SASKATOON — Health care is only one element of what can make a significant difference in health outcomes, with social factors, such as education or affordable housing or a safe working environment, playing a much more significant role in determining whether we will be healthy or ill.
This has been understood for centuries and, in recent decades, has been empirically validated with study after study clearly demonstrating health inequalities between wealthy and disadvantaged populations.
Yet political conversations still tend to fall into familiar traps. If we talk about health we return by reflex to doctors and nurses, hospitals and pharmacies. And when we talk about politics — the field of endeavour with the greatest impact on what determines health outcomes — we too often insist the social factors that affect health, such as poverty or inequalities, are too complex or expensive to tackle.
We get stuck, in other words, and it appears there is no way out of the impasse.
To imagine a different approach, it’s helpful to start with a classic public health parable. Imagine you’re standing on the edge of a river. Suddenly a flailing, drowning child comes floating by. Without thinking, you dive in, grab the child, and swim to shore. Before you can recover another child comes floating by. You dive in and rescue her as well.
Then another child drifts into sight... and another... and another. You call for help, and people take turns fishing out child after child.Hopefully, before too long some wise person will ask: Who keeps chucking these kids in the river? And they’ll head upstream to find out.
Every time we have to clean up an environmental disaster, every time a young person winds up in jail, every time people have to take medicines to make up for the fact that they couldn’t afford good food, we’re suffering from the results of downstream thinking.
Thinking upstream means making smarter decisions — long-term decisions — about what kind of country we want. What better goal than creating the conditions for all people to enjoy true health — complete physical, mental, and social well-being? And what better measure of a country’s success than the health of its people?
First, we have to see beyond health care to what really makes us ill or well — income and its distribution, education, employment, social supports, housing, nutrition, and the wider environment — the social determinants of health. Examining our decisions through the lens of optimal health allows us to focus our efforts on what makes the biggest difference to our well-being.
This also allows us to stop seeing investment in people as a cost. When we take into account the economic and social benefits of a healthy, educated population, we see that by doing nothing to address the factors that make people sick, we ensure that more and more kids will come down the river, and that many of them will drown.
A new national, non-partisan organization launching this month seeks to bring forward a new way of talking about politics in Canada. Upstream is a movement to change the current conversation. It aims to make the mainstream look upstream, helping citizens to demand a healthy society, and to understand the best ways to get there.
Upstream seeks to propagate a new frame, one that focuses in on the decisions that will make the most impact on the quality of our lives. By gathering the best evidence available, academics and advocates will promote decisions made on the basis of practicality rather than ideology.
Using storytelling through multiple forms of media, Upstream will help to bridge the gap between knowledge and practice. By connecting individuals and partner organization through common language and goals, Upstream can help to create public demand for language and ideas consistent with the new frame, and can ultimately open up the space for action on the part of citizens and governments to build a truly healthy society.
The evidence is clear, addressing the social determinants of health is essential to improving our lives. Too often, however, the immediacy of acute care distracts decision-makers from upstream investment to prevent ill health. By seeking to prepare, rather than waiting to repair, we can make wiser decisions and enjoy better lives.
Ryan Meili is an expert advisor with EvidenceNetwork.ca and a Saskatoon-based family doctor. He is head of the Division of Social Accountability at the University of Saskatchewan’s College of Medicine.