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

Reverse 45 years of neglect of health centres

Dr. Trevor Hancock

17 April 2017

703 words

In the late 1970’s I was one of two family physicians in a brand-new community health centre (CHC) in Toronto. We were on salary and worked with a nurse-practitioner (NP) and a community board. These were the early, heady days of CHCs, with several CHCs established at the same time across Toronto and elsewhere.

It wasn’t easy, we were met with suspicion, resentment and some times outright hostility from the medical profession, for whom we were traitors, undermining physician autonomy and the fee-for-service system while bringing in NPs. But we were passionate, idealistic and committed to implementing the model proposed just a few years before in the Hastings Report.

This Report, released in 1972, was commissioned by Canada’s Ministers of Health and led by Dr. John Hastings, a distinguished professor of health administration at the University of Toronto. Its key recommendation was “the development . . . of a significant number of community health centres . . . as non-profit corporate bodies in a fully integrated health services system”.

The authors described a CHC as “a facility . . . enabling individuals and families to obtain initial and continuing health care of high quality . . . provided in an acceptable manner through a team of health professionals and other personnel working in an accessible and well-managed setting”. What’s not to like about that?

Ideally a CHC would be responsible for providing care to people living in a defined geographic area, coordinating their primary care with home and community care. Facilitated by a community board, the CHC would become involved with public health, various community-based organizations and local government in efforts to improve the overall health of the community.

But while a few CHCs were established, the model did not become widely adopted, in large part because of the opposition noted earlier. In fact CHCs mostly became seen as a way to provide health care to low income and disadvantaged populations. For example, there are only three CHCs here in Victoria, of which one is for adults over the age of 55 and another is for people who are homeless, vulnerable and living on very low incomes; only one, the Victoria Community Health Cooperative, is for the general population.

Thus average Canadians did not get to reap the benefits of this superior form of health care. This is a shame because a 2012 report from the Canadian Foundation for Healthcare Improvement noted “despite significant progress since 2000, the performance of Canadian primary care trails that of many other high-income countries”.

Fast forward 40 years and there is a growing interest in CHCs, including a much more favourable attitude amongst family physicians. Moreover, there is growing body of evidence that the belief espoused by the Hastings report – “that some shift from the present emphasis on acute hospital in-patient care to other forms of health care, including types of community health centre, offer a means of slowing the rate of increase in health services spending” – is correct. But unfortunately CHCs in BC have only received weak support from the government and generally lack core operational funding.

A newly-released position paper from the BC Association of Community Health Centres (BCACHC), which speaks for the 29 CHCs in BC, cites evidence that CHCs have been shown to reduce avoidable use of hospital emergency rooms, improve accessibility and comprehensiveness of health and social services in rural areas, and enhance the accessibility and effectiveness of mental health and addictions programs – all of which are Ministry of Health priorities.

Importantly, last month the BC Legislature’s Liberal-dominated Select Standing Committee on Health released a report in which it supported many of the elements of CHCs. Specifically, they recommended implementing “a community health centre model of care” and providing “adequate operational and capital funding for new and existing community health centres throughout the province”.

In an online petition to all three major party leaders, the BCACHC calls on the next government to “invest in 20 new community-governed Community Health Centres throughout British Columbia” by 2020. It’s way past time the province did so.

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I have been writing this column without a break for over two years: So I am taking a break for vacation and will be back in June.

© Trevor Hancock, 2017

 

 

Child poverty is outrageous and unhealthy

Dr. Trevor Hancock

10 April 2017

699 words

Canada is a wealthy country and within Canada, BC is a wealthy province. And yet we have levels of child poverty that are shameful, that exert a terrible toll on the health of children, and that blunt our human and social development. If it is true that the worth of a society is best judged by the way in which it treats its most vulnerable, then we fail miserably.

In its November 2016 BC Child Poverty Report Card, First Call, the BC Child and Youth Advocacy Coalition, reported that one in five children – one in five! – live in poverty. Even worse, almost half of the children living in single-parent families – most of them single-mother families – are living in poverty. Most damning of all, child poverty rates have barely budged in recent years, demonstrating a complete absence of political commitment to fix the problem.

