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Looking forward and looking back part I – reflecting on the past and coming years in health promotion

Contents

I Introduction
II Will the year of the Charter renew or destroy health promotion?
III Health promotion roots: reflecting on 2011 and earlier
IV Chronic Disease Prevention Alliance of Canada (CDPAC) year in review
V Reflections on the WHO Conference on the social determinants of health
VI Association of Public Health Epidemiologists in Ontario
VII Safe Kids Canada WHO update

I Introduction

Each year the OHPE invites organizations and individuals working in health promotion in Ontario and across the country to reflect on the past 12 months and predict what lies in store for the coming year. This is the first part of the reflections piece and the final OHPE feature for 2011. The second half of the reflections will run on January 6, 2012. Thanks to everyone who contributed to this as well as the other features that ran throughout the year.

II Will the year of the Charter renew or destroy health promotion?
Submitted by Dr. Irv Rootman

2011 is the year in which the 25th Anniversary of the Ottawa Charter for Health Promotion occurred. So far, I have participated in three celebrations of the Charter and there is at least one more to go. By the end of the year, I expect that I will be worn out from celebrating it with no energy left to actually do what it suggests we do. Thus, the question for me is will the year of the Charter renew or destroy health promotion?

On the “renew” side of the question it would be fair to say that all of the celebrations of the Charter that I have participated in so far, have been energizing and positive events, extolling the virtues of the Charter and noting its impacts in Canada and internationally through the development of health promotion in its image over the last 25 years. I also came away with the impression that many of the participants left the celebrations feeling that at least most of the values of the Charter, as well as the strategies, approaches and action areas were still as relevant today as they were 25 years ago, particularly in developed countries like Canada.  

On the other hand, in the sessions that I attended, as well as in a number of the ones that I didn’t attend, many participants didn’t hold back their critiques of the Charter, among other things suggesting that it was a document of its time (i.e. dated), it neglected non-industrialized countries, it did not sufficiently emphasize the importance of “ordinary people” and it did not grasp the issue of “equity” very well. Some even suggested that we abandon the Charter or at least revise it or develop something else. It was also interesting to note, that although public agencies sponsored the events that I participated in, none stepped forward to offer additional resources for health promotion as articulated in the Charter or verbally declared their commitment to it.

So does this mean that health promotion in Canada is going to die when the year of the Charter ends? The short answer is “no.”  One of the reasons why this is the case is that in spite of some losses of the core infrastructure for health promotion over the past few years, enough of it still exists to continue to carry the torch for the field guided by the Ottawa Charter. Many of the new schools of public health are also featuring health promotion in their curricula which includes the study of the Charter. Another is that as mentioned last year, the field of health literacy which in Canada is driven by health promotion, is continuing to gather momentum with its acceptance as a cross-cutting issue by the Public Health Agency of Canada and by the launch of a National Literacy Council next year. Next year will also see the launch of the third edition of Health Promotion in Canada, which contains inspiring examples of health promotion on the ground throughout the country. Finally, there is continuing evidence of the spread of health promotion values, approaches and strategies as expressed in the Ottawa Charter to other components of the health system, including health care as well as to other sectors.

Thus, I remain an optimist about the future of health promotion—for 2012 at least!

III Health promotion roots: reflecting on 2011 and earlier
Submitted by Penny Sutcliffe, Medical Officer of Health and Chief Executive Officer, Sudbury & District Health Unit

Being asked to contribute some year-end reflections proved a much-appreciated opportunity to stop and think about how health promotion has been foundational to my own public health practice. Before embarking on the journey that would eventually qualify me to work as a medical officer of health, I had the privilege of being enrolled in a master’s program in health promotion.  Now, after almost 14 years of serving as a local medical officer of health—the last 11 of which have been with the Sudbury & District Health Unit—I still consider health promotion and issues of justice and equity to be the foundation of my work.  I am honoured to share with readers of OHPE a few reflections “from the field” on what I see as significant progress in health promotion. Though, with the editor’s indulgence, I will cheat and reflect back a little further than 2011.

