Dr. Trevor Hancock – Healthy people, healthy communities, a healthy planet

(Published as ‘It’s not population growth but inequality that’s the problem’)

Dr. Trevor Hancock

4 April 2023

702 words

Whenever I write about the problems of economic growth and our ecological footprint I get e-mails asking me why I don’t also address population growth. The short answer is that I have, on several occasions. The longer answer, as I wrote in a July 2018 column on this topic, is that the issue is complex, and the solution not just a matter of family planning.

According to UN data, as reported by ‘Our World in Data’, the rate of increase of the global population had dropped from around 2 percent per year 50 years ago to a bit under 1 percent now. Global population, the UN reports, “is expected to reach 9.7 billion in 2050 and could peak at nearly 10.4 billion in the mid-2080s.” (Canada’s population grew by 2.7 percent in 2022, mostly due to immigration, Statistics Canada recently reported, and would double in 26 years if that rate continues.)

However, a new report for the Club of Rome from Earth4All casts doubt on this. Guided by a Transformational Economics Commission,  Earth4All is “a platform to connect and amplify the voices that want to upgrade our economies.” By ‘upgrade’, they mean transforming our economies so that people everywhere can thrive within the limits of our one planet.

Their new report links population size, human development, social justice and ecological sustainability. It is a response to five questions posed by the Global Challenges Foundation, a Swedish organization founded in 2012 to “raise awareness of global catastrophic risks and to strengthen global governance to handle them.”

First, they looked at how large the world’s population would grow, and the result was somewhat surprising. If the world continues its present economic course, they found the population would peak at 8.6 billion in 2050 (we just passed 8 billion) before declining to 7 billion in 2100. Moreover, if the policies discussed below were enacted, says the report, population would peak at 8.5 billion around 2040 and decline to 6 billion by 2100. This is considerably less than the 10 billion or more people by 2060 or so that UN and many other models project.

The reason, the authors explain, is that their model pays more attention to the effects of rapid economic development, which “has a huge impact on fertility rates”, said Per Espen Stoknes, Earth4All project lead and director of the Centre for Sustainability at the Norwegian Business School. Fertility rates fall, he explained, “as girls get access to education and women are economically empowered and have access to better healthcare.”

The report then addresses the Foundation’s five questions, which in essence asked how many people could be supported if everyone could achieve the minimal conditions needed to meet the  requirements of Article 25.1 of the Universal Declaration of Human Rights, and how many could be supported at a standard of living up to 30 percent higher.

Article 25.1 states: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family (sic), including food, clothing, housing and medical
 care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

The research team translated this into threshold levels of food, energy, disposable income and social spending as a proportion of GDP needed to achieve this minimal standard of living. The resulting standard of living would be quite like South-east Asia today, but with six times as much energy and 50 percent more social spending. Thus they concluded that “socio-economic and natural resources are sufficient to ensure a dignified existence for the projected global population.”

However, they add, getting there would require achieving “an equal distribution of resources.” This would involve “unprecedented investment in poverty alleviation – particularly investment in education and health – along with extraordinary policy turnarounds on food and energy security, inequality and gender equity.”

Importantly, they conclude that “contrary to public popular myths, . . .  population size is not the prime driver of exceeding planetary boundaries . . . Rather, it is extremely high material footprint levels among the world’s richest 10 percent that is destabilising the planet” – my topic for next week.

© Trevor Hancock, 2023

thancock@uvic.ca

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

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

B.C. government continues to support new fossil fuel infrastructure, while vainly proclaimimg it can meet its emissions targets

Dr. Trevor Hancock

28 March 2023

698 words 

The Intergovernmental Panel on Climate Change just released its synthesis report, summarising the three volumes of its 6^th Assessment Report. It found, with very high confidence, that:

• Climate change is a threat to human well-being and planetary health.
• There is a rapidly closing window of opportunity to secure a liveable and sustainable future for all.
• Risks and projected adverse impacts and related losses and damages from climate change escalate with every increment of global warming.
• Deep, rapid and sustained mitigation and accelerated implementation of adaptation actions in this decade would reduce projected losses and damages for humans and ecosystems.

So what does the B.C. government do in response? It continues to support new fossil fuel infrastructure, while still vainly proclaimimg it can meet its emissions targets. It has just approved the Cedar LNG plant, while at the same time announcing plans to reduce emissions from the fossil fuel sector.

