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Public health must address our most 'wicked problems'

Dr. David Butler-Jones was the first Chief Public Health Officer of Canada holding the position from 2004 to 2014. He is returning to Saskatchewan to speak to an audience brought together by the Saskatchewan Public Health Association on June 9th.

Upstream's Ryan Meili caught Dr. Butler-Jones on the phone recently to chat about the state of Public Health and it's role in addressing the 'wicked problems' our society faces.

Ryan Meili: You're coming to Saskatoon for a panel presented by the Saskatoon Public Health Association. What's the message that you're going to be bringing? 

David Butler-Jones: Much of what people would call the 'wicked problems' happen at the margins and really are something for which no one discipline, organization, or perspective is sufficient. Public health continues to be in a unique position to not only recognize these things, but also be a bridge to link other perspectives into 'common cause' — identifying those things that we can in fact do better together.

Sir Michael Marmot talks about the causes of the causes, because if you have any hope of not repeating the same problem all the time, you actually have to understand what gave rise to it in the first place. Public health is more and more inextricably linked to the work of other parts of the system. This is happening at a time when in some jurisdictions it's a challenge to get attention, as people retreat to their own mandates.

"None of these are insurmountable."

RM: How can we overcome the narrow, short-term thinking that is presented by difficult economic times, austerity, four-year political terms, etc.?

DBJ: One way is to be very articulate about what is the value added. If what we're trying to accomplish is health - there's no single aspect. Public health's role is not simply programs and services, it's a way of thinking about problems and it's also what we influence.

I used to say health promotion is easy to do poorly. People think ' well that's easy to do' and then they do things that don't make a difference, in fact make things worse. I'll give you some very simple examples. I remember when Physicians for a Smoke-Free Canada had these really great slick ads on TV — operating rooms, graveyards, and all this kind of stuff— and the ex-smokers and the non-smokers said 'yeah that'll convince them'. When they actually studied the smokers who saw them, they smoked more — because it increased anxiety, and they didn't have an alternative.

Or we have a maternal program in an area with no good transit and no care for their kids. We all make these mistakes, but it is something that is an area of understanding and expertise that requires a lot of humility and being articulate about what works and what doesn't and building the evidence. Just because you say you're doing prevention, doesn't necessarily mean you're doing it or effective at it.

"People who are connected — who have people that they care about and care about them — have half the risk of dying at any age, male or female."

None of these are insurmountable. There's a spirit and a willingness over the last decade interpersonally, interprofessionally and interjurisdictionally to focus on the common good and figure out how we could do some of these things better together, so I remain optimistic.

RM: So if health is what we're trying to achieve, that's obvious for public health or for people involved in healthcare. One of the things we talk a lot about at Upstream is the idea that it's not the sole property of those fields but really the work of all of government.

DBJ: Social determinants — those notions go way back, at least a couple hundred years. There are different ways of articulating the health impact of societies, and environments, and the ability to have food in your belly and clothes on your back and a roof over your head and to participate in society, etc.

Beyond those basic needs, the two things that fundamentally make a difference to real health, good health in it's broadest sense, including wellbeing, is that we have a sense that the decisions we make, the things we do, matter moving forward. That they matter to us, matter to making a difference. The other is that we have people we care about and care about us.

I'll give you two simple statistics — one is about Indigenous teens and suicide and in those communities that have a sense of control — having resolved land claims and other process of control - suicide rates virtually disappeared. Similarly, people who are connected - who have people that they care about and care about them - have half the risk of dying at any age, male or female. We have so many things in our policies and structures that work against that. The residential schools system, the reserve system, the way in which previous governments related to First Nations.

RM: You said that health promotion is easy to do poorly. One of the things that we tend to notice when discussing how to keep people healthy is that everyone's minds drift back to individual agency: smoking, exercising, eating well. How do we get beyond what some have called the trinity trap and get to actually convincing the public that where the real impact is in terms of prevention is in the social determinants. 

"If the only place I could get respect was a gang that required me to steal a car, I would steal that car."

DBJ: That's pretty fundamental, right? There are some things that just don't seem to make sense, but in our society it's been so engrained for so long. So part of it is I tell stories, and try to get people to think of themselves in the same situation. When I lived in Regina, my oldest daughter was going to the University of Regina. One day, she'd taken the van to university and she came out and it was gone. At that time, in Regina, part of the initiation in some of the gangs was to steal a minivan from one end of town, drive it up to the other end of town and trash it.

That's just what they did. And people would say how terrible that is, we need to catch these kids, we need to lock them up, we need to punish them more. And I said, honestly, if my parents were never parented because they were in residential school, and therefore they weren't able to parent me, there was addiction in the home, and school didn't seem very relevant. If everyone was telling me that there's not much point anyways, you're a loser in life, you're Indigenous. If the only place I could get respect was a gang that required me to steal a car, I would steal that car.

Too often we look at others and we don't put ourselves in that situation. We think of what they should do or should have done, instead of actually thinking — if I was in that same situation, how would I want to be treated? It's like my earlier examples about some ways of addressing poverty and the impacts of poverty. You sometimes wonder whether we actually want people to be poor so that we can feel better about ourselves. Otherwise, our policies would be very, very different.

RM: Speaking of different policies, taking this up to the level of government, moving beyond that individual agency that we tend to focus on, or reaction to ill health in terms of treatment, something that's getting more discussion across Canada right now is the idea of Health in All Policies. I wonder if that's something that you see as a useful tool.

DJB: How we frame it is important. You can have a few champions and you can get buy-in from a few people enough that you can get it passed, but people actually have to live it.

When I would go into other departments in Saskatchewan, the first thing I’d hear is ‘well, you already have 50% of the budget — what more do you want?’ And I'd say no, I'm not here to ask you for more, I know you are already doing things in this area. I'm asking to work together with you, what we could bring to the table. It's a very different conversation.

For example, we wanted to have other aspects involved in the environmental assessments — effects on communities, and people and other things as well. Early conversations were met with a lot of skepticism, because basically it just looked like we were adding work, and I said, no, we will do that part with you, we'd be happy to help with that to make that happen.

It doesn't matter if it's developing policy or programs - consult early and often, so that by the time you actually get to the point of being happy with it, it’s generally thought to be the right thing to do.

"How we frame it is important."

RM: How can Canadians be part of this effort to change how we think about health - changing the frame away from reacting to ill health or focusing on individual agency, rather than addressing the social determinants of health?

DBJ: The key thing is not either/or. You need to be able to do both. Individually agency and treatment and public health's ability to respond to emergency and crisis — those are fundamental. If we don't do them well, we have no credibility for anything else. At the same time, we need to have the supports and systems and work and thinking in place that allows us to tackle these longer-term wicked problems. 






DBJ.JPGDr. David Butler-Jones 

Dr. David Jones served as the Chief Public Health Officer of Canada from 2004-2014. He has held roles as President of the Canadian Public Health Association, Vice President of the American Public Health Association, Chair of the Canadian Roundtable on Health and Climate Change, Co-Chair of the Canadian Coalition for Public Health in the 21st Century and more.


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