Chapter 2: The Chief Public Health Officer's report on the state of public health in Canada 2008 – Canada's public health history

Chapter 2 - Public Health in Canada

Public Health in Canada

Canadas public health history

Prior to Europeans arriving and settling in North America, Canada was inhabited by millions of Indigenous peoples.Footnote 15 The origins of public health in this country can be traced back to traditional Aboriginal teachings that highlight the importance of maintaining and restoring balanced health through social and environmental sensitivity.Footnote 16Footnote 17 These long-standing traditions were jeopardized following the arrival of European settlers who brought new diseases and a way of life that led to a serious deterioration in the lives of Canadas Indigenous Peoples.Footnote 16

The threat of infectious diseases began to impact Indigenous peoples in North America in the early seventeenth century, with the first historically recorded outbreaks occurring between 1734 and 1741. The arrival of settlers not only meant illness and death for Aboriginal Peoples, but also a loss of traditional lands, resources and livelihoods – creating a new lifestyle involving competition, exploitation and a loss of long-standing norms, values, and societal and spiritual practices. These factors, along with others, allowed for an all too easy transition from a state of good health to ill health.Footnote16

1830-1900

Early settlers were not spared from infectious diseases.Footnote 15 In 1832, an estimated 20,000 lives were lost in Upper and Lower Canada from a cholera epidemic. In an attempt to contain the disease, the Lower Canada Board of Health created a quarantine station for new arrivals on Grosse Île in the St. Lawrence River. Quarantine measures were enforced by the military to prevent the spread of the disease through Upper and Lower Canada.Footnote 18

In 1847, the next wave of infectious disease, typhus, killed 6,000 of the estimated 100,000 Irish settlers fleeing the potato famine in their home country.Footnote 19 Again, quarantines of new immigrants were instituted. Unfortunately, this may have actually fuelled the spread of typhus since people in quarantine were more likely to contract the disease.

The Aboriginal population was exceptionally susceptible to these disease outbreaks because they lacked immunity to the new infections and their resistance to disease was further jeopardized through exposure to less healthy ways of life. Countless Aboriginal people succumbed to epidemics of smallpox, tuberculosis, diphtheria, typhus, measles and syphilis. In some cases, whole communities all but disappeared.Footnote 15

While Canada battled these waves of disease, research was underway in Europe to identify the sources of, and potential solutions to, these challenges. In 1842, a British report, The Sanitary Conditions of the Labouring Population of Great Britain, concluded that clean water, sewers and adequate housing were essential to prevent the spread of infectious disease.Footnote 20 The report led directly to the first Public Health Act in the United Kingdom in 1848, which established a central Board of Health with local boards.Footnote 21 The Board of Health often felt opposition from those who considered the Act to be a threat to “property rights and personal freedom” and the British government refused to renew the Act after the first five years.Footnote 22

In 1867, Britain established the British North America Act (became the Constitution Act in 1982). The Act was used to create the Canadian Confederation and enforced the division of power between the provinces and the federal government. Within Sections 91 and 92, the newly created Dominion of Canada was responsible for the creation of quarantine and marine hospitals and the provinces were responsible for the establishment, maintenance and management of hospitals and asylums.Footnote 23

Few public health initiatives were developed and activities were haphazard during the remainder of the 19th century, varying from city to city and from province to province. This may have been because, by the turn of the century, there was “a very remarkable decrease in the communicable diseases with which we are familiar” (1900 Annual Report of the Provincial Board of Health for Ontario), thanks in large part to improvements in water and sanitation and public infrastructure.Footnote 24

 

Water, Sanitation and Health in Canada

The link between water, sanitation and health has been known for centuries – tainted water supplies and deficient sanitation practices can cause illness and death among those exposed to these conditions.Footnote 25, Footnote 26 Although Canada has an abundance of fresh water, disease outbreaks related to water and sewage practices were commonplace among early settlers. It wasnt until the beginning of the last century that officials embraced the water/waste/health connection and began to actively pursue adequate sanitation and clean water systems with an eye to improving and maintaining public health.

There is no doubt that advances in sanitation, water treatment and distribution directly contributed to a reduction in mortality rates in Canada and the elimination of water-borne diseases such as cholera and typhoid.Footnote 27, Footnote 28, Footnote 29

Today, standards and policies supporting legislation exist at all levels of government to deal with water quality and sanitation.Footnote 30 The majority of citizens have the benefit of high-quality water treatment systems, although some Canadian communities – particularly those that are small, rural and remote – may face boil water advisories. These are issued to reduce the risk of waterborne diseases when conditions suggest possible increases of microbiological contamination.Footnote 31

Canada is continuing its work on developing and employing innovative technologies while maintaining a careful watch on water and sanitation systems across the country.Footnote 32 At the same time, it is shifting its focus toward a more sustainable use of fresh water that favours reduced water demand over increased supply.Footnote 33

