Vital lessons from the pandemic for the future

By Dr. Trevor Hancock

I suggested in recent columns we should use the pause in our society and economy resulting from the Covid-19 pandemic to re-evaluate what we want and how we want to live. Here are eight important lessons we might learn if we pay attention to what is happening.

First, having less and being less busy may not be so bad, maybe we can have a better quality of life – as long as we can meet our basic needs, of course. Normally we are too embedded in our way of life, and too busy leading that life, to step outside of it and reflect upon it. As a former student of my  friend and colleague Rick Kool at Royal Roads University wrote from Kathmandu, Nepal: “The air quality is SO much better here (it is usually the WORST!) and I can hear so many more songbirds in the morning. I’m loving it”. 

Second, there is the high price we pay for our way of life. The BBC reported this week that as a result of the pandemic air pollution emissions fell 25 percent overall in China. Meanwhile “levels of pollution in New York have reduced by nearly 50 percent” compared to the same time last year, and cleaner air has also been reported in Italy, Spain and the UK.

So it was timely that in a March 3rd press release the European Society of Cardiology, pointing to a new study, declared “The world faces an air pollution ‘pandemic’”.  The study found outdoor human-made air pollution, mainly from fossil fuel use, caused massive health problems, estimating that “five and a half million deaths worldwide a year are potentially avoidable”.

This vast toll of death and disease – and there are many other forms of death and disease that can be attributed to our economic and societal systems – is just shrugged off as the cost of doing business. But is that acceptable? 

Third, we are seeing very clearly that social solidarity matters, that we are all in it together, while the neoliberal cult of individualism, the notion that ‘you are on your own’, is toxic. You can’t face this all on your own, it takes a whole village, a whole society and a whole global community working together to manage this. Fourth, a related lesson, is that local matters a lot, whether it be local community organisations, businesses or governments. 

Fifth, we are learning that Government matters, and that the Canadian notion of ‘peace, order and good government’ completely out-performs the US model, which some, such as Derek Thompson, writing in The Atlantic on March 14, are likening to a failed state. 

Sixth, exponential growth – whether it be Covid-19 cases or carbon dioxide levels – is a really bad idea. As Elizabeth Sawin, co-director of the think tank Climate Interactive, puts it in an article in Yale Environment 360 by Beth Morgan last week, “if you wait until you can see the impact, it is too late to stop it.” 

Seventh, nature bats last, and we should not rely upon outwitting and out-performing nature. A Chicago Tribune Editorial (excerpted last week in the Times Colonist) noted: “We  learn anew that in nature we’re but temporary components of perpetual systems much bigger than ourselves”. 

Finally, hopefully we are learning that if we can act swiftly and massively on Covid-19, we could act just as massively, but with a bit more time for thought and planning, on the even greater but slower crisis of human-induced global ecological change, including climate change. As Eric Doherty, a local transportation and land use planner, writes in the Canadian independent online news outlet Ricochet, “if we can change everything for one kind of emergency, why not do it for another?” 

I am not saying all these shifts in perspective will happen, but they might happen. And if realisations of this sort come together, they could create a social tipping point, perhaps even set off the sort of ‘virtuous cascade’ of change that the new Cascade Institute at Royal Roads University has been set up to study and understand. That same process at a local level might lead to the creation of the ‘One Planet Region’ that we need.

© Trevor Hancock, 2020

A different perspective on COVID-19

By Dr. Trevor Hancock

There is no question Covid-19 is a serious issue. If we did nothing, hundreds of thousands of Canadians, especially older people, might die and the health care system would be overwhelmed, jeopardising the health of many other people with other health problems. Flattening the curve will reduce the peak of the epidemic, spreading it out over a longer period of time. This also buys us time to find treatment or a vaccine.

So around the world today and across Canada borders are closed, as are schools, universities, libraries, rec centres, cafés, pubs and many businesses, large and small. Our communities and societies have been brought to a halt, or at least to a dramatic slowdown, and our economies are in a tailspin.

