2 Priorities and Concerns of Provincial Governments: A Historical Public Health Landscape

Lindsay McLaren, Rogelio Velez Mendoza, and Jack Lucas

Introduction

In this chapter, we aim to provide a bird’s eye view of the historical landscape of public health in Alberta, from the perspective of successive provincial governments. By “landscape,” we mean two things: 1) overall attention to public health, and 2) the ways in which health and public health have been understood, over time, from the government perspective.

As noted in the introduction to this book, a challenge facing public health today is that it is frequently misunderstood. In contrast to its broad definition — which emphasizes population-level well-being and health equity via prevention, promotion, and upstream thinking about root causes — public health, in Canada and elsewhere, is often conflated with publicly funded medical care, and/or reduced to single elements, such as immunization or health behaviour change.¹ A historical analysis can shed light on how the socio-political context has shaped dominant understandings of health and disease causation, and thus public policy responses, such as an increasingly costly health care system that is overwhelmingly focused on acute medical care and technologies. It can also shed light on who is included and who is excluded from the public health community and its activities (see Chapter 1).² A historical analysis can furthermore illuminate core features of public health that have permitted the field to endure, even as specific priorities and concerns change. An understanding of those core features is essential if public health is to remain a strong and relevant public institution and policy priority moving forward.

Data Source

How has the public health landscape evolved in Alberta since the province was established in 1905? To answer this question, we draw on a unique and valuable data source that has existed through Alberta’s history as a province: government throne speeches.

In keeping with a large international research initiative called the Comparative Agendas Project,³ we focus in this chapter on policy attention — that is, the extent to which particular topics have been part of the government’s policy agenda through time. To capture policy attention, scholars in the Comparative Agendas tradition seek out data sources that allow for systematic analysis of policy agendas over very long spans of time. Throne speeches, which are explicit statements of the government’s legislative agenda at the beginning of each legislative session, are ideal documents for this purpose, allowing researchers to understand the relative importance of particular policy topics — in this case, public health — in a government’s legislative agenda over time.⁴

To allow for systematic analysis across jurisdictions and over time, researchers in the Comparative Agendas Project have developed a standardized coding scheme in which sentences (or portions of sentences) in a policy document are coded by topic.⁵ The data analyzed for this chapter consist of all text from all Alberta government throne speeches from 1906 to 2017, broken down into policy statements (i.e., sentences or sub-sentences, hereafter referred to as quasi-sentences). The full data set contains 14,193 quasi-sentences, spanning 1906–2017. Overall, as shown in Figure 2.1, there is a trend toward longer speeches in recent years. The number of quasi-sentences each year ranges from a low of nine in a war time speech in 1914 to a high of 357 in 1985.⁶

Each quasi-sentence in the data set is coded, according to the single predominant and substantive area, into one major topic code. For the Alberta data set, quasi-sentences were coded using a version of the policy agendas codebook adapted to the Canadian context.⁷ The Canadian version contains twenty-five major topic codes (each of which has several subtopic codes), which are shown in Table 2.1 and which provide the broader context for our analysis below.

Note: Those codes that were newly developed to reflect the Canadian context are denoted with asterisks.

Findings: Policy Attention to Health, Public Health, and Prevention in Alberta Government Throne Speeches, 1906–2017

One of the twenty-five major topic codes assigned to the throne speech data is health, and that was our starting point. Within the data set, we first examined the rise and fall of health — as a broad concept, as well as specific elements — as a topic of policy attention in the Alberta legislature. We then considered how concepts of public health, followed by prevention (based on public health’s stated focus on prevention, rather than treatment, of health problems), appeared in the speeches over time. As presented next, our findings shed light on subtle but important shifts in how these terms have been used and understood by Alberta’s provincial government, with implications for the field of public health and for the health and well-being of Albertans.

Health

In the Alberta throne speech data set, there were 1,125 quasi-sentences coded under health (major topic code 3), representing approximately 8 percent of the full data set. As with all major topic codes, the health code is broad and includes anything to do with health, medicine, well-being, illnesses, and health interventions.⁸

Trends Over Time in Policy Attention to Health

Figure 2.2 illustrates trends over time in the proportion of all Alberta throne speech quasi-sentences that were coded under the health major topic code.

