introductionWhat Is Public Health, and Why Does It Matter?

Lindsay McLaren, Donald W.M. Juzwishin and Frank W. Stahnisch

Public Health: “The science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts.”

— Charles-Edward Winslow,
“The Untilled Fields of Public Health,” 1920.¹

Introduction

The immediate impetus for this book, which considers a century of public health in the province of Alberta, is an opportunity to recognize the centenary of the 1919 provincial act that established Alberta’s first department of public health.² However, that impetus belies several other complex and contested aspects of public health that we seek to explore. First, lying beneath the seemingly straightforward definition with which we open this chapter is our recognition that, while public health is often celebrated for its achievements in improving health status and conditions of populations,³ those achievements are accompanied, and sometimes undermined, by significant challenges and tensions. For example, the oftentimes blunt and colonial nature of public health measures, which underlies their leverage for population-wide impact, can also — in interaction with socio-political context — create and perpetuate conditions of inequity and exclusion (see for example chapters 1, 3, 7, and 9).⁴

Second, and as described in more detail in this introduction and throughout the book, public health today faces important challenges: it is widely misunderstood (e.g., it is frequently conflated with publicly funded medical care), and there are tensions within the field, including between scholarly communities with a critical orientation and practitioner communities who may be more aligned with a biomedical perspective.⁵ These challenges limit the field’s ability to mobilize as a collective toward creating conditions for population well-being and health equity, and they provide a strong rationale indeed for reflecting on public health’s scope, developments, achievements, and failures in the province’s past.

To signal our concern with these challenges and our commitment to advancing a coherent vision for the future, we conceptualize public health as a field of applied practice and scholarly inquiry that brings unique elements to understanding and improving health and well-being. Distinct from the individualized and often reductive orientation of biomedicine and other aspect of health care, public health is characterized by a focus on populations as collectives. Also, rather than focusing on treatment or management of people’s illnesses when they are sick, public health emphasizes keeping people healthy in the first place through prevention, health promotion, and thinking about “upstream” or root causes of poor health and health inequity.⁶ Moreover, in line with its intersections with social sciences,⁷ public health activities are — or should be — conceptually anchored in critical perspectives that are concerned with collective and structural processes that shape well-being and health equity and aim to “speak truth to power.”⁸ This includes — but is not limited to — illuminating and demonstrating leadership around the pernicious effects on population well-being and health equity of medicalization (i.e., the processes by which problems that result from large-scale social forces and political decisions are reductively treated as individual-level problems amenable to technical or individualized solutions) and neoliberal capitalism (i.e., the dominant global political economic system since the early 1980s, characterized by aggressive pursuit of the capitalist vision of protecting and accumulating private wealth through policies such as deregulation of industry and labour markets, austerity and privatization of public services, and trade liberalization).⁹

We are fortunate, in this project, to draw and build on many existing contributions. However, a consolidated history from a contemporary vantage point that takes a broad vision of public health is scarce, and our aim with this book is to begin to address that gap. Perhaps the most wide-ranging history of public health in Alberta is the 1982 publication by Adelaide Schartner titled Health Units of Alberta,¹⁰ which was a celebratory effort by the Health Unit Association of Alberta on the fiftieth anniversary of the creation of health units in the province. That work analyzed local health boards, district nursing, and the activities of health units since the 1930s. However, it did not expand on efforts outside of health unit administration and structure. In 1984, public health physician Gerald Predy wrote a brief history of public health in Alberta, published in the Canadian Journal of Public Health as part of a historical issue commemorating the journal’s seventy-fifth anniversary.¹¹ Predy’s overview includes health concerns, demographic and economic circumstances, legislative changes and other public health efforts, and the professional public health workforce, in Alberta; the main limitation is its brevity of two pages.

Other important published historical accounts include, but are not limited to, publications by former Deputy Minister of Health of Alberta, Malcolm Bow, and indeed many papers published in what is now called the Canadian Journal of Public Health (see Appendix A). Bow’s papers, including “The History of the Department of Public Health of Alberta” from 1935; and “Public Health Yesterday, To-Day, and To-Morrow” from 1937; coupled with later publications such as 1959’s “The Alberta Department of Public Health” by A. Somerville, Alberta’s then deputy minister of health, provide insights into major health problems at the time and the nature and extent of Alberta’s societal response, as well as public health’s origins in a largely medical practice.¹² As one example of early provincial attention to some forms of health inequality, intersecting with economic development in a province in its early stages of governance, Bow pointed out in 1935 that unequal access to preventive services had resulted from some areas of the province developing rapidly, while “pioneer conditions [were] still to be found in many others.”¹³

More recent works include 1994’s Public Health: People Caring for People by Edmonton writer Bill Carney, prepared for the Health Unit Association of Alberta,¹⁴ which acknowledges Schartner’s Health Units of Alberta as a key source; 2007’s A Century of Public Health Services in Alberta written by Alberta social worker and historian Baldwin Reichwein for the Alberta Public Health Association, which gives an overview of public health services in the province organized into social and economic epochs;¹⁵ and our own project, 2017’s Public Health Advocacy: Lessons Learned from the History of the Alberta Public Health Association, which served as a starting point for this project.¹⁶ In addition to these provincial works are historical overviews of local public health authorities and activities within Alberta’s cities — especially Edmonton and Calgary¹⁷ — and recent work with a national scope, such as 2010s This is Public Health: A Canadian History by Christopher Rutty and Sue C. Sullivan, which commemorates the centenary of the Canadian Public Health Association.¹⁸

We have opportunity, through this project, to update these important works and to consider them from a contemporary perspective characterized by, among other things, increasing attention — in theory if not in practice — to significant and entrenched forms of social inequities in health;¹⁹ emergent public health concerns such as intensification of climate change and ecological degradation (see Chapter 8),²⁰ the opioid crisis (see Chapter 7 where we share the Kainai Nation’s community response to this issue),²¹ and the COVID-19 pandemic (see Chapter 14);²² a broad and diverse public health community that includes scholars, activists, practitioners, and members of publics; and a socio-political environment that, as described in this introduction and throughout the book, is increasingly unfriendly to the public’s health.

