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

Better living through green chemistry

Better living through green chemistry

Dr. Trevor Hancock

20 August 2018

696 words

“Better things for better living…through chemistry” was a bold and optimistic Dupont advertising slogan that ran from 1935 until 1982. The phrase – often shortened to ‘Better living through chemistry’ – has lodged in the public mind as an unintentionally ironic comment on the sometimes dubious benefits of the chemical industry. This industry is the largest manufacturing sector in the world, according to GreenCentre Canada, which claims that “chemistry makes everything we do possible”.

While in many respects that may be true, we all know that not all chemistry has brought us better living. The recent Lancet Commission on Pollution and Health reminded us that “chemicals and pesticides whose effects on human health and the environment were never examined have repeatedly been responsible for episodes of disease, death, and environmental degradation” and that “newer synthetic chemicals that have entered world markets in the past2–3 decades and that, like their predecessors, have undergone little pre-market evaluation threaten to repeat this history”.

Troublingly, we have known about these problems for decades, but have been glacially slow in addressing them. Rachel Carson warned of the environmental and health impacts of pesticides almost 60 years ago in her 1962 book Silent Spring, but we are still fighting against pesticides such as Roundup and the newer neonicotinoid pesticides, in spite of considerable evidence of their harm. That is hardly surprising when we are fighting against the largest manufacturing sector in the world.

But amidst all that bad news, here is some good news: ‘Green chemistry’ is gaining strength. So what is green chemistry? It is chemistry that is “focused on the design and implementation of chemical technologies, processes, and services that are safe, energy efficient, and environmentally sustainable”, according to GreenCentre Canada – a company funded in part by the Federal and Ontario governments and with links to Queen’s University in Kingston – that is in the business of “commercializing emerging Green Chemistry innovations originating from academia and the entrepreneurial community”.

GreenCentre Canada also points to a set of 12 principles, derived from a 1998 book by Paul Anastas and John Warner. These include prevention (“it is better to prevent waste than to treat or clean up waste after it has been created”); safer chemicals (“designed to affect their desired function while minimizing their toxicity”); use of renewable materials “rather than depleting whenever technically and economically practicable” and design for degradation “so that at the end of their function they break down into innocuous degradation products and do not persist in the environment”. Hard to argue against that.

In fact, this column was prompted by the recent announcement that a team led by Professor Heather Buckley of the UVic School of Civil Engineering – one of a new breed of ‘green’ chemists – had just won first place in a global competition to identify new preservatives for use in cosmetics and household products. According to a UVic press release, the team won for its “reversible” anti-microbial that fights bacteria while in the container but breaks down into two harmless ingredients once outside of it.

The award came from the Green Chemistry & Commerce Council, a US-based organisation that “drives the commercial adoption of green chemistry”.Among other activities, the Council holds an annual Green & Bio-Based Chemistry Technology Showcase & Networking Event, at which start-up companies get to pitch their new green chemical products. At the most recent event, in May 2018, companies were pitching greener, safer “adhesives, coating technologies, flame retardants, monomers/polymers, ingredients for formulated consumer products (including personal care and household products), and recycling technologies”.

While it may be true that “chemistry makes everything we do possible”and that we want and need the benefits of all – or at least many – of these chemicals, we obviously don’t want all the environmental and health impacts that result. Thus we need to pressure corporations and governments to only allow new chemicals on the market that meet the standards for green chemicals. In addition, if the new, safer green chemicals are more expensive, governments must use taxation to tilt the market in favour of the greener products, allied with regulations to quickly rid us of the chemicals that bring us worse living.

© Trevor Hancock, 2018

Loneliness is an emerging public health concern

Loneliness is an emerging public health concern

Dr. Trevor Hancock

14 August 2018

698 words

It is ironic in this internet age, when everything and everyone seems to be connected, that we seem to be increasingly disconnected and lonely; moreover, many more of us are living alone. The 2016 Census found that the proportion of one-person households has been increasing steadily since 1951 (when it was 7.4 percent) to 2016, when it became the most common type of household, at 28.2 percent; more than households of couples, either with or without children,

Now living alone is not the same thing as being lonely; at various times we probably all want to be alone, and some people like to be alone a lot. But while being alone can be a choice, that is very different from loneliness, which the Oxford Dictionaries define as “sadness because one has no friends or company”.  That kind of being alone is involuntary, and the key word in the definition is sadness, which is only a step or two away from depression. After all, humans are social animals, sowhile being lonely on occasion is part of being human,chronic social isolation and loneliness is problematic.

