7b. The Role of Healthy Public Policy in Improving the Lives of Canadians: Lessons from the Past  

Following the trend of western, industrialized nations, Canada has realized substantive improvements in population health status over the past century.

Between 1926 and 2011, Canadian males gained an additional 20 years of life expectancy at birth, while females gained an additional 22.7 years.^{1, 2}

During the same time frame, the rate of first-year infant mortality (a key indicator of the health of populations) declined from just over 100 per 1000 births to 4.8 per 1000 (see Figure 1).^1,2

The impact of the steep decline in infant mortality can be seen when comparing the age structure of Canadian deaths over time.

• As Figure 2 illustrates, the number of deaths occurring between age 0 and 1 in 2011 was less than one percent compared to over 20 percent in 1926.  

• As Figure 3 illustrates, about one third of Canadian deaths in 1926 occurred above age 65: in 2011, the corresponding number was more than three out of four.^{1, 2}

These improvements in the population health status of Canadians were the focus of the Canadian Public Health Association’s centennial conference in 2010. To mark the occasion, the Association released a report identifying “12 great achievements,” key advances in public health associated with increased life expectancy and reduced morbidity from infectious and chronic diseases.²

In this CPHA-produced video, public health experts summarize some of these key accomplishments:

A description of each achievement is accompanied by a list of key “milestones,” developments or interventions, that were (or are commonly thought to be) responsible for each achievement. When reviewing the lists of milestones, the role of healthy public policy as a catalyst for improved population health outcomes is readily apparent.

Ensuring Food Safety

Hospital for Sick Children (n.d). Workers operating the pasteurization machinery. Retrieved from http://heritagetoronto.org/milk-pasteurization-at-sick-kids/

Healthy public policies feature prominently in the CPHA list of milestones contributing to safer, healthier foods. Legislative measures such as the mandatory pasteurization of milk, first introduced by the city of Toronto in 1915 (for all milk sold in the city)³ and implemented by the province of Ontario in 1938, reduced the number of infant and children deaths from bovine tuberculosis, typhoid, and a range of other diseases linked to contaminated milk.⁴ At the federal level, the Foods and Drug Act, passed into law in 1920 and strengthened in 1954, established safeguards against the preparation and sale of food under unsanitary conditions, with violations treated as criminal offences.⁵

Taxation is Good for your Health!?

Advances in tobacco control can also be traced to the implementation of healthy public policies. Increases in tobacco taxes (a milestone curiously absent from the CPHA list) are a proven deterrent to consumption.⁶ Figure 4 illustrates “a clear pattern of declines in sales of cigarette products in the US when prices increase but also a clear pattern of increases in sales when prices decline in real terms.”⁷  

The importance of taxes as a countermeasure to tobacco use in Canada was illustrated through an example of “unhealthy” public policy in 1994, when a tax rollback introduced by the federal government in an effort to combat smuggling reduced the price of cigarettes by half in much of Canada. Two years after the implementation of this policy, smoking rates among 19–24 year old adults had risen by four percent.⁸

Taxation has also been proven to be an effective deterrent to the high-risk consumption of alcohol products.⁹ And, as one of your readings notes, evidence supports taxation policies increasing the price of sugar sweetened beverages (SSBs) and other unhealthy food products by 20% or more to reduce consumption.¹⁰

Population Health Benefits of Progressive Taxation Policies

Taxation policies have the ability to impact health in ways that extend beyond deterring unhealthy behaviours. Specifically, progressive taxation, where people with more income pay a higher percentage of tax than those with less income, can also yield population-level benefits in the form of reduced health inequities and increased social capital.

A progressive taxation system, where the tax rate increases with the amount of taxable income, is one of the key policy tools for ensuring a more equitable distribution of wealth at the population level. You may recall the concept of the social gradient from Module 2 of this course. Analyses have illustrated how the social gradient becomes exacerbated in unequal societies. For example, Wilkinson and Pickett compiled data from all advanced industrialized nations to explore the relationship between levels of income inequality and performance in key health and social indicators, including life expectancy, infant mortality, and child obesity (see Figure 6).¹¹ The study consistently found that countries with higher levels of inequality had higher levels of health and social problems at all income levels. Simply living in a more unequal society puts individuals at greater risk of negative health outcomes.¹¹

 

 

Increased economic equality through progressive taxation also has a beneficial impact on social capital, which — as you may recall from Module 6 — has been defined as the key aspect of social organization, such as community or civic engagement, norms of reciprocity, and a sense of trust in others, that fosters collaboration for collective benefit.¹² Research by Kawachi et al found that low levels of social capital predict poor health outcomes, poor self-reported health, and high mortality rates at the state, community, and neighbourhood level. Through the application of path analysis, Kawachi et al found that social capital measures were the strongest pathways linking income inequality to age-adjusted all-cause mortality.¹³ In summary, high degrees of income inequality are associated with low levels of trust and support, which, in turn, increase stress and diminish health.¹⁴

One study points to a direct link between social capital and progressive taxation. Using tax rate data from 54 countries, Oishi, Schimmack, and Diener found that residents of nations with more progressive taxation policies reported higher levels of subjective well-being and greater satisfaction with public goods (e.g., the educational system). Conversely, tax rates for average earners and government spending as a percentage of GDP were associated with lower levels of subjective well-being.¹⁵ It thus appears that tax policies aimed at a fair redistribution of wealth, rather than large government spending or a high average tax rate per se, are linked to greater levels of subjective well-being.

Other Milestones in Healthy Public Policy

Motor Vehicle Safety

One of the most significant policy measures to improve motor vehicle safety occurred in 1976, when Ontario became the first jurisdiction in North America to mandate the use of seatbelts in motor vehicles. All provinces had passed similar legislation by the late 1980s.³ A study of provincial data between 1980 and 1996 to analyze the impact of seat belt use on traffic fatalities found that roughly 17 percent of the observed decline in vehicle occupant deaths over this time was attributable to the enactment of mandatory seat belt legislation and the corresponding increase in seat belt use.¹⁶

David James/Mike McCune (1984). Seat-belt poster. Automobile Club of Southern California Archives. Retrieved from https://amhistory.si.edu/onthemove/collection/image_321.html

Maternal and Newborn Health

Improvements in maternal and newborn health over the past century were brought about by policies aimed at improving sanitation, access to immunization and hospital care, nutrition, and higher living standards through income supports. Examples include the distribution of free vaccines, increased access to pre-natal care, and the introduction of the Family Allowance program, more commonly known as the “baby bonus.”³

Workplace Health 

Library of Congress (1937). [Female employees of Woolworth's holding sign indicating they are striking for a 40 hour work week]. Retrieved from http://www.loc.gov/pictures/item/00649864/

Healthy public policies also had a mitigating effect on the many diseases or injuries linked to unsafe workplaces and high-risk occupations. Successive provincial and federal legislation and regulations have been put in place to enforce workplace health and safety standards.³ At the same time, legislation recognizing and protecting the bargaining rights of labour unions helped to bring about decreased working hours, safer working conditions, and increased wages and benefits. These advances had positive impacts on locus of job control and perceived fairness of rewards, both of which have been identified as determinants of workplace health.¹⁷

In summary, a very strong case can be made that healthy public policy is the single most important type of public health intervention, accounting for the improvements in population health status arising over the past century. If the past is any indication of the future, there is great potential to reduce the growing burden of chronic diseases, such as diabetes, through the systematic development and implementation of policy-based interventions.