By Dr. Trevor Hancock

Canada’s Health Ministers are meeting in Vancouver today and tomorrow. All indications are that they are going to be talking a lot about health care and funding, and very little about health itself. After all, let’s face it, our ‘health’ ministries are really ministries of illness care, there to manage a (very expensive) illness care system. And that system is there mainly to pick up the pieces once we become sick or injured or ‘unwell’ – not so much diseased as ‘dis-eased’.

Now don’t get me wrong, when the time comes when I need it, I would like a good illness care system there to look after me and – hopefully – restore me to pretty good health. And when I am too frail to manage, I hope it will be there to care for me with kindness and compassion. But wouldn’t it be better if I didn’t need it – or didn’t need it very much?

The problem is, we have been looking at this issue from the wrong end. We started with hospitals and sophisticated and expensive specialty care as the pinnacle of the system and then worked down. Its worth remembering that in Canada, following a 1948 federal program to support hospital building, publicly funded health insurance started by covering hospitals in 1958, but did not extend to care outside the hospital until 1968. No wonder health policy consultant Stephen Lewis once joked that ‘Saskatchewan is a Cree word for too many hospitals’.

Think about it – there are lots of media stories about the newest wonder drug or procedure, the heroic life-saving surgery, the latest hospital expansion and so on. As Monty Python memorably parodied it, every hospital wants a machine that goes ‘ping’. To which I might add that these are the machines and the stories that enable fund-raisers to go ‘ka-ching’!

But there are not so many stories about primary and community care – which is in fact where the majority of care happens. And as I pointed out recently, very little attention is paid to prevention and public health, and even less to the upstream determinants of population health. (A cynic might point out that these other parts of the system lack the budgets and resources for a good public relations department that can generate all these high-tech, feel good or crisis stories.)

So let’s look at this issue from the right end. Strategically, the first thing we need to do is to keep people healthy. In an Utopian world, we would all live in good health to a ripe old age, then quickly and quietly drop dead. Interestingly, that is a nightmare scenario for the illness care system – what would they do? The pharmaceutical industry would go bankrupt! Of course, that is not going to happen, but I suggest it is an ideal worth aiming for.

So if not everyone is going to be healthy forever, the second thing we need to do is enable them to stay healthy as long as possible. That begins with a focus on all the upstream factors that adversely affect our health, from poverty to illiteracy, from unhealthy communities and workplaces to the marketing of unhealthy products. It includes ensuring that everyone has access to good public health and clinical preventive services, especially those who are most disadvantaged but whose needs are often greatest.

Third, people need to be given the skills, capacities, resources and support that enable them to care for their own minor ailments and injuries, to manage their own chronic illnesses, and to remain living in their own homes or in the community. In fact, most care is self-care, and self-care is the largest part of the health care system. It is also the most neglected part; no health ministry in Canada has made it a priority or even paid it much attention.

Only once these key strategies are in place should we look to the health care system, starting with primary care and home and community care. We need to see the hospital as the place of last resort, only to be used when all else has failed. It’s time our Ministers stepped back and did some strategic thinking. We need to turn the system on its head.

© Trevor Hancock, 2016

Originally published in Times Colonist Jan 20, 2016

By Dr. Trevor Hancock

Thirty-five years ago I identified what I believed to be the key principles of public health. At the time I called them ecological sanity and social justice: Today we would say sustainability and equity. In retrospect, I should have added peace as a third principle – the topic of my column last week – and the creation of community as a fourth principle.

I came to the concept of ecological sanity from the writing of James Robertson, a leading alternative futures thinker. In his 1978 book The Sane Alternative he proposed an alternative sane, humane and ecological (SHE) future. Sanity, he wrote, is balance within ourselves; humanity is balance between ourselves and other people, while being ecological means finding balance between people and the planet. All three are fundamental determinants of our health.

Today, it seems we are out of balance in all three domains; in particular we are acting in ways that are ecologically insane. How else would you describe a species that is knowingly making demands upon the Earth’s ecosystems beyond the Earth’s capacity to meet them. We are changing the climate, acidifying the oceans, polluting entire ecosystems and foodchains with persistent organic pollutants whose combined effects we don’t understand, and triggering a sixth great extinction. So massive is our impact that we will show up in the fossil record as a new geologic epoch – the Anthropocene.

As to social justice, that is another way of talking about what Robertson calls humanity: Balance between ourselves and other people. To me, that involves having respect for others, trying to see the world through their eyes, understanding their culture and not seeking to impose our own. However, this does not mean accepting behaviours that oppress, injure or kill others, or otherwise violate their basic human rights: A useful principle, it seems to me, is the Wiccan precept “Do as you will, so long as it hurt no other’.

