A vision for the role of governments in supporting the public's health: Learning from the past and expanding our imaginations for the future

Abstract

Governments in Canada and elsewhere play a very significant role in shaping the health of populations, but the main ways in which they do so are largely hidden because they lie outside of the health sector and are thus under-leveraged. Neoliberal economic and social policy has eroded upstream determinants of health, with profound consequences for health equity. The current polycrisis—a predictable outcome of neoliberalism—provides an opportunity to re-imagine a role for governments in supporting the public’s health. Anchored in a broad version of public health, I consider three levels where we, as a community of health professionals, could start to envision such a version of government, focusing primarily on federal government: (1) public spending; (2) overall orientation of government vis-à-vis the well-being of the population; and (3) the broader political economic paradigm and its dynamics of power. Collectively, these offer opportunity to learn from our past while expanding our imaginations for the future. Such a vision will require the support, and the humility, of healthcare leaders.

Introduction

On the surface, it may seem obvious that governments in Canada and elsewhere play a large role in shaping the health of the population. Examples that might readily come to mind include federal legislation and transfer payments to support Canada’s healthcare systems, or provincial and municipal public health policies that have contributed significantly to reducing population-level morbidity and mortality in domains like tobacco control and prevention of infectious diseases.^1,2

These examples, while significant, constitute only a small part of how governments support the public’s health. It is well-established that the main factors shaping health go well beyond the health sector to include the conditions in which we are born, grow, live, work, and age, including the quality and integrity of our natural environments—the social and ecological determinants of health.^3,4 Crucially, these determinants are not distributed equally; this is “in no sense natural but [is] rather the result of a toxic combination of poor social policies and programs, unfair economic arrangements, and bad politics,” ³ and it results in health inequities—differences in health that are systemic, avoidable, and unfair. ⁵

More concretely, social and economic policy under neoliberal capitalism—the dominant global political economic paradigm since the early 1980s, which privileges measures of progress rooted in economic models of infinite growth and productivity rather than human and planetary well-being ⁶ —has harmful health effects. These neoliberal epidemics ⁷ intersect with racism, sexism, ableism, and other forms of systemic discrimination to create highly unequal and avoidable health damage. One example is policies of austerity, which have underpinned government program cuts in areas like social assistance, housing, and education. ⁸ Economic policy and deregulation under neoliberalism have transformed labour markets, leading to widespread precarious employment (employment characterized by job insecurity, income instability, schedule uncertainty, low wages, limited workplace rights and social protections, and powerlessness to exercise workplace rights). ⁹ Income, housing, education, and working conditions are all well-established social determinants of health with well understood pathways to sickness. ¹⁰ Under the neoliberal regime, Canada has slipped in Organisation for Economic Co-operation and Development (OECD) infant mortality ranking—considered the most sensitive measure of structural supports for health and well-being—from 10^th of 24 countries in 1980, to 26^th of 34 countries in 2011, to 30^th of 38 countries in 2021. ¹¹ Moreover, income inequality in Canada under neoliberalism has widened to such an extent that it is now associated with reduced life expectancy at the population level. ¹²

A vision of government that supports the public’s health must therefore centre this health damaging context and orient policy accordingly. Such an orientation, which is consistent with a broad version of public health, presents important opportunities and challenges for health communities including healthcare leaders.

Public health vs. the public’s health, past and present

Public health has long been defined as something along the lines of, the art and science of preventing disease and promoting health through organized efforts of society.^13,14 This definition conveys some core features which theoretically distinguish public health from other aspects of the formal health sector such as clinical medicine, and which are very important to a vision of government that supports the health of the public. These include a population-level lens and an upstream focus on why people get sick in the first place. These in turn demand an intersectoral orientation that recognizes the significant role of government ministries other than health in supporting population well-being and health equity.

This broad version of public health is, to some extent, borne out historically, thus providing opportunity to build on our past. It has become lore in public health and related higher education programs to celebrate mid-19^th century figures like John Snow, who famously identified the Broad Street water pump as the cause of cholera in Victorian London; Friedrich Engels, who established that living and working conditions in urbanized Manchester, United Kingdom, were the major determinants of health for working people; and Rudolf Virchow who, in an investigation of a typhus outbreak in what is now Poland, argued that the causes and solutions lay in radical political, economic, and social conditions and reforms to transform living conditions; recommendations for which he was famously fired.^15,16 In all cases, there is a clear focus on social conditions affecting the health of populations.

In the Canadian context, there are likewise historical hints of a broad version of public health. The province of Alberta is illustrative. ² From its beginnings as a province in the early 20^th century until around the 1970s, public health activities in Alberta were governed and administered locally with strong links to municipal governments. This arrangement permitted proximity to the public and the conditions of peoples’ lives—that is, the social and environmental conditions that shape health. At the provincial level, early Alberta government discourse about public health—as gleaned through throne speeches—signalled attention to the goal of keeping people healthy in the first place through frequent reference to primary prevention and health protection activities that were often universal (population-wide) in scope.