One can see from Figure 2.2 that health, broadly conceived, occupied a relatively higher proportion of the throne speech entries during two periods: first, the post-WWII decades (late 1940s), and second, the decades following health system regionalization in Alberta (late 1990s and early 2000s). By considering the content of the speeches, one can shed light on these trends.

First, the throne speeches indicate that the post-WWII decades, under the Social Credit (SC) leadership of Ernest Manning, were a period of growth and expansion for health. The Manning government’s 1946 speech opened by stating that “the Provincial Department of [Public] Health has prepared a comprehensive post-war program designed to improve the health conditions of our people.”¹⁰ Throughout the late 1940s and early 1950s, speeches made frequent reference to building or expanding health-related infrastructure. Examples include efforts to expand the public health workforce, protect health care workers, provide preventive health services in rural areas, and address particular diseases.

A training school will be opened to provide facilities for field training of physicians, public health nurses and sanitary inspectors. (1946)¹¹

Services safeguarding the health of workers in industry will be advanced through a survey of the industrial hazards and a study of diseases peculiar to the workers in various industries. (1948)¹²

Legislation also will be introduced providing for the establishment, administration and services of Rural Health Units. (1951)¹³

You will be asked to approve the emergent actions taken by my Government to relieve the financial burden of those afflicted by the severe epidemic of poliomyelitis . . . to provide adequate facilities for the care of those afflicted. (1954)¹⁴

Second, the period of the late 1990s and early 2000s was also an active one in terms of policy attention to health in Alberta, based on the throne speech content (Figure 2.2). This period aligns with regionalization of health services in Alberta (see Chapter 4). Under the Progressive Conservative leadership of Ralph Klein, throne speech references to health during that period suggested a strong focus on health care, with an emphasis — not surprising in the neoliberal period — on efficiency, privacy, and individualized diagnostic and treatment-oriented activities.

Initiatives to improve patient care and ensure an efficient system will include a pilot project using health smart cards. (1996)¹⁵

It will introduce new legislation to protect information related to Albertans’ personal health. (1999)¹⁶

Government will increase access to essential services by . . . reducing waiting times for surgeries and diagnostic procedures. (2000)¹⁷

In addition to these broader periods, policy attention to health was especially prominent in the throne speeches in three individual years (see outlier high points in Figure 2.2): 1919 (16.7 percent of speech quasi-sentences that year), 1963 (20.8 percent), and 2002 (18.3 percent). First, references to health in the 1919 speech, from the Liberal government of Premier Charles Stewart, focused entirely on influenza and efforts taken to address it.

The epidemic of influenza from which the Province suffered in the latter part of 1918 has been, I regret to say, uncommonly severe, particularly in the more sparsely unsettled sections of the province. . . . This experience brings clearly to view the need of further health and sanitation laws and regulations throughout the province.¹⁸

These statements foreshadowed both the creation of the provincial Department of Public Health in 1919,¹⁹ and an amendment to Alberta’s Public Health Act that expanded the list of communicable diseases, over which the provincial board had authority, to include influenza.²⁰

Second, in 1963, Premier Ernest Manning’s SC government focused on broadening access to public health and health care services and expanding infrastructure:

To further improve the province’s extensive public health services, amendments will be introduced to The Health Unit Act and The Treatment Services Act.

A 100-bed hospital-school for multiple-handicapped children will be constructed in Edmonton.²¹

The context of Manning’s comments included important milestones in health policy in Alberta, including the 1965 Report of the Special Legislative and Lay Committee Inquiring into Preventive Health Services²² and the province’s transition to national medical insurance in 1969.²³

The third single-year peak in Figure 2.2 is 2002, corresponding to the government of Premier Ralph Klein (Progressive Conservative). Klein’s government acknowledged the broader determinants of health.

