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Rev Panam Salud Publica vol.12 n.3 Washington Sep. 2002
Perspectivas de los héroes de la salud pública de la OPS /
Perspectives from PAHO public health heroes
As part of its 100th-anniversary celebration, the Pan American Health Organization has named 12 persons as "Public Health Heroes of the Americas" in recognition of their noteworthy contributions to public health in the Region of the Americas. Over the course of this year, the Revista Panamericana de Salud Pública/Pan American Journal of Public Health will be carrying pieces written by or about these heroes.
Como parte de la celebración de su Centenario, la Organización Panamericana de la Salud (OPS) ha distinguido con el título de Héroes de la Salud Pública a 12 personalidades que se han destacado por su valiosa contribución a la salud en el continente americano. A lo largo de este año, la Revista Panamericana de Salud Pública/Pan American Journal of Public Health publicará una serie de escritos de los mismos galardonados o acerca de ellos.
New perspective on the health of Canadians: 28 years later
I am deeply honored and grateful to have been selected by the Pan American Health Organization (PAHO) as one of the Heroes and Heroines of the 20th century in the field of public health. In my case, this award is in connection with the publication on May 1, 1974 of a Canadian Government document entitled A new perspective on the health of Canadians, which has since come to be known as the Lalonde Report, as I was the Minister of Health who tabled it in Parliament on that date. That shorthand title, however, is somewhat of a misnomer. I was closely associated with the production of that document and had to assume the political responsibility for it, but the largest credit should go to the Long Range Planning Branch of the Department of Health and Welfare headed by Mr. Hubert Laframboise, as well as to Dr. Maurice LeClair, my Deputy Minister of Health at the time.
In the early seventies (what else is new!), two major concerns were growing in Canadian government circles: (1) the rising cost of health care, and (2) the fact that the health status of Canadians did not seem to improve proportionately with the rise in the cost of health services. After the significant improvements in health statistics following the introduction in Canada of public hospital and medical insurance in the fifties and sixties, the correlation between health expenditures and health improvement was becoming far less direct. When I was appointed Minister of Health and Welfare in 1972, it was clear that the issue had to be addressed.
Rather than spending our time trying to squeeze money out of health care, which in my country falls mainly under provincial jurisdiction, we decided to go back to basics and to accelerate work already initiated by the Long Range Planning Branch. Interestingly, that Branch was very small, just a few individuals plus eight external consultants, most of them outside the medical profession. To use a current expression, what was needed was to think "outside the box."
We started from the very broad definition of health adopted by the World Health Organization (WHO) in 1948, which took into account not only the physical and biological conditions of man but also his psychological, social, and economic dimensions. That definition was headlined in New Perspective when it was published.
An analysis of the nature and underlying causes of morbidity and mortality led us to the conclusion that the traditional approach to health issues, with its concentration on health care services, was woefully inadequate. We therefore proposed what was called the Health Field Concept as a tool to help us better understand the causes of sickness and death and facilitate the identification of courses of action that might be taken to improve health. In our view, the Concept could be broken down into four elements: human biology, environment, lifestyle, and health care organization, and those elements had to be given equal analytical, if not financial, importance if governments were to pursue a comprehensive and effective health policy.
We then proposed two broad objectives: (1) to reduce mental and physical health hazards for those segments of the population whose risks were high; (2) to improve the accessibility of good mental and physical health care for those whose current access was unsatisfactory.
In the pursuit of those objectives, we identified five strategies: (1) a health promotion strategy; (2) a regulatory strategy; (3) a research strategy; (4) a health care efficiency strategy, and (5) a goal-setting strategy. As a fist step, we proposed some 74 possible courses of action for the consideration not only of governments but also of citizens at large and organizations that had a role in the implementation of such strategies.
