Since the first edition of this book came out, there has been a growing and robust body of evidence that continues to highlight the significance of the social determinants of health (SDOH). Validated in study after study, findings show that the factors that have the greatest overall influence on an individual’s health are socioeconomic—income, education, employment, housing, food security, and so on. In fact, the SDOH are the most potent variables we have to predict wellness and longevity.

Dennis Raphael has described in this edition how “[a] social determinants of health approach sees the mainsprings of health as being how a society organizes and distributes economic and social resources, [and] directs attention to public policies as means of improving health.” Through the work of Raphael and others, we know it is not simply personal life choices or bad genetic luck that makes us sick. Rather, it is the structural inequalities embedded in how we organize our society that are the largest barriers to improving our collective health.

Yet, despite knowing what ails us, the last 20 years have seen successive Liberal and Conservative federal governments unwilling to act on the evidence before them. This fundamental disconnect continues to be a key obstacle to providing the simple dignity of genuine and equitable health for all Canadians. It is time for governments to move beyond superficial nods to the SDOH. As the authors of this third edition of The Social Determinants of Health: Canadian Perspectives explain, the lived realities of Canadians’ health cannot be separated from our social relations and inequalities.

The health of Canadians is getting worse—make no mistake—and this state of exception is becoming the norm. One in seven Canadian children live in poverty (placing us 15th out of 17 similar nations). In Canada, 30,000 people are homeless on any given night, with an estimated 50,000 hidden homeless. Canada is now ranked 13th among OECD nations for life expectancy, whereas we ranked 8th in 1980. In addition, approximately 1.1 million households in Canada experience food insecurity. Roughly 40,000 Canadians die prematurely each year as a result of the tenuous calculus of social inequality (equal to 110 Canadians dying each day). Further, despite the scarcity of research regarding race and SDOH in Canada, it is clear that racialized groups are disproportionately and adversely impacted by the institutions and processes that determine quality of health in Canada. While the lived experience of racialized poverty and marginalization differs between groups, it is estimated that racialized people are two to three times more likely to be poor than other Canadians.

Though there is no official measurement of “poverty” by Statistics Canada, looking at income alone we see that the wealthiest 20 percent now control nearly 70 percent of all wealth in the country. The top 10 percent own almost half of all the wealth; the poorest 20 percent own no share of the wealth at all. This income gap has accelerated without remorse, such that in the last 10 years, the wealth of the top 10 percent of Canadians increased by 42 percent. In these “tough economic times” Canadian CEOs earned 189 times the average wage, increasing from 105 times in 1998. Our largest city, Toronto, is now the inequality capital of Canada, with income inequality growing by 31 percent between 1980 and 2005. Meanwhile, the average gap across the country grew by 14 percent. Even the most cursory look at the available data exposes the appalling and pathological asymmetry occurring in our country.

A person’s class and socioeconomic position is the strongest predictor of their health status: being poor means you are more likely to be sick and being wealthy means you are healthier. But, we do not need tables or slideshows to see this troubling correlation between deepening class and socioeconomic cleavages and their negative impact on the SDOH for Canadians. The social gradient of health is apparent in the everyday voices and stories of housing, employment, education, and other lived realities.

Sadly, not only are politicians and policy makers failing to address the upstream causes of illness, but they are absconding themselves from downstream responsibilities. Across Canada we are seeing one of the founding principles of our medicare being eroded: that care must be based on need, and not the ability to pay. Accelerating this erosion, the former Harper government unilaterally cut over $36 billion from public health care over the next ten years and decided it would not enforce the Canada Health Act. Provincially, the race to the bottom to privatize the health sector and promote two-tiered systems has become commonplace. The new Liberal government, elected in 2015, has promised to create a new health accord with a different long-term funding formula, but the form that this will take is unclear.

It comes as no surprise then that our health policies are not working—this is precisely because they are designed to listen to ideology over evidence in order to ignore the structural issues at the core of the SDOH. While solutions to health inequalities pose complex challenges, there is an alarming tendency by policy makers to simply apply another coat of veneer to cover up the rot until a later date. The ugly consequence is a more downstream set of strategies with the artifice of health bureaucracy solutions (the panacea of more “innovation,” “efficiency,” and “lean management”). We do not need more euphemisms for the marketization of our health or tired arguments from neoclassical economists. Canadian health care is an empty signifier; everything depends on who gets to fill it with meaning. Right now, the wrong people are giving it meaning. Our challenge is to ascribe new meaning to our health care policy. If we are honest with ourselves, we know health inequalities are avoidable. The problem is not a failure to understand, but the will to design policy guided by creating the conditions for all people to enjoy true health—a collective responsibility to one another.