Yet in May 2021 the International Energy Agency stated “the global journey to net zero by 2050 . . . includes, from today, no investment in new fossil fuel supply projects”, while in April 2022 UN Secretary General Antonio Guterres said “Investing in new fossil fuels infrastructure is moral and economic madness”

Or as Martyn Brown, former chief of staff toLiberal Premier Gordon Campbell, put it during CBC Radio‘s ‘On The Island’ political panel on March 17th, “This is the government sucking and blowing at the same time on climate action.”

After all, it was David Eby himself who stated in the weeks before he was sworn in as B.C.s’ new Premier  that “we cannot continue to expand fossil-fuel infrastructure and hit our climate goals.” So as Green Party MLA Adam Olsen pointed out: “Announcing a plan to reduce climate pollution from LNG facilities on the same day as approving another LNG project doesn’t make sense.”

The Cedar plant will not only increase emissions in B.C., it will also benefit from the incentives offered to the LNG industry by the BC government.  As tallied by Marc Lee, Senior Economist at the Canadian Centre for Policy Alternatives in July 2018, these include “eliminating the LNG income tax, a lower price for BC Hydro electricity, exemption of the provincial sales tax on construction materials and a rebate on new carbon taxes.”

Another reason for concern was touched on by Mr.Olsen, in noting that the Cedar LNG plant is a partnership with the Haisla Nation. While agreeing that it is “a significant opportunity for economic reconciliation”, he added “it is concerning that the BC NDP is using that opportunity to disguise the fact that they are creating new fossil fuel projects.”

Indeed, far from welcoming the announcement, the Union of B.C. Indian Chiefs issued a press release expressing concern. Grand Chief Stewart Phillip, the UBCIC President, called the announcement of “the expansion of the LNG industry and associated fracking . . . frightening”.

B.C. is not alone in this behaviour.The federal government has a long history of sucking and blowing on fossil fuels. In June 2018 Parliament passed a resolution declaring a climate emergency, and the very next day approved the expansion of the Trans Mountain pipeline expansion (TMX), which ships bitumen from the Alberta tarsands for export to Asia.

When it became clear the private sector was not dumb enough to continue investing in the TMX, the federal government went ahead and purchased it. Initially priced by Justin Trudeau at $7.4 billion to complete, it is now up to $30.9 billion.

Back in October 2022, when the price tag was only $21.4 billion, Robyn Allan, a former CEO of ICBC, in a report for West Coast Environmental Law, found oil producers would be paying tolls well below the true cost and that “the federal government will forgive $17 billion in debt Trans Mountain owes to Canadians.”

So we are subsidising LNG and are stuck with a pipeline that will never make a profit. Andrew Nikiforuk, a seasoned environmental reporter, summed it up well in the Tyee this month; this amounts to “the transfer of billions of dollars from ordinary Canadians to wealthy oil companies”  – while expanding fossil fuel production that results in climate chaos. Moral and economic madness indeed!

© Trevor Hancock, 2023

thancock@uvic.ca

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

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

Dr. Trevor Hancock

21 March 2023

702 words  

Given that we only have one planet, we need to live within the carrying capacity of the global ecosystem that is the Earth. Yet as I noted last week, Canada’s Ecological Footprint per person is equivalent to using 5.1 planet’s worth of biocapacity and natural resources every year.

By March 13^th we had already used our fair share of biocapacity for the year. After that our demands are taking from other people around the world, future generations and other species, who need that biocapacity to meet their needs.

But troubling as this is, the reality is worse than the Ecological Footprint suggests because, to paraphrase statistician George Box’s observation about models, ‘all indicators are wrong, but some indicators are useful’. The problem with both models and indicators is that they can only give us a partial picture of reality.

So while useful in many ways, it is important to understand the limitations of the Ecological Footprint. The Global Footprint Network goes to some lengths to clarify both its strengths and its weaknesses on their website (go to their FAQs for more details).

The key point is that the Ecological Footprint measures the ecosystems’ annual capacity to produce biological materials (in essence, microbes, fungi, plants and animals, all of which are renewable resources). These can then be used to meet the demands of humans and to absorb our wastes, primarily our carbon emissions. However, it does not measure things that are “not created by biological processes nor absorbed by biological systems”.

