in the 21stcentury. Next week, I will delve into some of the key aspects of this challenge.

© Trevor Hancock, 2018