So, what is to be done? First, it is crucial to transform the policy, political, and public discourse on health from an individual to collective approach. Our current individualistic approach to health flattens and narrows lives—meaning becomes less concerned with larger structural conditions influencing our health and our relations with others in society. We are not merely our individual behaviours, and our health should not be held captive by this framework. Health policy designed to address lifestyles and behaviours does not recognize the myriad SDOH factors beyond an individual’s full control. This atomization and decentralization (which we are all too familiar with in Canada, where we are no longer citizens but “taxpayers”) functions as the main catalyst for neo-liberalism to produce the growing inequalities and the reproduction of class privilege we are currently seeing. Make no mistake, neo-liberalism is an insidious paradigm that destroys our society’s health and well-being.

Second, we need to reframe the debate to really begin dealing with the egregious and persistent disparities in Canadians’ health. At the heart of the debate is the distinction between a right and a need. This is not simply a semantic distinction. Far too often politicians and policy makers see health not as a right, but as a privilege or need that they can ration to individuals. On the other hand, a human right is something that cannot be traded, sold, or denied based on someone’s social economic position and ability to pay. In the political consensus of the post-war period we saw many first-wave human rights enshrined in Canadian law (freedom of speech, freedom of assembly, freedom of religion). In contemporary Canada, many important third-wave rights (sexuality, gay marriage, and ethnic and racial identity) have been won. In both cases, the focus falls largely upon the individual. Absent from our political and social discourse are second-wave rights, the collective rights, which encompass the SDOH. This is because these rights challenge the logic of capital and inherently offer a systematic critique by demanding power over process and a stake in shaping the system. They are rights that claim the agency to shape the socioeconomic world around us, from wages, to housing, to education, and refuse to be captive in an economic system that promotes profit over well-being.

The health of Canadians is not a gift; at its best, it can be a fragile accomplishment attained only through our collective actions and understanding of the SDOH. We cannot rescue our health care policy from its own contradictions. Such contradictions are structural, embedded in the fabric of a society that facilitates inequality. Consequently, it is time to move beyond symbolic recognition of the SDOH and demand the changes necessary to make Canada a truly healthy society. At their core, discussions about the SDOH are about agency, systemic critique, and structural change. They are a revolt against current convention. The right to health is both a cry in response to lived experiences of inequity and a demand to create an alternative society animated as much by aspirations as possibilities: we can make Canada as healthy as we want it to be.

Yet addressing the SDOH and recognizing the right to health can never be an end in itself; rather, these represent a way point in the process of changing socioeconomic inequalities and class structures. It is a vision for ourselves and our communities, for the qualities and principles we aspire for and choose to protect. These values stand for something meaningful and greater than themselves. They speak for what is right; are inspired by building a better country; and are about making choices that are grounded in community, kindness, and decency. There is no more powerful symbol of these desires than our health.

—Michael Butler, National Health Campaigner for the Council of Canadians, and Maude Barlow, National Chairperson of the Council of Canadians

When Tommy Douglas brought our first universal publicly funded health system to the province of Saskatchewan, he passionately argued that medicare must not only ensure that people get the health care they need when they need it, but it must implement public policies for keeping people well, not just patching them up once they get sick.

Unfortunately, since that time, medicare has been pulled toward a commitment to the service contract of health care delivery. Thankfully, in Canada we have had Dennis Raphael sounding the alarm that just focusing on the “repair shop” is not only counter to our Canadian values of social justice, it will ultimately put the sustainability of our cherished health care system at risk. His scholarship and dogged advocacy on the need to address the broadest possible approach to social determinants of health has been a powerful antidote to the “tyranny of the acute.”

It has been said that Canada led thinking on population health with the Lalonde Report of 1974, New Perspectives on the Health of Canadians. In 1986 the Ottawa Charter identified five action areas for health promotion, the fourth of which, “Building healthy public policy,” called for “complementary approaches, including legislation, fiscal measures, taxation and organisational change. Health promotion policy requires the identification of obstacles to the adoption of healthy public policies in non-health sectors and the development of ways to remove them.”

Since then, a tremendous amount of research has shown that health is influenced by a wide range of policies and interventions that go beyond health care. Interestingly, the Canadian Institute for Advanced Research estimates that only 25 percent of the health of the population is attributable to the health care system, while 15 percent is due to biology and genetic factors, 10 percent results from the physical environment, and 50 percent is attributable to the social and economic environments. Health can no longer be the sole responsibility of the ministers of health.

Throughout this volume there is a profound sense of frustration that despite the increasing discussions and evidence on the importance of dealing with the social determinants of health, Canadian public policy makers have been embarrassingly resistant to these concepts.

