The province’s overwhelmed emergency departments could be helped in the short and long term by more spending on public health.
That was one of the messages shared with the legislature’s standing committee on health on Thursday. The meeting’s focus was funding for public health in Nova Scotia.
“The returns may not be immediate, and I appreciate that this may perhaps be the very worst day in years to be talking about funding public health rather than things like emergency services,” Dalhousie University professor and researcher Katherine Fierlbeck told the committee.
“But as we’ve learned in Nova Scotia, it’s pay now or pay later. We build hospitals knowing that there is an upfront cost and if we don’t want to be treating patients in yurts, we know that it’s something that we have to do. And public health infrastructure is no different.”
Beyond a crisis response
Fierlbeck said for many years we’ve addressed public health within the context of crisis. She said it’s important to refrain from normalizing public health as a form of crisis response.
“Public health funding historically is linked fairly directly to crises. From the 2003 SARS pandemic to Walkerton to H1N1, funding is often channeled to public health when people are scared. But when the crisis is gone, there is a paradox in public health funding,” Fierlbeck said.
“The better that public health functions in getting things working well, the more likely they are to lose the funding to more immediate health care issues, largely because of political pressures. So please don’t forget about public health even when the crisis settles down. If you ignore what’s happening at the upstream end of things, you’re always going to be desperately trying to put out fires at the downstream end.”
While COVID-19 resulted in a dramatic bump to public health spending everywhere, Fierlbeck said public health in Nova Scotia wasn’t well supported in its day to day functioning prior to the pandemic.
She stressed that while spending on public health is important, it’s not just about funding. It’s also about how public health funds are used, how public health services are organized, about partnerships, accountability, measuring and monitoring of programs, and making information accessible.
“There’s really no point in trying to run health promotion strategies, for example, devoid of data, information, on why the program is needed, where it’s needed the most, how well it’s doing, and why,” Fierlbeck said.
Fierlbeck described public health as the eyes and ears of the province’s overall health.
When armed with the resources to monitor the health of Nova Scotians, it’s easier to identify how to most efficiently address emerging issues.
Without such information, Fierlbeck said we’re “simply flying blind.”
“The connections between the day to day lives of Nova Scotians and the effects that we see in emergency rooms are very closely connected, but not directly. We know that if we have a serious accident, we go to emergency,” Fierlbeck said.
“But also emergency departments are filled with people who have chronic conditions that haven’t been addressed, who are dealing with issues that are a result of where they live, of their lifestyle, of the kinds of pressures that they have every day.”
In Nova Scotia, Fierlbeck said 5% of the population accounts for about two-thirds of in-patient hospital and physician costs, and 1% of the population accounts for about one-third of these costs.
“So it’s very useful, not to mention cost effective, to understand and address what’s happening on the ground in more detail,” she said, adding that much of it involves prevention.
This is especially true with seniors.
“If we can keep them moving, if we can keep them healthier longer, if we can provide a stimulating and supportive social environment, then you find a lot of the physical problems that they experience are mitigated,” Fierlbeck said.
“And if we have a healthier older population, then they are less likely to go to emergency departments, especially if they don’t have primary health care. So it all is interlocking, and if we take our eye off of the quieter, more indirect aspects of health and wellbeing, we are going to end up sooner or later with more people coming into emergency departments.”
Short and long term impacts
The province’s chief medical officer of health, Dr. Robert Strang, also appeared before the committee. He built on Fierlbeck’s comments, suggesting examples where public health could help with the current crisis.
He pointed to vaccination and initiatives like public health’s work on some of the major drivers of emergency department visits. These drivers include road safety and alcohol and substance use.
“Alcohol and other substance use are major drivers of emergency room use, and so how do we work collaboratively in those areas to reduce the impacts and a safer use of legal and illegal substances,” Strang asked.
One public health initiative he pointed to that had a tangible impact was banning smoking in public indoor spaces.
“When we made indoor places smoke free, the research very quickly showed that doing that significantly decreased…the [number of)] people with heart attacks that were appearing in emergency rooms,” Strang said.
“So that is one example of a health promotion approach which actually can have fairly immediate impacts on health care utilization. So it is both short term and long term, these investments.”
Strang told the committee that spending on public health is “fundamentally necessary.”
“We need to talk about health in all its broad dimensions. Physical, mental, emotional, spiritual health, and all the factors that ultimately contribute to health. Not just about health care. I think that’s the key point we’d like to leave you with,” Strang said.
“That investing in public health so we have the appropriate resources and capacity to fulfill our role, as well as investing in a broad range of initiatives…that are outside the health care system that impact the health of the public is fundamentally necessary to create a sustainable, publicly funded health care system.”
‘Prevention is better than cure’
Dr. Sara Kirk told the committee that inadequate funding for public health is a “false economy.”
She said research demonstrates a 14 to 1 return on public health interventions. For every $1 spent, another $14 is returned to the wider health and social care economy.
“Evidence like this clearly demonstrates that prevention is better than cure,” Kirk said.
Kirk, a professor and researcher at Dalhousie University’s School of Health and Human Performance, co-authored a 2021 study (reported here) about Nova Scotia’s “chronically underfunded” public health system.
Titled ‘Fare well to Nova Scotia? Public health investments remain chronically underfunded,’ the study found that based on provincial health care budgets and spending, Nova Scotia is “continually” in last place when it comes to public health spending compared to other Canadian provinces.
Kirk’s research is focussed on understanding and looking for ways to design supportive environments that keep people healthy in schools and communities.
“The timing of this meeting could not be better. I see an opportunity for change and I’m encouraged by the focus on the broader health system, not just on our sickness care system,” she said.
‘It is all connected’
Kirk said the immediate challenges facing Nova Scotia’s health system include a growing population with higher rates of chronic disease, such as cancer and heart disease, and lower life expectancy compared to the national average.
“Nova Scotia also has an aging population that is more likely to live with one or more chronic diseases…Living with more than one chronic disease is linked to social deprivation, and people who experience social deprivation are more likely to live with one or more chronic disease,” Kirk said.
“We’re also seeing chronic diseases develop at a younger age, which further increases pressure on our health care system.”
Kirk echoed the comments of other speakers, noting that many factors influencing the health of Nova Scotians go beyond the health system. These include poverty, systemic racism or discrimination, and precarious housing.
While all impact health, Kirk said they have their roots in economic or social policies that disproportionately affect some communities more than others.
“Living in poverty or experiencing racism and discrimination or precarious housing is understandably stressful, and chronic stress itself increases the risk of things like heart disease or stroke,” Kirk said.
“It is all connected.”
‘We’re at a critical juncture’
Kirk said there needs to be better promotion of health in the places where Nova Scotians live, learn, work, and play.
Any delay, she said, is too long.
“We’re at a critical juncture in our health system evolution,” she said.
“Creating the conditions to improve the health of the province must be a long-term goal, and that means a commitment and required investments beyond the life of one government and across multiple sectors and settings.”
Instead of constantly fixing gaps in the health care system when they appear, Kirk said we must spend on a resilient and robust public health system. We also need to fix the conditions that contribute to the poor health status of many Nova Scotians.
Kirk said doing anything less is “a disservice to our population.”
Given the importance of public health approaches to disease prevention and addressing health inequities and this impressive return on investment, there is a financial as well as a moral imperative for governments to increase their investments in promoting health and well-being across the life course.
What I’m saying to you today is not new or novel. We’ve actually known this for years. But knowing and doing are not the same thing. The solutions to improve health and wellbeing exist, but we need to act on them consistently and resource them adequately. With such a clear link between health and wealth, a healthy population means a productive and prosperous population, and that benefits us all.