What Is Public Health?

The overall objective of this volume is to commemorate, critique, and learn from Alberta’s public health history. By doing so, we aspire to articulate the contours of a public health that, as a discipline and field of practice, is positioned to address contemporary health concerns and their determinants.²³ A historical approach is well suited to this task, because it theoretically allows for the identification of core, enduring features of public health. Being able to identify and articulate those core features is critical if public health is to remain a relevant societal institution through significant demographic, social, political, economic, epidemiologic, and technological trends that characterize its past, present, and future.²⁴

What are public health’s core features? Writing in 1920, American bacteriologist and public health expert Charles-Edward Winslow offered “a tentative, if necessarily imperfect, formulation of the scope and tendencies of the modern public health campaign,” from which one can begin to glean core features.²⁵ In addition to a focus on communities or populations, rather than individuals (which he aligned with “private medicine”), Winslow viewed public health as concerned with prevention, arguing that: “medical knowledge has generally been applied only when disease has gone so far that the damage is irremediable. Medical knowledge will be highly effective only when applied in the incipient stages of disease.”²⁶

Additionally, Winslow recognized the importance of social and economic determinants of health: “we come sooner or later to a realization of the fact that education and medical and nursing service, while they can accomplish much, cannot cope successfully with the evil effects of standards of living too low to permit the maintenance of normal physical health.”²⁷ Acknowledging the implications of that knowledge, he further stated: “If an initially normal family cannot gain a livelihood adequate for its minimum physical needs, there is evidently a problem of social readjustments which our nation must face” [emphasis added], thus speaking to the need for societal solutions to population health problems.

Nearly 100 years later, the Canadian Public Health Association identified similar core elements for public health, including concern with maintaining and improving (e.g., through promotion, protection, and prevention) the health of populations, key principles of social justice and equity, and attention to addressing underlying social, economic, political, ecological, and colonial determinants of health, along with evidence-informed policy and practice.²⁸ A newer emphasis on maintaining and improving health, as distinct from preventing illness as articulated by Winslow, reflects historically significant interim occurrences such as the 1946 Constitution of the World Health Organization,²⁹ the Health Field concept contained in the 1974 report, A New Perspective on the Health of Canadians,³⁰ and the 1986 Ottawa Charter for Health Promotion (see Chapter 10).³¹ These documents, and others, signal a shift, at least in theory, toward a more holistic conceptualization of health that includes not only illness or its absence, but also well-being (social, emotional, spiritual), and recognition that medicine and health care are only partial options for maintaining and improving the health of populations.

Public health’s emphasis on improving health and well-being among populations via attention to upstream social determinants of health introduces an additional core feature of the field and of this book — namely, power and politics. In the introduction to her important, and still highly relevant, 1988 book, Hidden Arguments: Political Ideology and Disease Prevention Policy, University of Arizona professor Sylvia Noble Tesh argues that “behind debates about such questions as the toxicity of environmental pollutants, the hazards of smoking, and the health effects of cholesterol lie other, hidden arguments. These arguments are more fundamental: What is the legitimate source of knowledge? What is the nature of human beings? And what is the ideal structure of society?”³² American historian of public health, Dorothy Porter, speaks to the enduring importance of these considerations in her 1999 volume where she said, “the concern with collective social action involves an analysis of the structural operation of power, which makes the political implications of population health in different periods and in different societies a persistent theme.”³³ That is, although the details of power and politics may take different forms depending on time and place, their importance to our field persists. Finally, American author Deborah Stone in her book Policy Paradox: The Art of Political Decision Making emphasizes that how problems are identified and defined is determined by those in power, those who have the authority to make decisions and policy, thus prompting the importance of asking questions such as: “Who is given the right to make decisions about the problem? Whose voice counts, both for choosing leaders and for choosing policies? Who is subordinated to whom? What kind of internal hierarchy is created? Who is allied to whom? How does the authority structure create loyalties and antagonisms among members of the community?”³⁴ One of our goals in the succeeding chapters is to keep a critical eye on structures and relationships and their intersections with public health priorities and activities.

