Building the Case for Prevention is Not Easy

By Ted Bruce

The debate over the mandatory use of bike helmets has predictably heated up with the arrival of ideal biking weather. And there is an abundance of population level data being tossed around to buttress both sides of the argument. On one side is the position that mandatory bike helmet use discourages ridership and it is high ridership that creates safer riding environments – thus mandatory helmet laws might impede reductions in injury rates. This argument also suggests that by discouraging cycling, society does not achieve the benefits of more people participating in active transportation. On the other side, there is data showing the lower injury rates associated with helmet use and little evidence that mandatory laws have dampened the uptake of bicycling as form of transport.

There has been an impressive array of data to bolster both sides of the debate. The importance of epidemiology to good policy making cannot be underestimated. But the debate highlights the challenge in securing the quality of evidence we need to advocate for prevention strategies.

Of particular concern is the considerable lag time between a prevention intervention and the measureable benefits it is intended to produce. This is compounded by the reality that the intervention is only one of many interventions that co-exist in a messy policy world. How does one assess the benefits of a specific intervention in a complex, real world, uncontrolled environment where there are many confounding variables that are affecting the measured outcome? In addition, prevention interventions have an underlying problem with generating data since if they are impactful they have prevented an occurrence and there may be limited mechanisms to collect data within our routine normal data collection systems.

The Canadian Best Practices Portal is a source of best practice reviews.

The Canadian Best Practices Portal is a source of best practice reviews.

There are a number of research methods such as cross jurisdictional studies that can assess the benefits of prevention interventions as we see in the case of the debate on bike helmet laws. Rates of injury and disease, for example, can be compared between jurisdictions that implement a prevention strategy and those that don’t. In spite of more innovative methods, many of these studies are still open to challenge because of the differences in real world contexts that are being compared. Fortunately there is an ever increasing body of quality evidence available to argue the case for prevention. Check out this source of best practice reviews: Canadian Best Practices Portal (Public Health Agency of Canda).

While it is never wise to base decisions on individual cases that are not representative of the larger population, the importance of case studies and narrative analysis can be quite informative and convincing. As we all know, it is the “stories” of real people that often influence decisions whether good evidence is available or not.

Cancer Prevention Works – Time for a New Health Care Paradigm

By Ted Bruce

The cancer community has done a remarkable job of documenting the importance of prevention. They estimate that 50% of cancers are preventable and have an active campaign to encourage provincial government action on prevention. Learn more via the Canadian Cancer Society’s (BC & Yukon) Cancer Gameplan Election website.

Think about that number: 50%. Compare it to the 3% of health care we devote to public health preventive efforts.

The cancer community’s understanding and commitment to prevention is likely influenced by the remarkable story around tobacco reduction. A public health approach to tobacco reduction is a model that we can use to tackle a range of deadly and costly chronic diseases. But it comes at a price. The victories in the battle against smoking related diseases did not solely come from anti-smoking awareness and public education campaigns. In fact the amount of funding available for these types of campaigns is almost laughable compared to what industry spends marketing what we know are unhealthy products – a great deal of this marketing aimed a kids. Although we have seen prohibitions on advertising cigarettes in Canada, the food industry provides an example of the marketing battleground. The Ontario Healthy Kids Panel report No Time to Wait was unable to calculate the actual expenditure on food advertising aimed at children but they quote one study showing that “ four food ads per hour were shown during children’s peak television viewing times and six food ads per hour were shown during non-peak times. Approximately 83 per cent of those ads were for “non-core” foods and 24 per cent of food ads were for fast food restaurants.”[1]

The Prevention Institute, a non-profit organization in the US, quoting a Federal Trade Commission Report states that the fast food industry spends more than $5 million every day marketing unhealthy foods to children. A full fact sheet on marketing foods and beverages to children is available on their website.

The tobacco battle has shown us that effective prevention programming incorporates a variety of strategies including taxation to affect price, marketing regulations, enforcement and efforts to change the environment to deter consumption. The National Collaborating Centre on Healthy Public Policy has an informative interactive timeline that is worth a look to see the long and hard fought battle over tobacco.