Social justice also means recognising the fundamental injustice of the levels of wealth concentration we see today, whether at a local or a global level. It may be, as the Bible says, that ‘the poor you will always have with you’, but that doesn’t mean we should tolerate policies that make this inequality worse.

Levels of wealth inequality have reached unacceptable – and unhealthy – levels. A 2014 report from the Broadbent Institute, using Statistics Canada data for 2012, found that the top 10 percent of Canadians owned 48 percent of the wealth, while the bottom 50 percent owned 5.5 percent – and the bottom 10 percent had no net worth, but were in debt. Moreover, the concentration of wealth was highest in BC, where the top 10 percent owned 56 percent of the wealth.

The French philosopher Raymond Aron wrote that ‘when inequality becomes too great, the idea of community becomes impossible’. I fear that we have reached or even passed that point, which may be why there is not enough outrage about this; ‘they’ – the poor, the homeless, Indigenous people, refugees – are not ‘us’. This level of inequality is no more socially sustainable than our impact on the Earth is ecologically sustainable.

Which brings me to my final theme: Governance for health. In the 1980s I worked for the City of Toronto Department of Public Health. Over the next few years, I helped create a Healthy Cities and Communities movement, both locally and globally. Key to that movement is to understand that governance – the shared management of the city by its citizens, community organisations and institutions – is crucial in creating a healthy city, one that is ecologically and socially sustainable.

In particular we must recognise that the policies that most affect health lie beyond the health care system. This means we have to work beyond health care and partner with other Departments and sectors at all levels to create public (and private) policies that are good for health. Chief amongst these are policies to promote ecological sustainability and social justice.

Additionally, knowing that community matters, we have to help create community by recognising and building on existing community strengths, establishing and supporting community networks and strengthening community engagement in governance.

In the coming year I will continue to explore these three key themes: Equity, sustainability and governance for health.

© Trevor Hancock, 2015

Originally published in Times Colonist 30 Dec 2015

Photography by Claudio Vasquez

By Dr. Trevor Hancock

Canada’s Health Ministers are coming to Vancouver on January 20th. It is good to know that we now have a federal government that will engage with the provinces on health care. Now let’s hope they will engage on health, not just health care.

Forty years ago, the Trudeau government of those days produced the fabled Lalonde report. They became the first government in modern times to acknowledge that further improvements in the health of the population would not mainly come from more health care. Instead, the report boldly stated “there is little doubt that future improvements in the level of health of Canadians lie mainly in improving the environment, moderating self-imposed risks and adding to our knowledge of human biology.”

Initially there was a strong focus on changing personal behaviour, forgetting that our choices are largely shaped and constrained by environmental, social, cultural, economic and commercial pressures, and that ‘lifestyle’ is a collective noun. But our experience with tobacco has shown clearly that a combination of legislation, taxation, environmental change, enforcement, social marketing and education can change the social norm and massively re-shape individual and collective behaviour.

Today, perhaps the greatest threat to our collective health comes not from what we smoke, but what we eat. Obesity, it is said, is the new tobacco, while unhealthy food also contributes to heart disease, cancer, dental decay, diabetes and other ailments. So while the Ministers may want to talk a lot about the costs of healthcare, they need to recognise that the burden of disease – and the economic cost of treating these diseases – could be significantly reduced if they focused more on a healthy food policy for Canada.

A good place for the Ministers to start is with the failed efforts to reduce salt levels in our diet, especially in processed and fast foods. In a 2012 article in the Canadian Medical Association Journal, it was noted that “the numbers of deaths averted by moderate reductions in population salt consumption would be at least as many as those achieved by plausible reductions in population smoking rates”.

Moreover, that same article reported that for a variety of fast food products from six major companies in six Western countries, “individual items marketed as the same product had very different levels of salt in different countries”. Levels were generally highest in the USA and Canada and lowest in France and the UK.

Regrettably, but consistent with its general preference to protect the health of corporations rather than the health of people, the Harper government did very little. Its voluntary approach, as predicted, has largely failed. It didn’t ever work with tobacco, so why would it work for salt? It’s time for a much stronger response, Ministers. Time to take what we learned from fighting tobacco and turn it on eating, starting with salt.

But its more than salt, we also need to address levels of sugar and fat, and we also need to address the elephant in the room – portion size. The food industry’s unhealthy private policies are a major public health problem that must be tackled forcefully.

A good place for positive action is healthy food for our kids, because if we can establish healthy eating patterns early, we have some hope that they will remain healthy for life. Moreover, the benefits of healthy food for our kids extend beyond better health to include learning and economic benefits.