So the Ecological Footprint does not reflect the extraction of non-renewable resources such as metals and minerals, since they are not produced biologically, although the energy and any biologically produced materials used in extracting, refining, processing, and shipping these mineral resources are included. Moreover, if they are toxic, then when they or their wastes enter the environment, they may cause a loss of bioproduction that can be measured

However, the Ecological Footprint does not measure the impact of pollutants that are not produced biologically and “cannot be absorbed or broken down by biological processes”. Thus it cannot directly measure the impact of persistent organic pollutants, heavy metals or plastic, although if they cause harm to ecosystems the resultant loss of bioproductivity can be measured, but this is in practice difficult.  

Fossil fuels are a little different. They were initially produced through a biological process millions of years ago, and when combusted, produce carbon dioxide and other pollutants. Carbon dioxide is used by biological systems so the Footprint of carbon is “the amount of productive area required to sequester the carbon dioxide emissions and prevent its accumulation.”

Importantly, of the 2.8 hectares per person of biocapacity being used globally to meet current global consumption and waste production, 1.7 hectares per person – just over 60 percent of our total global footprint – is needed just to absorb our carbon emissions. For Canada, our carbon Footprint is 5.3 hectares per person, 65 percent of our total footprint

Yet the Earth’s annual biocapacity per person is only 1.6 hectares. In other words, absorption of our global carbon emissions requires a bit more than all the bioproductive land available today, while on a per person basis, Canada’s carbon emissions require more than three times the total global biocapacity available per person.

So if the whole world lived the way we do today in Canada, we would need more than 2 new planets just to absorb our carbon emissions. This is why we have to drastically cut carbon emissions globally, as the IPCC reported just this week, and why high-emitting countries such as Canada have to lead the way.

Finally, the Global Footprint Network notes, the Ecological Footprint “is not an indicator of the state of biodiversity, and the impact of a particular activity or process on biodiversity does not directly affect the Ecological Footprint calculation for that activity.” So that too is not reflected in the Footprint.

Thus in reality, our global impact is even greater than the ecological footprint would lead us to believe, making it all the more urgent to rapidly reduce our ecological footprint, while also reducing our extraction of metals and minerals, our production of pollutants and our devastating impacts on biodiversity.

© Trevor Hancock, 2023

thancock@uvic.ca

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

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

Dr. Trevor Hancock

14 March 2023

700 words  

Just a few days ago, on March 13^th, Canada overshot its fair share of the Earth’s biocapacity and resources, as measured by the ecological footprint in 2018, the latest year for which data is available. That is to say, by March 13^th, Canada had already consumed its fair share of the Earth’s bounty for the year. Collectively, humanity passed its 2022 Earth Overshoot Day on July 28^th.

So what does this mean? Well, first, we need to understand the concept of the ecological footprint, which is, put simply, a measure of “how much nature we have and how much nature we use”, as the Global Footprint Network puts it.

The amount of nature we have is measured in terms of a nation’s or the world’s biocapacity, which “represents the productivity of its ecological assets (including cropland, grazing land, forest land, fishing grounds, and built-up land).” It reflects “the ability of an ecosystem to produce useful biological materials and to absorb carbon dioxide emissions.”

Because of its large land area and abundant forests, farms and fishing grounds, Canada has a large biocapacity. But of course a lot of that is exported, as the world depends upon Canada’s natural resources to meet its needs. In addition, a lot of it – forests and other natural areas – is not used directly by humanity and would seem to remain relatively untouched, although this is in fact the carbon sinks that absorb our carbon dioxide pollution.

The amount of nature we use, on the other hand, is measured as a nation’s or the world’s ecological footprint. In a nutshell, this is the amount of bio-productive land needed “to produce the natural resources it consumes (including plant-based food and fiber products, livestock and fish products, timber and other forest products, space for urban infrastructure) and to absorb its waste, especially carbon emissions.” Those ecological assets can be anywhere in the world, as we import food, raw materials and products from around the world and pump out carbon dioxide and other greenhouse gases.

Globally, the world had the equivalent of 1.6 hectares of bio-productive land per person in 2018, but collectively we consumed the equivalent of 2.8 hectares. In other words, at present rates of global consumption, it takes the equivalent of 1.8 Earths to meet our collective needs.

But Canadians, with our high incomes, high consumption of resources and high levels of carbon emissions, actually require the equivalent of 8.1 hectares of bio-productive land, or 5.1 times as much as is available per person, globally. So if the rest of the world lived as we do, we would need another 4.1 planets, which we clearly do not have.