But many may be concerned that the public health and societal effort to contain Covid-19 comes at a huge cost to society, that it is triggering a global recession, that it might even lead to a depression. Could it even be the case that the social and economic disruption we create will kill or sicken more people than does the
disease?

After all, the Great Depression in North America and Europe was a time of great misery and despair. Surely that was bad for health. Surprisingly, it seems that was not the case; in fact, the opposite was true.

A 2009 paper co-authored by a leading American social epidemiologist, Ana Diez Roux at the University of Michigan, examined life and death during the Great Depression. They found “population health did not decline and indeed improved during the Great Depression of 1930–1933” and that death rates “decreased for almost all ages, and gains of several years in life expectancy were observed for males, females, whites and non-whites—with the latter group being the group that most benefited.”

This is not to say there are no ill-effects of a recession or depression. They note that among the six main causes of death, accounting for around about two-thirds of all deaths in the 1930s, “only suicides increased during the Great Depression”. Today, at a time of industrial decay in some parts of the USA, we have seen an increase in deaths from the ‘diseases of despair” – alcohol and drug use (especially opioids) and
suicide – among lower-middle income middle-aged men.

But contrary to our expectations, they note, “years of strong economic growth are associated with either worsening health or with a slowing of secular improvements in health”. Moreover, they added, this “was first noted decades ago, but was largely ignored until recently”.

The reasons for increased deaths during economic expansions, they report, include “increases in smoking and alcohol consumption, reductions in sleep and increases in work stress” as well as increases in “traffic or industrial injuries . . . [and] atmospheric pollution”.

As I have noted before, there are many businesses and many ways of making a profit that can harm health. Just recently I reported that a joint WHO-Unicef-Lancet Commission had identified commercial activities as one of the three greatest threats to children’s health, along with climate change and poverty; all are influenced by this Covid-19 recession.

Environmental scientists have already noted a dramatic reduction in air pollution and carbon emissions in China and Italy, and this will soon become world-wide. Indeed, Stanford University environmental resource economist Marshall Burke suggested in early March that the reduction in air pollution in China might have already saved more lives than the Covid-19 epidemic had cost.

We can already see the reductions in traffic on our local roads, which will not only reduce air pollution and carbon emissions but crashes and injuries. If this goes on for months, as it might, we will likely see increasing need for government support for laid-off workers, strengthening support for some form of guaranteed income and/or ensuring people’s right to access food and shelter – basic requirements for health – is met. Coupled with that we can expect reduced demand for more ‘stuff’, as people adjust to lower incomes.

It may be that with this combination of reduced consumption and reduced environmental harm, coupled with societal commitment to ensuring the meeting of basic needs for all, we will find ourselves unintentionally creating the wellbeing economy we need in the 21 st century.

© Trevor Hancock, 2020

Creating a livable future for our kids

By Dr. Trevor Hancock

The Lancet, one of the world’s leading medical journals, has been making an important pivot towards health in recent years. Under the inspiring leadership of its long-time Editor-in Chief, Dr. Richard Horton, it has championed the concept of planetary health, which is “the health of human civilisation and the state of the natural systems on which it depends”.

Now comes the latest in a series of Commissions on various aspects of planetary health. This one, published February 22nd and co-sponsored with the World Health Organisation and UNICEF, is on the health of children in the future. The Commission’s report places children “at the centre of the SDGs [Sustainable Development Goals]: at the heart of the concept of sustainability and our shared human endeavor”.

It has three main foci: the health impacts of poverty and inequality, climate change and ecological damage, and commercial activities that harm children. I will deal with the first and third of the Commission’s concerns next week, but this week I want to focus more on the second, given the state of the debate on climate change and energy policy in Canada today.

The Commission is clear: “The ecological damage unleashed today endangers the future of children’s lives on our planet, their only home”. And the report points to the fact that while high income countries do well with respect to ‘child flourishing’, as one would expect, “wealthier countries threaten the future of all children through carbon pollution”.