Presently, however, a broad version of public health does not really exist. In mainstream public and political discourse, public health is poorly understood; it is frequently, and incorrectly, conflated with publicly funded medical care, or it is reduced to individual lifestyle behaviours. ¹⁷ Focusing on the American context, Yong ¹⁸ discusses public health’s downfall from its stronger and more ambitious past characterized by a commitment to “a simple yet radical notion: that some people were more susceptible to disease because of social problems,” towards today’s more reductive orientation embodied in downstream services and decontextualized epidemiology. ¹⁹ In the Alberta context, the broad version evidently started to dwindle in the late 1950s, when the population-level, prevention-oriented discourse began to be displaced by a focus on organized healthcare and its downstream orientation to diagnosis, treatment, and management of sickness among individuals; ² this occurred to such an extent that public health is now indistinguishable from healthcare in some settings. ²⁰

The result of these historical shifts is that the chasm between public health, as a set of formal duties, programs, and services carried out by governments and healthcare systems, and the public’s health, or the broad range of factors that shape the health of populations, ²¹ is arguably at its widest ever. This provides an important opportunity to ask, What would a broad version of public health look like, that meets the current moment of polycrisis—the intersecting and synergistic economic, political, and environmental crises that are likely to amplify and deepen health inequities ²² —and the corresponding imperative of centring an upstream orientation that extends far beyond the health sector? And, what are the implications for healthcare leaders?

A vision for the role of governments in supporting the public’s health: Learning from the past and expanding our imaginations for the future

To begin to envision a role for governments in supporting the public’s health, one can consider different levels, ranging from specific to broad. Below I consider levels of (1) policy including public spending; (2) the overall orientation of government vis-à-vis the well-being of the population; and (3) the broader political economy which shapes the legitimacy and authority of government in acting in the public’s interest. Each has historical precedent in Canada and/or existing platforms for advocacy and activism.

Increase public spending on social determinants of health

A role for governments in supporting the public’s health would, first, require far greater emphasis on social determinants of health. One way to assess emphasis is public spending. Currently, in Canada, the amount of federal and provincial government spending on medical care (healthcare systems) is immense and increasing, both in absolute terms and as a percent of all spending.^23,24 Provincial government spending on medical care exceeds, for example, by a four-fold margin in 2011, ²³ spending in social sectors, which are responsible for reducing poverty, improving the affordability of basic needs such as housing and childcare, and so on: the social determinants of health. This is despite that social spending is more important than medical spending for population health outcomes; Dutton et al., ²³ for example, showed that a one cent increase in social spending per dollar spent in medical care in Canadian provinces, 1981-2011, was associated with a statistically significant decrease in potentially avoidable mortality and increase in life expectancy.

Importantly, this contemporary spending pattern has not always been the case: the ratio of social to medical spending—a proxy for relative investment in social determinants of health—has worsened over time in Canada. While the ratio is currently (pre-COVID, 2019) well below one in nearly every province (reflecting that medical spending exceeds social spending as noted above), in the 1970s it was the opposite, meaning that for every $1 spent on medical care, well over $1 was spent on social determinants of health. ²⁴ Public spending in Canada therefore was previously far more aligned with social determinants of health, which offers an important historical precedent to do so again.

Advocating for social determinants-aligned public spending, and for monitoring and public reporting of the social-to-medical spending ratio to support such advocacy, offers a specific and important action around which health communities, including healthcare leaders, could mobilize, towards a version of government that better supports the public’s health.^24,25 Moreover, this can easily be extended to ecological determinants-aligned spending, through such initiatives as climate-aligned finance. ²⁶

Place spending in context: Reclaim an active role of government in keeping people well

While reorienting public spending towards upstream determinants of health is a good place to start, one must recognize that spending does not exist in a vacuum—it is shaped by, and indeed is the embodiment of, governments’ values and commitments, which likewise shift over time.