 

While waterborne diseases came mostly under control, other contagious diseases remained the leading causes of death in Canada.Footnote 34 Diseases including scarlet fever, diphtheria, measles, whooping cough, and tuberculosis continued to put the publics health at risk.Footnote 15 In Ontario alone, 36,000 children died from diphtheria between 1880 and 1929.Footnote 35 In the mid-1880s smallpox remained a threat, with Montréal experiencing the last major epidemic in a North American city.Footnote 36

1900-1950

In the early part of the 20th century, public health activities continued to be largely uncoordinated and mostly in response to infectious disease outbreaks. Aboriginal Peoples health and social conditions reached a low point, as traditional ways of life (e.g. consuming whole foods, maintaining high activity levels, practicing natural medicine) continued to be significantly weakened and suppressed.Footnote 16

However, some significant public health developments did emerge during this period. For example, immunization against smallpox and diphtheria had begun in Ontario schools.Footnote 37, 38 About the same time, cities such as Toronto and Montréal began to pasteurize milk against bovine tuberculosis and towns, such as Peterborough, began using chlorination to disinfect drinking water.Footnote 39, 40, 41

Public health activities accelerated when Canadian soldiers returned home from the First World War, bringing with them the Spanish influenza of 1918-1919.Footnote 42 An estimated 40 to 50 million people were killed worldwide by the pandemic, including approximately 50,000 Canadians.Footnote 42, 43 Once on Canadas shores, the virus spread quickly across the country, even to remote communities.Footnote 43

Conscious of the need to manage federal health functions, the Canadian Public Health Association played a key role in advocating for the creation of a Department of Health in 1919.Footnote 44, 45 The department retained functions of quarantine and ensuring food and drug standards, but also acquired new responsibilities to implement campaigns against sexually transmitted infections (STIs) and tuberculosis, as well as to promote child welfare.Footnote 45

The next two decades were periods of major contrasts. Most Canadians standard of living was on the rise as employment and incomes increased and education and housing improved, resulting in better living conditions and enhanced nutrition. Childhood immunization against infectious diseases was becoming commonplace, life-altering scientific discoveries – such as insulin and penicillin – led to treatments for diabetes and infection, and new techniques were introduced to treat injuries, all of which helped to improve the health of Canadians.

However, the Canadian economy and society were dealt a serious blow during the Great Depression of the 1930s. As farmers went bankrupt and industries in towns and cities collapsed, people lost their homes and livelihoods. The uprooted and unemployed became migrants and, in some cases, vagrants – homeless, hungry and frequently ill. The Depression was quickly followed by the Second World War (1939-1945), which again took a toll on the health of individuals and the well-being of society. As well, the prevalence of polio, another highly contagious, frequently disabling and sometimes fatal disease, during this era reinforced that infectious diseases remained a serious threat to public health.Footnote 46

These events laid the groundwork for contemporary concepts of public health as Canada recognized its obligation to look after returning soldiers and the population at large. A range of initiatives were launched to strengthen the social fabric of the country, from the construction of new housing to the provision of education for returning soldiers and their families.Footnote 47, 48, 49

 


The Case for Immunization


Before the benefit of mass immunization, generations of Canadians lived with the threat of a range of debilitating diseases that frequently swept through their communities.

Polio, for example, left many people paralyzed or otherwise disabled. At its peak in 1953, it caused nearly 500 deaths in Canada. Two years later, an injectable polio vaccine was introduced and incidence of the disease dropped dramatically.Footnote 46 By 1994, all of the Americas were certified polio free.Footnote 50 Today, it has been eliminated from most parts of the world.

Measles is another contagious disease that has afflicted millions worldwide. According to the WHO (2002), it is the leading global cause of vaccine-preventable death in children under the age of five.Footnote 51 Before the introduction of a measles vaccine in the early 1960s, Canada averaged 300,000 to 400,000 annual cases.Footnote 52 By 1995, that number had dropped to 2,362 and adopting an improved two-dose program in 1996 has resulted in a further decline.Footnote 53

Canadas success in reducing and eliminating vaccine-preventable diseases can be largely attributed to high vaccine coverage rates. However, work in this area is ongoing as certain populations continue to exhibit lower coverage rates.Footnote 54, 55 This may be the result of barriers to awareness and access, or because of differing cultural norms.Footnote 56

Today, Canada maintains various surveillance systems to assure Canadians that vaccines continue to be safe and effective and to allow early interventions and control measures to be implemented in the event of a disease outbreak.Footnote 54, 56


Canadas first food guide was introduced in 1942 to reduce nutritional deficiencies resulting from war-time food rationing.Footnote 57 This development was followed by the 1944 family allowance, a universal program to help families raise healthier children.58 In 1947, Saskatchewan introduced the first hospital insurance program to ensure that personal finances would not be a barrier to receiving health treatment.Footnote 59

