A shared vision for public health: then and now.

Douglas, Rachel E. ; Best, Allan

The focus of this paper is the constancy of vision for public health across the first century of its development in Canada. The unique perspective of a family with five generations in Canadian public health* is used to explore guiding principles that have endured over the past 100 years. The analysis is anchored in the writings of the first Chief Officer of Health in Canada, Peter Henderson Bryce, and historical accounts of his work. This article examines ways in which a shared vision for public health stretches across the history of the Canadian Public Health Association. Drawing on public records, Bryce's writing, historical research, and current initiatives in public health (as experienced by Bryce's great-grandson and great-great-granddaughter), the paper will explore ways in which key principles play out then and now.

Three enduring principles are illustrated by the current public health context and Bryce's writings; they include: equity, action on the determinants of health, and use of evidence. The anchoring focus for Bryce's work and this reflection was the controversial 1907 Report on the Indian Schools of Manitoba and the North West Territories and his "crusading for the forgotten" in residential schools. (1)

Equity

Peter Bryce authored the first public health legislation in Canada, the 1884 Ontario Public Health Act of Ontario. From 1904 to 1921, Bryce was Chief Medical Officer (CMO) for the Departments of the Interior and Indian Affairs. Soon after his appointment as CMO, Bryce gained notoriety within the Department of Indian Affairs for his criticism of the sanitary and structural conditions of native industrial and boarding schools in western Canada. He advocated sweeping reforms for native education to ensure that native children received the same basic comforts as other children in Canadian public schools.

Believing firmly that the state was responsible for promoting the health and welfare of its people, Bryce insisted that the federal government address the conditions in residential schools. His tireless crusade on behalf of the native population demonstrated the extent to which native affairs were influenced by the broader social, political and economic agendas of the day.

Today, equity is an integral piece of many of the public health frameworks that are emerging across the country. One of these frameworks is the Core Public Health Functions initiative in British Columbia. (2) This initiative is explicitly grounded in public health values and includes an Equity Lens (3) that encourages health authorities to document inequalities, work with communities to change the conditions that contribute to inequalities and advocate for healthier public policies. Inequalities were also featured in the 2008 Chief Public Health Officer's report on the State of Public Health in Canada (4) and an argument for a balanced approach to public health, including both universal programs and those targeted at vulnerable populations, was endorsed.

Of course, framing the issues through an equity lens is only a first step in reducing inequalities. Then and now, it has proven an enormously difficult challenge, resistant to the coordinated multi-sectoral action essential for progress given the complexity of the problem and systems involved.

Action on the determinants of health

Bryce fostered the strong rapport with public health and urban reformers of the late nineteenth and early twentieth centuries. This rapport convinced him that government intervention was the key to the betterment of society. Yet, unlike most of his public health colleagues who worked through volunteer associations to effect change, Bryce sought to reform the system from within. As Chief Medical Officer, he endeavoured to push humanitarian concerns to the forefront of the government's agenda for the management of native schools, and challenged Canadians to reassess the laissez-faire philosophy governing social policy.

The determinants of health have continued to shape the field of public health, as demonstrated in the final report of the WHO Commission on the Social Determinants of Health. (5) Our growing understanding of how factors like poverty, housing and early childhood development influence health outcomes has formed the foundations of many of today's public health policies and programs. There is also a continuing recognition in public health that government health departments do not hold many of the levers that are most critical for addressing the determinants of health (6) (e.g., housing and food systems). As such, a continued focus on partnerships with other sectors echoes Bryce's early efforts to approach public health issues on multiple fronts.

Then and now, a missing piece in the puzzle is comprehensive, coordinated action plans to bridge from principles and evidence to collaborative action. "Solution maps" are starting to emerge (e.g., the Obesity System Map generated by the Foresight Programme of the UK Government Office for Science (7)), but most priority public health challenges still lack the integrated action plans necessary for success.

Use of evidence

In his first annual report for the Department of Indian Affairs, Bryce commented on the lack of statistics and poor record keeping by local medical officers. He announced that these officers would, under his supervision, submit detailed monthly medical reports so that the department could gain a "systematic knowledge of the health conditions" of the native people. Bryce insisted that the collection of vital statistics, long a practice of the Ontario Provincial Board of Health, was integral to the fight against communicable diseases on reserves across the country. Such information ensured, in his opinion, a solid foundation for native health policy and reforms. For 17 years, Bryce amassed grim statistics on the health conditions and mortality rate of the native population, documenting that native Canadians were almost 20 times more likely to die from tuberculosis than non-native. This figure was often much higher for prairie native children attending residential schools. In 1907, three years after his appointment as CMO, he released his controversial Report on the Indian Schools of Manitoba and the North West Territories, (8) revealing that 24% of all native residential school students had died of tuberculosis. In response, the government, by 1911, had not only revised the curricula and daily operations of its industrial and boarding schools, but for the first time had also established health standards for the management of these institutions. Strict admissions policies, an emphasis on preventive medicine and health education, and the gradual closure of all industrial schools were the legacies of those who joined Bryce in his crusade for the forgotten.

Use of evidence continues to represent a cornerstone of modern public health. There are ongoing efforts to increase collaboration at all levels with a view to refining our strategies for collecting consistent and meaningful data about the health of the Canadian population and using it to inform policy and practice. (9-11) Moreover, there is an increasing focus on collecting and sharing evidence about the impact of various policies and programs on health outcomes and inequities as demonstrated by the Canadian Best Practices Portal (12) and numerous other initiatives.