In 1989, the House of Commons resolved to eliminate child poverty by the year 2000, which turned out to be a cruel hoax. BC’s child poverty rate climbed from 15.5 percent in 1989 to 25.3 percent in 2000. Between 2004 and 2007 it dropped to about 20 percent and has been around there ever since. In essence, we have come to accept that this level of child poverty is just a normal part of life.

Yet this is a fixable problem; other advanced industrial nations have almost eliminated child poverty. A 2016 OECD report, using 2013 data, notes “In Finland and Iceland the child income poverty rate is only around 5 – 6%, while in Denmark it is less than 3%”; using that measure of poverty, Canada’s rate is around 16 percent. So clearly, as my late friend and colleague Clyde Hertzman used to remark, “it doesn’t have to be this way.”

There is quite a price to be paid for keeping it that way. It is paid most of all by children living in poverty, and is a price they will pay for the rest of their lives. But the rest of society also pays a price in lost human potential, lost economic production and increased costs for health, social assistance and other supportive services.

Working at UBC, Clyde was the founder of HELP – the Human Early Learning Partnership – which developed an international reputation for its work on what made children healthy. So much so that when the World Health Organisation established a Commission to examine the social roots of health and illness, Clyde was asked to head up one of eight ‘knowledge networks’, the one on early child development (ECD).

The network’s final report to the Commission noted that ECD “strongly influences basic learning, school success, economic participation, social citizenry, and health” – that is a pretty broad swathe of social benefit. They also noted that inequality in the availability of ‘socio-economic resources’ (in other words, poverty) resulted in inequalities in ECD. On the other hand, “any additional gain in social and economic resources to a given family results in . . . gains in the developmental outcomes of the children in that family”.

In a nutshell, poverty harms early child development, which harms social and economic development over many decades. Thus they concluded “investment in early childhood is the most powerful investment a country can make, with returns over the life-course many times the amount of the original investment.”

 

Such investments would include “family-friendly social protection policies that guarantee adequate income for all, maternity benefits, financial support for the ultra-poor, and allow parents and caregivers to effectively balance their time spent at home and work” as well as policies that guarantee “universal access to a range of early child development services: parenting and caregiver support, quality childcare, primary healthcare, nutrition, education, and social protection”.

That is an agenda for healthy children and adults, healthy communities and a healthy society. One would think that a wise government would take heed of this advice, especially as it came from a world expert right here in BC, and that a Premier and a government committed to a Family First approach would adopt such policies. Sadly, that has not been the case, and as a result, children and our whole society continue to pay the price.

© Trevor Hancock, 2017

 

‘Mincome’ is pro-health and against poverty

Dr. Trevor Hancock

2 April 2017

702 words

Last week I wrote about the health, social and economic benefits of a poverty reduction plan for BC. Not unreasonably, a reader challenged me to explain how we could afford that. “Just what price tag would you set on the actions you propose?”, he wrote, “Then we could move on to that tricky part about how well — or if — the plan works.” Fair enough, so here goes.

I wrote about the costs in my column on January 7^th 2015. As that is more than two years ago, I will repeat some of it here. In a 2011 report the Canadian Centre for Policy Alternatives looked at the total costs of poverty in BC. They estimated that overall, the annual direct costs to government from increased costs for health care, justice services and foregone tax revenues were $2.2 – 2.3 billion. Note that this is an understimate, because estimates of the costs of social services were not available.

The added health care costs alone related to poverty were estimated to be $1.2 billion, based on the potential savings in reduced health care utilisation if people in the lowest 20 percent of income had the same health status as those in the next 20 percent, which is only a modest change.

When they added up all the costs, including costs due to lost production, lost income and lost tax revenues attributable to poverty, they concluded that poverty costs between $8.1 and $9.2 billion per year. This is more than double the $3 – 4 billion they estimated it would take to markedly reduce poverty by investing in a poverty reduction strategy that would end homelessness and hunger, ensure access to affordable housing and child care, and improve pay and working conditions for people in low–wage jobs.

So on the face of it poverty is so expensive that we can’t afford it, and there might be an economically beneficial alternative. This seems like an idea that any fiscally responsible government would consider worth invesigating and testing, not just dismissing out of hand. Which is presumably why all the other provinces have developed some form of a poverty reduction plan.

