This is what a health system looks like

  • Published as “Human behaviour is affected by factors beyond personal choice”

Many of the conditions we live in and the behaviours we adopt are not freely chosen, no matter how much we may wish to think so

Dr. Trevor Hancock

14 February 2023

699 words

Last week I started to sketch out the elements of a health system – a system designed to keep people healthy so they don’t need to use the illness care system (which we usually call the health care system). The key point is that although illness care is an important part of a health system, most of what keeps us healthy happens beyond ‘health care’, beyond the scope of the Ministry of Health and most health care professionals.

The most fundamental determinants of our health are what I and others call the ecological determinants of health: Air, water, food, fuel, materials, and other ‘ecosystem goods and services’ we derive from nature. A second major set of determinants are the social factors that enable us to meet our basic needs: Healthy food, adequate shelter, clean air and water, sanitation, basic education and health care, an adequate income, social connections and support and other factors.

A vivid illustration of these social determinants came from former Saskatchewan Premier Roy Romanow, who chaired a Federal Commission on the Future of Health Care. In his 2004 address to the inaugural meeting of the Health Council of Canada, he suggested seven things we could do to stay healthy: Number one was “Don’t be poor”.

This was followed by “Pick your parents well; Graduate from high school and then go on to college or university; Don’t work in a stressful, low-paid, manual job in which you have little decision-making authority or control; Don’t lose your job and become unemployed; Be sure to live in a community where you trust your neighbours and feel that you belong, and finally, live in quality housing, but not next to a busy street, in an urban ghetto or near a polluted river.”

Clearly, these are not really conditions we can freely choose, influenced as they are by the socio-economic, Indigenous or ethnic status of the families and communities into which we are born. Which is why the third major set of determinants – human behaviour, can be problematic.

Because while there is of course an element of personal choice, our behaviour is very much shaped by our culture, our society, our community, our family and our peers, as well as – these days – a multi-billion dollar industry that markets unhealthy products and behaviours. Roy Romanow’s tongue-in-cheek advice reminds us that many of the conditions we live in and the behaviours we adopt are not freely chosen, no matter how much we may wish to think so, for a wide variety of reasons.

A final major category, of course, is human biology, but much of that – our genetic inheritance – cannot be changed easily, if at all. Of course, when our body or mind does not work well, or is damaged, we try to fix it, or help people to adapt to live with the damage; that is what the illness care system is mainly focused on.

This broad understanding of what keeps people healthy is hardly new; it is as old as humanity, as well as being a modern insight. One of the things that inspired me to work in public health was the 1974 federal government ‘Lalonde Report’ on the health of Canadians. Among other things, it 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.” But unfortuantely we have largely ignored that important insight ever since.

Which brings us to the latest attempt to drag our focus back to creating health. As I laid out in a series of columns in January and February this year, the World Health Organization has started calling for the creation of Wellbeing societies. These are societies that will “provide the foundations for all members of current and future generations to thrive on a healthy planet.”

Of the five key action areas proposed, I have previously dealt with the first two – valuing and respecting the earth and its ecosystems, and creating a wellbeing economy. Over the next two weeks I will look at the third – develop healthy public policy for the common good – and the fourth, achieve universal health coverage.

© Trevor Hancock, 2023

Dr. Trevor Hancock is a retired professor and senior scholar at the

University of Victoria’s School of Public Health and Social Policy


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