During this same period, a broader understanding of health was emerging at the international level by global bodies like the World Health Organization (WHO). In 1948, the WHO defined health as: “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”Footnote 60 The newly formed organization set standards and agreed on regulations to promote health among member countries and began providing assistance to promote disease surveillance.Footnote 61

1950-present

Following the Second World War, the country prospered and the health of the population improved. By 1950, mortality rates were reduced by one quarter compared to those of 1921 (9 per 1,000 compared with 12 per 1,000) and the number of deaths attributable to infectious diseases was significantly reduced.Footnote 34, Footnote 62

The post-war economic boom resulted in new jobs and rising affluence. More people were completing higher levels of education and more women participated in the workforce.Footnote 63, 64 While women of the previous generation had advocated for the right to vote, women of the post-war era fought for better educational and job opportunities, equal wages, and paid maternity leave, resulting in an improvement to the factors (or determinants) that impact health.Footnote 63, 65 In addition, broad social programs such as the Canada Pension Plan (CPP) and Old Age Security (OAS) were introduced.Footnote 66 Access to acute hospital services was guaranteed through the 1957 Hospital Insurance and Diagnostic Services Act, while the 1966 Medical Care Act afforded access to insured medical services.Footnote 59 In 1962, the Medical Services Branch of the Department of National Health and Welfare was established with a primary mandate of supporting Indian and Inuit Health.Footnote 67

This period also presented new challenges, however, as people were living longer and chronic diseases and injuries increasingly became the more common cause of disability and death.Footnote 68 Other trends emerged, such as widespread smoking, increased social drinking, the recreational use of drugs, a resurgence of STIs and the introduction of new infections like HIV-AIDS. Meanwhile, the proliferation of cars led to a reduction in physical activity as well as an increase in smog, air pollution, and injury and death related to motor vehicle crashes.Footnote 69, 70, 71

The discipline of epidemiology began to explore the causes of these trends with a view to their prevention.5 Many studies identified associations between smoking and lung cancer; diet, physical activity and heart disease; seatbelt use and road traffic injuries; and air pollution and worsening of asthmatic conditions.Footnote 72, Footnote 73, Footnote 74, Footnote 75, Footnote 76,Footnote 77

 


Trimming Tobacco Use in Canada

A hundred years ago, it was believed that tobacco was beneficial and its use was encouraged. By 1965, half the Canadian population over 15 years old smoked.Footnote 78 As smoking rates continued to rise, research uncovered the truth – tobacco use is an addiction that harms the health of the smoker and those exposed to second-hand smoke.Footnote 79 Once these dangers were understood, Canada began to take action through tobacco control strategies involving concerted effort across all levels of government, including: education and promotion, taxation, introduction of smoking by-laws and cessation support.

The most recent data from the 2006 Canadian Tobacco Use Monitoring Survey (CTUMS) show that these efforts have paid off. Only 19% of the Canadian population now smokes.Footnote 80 In addition:

  • more than half of Canadians who have ever smoked have quit;
  • every region in the country is experiencing success in decreasing smoking rates among all age groups; and
  • Canada is one of the first countries in the world to see a decrease in youth smoking.

Today, Canada is universally recognized as a leader in tobacco control and shares its experience with other nations under the WHO Framework Convention on Tobacco Control.Footnote 81

Despite these achievements, Canada needs to continue pursuing tobacco reduction efforts – especially among populations with higher rates of smoking and where children are still regularly exposed to second-hand smoke.

 

Globally, Canada was at the forefront of the public health approach with the 1974 Federal publication of New Perspectives on the Health of Canadians by then Minister of Health Marc Lalonde. The report helped Canadians to understand that achieving good health requires more than just a good health care system and it emphasized the importance of human biology, environment, lifestyle, health care organization and the need to “understand what contributes to sickness and death, and to facilitate the identification of courses of action that might be taken to improve health.” It also highlighted the impacts of social influences on health and underscored that social inequalities can lead to health inequalities. And the report emphasized the need for greater inter-sectoral collaboration in research, community development, social marketing and public policy to adequately address the various factors that determine health.Footnote 82

The Lalonde Report had a profound impact on public health practice around the globe, highlighting the benefits of investment in promoting health and preventing illness and injury to reduce pressure on the health care system.Footnote 83 It led to renewed efforts to develop new approaches in health promotion, community advocacy and the use of legislation.