Despite this identification of core features and principles that have endured over time, public health is a term that is frequently misunderstood. It is often conflated with publicly funded medical care, which dilutes its unique emphasis on root causes of population-level health problems and health inequities. Public health is moreover often reduced in scope and substance to singular elements such as immunization, the opioid crisis, or communicable disease outbreaks.³⁵ The COVID-19 pandemic is a case in point: although the pandemic has thrust public health into the spotlight, it has perpetuated a narrow, technical, and individualized version of public health, focused on physical illness and characterized by communicable disease control, and led by medical practitioners in the health care system.³⁶

Furthermore, even within the public health community, including practitioners, academics, and activists, there are different perspectives on public health that differ importantly in structure and scope.³⁷ A narrower perspective focuses on the formal public health system and its institutional parameters, including delivery of public health services by health authorities; while another, broader, perspective embraces root causes of poor health and health inequities embodied in systems and structures that extend far beyond the formal health sector. Taking a narrower view of public health has the advantages of making the term more readily definable and having existing institutional (e.g., legal and governance) structures.³⁸ Its primary disadvantage — and this is a significant criticism — is its limited scope and usually uncritical nature.³⁹ As scholars in critical public health and health promotion traditions have long recognized, foundations of population health are social and political in nature and demand an intersectoral and interdisciplinary approach coupled with deep reflexivity and humility, including epistemic humility, to tackle entrenched forms of power that underpin social and health inequities.⁴⁰ These considerations demand a broader conceptualization of public health. Yet, any concept — including public health — that is too broad risks being useless. Although different perspectives on public health can be a strength for the field, it can also create fracture and lack of unity, especially if — as described in this introduction — public health is “weakening.”⁴¹

This question of “how broad the mandate” should be for public health, which has been described as “timeless,”⁴² presents important challenges for this book and for the field more broadly. For example, on a practical level, a narrower versus broader conceptualization of public health has implications for identifying which government departments are relevant to public health, or for deciding what should be included or excluded in public health spending.⁴³ Beyond these practical decisions, the question of the scope of public health has deeper implications. With the future well-being of all populations in mind, do we want to continue to focus on current public health programs and services and their institutional parameters (a narrower version of public health)? Or do we want to focus on the ultimate aims of public health — population well-being and health equity — and use that broader aim to shape what we do as a society, including the messiness of boundaries that comes with it?

Why Do This Now?

The year 2019 marked the centenary of the 1919 act that led to the establishment of Alberta’s first provincial Department of Public Health.⁴⁴ Alberta was the second province in Canada to establish such a department, following New Brunswick in 1918. The federal government also introduced a Department of Health in 1919.⁴⁵ Anniversaries provide an opportunity to reflect and learn from our past, toward strengthening our future.

The mere year of 1919 is of course not the beginning of public health in Alberta. As discussed elsewhere in this book (e.g., Chapter 4), public health activities in the area predated the formal creation of the province.⁴⁶ As with many foundational dates in the wider history of social movements, we could have chosen to commemorate various earlier occurrences or pieces of legislation; for example, Alberta’s first Public Health Act or its Vital Statistics Act, which were passed in 1907,⁴⁷ or the signing of Treaties 6, 7, or 8 in the late nineteenth century, which brought devastating implications for the well-being of Indigenous communities that persist to this day (see also Chapter 7).⁴⁸

We singled out the 1919 act because it has features that make it interesting and relevant as a starting point for historical study. First, prior to 1919 — in the first fourteen years of the province⁴⁹ — formal public health activities in Alberta were housed under various departments and ministries, including the Attorney General, Agriculture, and Municipal Affairs.⁵⁰ The year 1919 marked the establishment of a provincial department devoted specifically to public health, signifying public health’s importance to at least some in Alberta at that time. Second, the wording of the 1919 act communicates a consolidation of public health under one umbrella; for example, “All that part of the administration of the government of the province, which relates to public health.”⁵¹ This provides an opportunity for insights around why this centralization occurred and to what end, including from a contemporary vantage point anchored in a broad vision of public health.⁵²

The Current State of Public Health in Canada and Alberta

While the centenary of the 1919 Public Health Act provides a convenient opportunity for historical reflection, the substantive impetus for our project concerns the state of public health in Canada and Alberta. First, contemporary national discourse suggests that public health is weakening. Quite recent scholarly and review commentaries by public health professors and practitioners Louise Potvin (Université de Montréal), Ak’ingabe Guyon (Université de Montréal), and Trevor Hancock (Prof. Emer., University of Victoria) for instance have identified important trends across Canada.⁵³ Within the formal public health sector, emphasized in the narrower version of public health, these include a downgrading of the status of public health activities within health authorities, eroding the independence of medical officers of health (for example, the arbitrary dismissal of medical officers of health who “speak truth to power” on matters of public health concern),⁵⁴ decreasing funding, and limiting or diluting the scope of public health. This latter trend includes instances where public health departments or activities are combined with primary or community care in such a way that, problematically, community and population-level public health responsibilities are displaced by individually-focused clinical tasks.

Moreover, there are indications of resistance to a broader version of public health that is concerned with upstream determinants of well-being and health equity. As reported by Potvin in her editorial, “Canadian Public Health Under Siege,” a 2014 Globe and Mail column asserted that, “it is not the job of public health to have an opinion on taxes, economic policy, free trade or corporate control,” arguing instead that public health should limit itself to a narrow focus on communicable disease prevention and control.⁵⁵ The important role of the popular press in shaping (i.e., limiting) the contours of public health is supported by scholarly work demonstrating that mainstream media coverage of “health” in Canada is dominated by topics related to medical care (e.g., service provision, service delivery, management, regulation) and only very infrequently considers social determinants of health.⁵⁶ This is a significant challenge that must be overcome to realize a broad public health vision.