As health promotion professionals concerned with health equity, we will each have our own stories of battles won and lost.  I reflect back to Manitoba in 1998 when we (the province’s 13 medical officers of health) sought to convince the minimum wage review board that adequate wages were as important to health as immunizations. It was radical – we were panned. Fast forward to 2011 where the Ontario government mandate for public health (Ontario Public Health Standards) and the legal objects of our public health agency (Public Health Ontario) include requirements to improve health equity and work with vulnerable populations. Advocacy from the public health field helped in no small measure to create these successes. Our province has made significant gains in terms of recognizing the “rightful” place of health equity – the social and economic determinants of health – on the public health agenda.  But are our workforces ready for this challenge?

At the Sudbury & District Health Unit, our answer to this a few years ago was “no.”  We knew that we were ready from a governance and values perspective. We even felt like we knew what it – the province – should do.  But when we looked in our own backyard, it wasn’t so clear.  What actually should local public health do to reduce health inequities? What could we do other than try to mitigate the health impacts of poverty?  We embarked on answering this question from which our “10 promising practices” emerged (available at http://www.sdhu.com/uploads/content/listings/10PromisingPractices.pdf).  Then this past year, we produced a video to engage our non-public health partners to “start a conversation about health without talking about health care at all” (available at http://www.sdhu.com/content/healthy_living/doc.asp?folder=3225&parent=32...)

Our hope was, and is, to do our bit; to take very seriously the positive evolution in government mandate, to leverage the skills of our very talented staff, and to recognize the privilege of being in a well-funded (relatively speaking in the Canadian context) public health system.  While as an organization, we are committed to acting responsibly to reduce health inequities locally, the Sudbury & District Health Unit faces challenges common to all of us.  Our collective go-forward challenge is to continue to build the evidence base for effective local public health practice to reduce social inequities in health.  We need good interventions, even better evaluations, skilled and knowledgeable staff (and students), and explicitly articulated values so that our public health work to improve equity becomes normative, increasingly sophisticated, and measurably effective…until there is no turning back.

IV Chronic Disease Prevention Alliance of Canada (CDPAC) year in review
Submitted by Bill Callery and Craig Larsen

As we wrap up 2011 at the Chronic Disease Prevention Alliance of Canada (CDPAC) we look back proudly, taking stock of numerous successes, while at the same time looking back in critical self-reflection. In our 2011 year in review we note a number of significant accomplishments towards the organization’s vision of an integrated system of research, surveillance, policies and programs for maintaining health and preventing chronic disease in Canada through knowledge exchange and advocacy.

We know that chronic diseases are the leading causes of death and disability worldwide, and in Canada. About two thirds of total deaths in Canada are due to chronic diseases, and three out of five Canadians over age 20 are living with a chronic disease. In total, chronic diseases are estimated to cost the Canadian economy at least $190 billion a year (2010) (http://www.phac-aspc.gc.ca/media/nr-rp/2011/2011_0919-bg-di-eng.php). At the same time, we know that a large portion of these diseases are preventable.

The year 2011 could certainly be known as “chronic disease prevention year.” In 2011, Canada as well as nations worldwide showed an increased interest and engagement in addressing the heavy health, social, and economic burdens of chronic diseases, through the United Nations high-level Meeting on Non-Communicable diseases (UN NCD) in New York on September 19 – 20; an international gathering of more than 30 heads of state and government and at least 100 other senior ministers and experts. Indeed, the meeting’s importance cannot be overstated. It was only the second time in the UN’s history where the General Assembly met to discuss a health issue with major health, social and economic impacts; the last being on HIV/AIDS. (http://www.who.int/nmh/events/un_ncd_summit2011/en/)

CDPAC was honoured to be invited to attend the UN NCD summit as part of the Federal Minister of Health’s six-person delegation. CDPAC’s Chair, Ida Thomas, attended the summit as part of the small delegation, led by Minister Aglukkaq and Canada’s Chief Public Health Officer Dr. David Butler-Jones. Through Ida, we viewed first-hand the global emphasis being placed on chronic diseases, and our determination to address the common risk factors in Canada was re-enforced. CDPAC took this opportunity to deliver several key messages to the minister, including applause for federal leadership on curbing childhood obesity and the Declaration on Prevention and Promotion, insisting that largely preventable chronic diseases must rise to the top of health priorities, and asserting that the best way to tackle the problem is to address the common risk factors and underlying determinants that lead to unhealthy lifestyles. Finally, CDPAC offered itself as a national coordinating organization in support of federal leadership to address those common risk factors.

