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The State of Health Promotion & Public Health in Ontario


This week's feature looks at changing situations for public health and health promotion in Ontario with notes about 5 events that have happened in the last 10 days. To start off the feature, there is a summary of an important discussion that has been happening on the list-serv CLICK4HP over the last week on how health promoters have been addressing inequalities in health.

Immediately after this summary, there are two short summaries of speeches given at the recent OPHA conference in Kingston, offering two views of the imminent changes to the public health system, to downloading of services to a municipal level and new Mandatory Guidelines for Public Health. The two speakers were Dr. David Mowat, Chief Medical Officer of Health for Ontario, and Dr. Richard Schabas, who held that position for 10 years until August 31, 1997.

Following these brief summaries are two other items : a brief report on the first of a series of regional forums that Ontario Prevention Clearinghouse is organizing on "keeping health promotion on the public agenda", and an excerpt from Irv Rootman's remarks on the launch of a new book he co-authored with John Raeburn "People Centred Health Promotion".


In the past week on the list-serv CLICK4HP (Health Promotion on the Internet) there has been an energetic and long-overdue discussion about the role of health promoters in talking about and working on inequalities in health. As CLICK4HP is now accessible on the Internet (see the previous message OHPE #32.0) - please take the opportunity to view these messages at news://

By next week, these messages may be available on the click4hp general page at:

Colleen Nisbet started the commentary on inequalities in health saying: "As the differences between the wealthy and the less fortunate become more dramatic the issue of inequality demands more of our attention. As health promoters we should not be deciding whether

income inequality is pertinent to our discussion but how we can better understand the forces that drive income and health inequalities."

Dennis Raphael, Ph.D. replied "As we in Ontario and Canada continue to observe the effects of increasing inequality on our society, I have to wonder about the deafening silence among many health promoters." Which started a volley of responses!

In a comprehensive message, offering an overview of the impact of cuts in welfare payments to the well-being of people living in poverty, activist Sherrie Tingley commented: "I think there is a large role for the health community to assist people in gaining control over their lives with-in the new systems and to reflect to the larger community the affects of the changes on their ability to parent and maintain their health."

Liz Rykert added: "I think there is one fundamental and perhaps concrete barrier which stops many health promotion practitioners from organizing and speaking out - namely - biting the hand that feeds you. In many cases the purse for health promotion resides with the very governments who are implementing policies which fuel health inequity - perhaps at their peril.

One of the most eloquent commentaries, written by Cathy Crowe, has been published in the Globe and Mail by columnist Michael Valpy. It can be seen on the Internet at:

"The impact of the government's 21.6-per-cent welfare cuts on families, the escalating number of unnecessary homeless deaths, intolerable hostel conditions and the return of tuberculosis are but a few issues that community workers have highlighted for a public discourse. . . .We need to talk about the front-line workers [themselves] and not consider it selfish".. "Perhaps even more serious is the code of silence now imposed on workers by employers. Fearing government backlash in the form of funding cuts, many community boards and managers have created new media and public-relations policies that tighten and censor information that comes out of the organization".. "We need to examine it honestly, and as we prepare new workers to enter the field we must ask ourselves how we can insert energy, hope and a fighting spirit into the theory and practice of course curriculum."

To which Rhonda Love added "I don't think many of us here in Canada, working in health promotion think we control the discourse.. So, we are left teaching students about the value of labour unions, and of networking, of social support, of lobbying, of voting, of organizing, of community development, of ........ (fill in the blank with your favorite political strategies).

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From Dr. David Mowat's address:

Bill 152 recently completed its committee stage and is expected to go to Third Reading within a few weeks. The Bill comes into effect on January 1st, 1998. It contains significant changes in how public

health services are provided in Ontario.

Dr. Mowat emphasized that "these changes are about funding." He said that the bottom line is that all Ontarians are entitled to receive necessary level of public health services and he expects that "in the

aggregate, people will receive the same level of services."

It is now municipalities who must provide the funding for this service delivery. Municipalities also will not determine which services to provide but rather the Mandatory Programs will serve as minimum benchmarks for service. Dr. Mowat sees a continued role for provincial government: as the enforcer. The Ministry "will need to ensure that the Mandatory Programs are being enforced." A number of monitoring mechanisms will be in place specifying volumes and standards to be met.

Dr. Mowat said that the Ministry will appoint assessors, will issue orders to local municipalities if the necessary levels of service are not being met. There will be penalties and the Ministry will step in directly.

He finished by saying that those in the room "are fairly apprehensive about what the future might hold for us." But, when OPHA meets again next year in Barrie, Mowat said "I'll be there, many of you will be there." Those final comments were met by a hush through the crowd and lots of crumbling.