Canada exemplifies that point. With a score of 90 percent, we rank 21st on an index of child flourishing, where the top 33 spots, with a range from 85 to 95 percent, are held by high income countries in Europe, as well as Australia, New Zealand and the USA. However, in terms of the threat to the future health of children resulting from CO2 emissions in excess of internationally agreed 2030 targets, Canada ranks 170th out of 180 countries. This puts us “on course to cause runaway climate change and environmental disaster”.

That concern is reflected in two other recent reports, from very different sectors, that underline the urgency of the climate crisis we have created.

The first is an extract last week in the British daily The Guardian from a new book by Christiana Figueres – an experienced Costa Rican diplomat and from 2010 – 2016 the Executive Secretary of the UN Framework Convention on Climate Change – and her then Senior Adviser, Tom Rivett-Carnac. Their book, The Future We Choose, includes a ‘worst case’ scenario, set in 2050, in which no real action on climate change has been taken since 2015.

It is a grim picture of a world headed towards more than 3 degrees of warming by 2100: “No one knows what the future holds for their children and grandchildren: tipping point after tipping point is being reached, casting doubt on the form of future civilisation”.  (To be fair, the book has a positive bent, looking at how we can avoid this scenario.)

The second is a leaked report – also in The Guardian last week – from JP Morgan, one of the world’s leading investment banks.  The Guardian reported that JP Morgan alone provided $75 billion to the fossil fuel sector since the Paris Accord on Climate Change.

According to The Guardian, the report by two JP Morgan economists warns that if we don’t change direction, but carry on as we are, this “would likely push the earth to a place that we haven’t seen for many millions of years”. The consequences would be dire: “We cannot rule out catastrophic outcomes where human life as we know it is threatened,” they wrote, noting also that we have considerably understated the health and economic costs.

Clearly, further investment in fossil fuels is unethical, and is fast becoming a risky investment; the withdrawal by Teck Resources of its proposal for a vast tarsands mine has to be seen in this light. So why would so many of Canada’s federal and provincial governments continue to support expansion of the extraction and export of fossil fuels? Instead of defending a dying industry, they need to be working to secure our children’s future by hastening the transition to a zero net carbon economy.

© Trevor Hancock, 2020

Our health should be an election issue

By Dr. Trevor Hancock

To the extent health is an issue in the federal election, it will be about health care, as usual. Now I am not saying health care is an unimportant issue, but this focus on ‘health care as health’ is wrong for two reasons. First, health care is a provincial responsibility under the Constitution, so the federal government plays no real role in managing Canada’s various provincial and territorial health care systems.

Second, and more important, health is not health care, it is a much bigger issue – and one where the federal government can indeed play a major role. If we really want to improve health care, we must improve health, thus reducing the growing burden of disease and injury the health care system has to handle.

So as we think about the federal election, look at party platforms and promises, and engage with candidates, the question we should be asking is “What will you do to protect and improve the health of Canadians?” Here and in the next few columns I will discuss the policies I believe we should be looking for to determine whether our political leaders really understand and care about the health of Canadians.

In this I am not alone. The Canadian Public Health Association (CPHA) has identified eight top election issues and has produced an excellent set of resources for citizens and public health professionals, giving easy access to the parties’ platforms and tools to help people engage candidates in their riding (see www.cpha.ca/election-2019)

CPHA’s priorities include such basic determinants of health as income, housing, early child education and climate change. They also focus on the opioid crisis, decriminalization of personal use of psychoactive substances, racism, and not surprisingly, on the funding of public health. To this list, I would add food, transportation and urban development, although the latter, like health care, is within provincial but not federal jurisdiction.

But over and above all of this is the need for a comprehensive and strategic approach to improving the health of Canadians. There was a time, in the 1980s and 1990s, when Canada was a world leader on these issues, but sadly that is no longer the case. As with so much else that is wrong with public policy, it is not lack of knowledge that leads to poor policy choices, but lack of wisdom, lack of a long term perspective and the inability to act in the public interest rather than in the interest of powerful corporate and institutional players.