It is most important to understand, however, that tobacco reduction efforts required human resources for leadership, advocacy, policy development,  program development and program delivery. And there are just not enough of these resources available in the public health system to do the job for the chronic disease epidemic we are facing.

Is the battle against smoking related disease and death over? Not by a long shot. Smoking rates may have come down but we know they can go lower. And sadly in some populations smoking rates are still at very high levels with estimates that some groups smoke at 2 to 3 times the overall rate. Learn more through Health Canada’s Canadian Tobacco Use Monitoring Survey.

We need to shift our thinking to support the cancer community’s prevention efforts. And we need to realize that cancer prevention is about more than tobacco. Chemicals in our environment, sedentary behaviour and poor diets are contributors to cancer. The time is overdue for a comprehensive prevention effort. Our political leaders need to have a vision for the future. Why is it good enough to prevent children being exposed to tobacco yet we tolerate an “in your face” obesity promoting environment for children. It is time to dream big and to put in place the human resources we need to realize that dream. We can all take a lesson from the efforts to prevent cancer. We need to shift to a new health and health care paradigm built on prevention.

–  Ted Bruce is the past-president of the Public Health Association of British Columbia.

[1] Kelly B, Halford JCG, Boyland E, Chapman K, Bautista-Castaño I, Berg C, et al. (2010). Television food advertising to children: A global perspective. Am J Public Health. 2010;100(9):1730-5

Embrace the wisdom of investing in children

By Dr. Brian O’Connor

In a recent blog (‘It Doesn’t Have to Be this Way’, March 27th), Trevor Hancock, in a tribute to Clyde Hertzman, reviewed the policy platform of the Human Early Living Partnership (HELP) as contained in the 15×15 document.  Much of this speaks to the importance of ensuring adequate incomes for families and some of the key aspects of a poverty reduction plan.

One of Clyde’s colleagues at HELP, Professor Paul Kershaw, has put a unique twist on early child development and the need for adequate resources for families in terms of income, time and services.  Young people and young families have unique challenges in today’s social environment that present huge impediments in terms of the ability of children to develop optimally.  Professor Kershaw refers to the young families of today as the squeezed generation or GenSqueeze (  His thesis is that today’s young families, quite unlike their predecessors (boomer, gen x, etc.) are severely under resourced in terms of

1) the time they have available for optimal parenting

2) the lack of supportive services – the consequences of a paucity of sound social policies in support of today’s families such as universal, quality, affordable for all, day care – Professor Kershaw proposes a $10/day solution, a solution also promoted by the Coalition of Child Care Advocates of BC ( and

3 ) income issues arising from discrepancies in wages and the cost of living over time leading to two working parent families with very long hours

Professor Kershaw has contrasted the social policy supports that as Canadian society, we have put in place for seniors as an example while at the same time we have not been as generous in our support for young people and young families.   While he is not trying to pit one generation against another, he does point out that our social spending on seniors comes to $45,000 per Canadian over 65, while a similar young family today is afforded social policy spending of only $12,000 per Canadian under 45.   He does not support reapportioning  spending  (maintain funding to existing social programs) but adding a mere $1000 per Canadian in additional spending which will as an investment bear vast return in mitigated costs from things such as reduction in costs from crime, education, avoidable absenteeism and improvements in human capital, and competitiveness.

It is interesting that our society has not fully embraced the wisdom of investing in children, the future of our province, by ensuring optimal early child development for all BC’s children.  While our universal Medicare program is a defining national characteristic and the support we provide seniors is never questioned, we can hear the negativity that arises when one proposes $10/day child care – “why do I have to pay for their child’s day care?”

So Professor Kershaw comes at the poverty reduction question in a slightly different way.  But it is anchored in the recognition that optimal child care development if not addressed through policy options that provide more resources, will perpetuate the continuum of poverty, poor child outcomes and increased health inequity.

