Modern transport planning has rapidly moved away from an expensive, outdated system of car-dependent suburban sprawl. Understanding that health is different from and more than healthcare, wider societal discourse needs to apply planning’s lessons learned to move away from a singular focus on healthcare that is similarly expensive and outdated
by Lawrence Loh
Dalla Lana School of Public Health Toronto University, and Director of Programs at The 53rd Week Ltd
Health versus Healthcare – Learning from Transport Planning
Introduction – systems in crisis
North America is seeing an outdated paradigm coming of age.
The system as developed is showing wear and tear, with breaks and cracks everywhere influencing the experience of system users and those tasked with maintaining it. System users are also getting older; staying longer, working harder, and wearing out faster. Infrastructure meant to maintain and support the system is also starting to give, unable to cope with demand. There is almost never enough funding to keep the system optimally functioning; congestion frequently occurs, fraying tempers and leaving people fuming as they wait. Workers try their best to patch the system, but ultimately, they’re just keeping up as this antiquated mode of thinking continues to influence our health and well-being.
Lest you think I am referring to a contemporary healthcare system, I am actually talking about a similarly complex system that is often the lifeblood of modern North American cities: road transport and the suburban-urban divide.
The parallels with healthcare, though, are hard to miss.
Growing literature has documented the surging costs of healthcare in many industrialised nations. Consuming 18% of the United States’ Gross Domestic Product (GDP), at least one model put forward by the Brookings Institute calls for that proportion to be 25% within the next two decades. Many other countries are seeing the same increase in their GDP share of health. Occurring at the same time, are pressures around quality of care received, accountability, waiting lists and access to care, and insurance reform and models of remuneration; of course, underpinned by long-term economic stagnation that continues to rob governments of critical revenues.
In this environment, funding for healthcare professional salaries are being frozen or axed and hospital budgets are being held constant to encourage rationalization exercises and doing “more with less.” Yet demand for healthcare services continues unabated. Aging populations continue to fuel the inexorable rise of chronic diseases, which contribute the bulk of population mortality and morbidity; emerging infectious diseases, mental health issues, and injuries continue to take their toll, and even anti-science groups burden the system through the resurgence of vaccine-preventable communicable disease and complications arising from alternative therapies.
Some advocates espouse a time-tested solution: “An ounce of prevention is worth a pound of cure”; simple and elegant to state, but seemingly difficult to disseminate. Unfortunately, the understanding that healthcare is not health continues to elude the understanding of those who need to hear it most: policymakers, regulators, civil society, and the private sector, to name a few. Whether this is due to a limited availability of robust evidence for population-level health programs, personal ideology, inertia, or otherwise, it is often too easy for key stakeholders to commit the focus of funding and resources to the acute healthcare system, rather than pursuing the broader concept that health is shaped every day by every policy, every program, and every decision taken.
The advocates that call for a paradigm shift understand that health is more than just healthcare and building health is what happens outside the walls of a hospital, but in our neighbourhoods and our communities. They also believe reducing the causes of ill-health is critical to reducing future healthcare demand. They call for thinking about lifestyle choices, community contexts, outreach and opportunities, to give people the resources they need to make the healthy choice the easy choice. The goal is to keep people healthy and out of the increasingly unwieldy healthcare system; stemming the burden of disease by prevention and health promotion.
This alternative paradigm has driven health to build partnerships with urban planning. In this cross-over field, city policy stakeholders consider how cities and urban streetscapes influence our health and wellbeing. Working together, they make cities more likely to support the health of their residents through transport policy, commercial policy, school policy, and so on.
Keeping people healthy. Reducing the burden of disease through policy. Reducing demand on the healthcare system. Perhaps not-so-novel concepts.
So then, why is there still such a focus on pouring resources into acute care?
And returning to our first example: what can we learn from transport planning about shifting away from an obsolete paradigm?
Building your way out of traffic
The field of transport planning has looked at demand for a while now, and a growing body of literature is showing what we intuitively know about the old suburban sprawl paradigm.
The news, quite simply, is not unexpected. But it’s also not good—on many levels.
Using metrics such as quality of life, economics, physical and mental well-being, community cohesiveness, and even (ironically) travel times, the post-war suburbs that really mushroomed in North America in the 70s and 80s are mostly bad news, on a daily and long-term basis.
Trends increasingly show the adoption of alternative paradigms: young professionals in North America are increasingly getting out of their cars and move into downtown cores of cities, repopulating neighbourhoods that had long been abandoned in the latter twentieth century flight to the burbs. Surveys have time and time again showed that a younger generation desires mixed development and amenities, community and experiences, and the option of using active transport to get to and from work. The resulting benefits pay off in dividends on their quality of life, the money saved on avoiding congestion or maintaining a vehicle, and the creativity and innovation that comes from chance meetings and community development.
