摘要：An internationally influential model of population health was developed in Canada in the 1990s, shifting the research agenda beyond health care to the social and economic determinants of health. While agreeing that health has important social determinants, the authors believe that this model has serious shortcomings; they critique the model by focusing on its hidden assumptions. Assumptions about how knowledge is produced and an implicit interest group perspective exclude the sociopolitical and class contexts that shape interest group power and citizen health. Overly rationalist assumptions about change understate the role of agency. The authors review the policy and practice implications of the Canadian population health model and point to alternative ways of viewing the determinants of health. IN 1991, CANADIAN HEALTH economists Robert Evans and Greg Stoddart, of the Canadian Institute for Advanced Research (CIAR), published a highly influential article 1 in which they developed a model for analyzing the determinants of the health of populations. In a nutshell, their model (outlined in collaboration with other members of CIAR, a think tank funded from corporate and public sources) reflected the conviction that it is the social environment, of which health care systems are a relatively small part, that determines health. Evans and Stoddart’s framework provided a template, they suggested, that could incorporate evidence regarding the health effects of the social environment. Further publications, products of CIAR’s Population Health Program, quickly followed 2, 3 as the emerging field of population health took shape. Similar reports were published in other countries 4 as the population health perspective gained momentum. Members of the Population Health Program became key contributors to federal and provincial government studies of health and health care in Canada, and they are now powerful players in new institutions, such as the Canadian Institutes for Health Research, that fund research on the determinants of health. The CIAR model became internationally influential partly because of Canada’s prominent role in the health promotion movement. The CIAR model of population health has helped to expand the health research agenda beyond health care as the producer of health. In that respect, it revives a public health policy tradition reaching back at least to the 19th century. It has highlighted the relationship between economies, societies, and health, and it has led to a focus on the health of children. In what follows, however, we provide a critical reading of the population health model emanating from CIAR. Our argument is that the framework, as described in various publications, 1– 3 is flawed because of assumptions in its perspective that limit analyses of the determinants of health at the macrolevel; because it excludes, at the microlevel, the local contexts in which the health of real people is shaped; and because it fails to adequately conceptualize possibilities for change. We conclude with suggestions for responding to these difficulties.
