This is Public Health: A Canadian History.

Hancock, Trevor

This is Public Health: A Canadian History

Canadian Public Health Association; 2010; http://cpha100.ca/history/history-e-book

First, what a grand thing it is that the Canadian Public Health Association is 100 years old, and how important it is to be reminded by them of the history of public health in Canada. I know it is a stale aphorism, but those who do not know their history are doomed to repeat it, and history is often an important guide to--or forewarning of--the future. As a health futurist, I firmly believe that all good futurists are also good historians, and there are important lessons for us here. So, kudos to the authors especially, and the many others who contributed to this book!

Before I get to the future, a bit about the book itself. It's an interactive e-book, which, as the website says, is "engaging, richly illustrated, suitable for a broad audience and available as a free download" (at http://cpha100.ca/history/history-e-book)--but the full text is only available in English for now, with plans underway for a French version. The interactive and downloadable nature makes it easy to recommend as a text for students. I have always believed that the history and philosophy of health and medicine should be a required introductory course for ALL health sciences/studies students, as it might engender some sense of proportion about clinical medicine's relative unimportance to population health, as Thomas McKeown so powerfully pointed out in "The Role of Medicine" back in 1979.

The book begins with an introductory section on health in the first few centuries of European settlement and a chapter summarizing the health issues from Confederation in 1867 to 1910, when CPHA was founded. From there, it tells the story of public health decade by decade until 1986, where it stops with the Ottawa Charter for Health Promotion, although there is an epilogue by John Last which summarizes key issues and events since then and looks to the future. (In the interest of full disclosure, I had some input to this section.)

One of the strengths of the book is that it is richly endowed with short profiles of important public health figures of the day, which gives us some insight into the challenges they faced and the dedication and passion--and long-term commitment--they brought to their work; it is inspiring stuff. It is thus a very personal history, although there is at the same time a lot of material about public health organizations, both governmental and non-governmental, and the challenges they faced. It is also, incidentally, a useful source of dates for upcoming centennials; the first public health nurses hired in Toronto in 1911, in Manitoba in 1916, in BC in 1917, the first full-time county health unit (Saanich, BC) in 1921 and so on--go find your favourite one.

Another of the book's strengths is the continual reference, in every decade of that history, to the appalling health problems faced by--and created for--Aboriginal people. The Introduction reminds us that European expansion across North America brought with it a host of diseases that "destroyed many indigenous lives". This process continued well into the 20th century; smallpox brought from California during the Gold Rush in the 1860s devastated BC's First Nations, as did the 'Spanish' 'flu in 1918/19, wiping out entire settlements among the Haida. In the 1930s, the combination of poor living conditions and neglect meant that the mortality rate for TB among the Aboriginal people of Saskatchewan was 20 times the national rate; by the 1940s, death rates from TB among Aboriginal people were "among the highest ever reported in a human population"--at a time when the national mortality rate for TB was rapidly declining. By 1986, when the story stops, it was still the case and remains so today--that the relatively poor health of Aboriginal people is a stain upon the nation.

In a review this short of a book this large, it is difficult to do full justice to all that can be gleaned. But here are a couple of other points I noted which have application today:

* The leaders in public health in the 19th and early 20th century arguably the high point of the history of public health--brilliantly combined solid research and the application of science with education, strong communication skills and a commitment, indeed a passion, for reform and fearless advocacy. We have seen that same combination of the development and use of good research with passionate advocacy be effective in the fight against tobacco, and we need it more than ever today if we are to fully address the broad determinants of health and reduce the unacceptable inequalities in health that still exist.

* Our current concerns with the low status of public health are nothing new. In the late 1940s, shortages of public health professionals were linked to the low pay of public health physicians compared to GPs or specialists, and to "a legacy of undervaluing public health work"; in 1959, an American Public Health Dean lamented in the Canadian Journal of Public Health (CJPH) that public health seemed to be 'losing ground' and 'falling into disrepute', while in 1966 John Hastings strongly criticized the Hall Report that laid the groundwork for Medicare for its lack of attention to preventive medicine, health promotion and community health programs. But he also "added that the field had to shoulder much of the responsibility for its poor showing" because of its timidity, its failure to live up to its predecessors, who were "crusading, dedicated, militant people".

I think that is still the case today, in spite of the best efforts of many of our leaders, whose commitment and passion are clear. But we have not made the case for public health forcefully enough. When I lecture to medical students, I tell them that public health is not only more important to the health of the population than clinical medicine, but it is in fact the most complex, challenging, sophisticated and difficult of all the specialties. This is because we not only have to know biology and medicine, but anthropology, sociology and other social sciences as well as engineering, urban planning, ecology and other natural sciences, in addition to epidemiology and health administration! But we don't act as if that were the case. Given the depth and breadth of population and public health, we should invest at least as much in research in these areas as we do in basic and applied clinical research, but our research budgets tell us that we are a long way from realizing that objective.

We are, sadly, still a long way from realizing the promise laid out in the CJPH in 1948 by Paul Martin Sr., then Minister of National Health and Welfare, that the new federal philosophy was that "social well-being is an essential and basic consideration of healthful living," and that "Canada is among those countries where public health is shifting its emphasis and broadening its outlook to embrace all that affects human life."

That, of course, is a pretty good definition of population health and human-centred development, and it rather neatly encapsulates the challenge we face as CPHA enters its second century, as do the challenges John Last lays out in the Epilogue:

* A focus on maternal health, infant and early child development as part of a long-term investment in human development;

* A focus on health and the built environment;

* A focus on health equity... urgent attention must be given to correcting the iniquitous status of First Nations Canadians;

* A focus on the ultimate determinant of human health, ecosystem health;

* A focus on appropriate application of scientific discoveries and technical developments.

It is, I suspect, an agenda that our 'crusading, dedicated, militant' predecessors would have embraced.

Trevor Hancock, Public Health Consultant, BC Ministry of Healthy Living and Sport, Chair, Core Public Health Functions Steering Committee and Co-chair, Population Health Promotion Expert Group, Public Health Network of Canada

Reprinted with permission of the author. This article first appeared in CIHR-IPPH POP News http://www.cihr-irsc.gc.ca/e/42730.html#2.