The first step in making the health of Canadians a priority is to recognize that the Minister of Health is actually largely the Minister of Illness Care, and that it is the Cabinet as a whole, and the Prime Minister or Premier in particular, that is really the ‘Minister of Wellbeing’. Improving the health of Canadians depends more upon the Ministers of food, housing, education, finance, social development, environment and climate change and others than the Minister of health.

The Canadian Senate recognized this in a 2009 report that recommended “A new style of governance: leadership from the top to develop and implement a population health policy at the federal, provincial, territorial and local levels with clear goals and targets and a health perspective to all new policies and programs”.

Specifically, the Senate recommended creating a Cabinet Committee on Population Health (which should be chaired by the Prime Minister/Premier) that would develop and implement a population health policy. This policy would require an assessment of the health impact of policies in all sectors, and a spending review to determine where we would get the biggest health/human development return on our investment.

To this, I would add the creation of an independent Canadian Population Health Officer, reporting to Parliament (not to the government) on the effectiveness of public policy and programs in improving the health of the population.

The report sank like a stone! So if you are concerned with the health of the population and the sustainability of the health care system, you should ask candidates if they will commit to creating a Cabinet Committee on Population Health, displacing economic development as the central focus and instead putting development of human wellbeing at the heart of government.

© Trevor Hancock, 2019

Originally published 17 September 2019

New Zealand leads the way by focusing on quality of life

By Dr. Trevor Hancock

One of the central themes in my columns, and in my academic and professional writing and presentations, is that, as a society, we have got our priorities wrong.

We have focused on economic growth and increase in material wealth rather than on increased human and social development and quality of life. With that in mind, it is heartening to see that at least one government is making the shift to these broader objectives.

Don’t get too excited — it’s not happening in Canada.

It’s New Zealand, where they have a different outlook. On May 30, the New Zealand government delivered what is surely the world’s first wellbeing budget. But what exactly is a wellbeing budget and what makes it different?

In her budget message, Prime Minister Jacinda Ardern commented: “While economic growth is important — and something we will continue to pursue — it alone does not guarantee improvements to our living standards. Nor does it measure the quality of economic activity or take into account who benefits and who is left out or left behind.”

Here we have a government that understands not all growth is good, and even more important, that the purpose of the economy is not simply to grow, but to improve our living standards, without leaving people out or leaving them behind.

“[It] signals a new approach to how government works, by placing the well being of New Zealanders at the heart of what we do,” said Grant Robertson, the Minister of Finance. Instead of focusing on “a limited set of economic data,” with success defined by “a narrow range of indicators, like GDP growth,” this new approach measures success in line with New Zealanders’ values — “fairness, the protection of the environment, the strength of our communities.”

To do so, the government has built on 30 years of work in New Zealand and internationally to create a Living Standards Framework that considers “the inter-generational well being impacts of policies and proposals.” It recognizes four forms of capital — natural, human, social and the combination of financial and physical capital.

These are then linked to 12 domains of well being that include civic engagement, cultural identity, safety and security and subjective well being. These are similar to the domains in the Canadian Index of Wellbeing, which was initiated by the Atkinson Foundation in 1999 and has been housed at the University of Waterloo since 2010.

To my knowledge, regrettably, no federal or provincial government has adopted its guidelines.

The wellbeing budget “focuses on five priority areas where evidence tells us there are the greatest opportunities to make real differences to the lives of New Zealanders.” Priorities intend to: Support mental well being, especially for those under 24; improve child well being and reduce child poverty; increase incomes, skills and opportunities for Maori and Pacific Islanders; support a thriving digital-age economy, and create opportunities for organizations and communities to transition to a sustainable and low-emissions economy.

Just as interesting as the budget is the process used to create it. Rather than the usual siloed approach, where each ministry just considers its own issues and concerns, “ministers had to show how their bids would achieve the well-being priorities.” Cabinet committees then worked to create collaborative approaches across ministries, supporting collective approaches to the well-being priorities.

New Zealand is similar, in many ways, to B.C. With nearly five million people, it is a resource-rich country with a long coast line, a significant and increasingly assertive Indigenous population and a British colonial history.