I believe that as long as citizens think of the “sickness care system” whenever they hear the word “health,” we are going to have real trouble in our efforts reorienting public policy to the social determinants of health. Surely the production of health through poverty elimination or workplace hazards reduction must fit side by side with a system mandated to operate emergency rooms and to reduce wait times for surgical services? Canadians must understand that upfront investment in the social determinants of health today will prevent larger amounts of money being spent on treatment and rehabilitation later on.

Dr. Halfan Mahler has said that “Health is politics,” and that “If you want to move healthy public policies forward, you have to have political dynamite.” SARS, Kashechewan, Hurricane Katrina, or the heat wave in France in 2004 that killed over 14,000 have been important teachable moments. I believe we have done a terrible job of explaining the “Pay now or pay a lot more later” economic arguments for investing in health of citizens. “A stitch in time saves nine,” “penny-wise and pound foolish” are axioms we were all raised on. But the “tyranny of the acute” means that putting new drugs on the formulary and a new gamma knife for the world-class surgeon becomes the squeaky wheel and active measures on the social determinants of health take a back seat again and again. In Canada we have also suffered because the social determinants of health criss-cross many government departments and all jurisdictions. We have been unable to break through the gridlock of jurisdictional squabbles and vertical ministerial accountability for these complex challenges.

I think citizens do understand the social responsibility—health as a fundamental human need and therefore a basic human right and our moral obligation to do the right thing. But if they or a loved one are on a wait list, they expect their politicians to immediately respond and fix it. The medical model still rules.

There is no question that the political will to do the right thing dramatically improves with an educated public. Health literacy means that citizens can be pulling healthy public policy from their governments and politicians. I am a big believer in bottom-up solutions and the importance of improving the methodologies for true civic efficacy.

However, we have a formidable enemy in the sales department of modern media. Simple messages and simple solutions fit on a bumper sticker and in a seven-second sound bite. Every day I am reminded of the quote of H.L. Mencken: “For every complex human problem there is a neat simple solution, it’s just that it’s wrong.” I believe that we must fiercely defend the complex solutions for the complex problems that are facing health and health care, but I believe we have to find simpler messages, plain language if we are going to have citizens onside.

The WHO Commission on Social Determinants of Health, which is headed by Sir Michael Marmot, is examining the “social determinants of health” and “health inequities,” but he is now brilliantly talking about the causes and the “causes of the causes” that better explain the huge gaps in health outcomes.

Lately I have found that the following short health literacy quiz has been helpful in putting the public back into public health and replacing “health care” with “systems for health.”

HEALTH 101

Do you think we should have a

(a) strong fence at the top of the cliff or

(b) state-of-the-art fleet of ambulances and paramedics waiting at the bottom?

Would you prefer

(a) clean air or

(b) enough puffers and respirators for all?

Would you prefer that wait times be reduced by

(a) a falls program to reduce preventable hip fractures or

(b) private orthopaedic hospitals and more surgeons?

Should we invest in

(a) early learning, child care, literacy, the early identification of learning disabilities, and bullying programs or

(b) increase the budget for young offenders’ incarceration?

Should we

(a) assume that the grey tsunami will bankrupt our health care system or

(b) include our aging population in the planning of strategies to keep them well?

Is the best approach to food security

(a) food banks and vouchers or

(b) income security, affordable housing, community gardens and community kitchens, and a national food policy?

Pick the one that is not correct:

Pandemic preparedness should focus on

• Tamiflu for all

• working with the vets to keep avian flu a disease of birds

• making sure people wash their hands, especially the doctors and nurses

• research on vaccines

• community care plans for our most vulnerable

Should governments boast about

(a) how much they spent on the sickness care system or

(b) the health of their citizens, leaving no one behind?

The profound structural change needed to secure investments in the social determinants of health in our complex federal system will occur only if we succeed in raising public awareness and developing political will. As you know, politicians tend to follow where the public goes, so helping the public understand the issues and demand change from governments will be crucial. For me, a major challenge in Canada is to make the public understand, believe, and take ownership that ill health, poverty, and social exclusion are unacceptable in one of the richest countries of the world. Progress toward a healthier world thus requires broad participation, sustained advocacy, and strong political action.

I firmly believe that this book provides an imperative for Canada to move from the description of the problem and the prescription of solutions to implementation of systematic and meaningful strategies and interventions to improve the health of our citizens and eliminate the inequity particularly among our First Peoples.

Population health is ultimately a question of what kind of society we wish to live in. The aim of population health is for human health to be seen as one of the most important overall objectives of public policy.