In a 2017 report on connection and engagement, the Vancouver Foundation found that “14% of residents say they feel lonely often or almost always” – which is one in seven people. But among people with a household income less than $20,000 more than one in three people are often or almost always lonely, while it is almost one in three of 18 – 24 year-olds and around one in four of those who are unemployed or are aged 25 – 34. Clearly, loneliness is an issue that affects the young and the poor, not just an issue among seniors, although it is often thought of that way.

Indeed the mental and physical health consequences of loneliness are an emerging public health concern; the UK actually appointed a ministerial lead on loneliness earlier this year. This was greeted with derision in some quarters, perhaps in part because of a failure to understand both the difference between loneliness and being alone and the severe health consequences of loneliness.

In his landmark book Loneliness: Human Nature and the Need for Social Connections,the late Dr. John Cacioppo, director of the University of Chicago’s Center for Cognitive and Social Neuroscience, described loneliness as ‘social pain’ and ‘a deeply disruptive hurt’ analogous to physical pain. He reported loneliness affects our immune system and our stress hormones, and can lead to suicidal thoughts and other mental and physical health problems.

Even more dramatically,he noted“social isolation has an impact on health comparable to the effect of high blood pressure, lack of exercise, obesity, or smoking”. In fact a 2015 review based on 70 studies from around the world found that on average those who reported they were lonely at the beginning of the study were 26 percent more likely to die – greater than the increased risk of death due to obesity overall, and comparable to the mortality risk for moderate and severe obesity.

If loneliness is largely a lack of social connection, then presumably the answer is to create social connections among those who are lonely or are at risk of being lonely. But it is not that easy, especially among those who are chronically lonely. Cacioppo makes the point that loneliness itself can “create a persistent, self-reinforcing loop of negative thoughts, sensations, and behaviours” that make it difficult to reach out or get out and make connections.

In a 2015 article in Perspectives on Psychological Science, Cacioppo’s team largely dismissed such seemingly common-sense approaches as providing social support, encouraging social engagement or teaching social skills, commenting “interpersonal contact or communication per se is not sufficient to address chronic loneliness in the general population”. Instead they suggested a combination of cognitive behavioural therapy and some hoped for medication in the future.

I find that completely unsatisfactory, not only because it would be individualized and very expensive, but because with such a large scale problem we need a population-wide public health approach, just as we do for smoking or obesity. Clearly we need to give a lot more thought to how we combat loneliness at a community level and strengthen social connections.

© Trevor Hancock, 2018


Making homes truly healthy

Making homes truly healthy

Dr. Trevor Hancock

8 August 2018

703 words

Interestingly, we have two different words for the place in which we live – house and home. The Oxford English Dictionaries define the former as “A building for human habitation”and the latter as “The place where one lives permanently, especially as a member of a family or household”. That matches my own sense of the term: A house (or apartment) is a building, but when we add people it becomes a home, a social setting, not simply a physical space.

Curiously, we don’t make this distinction for other important buildings in our lives such as schools or workplaces; I am unaware of a different word for these or any other buildings that distinguish the physical building from that same building as a social space. Which suggests that the home is seen as something different, something special.

Last week I suggested we should aspire to more than housing that is not a threat to basic health; surely we want to create homes, places that improve our overall physical, mental and social wellbeing – and that do so without harming the natural environment. In the 1990s, Canada Mortgage and Housing Corporation suggested “a truly healthy house (is) one that is good for the people who live in it, good for the community and good for the earth”.

But we should be careful not to be too environmentally deterministic. We might be able to design and build clean, green, healthy and beautiful houses, but that does not mean the people or family that live there will be healthy; there are lots of unhealthy and unhappy people living or working in seemingly healthy buildings. Conversely, there can be happy and healthy people living in housing that is far from ideal – although meeting the basic needs I discussed last week is a vital prerequisite for good health.

