Executive summary: The Chief Public Health Officer's report on the state of public health in Canada 2008

Executive Summary

This report is the Chief Public Health Officer of Canada’s first annual report to Canadians on the state of public health in Canada. It explores the public health approach, the health of the Canadian population, variances in health status among the population and factors that contribute to health inequalities. Efforts to reduce these inequalities can be found across the country and at many levels. They include successful interventions that – through better understanding, collaboration and collective action – may serve to reduce Canada’s health inequalities and improve quality of life for all Canadians.

The report covers the following areas, with main findings summarized below.

Public Health in Canada

To understand the population approach to health covered in this report, an overview of public health, its definition, mandate and the key players involved in this area of responsibility are outlined. This includes a brief history of public health in Canada – spanning the earliest efforts to quarantine new immigrants in the 19th century and the introduction of vaccines, pasteurized milk, food safety, sanitation and clean drinking water, to the introduction of Medicare as a major advance in helping all Canadians to access health care.

The success of the public health approach is underlined by an examination of public campaigns that have made a positive impact on the health of Canadians: the introduction of mass immunization; reducing tobacco use; and increasing seatbelt use. These achievements, along with new and enduring health challenges, serve as a benchmark for the continuous improvements in public health to maintain Canada’s global standing as one of the healthiest nations in the world.

Our Population, Our Health and the Distribution of Our Health

When asked to rate their own health, most Canadians consider themselves to have either excellent or very good health. Life expectancy has increased substantially over the last century and is currently one of the highest in the world at just over 80 years. The infant mortality rate has also improved, decreasing by 80% from 27 deaths per 1,000 live births in 1960 to 5 per 1,000 live births in 2004.

The main causes of death in Canada are circulatory diseases, cancer and respiratory diseases. Premature deaths are most often due to cancers, circulatory diseases, injuries (both unintentional and intentional) and chronic respiratory disease. Other illnesses and conditions also impact the health of the population – and some, like diabetes and obesity – are on the rise. Although the number of Canadians who die prematurely and suffer from poor health is low in comparison to other countries, those who do so tend to belong to specific sub-populations – Aboriginal Peoples, residents of northern and remote communities, and those with low income and education.

Social and Economic Factors that Influence Our Health and Contribute to Health Inequalities

Why do some people enjoy good health while others do not? These inequalities in health status are partially due to social and economic factors that influence health behaviours and health outcomes.
Socio-economic and personal factors profiled within this report include:

• income;
• employment and working conditions;
• food security;
• environment and housing;
• early childhood development;
• education and literacy;
• social support systems;
• health behaviours; and
• access to health care.

This list does not cover all factors that influence health, but represents areas that are currently understood and where action has been proven to influence outcomes. For example, while genetics play an important role in health and illness, and geneticists have made great strides in understanding what impacts can be made, this factor currently has less of an ability to bring about change in population health than other factors.

In general, health status follows a gradient where people in less advantageous socio-economic circumstances are not as healthy as those at each subsequently higher socio-economic level. In other words, those with the lowest incomes and education, inadequate housing, poor working conditions, detrimental health behaviours, limited access to health care and who lack early childhood support and/or social supports are more likely to develop poorer physical and mental health outcomes than those living in better circumstances. This is true for each level (or rise) along the gradient. However, improvement to one or more of these factors can result in an improvement in overall health. Many programs and services targeted at reducing social and health inequalities through improvements to, or by mitigating, socio-economic factors have been undertaken in Canada at all levels. Successful, promising and/or unique responses are profiled for each factor.

Despite these efforts, however, certain trends continue to raise concerns. For example, the gap between those with the highest and lowest incomes in Canada continues to grow and poverty rates for some children, Aboriginal Peoples, recent immigrants and persons with disabilities are significantly higher than for the general population. As well, Canada’s child poverty rate is higher than many similarly developed countries. Food security is also a critical issue, with the prevalence of school food programs and food banks on the rise. Inadequate housing and homelessness continue to plague Aboriginal Peoples, immigrants, low-income earners and marginalized youth; while urban sprawl and other environmental conditions are a growing concern for many.