In terms of whether public health has been weakened by inadequate funding, this is another dimension that is complicated by the existence of different definitions of public health. On the one hand, it is clear from available data that although spending on medical care in Canada is significant, spending on formal public health activities, as a component of medical care spending, constitutes only a very small proportion of those costs. For example, according to the Canadian Institute for Health Information, total health care expenditure in Canada in 2019 was estimated at $264.4 billion, or $7,068 per Canadian, corresponding to 11.6 percent of Canada’s gross domestic product (GDP), up from 7 percent of GDP in 1975.⁵⁷ Public health, defined by the Canadian Institute for Health Information as “expenditures for items such as food and drug safety, health inspections, health promotion activities, community mental health programs, public health nursing, measures to prevent the spread of communicable disease and occupational health to promote and enhance the safety at the workplace in public sector agencies,” constituted 5.4 percent of those expenditures.⁵⁸

Focusing on Alberta in particular, Figure 0.1 presents annual provincial government per capita health expenditure from 1975 to 2019,⁵⁹ for two spending categories as defined by the Canadian Institute for Health Information : 1) public health and — as a contrast — 2) hospitals, which is the largest health spending category:⁶⁰

Source: Canadian Institute for Health Information, Open data on health spending (modifiable data set that can be freely used). Available at: https://www.cihi.ca/en/national-health-expenditure-trends-1975-to-2019 (scroll down to “Health spending data tables”; Table D4: Provincial/territorial government expenditures; Table D.4.9.3 Provincial government per capita health expenditure by use of funds in current dollars, Alberta, 1975 to 2019).

The figure illustrates that per capita spending on both public health (as defined above) and hospitals in Alberta has increased over time; however, the amount spent on hospitals is consistently much higher than that spent on public health. Figure 0.2 shows relative spending on public health in Alberta, that is, the annual provincial government spending on public health, as a percent of total health expenditure, 1975 to 2019.

Source: Canadian Institute for Health Information, Open data on health spending (modifiable data set that can be freely used). Available at: https://www.cihi.ca/en/national-health-expenditure-trends-1975-to-2019 (scroll down to “Health spending data tables”; Table D4: Provincial/territorial government expenditures; Table D.4.9.2 Percentage distribution of provincial government health expenditure by use of funds, Alberta, 1975 to 2019).

The figure shows that, during the 1975 to 2019 period, the relative spending on public health in Alberta ranged from approximately 5 percent (early 1990s) to almost 12 percent (2007) of total health spending. Some variation is evident, including that which coincides with significant changes to health care system governance in the 1990s (health care regionalization) and early 2000s (transition from regional health authorities to Alberta Health Services).⁶¹ Overall, however, the modest trend over time in terms of percent of health spending on public health has been upward, not downward, in Alberta.

The story told by these spending data, however, is incomplete. From a social determinants of health point of view (embraced by a broad definition of public health), the primary determinants of health and well-being are economic and social conditions, which reflect public policy decisions including spending outside of health care. Yet, spending in ministries outside of health is not typically included in estimates of public health spending. This is an important omission.⁶² For example, based on an analysis of provincial spending data from 1981 to 2011, professor Daniel Dutton and colleagues demonstrated a positive association between social spending (i.e., spending in social service sectors) and population health outcomes; in fact, social spending was more important to population health outcomes than health care spending.⁶³ Yet, social spending across provinces in Canada remained at a low and in some cases declining level during this time period, while health care spending increased significantly.

Thus, although public health spending as defined by the Canadian Institute for Health Information has not shown a decreasing trend in Alberta for the period for which data are readily available, government spending on activities that would improve population health and well-being — that is, spending in the social and other public sectors — is low and is declining — especially relative to health care spending — over time. A broader definition of spending that includes social spending better aligns with Winslow’s definition of public health with which we opened this chapter: “The science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community efforts,”⁶⁴ which necessarily extends beyond the formal health sector. Taking a broad public health perspective, public sector investment in health in Alberta and across Canada is low and has indeed declined over time.

Although a one hundred-year analysis of public health spending in Alberta was not feasible, we have an early glimpse of this issue from the 1939 annual report of the Department of Public Health, in which Deputy Minister of Public Health, Malcolm Bow, made the following comments, with reference to the statement of revenue and expenditure for the 1939–1940 fiscal year [emphasis added]:

An analysis of this statement shows that the total expenditure for all activities of this Department was $2,600,711.25. The expenditure for the Child Welfare and Mothers’ Allowance Branch amounted to $710,811.63. . . . Of the [remainder] [$1,889,959.62], $1,677,366.16 was expended for the maintenance and operation of the various institutions which are under the administration of the Department, for grants to hospitals and homes, and for other forms of what might be termed treatment services; $212,593.46 representing 11.2% of the total budget of the Department, excluding the amounts expended for Child Welfare and Mothers’ Allowances, was expended for all other activities, including clinic services, vital statistics, communicable disease control, public health units, general administration and all preventive services. Thus, out of every dollar expended by the Department, 11.2 [cents] were spent for preventive health activities. The need for the extension of preventive health service, particularly in our rural and smaller urban centres is great. No expenditure will pay larger dividends in ensuring a sound structure of health in this Province.⁶⁵

Dr. Bow’s comments in 1939 illustrate two things: first, that there is a historical legacy of separating social spending (at that time, child welfare and mother’s allowance) from health spending, which presents a challenge to a broad version of public health; and second, that spending on preventive health activities relative to treatment services was limited, thus showing early concern about an issue that continues to preoccupy the community today.

What This Book Is, and What It Is Not

This book offers “a” history of public health in Alberta. It was prompted by our observation and concern that public health, as a field of scholarly inquiry and applied practice, is diffuse, divided, and poorly understood. This creates a problem when it comes to mobilizing as a collective to support efforts to improve well-being and health equity in populations. It is also important for our political leaders who are charged with the responsibility of providing conditions to protect and support the health and well-being of all of us.

