Allies and Advocates for Upstream Action

By Dr. Marjorie MacDonald

In July 2013, the Canadian Medical Association (CMA) released its Town Hall Report called “Health Care in Canada – What Makes us Sick?” [1] Over the past year, the CMA has been hosting a series of town hall meetings in various parts of Canada to gather input on Canadians’ views on the social determinants of health. This followed an initial phase of a National Dialogue on Health Care Transformation in which CMA heard that the health care system was not the most important determinant of health and that social and environmental factors were more important. That understanding is certainly not news –  it goes back many years – but perhaps was most memorably reflected in an internationally influential federal white paper authored in 1974 by then Minister of National Health and Welfare, Marc Lalonde [2]. This was followed by the Ottawa Charter for Health Promotion [3] in 1984 that elaborated on the determinants of health (peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, equity). Since then, the public health community in particular has been grappling with how to address the determinants of health and entire libraries could be filled with what has been written about this. Thus, it is not the news that the Town Hall Report, and the media response to it, seems to suggest.

What Makes Us Sick?

CMA Town Hall Report: ‘What Makes Us Sick?”

Perhaps what is news is that the CMA Town Hall report suggests that the Canadian public may now be aware of the importance of the social determinants of health. If that is true, it is definitely a good thing, given public health’s longstanding efforts to inform the public about and to advocate for upstream actions to address the social determinants of health.  I wonder, however, about the extent to which the town hall meetings drew from the ‘usual suspects’ – i.e., those who were already in the know about health equity and the social determinants of health. I could be wrong of course, but a recent British Columbia Medical Association (BCMA) survey [4] found that the public of BC is most concerned with issues of wait times, doctor shortages, the aging population, and hospital overcrowding and not so much about prevention, let alone the determinants of health. The poll also suggests that British Columbians are supportive of moves to make people more responsible for their own health (blaming the victim?), a move counter to an understanding about how living conditions and social disadvantage (i.e., the social determinants of health) can cause inequities in health status. Either the BC public is out of step with the rest of the country, or the results of CMA’s consultations may not be as representative of Canadians’ views as the report suggests. I think we still have our work cut out for us!

The Town Hall Report also states that “the medical profession has the authority and voice to take leadership on these issues” [1, p. 1].  My initial response to this was perhaps a bit of ‘sour grapes’.  How could this group who has historically had such a limited focus on the social determinants now claim a leadership role, particularly when public health has been providing strong leadership for years? Medical standards of practice and the CMA code of ethics [5] do not even reference the determinants of health let alone provide guidance to physicians about how they might enact their “ethical duty to their patients to work toward a society in which everyone has the opportunity to live a healthy life” [1, p. 3].

The Canadian Nurses Association (CNA), by contrast, explicitly includes a focus on the social determinants of health in their Code of Ethics [6] and the Community Health Nurses of Canada are also explicit about the role of nurses in addressing the determinants of health in 6 of their 8 competency domains [7]. The CNA website has 10 full pages of links to publications, policy statements, and advocacy papers dealing with the social determinants of health and providing guidance to nurses. Our own BC Health Officers Council has been a strong advocate for addressing the determinants of health as reflected in several influential documents, including a Discussion Paper on Health Inequities in British Columbia [8]. Other public health disciplines have made similar contributions.

However, we need to take a step back.  I fundamentally agree with and support most of the recommendations in the CMA Report (although their recommendation for a comprehensive drug plan is not really an upstream action, nor does it address the determinants of health). Maybe CMA is a  more recent advocate to this endeavor. But, they are taking an important position that is not being addressed by many provincial medical associations, so CMA should be applauded for this.  We can never have too many influential people advocating for and engaging in upstream actions on the determinants of health. And our physician colleagues do have authority and voice. We need them in the fold.  Welcome CMA, there is a place for you at the table. We are here to support you, to applaud your efforts, and to share our own learning along the way.

– Marjorie MacDonald is the President of Public Health Association of BC

  1. Canadian Medical Association. (2013). Health Care in Canada – What Makes us Sick?
  2. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Information Canada.
  3. World Health Organization. (1984). Ottawa charter for health promotion.
  4. British Columbia Medical Association. (2012). Charting the course: Designing British Columbia’s health care system for the next 25 years.  BCMA Submission to the Select Standing committee on Health (January 2012).
  5. Canadian Medical Association. (2004, reviewed 2012). Code of ethics.
  6. Canadian Nurses Association. (2008). Code of ethics.
  7. Community Health Nurses of Canada. Standards of practice and professional practice model.
  8. Health Officers Council of BC. (2008). Health inequities in British Columbia: Discussion Paper.