The “social determinants of health” – like adequate income, stable employment and quality education that impact health – need critical attention
Last year at a camp in southern New Brunswick I met Evan. Before turning eight, he had bounced from foster home to foster home. He was sent to camp without a bathing suit or sufficient lunch. Regardless, Evan smiled constantly, excelled in school and had a striking sense of compassion. I still think about Evan all the time – what allowed him to thrive in spite of the cards he had been dealt?
Aaron Antonovsky was a medical sociologist with a similar curiosity. He worked with women who had undergone severe hardship in the past, many of whom survived the Holocaust. He found that some suffered more profoundly while others were more perseverant. He spent his life trying to figure out why.
As a medical student, I learn plenty about complex management of disease once it’s started – but rarely do we learn about what keeps people well in the first place. What contributed to those women’s ability to overcome physical and psychological trauma? What keeps Evan so resilient?
Antonovsky’s research led to what he called a “sense of coherence,” a concept just beginning to gain traction outside of academic circles in many countries. He theorizes that it is the most fundamental protective factor against disease. Based on three components, it also provides a valuable framework for how we should approach public policy making in the area of health and wellness in Canada.
First, Antonovsky found that whatever stresses you encounter must be comprehensible. Children, for example, must have the basic understanding that an action will often have a predictable, stable reaction. Imagine how difficult this must be when moving homes constantly or not having one at all. In 2010, 52 per cent of single-mother households in Canada with children under six years of age were living in unstable housing. Just last year, by the age of seven, 7.5 per cent of children in Manitoba had been placed in some form of foster care. How can we expect children to comprehend stress when they don’t even have a home base in which to do it?
Secondly, children must have the basic tools to see challenges as inevitable yet manageable. For example, one in six Canadian children have vision problems interfering with their ability to read, yet despite our “universal” health care, just 14 per cent receive professional eye care before first grade. I would imagine it’s a lot easier to break the cycle of poverty when you’re able to see the blackboard.
Finally, children must be able to find things meaningful. To thrive, it’s pivotal that children have the opportunity to find satisfaction and a sense of purpose. Sadly, even that isn’t guaranteed.
Jordan River Anderson, a five-year-old aboriginal child with a rare muscular disorder, spent nearly his entire life in hospital while provincial and federal governments fought over who should pay for his at-home care, as responsibility for First Nations’ health services is often shared between jurisdictions. Jordan was denied the opportunity to make meaningful memories outside of his hospital room. This gave birth to Jordan’s Principle, which makes the reasonable request of the department first in touch with the child to cover services in the legal interim.
A strong sense of coherence – the cognitive capacity to see challenges as comprehensible, manageable and meaningful – isn’t just a fluffy sociological construct. It has been tied to evidence: better glycemic control in Type 1 diabetics and faster return-to-work following musculoskeletal injuries. In Scandinavian countries, it was found to predict the need for social assistance and unemployment benefits later in life.
Such findings present major opportunities for rethinking public policy from an “upstream” perspective – creating the foundation for good health in the first place – and pay off with a more effective use of public funding in the process. In other words, the “social determinants of health” – the multitude of non-medical factors like adequate income, stable employment and quality education that impact health – need critical attention.
So what do our policy makers and politicians need to do in real terms?
Build an effective national housing strategy so kids have a place to call home, institute comprehensive pre-school vision screening across the country so classrooms can have their full impact and cut red tape for First Nations children by committing to Jordan’s Principle.
Isn’t it time we put children’s long-term health and wellness on the national agenda?
By Chris Harper
Chris Harper is a Contributor with EvidenceNetwork.ca and a medical student at the University of Toronto.