1 Much of what we know about the health of the original peoples in Canada comes from their oral histories. These histories reveal diverse and complex societies with close-knit integrated communities made up of people who were, by and large, strong and healthy. While their well-being varied depending on the particular combination of physical, environmental, and social factors that they found themselves in,1 the influences contributing to their overall good health have been well described. These include access to local, safe, and nutritious foods; a sustainable and close relationship with the environment;2 and cultural and spiritual supports that included traditional medicine and healing practices.3 There is no doubt that the loss of these health-determining factors as a result of the arrival of outsiders had a major influence on the health of the population at the time. Although many of the newcomers were well- meaning, driven by evangelical or benevolent intent, ultimately the relentless pursuit of trade, wealth, and territory had a cumulative impact from which the original people of this country have still not recovered. If the new Liberal government wants to make a difference in improving the health of the present-day population as a whole, it should, in addition to specifically addressing First Nations’ health needs, look carefully at the lessons that can be learned from those past mistakes.

2 Health is largely a product of the complex interaction between people and their social and environmental influences. The choices made now determine not just the health of those living but those yet to be born. Failing to recognize that government policies, legislation, and values are critical in promoting, protecting, or, conversely, harming the health of the people now and in the future would be (to extend the African proverb) to continue to fall without preventing the slip. Making the changes needed will require a re-evaluation of what health truly is, the commitment to making the hard decisions, and the possession of strong political will. Does this new government have the courage to exercise the leadership we need? The people of New Brunswick expect so—they expect that government will make the best decisions on their behalf. Beyond that, the government has a moral imperative to take the steps necessary to aim for optimal health for us all.

3 Health, as defined by the World Health Organization, is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Although there can be variants to the definitions used, looking at “health” in a positive way is now the norm among most forward-thinking health-care professionals. Ironically, though, the system of health-care services that we have built up around us in the last half century has increasingly trapped us into a seemingly insatiable demand for improved diagnostics, therapeutic agents, and other interventions focused almost exclusively on people after they have become sick or think they are sick. Most of us want services to be there to alleviate suffering should we or a family member be afflicted, but our society’s negative and narrow view of what it means to be healthy has meant that very little consideration has been given to, and therefore very little funding actually spent on, achieving better health overall.

4 The main objective of a national or provincial health system should be to improve the health of the population. While it might be more comfortable to think that such an aim can be realized by providing more beds, more technology, and more drugs, eventually we as a society will need to accept that these measures yield diminishing returns. Spending increasing amounts of money on a subset of the population (the ill) will never make us healthier as a whole. Rather, it needs to be recognized that the first wealth is health. If we want to be successful, we need to put the well-being of people first. Although the argument is often made that if we make more money we will have more money to spend on health— and thus we will be healthier—I believe this is fallacious. Rather, the sole pursuit of economic interests can be counterproductive to improving people’s health. The pursuit of wealth can be advantageous, of course, but it has to be done in a way that considers primarily the well-being of people and the environment, which are one and the same thing. This new government needs to understand that quality of life throughout the lifespan contributes more to our overall health than the sole objective of lengthening duration—and that if the success of government is solely measured by GDP, then population health will always suffer.

5 Healthy people are more productive and contribute to a stronger, safer economy, but the relationship between health and wealth is not straightforward. Inequity in society is often considered a more powerful determinant of health than population income. Differences in health across the population are due to naturally occurring variations in genetics and constitution between individuals; however, social gradients are well understood to have strong influences as well. By and large, the poorer people are, the worse their health is. We see this in many diseases such as heart disease, diabetes, cancer, self-perceived health, and mental health.4 Poverty can be related to both material deprivation (income, employment, education, etc.) and social deprivation (social isolation, marital status, etc.)—and having both has a cumulative effect.5 Conversely, having a higher socioeconomic status also means that one is less likely to die or be sick from many diseases. When the causes of ill health result from unfair and unjust societal conditions and practices, they are known as health inequities.6 Those countries that have a close gap between rich and poor (less health inequity) have better health outcomes.7 It has also been shown that differences in environmental factors can mitigate the impact of lower socioeconomic status.8 This suggests that income itself may not be so much the cause of poor health as the social and environmental conditions that result from being poor.9 It is vital therefore that the new government adopts a health-equity approach to assess and mitigate health impacts. Such an approach will allow policies and decisions10 to be made in a way that actually can improve the overall health of the population rather than diminish it.