 


The Proven Benefits of Buckling Up

Between 1975 and 2003, traffic fatalities decreased by over 50% in Canada even though the number of drivers and cars on the road increased substantially.Footnote 84 Part of the reduction may be credited to an increase in seatbelt use with 90% of Canadians now buckling up when riding in or driving a motorized vehicle.Footnote 85

Achieving this improvement was not easy. Seatbelts did not become standard equipment in Canadian vehicles until the late 1960s.Footnote 86 Use was voluntary and very limited until the next decade when medical professionals linked the use of seatbelts in traffic crashes with lower incidences of serious injury and death.Footnote 87

Public awareness campaigns followed, as did legislation making seatbelt use mandatory. The first law was passed in Ontario in 1976. By the late 1980s, all provinces and territories had adopted similar legislation.Footnote 88

Although rates of traffic deaths and injuries have greatly improved, more can be done – especially with respect to child safety. Roadside checks have shown that just 51% of children are buckled up and more than 80% of car seats are improperly installed.Footnote 89

As a result, new public awareness campaigns have been launched and legislation for mandatory vehicle booster-seat use has been passed by seven provinces to ensure the safety of children too big for a car seat but too small for an adult seatbelt.Footnote 90

 

In the early 1980s, the Canada Health Act was passed, updating the preceding Hospital Insurance and Diagnostics Services Act and the Medical Care Act. It ensured comprehensive, universal and accessible insured health care services to all Canadians without cost or discrimination based on age, health status or financial situation.Footnote 91 During this decade, Canada further developed the concept of health promotion with the publication of Achieving Health for All: A Framework for Health Promotion as tabled by then Minister of Health Jake Epp in 1986.Footnote 92 The Epp Report placed greater focus on the determinants of health – specifically identifying income-related health inequalities as an area for priority action and recognizing that health behaviours are not just a by-product of personal choice, but also of the surrounding environment.Footnote 93 In the same year, Canada responded to the growing international public health movement by hosting the first International Conference on Health Promotion. The Ottawa Charter for Health Promotion, presented at the conference, called on countries to establish strategies and programs for health promotion through building healthy public policy, creating supportive environments, strengthening community actions, developing personal skills and reorienting health services.Footnote 94

In keeping with the Ottawa Charter, the decade that followed was a productive one for Canada in the health and health promotion fields. Early in the 1990s, the creation of a Breastfeeding Committee for Canada sought to establish breastfeeding as the cultural norm across the country and a new Canadian Institute for Health Information provided an independent means of amassing essential data and imparting analysis on Canadas health system and the health of Canadians.Footnote 95, 96 Several key reports were also released, including the Report of the Royal Commission on Aboriginal Peoples (1996) and the first and second reports on the Health of Canadians (1996 and 1999).Footnote 97, 98 The Tobacco Act, passed in 1997, provided new regulations on the manufacture, sale, labelling and promotion of tobacco products.99 And at the end of the decade, efforts to improve the nations understanding of population health culminated in the creation of a Canadian Population Health Initiative (CPHI).Footnote 100 The growing burden of HIV infections and outbreaks of invasive meningococcal disease that affected school and college-aged youths served once again as reminders that infectious diseases remained a challenge.Footnote 101, 102, 103, 104

Another reminder came in 2003 with the arrival of Severe Acute Respiratory Syndrome (SARS) in Canada. Caused by a virus that originated in Asia, SARS claimed the lives of 30 Canadians and significantly damaged segments of the Canadian economy.Footnote 105 In the aftermath of SARS, it became clear that the next infectious disease emergency may now be just a plane ride away. Canadians also realized that, for all the strengths of Canadas health care system, exceptional care alone is not enough to protect them from the full range of threats to their health and safety.

The lessons of SARS, including recommendations from Dr. David Naylors report, Learning from SARS: Renewal of Public Health in Canada, were the primary drivers behind the creation of the Public Health Agency of Canada in 2004.Footnote 2, 6 The Agency has essential responsibilities related to preventing diseases and injuries, promoting good health, preparing for emergencies and strengthening the public health infrastructure in Canada. Additionally, it strives to understand and address the basic factors that determine individual and population health in Canada.Footnote 107

 

Public Health Agency of Canada

Mission:
To promote and protect the health of Canadians through leadership, partnership, innovation and action in public health.

Vision:
Healthy Canadians and communities in a healthier world.Footnote 106

 

Also in 2004, Canadas First Ministers committed to the development of “goals and targets for improving the health status of Canadians through a collaborative process”.Footnote 108 The following year, the Public Health Agency of Canada led the broad consultation and validation process that culminated in a set of goals (the Health Goals for Canada) that were agreed on by the Federal, Provincial and Territorial Ministers of Health (see Appendix C).

Most recently, Canada hosted the 19th International Union for Health Promotion and Education World Conference − Health Promotion Comes of Age: Research, Policy & Practice for the 21st Century. The event, held in 2007, provided an opportunity to reaffirm the commitment and vision of the Ottawa Charter, as well as the chance to look to the future and enhance partnerships and inter-sectoral collaborations for health promotion.Footnote 109

 

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