CDPAC is also proud to be a leading source of information on chronic disease prevention. Before, during, and after the summit, CDPAC maintained a website section devoted to the UN NCD summit proceedings, breaking news, and links to social media coverage. Two days after the summit, upon returning, Ida Thomas reported on her participation via teleconference to over 60 members of the broad chronic disease prevention community across Canada. Ida has since reported via webinar to a group of approximately 20 University of Waterloo graduate trainees in Population Interventions for Chronic Disease Prevention. Additionally, Ida and CDPAC Executive Director Craig Larsen appeared before the House of Commons Standing Committee on Health in early December to help inform the Committee’s study of Health Promotion and Disease Prevention.

CDPAC also reflects on the great strides we have made in 2011 in our efforts to prevent childhood obesity. Through the Collaborative Action on Childhood Obesity (CACO) initiative, one of seven Canadian Coalitions Linking Action and Science for Prevention (CLASP) initiatives funded by the Canadian Partnership Against Cancer (CPAC), we have worked with our five national and provincial/territorial partner organizations to contribute to a reversal of the escalating trend in obesity rates in Canadian children.
The CACO initiative has been so tremendously successful in large part because of the collaborative efforts of our partner organizations – the Childhood Obesity Foundation, University of Ottawa, Heart and Stroke Foundation Quebec, Quebec Coalition on Weight-Related Problems (Coalition québécoise sur la problématique du poids), and Government of Northwest Territories – who work together to comprehensively and simultaneously address three levels: individual (i.e., behaviour change), community (i.e., school and community regulations), and policy (i.e., marketing to children and taxation of unhealthy foods).

Our collaborative efforts in CACO have resulted in numerous successes, including the adaptation and implementation of B.C.’s school-based “Sip Smart” program in Northwest Territories and Quebec to reduce the consumption of sugar-sweetened beverages; the pilot and evaluation of a zoning project to limit fast-food restaurants around schools in Quebec; and improved access to traditional land-based food procurement and preparation and healthy market alternatives in several remote northern First Nations communities.

CDPAC was thrilled to hear in November that CPAC plans to renew its CLASP initiatives beyond 2012. CDPAC is now working with its CACO partner organizations to submit a proposal for a ‘CACO version 2’, bringing on additional partners in order to increase our reach and build on our successes to date.

Over the course of 2011 our chronic disease webinar series, delivered in collaboration with the Public Health Agency of Canada’s (PHAC) Canadian Best Practices Initiative, have become an ever more popular learning tool and best-practices resource to a pan-Canadian audience of chronic disease prevention practitioners and decision-makers in the public health, government, and non-profit sectors. In fact, our most recent webinar was record-setting, being attended by well over 200 participants. At the end of 2011, we are well into our second series of CDPAC/PHAC webinars; our first series was on childhood obesity prevention, and our second series covers a range of chronic disease prevention topics from obesity prevention, to food insecurity, to mental health. CDPAC is delighted to offer the chronic disease prevention webinars in collaboration with PHAC, and we hope to continue to improve upon the series well into 2012. Information about past webinar series, including podcast recordings and presentations, can be found on the CDPAC website.

The year of 2011 was also one of critical self-reflection for CDPAC, one of looking back on our history and looking forward to our future. In September 2011 the CDPAC alliance of representatives from our nine respective member organizations met in Ottawa for two full days to reflect on past years’ activities, examined our vision, priorities and mandate, and began to develop a strategy for moving forward. The CDPAC alliance will meet again in the early new year to continue development of a strategic plan that will carry CDPAC through to the end of 2012.

CDPAC is looking forward to an exciting new year of continued success in 2012. To start off the new year, CDPAC will be convening stakeholders from across Canada for our fourth pan-Canadian conference entitled Integrated Chronic Disease Prevention: It Works! The conference, which runs from February 7 – 10th 2012, builds on our previous three conferences to take stock of advances that have been made with regard to integrated action for chronic disease prevention in Canada; the successes, the challenges, the gaps, and our opportunities. In recognition of the multi-factorial causes of chronic diseases, the emphasis will be upon ‘what works’; how are sectors coming together for collaborative action on chronic disease prevention. We encourage those interested to visit CDPAC’s website at www.cdpac.ca for more information, and to register early to take advantage of the early registration rate.