The National Coalition for Healthy School Food, which includes the Heart and Stroke Foundation and several Indigenous health organisations among others, notes that “1/3rd of students in elementary schools and 2/3rds of students in secondary schools do not eat a nutritious breakfast before school, leaving them at risk for learning, behavioural and health challenges at school”. This also reduces their likelihood of graduating, and harms their future job prospects and income potential.

The Coalition is calling on the federal government to invest $1 billion over 5 years “in a cost-shared Universal Healthy School Food Program that will enable all students in Canada to have access to healthy meals at school every day”.

It’s time for a healthy food policy for Canada, one that promotes healthy eating and combats unhealthy food products. This needs to be on the Ministers’ Vancouver table.

© Trevor Hancock, 2016

Originally published Times Colonist 6 January, 2016

By Dr. Trevor Hancock

On Monday December 21^st the sun reaches its northernmost point and starts its long slow trek back to the south, heading for the summer solstice. For thousands of years, throughout the Northern hemisphere, this has been an important turning point. The fear that the sun would not return, that our world would continue to get darker and colder, would have haunted our forebears.

But the turning of the sun brought with it the promise of light and warmth, a new spring, new life, new planting and a new harvest. No wonder it was a cause for celebration, a time for fires and lights to ward off the dark and celebrate the return of the light.

In more recent times, those celebrations have been taken up as Christmas, Hannukah, Diwali and related events, but their roots lie in the observation and celebration of the Winter solstice. Today, the focus is on these modern celebrations – and especially their commercialised incarnations – but their roots in solstice, like many of our connections to nature, have been drastically reduced, if not severed.

The Paris Agreement on Global Climate Change is a good illustration of that loss of connection – but perhaps is also a symbol of a turning, a coming of the light of hope, and a cause for celebration. It holds out the hope that we may avoid the worst of the damage that can come from climate change, damage that includes significant threats to the health of people around the world.

The Agreement illustrates our loss of connection with nature because it should have come decades ago. The science of climate change was clear long ago, as were the probable consequences and potential solutions – and the signs of global warming were there to be seen. But we chose to ignore them – helped on by a denial industry supported by the fossil fuel industry and its supporters – until the signs became so obvious that they could no longer be ignored.

Yet at this turning point of the year, the Paris Agreement brings hope. In the decline of the fossil fuel industry we also see the possibilities inherent in the birth of a new clean energy industry based on conservation and renewable energy.

Not only will there be significant economic and employment benefits in this new energy industry, there will be significant health benefits too. Certainly the people of Beijing and many other cities around the world will be able to breathe easier in the future as the shift away from fossil fuels leads to cleaner air.

But there is a deeper lesson in the climate change debate and decision-making process to which we need to pay attention, and that is the limitations of the scientific approach.

It has taken decades longer than it should have to reach this climate change agreement, in part because logic and science have not been enough to change policy. Knowing something intellectually is not enough; people need to know it in their hearts and in their guts, they need to feel the changes in the Earth’s ecosystems.

In her latest book, Naomi Klein says of climate change that “this changes everything”, and it does. If we are to live successfully within the limitations of our home planet, we need to foster a social and indeed a cultural transformation.

Key to that transformation is to see ourselves not as separate from and superior to nature, but part of and deeply interdependent with nature. But creating such a feeling is not science’s strength, it is the role of the arts, culture and the humanities, which is why I believe they have a large role to play in addressing the challenges we face.

Which brings me to the celebration of solstice. Part of re-connecting with nature is to re-connect to the seasons, to the turning of the year and to the coming of the light. Which is why you will find me this Sunday, as the Green Man, participating in our annual Mummers Play at the Lights on the Gorge Solstice celebration. My closing lines say it all: ‘our purpose is to celebrate the turning of the year, so we wish joy and happiness, great mirth and great good cheer’.

© Trevor Hancock, 2015

Originally published Times Colonist, December 16, 2015

By Dr. Trevor Hancock

This summer was unusual for us – we could actually sit out in our garden quite often without being driven indoors by power saws, drills, hammering, motor mowers or – worst of all, leaf-blowers. But noise is a problem everywhere these days – in our parks, in cafés, pubs and restaurants, in our arenas and movie theatres, on our streets and in our neighbourhoods. I am sure my experiences are shared by many of you.

Just recently, I was on one of my favourite dog-walks on the back-trails of Thetis Lake Park when my quiet enjoyment of nature – which we know is good for health – was ruined, yet again, by the roar of engines and the squeal of tires and brakes; yep, the Western Speedway! I really do not understand why this noisy and polluting activity is allowed to disrupt the local neighbourhood and the park.