6 The diseases the people of New Brunswick have faced over the past hundred years are not significantly different than what others have faced in the rest of Canada, the United States, and Europe. Although it had been known for thousands of years that environment affected health, and that clean air and water were important, the evolution of “germ theory” in the late nineteenth and early twentieth century led to major improvements in understanding the causes and transmission of disease.11 The increasing scientific knowledge about microorganisms and how to reduce exposure, increase host resistance, and treat infections has been the most fundamental change in our ability to prevent disease and improve health. The development of vaccinations; legislation to create more sanitary environments; the ability to treat venereal diseases, tuberculosis, and pneumonia; and improved nutrition have all contributed to our success in reducing morbidity and mortality from communicable disease. Now these are no longer significant causes of sickness and premature deaths, at least in the developed world. Although we cannot become complacent about communicable diseases and the need to continue vigilance on that front, this epidemiological transition means that just as microorganisms were painstakingly identified and rooted out as causes of poor health, we also need to switch our attention to the causes of the primary diseases of today: cancers, diseases of the heart and lungs, and intentional and unintentional injuries. Sowing the seeds for better health—by addressing the causes of disease, and not just treating the results—will allow us to reap the rewards later.

7 Fortunately we don’t have to start at the beginning to understand what makes us healthy. The prerequisites have already been determined by the Ottawa Charter for Health Promotion (1986).12 The World Health Organization, with much Canadian involvement, identified the fundamental conditions and resources for health: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity. Creating a strong foundation for these prerequisites enables a healthy population. While the social and ecological determinants of health contribute to the health of individuals and communities, the complex and intergenerational interdependence and interaction of those determinants needs to be well understood before they can be properly addressed. For instance, in the past it was recognized that poor sanitary conditions in milk barns or hospitals could lead to outbreaks of disease, but it was the identification of microbes as the cause of disease that allowed for their spread to be prevented. The “germs” of today may look different than those of the past and come in many guises: sugary drinks or fatty and highly processed foods; intoxicants such as tobacco, alcohol, or prescription drugs; chemicals in our air, water, and soil. Similarly, while cars can bring benefits, they are also a significant health hazard that contributes not just to many accidents but also to our unhealthy sedentary lifestyles. Likewise with intergenerational complexities. Even if we could entice our children to abandon their screens for a while, we are often afraid to let them out to play. The “contagion” of stress is rampant, and mental illness is now one of the largest contributors to poor health. The forthcoming pandemic of climate change will impact our ability to live safely and securely through extreme weather events, drought, and social disruption. It is imperative that New Brunswick’s new government takes the time to understand the real causes of health, or the lack thereof, in order to make informed decisions that address and remedy these complex problems. Although we live in a society dominated by short-term political turnover and the expectation of immediate gratification—where it is often easier to yield to the individuals and the communities with the loudest voices—the new government must learn to resist that temptation, for health is more complex than remedial—that is, merely therapeutic—solutions allow.

8 Changing the status quo is not easy, but our government can take some solace in the knowledge that New Brunswick has succeeded in addressing similar challenges in the past and indeed was recognized as a world leader in this regard. Jane Jenkins13 gives an excellent overview of some of the earliest interventions in protecting and promoting public health in New Brunswick. An early piece of legislation, a Health Act in 1786, was passed to prevent “infectious distemper” from entering Saint John. In 1877, local boards were established that were responsible for regulation and control of public health policies at the community level. A provincial Board of Health was established in 1887 to augment central control. The board’s first chair, Dr. William Bayard, set the goal of seeing that the entire province had clean air, water, food, and milk. Probably most notable of all was the creation in 1918 of a government department with responsibility for health.

9 These early leaders and bureaucrats did not face their work without challenges. Even then it was difficult to convince the establishment of the need for innovation and change. Dr. Melvin, one of the first district health officers, described how the municipal boards were poorly resourced and noted that epidemics would provoke “sudden, brief and always expensive activity,” but once people stopped dying, “so would, again, lassitude set in.”

10 Dr. William F. Roberts, a Saint John physician and the first minister of health in the British Commonwealth, did not have an easy time, either. He set out to run for public office and received support in principle for a provincial health department before standing for nomination. However, once elected, his bill did not have easy passage in the house. Armed with a report deploring the status of health of the province and justifications based on fiduciary responsibility, economic value, humanitarian need, and the preservation of general order, Roberts fought hard while being undermined by personal and professional criticism. Unsurprisingly, some of the strongest challenges he faced were based on the economic constraints of the province: How, went the now-familiar argument, could anyone expect an economically hard-pressed government to find enough revenue to pay for seven new positions and all the expenses that accompany them? There were also arguments suggesting that it would be autocratic in a government already considered top-heavy to proceed with health initiatives—and that there was too much government interference for too much money. Eventually the Public Health Act 1918 passed by a narrow margin. This Act established New Brunswick as a leader not only in Canada but internationally, as we became the first jurisdiction in the British Empire to have a minister of health. As Jenkins notes, the action was timely and legitimized the ability of New Brunswick to respond in a comprehensive and coordinated way following the arrival of the devastating “Spanish influenza” pandemic later that year. It should be reassuring to this new government to know that there is precedent in New Brunswick for being forward-thinking with respect to public health, but continuance of that leadership will take leaders who not only can take the long run but also leap high.