Anchored in long-standing definitions of public health (i.e., the science and art of preventing disease and promoting health through organized efforts of society) that have yet to be fully realized, we present a work that aims to illustrate contours of the field historically in Alberta. Inevitably, we brought our own experiences and perspectives to this project. These shaped the overall orientation of the book, its largely narrative approach, and the topics and examples we have chosen. Our focus on illustrating a broad version of public health, as discussed above, at times precluded deeper analysis of the episodes covered; this is a trade-off for which we feel some discomfort. We enthusiastically await the efforts of those who follow, to take those deeper and more critical dives while, we hope, retaining a focus on strengthening a coherent vision for the field as a whole.

Consistent with our broad definition of public health, the intended audience for this book is also broad. While we carry no illusions that everyone will agree with our approach, we hope that our efforts to articulate and illustrate contours of our field will resonate in some way with researchers, scholars, activists, practitioners, policy actors, students, and members of publics.

The Chapters Ahead

The book is organized as follows. The first three chapters aim to set the stage for the remainder of the book. Chapter 1 addresses what we view as a fundamental question, namely, who is the public in public health. In Chapter 2, we use an innovative data source — Alberta government throne speeches since 1906 — to shed light on how health and public health have been understood by provincial leadership over time. Chapter 3 considers, from the perspective of historically available statistics, the health — or more accurately, the sickness — of Albertans over time.

In chapters 4 through 7, we consider a range of institutions, sectors, and populations. Chapter 4 focuses on public health governance; it provides a historical overview of legislative and institutional dimensions of public health in the province, anchored in the provincial Public Health Act. Chapter 5 considers the non-profit sector, with a particular focus on the only provincial non-profit organization that is explicitly concerned with public health: the Alberta Public Health Association. Chapter 6 focuses on public health education in the province, with attention to university programs in public health. And in Chapter 7 we share stories about public health from First Nation communities in Treaties 6, 7, and 8.

Chapters 8 through 12 are organized using contemporary public health functions as described by the Public Health Agency of Canada;⁶⁶ these include health protection (Chapter 8), disease and injury prevention (Chapter 9), health promotion (Chapter 10), and emergency preparedness and response (Chapter 11), in addition to the social determinants of health (Chapter 12). Each chapter considers a small number of focal topics or examples to illustrate different types of problems and solutions, and how those played out within their socio-historical context.

To anchor the book, chapters were prepared while keeping two questions in mind. The first question, informed by our concerns about the state of public health in Alberta and Canada, asks, what happened, when, and why? Learning from our history, the second question asks how we might work to strengthen public health moving forward. Our final two chapters shed additional light on these questions: Chapter 13 by showcasing a subset of individuals across Alberta’s public health history who have publicly contended with these challenges, and Chapter 14 by synthesizing some substantive insights from the volume as a whole. Written during the COVID-19 pandemic, that concluding chapter considers the significant opportunity presented by the pandemic to shape a coherent vision for the future of public health, in Alberta and beyond.⁶⁷

notes

1. 1 Charles-Edward Winslow, “The Untilled Fields of Public Health,” Science 51, no. 1306 (1920), 23.

2. 2 An Act respecting the Department of Public Health, Statutes of the Province of Alberta (S.P.A.), 1919, c. 16.

3. 3 Christopher Rutty and Susan C. Sullivan, This Is Public Health: A Canadian History (Ottawa, Canadian Public Health Association, 2010), 2.9f; Winslow, “Untilled Fields,” 23.

4. 4 Marjorie MacDonald, Introduction to Public Health Ethics 1: Background (Montréal, QC: National Collaborating Centre for Healthy Public Policy, 2014), http://www.ncchpp.ca/docs/2014_Ethics_Intro1_En.pdf; Nuffield Council on Bioethics, Public Health: Ethical Issues (London: Nuffield Council on Bioethics, 2007), http://nuffieldbioethics.org/wp-content/uploads/2014/07/Public-health-ethical-issues.pdf.

5. 5 Kelsey Lucyk and Lindsay McLaren, “Commentary — Is the Future of ‘Population/Public Health’ in Canada United or Divided? Reflections from within the Field,” Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice 37, no. 7 (July 2017), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5650033/; Lindsay McLaren and Trevor Hancock, “Public Health Matters — but We Need to Make the Case,” Canadian Journal of Public Health 110, no. 3 (1 June 2019), https://doi.org/10.17269/s41997-019-00218-z; Canadian Network of Public Health Associations (CNPHA), “A Collective Voice for Advancing Public Health: Why Public Health Associations Matter Today,” Canadian Journal of Public Health 110, no. 3 (2019), https://pubmed.ncbi.nlm.nih.gov/30937728/.

6. 6 Canadian Public Health Association (CPHA), Public Health: A Conceptual Framework, Canadian Public Health Association Working Paper, 2nd ed. (Ottawa: CPHA, 2017); McLaren and Hancock, “Public Health Matters.”

7. 7 Lori Baugh Littlejohns, Neale Smith, and Louise Townend, “Why Public Health Matters Today More than Ever: The Convergence of Health and Social Policy,” Canadian Journal of Public Health 110, no. 3 (7 January 2019), https://doi.org/10.17269/s41997-018-0171-1; Lindsay McLaren, “In Defense of a Population-Level Approach to Prevention: Why Public Health Matters Today,” Canadian Journal of Public Health 110, no. 3 (1 June 2019), https://doi.org/10.17269/s41997-019-00198-0.