Urban planners are increasingly favouring denser, more mixed-use urban forms as opposed to suburban sprawl for the many demonstrated benefits. They have known for a long time that you can’t build your way out of traffic. Called the “induced demand phenomenon”, the idea that a congested road can be relieved by building another road is often put to rest when the existence of that road, in turn, leads to greater demand and use. New roadways simply add to the congestion problem rather than solve it.
New roadways also add to the maintenance problem that exists in many suburban environments today. Roads built in the 80s and 90s, together with their parallel utilities, are coming to the end of their lifecycle and need to be maintained to ensure suburban residents continue to enjoy their quality of life. When costs of upkeep along with costs of congestion are factored in, sprawl actually becomes a much pricier proposition than living in an urban setting.
Knowing that they can’t build their way out of congestion, and that doing so just creates a greater resource sink, planners are increasingly pursuing a different paradigm. By redeveloping dense urban centres and fostering mixed use planning, changing from a focus on moving motor vehicles in and out of the core to instead building human-sized communities, planners are aiming to cut sprawl and mitigate its effects, particularly reducing demand for road transport at the source.
Of course, it’s a careful balancing act for policymakers in a complex ecosystem where reasonable alternatives (e.g. public transport) should exist, and it’s equally challenging when folks may seem stuck in the old paradigm (e.g. “why aren’t you fixing my road?”). In many ways, though, transport planning is returning to the ideas that built the cities of the old world, which were built for walking. The new paradigm being pursued in cities today are thus, in some ways, a return to our roots.
Et tu, health?
So what can health learn about returning to its own roots, where an ounce of prevention is worth a pound of cure? It’s important to note that the concept is not new. Major organizations, public health professionals and other health advocates have long pushed the concept of health as a resource for daily life, and not merely something to think about when one falls ill. Many in the field are familiar with the Ottawa Declaration, the World Health Organization’s definition of health, and the various principles around social determinants of health.
Thomas Edison, one of history’s great thinkers, once stated ““The doctor of the future will give no medication, but will interest his patients in the care of the human frame, diet and in the cause and prevention of disease.” How do we get there, and what can we learn from the shift that has taken place in urban planning?
It’s about winning hearts and minds outside of the ongoing discourse, and really just committing to working with others towards action.
Urban planning very quickly moved away from a paradigm that wasn’t working and that wasn’t amenable to being built out of, and they did so by building alliances and altering the conversation. For health and healthcare, the trouble lies in the fact that acute healthcare still dominates so much of the wider societal conversation about health. One notices that acute healthcare still swallows the bulk of the budgets of many health ministries. There is an almost never-ending discourse in Western countries around healthcare specific topics, such as access and wait-times, insurance reforms, standards and accountability, primary care versus specialty training, and health human resource planning.
With all this focus on healthcare, it’s not surprising that the broader idea of health gets lost in the wider discourse. In many ways, though, the constant focus on healthcare is similar to the induced demand of traffic. Building another hospital without addressing the causes of ill health is like building another roadway without changing the base assumption that sprawl exists. Like planners moved to ask “why sprawl”, health must move to ask “why only healthcare?”
It is clear that we cannot fix the demand for healthcare by building our way out of it. Health, together with key partners, must change the discourse towards taking the alternative paradigm more seriously, and encourage the populace to sign on. Focusing the discourse solely on a system that treats people when they are ill minimizes “keeping people healthy” as a societal imperative.
A broader public discourse about keeping people healthy is needed to bring the concept of health in all policies into public consciousness. It will take partnerships with leaders willing to shoulder responsibility. It will take multisectoral collaboration. It will take support for research and evaluation to determine what works and what does not, and it will take political appetite to make difficult decisions and calls. But the alternative is similar to where a suburban dystopia was taking us in the urban planning world.
Today’s discourse on health must pivot away from a singular focus on healthcare. Only by recognizing and addressing the myriad underlying causes that drive healthcare demand can we achieve true health for all.
Based in Toronto, Dr. Lawrence Loh is a public health physician at Public Health Ontario, adjunct lecturer in Clinical Public Health at the Dalla Lana School of Public Health at the University of Toronto, and Director of Programs at The 53rd Week Ltd. To learn more about The 53rd Week and its efforts to incorporate health into short-term medical volunteering abroad, visit http://www.53rdweek.org/