When Albertans speak about health, they don’t only mean services provided in hospitals or prescription drugs or ambulance services. . . . They know that people’s health status is affected by their lifestyles, their socioeconomic status, their education, their sense of inner security and external security, their feeling of being part of a larger community, their access to jobs and safe and healthy foods and cultural experiences, and by many other factors that exceed the scope of the conventional health system.²⁴

Although these comments appear to align with trends at the time toward greater attention to the social determinants of health,²⁵ with few exceptions²⁶ Klein’s subsequent comments betray alignment with a biomedical and behavioural view of health, characterized by emphasis on individualized lifestyle and health care, and are thus contrary to a public health perspective. For example, intentions identified for the coming year included to “launch a campaign to give Albertans reliable health information and encourage them to make healthy lifestyle choices;” to “work with physicians and health authorities to explore new options in physician compensation;” and to expand “the pharmaceutical information network to improve drug therapy and reduce costs.”²⁷

Policy Attention to Subconcerns Within Health, over Time

To get a better sense of how health was described over time in the throne speeches, we developed subtopic codes for the quasi-sentences coded within health as a major topic.²⁸ The sub-codes are described in Table 2.2. They are:

• establishment or construction of facilities or infrastructure (treatment-oriented, e.g., hospitals);
• non-insured health services (treatment-oriented, e.g., pharmaceuticals);
• prevention, protection, promotion, core public health functions;
• costs and financing;
• major or inter-jurisdictional health care reform;
• treatment-, curative-, or management-oriented health care;
• health status assessment;
• health professionals, the health workforce;
• research; and
• general, other, or generic.

Overall, between 1906 and 2017, the three most common health sub-topics were establishment or construction of treatment-oriented facilities or infrastructure (18.9 percent of all health sub-topics), and treatment-, curative-, or management-oriented health care (24.4 percent), along with the less informative general, other, or generic (20.4 percent). In contrast, prevention, protection, promotion, and core public health functions were less common, representing 11.7 percent of all health quasi-sentences.

Trends over time for select sub-codes are shown in Figure 2.3.

First, one can see from Figure 2.3 that reference to the sub-category establishment or construction of treatment-oriented facilities or infrastructure (solid line) shows a gradual decline over time. An early prominence of this sub-code reflects attention to infrastructure and facilities in the context of a new and growing province, such as an institution for “the relief of the mentally afflicted” at Ponoka (1911), a system of travelling clinics (1927), and hospitals for tubercular patients (1931). During the late 1940s through the early 1960s, infrastructure-related policy attention was focused on mental health (e.g., a mobile mental hygiene clinic to serve the northern areas of the province, 1948), tuberculosis (e.g., the Aberhart Memorial Sanatorium, completed in 1952), polio (e.g., addition of a poliomyelitis unit to the University Hospital in Edmonton, 1954), and physical disability (e.g., facilities for the treatment and education of children with physical disabilities, 1963). Finally, the 1970s and 1980s were diverse with respect to the sub-category establishment or construction of treatment-oriented facilities or infrastructure, but Alberta throne speech content indicated policy attention to building or expanding facilities for seniors, such as extended care facilities and nursing homes; rehabilitation centres for alcohol and drug dependence; and a variety of specialized services for patients with cancer (e.g., diagnostic radiology) and cardiovascular illnesses (e.g., catheterization laboratories). The rise of this construction sub-code in the late 1970s and early 1980s illustrates the Progressive Conservative policy, under Premier Peter Lougheed, of “modernizing the province,” including building key infrastructure such as hospitals, during a period of significant economic growth in Alberta.²⁹

Second, Figure 2.3 shows that relative attention to the sub-code prevention, protection, promotion, and core public health functions (dashed line) has gradually decreased over time, while treatment-, curative-, or management-oriented health care (dotted line) has shown a gradual increase. The greater policy attention to prevention and other core public health functions early in the period reflects items such as early iterations of the Public Health Act,³⁰ medical inspection of children in schools and public health nursing,³¹ prevention of the spread of infectious diseases,³² prevention-oriented health units,³³ and maternal and child health and welfare.³⁴ We further explore the shifting focus and meaning of references to prevention and public health over time below.

Public Health

Another way to glean insight into how public health is understood and referenced over time is to search within the quasi-sentences coded as health (major topic 3) for the phrase “public health.” There was a total of just fifty-eight occurrences of the term, and interesting trends are apparent, as shown in Figure 2.4.