Brian O’Connor is the Co-Chair of the Population Health Committee, Health Officers Council of BC

Additional Reading:

15 by 15: A comprehensive policy framework for early human capital investment in BC | Human Early Learning Project | 2009

Poverty is Bad for Your Health – Backgrounder and Q&A info series | PHABC 2012

Public Health is ROI

By Dr. Marjorie MacDonald

Earlier this week, I posted a blog on this website about the economic benefits of prevention. After writing the blog, I realized that in the US, it is National Public Health Week with the theme “Public Health is ROI” (return on investment). Since this deals with the focus of my earlier blog, I thought I would post a weblink from APHA on this very theme.

National Public Health Week — Public Health is ROI: Save Lives, Save Money (video by the American Public Health Association)

–  Marjorie MacDonald is the President of Public Health Association of BC

The Economic Benefits of Prevention

By Dr. Marjorie MacDonald

A common theme has emerged in the last three blogs posted on this website – that is, the need for an increased investment in prevention. Ted Bruce (March 8th) argued for a prevention agenda for addressing childhood obesity and called for a well-funded prevention effort. Trevor Hancock (March 17th) suggested we need to invest in the determinants of health through a whole of government approach because prevention will give us a bigger bang for our buck. Victoria Lee (March 25th) argued that investing in prevention is an investment in our future and provides evidence that there is a significant return on investment for every dollar spent on early learning for children.

I want to pick up on this theme and present additional evidence that prevention makes good economic sense for government investment. In fact, not investing in prevention puts our health care system at risk.  In a PHABC presentation to BC’s Select Standing Committee on Health [1] in 2012, Dr. John Millar argued that at current rates of increase, provincial health care expenditures are projected to increase from the current 40% of spending to about 80% by 2030. This leaves very little money for other essential programs that keep the province functioning and address the determinants of health.

Although there has been controversy over whether prevention will save the health care system money, there is growing evidence that many preventive interventions are cost effective.  The best evidence comes from tobacco prevention. For example, one study in California demonstrated that over 20 years, a 2.4 billion dollar investment in tobacco prevention reduced health care costs by 134 billion dollars – a $55 return for every dollar spent on prevention [2]. Studies in other states have also demonstrated a good return on investment for tobacco prevention [3]. Although heath care savings from young people quitting or not starting to smoke may not show up for many years, some savings occur almost immediately by preventing or reducing smoking among pregnant women and teens thereby lowering pregnancy and birth complication rates.

There is an emerging consensus on a core set of cost effective clinical as well as population-based prevention services that not only provide good economic value for money but yield net savings [4,5]. Cost-effective clinical prevention strategies in primary care include, for example, childhood vaccination programs, colorectal cancer screening, HIV/AIDS prevention, diabetes prevention, and smoking cessation, among others. Cost effective community services include indoor smoking bans, increased taxes on cigarettes and alcohol, immunization requirements for school entry, needle exchange programs, obesity interventions for children and adolescents, and mandatory seat belt and helmet laws.

More evidence on the economic benefits of prevention is emerging from economic modelling studies that illustrate economic returns over the long term. For example, a recent study in the US [6] tested three strategies to reduce avoidable deaths and reduce health care costs, including expanding health care coverage, delivering better clinical prevention and chronic care, and establishing healthier behavioural and environmental conditions. The first two strategies increased costs over the long term but an approach that added the 3rd strategy (i.e., a public health approach) to the first two resulted in significant cost savings to health care by year 25. This illustrates the need for governments to take the long view and to look further ahead than the end of their term in office.

With respect to public health spending, another recent US study examined whether spending increases by local public health agencies reduced mortality rates from preventable causes of death [7]. They found that a 10% increase in public health spending could result in an average 3.2% reduction in cardiovascular disease mortality which, at the population level, represents a significant decrease. By spending just $312,274 dollars more per year, the potential savings in medical care resources were significantly in excess of this amount representing a very high return on investment.

Overall, as Trevor Hancock argued, prevention is good bang for the buck and it is a kinder, gentler solution. If we can reduce overall health spending by investing in prevention, it is a ‘no brainer’ decision for governments. We must remember, however, that preventing people from getting sick also has value in human terms that go beyond economic considerations. The twin moral aims of public health are to improve the health of the population and reduce health inequities. Investing in evidence-based prevention can help us achieve those aims with the added bonus of reducing health care costs.