One way to look at this is that it is like every Canadian spending their annual income by March 13^th each year and then living off loans, or everyone on Earth doing so by July 28^th. Clearly, that is not sustainable for very long – and yet we seem to expect that every year the Earth will somehow, magically, cover our ecological debt.

Moreover, in ‘borrowing’ the equivalent of 4.1 planet’s worth of biocapacity, Canadians are consuming more of the Earth’s biocapacity and resources than we are entitled to, if everyone on Earth were to get their fair share. In doing so we are, in effect, taking precious resources not only from others around the world who need them for their own human and social development, but from future generations and from other species.

Clearly, we only have one planet – no matter what fantasies crazed billionaires may entertain – and we need to learn to live on it. The implications for Canada are profound. In particular, it means we need to reduce our footprint by 80 percent, and quite rapidly, to become a One Planet Canada – a country that uses only its fair share of the Earth’s biocapacity and resources.

I have only been able to provide an overview of the ecological footprint in this column. In my next column I will dig deeper into this important indicator. In particular I will look at what it has to say about our use of fossil fuels, and why it is itself an underestimate of our true impact on the Earth.

© Trevor Hancock, 2023

thancock@uvic.ca

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

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

(Published as “Learning self-care should start in school”)

Dr. Trevor Hancock

7 March 2023

700 words

Last week I suggested self-care should be a strategic priority for Canada’s health system. Done well, it can reduce unnecessary demand for professional care while at the same time, improving outcomes, empowering patients and enhancing personal and community capacity for caring.

While self-care is often seen as being about the self-management of minor ailments and injuries (coughs and colds, upset stomach, cuts, bumps and bruises, sprains etc.) and chronic diseases, it is – or should be – much more than that. It is about all the things we do for ourselves and with our families, neighbours and communities that make us healthier, protect us from harm and even prepare us for our end of life passage.

Importantly, self-care is not simply about education, although obviously education is important. A 2010 article on self-care in the British Medical Journal noted the literature on changing health behavior “shows that mere provision of information has little effect. Changing behaviour often requires multiple interventions that work at several levels: the individual, the immediate family or social circle, and society in general.”

A comprehensive strategy must begin in school, where children need not only to learn about how their body works, but how to look after their health and deal competently with minor health problems. While the usual lifestyle issues of diet, physical activity, use of tobacco, alcohol and other drugs should be addressed, so too should mental wellbeing. Given the crucial importance of social connections, children should be supported in the development of social skills that will help improve their ability to create and maintain social networks.

In the latter years at school, they should also learn first aid and CPR, a set of skills that should be maintained over the years through refresher training. After all, while not in the literal sense self-care, the ability to provide emergency first aid before the professionals arrive is a form of collective self-care.

But since most of us are well past childhood, we also need a system of education, training and support that enables adults to acquire the skills they need to keep themselves and their families healthy, to manage minor ailments and injuries, and live well with chronic diseases and disabilities. They also need to learn when it is appropriate, and indeed necessary, to access the illness care system, and to work with their primary care team to ensure they receive the preventive services laid out in BC’s Lifetime Prevention Schedule.

With HealthLink BC, British Columbia has in place an important component of this support system. Available by phone or online 24/7, and in many languages, the service can provide you with health information, help you navigate the health care system and find health services across the province, or connect you with a registered nurse, registered dietitian, qualified exercise professional, or pharmacist.

When it comes to chronic diseases, B.C. supports an independent program, Self-Management BC, provided through the University of Victoria. The program serves people with chronic pain, diabetes, cancer and other chronic conditions, and has programs tailored to the Chinese, Indigenous and Punjabi communities. These programs are delivered by trained volunteers, and range from one-on-one coaching by phone to both in-person and web-based group learning and support. Importantly, Self-Management BC also trains health care professionals to use self-management support strategies when interacting with patients.

But self-care can and should reach even further. Social prescribing is an approach that refers people needing social support to community groups and activities. Learning the skills needed to work with people in mutual support can enable us to work with others in our own community to make it healthier. The BC Healthy Community initiative is just one of the many organisations that supports such work in B.C.

Finally, at the end of life, being supported in making preparations for one’s own death, including being supported in having conversations with family, friends and care providers about one’s wishes, is perhaps the ultimate form of self-care.  

While not cost-free, when done well self-care should should cost less overall than business as usual, making it cost-saving for the illness care system while improving the health and wellbeing of the population. To be truly effective, then, the health system must invest in self-care support.