One possible solution was tested in Canada 40 years ago – and seemed to work. Between 1974 and 1979 the federal and Manitoba governments collaborated on a project – Mincome – to provide a guaranteed annual income (GAI) to the residents of the town of Dauphin MB. The GAI is a form of negative income tax or refundable tax credit; its proponents claim it is particularly effective in aiding the working poor and is simpler and cheaper to administer than the many existing and overlapping programs. Regrettably, the research on Mincome was shelved – the data were collected but not analysed – amidst waning political support.

Mincome was available to all the roughly 10,000 people of the town and the 2,500 people in its rural municipality. However at any one time, “only about a third . . . of families qualified for support and many of the supplements would have been quite small”, according to Professor Evelyne Forget, an economist in the Department of Community Health Sciences at the University of Manitoba, who came across this forgotten study about a decade ago and analysed it.

In a report published in Canadian Public Policy she concluded “a relatively modest GAI can improve population health, suggesting significant health system savings”. Specifically, she found an “8.5 percent reduction in the hospitalization rate for participants relative to controls, particularly for accidents and injuries and mental health”, and she also found that “participant contacts with physicians declined, especially for mental health”. She noted that the reduction in hospitalisation would have amounted to savings of $4.6 billion annually in Canada in 2010.

Also important was the finding that people did not stop working – except for new mothers and teenagers. Given the health and social benefits of mothers spending more time at home with their infants and adolescents continuing on into grade 12, these are desirable outcomes.

Small wonder that Quebec has explored the idea, while Ontario is actively considering testing a basic income in several communities, based on a report commissioned from former Conservative Senator Hugh Segal. Would that the BC government were that forward-thinking and thoughtful.

© Trevor Hancock, 2017

 

BC’s pro-poverty policy is sickening and costly

Dr. Trevor Hancock

27 March 2017

703 words

Last week my students were discussing public health ethics. One group pointed out, correctly, that doing nothing is a policy decision. What then are we to make of the BC government’s persistent policy, over the past 15 years, to do little or nothing about poverty reduction? In effect, their decision to do nothing is a ‘pro-poverty’ policy; it seems they prefer to prolong and deepen poverty, and to fail to offer adequate relief for those living in poverty, in an attempt to force them into the low-wage workforce.

BC remains the only province that has not adopted a poverty reduction plan, and seems to glory in having a low minimum wage and low rates of social assistance. In fact BC, a wealthy province, has the second highest rate of poverty in Canada at 13.2 percent – almost 1 in 7 people – according to a January 2017 report from the Canadian Centre for Policy Alternatives (CCPA).

The report notes that “BC’s minimum wage was frozen at $8 an hour for nearly a decade between November 2001 and April 2011”. While it has increased since then, someone working full-time at minimum wage in BC today is about $3,500 below the poverty line for a 35-hour week and about $750 below if they work a 40 hour week. So even if they buy into the government’s mantra that the best social program is a job, they are going to live in poverty unless they get a second job or work overtime (if it’s available).

Social assistance rates are even more impoverishing; rates have been frozen since 2007 and are now the third lowest in the country, at $610 a month for a single person, in a province that has a high cost of living. According to a 2015 Caledon Institute report cited by the CCPA, a single person on welfare in Metro Vancouver in 2015 would have reached only 40 percent of the poverty line, while a single parent with one child – mainly women – would reach 66 percent of the poverty line.

Moreover, many of the jobs that are being created in BC are in part-time, low-wage work. In its submission to the 2017 Budget Consultation, the CCPA pointed to Statistics Canada data showing that in the first quarter of 2016 “among the ten occupations with the most job vacancies in BC . . . five paid less than $12/hour”.

As they drily note, “these are not family-supporting wages”, while Irene Lanzinger, president of the B.C. Federation of Labour commented to the CBC in January that “We have not seen good, permanent full time family-sustaining jobs created by the [province’s] job plan,”

Not only is the lack of attention to poverty an ethical lapse, it does not make economic sense, because poverty is associated with higher levels of ill health, which costs the health care system a great deal in additional care.