8. 8 Michael Harvey, “The Political Economy of Health: Revisiting Its Marxian Origins to Address 21st-Century Health Inequalities,” American Journal of Public Health 111, no. 2 (22 December 2020), https://doi.org/10.2105/AJPH.2020.305996; Dennis Raphael et al., Social Determinants of Health: The Canadian Facts, 2nd ed. (Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management, 2020), http://www.thecanadianfacts.org/.

9. 9 Ted Schrecker, “What Is Critical about Critical Public Health? Focus on Health Inequalities,” Critical Public Health 32, no. 2 (15 March 2022), https://doi.org/10.1080/09581596.2021.1905776.

10. 10 Adelaide Schartner, Health Units of Alberta (Edmonton: Health Unit Association of Alberta, 1982).

11. 11 Gerald Predy, “A Brief History of Public Health in Alberta,” Canadian Journal of Public Health 75, no. 5 (1984); John M. Last, “Seventy-five Years On,” Canadian Journal of Public Health 75, no. 5 (1984).

12. 12 Malcolm R. Bow and F. T. Cook, “The History of the Department of Public Health of Alberta,” Canadian Public Health Journal 26, no. 8 (1935); Malcolm R. Bow, “Public Health Yesterday, To-Day, and To-Morrow,” Canadian Public Health Journal 28, no. 7 (1937); A. Somerville and R.D. DeFries, “The Alberta Department of Public Health,” Canadian Journal of Public Health 50, no. 1 (1959).

13. 13 Bow and Cook. “Department of Public Health,” 396.

14. 14 Bill Carney, Public Health: People Caring for People (Edmonton: Health Unit Association of Alberta, 1994).

15. 15 Baldwin P. Reichwein, A Century of Public Health Services in Alberta: Celebrate Success while Remaining Alert to New Threats (Edmonton: A monograph developed for the Alberta Public Health Association, 2007).

16. 16 Lindsay McLaren, Kelsey Lucyk, and Frank Stahnisch, “Public Health Advocacy: Lessons Learned from the History of the Alberta Public Health Association.” Research grant, Alberta Historical Resources Foundation — Heritage Preservation Partnership Program, July 2015–June 2018; Rogelio Velez Mendoza, et al., “The History of the Alberta Public Health Association” (narrative report produced for the Alberta Public Health Association) (Calgary: APHA, 2017), available at www.apha.ab.ca.

17. 17 For example, James M. Howell, “Edmonton Board of Health Celebrates 100 Years — or More,” Canadian Journal of Public Health 83, no. 4 (1992); Jack Lucas, “Urban Governance Backgrounders for Six Cities (Calgary, Edmonton, Hamilton, Toronto, Vancouver, Victoria) and Five Policy Domains (education, policing, public health, public transit, water supply),” Scholars Portal Dataverse, V1 (2018), doi.org/10.5683/SP/HLKDPK.

18. 18 Rutty and Sullivan, This Is Public Health.

19. 19 Alberta Health Services and Calgary Institute for Population and Public Health, Measuring Health Inequalities: Learning for the Future (Calgary, 28 February 2011), https://www.albertahealthservices.ca/assets/healthinfo/poph/hi-poph-surv-shsa-measuring-health-inequalitie.pdf; Public Health Agency of Canada, Reducing Health Inequalities: A Challenge For Our Times (Ottawa, 2011), http://publications.gc.ca/collections/collection_2012/aspc-phac/HP35-22-2011-eng.pdf; Commission on Social Determinants of Health, Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health, Final Report of the Commission on Social Determinants of Health (Geneva: World Health Organization, 2008); Truth and Reconciliation Commission of Canada, Honouring the Truth, Reconciling for the Future, Summary of the Final Report of the Truth and Reconciliation Commission of Canada (Winnipeg, MB: Truth and Reconciliation Commission of Canada, 2015), www.trc.ca.

20. 20 Canadian Public Health Association, Global Change and Public Health: Addressing the Ecological Determinants of Health, Discussion Paper (Ottawa: Canadian Public Health Association, May 2015).

21. 21 Benedikt Fischer, et al., “Non-medical Prescription Opioid Use, Prescription Opioid-related Harms and Public Health in Canada: An Update 5 Years Later,” Canadian Journal of Public Health 105, no. 2 (2014), https://www.canada.ca/en/public-health/news/2017/09/statement_from_theco-chairsofthefederalprovincialandterritorials.html; “Opioid Reports,” Government of Alberta, accessed 20 March 2020, https://www.alberta.ca/opioid-reports.aspx.

22. 22 Theresa Tam, From Risk to Resilience: An Equity Approach to COVID-19, The Chief Public Health Officer of Canada’s Report on the State of Public Health in Canada 2020 (Ottawa: Public Health Agency of Canada, Minister of Health, 2020), https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/from-risk-resilience-equity-approach-covid-19.html.

23. 23 Lindsay McLaren and Trish Hennessy, “A Broader Vision of Public Health,” The Monitor (January/February 2021), https://www.policyalternatives.ca/publications/monitor/broader-vision-public-health.

