Boozary and Laupacis are absolutely right on the problem: Canada is undoubtedly beset by substantial disparities in health status.1 My desire to respond, however, arose after my review of their proposed solutions, including a final rhetorical question and belief that the status quo has been inaction.
Throughout the editorial, most notable in its absence was any mention of the work of public health agencies. Working at all 3 levels of government, these agencies are mandated to use data and evidence to protect, promote and optimize health through shaping determinants, contexts and conditions in the jurisdiction they serve. Working with community partners, often apart from health care, these agencies bring a health perspective in calling for, designing, implementing and evaluating various social policies and programs. This includes many of the initiatives described in the editorial’s sixth paragraph, including the Basic Income pilot.2
Granted, one common misconception is that public health is part of the health care system. This arises from history and various structural factors in Canada that see public health agencies receive funding from health care service pots. In many provinces, this has also lumped public health together with health care services like hospitals and clinics. The reality is that, although health care is undoubtedly an important partner for public health, the 2 sectors do not often share a common goal.
The goal of public health, arguably, is to create contexts that keep people well and out of the health care system altogether, in the same way laws and policies aim to level-set public behaviours and societal norms. In continuing that analogy, the health care system is much like the legal system: one does not wish to be involved unless they absolutely have to be, and many who are become involved because of structural contexts and situations that disadvantage them, rather than any intrinsic desire.
The authors also suggest that it is “commendable of the health care sector to address patients’ social needs that are largely under the purview of municipal, provincial and federal governments.” My question is simple: Is it, truly? Is the delivery of quality education or social welfare programs, the setting of just laws, effective police enforcement or oversight of the economic system within the realm of expertise of usual physicians and health care professionals, hospital administrators or manufacturers of medical devices? Turned on its head, if healthy clients are wealthy clients, should health care professionals countenance bankers practising in their own hospitals and clinics to “address the financial needs of their clients?”
It is undeniable that health care must understand the effect of social determinants on health in advocating and bringing voice to patient stories, but this is very different from actually “meeting the need.” That hospitals or doctors might, for example, take over leadership of implementing comprehensive housing plans or even manage subsidized housing facilities would be a major sector overreach; the mandate for such efforts rightly lies with housing agencies and governments. Furthermore, even in advocating for the health concerns of homelessness, health care would also do well to remember that public health agencies have long provided the health perspective on this file through its data, evidence and extant partnerships.
That leads me to the broader question: Why focus on the health care system if we’re talking about advancing health equity? Although the authors correctly assert that the health care system has room to improve, particularly around access, much of what keeps people healthy and well exists outside of the walls of hospitals, in how our society (which in many ways is the true “health system”) is organized.3,4
No doubt, for certain diseases there will always be a need for health care. However, if we are truly looking at preventable illness, as the authors begin with, we must look beyond screening, therapeutics and primary care. Although important (and recognizing that pharmacare would be a great equity driver), we must remember that these interventions generally target natural history instead of etiology. As the old truism goes, the best trauma system in the world will do nothing to stop car crashes from happening in the first place. On that point, quick quiz: Which sector is already involved in trying to address the root causes of ill health in the community? You guessed it: public health.
The authors close with a call for greater investment in health (care) system research, pointing out a meagre 0.03% commitment from Ontario’s health care budget in 2019–2020.1 It may come as a surprise that the entire public health sector is similarly a rounding error, coming in at 1% of the budget in the same report.5 Worth noting is that this is down from 3% in the Lalonde report (that gave rise to public health’s nickname of being “the 3-percent”).6
Given these funding sizes, it is not surprising that the work of public health was entirely left out of the authors’ well-meaning editorial. If anything, though, what the authors see as inaction, I see as historic underinvestment. And yet, what has that investment provided? For so long, public health has done so much with so little, although that little often returns in 100- or 1000-fold health benefits through forestalling disease.7 Of course, this makes the sector silent in success; no one talks about the diseases averted, the child who never starts smoking or the young adult who lives to a ripe old age because a separated cycle lane kept them safe from a runaway truck.
Although greater evaluation and research is always helpful, the old proverb around ounces of prevention and pounds of cure has been borne out through studies for as long as studies have been done. If we are calling for more health care dollars to be spent on research, then we should also start talking about reorienting some of those dollars toward public health and its preventive work. After all, such a move is a stated tenet of the nearly 35-year-old Ottawa Charter for Health Promotion.8
Footnotes
Competing interests: None declared.