© Trevor Hancock, 2023

thancock@uvic.ca

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

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

If we really want to reduce the burden on the illness-care system, we need to prioritize self-care, so people do not inappropriately access the system.

Dr. Trevor Hancock

27 February 2023

700 words

The most important task in creating a health system is to keep people healthy, so they do not need to use the illness-care part of the system. My three most recent columns looked at ways in which we could keep the population healthy through societal change.

The next most important way to reduce the burden on the illness care system is self-care. If people know how to recognise and manage their own and their families’ minor ailments and injuries and chronic diseases, they will not need to use the health care system.

A couple of recent articles in this newspaper by local physicians have lamented the lack of healthy living and self-care skills and the lack of ‘common sense’ among the general public. This leads to people not making healthy choices in the first place, and not knowing how to care for minor problems when they occur, both of which result in an unnecessary burden on the illness care system.

But the real problem is that self-care has never been afforded the respect and attention it requires. Yet in reality, most care is self-care, a simple fact that the professionally-oriented illness care system has never fully recognised. A 2010 UK survey found half of those with a minor ailment self-treat, while almost one quarter do nothing.

Self-care is also hugely important in chronic illnesses. For example, a UK study found that “people with diabetes have on average about 3 hours contact with a care professional and do self-care for the remaining 8757 hours in a year”. Moreover, self-care is effective. A recent article in BMC Public Health noted: “In chronic illness, higher levels of self-care have been associated with better health outcomes, including decreased hospitalization, costs, and mortality.”

But it’s no good lamenting people’s unwise use of the illness care system if we have not trained them in self-care in the first place. In fact, not only have we not given them the knowledge and skills they need to look after their own minor ailments and injuries, we have only too often implied that they shouldn’t risk being wrong, but should consult a health professional.

So it should be a strategic priority for the health system to help people develop the knowledge and skills needed to stay healthy, to care adequately and appropriately for minor ailments and injuries and chronic illnesses, and to know when it is time to seek professional care. And when they do, they need to be secure in the knowledge that appropriate professional care will be there when they need it.

It is important  to stress that self-care is not about abandoning people to their own devices. As Swedish doctoral student Silje Gustafsson noted in her 2016 dissertation: “Just as health is more than the absence of disease, self-care is more than the absence of medical care.”

Self-care does not just happen, we are not born with a set of self-care skills. We need both to train people in self-care from an early age and put in place a support system – including mutual-support groups – that enables them to practice self-care with confidence. People also need support from health professionals – who themselves need to be trained and supported so they can in turn support self-care.

Yet while self-care is arguably the largest and most important part of the entire illness care system, we do not have a robust self-care strategy. In fact, no province that I am aware of has prioritised self-care or created a proper self-care strategy. The only group I am aware of that has argued for a national self-care strategy is an industry association, Food, Health, and Consumer Products of Canada. However, unsurprisingly, their motivation is self-interest and focuses on improving access to, and reducing the cost of and taxes on their products

But if we really want to reduce the burden on the illness care system, we need to prioritise self-care, so people do not inappropriately access the system. At a time when the federal government and the provinces are squabbling over money for hospitals and primary care, we should demand that they also put money into a comprehensive national self-care strategy. Next week, I will discuss what that might look like.

© Trevor Hancock, 2023

thancock@uvic.ca

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

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

Dr. Trevor Hancock

21 February 2023

700 words

In this series of columns I am exploring what a true health system would be like, and what that means for reform of our ‘health care system’. In my last column I stressed the importance of ecological and social factors as determinants of health, noting these conditions also play a big role in shaping our health behaviours.

But ecological and social conditions do not just arise spontaneously, they are the result – intended or not – of societal decisions, often expressed through public policy. Thus to create a Wellbeing society we need to put the wellbeing of people and the planet at the heart of governance.

Back in the early 1980s, building on the work of others, I came up with the concept of  ‘healthy public policy’, which has since been taken up by the World Health Organization and many national and provincial governments; Canada even has a National Collaborating Centre on Healthy Public Policy.

The basic principle is very simple; since most of the major determinants of health come from beyond the illness care system, healthy public policy is concerned with public policy in non-health sectors that affects health. This raises the interesting question as to which policy areas are most important for health.

Let’s start with the most fundamental determinant of human wellbeing, indeed of our very existence: The state of the planet. UN Secretary General Antonio Guterres has been clear in stating we are war with nature and that this is suicidal. So  the most important public policy is to make peace with nature, as he puts it.