 –  Marjorie MacDonald is the President of the Public Health Association of BC


[1] Millar, J. (2012) Sustainability of the health care system. Presentation to the BC Select Standing Committee on Health, January 2012. Victoria, BC.

[2] Lightwood, J.M., Dinno, A. & Glantz, S.A. (2008). Effect of the California Tobacco Control Program on personal health care expenditures. PLOS Medicine 5(8): e178.

[3] Riordan, M. (2012) Comprehensive state tobacco control programs save money. Campaign for tobacco free kids.

[4] Woolf, S.H., Husten, C.G., Lewin, L.S., Marks, J.S., Fielding, J.E., Sanchez, E.J. (2009). The economic argument for disease prevention: Distinguishing between value and savings.

[5] Public Health Agency of Canada. (2009). Investing in prevention – the economic perspective. Key findings from a survey of recent evidence.

[6] Millstein, B., Homer, J., Briss, P., Burton, D., Pechacek, T.(2011). Why behavioural and environmental interventions are needed to improve health at lower cost. Health Affairs, 30(5), 823-832.

[7] Mays, G.P. & Smith, S.A. (2011). Evidence links increases in public health spending to declinces in preventable deaths. Health Affairs, 30(8), 1585-1593.

Investing in Prevention = Investing in our Future

By Dr. Victoria Lee

Dr. Hancock outlined that increasing our investment in prevention translates into a better health bang for the buck.  This requires us to collectively shift the current paradigm from illness to wellness.  Approximately 78% of illness care costs in acute care are from life-sustaining measures in the final year of life[1].  However, consider that the benefit of every dollar invested in early learning for children far outweighs the costs at 1.5 to 10 times with long lasting social and economic benefits[2].  Children in early childhood education programs are less likely to smoke, drink alcohol and use drugs.  Access to high quality and affordable childcare provides increased family income, and better educated children lead to a more educated workforce for the province2.  However, we dedicate less than 1.5% of the total provincial budget to early childhood education.  BC and Canada are lagging behind other high income jurisdictions in supporting our children.  By increasing our investment in early childhood education and development, we can effectively get “a better health bang for the buck”.

Another shared solution was highlighted by Professor Friel at the recent BC Population Health Network meeting.  Intricate linkages exist between social and economic determinants of health with the physical environment.  Mitigation and adaptation to climate change therefore is not only an environmental issue, but also a significant socioeconomic concern.  Climate change will cost roughly $5 billion per year in 2020 and up to $44 billion per year by 2050[3].  Those in poor housing and working conditions will suffer most in terms of socioeconomic and health impacts (e.g. injury, heat stress, and food insecurity).

“The rich will find their world to be more expensive, inconvenient, uncomfortable, disrupted and colourless – in general, more unpleasant and unpredictable, perhaps greatly so.  The poor will die.”  (Kirk R. Smith, 2008.  Professor, Environmental Health Sciences.  University of California, Berkely)

On the other hand, over consumption and globesity are not only significant health concerns, but are “major drivers of environmental degradation”[4].

Complex health challenges of the 21st century (globesity, climate change and health inequities) require investments upstream that prevent disease, protect health and promote wellness.  Certainly, co-benefits exist for BC, its citizens and all stakeholders to develop a robust provincial poverty reduction plan, to support early childhood education, to reduce environmental impacts within the food system and to create sustainable communities.  Investing in prevention = investing in our future.

– Dr. Victoria Lee is the Co-chair of the Population Health Committee, Health Officers’ Council.

[1] Zhang, B. et al. Health Care Costs in the Last Week of Life Associations with End-of-Life Conversations.  Arch Intern Med. 2009;169(5):480-488. doi:10.1001/archinternmed.2008.587.

[2] TD Economics (2012).  Special Report: Early Childhood Education has Widespread and Long Lasting Benefits.  Available at

[3] National Round Table on the Environment and the Economy (2011).  Paying the Price: the Economic Impacts of Climate Change for Canada.  Available at

[4] Friel, S. Presentation at BCPHN Meeting.  March 19, 2013.  Vancouver, BC.

