Key public health issues for the 2020s
Dr. Trevor Hancock
1 January 2020
I was prompted to write this column by an article in The Tyee (a Vancouver-based on-line news service) about public health issues in 2020. It’s not often people write about public health, as opposed to health care, so the attention is welcome. However, I found the column heavily focused on infectious diseases and newsworthy items such as the opioid epidemic, dementia, brain injury and air pollution. But while not unimportant – Alzheimers disease and opioid overdose were seventh and eighth in the list of causes of death in 2018 – these are not the biggest public health problems we face over the next decade.
The major causes of death in Canada are chronic diseases, with cancer and cardio-vascular disease (CVD) causing more than half of all deaths. The good news is that overall mortality rates for these and two other major forms of chronic disease (chronic lung diseases and diabetes), age-adjusted to allow for the aging of the population “has decreased by a third over an 18-year period” (from 1998 to 2015), according to a 2018 update from the Public Health Agency of Canada (PHAC). Even better, the death rate for cardio-vascular disease declined 50 percent.
On the other hand, the 2017 Canadian Survey on Disability found “an estimated one in five Canadians (or 6.2 million) aged 15 years and over had one or more disabilities that limited them in their daily activities”. The leading causes of disability were pain-related problems (15 percent), flexibility and mobility problems (10 percent each), and problems related to mental health (7 percent).
Tobacco use continues to be the most important behavioural risk factor contributing to death and disease, a recent study in the Canadian Medical Association Journal (CMAJ) noted, even though smoking has dramatically declined (only 13 percent of the population 15 and over report they are current smokers), thus markedly reducing tobacco-related illnesses. This is because the damage it has inflicted lasts for decades. Other good news is that better medical and lifestyle management of high blood pressure and high blood lipid levels has significantly reduced their contribution to premature death and disability since 1990.
Meanwhile, growing impacts on death and disability are being seen from physical inactivity (nearly two-thirds of children and youth and more than four in five adults do not get adequate exercise), unhealthy eating (7 out of 10 Canadians aged 12 and over) and harmful use of alcohol (more than 1 in 6 Canadians aged 15 and over) and drugs.
In addition, the PHAC update reports that 13 percent of children and youth aged 5 to 17 years and 28 percent of adults were found to be obese in 2014/15 – and many more were overweight. Because having a high BMI contributes to diabetes and muskulo-skeletal disorders, the major diseases causing disability, a high BMI is “the top risk factor contributing to years lived with disability in Canada”, according to the CMAJ study.
Since the major causes of death and disease in Canada are chronic diseases that last for years and are rooted in a life-time of exposure to unhealthy living, rates do not change very swiftly. As the CMAJ study noted, “risk factors can influence the population for a substantial length of time and . . . decreasing [the] health burden for Canadians requires a long-term commitment to risk reduction”.
Looking to the 2020s, I do not expect to see major changes in this pattern, with perhaps one exception; a growing recognition of the increasing burden of disease related to poor mental health. So the critical issues in public health in the 2020s will be much the same as today: Continuing the fight against tobacco (and now vaping, which may become an entry-level drug for smoking); working to reduce the impact of increasing behavioural risk factors related to diet, physical inactivity and alcohol and drug use; and improving the management of chronic diseases.
However, the real fight will be against the commercial, social, economic and environmental conditions that encourage and support these risk behaviours, the complex social factors leading to increasing mental health problems, and the broader ecological changes and underlying cultural values that threaten our health for the rest of the century and beyond. More on all that next week.
© Trevor Hancock, 2020