Another pet peeve is the volume of noise in our eating-places. If I actually want to talk with the people I am sitting with, I usually have to ask for the noise to be turned down. Frankly, I consider it rude and discourteous of the owners and managers that they value my conversation so little that they are content to drown it out. Why? What is the point of this level of noise? How can we maintain social contacts if we can’t hear each other talk?

Now you may think that this is just me being a grumpy old guy, but noise is more than a nuisance, it’s a health problem. By noise, I mean what the dictionary says: “a sound . . . that is loud or unpleasant or that causes disturbance”. Or even more succinctly, as the World Health Organisation put is, “noise is unwanted sound”.

That unwanted sound can be quite localised, as in eating establishments or places of recreation and entertainment, and we have the option of moving away. But then, in effect, people who seek peace and quiet, or at least a reasonable level of noise, are excluded from these public places. This is particularly problematic for those who are especially sensitive to noise – as some are – or are hard of hearing, something we all tend to experience as we age.

In addition to localised noise, there is also the more generalised ‘environmental noise’, which the World Health Organisation’s European Region dubs ‘noise pollution’. In a 2011 report, WHO noted that noise pollution “is among the most frequent sources of complaint regarding environmental issues in Europe, especially in densely populated urban areas and residential areas near highways, railways and airports”.

The WHO report identified a number of health effects of noise pollution, including cardiovascular disease, cognitive impairment in children, sleep disturbance, tinnitus (ringing in the ears) and annoyance. Of these, the most severe effects are high blood pressure and heart disease, but the most widespread health impacts arise from sleep disturbance and annoyance.

Writing in the Southern Medical Journal in 2007, Lisa Goines and Dr. Louis Hagler make an interesting point:

“In a way that is analogous to second-hand smoke, second-hand noise is an unwanted airborne pollutant produced by others; it is imposed on us without our consent, often against our wills, and at times, places, and volumes over which we have no control.

So just as the Non-smokers Rights movement was crucial in the fight against tobacco, maybe it is time for a ‘Quiet Enjoyment Rights’ movement to take on the issue of unwanted sound in public places. In fact right here in Vancouver we have the Right to Quiet Society, which was established in 1982. The Society seeks to “foster recognition of the right to quiet as a basic human right” and wants to see “a world where quiet is a normal part of life and where it is possible to listen to the sounds of nature without the constant intrusion of machine noise and artificial stimuli”.

There is even an International Noise Awareness Day, established by the US-based Center for Hearing and Communication in 1996, with the wonderful slogan “You have to make some noise to end it”; the next day is Wednesday, April 27, 2016.

Maybe it’s time we made some noise about noise!

© Trevor Hancock, 2015

Originally published Times Colonist, Nov 11th, 2015

Bridge for Health recognizes that shifting policy from a health-care focus to an approach that engages citizens to create healthy communities requires leadership and public dialogue. Voting is a critical component of civic engagement. Given the national election coming up in Canada on October 19th, we are very pleased to support Promote the Vote with this leadership training program!

Engagement Leader training

Do you want more of your friends, family, neighbours and coworkers to be politically engaged?

Do you want more dialogue in politics?

Do you want to make sure people feel heard in political conversations?

If you answered yes to any of these questions, volunteer as a Promote the Vote Engagement Leader! Engagement Leaders use dialogue (an approach to communication focused on listening, understanding and respect) to get people they know more involved in politics and the political process. The training will cover:

• An introduction to Promote the Vote
• An introduction to dialogue and how to use a dialogue approach, including active listening and speaking from values
• Interactive activities to help you prepare for conversations with people who are not politically engaged

The training workshop is FREE, but registration is required as there are limited spaces available. Register for either our workshop in Surrey or Vancouver:

Surrey workshop – October 6, 2015, 6:45pm – Info & Registration 

Vancouver workshop – October 8, 2015. 6:00pm – Info & Registration 

Get Out The Vote! Film screening supporting Promote the Vote

Reel Causes and PIPSC are presenting Get Out The Vote! on October 14 in support of Promote the Vote. The event is a free/by donation film screening of The Price We Pay, a Canadian documentary about the history and present-day reality of big-business tax avoidance through off-shore tax havens. This gripping documentary offers a thought-provoking perspective on inequality, the economy and the power of multi-national corporations as these same issues pulse through the current federal election campaign.

The film’s director, Harold Crooks, will join via Skype for a discussion after the screening. Hope to see you there!

The Film: The Price We Pay (running time: 93 minutes)

When: October 14, 2015, Doors: 6:45, Show Time: 7:00

Location: SFU Woodward’s Djavad Mowafaghian Cinema, 149 West Hastings Street

Cost: Free / by donation

Synopsis and event details. http://www.reelcauses.org