24. 24 Robert E. McKeown, “The Epidemiologic Transition: Changing Patterns of Mortality and Population Dynamics,” American Journal of Lifestyle Medicine 3, no. 1, Suppl (2009); https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805833/; Paul Weindling, “From Germ Theory to Social Medicine: Public Health, 1880–1930,” in Medicine Transformed: Health, Disease and Society in Europe, 1800–1930, ed. Deborah Brunton (Manchester: Manchester University Press in association with the Open University, 2004).

25. 25 Winslow, “Untilled Fields,” 24.

26. 26 Winslow, “Untilled Fields,” 28.

27. 27 Winslow, “Untilled Fields,” 29.

28. 28 Canadian Public Health Association (CPHA), Public Health: A Conceptual Framework.

29. 29 Constitution of the World Health Organization: Principles (1946), https://www.who.int/about/accountability/governance/constitution; William F. Bynum and Roy Porter, “The World Health Organization and Its Work,” American Journal of Public Health 98, no. 9 (1 September 2008).

30. 30 Marc Lalonde, “A New Perspective on the Health of Canadians,” Government of Canada working paper (Ottawa: Minister of Supply and Services Canada, 1981); Hubert L. Laframboise, “Health Policy: Breaking the Problem Down into more Manageable Segments,” Canadian Medical Association Journal 108 (3 February 1973).

31. 31 World Health Organization, “Ottawa Charter for Health Promotion: An International Conference on Health Promotion: the Move Towards a New Public Health,” November 17–21, 1986, Ottawa, Ontario, Canada, http://www.who.int/healthpromotion/conferences/previous/ottawa/en/index4.html; Trevor Hancock, “The Ottawa Charter at 25,” Canadian Journal of Public Health 102, no. 6 (2011): 404; Louise Potvin and Catherine M. Jones. “Twenty-five Years after the Ottawa Charter: The Critical Role of Health Promotion for Public Health,” Canadian Journal of Public Health 102, no. 4 (2011).

32. 32 Sylvia Noble Tesh, Hidden Arguments: Political Ideology and Disease Prevention Policy (New Brunswick, N.J.: Rutgers University Press, 1988), 3.

33. 33 Dorothy Porter, Health, Civilization and the State: A History of Public Health from Ancient to Modern Times (London: Routledge, 1999), 163–278, 5.

34. 34 Deborah Stone, Policy Paradox: The Art of Political Decision Making, Revised Edition (New York: W.W. Norton and Company Inc., 2002), 356.

35. 35 Ruta K. Valaitis et al., “Strengthening Primary Health Care through Primary Care and Public Health Collaboration: The Influence of Intrapersonal and Interpersonal Factors,” Primary Health Care Research & Development 18, no. 1 (2018); Alberta Public Health Association. “Public Health: Taking It to the Streets.” Created in 1993, video, available from the authors; Susan Nall Bales, Andrew Volmert, and Adam Simon, Overcoming Health Individualism: A FrameWorks Creative Brief on Framing Social Determinants in Alberta (FrameWorks Institute, March 2014).

36. 36 Trevor Hancock et al., “There Is Much More to Public Health than COVID-19,” Healthy Debate, 15 June 2020, https://healthydebate.ca/opinions/more-to-public-health-than-covid.

37. 37 Michael M. Rachlis, “Moving Forward with Public Health in Canada,” Canadian Journal of Public Health 95, no. 6 (2004), 405; Sutcliffe and others, “Public Health in Canada;” Canadian Network of Public Health Associations (CNPHA), “A Collective Voice for Advancing Public Health; Canadian Public Health Association, Public Health: A Conceptual Framework.

38. 38 An Act respecting Public Health, S.P.A. 1907, c. 12; Jack Lucas, “Historical Overview: Public Health Governance in Calgary,” Canadian Urban Policy Governance Backgrounders (2015), http://jacklucas.pennyjar.ca/governance; Jack Lucas, “Historical Overview: Public Health Governance in Edmonton,” Canadian Urban Policy Governance Backgrounders (2015), http://jacklucas.pennyjar.ca/governance.

39. 39 CNPHA, “A Collective Voice for Advancing Public Health.”

40. 40 Commission on Social Determinants of Health, Closing the Gap in a Generation; Sarah Whitmee et al., “Safeguarding Human Health in the Anthropocene Epoch: Report of The Rockefeller Foundation-Lancet Commission on Planetary Health,” Lancet 386, no. 10007 (2015); Truth and Reconciliation Commission of Canada, Honouring the Truth; Louise Potvin and Jeff Masuda, “Climate Change: A Top Priority for Public Health,” Canadian Journal of Public Health 111, no. 6 (1 December 2020), https://doi.org/10.17269/s41997-020-00447-7.

41. 41 Lucyk and McLaren, “Is the Future of “Population/Public Health” in Canada United or Divided?”

42. 42 Michael M. Rachlis, “Moving Forward with Public Health.”

43. 43 Lindsay McLaren and Daniel J. Dutton, “The Social Determinants of Pandemic Impact: An Opportunity to Rethink What We Mean by ‘Public Health Spending,’” Canadian Journal of Public Health 111, no. 4 (1 August 2020), https://doi.org/10.17269/s41997-020-00395-2.

44. 44 An Act respecting Public Health, S.P.A., 1907, c. 12.

45. 45 Jasmin H. Cheung-Gertler, “Health Canada,” The Canadian Encyclopedia, Historica Canada, last edited 5 August, 2014.

