Introduction
The primary factors that shape the health of Canadians are not medical treatments or lifestyle choices but rather the living conditions they experience. These conditions have come to be known as the social determinants of health (SDH). The importance to health of living conditions was first established in the mid-1800s and has been enshrined in Canadian government policy documents since the mid-1970s. In fact, Canadian contributions to the SDH concept have been so extensive as to make Canada a “health promotion powerhouse” in the eyes of the international health community. Recent reports from Canada’s Chief Public Health Officer, the Canadian Senate, and the Public Health Agency of Canada continue to document the importance of the SDH. But this information – based on decades of research and hundreds of studies in Canada and elsewhere – tells a story that is still unfamiliar to most Canadians. Canadians are largely unaware that our health is shaped by how income and wealth are distributed, whether or not we are employed, and if so, the working conditions we experience. Furthermore, our well-being is determined by the health and social services we receive, along with our access to quality education, food and housing, and other factors.
Contrary to the assumption that Canadians have personal control over these factors, in most cases these living conditions are – for better or worse – imposed upon us by the quality of the communities, housing situations, work settings, health and social service agencies, and educational institutions we have access to. There is much evidence that the quality of the SDH Canadians experience helps explain the wide health inequalities that exist. How long Canadians can expect to live and whether they experience cardiovascular disease or adult-onset diabetes is very much determined by their living conditions. The same goes for the health of their children: differences among Canadian children in surviving beyond their first year of life, in experiencing afflictions such as asthma and injuries, and whether they fall behind in school, are strongly related to the SDH they are exposed to.
Research is also finding that the quality of these health-shaping living conditions is strongly determined by decisions that governments make in a range of different public policy domains. Governments at the municipal, provincial/territorial, and federal levels create policies, laws and regulations that influence how much income Canadians receive through employment, family benefits or social assistance, along with the quality and availability of affordable housing, the kinds of health and social services and recreational opportunities we can access, and even what happens when Canadians lose their jobs during economic downturns.
These experiences also provide the best explanations for how Canada compares to other nations in overall health. Canadians generally enjoy better health than Americans, but do not do as well as when compared with other nations that have fully developed public policies that strengthen the SDH. The World Health Organization sees health-damaging experiences as resulting from “a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics”.
Despite this evidence, there has been little effort by Canadian governments and policymakers to improve the SDH through public policy action. Canada compares unfavourably to other wealthy developed nations in its support of citizens as they navigate the life span. Our income inequality and poverty rates are not only growing but are among the highest for wealthy developed nations. Canadian spending in support of families, persons with disabilities, older Canadians and employment training is also among the lowest for these same wealthy developed nations.