A 2016 report from BC’s Provincial Health Services Authority reported that people who live in local health areas with high socio-economic status (SES) “are expected to live nearly four years longer than people living in low SES areas” and that “people in the highest income group reported significantly more favourable rates than those in the lowest income group for a number of indicators” of health.

Not surprisingly, a 2016 report from the Public Health Agency of Canada on the economic costs of health inequality noted that “health care costs generally decline as income rises”. Overall, they found that in 2007-8 “socio-economic health inequalities cost Canada’s health care system at least $6.2 billion annually” – and they were only looking at about a quarter of all health spending. This finding was echoed in a 2015 report from the Canadian Institute for Health Information, which also noted “there has been minimal progress in reducing the health gap between lower- and higher-income Canadians over the past decade”.

A government truly concerned about the health of both its citizens and its economy and the financial sustainability of its health care system needs to act on the understanding that poverty is both sickening and expensive, and that investing in poverty reduction is a smart and healthy decision. Let us hope the next government is sufficiently wise to see this.

© Trevor Hancock, 2017

 

Compassionate communities support those who are dying

Dr. Trevor Hancock

20 March 2017

694 words

I have been involved recently with people and organisations working in the area of hospice and palliative care. What I found intriguing was their interest in a public health approach to death and dying. As noted by Dr. Alan Kellehear, a UK-based social scientist working in this area, “to achieve optimal health and wellbeing in the 21st century a community engagement approach to health must extend its active concern to the end-of-life itself”.

On the face of it, adopting a public health approach in palliative care may seem odd, since public health is focused on preventing death and disease. But in the field of prevention we talk about several levels of prevention, beginning with ‘primordial prevention’ – looking upstream at the large environmental, social, economic and cultural factors that shape our health – and primary prevention. The latter is focused on preventing a disease or injury from occurring in the first place; think of immunisation, or creating a non-smoking society.

But there is also a less well-known form of prevention: Quaternary prevention. This is concerned with preventing harm within health care, including preventing an ‘unhealthy’ death. That puts us in the same business as palliative care and hospices. But they are also interested in public health for another reason; our community orientation, and especially our interest in creating healthy communities.

Pallium Canada, a national organization created to improve the quality of hospice and palliative care services, notes that a public health approach to palliative care “takes the responsibility . . . from a few highly trained specialists to a community that considers it ‘everybody’s business’”. This approach is known internationally as Compassionate Communities, a concept championed since the 1990s by Dr. Kellehear.

In a 2013 article, he reported that a survey of more than 200 UK palliative care programs found a significant number of them were developing ‘compassionate community’ programs. He suggested that “involving schools, workplaces, places of worship, the mass media or local businesses could help mobilize untapped sources of social and spiritual care and support as well as practical resources”. Pallium has now brought this concept to Canada, launching its initiative in the fall of 2015.

Here in BC the BC Centre for Palliative Care has also endorsed the Compassionate Communities approach, noting that it can provide “access to the many social aspects of care that are not provided by the health care system . . . but which are central to the well-being of patients with advanced illness and their family / friend caregivers”.

But it seems to me compassion is something we need more generally in society, not just in dealing with death, but in living life. So I am heartened by the wider mandate assumed by one of the Compassionate Communities pilot sites, Windsor-Essex in Ontario. There the aim is “to increase the happiness and connectedness of everyone in the community, raise quality of life for citizens with life-long care needs, and to reduce the inequitable outcomes experienced by the most vulnerable”.

Their approach includes creating neighbourhood networks through social media to enable people to “to watch out and care for one another”; a ‘Distress Outreach’ system, operated through the Distress Centre that “aims to ensure that those who need help do not fall through the cracks”, and creating a ‘Citizens’ Care Hub’.

The Hub is intended for “people in their last year of life, with dementia, or who need personal support such as help with eating, dressing and bathing – that is, people who need a high degree of social and practical help as well as medical care to live well”. The people and their caregivers are then linked to a community volunteer, who helps them set up their volunteer personal care team.

Interestingly, the Windsor-Essex project is also involving young people by using “tech savvy students . . . to help out with technical support”. This fits well with another aspect of the Compassionate Communities approach promoted by Pallium; the Compassionate School, which is “a place of learning that incorporates death education into its curriculum”. I see this as an important step in re-introducing the reality of death and dying into our lives, and making our communities more compassionate.