46. 46 See for example: Anne Woywitka, “Pioneers in Sickness and in Health,” Alberta History 49, no. 1 (2000): 16; John Bunn, “Smallpox Epidemic of 1869–70,” Alberta Historical Review 11 (1963): 18; Eileen M. McNeill, “Women of Vision and Compassion: The Foundation of Health Care in Calgary,” Alberta History 50, no. 1 (Winter 2002); Janice P. Dickin McGinnis, “A City Faces an Epidemic,” Alberta History 24, no 4 (1976); Sharon Richardson, “Frontier Health Care: Alberta’s District and Municipal Nursing Services 1919 to 1976,” Alberta History 46, no 1 (1998).

47. 47 An Act respecting Public Health, S.P.A., 1907; Act respecting the Registration of Births, Marriages and Deaths, S.P.A., 1907, c.13; Bow and Cook, “Department of Public Health.”

48. 48 Truth, and Reconciliation Commission of Canada, Canada’s Residential Schools: The History, Part 1, Origins to 1939: The Final Report of the Truth and Reconciliation Commission of Canada, Vol. 1 (McGill-Queen’s Press-MQUP, 2016), http://nctr.ca/reports.php

49. 49 Howard Palmer and Tamara Palmer, Alberta: A New History (Edmonton: Hurtig, 1990); Catherine Anne Cavanaugh, Michael Payne and Donald Grant Wetherell, eds., Alberta Formed, Alberta Transformed (Edmonton: University of Alberta, 2006).

50. 50 Gerald Predy, “Public Health in Alberta.”

51. 51 Predy, “Public Health in Alberta.”

52. 52 World Health Organization, Health in All Policies: Helsinki Statement. Framework for Country Action, 8th Global Conference on Health Promotion 2013 (Helsinki, 2014), http://www.who.int/healthpromotion/frameworkforcountryaction/en/; “Health in All Policies,” Centers for Disease Control and Prevention, last updated 9 June 2016, https://www.cdc.gov/policy/hiap/index.html; Fran Baum et al., “Evaluation of Health in All Policies: Concept, Theory and Application,” Health Promotion International 29, suppl, 1 (June 2014), https://doi.org/10.1093/heapro/dau032.

53. 53 Ak’ingabe Guyon et al., “The Weakening of Public Health: A Threat to Population Health and Health Care System Sustainability,” Canadian Journal of Public Health 108, no. 1 (2017); Trevor Hancock, “Erosion of Public Health Capacity Should be a Matter of Concern for All Canadians,” Canadian Journal of Public Health 109, no. 1 (2018); Louise Potvin, “Canadian Public Health under Siege,” Canadian Journal of Public Health 105, no. 6 (2014).

54. 54 Brad Mackay, “Firing Public Health MD over pro-Kyoto Comments a No-no, Alberta Learns,” Canadian Medical Association Journal 167, no. 10 (November 12, 2002).

55. 55 Potvin, “Canadian Public Health under Siege.”

56. 56 Michael Hayes et al., “Telling Stories: News Media, Health Literacy and Public Policy in Canada,” Social Science & Medicine 64, no. 9 (1 May 2007), https://doi.org/10.1016/j.socscimed.2007.01.015; Mike Gasher et al., “Spreading the News: Social Determinants of Health Reportage in Canadian Daily Newspapers,” Canadian Journal of Communication 32, no. 3 (2007), doi.org/10.22230/cjc.2007v32n3a1724.

57. 57 For the Canadian Institute for Health Information, health expenditure includes “any type of expenditure for which the primary objective is to improve or prevent the deterioration of health status;” including “activities that are undertaken with the direct purpose of improving and maintaining health.” The main categories included in health expenditure are hospitals; other institutions, such as residential care types of facilities; physicians; other professionals; drugs; capital; public health; administration; and other health spending, such as research. Canadian Institute for Health Information (CIHI), National Health Expenditure Trends, 1975 to 2019 (Ottawa: CIHI, 2019), Methodology Notes, https://www.cihi.ca/sites/default/files/document/nhex-trends-narrative-report-2019-en-web.pdf.

58. 58 Canadian Institute for Health Information, National Health Expenditure Trends.

59. 59 Expenditure data from 1975 through 2019 are readily available from CIHI, through their National Health Expenditure Trends publication. We would like to have included expenditures for the entire period of interest in this volume, however, that exercise is significantly complicated by changes over time in what public health entailed and how those activities are recorded in provincial budgets.

60. 60 The largest spending categories across Canada are hospitals (26.6% for Canada in 2019), drugs (15.3%) and physicians (15.1%), which amounted to almost 60% of total health spending in Canada in 2019. Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2019.

61. 61 Jack Lucas, “Historical Overview.”

62. 62 McLaren and Dutton, “Social Determinants of Pandemic Impact.”

63. 63 Daniel J. Dutton et al., “Effect of Provincial Spending on Social Services and Health Care on Health Outcomes in Canada: An Observational Longitudinal Study,” Canadian Medical Association Journal 190, no. 1 (2018).

64. 64 Winslow, “Untilled Fields,” 23.

65. 65 Alberta Department of Public Health, Annual Report 1939 (Edmonton: Printed by A. Shnitka, King’s Printer, 1941), 24–25 [emphasis added].

66. 66 Public Health Agency of Canada, Core Competencies for Public Health in Canada: Release 1.0 (Ottawa: Her Majesty the Queen in Right of Canada, represented by the Minister of Health, 2008), https://www.phac-aspc.gc.ca/php-psp/ccph-cesp/pdfs/cc-manual-eng090407.pdf.

67. 67 McLaren and Hennessy, “A Broader Vision of Public Health.”