Before publication, we had made a number of preliminary tests of the concept with various specialized groups. I would like to mention in particular the June 1973 WHO Conference in Geneva, and, later in the fall, an important Pan-American Conference sponsored by PAHO in Ottawa. On both occasions, the reception was very positive and it encouraged us to move on. In addition, the broad outlines of the document received the unanimous endorsement of a federal-provincial conference of Health Ministers in Canada in January 1974.
I must say, nonetheless, that when the document was tabled in the Canadian House of Commons, the reception was rather disappointing. The opposition mocked the paper as being against sin and for motherhood and added that they had known for some time that it was better to be slim than fat. As to the media, they gave minimal attention to New Perspective. One could have fairly concluded that the whole thing was a non-event and that it would be added to the pile of other unread public government documents. Anyhow, we distributed at home and abroad the 50 000 copies that had been printed.
"Nul n'est prophète en son pays." Almost immediately after the release of New Perspective, Ivan Illich, a well-known and influential author at the time, published a book entitled in French Némésis de la médecine. Several of his concepts were close to ours. Our publication had somehow come to his attention just before it was published, because he added a footnote in the first page of his book in which he praised New Perspective as the first government document to adopt the Health Field Concept as public policy and put forward specific strategies and a plan of action to implement them.
Foreign (and, in fairness, some Canadian) public health academics wrote very positive reviews of our document and Dr. Halfdan Mahler, the new Director-General of WHO at the time, endorsed New Perspective in many of his written and oral statements. He even ensured that the concepts of New Perspective found their way into the WHO Global Health for All Strategy launched in 1988. In the mean time, my French and American colleagues, Simone Veil and Jos. Califano, announced that they would pursue an approach similar to ours. Over time, health ministers in other countries issued analogous statements.
With the boomerang effect of success abroad, an aggressive pursuit by my department of the objectives of New Perspective, and the cooperation of my provincial colleagues, the analytical framework of New Perspective gradually gained respect as a valuable instrument of health policy. As a matter of fact, New Perspective even became a Canadian government "best-seller" (mind you, it was free); I am told that, by the time the government stopped authorizing reprints in the mid-eighties, well over 200 000 copies had been distributed. By 1984, a writer in the field of public health, Mr. Milton Terris, referred to it as a "world-class document" and "one of the great achievements of the modern public health movement."
In any event, over the last 28 years, the Health Field Concept has been discussed, enlarged, and refined; hundreds of conferences, thousands of research projects and articles, and a large number of government reports and policy statements have encouraged a holistic approach to health issues. WHO has over the years initiated a number of programs pushing the concepts of "healthy public policies," "healthy cities," ''healthy communities," and Canadian governments and organizations have been quite supportive of such programs in our country. As a matter of fact, the first WHO International Health Promotion Conference, held in Ottawa in 1986, led to the adoption of the now famous Ottawa Charter on Health Promotion.
Revisiting New Perspective 28 years later, I would have the following to say:
(1) It is important to reassert the fundamental validity of the Health Field Concept and the interrelationship between its four components: human biology, environment, lifestyle, and health care organization. Although conceived in the context of an economically advanced country, the strength and the appeal of the Health Field Concept are its universal application. The specific plans of action would obviously need to reflect local conditions, but the general strategies are capable of application in developing as well as developed countries. New Perspective cannot be dismissed as a document of interest only to rich countries.
If we really want to improve the health of our citizens, we cannot concentrate only on the health care organization. Unfortunately, the impact of the first three elements of the Health Field Concept is much more diffuse and is generally, but not always, felt only in the medium to long term. In comparison, the inadequacies of the health care system are immediately visible and understandable by the media and the general public. The lack of health professionals, of adequate facilities or of proper equipment, the cost of prescription drugs or even some catastrophic anecdotes in the health care system, make for much better headlines than the negative impact of malnutrition, poor housing, poverty, air pollution, or bad roads and drunk driving¾the list could easily go on. Yet it is quite fair to argue that further action on some of these latter factors can be much more cost-efficient than additional funding of health care itself.