But it also has a history of democratic innovation. In 1867, it created four parliamentary seats for Maori and in 1893 it became the first country in the world to give women — including Maori women — the right to vote in parliamentary elections.

It is also noteworthy that New Zealand has had proportional representation since 1996, which resulted in no party having a clear majority in the 2017 election. The government that introduced the wellbeing budget is a coalition, led by the Labour party.

Clearly, coalition governments can take bold initiatives.

If they can do it in New Zealand, there is no reason why we cannot have a wellbeing budget in British Columbia.

© Trevor Hancock, 2019

Originally published in Times Colonist, 9 June 2019

Innovation for Gender Equity, Youth & Representation [Symposium]

An evening of talks and networking to generate discussions surrounding social innovation, gender equity & representation, and youth development within communities, in alignment with Bridge for Health’s Youth Engagement initiative and proud supporter of Women Deliver 2019 — the world’s largest conference on gender equality and the health, rights, and wellbeing of girls and women in the 21st century.

What does social innovation look like beyond Vancouver? How can we think global, but act local to support our own community? As we move towards progress and changemaking, how can we simultaneously promote gender equity & representation to reflect our diverse communities?

ABOUT BRIDGE FOR HEALTH
Bridge for Health is an international cooperative of changemakers. By shifting dialogue and practices about health, from absence of illness to wellbeing, we can mobilize the change towards a safe, sustainable, and healthy future for all.

KEYNOTE SPEAKER
Patrick Mwesigye (Team Lead of the Uganda Youth & Adolescents Health Forum) will be presenting his talk “Young People at the Periphery of Universal Health Coverage – A case of Uganda Youth and Adolescents Health Forum”

PECHA KUCHA TALKS
Each presenter will share personal presentations about their work. The theme is “Social Innovation, Gender Equity & Representation, and Youth & Community Development”. Click ‘attending’ on the event to stay updated on our speaker announcements!

Tickets are free but limited – RSVP before they run out!
Link: http://b4hsymposium2019.eventbrite.com
#B4HSymposium2019 #WD2019

Please email Larissa (larissa@bridgeforhealth.org) for accessibility requests or more information.
www.facebook.com/bridge4health/

We face alternative health futures

By Dr. Trevor Hancock

Last week, I referred to Norman Henchey’s categorization of four sorts of future: Probable, possible, plausible and preferable. This week, I explore the latter three, especially in the context of the future of health and the health-care system.

But first, an important distinction. Many of those who describe themselves as health futurists are really health-care-system futurists. They are focused on the future of the health-care system, rather than on health itself.

But if you want to think about the future of health, you have to think about much more than just the health-care system; you have to think about the future of society as a whole and the state of our environment, as they are what largely determine the health of the population.

In fact, our society also determines what kind of health-care system we have, because that system will reflect the values and social norms of the society of which it is a part — not the other way around. So with that in mind, what can we say about the possible, plausible and preferable futures of health and health care?

The possible future encompasses all the things we can imagine happening, which can take it into the realm of science fiction. This is not to disparage science fiction; at its best, it can illuminate our present world and its values, and imagine and test ideas most of us have never considered.

But the possible can also get pretty wild, both scientifically and socially, which can make it implausible. The transporter beam of Star Trek is a case in point, as perhaps are its instant diagnostic scanners, or the extreme genetic manipulations in the novels of William Gibson or Iain M. Banks. I would put the visions of limitless free energy and hopes for instant cures for cancer and other diseases in the implausible zone.

The plausible future is a narrower band within the wide range of possible futures. It can be best explored by the use of scenarios — narratives of alternative futures based on what we know and can reasonably anticipate. In scenarios work, we not only explore the “business as usual” scenario, but a plausible future in which many things go wrong, which can be described as decline or collapse.

This is definitely not a preferable future, and people don’t like to explore it, but if asked, they find it plausible, even quite likely. By exploring such a future we can both recognize what we need to do to avoid it and/or to cope with and manage it.