© Trevor Hancock, 2017

 

 

 

 

Toward a BC Framework for Wellbeing

Dr. Trevor Hancock

13 March 2017

701 words

Too many governments seem to think that the business of government is business. This comes from the erroneous belief that the central purpose of government and society is economic development. And it leads to the equally erroneous belief that the corporate sector is governments’s primary partner. Of course, if they are the principal funders of your party, that may explain why you think that way – and that may lead you to go easy on them.

But there is a better approach, in which the central purpose of government is human development rather than economic development. In that case, organisations of people – as communities, as NGOs, as unions, as faith communities and so on – are the most important partners. Corporations are partners only to the extent that they are contributing to human development.

But to the extent that their activities damage human health or social wellbeing – be it here in BC or elsewhere in the world – corporations are not fit to be partners of a government committed to human development. On the contrary, they would be subject to regulation and taxation intended to prevent the harm that they might otherwise cause.

Moreover, if our purpose is human development, a simplistic focus on job creation – any kind of jobs – is wrong-headed. We need jobs that contribute to, not take us away from, the overall goal. There are lots of jobs in selling tobacco, or in making and selling junk food or in polluting industries – and many more jobs in treating the health consequences of these bad practices. These all add to the GDP, which only shows what a truly idiotic measuring stick it is. But that is not a healthy way to do business or run a province or a country.

There is another aspect to the approach I advocate here that is worth noting, and that is how we consider human services. In a business-focused world, education, health care and social services are too often seen as expenses that must be reduced. But in a human-centred approach, these are investments we should welcome. In addition, we should recognise that the assistance and support that families provide for each other and that communities offer each other as volunteers are an important contribution to social wellbeing – a contribution that conventional economic accounting, such as the GDP, completely misses.

Which brings me to the BC Framework for Wellbeing that BC’s Board Voice is proposing. Board Voice is a non-profit organization that was established in 2010 to bring together and represent the volunteer Boards of BC’s social services sector. The organisation’s vision is of “strong, vibrant communities and a high-quality community social benefit sector”. Yet they point out that while BC spends billions of dollars annually on social interventions and supports “we spend it with no clear idea as to what we’re trying to achieve, or how we’ll know when we get there”.

Some of the problems they identify include Government ministries providing services and funding in vertical envelopes with little or no coordination; ad hoc and short-lived initiatives with few measured outcomes, and very little capacity at the local level to support community social planning. As a result, they state, “decisions related to community services are very often made by individual ministries and /or health authorities based on short-term fiscal plans, without significant input or consultation from and across communities”.

In short, we lack a comprehensive human development strategy, there is nothing to match the economic development strategies that governments spend so much time and energy on. So Board Voice is proposing the development of a social policy framework through a new project they are launching – There is a Better Way: A BC Framework for Wellbeing.

They are undertaking consultations in 15 communities around BC to learn how such a framework could benefit people and their communities, as well as consultations with key provincial organizations. Hopefully, the next BC government, whomever it is, will pay more attention to this issue, and will pay heed to the advice that will come from this process. We would all be better off if governments spent more time focused on human development and social wellbeing, and not simply pursuing the false god of GDP.

© Trevor Hancock, 2017

 

Thirteen municipalities, but only one planet

Dr. Trevor Hancock

6 March 2017

702 words

The CRD’s Regional Growth Strategy has been rejected, but I will not be mourning, it was never the right strategy anyway. First, the very name tells us all we need to know; a growth strategy. Not even a growth management strategy, and certainly not the sustainability strategy it originally was meant to be. But what we actually need is a One Planet strategy.

What does not seem to have penetrated the consciousness of many councils in the region – and the provincial government, for that matter – is that we only have one planet. So we need to learn to live within the constraints of this one small blue dot that we call home.

Our governments also fail to accept that we are entering The Anthropocene, which encompasses more than just climate change. We face a rapidly growing ecological crisis that will undermine the economic and social wellbeing and the health of today’s young people and their descendants, unless we take swift action.

Business as usual is not an option, we cannot grow our way out of this situation, since growth itself is the problem. Consider the increase in resource demand that will be seen by an infant born today, if current patterns of population and economic growth continue. They can expect to live about 80 years – or they could if ecological constraints, obesity and other problems don’t reduce their life expectancy.