This is about advocacy, leadership, and action. It is about the civic literacy of putting health back into health care. Dennis Raphael has articulated a vision. The other contributors have shown us that real solutions are out there in trenches. We need the political will to harvest those solutions into better public policy across government departments and across the squabbling jurisdictions.

I was there that Friday night in November 2002 at York University in Toronto for the opening of the conference “Social Determinants of Health across the Lifespan.” I remember hearing John Frank and Dennis Raphael speaking so passionately about these things that seem so sensible and doable.

This book updates the progress to date in the scholarship and evidence of the interventions that can improve the overall health of the population and reduce health disparities, which will allow tens of thousands, and maybe even millions, of Canadians to lead longer lives in better health. This, in turn, will result in increased productivity because a healthy population is a major contributor to a vibrant economy, reduced expenditures on health and social problems, and overall social stability and well-being for Canadians. Perhaps even more importantly, a focus on interventions to deal with the social determinants of health will translate into a fairer and more equitable society.

Disraeli said that “The care of the public health is the first duty of a statesman.” Unfortunately, in our present political system, statesmen, as defined by James Freeman Clarke, are rare: “A politician thinks of the next election, a statesman the next generation.” If this book were compulsory reading for all elected officials and public servants, we could achieve not only a healthier, more equitable society but also the added dividend of more statesmen!

—Dr. Carolyn Bennett, MP, FCFP; assistant professor, Department of Family and Community Medicine, University of Toronto; Canada’s first minister of state for public health, 2003–2006

One of the key points that I made in Building on Values: The Future of Health Care in Canada is that we have to set a national goal of making Canadians the healthiest people possible. One of the keys to achieving this goal is a greater emphasis on preventative health measures and improving population health outcomes.

Although I referenced this in my report, I will be the first to admit that even if all of my 47 recommendations are adopted, and even if they are implemented the way I would want them to be, it will only take us partway toward this goal.

A health care system—even the best health care system in the world—will be only one of the ingredients that determine whether your life will be long or short, healthy or sick, full of fulfillment or empty with despair.

If we want Canadians to be the healthiest people in the world, we have to connect all of the dots that will take us there. To connect the dots, we have to know where they are. Those who have contributed to this volume have added valuable perspectives in this regard as they connect research and ideas on the social determinants of health to the health outcomes we seek as a nation.

Healthy lifestyle choices may be important and vital—and they are. A comprehensive, responsive, and accountable national health care system may be important and vital—and it is. But the main factors—the main “determinants,” as the experts call them—that will likely shape our health and lifespan are the ones that affect society as a whole. And if we want Canadians to be the healthiest people in the world, we have to deal with them at that level.

The editor of this text, Dr. Raphael, has gathered together some of Canada’s important thinkers on the key determinants. This volume provides the latest research and ideas regarding income distribution; the importance of a healthy workplace; the critical role that early childhood education, and public education generally, plays in the life-cycle process; the importance of food and shelter; and the importance of belonging reinforced by various views of social inclusion.

I noted recently that our policy-making and program-developing mechanisms in Canada are suffering from what I call “hardening of the categories.” Something useful is proffered by one government department with the intended gains stifled by something counterproductive in another department.

Our policy-making processes need to be integrated and integrating. We need to move from an illness model to a wellness paradigm that connects the dots of all of the factors that contribute to health for individuals and society at large.

Even if we make great strides to improve our systems of health care in Canada, our genuine gains in health will be hindered unless we pay serious attention to the other determinants of health. At present, there are too many children going to school and to bed hungry, too many people living on our urban streets, an increasing number of working poor, and too many people feeling like they are on the outside looking in when it comes to decision making in our communities.

How important is it that we think in new ways?

Historians and health experts tell us that we have had two great revolutions in the course of public health. The first was the control of infectious diseases, notwithstanding our current challenges. The second was the battle against non-communicable diseases.

The third great revolution is about moving from an illness model to all of those things that both prevent illness and promote a holistic sense of well-being.

In my view, the wellness model needs to be informed:

• by inspired leaders who genuinely share power with those less fortunate

• by a commitment to social inclusion and civil society that provides opportunities for all Canadians to participate in the things that count in our neighbourhoods across this great country

• by an understanding that hopelessness kills and hopefulness with opportunity is a prescription for good health

That’s my kind of revolution. It’s the kind that will ensure that Canadians are the healthiest people we can be. It’s also the kind of revolution that understands that the exceptional health we seek, and how we achieve it, can provide a Canadian model for the world to emulate.

Social Determinants of Health provides a rich companion to our work on health care and a useful springboard for integrated healthy public policy.

—The Honourable Roy J. Romanow, PC Saskatoon February 2004