The challenge--then and now--is how best to position science as a tool for system change. Bryce introduced sound epidemiological methods to quantify the problem. Today, the challenge is how to conceptualize public health as a complex adaptive system, and use new system science methods for knowledge creation and analysis that are appropriate to this complexity. (13)

CONCLUSION

These core principles of equity, action on the determinants of health, and the use of evidence have retained their salience across the generations. However, many public health practitioners have, like Bryce, encountered barriers to putting them into policy and practice. Current thought indicates that these barriers may be partially attributable to how we frame our discussion of these principles with other sectors and with the Canadian public. At the 2009 Public Health Association of BC conference on Health Inequities, Lawrence Wallack discussed a need to better understand how our core public health values align with those of the public and use this understanding to frame our communications to the public. (14) By doing this, we can demonstrate the benefits of acting on these values in a way that resonates with what the public feels is worthy of investment. More than ever, in this time of financial constraint, coordinated efforts by public health practitioners across work settings will be required to assure Canadians that putting public health principles into action will result in a better quality of life for their families and their communities.

Key words: History of public health; equity; determinants of health; evidence

REFERENCES

(1.) Sproule-Jones M. Crusading for the forgotten: Dr. Peter Bryce, public health, and prairie native residential schools. Can Bull Med History 1996;13:199-224.

(2.) Ministry of Health Services. A Framework for Core Functions in Public Health. March 2005. Available at: http://www.health.gov.bc.ca/prevent/pdf/core_functions.pdf (Accessed April 14, 2010).

(3.) Population Health and Wellness, BC Ministry of Health. Core Public Health Functions for BC, Evidence Review: Equity Lens. July 2007. Available at: http://www.phabc.org/pdfcore/Equity_Lens-Evidence_Review.pdf (Accessed April 14, 2010).

(4.) Public Health Agency of Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada 2008: Addressing Health Inequalities. Available at: http://198.103.98.77/publicat/2008/cphorsphc-respcacsp/pdf/ CPHO-Report-e.pdf (Accessed April 14, 2010).

(5.) Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2008. Available at: http://www.who.int/ social_determinants/thecommission/finalreport/en/index.html (Accessed April 14, 2010).

(6.) Population Health Promotion Expert Group of the Pan-Canadian Public Health Network. Summary of the Senate Sub-Committee on Population Health--Final Report; A Healthy, Productive Canada: A Determinant of Health Approach. 2009. Available at: http://www.phn-rsp.ca/pubs/ssphfr-rfscssp/pdf/ssphfr-rfscssp-2009-10-eng.pdf (Accessed April 14, 2010).

(7.) Finegood DT, Merth TDN, Rutter H. Implications of the Foresight Obesity System Map for Solutions to Childhood Obesity. Obesity 2010;18(Suppl 1):S13 S16.

(8.) Bryce PH. Report on the Indian Schools of Manitoba and the North West Territories. Ottawa, ON: Government Printing Bureau, 1907.

(9.) Dubois N, Wilkerson T. Rapid Risk Factor Surveillance System: Strategic Plan for Action. 2005. Available at: http://www.rrfss.on.ca/resources/RRFSS%20 Strategic%20Plan%20Report%202005%20final,%20April%2005.pdf (Accessed April 14, 2010).

(10.) Pan-Canadian Public Health Network, Surveillance and Information Expert Group. Available at: http://www.phn-rsp.ca/Groups_e.html (Accessed April 14, 2010).

(11.) First Nations Centre. Health information, research and planning: An information resource for First Nations health planners. Ottawa, ON: National Aboriginal Health Organization, 2009. Available at: http://www.naho.ca/ firstnations/english/documents/HealthInformationResearchandPlanning.pdf (Accessed April 14, 2010).

(12.) Public Health Agency of Canada. Canadian Best Practices Portal: About Us. Available at: http://cbpp-pcpe.phac-aspc.gc.ca/about-eng.html# (Accessed April 14, 2010).

(13.) Best A, Holmes B. Systems thinking, knowledge and action: Towards better models and methods. Evidence and Policy2010;6(2):145-59.

(14.) Wallack L. Framing is more than a message. Presented at the Public Health Association of British Columbia Conference and Annual General Meeting "Action Towards Reducing Health Inequities". Vancouver, BC, November 2324, 2009. Available at: http://www.phabc.org/modules.php?name=Presentations& pa=showpage&pid=155&NSNST_Flood=yklsdntvfvhrijx (Accessed April 14, 2010).

Rachel E. Douglas, BA, [1,2] Allan Best, PhD [3-5]

* In addition to Peter Bryce, family members include: Albert E. Best, a physician who worked on population health in China; Stanley C. Best, who was the founding Director of Child and Maternal Health in Saskatchewan; Allan Best who was the founding Chair of Health Studies at the University of Waterloo and whose academic career focuses on health promotion and systems change; and Rachel Douglas who evaluates community-based population health programs with the Public Health Agency of Canada and is currently completing her Master of Public Health degree.

Author Affiliations

[1.] Public Health Capacity and Knowledge Management Division, BC & Yukon Region, Public Health Agency of Canada, Vancouver, BC

[2.] Department of Health Studies and Gerontology, University of Waterloo, Waterloo, ON

[3.] InSource, Vancouver, BC

[4.] Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC

[5.] School of Population and Public Health, University of British Columbia, Vancouver, BC

Correspondence: Dr. Allan Best, InSource, 6975 Marine Drive, West Vancouver, BC V7W 2T4, Tel: 778-279-6896; E-mail: allan.best@in-source.ca