Population growth in Canada and globally is now just over 1 percent, which means over 80 years the population will more than double. The economic growth that economists and governments often aspire to, and which largely means an increase in our ecological footprint, is 3 percent. An annual growth in real GDP of 3% over 80 years would result in a 10.6-fold increase. Together these would result in an increase in impact on the planet during their lifetime of more than 23 times the starting point (2.2 x 10.6).

Even if our technology became 5-times more efficient in terms of resource use and pollution reduction, as some believe is possible, the impact over this infant’s lifetime would more than quadruple. But we already use the equivalent of 4 or 5 planet’s worth of ecosystem goods and services, which is clearly not sustainable. Another 4-fold increase – never mind a 23-fold increase – is clearly out of the question.

Which is why for the past couple of months I have been organising a series of ‘Conversations for a One Planet Region’ at the Robert Bateman Centre. Because we need a conversation across the Region, and especially with young people whose future this concerns, about how to reduce our ecological footprint dramatically to take only our fair share of the planet’s resources, while preserving a good quality of life and good health for all.

We began with Jennie Moore from BCIT – who with Cora Hallsworth will be estimating the ecological footprint of Victoria and Saanich this year – that food and energy use accounts for most of our footprint, using a consumption-based approach.

When she did this for Vancouver, she found that to get to a ‘One Planet’ footprint, Vancouver would need to reduce its greenhouse gas emissions by 80 percent, improve building energy efficiency by 40- 60 percent, triple urban density, make 86 percent of trips by walking, cycling or transit, reduce by half the consumption of goods (e.g. paper), change to a low-meat diet to reduce the carbon footprint of food by half and reduce post-purchase food waste by half.

In subsequent sessions, we heard how this could be accomplished from Tom Hackney, Policy Director of the BC Sustainable Energy Association, Todd Litman of the Victoria Policy Transport Institute and Jeremy Caradonna, a UVic Professor and sustainable food systems expert.

This coming Saturday, March 11^th, we will take this Conversation further in an IdeaFest event at New Horizons in James Bay (1.30 – 4.30 PM), and in particular discuss how to sustain, broaden and deepen the Conversation in the coming months. Plans are already underway for a Phase 2, kicking off with Guy Dauncey discussing the sort of economy we need for a One Planet Region (March 20^th, 5 – 7 PM at the Bateman Centre). For further information visit the Conversations website at https://onlineacademiccommunity.uvic.ca/oneplanetconversations/

© Trevor Hancock, 2017

 

Healthy corner stores – well, why not?

Dr. Trevor Hancock

27 February 2017

699 words

A couple of weeks ago I spoke at a conference in the US on adolescent health. One of my fellow speakers spoke with energy and passion about the need for young people to eat a more healthy diet. But it was a very American speech, rooted in an ethos of personal choices and individual responsibility. While noting that our food is laced with fructose and high levels of sugar and fat (oddly, I don’t recall her mentioning salt or lack of dietary fibre) she did not suggest that we should be regulating the food industry that provides this unhealthy diet.

I pointed this out rather firmly, suggesting that we should. Repeating Nancy Milio’s famous phrase, I said we need to make the healthy choice the easy choice. But all too often we make the unhealthy choice easy – and then wonder why people make unhealthy choices. Unsurprisingly, this suggestion was not met with much enthusiasm. Nor was another questioner who wondered how people in low-income communities, faced with ‘food deserts’, could make healthy choices when all they had were corner stores and fast-food restaurants. The speaker suggested they should create community gardens.

I have nothing against community gardens, indeed I welcome them for all sorts of good reasons; at their best they strengthen community relationships, provide exercise, green havens and links to nature, even vegetables and fruit – and they might save some people some money. But I don’t see them as a viable solution for people who live in low-income food deserts.

Instead I suggest another approach: The Healthy Corner Store. This approach was pioneered in 2004 by the Food Trust, a Philadelphia-based non-profit, in partnership with the Philadelphia Department of Public Health. The Food Trust noted that in low-income communities, where supermarkets are often lacking, “families depend on corner stores for food purchases. The choices at these stores are often limited to packaged food and very little, if any, fresh produce.”

