The goal of the public health system in Canada is to improve the health of communities, whether that is locally, provincially, nationally, and/or globally. Historically, most significant improvements in health occurred in the realm of public health, including preventing infectious diseases and improving water quality. These areas are still vital – we don’t typically worry about our children dying from measles because of the ongoing work of public health – but those activities need to be situated in a context of what we have learned about the health of our communities.
We know that where we live, how much we earn, what job we do, what we eat, what our early childhood was like, and who we spend time with have significant impacts on our health. We also know that most differences in people’s long term health are due to factors we can change. For example, we can change what kind of housing people live in, how easily people can access healthy food, how we design our cities to promote active living. This is what is known as a determinants of health approach: dealing with the root causes of poor health. Public health needs to recognize this shift in knowledge and evolve in order to build upon strengths and increase the impact we can have on the health of the communities we work in.
A key figure in this shift is the Medical Officer of Health (MOH), a doctor whose specialty is in public health, who holds varying levels of responsibility depending on public health structures throughout the country. Irrespective of structure, the role of the MOH is to assess the health of the community s/he works for and work to improve its health. Many MOHs are embracing the evidence that indicates their work needs to address determinants of health, and even the systemic factors that shape these determinants. However, some are stifled by the acute care focused structures they are a part of, or by systems that do not recognize that a primary role of the MOH is to address health disparities. Some prefer to maintain historical roles and not move into the complex, and often controversial, world of addressing determinants.
The MOHs leading change throughout the country will hopefully create an impetus for others. Some examples of equity-focused initiatives include the creation of the Toronto Food Policy Council (TFPC) and the Peterborough Community Food Network. The TFPC advises the City of Toronto on food policy issues, and has been key in a number of areas, including the establishment of the Toronto Food Charter, creating links with agricultural bodies, and influencing city planning. The Sudbury District Health Unit had been a leader in embedding equity in all aspects of its work. Through an intensive multi-year process, they established equity as a foundation for staff members and interactions with community organizations, and contributed to the public health evidence base, most recently through the publishing of its “10 Promising Practices” fact sheets that give clear guidance to local public health units striving to address inequities. Outside of Ontario, the Saskatoon Regional Health Authority clearly demonstrated the glaring disparities in health between poor and wealthier neighbourhoods in its jurisdiction and suggested concrete policy steps needed to address these differences, many of which are being implemented through an intersectoral committee. These are just a few examples at the local level. Provincically, Ontario, BC, and Nova Scotia are including addressing inequities in their provincial standards for local public health. Nationally, one initiative involving public health and many others is the Coalitions Linking Action and Science for Prevention program, which focuses on the built environment.
This type of work is complicated and multi-faceted and requires long-term thinking with a goal to reduce structural inequities. Yet it is necessary if MOHs want public health to be truly relevant to the health of their communities. Aspects of traditional public health are still essential, but the new mandate of public health is (or should be) social justice focused. MOHs need to be part of that change. Public health, the healthcare system, community partners, and the public need to demand a focus on equity from their MOHs.