And for a contrast ... Dr. Richard Schabas on The State of Public Health in Ontario

"Don't be mislead that it's only a difference in who signs the cheque," Dr. Schabas told the room. As they prepare for the "municipalization of public health in Ontario," public health officials need to recognize that this is a "very profound and historic change."

There are a number of significant consequences, says Schabas, including a lack of an overall provincial public health agenda, fragmentation of public health workers and a losing battle for resources. He called public health "a minnow swimming among the whales."

Although Mandatory Programs will protect some public health programs, he emphasized that they are the same amount of support that Ministry of Health funding provided.

Dr. Schabas said that the lesson is that public health needs to work harder to ensure that its services are valued. He told the audience "it's up to you to fight and win the battles of public health." He said that they needed to learn to work more effectively within municipalities, to learn to fight for resources and learn how to highlight and make valued their work.

[submitted by Anne Simard]

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A series of regional forums being developed by Ontario Prevention Clearinghouse

At Ontario Prevention Clearinghouse (OPC), we also have seen many changes in the social health arena, and are realizing that we need to re-connect with people involved in health promotion at a local level. We need to create a place where people working in community health can talk about these changes, discuss what is yet-to-come, share insights and determine how to work together, share resources and help one another. What is working - what are the success stories, and the learnings? How can these stories and learnings be put on the public agenda? How can the Ontario Prevention Clearinghouse assist? One of the first steps is to find places to talk and plan. As a result OPC is looking to meet with people in a variety of communities, in regional forums to discuss "keeping health promotion on the public agenda".

Last week, OPC staff along with the North Kingston Community Health Centre, had the first regional forum in Kingston, with 18 participants and a resulting follow-up meeting arranged in Kingston.

We are hoping to arrange similar events January to April in Chatham, Thunder Bay, Timmins, Owen Sound; with related workshops and additional francophone forums in other locations, working always with a local partner or co-host. If you are interested or want additional information contact OPC at 1-800-263-2846 or by e-mail -

"People Centred Health Promotion"

By Irving Rootman & John Raeburn

Remarks by Irv Rootman, Centre for Health Promotion Annual Meeting

December 3, 1997

In contrast to most academically-produced books about health promotion, this is a book with a very strong perspective and message. As it's title indicates, it emphasizes the importance of "people" or "just ordinary folks" in health promotion.

To quote from the preface by Larry Green: "This book does not pretend to be an academic reference or textbook in the usual sense. It is a book about the heart of health promotion; it pleads for staying in touch with the people, communities and empowerment perspectives of health promotion. It is a counterweight, if not antidote, to the sometimes overworked parts of the Ottawa Charter that emphasized a potentially faceless policy and macro-systems approach to health promotion."

Irv Rootman went on to comment on why he and John Raeburn wrote the book:

We have also been feeling that as the 21st Century approaches, the juggernauts of technology, international finance, population growth, conflict and poverty are increasing the potential for facelessness, alienation and violence and that there was therefore a need for a set of human values and "true democracy" which might act as buffers against these "mega-trends". It is our feeling that a people-centred health promotion could make a contribution to this end and that is way we wrote this book.

The first three chapters of the book discuss what is people-centred health, and at the end of chapter 1 there is a summary of the broad principles underlying this approach. The rest of the book is designed to illustrate how these principles can be put into action. For example, the second part of the book focuses on basic concepts, issues and approaches and contains the chapters on empowerment, community development, cultural dimensions and spirituality. Part III of the book

considers how to apply health promotion in planning and evaluation using what we called the "People System", which consists of a set of 13 steps to follow in establishing and running a project. This is followed by three case studies of projects that illustrate the application of this system in a practical way. Finally, the book concludes with a visionary chapter which suggests what an ideal society, based on PCHP principles, might be like.

Towards a PCHP Society

In brief, the vision involves a society based on the principles of "true democracy" and "government from the periphery.". since the bottom line is "community control", "the system" would have to acknowledge constitutionally that the balance of power, and in particular, the

control of local activities is in the hands of the local people, not central government, although in practice, it would require a balance between local and central imperatives or "partnership". This is what we mean by "government from the periphery."

The last sentence in the book is "So how about it, dear reader?" Will you work together with us to create a "People-centred health promotion" which will contribute to the development of a "people-centred world"?

[submitted by Irv Rootman, excerpted by Alison Stirling]

The book can be ordered from John Wiley and Sons Canada, Ltd., Professional and Reference Division, 22 Worcester Road, Etobicoke, Ontario M9W 1L1; Phone: (416) 236-4433; FAX: (416) 236-8743; Cost: $45.00CDN + $3.50 (Shipping and Handling) + 7% (G.S.T.).