So they set out to change that, working with local stores and their communities. The Philadelphia network now involves more than 600 corner stores. A 2014 evaluation of the Philadelphia initiative found that it resulted in “healthier choices, healthier businesses and healthier communities” and the network has now gone national.

This approach is now underway in Canada, with an initiative launched by the Toronto Food Policy Council in 2014 and by the Food Policy Lab and others in Newfoundland in 2015. The Toronto initiative began by mapping areas of the city where there was lack of access to healthy food and where low income populations live.

They selected a pilot convenience store in a high-rise complex in East Scarborough whose owners were keen to sell healthier and more affordable food. Working with the local community, including the youth, they identified local healthy food preferences and worked to strengthen relationships between the community and the store owners. Then they worked with the owners to improve their business planning, including purchasing, marketing and signage.

The product will be a ‘how to’ toolkit they hope to take to some of the other 2,000 convenience stores across the city. The intent is to boost sales and profits in the store, which makes it an attractive option for other stores to adopt, although it is too soon to tell how much this will change people’s diets.

The Newfoundland project is based on the recognition that “Newfoundland and Labrador has the most corner stores per capita, as well as the highest proportion of corner stores in rural areas, of all of the provinces or territories in Canada”, according to the Food First NL website. In rural communities, they note, these stores are also important community hubs, which means these stores can help strengthen community as well as improve healthy food choices. As in Toronto, they have started with a pilot store from which they are learning, but then plan to expand across the province.

Of course, changing our food culture takes a long time, especially in competition with the powerful marketing of fast food and junk food. But this seems like a worthwhile effort that could readily be adopted in BC, both in big cities such as Vancouver and in small, rural communities.

© Trevor Hancock, 2017

 

Primary care is the heart of healthcare

Dr. Trevor Hancock

20 February 2017

702 words

I spent the first 4 years of my career working as a family physician, both in rural New Brunswick and in a community health centre in Toronto. It was very satisfying work and I enjoyed it greatly, but my wish to move further upstream and prevent rather than treat and manage illness took me into public health. While I have never regretted that choice, I have a soft spot for primary health care, which I see as the heart of health care, and the key to an effective health care system.

Primary care is the point of first contact for most health care, handles most of the patient load and is the gatekeeper for access to specialty care. Good primary care systems can and should coordinate care at home and in the community, and should be able to follow their patients into and back out from the hospital and specialty care.

The late Dr. Barbara Starfield, one of the world’s leading researchers on primary care, noted in 2008 that countries with strong primary care systems have better health outcomes, lower costs and greater equity in health. She also noted that “within countries, areas with higher primary care physician availability (but NOT specialist availability) have healthier populations” and that “more primary care physician availability reduces the adverse effects of social inequality”.

So it is distressing to see that family practice is not in good shape here in BC, or for that matter across Canada. A 2012 report from the Canadian Foundation for Healthcare Improvement noted “Despite significant progress since 2000, the performance of Canadian primary care trails that of many other high-income countries”. This is bad for patients, bad for the health of the population and bad for society as a whole. It’s also bad for doctors, who want to practice in a better way.

Last year, two experienced family physicians here in Victoria were so concerned about the state of primary care that they were moved to write opinion pieces in the Times Colonist. In June, Dr. James Stockdill, a family doctor here for 37 years, identified a number of problems including, above all the need to “very quickly to establish nurse practitioners in a community-care role”. But he concluded “The institutions that could favourably deal with this crisis have failed to implement effective policies that would alter the course of this downward spiral in primary care”.

And then in September a clearly frustrated Dr. Robert Brown, a family physician in a clinic in Sidney, wrote that primary care in BC is not working because it “operates in a foundational and structural vacuum”. He memorably described the present system as operating “much like a tent city — disorganized and not meeting anyone’s needs”. He called for the creation of ‘medical homes’ – what I would call community health centres. These would be facilities designed for teams of family physicians and other primary care providers (he suggested nurse midwives, nurse practitioners, licensed practical nurses and social workers), serving a patient population registered with the practice, and able to “adequately provide for all the needs of their patients at all times”.

