Island Health must focus on population and public health

Island Health must focus on population and public health

Dr Trevor Hancock

7 January 2019

698 words

The trigger for the weekly columns I have written over the past four years was an editorial on prevention in the Times Colonist in November 2014. In my response I wrote “in focusing on prevention in primary care, its prescription did not go far enough”. Fast forward four years to an editorial from Leah Collins, Chair of the Board of Island Health (“Health care means more than hospitals”, 2 January 2019); in response I am tempted to just reprint my first two columns – “Health care a small part of true health” and “What makes us healthy? Hint: It’s not health care”.

For while there is much that is welcome in what Ms. Collins writes, as was the case four years ago it does not go far enough. I agree that “we have to think and act more holistically when we think about the health of the population”, and that “keeping people healthy and thriving at home” and “working to take pressure off our hospitals” should be the aim. The strong commitment to primary and community care and addressing the inequalities in health experienced by Indigenous people is welcome.

But two key elements of an holistic approach are missing. An old adage is that if your bath is overflowing you should first turn off the tap, or at least reduce the inflow. For the health care system there are two taps that need to be turned off. The first is to reduce the burden of disease and injury (and ‘dis-ease’ – the mental and emotional discomforts of life) that the healthcare system has to deal with in the first place, by keeping people healthy and safe.

The second is to reduce the demand for care by improving people’s capacity for self-care – a term that was not even used in her editorial. Here I focus on strengthening Island Health’s approach by improving population health and reducing the burden of diseases to which the system has to respond; I will address self-care next week.

With respect to population health, much more is needed than the simplistic call to practice healthy living that comes at the end of the editorial. A mountain of evidence tells us that unhealthy behaviours are shaped by our social, economic and physical environments, our living and working conditions and the disgraceful marketing of unhealthy products. To simply shrug this off as a matter of personal choice and behaviour is unacceptable.

Instead we have to address the upstream determinants of our health. One of the most important of these is poverty and inequality, and Island Health sees the evidence of the health impacts of poverty and inequality every day. But oddly, while correctly recognising the inequalities in health experienced by Indigenous people, there is no apparent recognition that inequalities in health are experienced across the entire population by many other groups.

So if Island Health is serious about reducing the burden of disease and taking pressure off its hospitals, it needs to be publicly advocating for, encouraging and supporting poverty reduction strategies. The Board must also adopt an active partnership role, working with and supporting the many other sectors whose actions impact the health of the population more than does health care.

There are a number of other important population health issues that are not addressed in Island Health’s editorial, including the built environment, climate change and other worrisome ecological changes. In addressing these and other population health issues, the Board should turn to its public health staff, the only staff whose sole function is to protect and promote the health of the population.

Given the need to reduce the burden of disease, you would think Island Health would invest in population and public health activities that address these upstream determinants of health. Yet in 2017/18, Population Health and Wellness got a mere 2.6 percent of Island Health’s expenditure, down from 2.8 percent in 2011/12; meanwhile, acute care received 55.3 percent, up from 54 percent in 2011/12.

I will believe Island Health is serious about improving the health of the population when I see it speaking out about and taking action on the upstream determinants of health and investing in and strengthening its population and public health capacity.

© Trevor Hancock, 2019


The intangible gifts that keep on giving

The intangible gifts that keep on giving

Dr. Trevor Hancock

1 January 2019

701 words

The other day, inspired by the recent gift-giving and gift-receiving season, I found myself musing on intangible gifts. In fact, I awoke from a dream in which I had asked a group with whom I was working to list the best intangible gifts they had ever received. For a couple of minutes I lay there wondering what those intangible gifts might be in my case – and then the floodgates opened!

The list starts with the love my wife and I have shared for decades, but that was quickly followed by all the close friends with whom I have a special bond, another form of love. In my case, they are mostly people with whom I have worked closely over the years, with deep roots in shared values, shared challenges and shared accomplishments; others are those with whom I have danced over my decades as a Morris dancer. Another gift of love and friendship is from my dogs, who not only give me trust and love, but ensure I go outdoors and walk twice a day.

Then there are the gifts of strangers, the random acts of kindness that lighten our days. The one that came instantly to mind was the taxi driver in Kolkota, India, some years ago, who found the much-loved vest I had left in his taxi – a gift from a friend – and took it all the way back to the hotel where he had picked me up, a long drive. I had been very upset at losing it and was overjoyed to get it back – and made sure to thank him with a gift of my own.

Another set of intangible gifts involve beauty, from the beauty of nature – the dawn, the Milky Way, a flower or a mountain view – to glorious buildings or wonderful furnishings and to art, be it a painting, a sculpture, music or other performance art. Related to that, perhaps, is the gift of humour – which is why I read the comics at the start of every day, although spontaneous humour is matchless.

But I am deeply mindful of the fact that I have been able to have these experiences in part because my basic needs are met, I have shelter, food and income. But while it must be harder to appreciate intangible gifts such as these when hungry, tired and cold, they are not beyond reach. Certainly people living in those situations tell of experiencing kindness or seeing beauty and finding comfort from those experiences.

So then I thought, ‘well, I can’t be the first person to have had these thoughts, so what does the great god Google have to say about intangible gifts?’. On the whole, it was not edifying. Googling ‘intangible gifts’ gave me a bunch of sites that were chiefly about buying people experiences. To be fair, the very first site, from GROW Counseling in Georgia, suggested support and encouragement, forgiveness, quality time, helping others and giving up an unhealthy habit. But a travel site had 52 ideas, most of which involved buying tickets or buying an experience, while DealNews suggested a number of gifts of online music and videos.

So I decided to see what Wikipedia had to say about intangible gifts, thinking I would get something a bit more philosophical; I couldn’t have been more wrong. Top of the list was information about the Gift Tax in the USA, and questions about what one can give to family members and what tax to pay. Then came an item about the gift economy, followed by a discussion on the value of intangible assets such as patents, copyrights, franchises, goodwill and trademarks.

Perhaps not surprisingly in this material age, it seems that intangible gifts have too often been monetized and commercialised. But what strikes me about the intangible gifts that matter to me is that nobody consciously gave them to me and they didn’t pay for them; they are experiences and memories of things that happened to me or that I came across, found, or sometimes went looking for. Intangible gifts such as these are fully portable and always with me, they trigger positive emotions and contribute to mental wellbeing. They really are the gifts that keep on giving.

© Trevor Hancock, 2019