The chief public health officer's report on health inequalities: what are the implications for public health practitioners and researchers?

Kirkpatrick, Sharon I. ; McIntyre, Lynn

In June 2008, Canada's first Chief Public Health Officer (CPHO), Dr. David Butler-Jones, released his first annual report on the State of Public Health in Canada. (1) The report represents a parliamentary requirement of the CPHO, a position created in the aftermath of the SARS crisis in response to the recommendations of the National Advisory Committee on SARS and Public Health. (2) However, rather than focus on the potential threat of pandemic infectious diseases such as avian influenza, Dr. Butler-Jones chose to use his first report to draw attention to health inequalities and inequities in Canada. We highlight some of the strengths and limitations of the report, and reflect on the opportunity that it presents for public health practitioners and researchers working towards the recognition and reduction of health inequalities in Canada.

The report begins by describing the legacy of public health in Canada, celebrating our successes including the reduction of vaccine-preventable diseases and achievements in tobacco control. These and the report's other historical success stories illustrate the importance of strong epidemiological evidence, a population perspective, the evaluation of innovative interventions, and the mobilization of intersectoral partners. In speaking to the leadership role that Canada has played in health promotion and in stimulating widespread recognition of the range of factors at the collective and individual levels that influence health, the report also makes clear that there are many challenges that we have yet to tackle in improving the health of the population.

Subsequent chapters provide a compelling and graphic presentation of our current population health status and the uneven distribution of health across the population. The epidemiological evidence presented demonstrates the presence of persistent and sizeable gaps in life expectancy, infant mortality, self-reported health, prevalence of chronic diseases, and other health indicators between higher- and lower-income groups, as well as the extraordinary disadvantage experienced by Canada's Aboriginal peoples. Further, while it is recognized that we have made progress in narrowing the gap between more and less well-off Canadians, for example in cardiovascular disease mortality, it is also noted that much of this progress occurred in the 1970s and 80s, with little improvement apparent in recent years. While the case for inequalities is made, less is made of the case for inequities, distinguished by the latter's conceptualization as health differences that are unjust rather than merely unfortunate. (3) The report also fails to adequately emphasize that poor health is not only a problem for the poor, but for everyone below the top echelon of the social ladder.

Rather than offering a strategic approach to addressing and reducing health inequalities, the CPHO report provides a long list of actions: social investments to ameliorate the effects of poverty; improved community capacity for the design and application of strategies to address determinants of health; improved inter- and multi-sectoral action and integrated, coherent policies; an improved infrastructure for building an understanding of the health of subgroups of the population, the interactions between determinants of health, and how to address health inequalities; and improved public health leadership at all levels. While each of these elements could form a critical part of an integrated and holistic strategy to address health inequalities and inequities, this is not a call to action; this is a call for activity. What is missing is a call for governments to act. In contrast, the World Health Organization (WHO) Commission on Social Determinants of Health's report "Closing the gap in a generation: Health equity through action on the social determinants of health", (3) released shortly after the CPHO report, made the imperative of government commitment the centerpiece of its call to reduce inequities in a generation. Almost as bold were the 2008 report of the Canadian Senate Subcommittee on Population Health (4) on the social determinants of health with its call for a whole-of-government approach and the 2008 policy options paper from the British Columbia Health Officers' Council which points to government engagement and multi-sectorality as essential factors in moving forward to reduce health inequities. (5) Similarly, reports from Quebec have urged decision-makers in all sectors of government to play a role in addressing health inequalities (6) and provide examples of how equity could be enhanced through an integration of the health and social services. (7) Further afield, the United Kingdom proposed a government-wide strategy in its Tackling Health Inequalities report (8) and the Swedish government's report on social protection and social inclusion is lauded as an exemplar of a social justice model of government action. (9)

The CPHO report's failure to emphasize the essential role of government action is reinforced by the examples used to illustrate "successful interventions that ... may serve to reduce Canada's health inequalities and improve quality of life for all Canadians" (p.1). In fact, the interventions highlighted tend to be community-based programs that are unable to address the structural determinants of health inequalities. For example, children's feeding programs are offered as a promising response to problems of food insecurity and it is noted that "the importance of these types of programs cannot be overstated" (p. 41), despite evidence challenging the presumption that these and other community-based programs have the capacity to address problems of food insecurity arising in the context of financial constraints (e.g., refs. 10,11). Similarly, the work of a non-profit organization is noted as a promising intervention with respect to problems of housing affordability and homelessness; yet, despite its merits, the work of this organization or others with a similar approach cannot be expected to compensate for the withdrawal of federal and provincial governments from social housing and other changes to the social welfare system over recent decades that have compounded the vulnerability of those at the lower end of the socio-economic gradient. (12)