V Reflections on the WHO Conference on the social determinants of health
Submitted by James Chauvin, Director of Policy, Canadian Public Health Association; Vice President & President Elect, World Federation of Public Health Associations

At the start of my career, much of my work in Haiti and Tunisia focused on agricultural/food security, nutrition, early childhood development, water and sanitation, housing, education and farmland erosion control as means to improve health. In fact, I was involved in very few "health care" interventions.  The Declaration of Alma-Ata, adopted at the 1978 WHO/UNICEF International Conference on Primary Health Care, was a clarion call to all who worked in the field. While the term “determinants of health” had not yet been coined, we were working towards “Health for All by the Year 2000” by putting into place the conditions that would create healthy communities. What was perhaps not appreciated at that time was the important roles of governance, globalization and citizen engagement in decision-making as key determinants of health.

Some 35 years later, I attended the WHO Conference on the Social Determinants of Health from October 18 – 21 in Rio de Janeiro on behalf of the World Federation of Public Health Associations (WFPHA). Before boarding the flight to Brazil, I was looking forward to learning about and bringing back home stories about successful initiatives that were contributing to “closing the gap” in health and social equity. I ended up getting much more than I anticipated.

There were over 1,000 participants, including 122 country delegations, international and national non-governmental organizations (NGOs) and social movement organizations, representatives from WHO and other UN agencies, bilateral agencies and other interested parties. It is my understanding that the Canadian government delegation, led by the Chief Public Health Officer of Canada, was the second-largest governmental delegation after Brazil, the host country. One of the opening plenary panelists described the event as “Alma-Ata” for the 21st Century.

I attended several thought-provoking sessions including a pre-conference session on “Protecting the Right to Health as an Action on Social Determinants” organized by the People’s Health Movement in partnership with several other NGOs including the WFPHA. This session examined the many structural factors that affect individual and community health and the weaknesses in the provisional “Rio Declaration.” Concern was expressed by many about the lack of commitment and action by governments on structural social determinant of health issues related to unregulated capital transactions, the erosion of universal equity-based social protection systems, unfair tax regimes, unfair trade policies and practices, unregulated and unaccountable multinational/transnational corporations and the harm their products and practices inflict on human health, the lack of democratic and transparent decision-making and the impact of unregulated global speculation (what David Sanders of South Africa referred to during the closing plenary sessions as "casino-capitalism").

I also came out of a concurrent session on institutionalizing citizen participation in policy making feeling that, compared to their counterparts in Latin America, India and South Africa, Canadians are by and large quite complacent about citizen engagement in policy decision-making and implementation. As a society, we have much to learn from their experiences. In some countries, active social participation has become an institutionalized process due largely to popular uprisings against colonialism, racism and dictatorial governance. Governments actively and meaningfully consult with their citizens before formulating policies and programs. The processes may not be perfect, and some elements were criticized by the presenters, but they contributed to positive actions on health equity and the movement of millions of people out of poverty.

I was also honoured to participate during a concurrent session as a discussant alongside Ms. Beth Mugo, the Kenyan Minister of Public Health & Sanitation, Dr. Aaron Motsoaledi, the South African Minister of Health and Dr. José Gomes do Amaral, the new President of the World Medical Association. Together, we discussed the changing role of the health sector, including public health, in reducing health inequities through a social determinants of health approach. Ms. Mugo’s comments focused on the Government of Kenya's comprehensive and multidimensional strategy to address the tuberculosis situation in her country. Dr. Motsoaledi spoke about the multidimensional and complex determinants of HIV/AIDS in South Africa, especially with respect to miners and their families/partners, and the various initiatives being implemented to address the situation. Dr. Gomes do Amaral and I discussed our respective experiences in Brazil and Canada regarding the role of national and global professional associations in advocating for health equity through a social determinants of health approach.

During the conference’s final session, the Rio Political Declaration on Social Determinants of Health (http://www.who.int/sdhconference/declaration/en/) was released. It is a non-binding statement by WHO member states that sets out a series of pledged actions by governments to move towards achieving health equity through a social determinants of health approach. The declaration is organized around five "key action areas critical to addressing health inequities":

  1. Adopt better governance for health and development;
  2. Promote participation in policy making and implementation;
  3. Further reorient the health sector towards reducing health inequities;
  4. Strengthen global governance and collaboration; and,
  5. Monitor progress and increase accountability.