The UN identifies a triple crisis of climate change, biodiversity loss and pollution. So we need public policies that stop these things happening. This means an energy policy consistent with net-zero carbon emissions; a halt to activities that further deplete biodiversity (such as deforestation, loss of wetlands, over-fishing and unsustainable forms of agriculture, mining and so on), and a restoration of biodiversity.

In addition, it means stopping all pollution that exceeds the ability of nature to absorb or detoxify it; this particularly applies to the pesticides and various persistent organic pollutants that contaminate entire ecosystems and foodchains and contribute to loss of biodiversity.

Clearly, such policies have enormous implications for our current way of life – but then our current way of life has enormous and potentially existential implications for us and many other species. We have no choice but to develop policies that enable us to live well within the ecological constraints of this one small planet.

A second set of healthy public policies relate to the social factors that determine our health. In a society as wealthy as ours, hunger, homelessness, unhealthy housing and unsafe drinking water are not only morally outrageous, they are a threat to the health of those affected and to the wellbeing of the wider society. Healthy public policies ensure everyone has access to such basic necessities as food, adequate shelter and clean water, as well as a livable income.

A third set of healthy public policies have to do with the interaction between the ecological  and social determinants of health. For example, a low meat diet is not only needed to reduce the impacts of our modern agricultural system on the planet, it is also good for health. And more compact, walkable, mixed use neighbourhoods and active or public transportation systems are likewise good for both our health and the planet.

Fourth, healthy public policy does not allow the private sector to produce or market products or services that harm health. Tobacco is an obvious example, but there are many other examples worthy of attention.

Developing a true health system  will not be easy and it will not be swift.  To create a Wellbeing society and develop healthy public policies, governments must put people and planet at the heart of decision-making. They need to establish Wellbeing Secretariats within their Cabinets Offices, adopt Wellbeing budgets and follow the example of Wales in passing a Wellbeing of Future Generations Act and creating the position of a Wellbeing of Future Generations Commissioner.

The second important way to reduce the burden on the illness care system – a comprehensive self-care strategy – is the topic of my next column.

© Trevor Hancock, 2023

thancock@uvic.ca

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

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

• 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

thancock@uvic.ca

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

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

If you had to remake the health system from scratch, what would you do? Turn the system on its head, making the hospital the place of last resort and beginning with what keeps people healthy.

Dr. Trevor Hancock

7 February 2023

699 words

Last week I suggested we need to radically re-think Canada’s  ‘health care system’ – actually, thirteen separate, mainly publicly-funded, often privately operated non-systems for illness care, with federal cost-sharing.

Having worked as a family physician in primary care; as a public health physician in health planning and as a Medical Health Officer; as an advisor and consultant on health promotion to the World Health Organization – mainly in Europe; as a medical consultant in population and public health at B.C.’s Ministry of Health, and as a health futurist, I have had lots of time to observe and think about Canada’s ‘health care system’.

Back in the 1990s and into the 2000s I sometimes led workshops on health care reform which, over time, I came to call ‘Blow it up and start again!’. Now obviously we can’t blow up the system, so I did a thought-experiment, inspired by Albert Einstein’s approach to physics: What if the health care system disappeared overnight and we had to rebuild it from scratch? What would we build, knowing what we know today?

Well, we would not start with the hospital, which is what happened in Canada. If you look at the history of health care, the federal government first got involved by supporting the building of hospitals in the late 1940s, then supported public insurance for hospital care in the late 1950s, and then brought in public insurance for physician care outside hospitals in the late 1960s.

Unfortunately, we got it backwards. For the most part, ever since, we have been running around trying to plug holes in the system, without stepping back and seeing if perhaps we need an entirely different system.

What I propose instead is a true health system, one that is designed to first create good health. So the first thing to do is keep people healthy, because clearly, the best way to deal with an over-burdened illness care system is to stop over-burdening it. The second important way to reduce the burden is to increase people’s capacity for appropriate self-care, so they don’t seek medical care when they don’t really need it.

We need to begin, then, with a clear vision of what a true health system would look like, including what an illness care system within such a system would look like. Then every decision we make should be one that takes us closer to that vision.

Thus in my thought experiment I turned the system on its head, making the hospital the place of last resort and beginning with what keeps people healthy.  After all, various estimates suggest that medical care is responsible for around 10 – 20 percent of avoidable premature mortality. The other 80 – 90 percent is attributable to human biology, personal behaviours, social  and economic factors that shape our behaviours and our communities, and the quality of our built and natural environments. So that is where we need to start.