Let me give you a couple of examples, taken from the Canadian experience. The first two are related to road accidents; in that case, both measures had practically no cost and had an immediate significant impact. I refer to the compulsory wearing of seat belts which was the first recommendation contained in New Perspective to be adopted by the Canadian provinces and the amendments to the Criminal Code in the last two decades substantially increasing penalties for driving while under the influence of alcohol. In the first instance, there was an immediate resulting decline, varying between 15% and 20%, in the number of fatal or serious injuries.
Another example is one where the positive health impact will be felt only in the medium to long term. I now refer to the measures aimed at a reduction in smoking. In fact, some of those measures not only do not require public funds but they add to the public treasury. Such an instance occurred, in 2001, when tobacco tax increases generated some $500 million yearly in additional revenues to the federal and provincial governments. However, contrary to the first example, smoking has not been made a civil or criminal offense and, even though the damages to health caused by smoking are well established, the issue here is not only to impose restrictions on the marketing practices of manufacturers of tobacco products but, even more so, to change individual behavior in a democratic fashion. Such a change will never be immediate and, even after some of it will have been achieved, the cost benefits for the health care system, although irrefutable, will take even longer to appear.
In connection with this last issue, I find it unconscionable to see how the cigarette manufacturers, faced with legal restrictions and increasing resistance from the public in the developed world, have diverted some of their marketing to developing countries, where public awareness and government intervention are at a much lower level.
(2) A holistic health concept (an expression more frequently used now than the Health Field Concept of 1974) should not be sold or bought on fiscal arguments, and more particularly as a cost-saving technique. I have no doubt in my mind that the action under that concept taken over the years by governments, health professionals, and researchers in all kinds of fields has led to better health for their citizens, and one can produce very convincing statistics in support of such a statement.
Health care services, including drugs, whose costs are increasing at a frightening rate, will remain a fundamental, and the most expensive element of a holistic approach to health policy. The increase in longevity in most societies is bound by itself to require large health care expenditures.
But, there are plenty of arguments which stand on their own in support of action and expenditure with regard to human biology, lifestyle, or the physical and social environment, without the need to argue that this should mean a necessary reduction of expenditure on health care. As just mentioned, there are instances where such action may even lead to more financial resources being available for health care.
Governments are in the business of establishing priorities and they have constantly to allocate resources, which, by definition, will never be sufficient to meet all needs of society, but it is not true that investment in the environment, for instance, must necessarily be at the expense of health care services.
(3) A holistic health policy cannot be implemented by health professionals, health officials, and health ministers alone. No one in his right mind could attribute to these people the sole responsibility for dealing with such issues as smoking, poor physical fitness, drinking and driving, malnutrition, poor housing conditions, contaminated water supply, bad roads, environmental decay, inadequate income, etc.
In 1986, the Canadian government published a policy paper entitled Achieving health for all: a framework for health promotion. I will quote one sentence: "All policies which have a direct bearing on health need to be coordinated. The list is long and includes, among others, income security, employment, education, housing business, agriculture, transportation, justice and technology." Quite a list!
Clémenceau once said that war was too important to be left to the generals. The same could be said about health policy. A holistic health policy is a challenge for whole societies; and, in addition, we have come to realize that the contribution of the international community is essential to its success.
The French have an expression which says "Qui trop embrasse mal étreint." I remember reading a paper published in 1994 by the Canadian Public Health Association which noted the frustration prevailing at the time among health promotion advocates, resulting from the fact that without the tools of healthy policy which encompasses social justice and equity issues, most important determinants of health cannot be effectively addressed. And I also remember some of the criticism addressed at New Perspective, alleging that it did not deal sufficiently with economic and social policy issues.
All I can say is that we are all in for a long wait if we expect that a holistic health policy will be implemented by fiats from ministers of health or health officials. Health promotion needs to address those issues, and meaningful action on such a broad field will only take place in the context of general public policy supported by an enlightened electorate. In that regard, health promotion advocates, like politicians, have to be fundamental optimists!