Nonetheless, it is interesting to consider how the physical design of a house can improve mental wellbeing. Oddly, I cannot find much work from architects explicitly focused on the impacts of their design on the mental wellbeing of the inhabitants of houses. However, there is quite a bit about designing healthy workplaces, schools and hospitals, and much of that would carry over into designing healthy homes.

In an  article in the Winter 2016/17 edition of Sustainable Architecture & Building, a Canadian magazine, Kaitlyn Gillis and Michelle Biggar suggest that “architects and interior designers now face the challenge of embracing  . . . an approach that puts people at the centre of the process” of design. They describe several aspects of this approach in a workplace context, but with some obvious implications for designing domestic interiors.

In addition to discussing the importance of natural light and ‘biophilic design’, which is about “integrating nature and natural forms and processes into the built environment”, they discuss aesthetics and livability. While noting that the impact of aesthetics on health needs more research, they note that “the use of wood . . . can enhance user experience when left exposed to view”; others have noted the importance of colour in affecting our mood and behavior.

There is now an interesting evidence-based process to assess and certify buildingfeatures that “support and advance human health and wellness”. Launched in 2014, the WELL Building Standard, in its recently updated version, assesses 10 components of a building that are related to health and wellbeing: Air, water, nourishment, light, movement, thermal comfort, sound, materials, mind and community.

In the ‘mind’ component, the design requirement is for both direct and indirect access to nature, with the former focused on using plants, water, light and views and the latter involving the use of natural materials, patterns, colors or images. Both indoor and outdoor ‘restorative spaces’ – often involving nature – are also part of the mind standard, using access to spaces that allow for contemplation and relaxation; in our homes, that might be the bedroom or a living room or nook. Another standard, but one that would clearly overlap with this, is controlling both internal and external noise.

It is good to see that architects are turning their attention do these issues, now they must apply the lessons learned in workplace design to the places where we spend most of our time – our homes.

© Trevor Hancock, 2018

Healthy homes – The basics and beyond

Healthy homes – The basics and beyond

Dr. Trevor Hancock

30 July 2018

700 words

As I noted previously, in Canada we spend about 90 percent of our time indoors, and according to a 1996 study, 65 percent of our time is indoors at home and a further 10 percent indoors at school or work. Thus the environment of our buildings, and especially our homes, is enormously important for us. As Sir Winston Churchil remarked, “First we shape our buildings, then they shape us”.

So if we want healthy people, it would be a big help if we had healthy homes. Which raises the question – what is a healthy home? And an even more interesting question – how well are we doing at creating healthy homes? Let’s start with that first question.

There are some basic health functions a home needs to fulfil. In 1989 the World Health Organization (WHO) published a set of principles for healthy housing. It needs to protect us from the elements, keep us warm, dry and safe, and should keep out pests and noise. Also, it must not fall down or catch fire easily and must be well drained. It must have a proper water supply and provisions for sewage and solid waste removal, and “adequate provision for storing food, to protect it against spoilage and contamination”. Indoor air quality is also important (remember, 90 percent of the time we are breathing indoor, not outdoor air), as are issues of overcrowding. These and other basic safety and health functions are the reason we have building codes.

Here we might stop and reflect on the extent to which housing that meets these basic health needs is not the case in Canada today. As Bernie Pauly and Katrina Barber noted two weeks ago in these pages, we have signed several international covenants, such as the International Declaration on Human Rights, which enshrine the right to shelter. One would think such shelter would need to meet the WHO’s basic principles.

But those living on the streets or in tent cities do not have these basic amenities. Indeed, when the Medical Health Officer in Nanaimo recently used the Public Health Act to order the City of Nanaimo  to provide clean water and sanitation to the tent city there, he was initially and  deplorably met with outrage by some, including the Mayor, who called the idea ludicrous.