The model I created – first published in 1993 – is an upside down triangle, with each layer in the model involving fewer people needing services. The better the layers higher up in the model do their work, the fewer people the lower levels need to care for.

Thus the first couple of layers of the model, which affect the whole population, are about creating a Wellbeing society, something the World Health Organization has been calling for recently. Such a society puts the wellbeing of people and the planet at the centre of all decision-making, testing all policies, especially economic policy, against their ability to either improve or harm wellbeing.  It also ensures that people are protected from harmful activities by the private or public sectors.

Then come layers that are about people learning to look after themselves, both to keep healthy and to manage their minor ailments and injuries, activities the health system must support. The first real contact with the health care system involves receiving preventive services and quality primary care, then – if needed – specialty ambulatory care and home care. Only if all that is insufficient do people actually need to be admitted to a community facility or hospital.

In the next couple of columns I will describe this in more detail.

© Trevor Hancock, 2023

thancock@uvic.ca

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

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

(Published as “If doctors operate as a business, what’s wrong with surgery through private clinics?”)

Dr. Trevor Hancock

1 February 2023

700 words

There is much wringing of hands these days about the state of the Canadian health care system, as well there should be. But in fact there is no such thing as a Canadian health care system, although there is a Canadian way of funding health services. In the 1990s, when I helped organise study tours for Swedish health system managers to visit Canada, I used to describe the ‘Canadian health care system’ to them as ten publicly-funded private non-systems.

Let me pick that apart. First, there is no Canadian health system, because when Canada was formed in 1867, the federal government got what was then important in politics – foreign affairs, defence, international trade etc., while the provinces got the less important stuff; health, education, social support etc. So constitutionally, health is a provincial, not a federal responsibility.

That is why we have 10 health ministries and ministers, 10 sets of licensing and regulatory Colleges for physicians, nurses and so on; 13 if you include the territories. Each province licences its professionals – which is why it is hard to transfer from province to province, even though – in my experience – the human body and its diseases, and the treatment of those diseases, is the same across the country. Hardly a system, certainly not an efficient one.

As a result we have ten different provincial systems, each of which has its own policies and programs, negotiates its own fee schedule and salaries with staff, its own approved drug lists and so on. The only thing that really unites them are the five principles enshrined in the Canada Health Act; if the province is to receive federal funding the provincial system must be comprehensive, universal, accessible, portable and publicly administered.

Importantly, the principles only apply to physician and hospital services (and selected dental surgical services), which is why almost all dental care, as well as home care, pharmacy, physio, psychological counselling and similar services  are either not covered or only partly covered. This lack of coverage is why one quarter of all health expenditure in Canada is funded though the private sector – mainly out of your own pocket or through private insurance as part of a benefits package, unless your income is low enough that you qualify for public assistance.

An important area of confusion is that health services only have to be publicly administered, not provided by public authorities. So insured services can and are provided by the private sector. In fact a large part of the publicly funded system is privately owned and operated, starting with your doctor.

A 2016 brief from the Canadian Medical Association reported “the vast majority of physicians are self-employed professionals operating medical practices as small business owners”. Similarly, if you have had lab or X-ray work, chances are it was a privately operated lab or X-ray. But because they are providing an insured service and billing the single public payer, this is fine.  

Which is why the recent furore over providing surgery through private clinics is a bit puzzling. Now don’t get me wrong, I am opposed to a two-tier system in which the wealthy can jump the queue and get better services. Apart from anything else, that may draw staff and resources away from the public sector, leading to its deterioration.

But if you can go to a family doctor and then a surgeon who are private business people, and get your lab and X-ray work-up done by private businesses, then what is wrong with having your surgery done in a privately owned and operated clinic, as long as it is a procedure that the public system insures (if it isn’t, you would have to pay privately anyway), is as safe as and has outcomes at least as good as in the public system, is no more expensive than the public system, and bills only the public system, not the patient.

Finally, a system? Really? Well, if so, it is a badly-designed system, because, as the Institute for Healthcare Improvement likes to say, “every system is perfectly designed to achieve the results it gets”, and this ‘system’ is not delivering what we need. Time for a radical re-think, a topic I will return to soon.

© Trevor Hancock, 2023

thancock@uvic.ca

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

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