Unemployment rates are at a 30-year low, but remain higher among certain populations such as recent immigrants. For those who are employed, rates of injury in the workplace continue to be higher among blue collar workers and men, while work-related stress is more prevalent among women. Although Canada ranks among the top five Organisation for Economic Co-operation and Development (OECD) countries for high school completion rates, some young Canadians remain at risk of leaving school prematurely. For those who seek higher educations, women are now outnumbering men. If this trend continues, a difference in health outcomes between genders attributable to differences in education levels may emerge.

Social connectedness also plays an important role in health. Urban dwellers are less likely than rural dwellers to report feeling a part of their community and seniors are more likely to report feeling lonely and isolated. These populations represent two of the fastest growing populations in Canada. Aboriginal Peoples continue to struggle with social exclusion, lower workforce participation and disconnection from their traditions and culture. As a result, they more often experience poorer health outcomes than the national average. Research suggests, however, that Aboriginal communities with some level of self-government and cultural continuity have better health outcomes.

Individual health behaviours – both positive and negative – are influenced by an individual’s social and economic environments. Among the general population, rates of smoking and death related to alcohol dependence have declined, but poor eating habits and unsafe sexual practices are on the rise with related increases to incidences of diabetes and some sexually transmitted diseases, respectively. In addition, although rates of physical activity are increasing, the incidence of obesity continues to rise indicating that improvement in this area needs to continue. Compared to the national average, these negative behaviours are more often reported among certain populations.

While Canadians have universally insured health care, some experience difficulty accessing it. While it may seem obvious that residents of northern and remote communities have geographical accessibility issues, Aboriginal Peoples, immigrants and others can face additional challenges ranging from cultural insensitivities to language barriers. Among the marginalized, infant mortality rates can be much higher than the general population even though many live in close proximity to some of the most sophisticated hospitals in the world.

Addressing Inequalities – Where are we in Canada?

Social policies and programs that improve health outcomes have been in place in Canada for decades, with new and promising interventions and approaches continually at the ready. Efforts are widespread and include action on the part of governments, the private sector, not-for-profit organizations, communities and individuals. Despite this, health inequalities persist and – in some cases – are growing. One reason is an incomplete understanding of what works and what doesn’t, which makes focusing these efforts challenging. Unfortunately, Canada’s ability, as a country, to measure and report on the health impacts of many of these efforts is not strong and can be developed further. What is clear is that actions targeting individual health choices and behaviours must also consider the social and environmental conditions that shape these choices. Among such a diverse population, no single approach or solution is optimal. Ideally, a balance between targeted interventions for some and universal programs for all is best but the appropriate mix requires further study.

Although clarification and better understanding is needed in many areas, waiting for all the answers is not an acceptable option given what is already known, what can be done and the consequences of neglect while waiting.

Attention should be given to the following priority areas for addressing health inequalities:

• social investments, particularly investments in families with children living in poverty and in early child development programs;
• community capacity through direct involvement in solutions, enhanced cross-sectoral co-operation, better defined stakeholder roles and increased measuring of outcomes;
• inter-sectoral action through integrated, coherent policies and joint actions among parties within and outside of the formal health sector at all levels;
• knowledge infrastructure through a better understanding of sub-populations, the pathways through which socio-economic factors interact to create health inequalities, how best practices from other jurisdictions can be adapted to improve Canadian efforts and through more advanced measurement of the outcomes of the various interventions undertaken; and
• leadership at the public health, health and cross-sectoral levels.

Moving Forward

Canada has the capacity to address the full range of issues that can adversely affect the health of Canadians. An impressive past record of improving quality of life and health provides a strong foundation from which to act on becoming the healthiest nation with the smallest gap in health. It is a goal that is well within reach if the collective will to do so can be harnessed and directed through strong leadership and a firm commitment by individuals, community members and decision-makers to effect change.