Other plausible scenarios include some form of eco-social, economic and to some extent spiritual transformation, a sort of “green” future that sees us move away from the more high-tech “business as usual” or the conditions that lead to decline or collapse. Not surprisingly, such a future, while not necessarily seen as all that plausible or feasible, is often seen as quite healthy and thus desirable, especially when allied with the appropriate use of high-tech.

But embedded within and underlying each scenario are sets of values that guide the scenario, such as the value placed on health and how health is understood in that society — which in turn shapes that future’s health-care system. For example, is health just about physical well-being and length of life, or mental well-being and quality of life, or balance and harmony within society and nature?

In the first option, we might expect a more high-tech, biomedical system, but in the other two, a system more focused on achieving mental well-being or ecological well-being, while in a decline or collapse scenario we can imagine there would be a quite minimal, survival-oriented health-care system, and mainly for the rich and powerful.

But beyond imagining a range of plausible futures we face, the key question is what sort of healthy future we want for our kids and grandkids. As I said in last week’s column, thinking about the future should help us decide what we do and how we live today. Rather than just adapting to whatever happens, how do we help to shape and create the future we prefer? That will be the topic of next week’s column.

Dr. Trevor Hancock is a retired professor and senior scholar at the University of Victoria’s School of Public Health and Social Policy.

© Trevor Hancock, 2019

Originally published in Times Colonist, 31 March 2019

Future thinking can pay off

By Dr. Trevor Hancock

I am often accused, not unjustly, of being a “doom and gloom” merchant when it comes to the state of the planet and of our society. While there are good reasons to hold that view, it is not the only way of looking at the future.

Part of my professional work has been as a futurist, specifically a health futurist. That is to say, I have worked with people to help them think more effectively and creatively about the future of health and health care.

Futurists often get a bad rap, accused of being too visionary, even dreamy, by some, while others think futurists have done a poor job of predicting the future. Both those views, however, miss the point of good futures thinking.

Many years ago, I worked with James Robertson, a British futurist and author of an influential 1978 book, The Sane Alternative. In 1984, I brought him to Toronto to speak at a conference I was organizing, and one of the things he said captured for me the essence of good futures work.

“Thinking about the future,” he said, “is only useful and interesting if it affects what we do and how we live today.”

So good futures work is practical, because it helps us make better choices and decisions today that will shape our future. Of course, there is no guarantee that we will do so; witness the litany of failed opportunities over the past 50 years to avoid the environmental crisis that was predicted then and that we now face.

Which points to the other sort of problem: Futurists might help us understand and anticipate future events, but there is no guarantee their ideas will be understood, taken to heart and acted upon. Moreover, prediction is a bit of a mug’s game. As another colleague, and one of the world’s leading futurists, Jim Dator, used to say, the probable future is the least likely future.

By that he meant that predicting the future as a form of “business as usual,” especially based on past trends and performances, is inherently wrong, because it assumes that things will continue much as they are, when in fact the only thing that is constant is change. The future, as futurists like to remark, is plastic, it can and will be shaped, often in ways we don’t anticipate — witness the way the internet has changed our world.

Moreover, as we have come to understand complex adaptive systems better — systems such as the human body, the economy or the Earth’s natural systems — we have come to understand two important things about them that make prediction hard, if not impossible.

First, within such systems, small changes can perturb the system in ways that result in massive change, the so-called butterfly effect. (The analogy is that the beat of a butterfly’s wings in China today can spawn a tornado days later in America.) The opposite is also true. Large changes in input can have little or no effect, as the system adapts to them and smoothes out or absorbs their impacts.

The second realization is that there can be sudden, non-linear state-shifts in such systems. These systems are dynamic, but stable, though when enough strain builds up, or just the right small nudge occurs and they cross a threshold — which we might not know about in advance — they can shift suddenly to a different state. Some climate models, for example, suggest the Earth’s climate can be stable in its present configuration or two much different states: “Snowball Earth” or “ice-free Earth.” At present, we are pushing the Earth toward the latter.