The lack of recognition of the inadequacy of responses that do little to address the underlying structural drivers of health inequalities and the treatment of basic needs, including access to adequate food and housing, as isolated determinants of health are inconsistent with the population health approach. (13) Further, by profiling current community-based activities, some of which have emerged to fill a policy gap left by government retractions, the report does little to stimulate thinking about what broader, more integrated policies and strategies might look like. The reliance on solutions that "fall short of an upstream approach" (14) and a disregard for the primacy of structural determinants can only be interpreted as an indication of a lack of political will to truly acknowledge and act upon inequalities in Canada. A lack of political will is also suggested by the fact that the release of the CPHO's first report, a landmark publication of the highest-ranking public health worker in the country, was not accompanied by a press release and consequently received little, if any, media coverage.

Given constraints that may preclude the CPHO from going further in calling for government action, (15) where do we as public health practitioners and researchers go from here in our efforts to reduce health inequalities in Canada? One of the stated primary purposes of the CPHO report is to stimulate national dialogue and, despite its limitations, the report shines a light on major inequalities in this country, providing a foundation for discussion and action towards their reduction. Health practitioners and researchers must build upon the strong tradition of public health in Canada by seizing the opportunity provided by the CPHO report and other recent initiatives, including the work of the WHO Commission on the Social Determinants of Health, (3) to further our thinking on and action towards innovations that would meaningfully and structurally reduce health inequalities. This requires working together with the Public Health Agency of Canada and other stakeholders to create the political will and capacity needed to support a whole-of-government approach to address health inequalities in Canada. Imagine a CPHO report written within a generation that discusses the success story of reducing inequities in Canada!

Received: October 3, 2008

Accepted: January 20, 2009

REFERENCES

(1.) Public Health Agency of Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada 2008. Cat.: HP2-10/2008E. Ottawa, ON: Minister of Health, 2008.

(2.) National Advisory Committee on SARS and Public Health. Learning from SARS - Renewal of Public Health in Canada. Cat. H21-220/2003E. Ottawa: Health Canada, 2003.

(3.) Commission on the Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Geneva, Switzerland: World Health Organization, 2008.

(4.) Subcommittee on Population Health. Population Health Policy: Issues and Options. Standing Senate Committee on Social Affairs, Science and Technology, 2008.

(5.) Health Officers' Council of BC. Health Inequities in British Columbia: Discussion Paper. Victoria, BC: Public Health Association of British Columbia, 2008.

(6.) Direction de la sante publique. 1998 Annual Report on the Health of the Population: Social Inequalities in Health. Montreal, QC: Regie regionale de la sante et des services sociaux de Montreal-Centre, 1998.

(7.) La Direction des communications du ministere de la Sante et des Services sociaux. Guaranteering Access: Meeting the challenges of equity, efficiency and quality - Consultation document. Quebec, QC: Gouvernement du Quebec, 2006.

(8.) Department of Health. Tackling Health Inequalities: A Programme for Action. London, UK: The Stationery Office, 2003.

(9.) Swedish Ministry of Health and Social Affairs. Sweden's Strategy Report for Social Protection and Social Inclusion 2006-2008. Stockholm, Sweden: Government Offices of Sweden, 2007.

(10.) Raine K, McIntyre L, Dayle JB. The failure of charitable school- and community-based nutrition programmes to feed hungry children. Critical Public Health 2003;13(2):155-69.

(11.) Kirkpatrick SI, Tarasuk V. Food insecurity and participation in community food programs among low-income Toronto families. Can J Public Health In press.

(12.) Subcommittee on Cities. Poverty, Housing and Homelessness: Issues and Options. Standing Senate Committee on Social Affairs, Science and Technology, 2008.

(13.) Conceptual Framework Subgroup on Population Health for the Working Group on Population Health Strategy. Towards a Common Understanding: Clarifying the Core Concepts of Population Health. Cat. No. H39-391/1996E. Ottawa: Health Canada, 2008.

(14.) Canadian Public Health Association. The Chief Public Health Officer's First Annual Report is Released. Ottawa: CPHA, 2008.

(15.) Wilson K, Keelan J. Learning from Listeria: The autonomy of the Public Health Agency of Canada. CMAJ 2008;179(9):877-79.

Sharon I. Kirkpatrick, PhD, RD, Lynn McIntyre, MD, MHSc, FRCPC

Authors' Affiliation

Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB

Correspondence and reprint requests: Sharon Kirkpatrick, Department of Community Health Sciences, Faculty of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, E-mail: sharon.kirkpatrick@ucalgary.ca

Acknowledgements: Sharon Kirkpatrick receives financial support from an Alberta Heritage Foundation for Medical Research Post-Doctoral Fellowship. Lynn McIntyre receives financial support as CIHR Chair in Gender and Health.