Getting a Better Health Bang for the Buck

By Dr. Trevor Hancock 
Professor and Senior Scholar, School of Public Health and Social Policy, University of Victoria

In hard times, it is even more important to ensure that every tax dollar is wisely invested. And when you are spending more than 40% of all the tax dollars, its specially important to do so. So if one was a frugal politician with a sensitivity to the public purse, how would one best spend the government’s revenue?  When it comes to health, there are two forms of ‘bang for the buck’ to consider.

First, how do we get the biggest health bang for the public’s buck? For the most part, not by investing yet more in health care. This point was made as well as anyone has made it, surprisingly, by a very distinguished Canadian heart surgeon, Dr. Wilbert Keon. As a Senator and co-chair of the Senate’s Population Health Sub-Committee, he noted in an interview with The Hill Times in January 2008 that

“Increased expenditures on healthcare are likely impacting negatively on the general health of our population by virtue of diminished investments in other areas like education (especially early childhood education), public housing, income security, and other public services.”

So the first thing to do is to recognise that the major determinants of health lie beyond health care, and invest accordingly, in Ministries that deal with these fundamental determinants of health. This is going to require following the recommendations of the Senate Sub-Committee on Population Health, whose 2009 report was conspicuously ignored by Canada’s federal and provincial governments.

Specifically, the next Premier, whomever it may be, needs to establish and chair a Population Health Committee of Cabinet and adopt a ‘whole of government’ approach to improving health in BC. This  will require undertaking health impact assessments of policies that are having or might have an impact on the health of the population, and ensuring health is a key consideration in all policies, as is the case in South Australia.

In fact they might do well to go further and support a ‘whole of society’ approach by establishing a Premier’s Council on Health, as was done in 1987 in Ontario. That Council, regrettably killed by the Mike Harris government as soon as they took power, brought together the Premier, several key Cabinet Ministers, health care leaders and wider civil society leaders, all working together to improve health. Together, they can examine the wider societal benefits of a healthier population and address population health issues across society as a whole.

The second strategy concerns getting the biggest bang for the health buck, by wisely investing the $16 billion that is in BC’s health budget. Here the wise politician will take advice from the 2010 report on “Investing in Prevention” from BC’s Provincial Health Officer.  Put simply, prevention is sometimes a cost saving and usually a more cost-effective intervention than treatment. It is also kinder: most people would prefer not to have a disease or injury in the first place, they would prefer to avoid the pain and suffering, inconvenience and loss of income that usually results.

Investing in prevention within the health care system involves three main strategies:

  • Further strengthening and renewing public health services, expanding them where necessary.
  • Ensuring that everyone in BC has barrier-free access to the suite of effective preventive services recommended by BC’s Clinical Prevention Policy Review.
  • Improving health literacy and creating supportive social, physical and policy environments that enable people to make health choices.

These strategies, while not free, are relatively inexpensive, and will yield a better return on investment than further investments in high-tech health care. They can be funded in part through another prevention strategy – preventing the wasteful and expensive harm that health care can do – and in part by the higher tax revenues and reduced costs that will result from enabling people to be healthy, reduce their need for health care and, in many cases, earn a living and pay taxes.

So if I was an incoming Premier faced with almost half my revenues going into health care, that is where I would invest to get a bigger and better health bang for my buck.

Additional reading: 

Investing in Prevention: Improving Health and Creating Sustainability | The Provincial Health Officer’s Special Report – British Columbia | Author: PRW Kendall | September 2010

A Healthy, Productive Canada: A Determinant of Health Approach | The Standing Senate Committee on Social Affairs, Science and Technology Final Report of Senate Subcommittee on Population Health | June 2009

Health for all: questions from the past, lessons for the future | Senator Wilbert Keon | The Hill Times, Monday January 21, 2008

Art for Healthy Aging – Another Prevention Strategy

by Dr. Paul Martiquet, Medical Health Officer

At any age, art in all its forms can provide benefits; this is particularly true for the elderly. Neurological research clearly shows that making art can improve cognitive functions by producing both new neural pathways and thicker, stronger dendrites (involved in passing on signals in the brain). It even helps the brain to re-map how some connections are made as cells in one area become incapacitated. The process is called elasticity as some cells replace the function of others. In short, making art causes the brain to continue to reshape, adapt and restructure.