Greater spending on upstream determinants of health noted above occurred in the context of Canada’s Keynesian economics period (approx. 1946-1981), which was characterized by a commitment to the view that sharing the benefits of economic growth was an essential function of government. ²⁷ That commitment was embodied in the federal tax/transfer system (how the government raises and redistributes revenue), which at that time ensured that the distribution of income—an important social determinant of health^12,28 remained relatively equal. Also reflecting an orientation to providing the conditions for everyone to be well, many of Canada’s most important social programs—including those related to pensions, unemployment, healthcare, and housing—were created in this context, leading to Canada’s characterization as a welfare state. ²⁹

As Osberg ³⁰ points out, it is no coincidence that the architects of this welfare orientation in government had lived through the Great Depression of the 1930s and knew first-hand the serious consequences of destitution and mass unemployment; they designed policy accordingly. Although Canada’s welfare state has been fairly criticized,^31,32 it still provides an example from our history where government alignment with the goal of keeping people well was far stronger than it is now. Like the Great Depression, perhaps the current polycrisis can provide the impetus needed to reclaim active government as a force for good. ³³

Important opportunities exist for advocacy and activism in this space; one example is the Canadian Centre for Policy Alternatives’ Alternative Federal Budget, which is a participatory initiative that demonstrates tangibly what federal policy and budgets would look like if they were based on an orientation that put the interests of the public (the public’s health) ahead of the interests of an elite few. ³⁴

Engage meaningfully with political economy to envision alternatives

The orientation of Canadian government and its embodiment in public policy during the Keynesian era was eroded and undermined under neoliberal capitalism, as discussed above. The supremacy of business brought on by economic globalization fundamentally shifted the relationships among class structure, economies, and human well-being, and it provided the ideological underpinning for economic and social policy that exacerbated inequality and undermined the public institutions (the welfare state) that previously mitigated poverty and inequality and their impacts on health and well-being^27,35—that is, social determinants of health. Economic and social policies under neoliberalism, such as austerity, privatization, and deregulation, are underpinned by an ethos of individual responsibility (including for health); indeed, Himelfarb ³⁶ describes how neoliberalism in Canada entailed deliberate efforts to reduce peoples’ expectations of governments. Because, as discussed above, the social and ecological consequences of neoliberal policy are toxic to health equity, any discussion about a role of governments in supporting the public’s health must engage with political economy.

Importantly, the consequences of neoliberal capitalism, including for health, have prompted vigorous discussion and mobilization around alternative paradigms, thus providing a way to engage. In Canada and elsewhere, alternatives have been framed as well-being economies, briefly, economic systems that serve all people and the planet rather than the other way around. ³⁷ A well-being economy re-imagines the purpose of society to one that enshrines quality of life and the sustainability of the planet over material production and consumption. It thus flips the logic of capitalism—exploitation of people and planet for profit—on its head. A well-being economy provides a frame for governments in supporting the public’s health by addressing root causes of health inequities. Moreover, it is not only an abstract idea; there are important examples of well-being economic thinking emerging at various levels ranging from international to national to sub-national to hyper-local,^38-40 including in Canada.^41,42

The well-being economy idea draws from diverse intellectual and political traditions including Marxian, feminist, and Indigenous theories and paradigms. ⁴³ This lineage means that the movement is critical in its orientation: it is concerned with uncovering how particular social structures, in political and historical contexts, create and perpetuate conditions that threaten health; and challenging those structures. ¹⁶ The critical lineage speaks to the well-being economy’s transformative potential, versus fiddling at the margins. However, herein also lies the crux: because a well-being economy offers a radical vision for governments to support the health of the public, its realization hinges on illuminating and changing dominant ways of thinking and acting, and on meaningful efforts to redistribute power.

What does this mean for healthcare leaders?

This discussion may seem removed from the usual focus of those working in healthcare leadership and management. But that is the point: if we are serious about envisioning a role for governments in supporting the health of the public it will require thinking very differently about health—in public, private, and political domains, and across sectors. Efforts to think differently about health must include, and arguably start with, leaders in healthcare, whose support will be necessary to advance such a vision.

What would this entail for healthcare leaders? I offer three suggestions. The first is around precision of language. Popular and political discourse about health is dominated by healthcare, which serves to silence or sideline other ways of thinking about health including the upstream, intersectoral frames discussed above. Healthcare leaders could contribute importantly to the necessary narrative shift by not using “health” as shorthand for “healthcare” (this occurs constantly in government), and by not conflating “public health” and “healthcare,” which serves to obscure their important differences.

Second, healthcare leaders could be more open to engaging with critically oriented scholars. Such engagement, which is key to advancing the visions outlined above, often (but not always) plays out in ways that are disrespectful or dismissive (“they’re not really part of health/public health”). Such engagement therefore requires a foundation of openness and respect. ⁴⁴

The levels outlined above represent ways to learn from our past and expand our imaginations for a future version of government that supports the public’s health. They are significant because they involve a redistribution of power. They thus require, as a third suggestion, healthcare leaders to reflect on their own power and that of their field, and to come to terms with what a redistribution of power would mean. It could mean, for example, reductions in public funding to healthcare sectors, to support increased funding to other government activities that shape who gets sick in the first place and why. It could also mean a reduction in personal and professional prestige. Currently, the healthcare sector and its professionals including in leadership have immense cultural and financial power, which unfortunately is often (but not always) coupled with limited humility or willingness to reflect on that power. Are healthcare leaders ready for this?