Is­land Health must fo­cus on how we live

Times Colonist - - Islander - TREVOR HAN­COCK Dr. Trevor Han­cock is a re­tired pro­fes­sor and se­nior scholar at the Univer­sity of Vic­to­ria’s School of Pub­lic Health and So­cial Pol­icy.

The trig­ger for the weekly col­umns I have writ­ten over the past four years was an ed­i­to­rial on preven­tion in the Times Colonist in Novem­ber 2014.

In my re­sponse I wrote that: “In fo­cus­ing on preven­tion in pri­mary care, its pre­scrip­tion did not go far enough.” Fast for­ward four years to a com­men­tary from Leah Hollins, chair of the board of Is­land Health (“Health care means more than hos­pi­tals,” Jan. 2); in re­sponse, I am tempted to just re­print my first two col­umns — “Health care a small part of true health” and “What makes us healthy? Hint: It’s not health care.”

For while there is much that is wel­come in what Hollins writes, as was the case four years ago, it does not go far enough. I agree that “we have to think and act more holis­ti­cally when we think about the health of the pop­u­la­tion,” and that “keep­ing peo­ple healthy and thriv­ing at home” and “work­ing to take pres­sure off our hos­pi­tals” should be the aim. The strong com­mit­ment to pri­mary and com­mu­nity care and ad­dress­ing the in­equal­i­ties in health ex­pe­ri­enced by Indige­nous peo­ple is wel­come.

But two key el­e­ments of a holis­tic ap­proach are miss­ing. An old adage is that if your bath is over­flow­ing, you should first turn off the tap, or at least re­duce the in­flow. For the health-care sys­tem, there are two taps that need to be turned off. The first is to re­duce the bur­den of dis­ease and in­jury (and “dis-ease” — the men­tal and emo­tional dis­com­forts of life) that the health-care sys­tem has to deal with in the first place, by keep­ing peo­ple healthy and safe.

The sec­ond is to re­duce the de­mand for care by im­prov­ing peo­ple’s ca­pac­ity for self-care — a term that was not even used in her com­men­tary. Here I fo­cus on strength­en­ing Is­land Health’s ap­proach by im­prov­ing pop­u­la­tion health and re­duc­ing the bur­den of dis­eases to which the sys­tem has to re­spond; I will ad­dress self-care next week.

With re­spect to pop­u­la­tion health, much more is needed than the sim­plis­tic call to prac­tise healthy liv­ing that comes at the end of the op-ed. A moun­tain of ev­i­dence tells us that un­healthy be­hav­iours are shaped by our so­cial, eco­nomic and phys­i­cal en­vi­ron­ments, our liv­ing and work­ing con­di­tions and the dis­grace­ful mar­ket­ing of un­healthy prod­ucts. To simply shrug this off as a mat­ter of per­sonal choice and be­hav­iour is un­ac­cept­able.

In­stead, we have to ad­dress the up­stream de­ter­mi­nants of our health. One of the most im­por­tant of these is poverty and in­equal­ity, and Is­land Health sees the ev­i­dence of the health im­pacts of poverty and in­equal­ity ev­ery day. But oddly, while cor­rectly rec­og­niz­ing the in­equal­i­ties in health ex­pe­ri­enced by Indige­nous peo­ple, there is no ap­par­ent recog­ni­tion that in­equal­i­ties in health are ex­pe­ri­enced across the en­tire pop­u­la­tion by many other groups.

So if Is­land Health is se­ri­ous about re­duc­ing the bur­den of dis­ease and tak­ing pres­sure off its hos­pi­tals, it needs to be pub­licly ad­vo­cat­ing for, en­cour­ag­ing and sup­port­ing poverty-re­duc­tion strate­gies.

The board must also adopt an ac­tive part­ner­ship role, work­ing with and sup­port­ing the many other sec­tors whose ac­tions af­fect the health of the pop­u­la­tion more than does health care.

There are other im­por­tant pop­u­la­tion-health is­sues that are not ad­dressed in Is­land Health’s com­men­tary, in­clud­ing the built en­vi­ron­ment, cli­mate change and other wor­ri­some eco­log­i­cal changes. In ad­dress­ing these and other pop­u­la­tion-health is­sues, the board should turn to its pub­lichealth staff, the only staff whose sole func­tion is to pro­tect and pro­mote the health of the pop­u­la­tion.

Given the need to re­duce the bur­den of dis­ease, you would think Is­land Health would in­vest in pop­u­la­tion and pub­lic-health ac­tiv­i­ties that ad­dress these up­stream de­ter­mi­nants of health. Yet in 2017-18, pop­u­la­tion health and well­ness got a mere 2.6 per cent of Is­land Health’s ex­pen­di­ture, down from 2.8 per cent in 2011-12; mean­while, acute care re­ceived 55.3 per cent, up from 54 per cent in 2011-12.

I will be­lieve Is­land Health is se­ri­ous about im­prov­ing the health of the pop­u­la­tion when I see it speak­ing out about and tak­ing ac­tion on the up­stream de­ter­mi­nants of health and in­vest­ing in and strength­en­ing its pop­u­la­tio­nand pub­lic-health ca­pac­ity.

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