But while the province claims that primary care is a priority, it has not been getting anywhere near enough attention. The Ministry of Health’s 2015 Discussion Paper on a strategic policy framework for primary and community care in BC begins by admitting that “This is the first time that the Ministry of Health has attempted to capture the significant and sometimes loosely connected initiatives and policy that make up efforts to improve primary care and home and community care”. But there is no mention of either ‘medical homes’ or community health centres – only ‘team-based family practices’. And it does not sound as if there is any sense of urgency; the recurring theme is about being opportunistic and incremental.

So in the coming election campaign, we need our political parties to take a clear and strong position in support of primary care, and to commit to strong and urgent action on primary care reform. They must recognize primary care as the heart of the health care system, and its practitioners as the key to an effective and well-functioning system, and treat it and them accordingly.

© Trevor Hancock, 2017

 

 

 

 

 

 

The new public health entrepreneurs

Dr. Trevor Hancock

12 February 2017

702 words

There is a lot of money to be made from making us ill. The number one example is the tobacco industry, whose products, if used as intended, are bound to make us ill. But close behind them is the food industry, which for years has been selling us both too much food and the wrong sorts of food. Then there are the alcohol industry, the car industry, the firearms industry and many others; on top of that are all the businesses that reduce their costs by causing pollution or occupational injuries and illnesses – it’s a long list!

Our standard response – and it’s a valid one – is to educate people about the hazards they face and to regulate, tax or otherwise seek to control these industries. But a new approach is emerging, not to replace these approaches, but to complement them: Compete with these pathogenic businesses in the marketplace and perhaps in the process induce them to change their ways.

To some extent that has been happening for decades; health food stores, low-fat or low-sugar products, low alcohol or de-alcoholised drinks and so on. In the past few years, however, this has been taken further with the advent of public health entrepreneurs, as part of the wider interest in social entrepreneurship.

Social Enterprise Canada says that social enterprises are businesses that “create community impacts and social values”; moreover, “they limit or don’t have distribution of profits and assets to individual shareholders”. As such, their bottom line is both financial and social – “the simultaneous achievement of both economic and social values”. Here in Canada, the concept of social enterprise has recently caught the attention of the Institute of Population and Public Health (IPPH), which is part of the Canadian Institutes of Health Research.

In early 2015 the IPPH held a workshop on ‘New pathways to health and well-being through social enterprise’. Their understanding of social enterprise is that it includes a focus on the common good and on addressing social vulnerability, with profits used for social or community benefit. The workshop participants identified many potential health benefits, noting that social enterprises could focus on broad social determinants of health such as food and housing as well as benefits from local employment and improved community relationships.

This concept is now beginning to go mainstream within public health. Several US Schools of Public Health offer courses or programs in social entrepreneurship, although many of them seem in practice to be focused on health care as much as on improving the health of the population. And here in BC Paola Ardiles, a lecturer in SFU’s Faculty of Health Sciences, together with Shawn Smith from the Beedie School of Business, has been teaching a course called Health Change Lab in which students create projects designed to impact health and wellbeing in the community.

In a 2014 article in Public Health Reports, the authors defined public health entrepreneurs as social entrepreneurs “with a specific emphasis on achieving health impacts” and as “enterprises rooted in health promotion, disease prevention, health-care services, and the social determinants of health”. They identified a number of industries that they felt were “ripe for public health entrepreneurs”.

These included the design and development of healthy homes and healthy urban revitalization; sustainable approaches to water, waste, energy, and food production; the creation of healthy food stores, food co-ops, and cooking and food preparation classes, and alternative/active transportation options. Other industries they mention are education and social services, fitness and recreation, holistic health, information and communications, organizational support services and consulting, and product development.

Fresh Fare, one of the winners from an annual “Innovation in Action” competition at the University of Michigan School of Public Health that began in 2013, gives a sense of what is possible. They establish links “between grocery retailers and a rideshare program to enable transportation-limited individuals to shop for healthy foods in well-stocked grocery stores”. This points to another approach that has also been tried in the US, the Healthy Corner Store, of which more in the coming weeks.

Clearly, there is much scope for health promoters both to work with and indeed, work within these and other business and non-profit sectors that, collectively, are working to create a healthier future.

© Trevor Hancock, 2017