Letter from Canada: paradigms, politics and principles: An end of the millennium update from the birthplace of the Healthy Cities movement

The City of Toronto is in crisis. The percentage of children living below the Statistics Canada low-income cut-off is close to 40%. Homelessness is at levels not seen since the 1930s and food banks are used on an ongoing basis by 135 000 Toronto residents, a doubling in number since 1990. It is estimated that >800 Toronto residents die each year as a direct result of air pollution. In Canada as a whole, the average market income of the first income decile of families fell from 1986 to 1996 by 62%, while second decile average income fell by 33%. All this is occurring even as the Canadian economy continues a strong recovery. Health promoters trying to make sense of this have been forced to consider the social, economic and political forces within Canada driving these developments. The purpose of this ‘letter from Canada’ is to caution Health Promotion International readers not to ignore the impact of these broader forces upon their own efforts to promote health. How we think about and work to improve health is strongly influenced by the dominant health discourse within any nation. In Canada, the concept of ‘population health’ has replaced ‘health promotion’ as the dominant health discourse in many federal and provincial government statements. Ann Robertson argues that the ascendence of population health reflects a government retreat from the welfare state. What is especially disturbing is that population health ideology, focus and methods are embedded within epidemiological modes of thought. As its primary means of promoting health, and population health uses the biomedical definition of health as the absence of disease and illness, population health efforts concentrate on carrying out large-scale quantitative surveys that identify risk and protective factors across the population. As such it offers a fundamentally different vision of health from the values-based, pluralistic and community-oriented vision of health promotion. To illustrate the implications of this new approach towards health, two Canadian architects of population health identify Healthy Cities work as the most ambitious effort to develop healthy public policy, and then go on to state: At best, healthy public policy represents modern utopianism. At worse, it is simply a form of clever propaganda, piggybacking a set of other policy interests onto the powerful and broadly based public support for health. Not surprisingly, public health practice in the City of Toronto has retreated from its activist, participatory, and innovative vision that led to the development of the Healthy Cities concept. Public health now focuses upon health protection issues related to air pollution and restaurant and nursing home inspections with little if any emphasis on issues of poverty and social exclusion. Such shifts in discourses do not happen in a vacuum; they occur within the context of national and local political environments. Population health has arisen at a time of increasing influence of neo-liberal ideology in Canada. David Coburn outlines the key tenets of neo-liberalism as: (i) markets are the most efficient allocators of resources in production and distribution; (ii) societies are composed of autonomous individuals (producers and consumers) motivated chiefly by material or economic considerations; and (iii) competition is the major market vehicle for innovations. In Canada, the implementation of neo-liberal ideology has led to frozen or reduced government spending on social infrastructure including education, social and health services. Indeed, the federal Minister of Finance boasts that federal programme spending as a percentage of gross domestic product (GDP) is now at 1950 levels. In Ontario, the Ministry of Environment budget has been cut by 40% over the past 5 years with the not surprising result that a recent outbreak of Escherichia coli-infected drinking water killed at least seven residents and sickened thousands more in the Ontario municipality of Walkerton. Reductions in programme spending have been associated with dramatic changes in the tax structure such that economic inequality in Canada is increasing at an unprecedented rate, reminiscent of that experienced in the United Kingdom during the Thatcher years. The practical consequences for cities such as Toronto are reduced resources for social infrastructure at the same time as need has increased. Health promoters here find it increasingly unlikely that governments will support the World Health Organization (WHO) Healthy Cities axiom that: Since housing, environment, education, social service, and other city programmes have a major effect on health in cities, strengthening these are important. Indeed, both the federal and Ontario governments have removed themselves from developing any new social housing, a policy decision directly responsible for the record number of homeless people in Toronto. As a result of such shifts in responsibility, Toronto's debt is now more than a billion dollars. Yet, the provincial government continues to reduce income taxes and the Mayor of Toronto remains committed to not raising property taxes to provide needed services. Health promotion efforts in general, and Healthy Cities work in particular, are guided by core values of equity, participation and social justice. Another clear statement of principle that informs health promotion work is the definition of health promotion offered by Gordon MacDonald and John Davies: The key concepts in this definition are process and control … If the activity under consideration is not enabling and empowering, it is not health promotion. Additionally, core principles of Healthy Cities work include commitments to health, political decision making for health, intersectoral action, community participation, innovation and healthy public policy. All these principles are related to the concept of the ‘common good’—an idea increasingly more difficult to advance in Canada. Ann Robertson argues: The public ideas—and the language associated with them—which currently envelop us are those of the market, corporatism, fiscal restraint, and globalization, ideas which are driving the near universal dismantling of the welfare state, and eroding any notion we might have of the common good. Health promotion represents one possibility for countervailing ideas: ideas about equity, social justice, interdependence, the common good. In Canada, health promoters have come to recognize that powerful social, economic and political interests associated with economic globalization and the concentration of wealth are resisting this vision of the common good. In Canada, these forces have had notable success in influencing government actions. Neo-liberal ideology dominates federal policy making and the provinces of Alberta and Ontario are governed by ‘hard right’ neo-conservative parties that draw their policy inspirations from the United States. Cities such as Toronto suffer the consequences. In Toronto, health promoters committed to their vision continue to argue forcefully for government, community and individual actions consistent with health promotion principles of equity, participation and social justice. They receive support from the labour, faith and social development sectors. Increasingly, health promoters are recognizing that in the face of powerful opposition, ultimate success in achieving their vision depends upon political action involving both electoral politics and the mobilization of community members in support of their own interests. Bertolt Brecht wrote: All those who have thought about the bad state of things refuse to appeal to the compassion of one group of people for another. But the compassion of the oppressed for the oppressed is indispensable. It is the world's one hope. With best wishes, Dennis Raphael Raphael, D. (1999) Health effects of inequality. Canadian Review of Social Policy, 44, 25–40. Raphael, D. (2000) Health inequalities in Canada: current discourses and implications for public health action. Critical Public Health, 10, 193–216.

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