Expanding the health care debate

If the ultimate goal of a health care system is to keep people well rather than simply to treat them when they are sick, then we must broaden the health care debate in Canada and reconsider the push toward for-profit health services.

Keeping people well makes sense. Obviously, healthy people are not a burden to the health care system. This means that discussions about reducing costs and improving health care in Canada must include more than just who pays how much for what services and who provides those services. Instead, we must also look at the big picture and reduce, wherever we can, the causes of ill health.

When we think about it, most of us would agree that the health of our citizens is inextricably linked to the health of our surrounding ecosystems. But we don't often consider just how deep this relationship is. Some links are obvious. For example, the importance of safe, clean drinking water was recently hammered home by the tragedy in Walkerton, Ont. Thankfully, such high-profile disasters are unusual in this country. What are not so unusual are the chronic problems we live with every day.

Take obesity, for example. What does obesity have to do with ecosystem health? More than you might think. Children are now more sedentary than ever. A recent survey by the Heart and Stroke Foundation1 found that almost half of Canadian children between the ages of 9 and 12 do not get enough regular physical activity. Inactivity and poor diet have pushed the incidence of childhood obesity to alarming and unprecedented levels.2 This greatly increases the likelihood of developing several chronic diseases, including Type II diabetes. And, since obesity frequently continues into adulthood, other chronic conditions such as heart disease are often the end result.

Of course, a key element in the fight against obesity is exercise. But there's the rub: exercising in areas with poor air quality increases the risk of developing other illnesses such as asthma. Although the causes of this disease are not entirely clear, more and more studies are showing that air pollution not only exacerbates asthma but is also associated with its development. One recent study in southern California found that children who often play sports in areas with high ozone concentrations are more likely to develop the disease than children in communities with low ozone levels.3 Asthma is already one of our most common chronic childhood diseases, affecting some 12% or more of Canadian children.4

Children clearly need to be more active, and it is likely better to get exercise than to be sedentary, even if this means breathing polluted air. But children shouldn't have to face increased health risks just to play. We shouldn't have to exchange one chronic illness for another.

Because more than half of all Canadians now live in just 4 urban areas,5 urban air pollution is a growing health concern. A study published earlier this year reported that long-term exposure to tiny particles in the air (byproducts of fossil-fuel combustion) increases the risk of death from lung cancer and heart and lung disease. Researchers looked at 500 000 people over 16 years of age and compensated for the effects of smoking, diet and other risk factors before concluding that breathing polluted air may be as bad as inhaling second-hand smoke.6 This link between air pollutants and death is further examined in a report that indicates that exposure to particulate matter and ozone constricts blood vessels and may trigger heart trouble in people with cardiovascular disease.7

If we can reduce pollution, we can reduce illness, improve health and reduce health care costs. Air pollution is linked to the premature deaths of up to 16 000 Canadians every year.8 In Ontario alone, smog is estimated to cost taxpayers more than $1 billion a year from increased hospital admissions, emergency department visits and lost work days.9 And the costs of suffering and premature death are far higher.

It is important to discuss these problems now, because trends are not going in the right direction. Every day, more and more vehicles pour onto our streets. And because current fuel efficiency standards for vehicles are voluntary and have not improved since 1980, air pollution is getting worse. The most popular vehicles — SUVs, minivans and pickup trucks — are not even required to meet the same fuel-efficiency standards as cars.

Addressing these sorts of issues will help reduce health care costs, but such benefits are often overlooked. Consider the debate over the Kyoto Protocol. Some lobby groups are fighting it because of the perceived costs attached, but the health benefits and cost savings are often ignored. By improving fuel efficiency and burning less fossil fuel (which will reduce greenhouse gas emissions), we also reduce air pollution. Coal-fired power plants, found in many provinces, are an example. These are a major source of both particulate pollution and greenhouse gases. Replacing them with natural gas co-generation facilities or renewable energy sources such as wind power would greatly reduce emissions of both types of pollutants and improve public health.

Adopting the Kyoto Protocol is also an important public health measure in the long term because slowing global warming is vital to maintaining the health of human populations. Heat and sunlight are key components in the production of smog: as the globe heats up, air pollution will get worse. The expansion of disease vectors as a result of climate change is also a health concern.10 That is why global warming is one of the biggest challenges we face this century in terms of impact to our health and economy, nationally and internationally.

If the ultimate goal of our health care system is to keep people well, then we must look beyond service options and focus on what is making us sick. Discussions about radical restructuring of our health care system, especially the introduction of for-profit care facilities, seem misdirected. “Profit” in health care implies treating people when they are sick, not preventing them from getting sick in the first place. Sick people become the “customers,” and so the more sick people there are the better. This does not sound like a recipe for a healthy society.

We are lucky in Canada to be debating the future of health care. Access to such care may be a right, but it is one not afforded to most of the world's population. It would indeed be tragic if we let a model of health care that is the envy of the world become more focused on making a profit from sick people than on keeping us well in the first place.

• Lewis S. The bog, the fog, the future: 5 strategies for renewing federalism in health care. CMAJ 2002;166 (11): 1421-2.

• Maxwell J. Bringing values into health care reform. CMAJ 2002;166(12):1543-4.