Health, Determinants of

“Health is the crown worn by the well, but visible only to the ill”: this ancient saying speaks to how much we take our health for granted until faced with a crisis. Saskatchewan has a unique place in Canada’s history as not only the first jurisdiction to introduce Medicare, but also for its demonstration of how a combination of social, political and cultural attitudes and practices can successfully influence the average health of citizens. The notion that we can intervene to prevent illness and disability is a relatively modern one: whether it be the use of citrus juice to prevent scurvy in the British Navy, the symbolism of John Snow’s removing the pump handle to prevent the spread of cholera in London, or the major advances in immunization and epidemiology of the past century, these are the products of relatively new knowledge concerning our relationship to the world around us and the nature of disease, ill health and well-being.

For much of human history, disease has been viewed more as the result of the fates or some resident evil than the outcome of circumstances over which we have influence. Thus Jean-Jacques Rousseau in the 18th century was able to say without much debate: “one half of children die before their eighth year; this is Nature’s law, why try to contradict it?”

Our understanding that many diseases are in large part preventable and to some extent manageable continues to increase. With the developing sciences of epidemiology, population and public health, we have come to understand that much of what ails us has known causal pathways, and that there are a number of interventions which have the potential to avoid premature death or disability. Much of our improvement in health has been a result of dramatic reductions in infectious diseases, due to better housing, food and water safety, immunization, and smaller families. During the past century chronic diseases such as cancer, lung and heart disease and diabetes became the biggest killers in the developed world. Global warming and climate change, air and water pollution—all are newer challenges to health. The current and developing burden of chronic disease and injury, as well as the uncertainty of new infectious diseases such as severe acute respiratory syndrome (SARS), provide an insidious threat to health system sustainability. Strategies must be applied to address not only the obvious current concern but also the underlying determinants.

Since the mid 1800s, governments have established public health services to protect the public from the spread of infectious disease and health hazards. During the later part of the 20th century, governments became involved in ensuring access to medical services. Health and social policies have the ability to encourage improvements in basic underlying determinants of health through adequate food, shelter, employment and income, education, safer work environments, and the inclusion of all segments as active participants in society. Building community participation, support for and involvement in the arts, maintaining a healthy and active lifestyle, volunteerism, and maintaining social connections: all have been shown to be part of ensuring healthier communities.

Saskatchewan in its development was notable for its high levels of political, sports and cultural involvement, including high rates of participation in amateur sports and theatre. The province has also been an innovator in its approaches to addressing health care problems, whether they be community clinics based on the co-operative model, support for treatment of persons with tuberculosis in the 1920s and 1930s, or the development of medicare in the 1960s. Saskatchewan and Canada, however, have since fallen behind other jurisdictions and countries as the policy and funding focus in the 1980s and 1990s became more preoccupied with the struggles of the expanding treatment system, and less on the health of the public. The result of budget pressures and of this shorter-term focus has been a diminished capacity in education, housing, culture, social programs, and basic civic infrastructure, as well as a reduced ability of society to influence the other determinants of health. More recently, a renewed interest in understanding how all aspects of health care and society inter-relate to promote health and well-being bodes well for a healthier future. As Benjamin Disraeli remarked, “The health of the public is the foundation upon which is built the happiness of the people and the well-being of the nation.”

David Butler-Jones