While non-binding global declarations such as this are never perfect (an alternative civil society declaration was released by the People's Health Movement to address some of the Political Declaration’s perceived shortcomings – http://www.phmovement.org/en/node/6243), we need to take what we have and use it along with the proposed alternatives that merit attention to advocate for real action on health equity. It is our responsibility to mobilize our community to use the Rio Political Declaration locally, nationally and globally and to encourage governments and international agencies to uphold the pledges they have made. Together, we can close the gap in a generation.

VI Association of Public Health Epidemiologists in Ontario
Submitted by Anne-Marie Holt, MHSc. APHEO President

As the president of the Association of Public Health Epidemiologists in Ontario (APHEO), I have been asked to provide my perspective on the past year in public health.

While it has been a busy year, I think those of us in public health have been fortunate to have seen the implementation of a number of initiatives designed to renew and strengthen Ontario’s public health system. A number of those initiatives being realized at the local level are the result of recommendations from Operation Health Protection, as well as the final report of the Capacity Review Committee.

Throughout the year we have seen:

The launch of the province’s performance management program and accountability agreements, complete with indicators to measure the contribution of local public health units on the broader public health system. Tracking our progress and celebrating our successes is important.

Increased linkages between research and practice; the transfer of the former Public Health Research Education and Development program to Public Health Ontario (PHO) has really started to take shape with the introduction of the Locally Driven Collaborative Projects grant program, Library Services, Ethics Review support, and Student Preceptor Support and Knowledge Exchange.

Enhanced support from the public health laboratories has enhanced public health’s ability to respond to reportable diseases and outbreaks both at the local and provincial levels.

The transfer of scientific functions in many of the Ontario Public Health Standards (OPHS) program areas to PHO provides an opportunity to build scientific capacity in the system and has streamlined the provision of advice to the field in many areas

And, most recently, the transfer of the Ministry of Health Promotion to the Ministry of Health and Long-Term Care is a further opportunity to build capacity in the health promotion and disease prevention aspects of the OPHS.
   
A strong public health system can only be achieved through partnerships and collaboration. APHEO, together with our public health partners, have been privileged to participate in the planning groups behind many of these initiatives.

For the coming year, I think it’s important for us to continue to build and enhance these partnerships within public health and among government departments. While we are all facing an economically challenging time, the renewal of Ontario’s public health system is important. We are just finding our stride - let us not lose sight of future opportunities to improve the health of Ontarians.

VII Safe Kids Canada WHO update
Submitted by Amy Wanounou, Coordinator, Government Relations and Public Policy, Safe Kids Canada

In January 2011, the World Health Organization's (WHO) Executive Board adopted a resolution on child injury prevention and recommended its inclusion within the child survival agenda. The resolution notes that it will be difficult to achieve Millennium Development Goal 4 to reduce child mortality in some countries without addressing child injury. The resolution was adopted in May 2011 by the World Health Assembly.  

Globally, unintentional injuries are a major cause of death, responsible for approximately 830,000 deaths to children and youth under 18 years of age each year. In Canada, preventable injuries are the leading cause of death and a major cause of hospitalizations for children and youth.  Given the magnitude of the impact of injuries on children’s overall health, injuries need to be recognized as a child health indicator.  

The resolution calls for:

  • Prioritization of the prevention of child injury and ensuring necessary intersectoral coordination mechanisms are established or strengthened;  
  • Funding mechanisms for public health programs for child survival or child health that cover child injury prevention; and
  • Implementation, as appropriate, of the recommendations of the WHO/UNICEF World report on child injury prevention.

The WHO resolution is an opportunity to undertake concerted and coordinated action in order to reduce the burden of injury in Canada.  To date, much of the development that has occurred in injury prevention has been led from outside government – through the dedication of various nongovernmental organizations and provincial injury prevention organizations.  Injury prevention organizations like Safe Kids Canada continue to look for national leadership and coordination on this issue, as well as funding at a level more commensurate with the burden of injury on society and more in keeping with resources dedicated to other comparable health issues, including resources to sustain a ‘home’ to lead an evidence-informed pan-Canadian strategy for injury prevention.  

The injury prevention community will continue to harness the principles of the WHO’s resolution on child injury prevention in the coming year as it works toward increased federal commitment and investment in a national injury prevention strategy.  A number of opportunities, including discussions on the renewal of the Health Accord in 2014, will provide avenues to communicate the urgent need for child injury to be recognized as a significant health issue and the need for federal-provincial-territorial collaboration.