In a groundbreaking new book published in 2000, Dr Gene Cohen expounded on the idea of what was possible with aging, moving research towards a goal beyond “what is aging?” His research recognized that older adults had a capacity for creativity that was not being recognized due to negative attitudes towards the elderly.

His study, the first of its kind, found a link between creativity and healthier aging. Compared to those in the study’s control groups, people who participated in art programs enjoyed better health, both physical and mental.

In addition to improving the quality of life for seniors, there is a huge opportunity to reduce the volume of costly health care for seniors if we can maintain their health for a longer period of time. There are great examples of prevention oriented programs that use arts as a focus such as the Arts and Health initiative – a partnership between Vancouver Coastal Health, Vancouver parks and Recreation, community groups and local artists. Prevention works.

Dr. Paul Martiquet is the Medical Health Officer for Rural Vancouver Coastal Health including Powell River, the Sunshine Coast, Sea-to-Sky, Bella Bella and Bella Coola.

Read more:

The full text of this column can be found at:

Learn more about PHABC’s 6% solution to support disease prevention in BC:

A Prevention Agenda is Needed to Address Childhood Obesity

By Ted Bruce

An Ontario government report on childhood obesity has the potential to raise the bar for prevention efforts in BC. The report paints the same picture we know exists here in BC and was the subject of an all party committee of the BC legislature in 2006.

Obesity has huge health impacts on children and it is preventable. In spite of some commendable efforts as a result of BC’s report on childhood obesity 7 years ago we still do not see the all-of-government, well-funded prevention effort that is needed. What is important about the Ontario report is that it looks like there will be some serious action on a prevention agenda. The Ontario report calls for a new investment of $80 million dollars per year. They may sound like a lot but the report also points out that obesity is already costing Ontario $4.5 billion per year or about $313 per person each year. And the investment would only be 17% of the province’s health budget. The report also recognizes the key place that poverty plays in health inequities and calls for a speeding up of Ontario’s poverty reduction strategy.

It is time for BC to take a bold step towards increasing funding for prevention. It makes economic sense as well as a sure path to improving the health and well being of all of us. As is made clear in the Ontario report – the time is now.

Further Reading:

An Ounce of Prevention | Public Health Association of BC | 2012

No Time To Wait: The Healthy Kids Strategy  | Government of Ontario – Healthy Kids Panel | 2013

What is Physical “In”activity Costing British Columbia? | Government of British Columbia | 2011

A Strategy for Combatting Childhood Obesity and Physical Inactivity in British Columbia Report | Government of British Columbia – Select Standing Committee on Health | 2013


Minister of Health Protests Too Much?

By Ted Bruce

The B.C. Minister of Health, Margaret MacDiarmid, has spoken out in the media about the Auditor General’s report on the funding for prevention. She says she has no apologies for the amount spent on prevention, arguing that the more than $500 million spent this past year represents a 160% increase in the past 12 years. One hates to think what the percentage was before these increases if it is around 4% in most health authorities now. Or maybe what she fails to mention is the much bigger increases devoted to sickness care.

Let’s be clear, the fastest growing part of the health care system is not prevention. She also challenges people to say what acute services we could do without if we are to divert money to prevention. Surely the Minister knows health economists tell us that up to 30% of health dollars may now be spent inefficiently or on unnecessary care. Even at that no one is asking for us to take existing money away from acute care. We are talking about new money that will flow into the system in future years. Minister MacDiarmid goes on state that prevention is critical to the sustainability of the health care system. What is needed is leadership to begin the process of re-balancing the system to one that focuses on health and wellness. Perhaps putting money in place to achieve the stated focus on prevention outlined in recent Speeches from the Throne would be a good starting point.

Learn more:
Strengthening disease prevention in B.C. with PHABC’s Election Toolkit resources

Read more: 
Auditor General Report Slams B.C. Health Spending, Huffington Post, Thursday January 17, 2013
Minister says B.C. wait lists too long, Globe and Mail, Friday January 18th, 2013

– Ted Bruce is the Past President of the Public Health Association of BC.