All of this suggests that there is no such thing as the future, but rather we face many different futures. The Canadian futurist Norman Henchey put it well many years ago when he described four categories of future: Probable, possible, plausible and preferable.

The probable, as we have already seen, while interesting, might be neither likely nor preferable; the other three are more interesting, and I will describe them next week, particularly in the context of the future of health and health care, before turning to thinking positively about creating a preferred future in a third column.

Dr. Trevor Hancock is a retired professor and senior scholar at the University of Victoria’s School of Public Health and Social Policy.

© Trevor Hancock, 2019

Originally published in Times Colonist, 31 March 2019

Time to shift the bell curve toward health

By: Dr. Trevor Hancock

Life is lived on a bell curve. Many attributes of a population — height, for example — are distributed on a bell-shaped curve, with the average at the centre and then decreasing numbers of people as we get further from the centre.

At each end of the curve are the small number of people who are either extremely tall or extremely short. This pattern is found throughout nature, and is one of the most important concepts in biology, medicine and public health.

Understanding the bell curve is important for the work of public health. For example, we know that being overweight or obese increases the risk of developing diabetes.

An example from a Canadian population-health primer notes that those who are very obese have a 32 per cent chance of developing diabetes over the next 10 years, while those who are obese have a 21 per cent risk. But people who are overweight but not obese have only a 10 per cent risk, and those with a normal healthy weight or who are underweight have only a three to seven per cent risk.

So you might think it would make sense to focus our prevention efforts on those who are obese — and you would be wrong. Because in doing so you would miss 61 per cent of those who develop diabetes. Forty per cent of cases would occur in the overweight population and an additional 21 per cent of cases would occur in the low-risk normal weight population.

This is known as Rose’s Paradox, identified by the noted British epidemiologist Sir Geoffrey Rose. He pointed out that while the people at one end of the bell curve have a higher risk of getting a disease, more cases are found in the population with moderate or low risk. This is because there are far more people in these categories. For this reason, it is better to try to shift the curve for the entire population a bit.

Moreover, this doesn’t just apply to individuals, but to entire neighbourhoods. My friend and colleague, the late Clyde Hertzman, established and led the Human Early Learning Partnership at UBC. He led pioneering work in B.C. on early child development, and as a result, B.C. became the first jurisdiction in the world with maps of early development for every neighbourhood and school district in the province. These maps helped to show the relationships between patterns of vulnerability in young children and their socio-economic conditions.

As would be expected, lower incomes and more impoverished living conditions and neighbourhood resources were linked to worse outcomes. But importantly, HELP also showed that “although the highest risk of vulnerability is found in the poorest neighbourhoods of town, the largest number of children at risk is spread across middle-class neighbourhoods.”

This has important implications for public-health policy and programs. It is tempting to focus only on the small number of high-risk people, groups and communities — so called “targeted” interventions — because it seems as if that would be cheaper. But it’s not a very effective strategy because it misses most of the cases. For example, B.C.’s Nurse-Family Partnership provides regular visits by a public-health nurse throughout a woman’s first pregnancy, and those visits continue until the child reaches two years of age.

But it is only available to a select group of women; those under 19, or those age 20 to 24 who are lone parents, or have low income and education or are experiencing social, financial or housing challenges, including being homeless. Nobody would argue that this is not a high-risk group, but Rose’s Paradox and Clyde Hertzman’s work suggest the program may be missing most of the cases that need support.

If we want to have the greatest impact, we need to affect the entire population. What is needed, as Clyde and his colleagues at HELP point out in the B.C. Atlas of Child Development, is a combination of civil-society interventions that “create family-friendly environments across class and ethnic divides”; universal interventions, with barriers to vulnerable people removed; and targeted interventions.

In the U.K., this is known as “proportionate universalism”; everyone gets the intervention, but those with the greatest need get more. It’s the best way to shift the curve toward health.

Dr. Trevor Hancock is a retired professor and senior scholar at the University of Victoria’s School of Public Health and Social Policy.

© Trevor Hancock, 2019

Originally published in Times Colonist, 10 March 2019