Indigenous people in Canada are another group that lacks many of these basic housing needs. Statistics Canada reported last year that the 2016 census found that “One in five Aboriginal people lived in a dwelling that was in need of major repairs”; for First Nations and Inuit people, it was one in four people.‘Major repairs’ meant the housing had “defective plumbing or electrical wiring, (or) needing structural repairs to walls, floors or ceilings”. The only good news was that the rate was down by 2 – 3.6 percentage points (depending on the group) since 2011.

These high rates among Indigenous people are the legacy of 150 years of Canadian government neglect and colonialist policies. For comparison, 6.5 percent of dwellings overall in Canada needed major repairs, a bit less among owners, a bit more among renters. The rates for BC are much the same and are about one percentage point less in all categories in the Victoria region.

At the very least, a country as wealthy as Canada must ensure that everyone’s basic housing needs are met, that we all live in safe and healthy homes. But surely we should aspire to more than having housing that is not a threat to basic health? What is a health-enhancing home, one that improves our overall physical, mental and social wellbeing?

There are several aspects to this question. First, what  – beyond the basics – makes a home physically healthy? What makes it mentally and socially healthy – the latter implying that a home does not stand alone, so how does it – and how do we – relate to other homes and people in our neighbourhood. And finally, given our concern for the state of the environment, how environmentally friendly are our homes – and how might they be better for the environment as well as for us?

Next week, I will  go deeper into some of the leading edge ideas for creating healthier homes.

© Trevor Hancock, 2018


Tools for healthier built environments

Two BC tools for healthier built environments

Dr. Trevor Hancock

24 July 2018

699 words

We are lucky in BC to have two useful initiatives to help us create healthier built environments. The first, which I described briefly last week, is the Healthy Built Environment Linkages Toolkit. The second is a BC Ministry of Health funded initiative, PlanH, which “facilitates local government learning, partnership development and planning for healthier communities”. I will describe them both here. (Full disclosure: PlanH was developed and is implemented on behalf of the Ministry by the non-profit BC Healthy Communities Society, of which I am Vice-Chair of the Board.)

For each of the five key elements of the built environment that the Toolkit considers – neighbourhood design, transportation networks, natural environments, food systems and housing –it provides a chart showing the impact on the built environment and the strongest research correlations found in evidence reviews. I briefly covered the first two elements last week, so here I want to examine the others.

For the natural environment element, the focus is on preserving and connecting environmentally sensitive areas, expanding natural elements across the landscape and maximising the opportunity for everyone to access these natural environments. By doing so, we can increase the tree canopy, reduce urban air pollution and create cooler urban areas. (For a great discussion of the health benefits of trees and urban forests see the book Planet Heart by Dr. Francois Reeves, an interventionist cardiologist in Montreal.)

Among the health benefits identified in the Toolkit for which there is strong evidence are reduced deaths from heart and urban heat events; improved mental health and social wellbeing; increased physical activity and improved respiratory health. Other benefits include reduced health care costs, energy savings, reduced pollution control costs and increased recreation and tourism.

Turning to food systems, the Toolkit focuses on increasing equitable access to affordable and healthy food options, protecting agricultural land, increasing the capacity of local food systems and supporting community-based food programs such as community gardens and community kitchens.

The health-related impacts of these approaches include improved diet quality and social wellbeing. Evidence suggests community kitchens, such as the Shelbourne Community Kitchen in Saanich, are particularly useful. This small NGO provides small-group cooking, pantry, and gardening programs which help participants from low-income families acquire food skills and learn to access nutritious food affordably, while at the same time building community.

Finally, the Toolkit looks at four approaches to creating healthy housing, particularly through prioritizing affordable quality housing options, especially for marginalised groups. The evidence supports the need for diverse housing forms and tenure types, located so as to avoid environmental hazards. There are multiple health benefits, including improved overall health and social wellbeing and reduced domestic abuse, crime and violence. (I will return to the topic of healthy housing in a future column.)

While the Toolkit provides evidence and is intended primarily for planners, PlanH is more concerned with how to bring the health implications of decisions to the attention of municipal governments and citizens to support “leading-edge practices for collaborative local action”. It focuses on three key interconnected themes: Healthy people, a healthy society and healthy environments.

