It’s been 50 years since the publication of the groundbreaking Lalonde report, and it feels more timely than ever.
The document – official title, A New Perspective on the Health of Canadians – cautioned that continuing to pump money into a sickness-care system, without investing properly in prevention and health promotion, was a losing proposition.
Time has proven that warning to be all too prescient.
Using constant 1997 dollars, Canada’s health care spending has risen from $40-billion to $188-billion over the course of five decades, according to figures from the Canadian Institute for Health Information.
Given the four-fold increase in spending, is health care better today than it was back then? Medically, it certainly is, but access to care is decidedly worse.
We certainly haven’t learned the value of prevention. We still wait for people to get sick and then treat them rather than try to prevent illness and injury in the first place.
To this day, 95 per cent of our health dollars go to sickness care and only 5 per cent to health promotion and prevention.
Since its release in 1974, the Lalonde report has received international acclaim and has been credited with helping reconceptualize public health, moving it from a largely reactive approach to a proactive one.
The 77-page report was signed by then-health and welfare minister Marc Lalonde, but was actually written by senior bureaucrats in the ministry’s long-range health planning branch.
Before delving into the content, let’s reflect briefly and nostalgically on a few words in that previous sentence. Fifty years ago, the federal government cared about health and welfare. The ministry also did – shock, horror – long-range planning.
Alas …
“The traditional view of equating the level of health in Canada with the availability of physicians and hospitals is inadequate,” the Lalonde report stated in its introduction.
The health care system “is only one of many ways of maintaining and improving health. Of equal or greater importance … [is] the raising of the general standard of living, important sanitary measures for protecting public health, and advances in medical science.”
The Lalonde report introduced the concept of health fields, comprising four main elements: human biology (genetics, to use more modern language), environment, lifestyle, and health care organization.
In other words, the way we live matters as much, if not more, to our health than the medical care we receive, and we should spend our health dollars accordingly.
It even tackled a topic that is top-of-mind today: the importance of primary care, stating that Canada should have a network of 24/7 care centres to ensure patients are both treated promptly and have ready access to assistance programs.
The “health fields” concept was embraced by many countries around the world, notably Nordic countries like Sweden, who, to this day, invest heavily in social assistance programs like income redistribution, affordable housing, and early childhood education – and have better health outcomes as a result.
In Canada, the response to the Lalonde report was largely apathetic. The 74 sensible recommendations were mostly ignored. Provinces dismissed it as an excuse for the federal government to reduce health transfers, and physicians decried the approach as “blaming the victim.”
Even public-health officials, while praising the emphasis on prevention, said there was too much emphasis on lifestyle choices, and not enough on socioeconomic determinants of health such as income, housing and education. (Those issues were addressed in a companion report, A Working Paper On Social Security in Canada.)
Marc Lalonde, who died last year at age 93, was honoured by the World Health Organization for his “exceptional contribution to health policy” and named one of 11 Public Health Heroes of the Americas by the Pan-American Health Organization in 2002. But his approach never caught on at home.
The French expression, nul n’est prophète en son pays (no one is a prophet in their own land), springs to mind.
We know today, unequivocally, that investing in prevention can impact morbidity and mortality. We’ve seen this most dramatically with the campaign to reduce smoking.
But, 50 years after the Lalonde report, we know too that there is a bedeviling paradox that dominates our health politics and policies: While everyone agrees that prevention and health promotion are important in principle, we continue to disproportionately increase spending on treating existing illnesses.
A myopic vision that all but ensures our sickness-care system will never be able to meet the demands of the population.