11 Primarily as a result of the success of public health interventions over the last century, life expectancy has lengthened considerably. In the 1950s, Canada saw a rapid expansion and growth in health services when the establishment of universal health care related to hospital and diagnostic services led to a transition to the management of illness. This focus has continued to the present with the health system set up primarily to treat individuals. Where there have been moves toward “investing in prevention,” those moves have tended to be very downstream, often in the realm of clinical practice and still at the individual level (for example, management of chronic diseases, therapies for smoking cessation, or screening programs to facilitate earlier diagnosis). While these are important, they cannot be a substitute for properly thought-out population health approaches. Even within the public health community there are differences of opinion about emphasis. Rather than being clear about the relative benefits of interventions, we still sometimes focus on those areas in our comfort zone.

12 However, because public health is the science and art of promoting health, preventing disease, prolonging life, and improving quality of life through the organized efforts of society,14 the work that needs to be done to improve the health of a population requires the participation of all actors and organizations, regardless of their differences of opinion. Teachers, municipal councillors, parents, etc., all have an important role to play in contributing to better health. Moreover, everyone involved needs to be organized and informed by an adequate number of effective practitioners. The competencies of public health practitioners are broad and varied. Their skills include knowledge of the public health sciences (e.g., epidemiology, behavioural and social sciences), as well as the ability to assess and analyze, develop policy, plan programs, advocate, communicate, and lead. In order to make gains in our public health and well-being, one of the first steps the new government must take is to build a more competent and efficient public health workforce. The current model is not sufficient to enable it to carry out its mandate, and the health of the people of New Brunswick is suffering as a result. The new Liberal government must also allow that workforce the independence to do its job as effectively as it can. Such an organized effort should not be seen as autocratic (and thus a threat to democracy) but rather a major foundation for improved public health. To do this the new government does not have to put more money into the system but must shift the balance of where that money is allocated.

13 The ethics of health care are always contentious. Clinical decisions weighing longevity against quality of life in the context of limited resources are difficult enough, but adding the ethics of population health into the mix, and giving consideration to future generations, makes the decisions much more complex. Given that we are subjective individuals, how do we decide what an objective ideal such as a good society and good health is? How do we reconcile the differing sets of values contributing to what the right approach should be?

14 Carter et al.15 identified four significant ethical issues related to health promotion: health promotion as a collective benefit; the risk of health-promotion strategies to stigmatize or blame the victim; the potential for health promotion and disease prevention to limit the freedoms of some for the good of others; and the need to distribute the benefits of health promotion equally. It is important to realize that public health practitioners work to address these issues, which include the health of patients and the health of the general population. Thus any public health intervention at the population level must include moral and ethical deliberation, and must include consultation with the people being assisted. Asking the wearer where the shoe pinches is key to understanding problems. Asking how the wearer thinks the pinch can be alleviated, and the compromises that may involve, will help to achieve an acceptable solution. The new government needs to know that such engagement and respectful discourse in themselves contribute to sound public health. Not to ask or listen, not to work toward informed and collaborative decisions, is not only unethical—it is also bad medicine.

15 So what is a new government to make of all this? After many months of knocking on doors and barbecued hot dogs, newly elected members are no doubt overwhelmed and wondering where to start. They will have heard many individuals, families, and communities asking for more access to services, more beds, and cheaper drugs. They will have heard countless heartbreaking tales of suffering. They will want to help the people in their communities and make good public policy. It is clear, however, that continuing down the current well-trodden path is not only unsustainable but fails to make us healthier. The causes are complex but by no means impossible to address. The necessary actions must come from and be informed by all parts of society. Those actions will require a shift in values away from viewing success solely in terms of material gain to recognizing that people are one component of a complex ecosystem upon which health depends. Changes to improve our health require the realization that in most cases lifestyle risk factors are not conscious choices. If it were as easy as just telling people what to do, we would not be spending half the provincial budget fixing the problems after they have been inculcated. Because of this complexity, the changes needed require strong and committed leadership from our newly elected officials. They can look to our forefathers to learn about the mistakes they should avoid, but also to discover the precedence for making positive change. The new government will need to learn about the causes and conditions for health and will need to set a timetable to enact policies and legislation to lay the foundations to improve it in an ethical and equitable way. A charge must immediately be given to the Department of Health to truly become a Department of Health and not only a Department of Sick Care. Moreover, the new government must within a short time set in place a requirement for local governments and provincial departments to consider health in its broadest context in all of their policies, programs, and actions. This is known as a “health in all policies” approach.16 No more money is needed, but funding must be diverted within the Department of Health to population health and primary care, and from the Department of Health to social, environmental, cultural, and community development programs. All this will require a government with courage and a backbone of steel that, for the well-being of its people, will take on the role of leaders in the field of health and accept that political chips will fall where they will. As the old Jewish proverb said, “If God lived on earth, people would break his windows.” A few broken windows would be a small price to pay for better health for those of us alive now and for those to be born in the future.

Dr. Eilish Cleary is the Chief Medical Officer of Health in the province of New Brunswick.