In considering healthy people, PlanH emphasises that our health behaviours and choices are shaped by local social and environmental conditions; we need to create “vibrant places and spaces [that] cultivate belonging, inclusion, connectedness and engagement” in the context of “well-planned built environments and sustainable natural environments”.

To do so, PlanH helps local governments and their citizens learn about these issues and provides action guides and other practical resources and tools. It helps them connect and build relationships with community partners in other sectors (including regional health authorities) and with other local governments. And it helps them innovate with a funding program to support action, and by sharing success stories from around BC and beyond.

Together, these two initiatives give municipal governments, urban planners and citizens powerful support to help them make decisions that will improve the health and wellbeing of their citizens, which is surely one of their most important roles. So if you want healthier built environments in which to lead your life, raise a family and grow old, you may want to talk to your local government, community association and neighbours about the Toolkit and PlanH.

© Trevor Hancock, 2018


We can create healthy built environments

We can create healthy built environments

Dr. Trevor Hancock

17 July 2018

698 words

The BC Healthy Built Environment Alliance was established by the Provincial Health Services Authority in 2007 to provide leadership and action for healthier, more livable communities. The key purpose of the Alliance is to foster the partnership between urban planning and public health, which I wrote about last week. Members are drawn from the health, planning, NGO, municipal and academic sectors as well as from Ministries working in this area.

One of the problems with cross-disciplinary work such as this is that we all have our own language, so getting urban planners and public health professionals to understand each other and recognise each other’s skills and areas of focus and concern is key to taking joint action. Accordingly, one of the first things the Alliance did was to organise ‘Planning 101’ workshops for public health professionals, so they could develop a better understanding of urban planning. This was followed by ‘Health 201’, a guide, toolkit and self-assessment tool for the design professions.

Ongoing discussions both at the Alliance and through its network of members help keep this interaction and shared learning alive. This work is supported by the publication of case studies and best practices that highlight good examples across Canada of public health and urban planning collaborating alongside municipalities and communities to create healthier built environments.

But one of the most important things the Alliance has done has been to create a Healthy Built Environment Linkages Toolkit that makes clear the links between design, planning and health. While it is designed primarily for public health professionals, its clear, simple design and graphics means it can be used by anyone – including the development industry and the general public – who is interested in creating healthier built environments (and it’s easy to find – just Google the title).

The Toolkit is intended to provide all the participants in the planning process with evidence of the health implications of different aspects of planning and design. Its earlier version has been used by healthy built environment specialists in health authorities – yes, there are such beasts in some health authorities – and other public health staff to work with local municipalities on official plans, helping them to consider the health impacts and benefits of their policies and planning decisions.

But there is no reason why the Toolkit could not be used by community associations and other citizen groups to argue for better, more health-conscious planning decisions in their own neighbourhoods, or by private sector planners and developers to create healthier communities that would be more attractive to potential purchasers.

The Toolkit examines five key elements of the built environment that affect our health: Neighbourhood design, transportation networks, natural environments, food systems and housing. For each of them, the Toolkit provides evidence of the key health benefits that can result from applying the principles and measures that are included. So what are some of the key features of healthy built environments?

The Toolkit states that “healthy neighbourhood design is facilitated by land use decisions which prioritize complete, compact and connected communities”. By ‘complete’ they mean having a mix of residential, commercial, institutional and workplace sites so you can live, learn, work, shop and play largely in your own community. These mixed-use neighbourhoods are also more compact, which makes it easier to meet the need for transportation networks that prioritize and support active transportation such as walking, biking and public transit. In fact, neighbourhood design and transportation – and indeed all the key components of healthy design – are complementary and often positively reinforce each other.

We can also achieve significant health and well-being impacts, the Toolkit states, by preserving and connecting the surrounding natural environment; ensuring the “accessibility and affordability of healthy foods”, which – interestingly – “can be supported through land use planning and design”, and developing quality, affordable housing options for everyone, especially including marginalised people.

Interestingly, many of these are also features of sustainable community design, reinforcing the general principle that if we design for people and the planet, we are likely to build better communities – more pleasant, atttractive and livable as well as healthier and more sustainable.

Next week, I will delve in more detail into some of the key characteristics of healthy community design.

© Trevor Hancock, 2018