Figure 2.4 shows that, although the overall numbers were low, there were some periods when public health was mentioned consistently (at least once in nearly every throne speech), such as the mid-1940s to the mid-1960s. In other periods, public health was mentioned infrequently or not at all. Looking at the year-by-year counts (not shown), public health was not mentioned at all in Alberta throne speeches between 1908 and 1917 (ten years), between 1976 and 1983 (eight years), and, for the lengthy nineteen-year period between 1988 and 2006.

Reference to Public Health in Government Throne Speeches: Alberta’s Early Decades

Examining the content and context in which public health was mentioned sheds further light on these patterns. The first instance was in 1906 by Premier Alexander C. Rutherford’s Liberal government. From 1870, when the Northwest Territories entered Canadian confederation, until 1905, the territory now known as Alberta was governed as part of the Territories, and public health activities were administered under the territorial Public Health Ordinance.³⁵ Rutherford’s government was lamenting the limitations of the Northwest Territories’ Public Health Ordinance. They spoke of the need for Alberta to have its own law to govern “every phase of public health and sanitation;” Alberta’s first Public Health Act was passed in 1907.³⁶

The term “public health” did not appear again in the throne speeches until 1918; not surprisingly, this was in the context of the 1918/19 influenza epidemic and aftermath as illustrated by speech excerpts noted above from the Stewart government. In 1920, Stewart’s government provided an update on the new Department of Public Health, including that financial provision had been made for “such important matters as child welfare, medical inspection of children in schools, public health nursing . . . [and] the establishment of municipal hospitals.”³⁷ By 1922, Alberta had a new provincial government, under Premier Herbert Greenfield of the United Farmers of Alberta, which promised “earnest consideration” of public health by that government, “not only from the preventive but also from the curative standpoint.”³⁸ Seven years later, the government of subsequent United Farm Worker Premier John E. Brownlee spoke of an important provision to establish District Health Units that would serve “to supplement remedial measures by preventive and safeguarding methods,”³⁹ and an amendment to the Public Health Act to permit that initiative.⁴⁰

The depression-era conditions of the 1930s led Premier William Aberhart’s SC government to announce that there would be “some consideration” given to the revision and improvement of public health services and programs, “notwithstanding the necessity for rigid economy due to falling revenues.”⁴¹ Aberhart’s government, which spoke of public health and prevention on several occasions throughout its tenure, later made more specific statements about strengthening public health services, including:

[Providing] additional nursing services . . . to outlying areas remote from medical and hospital facilities.⁴²

[Proposing] to go forward with the organization of additional full-time health units until all districts in the Province have been given the advantage of modern preventive Public Health Service.⁴³

Public Health — the Manning Years

During Premier Ernest C. Manning’s Social Credit government’s lengthy time in office (1943 to 1968) there were many references to public health, suggesting that this was a topic of some importance to this administration. Across Manning’s tenure, which coincided with a recovery from the economic depression of the 1930s, throne speech statements about public health were about growth and expansion of services, staff, and facilities. However, partly because of the sheer length of time in office, one can see during his tenure a shift in the focus and nature of his statements about public health.

From the mid-1940s through the mid-1950s, the Manning government’s statements were heavily focused on the expansion of preventive programs and services throughout the province, which was part of his vision of a “post war public health program.” One statement proposed “a complete preventive public health program [that would permit Alberta to] continue in its position of leadership in the field of public health in Canada.”⁴⁴ This expansion involved the establishment or expansion of facilities and infrastructure (e.g., additional health units⁴⁵ and travelling clinics⁴⁶); training of health personnel (e.g., a training centre for public health nurses and sanitary inspectors⁴⁷ and grants to “assist and encourage young women to enter the nursing profession”⁴⁸); other facilities (e.g., a branch of the provincial laboratory in Central Alberta⁴⁹); and other initiatives, such as funding to purchase the polio vaccine⁵⁰ and regulations to control hazards associated with radiation.⁵¹

In 1958, Manning announced an “important change . . . in the field of public health” that would be considered, namely, “the statutory and financial provisions necessary to put into operation . . . a comprehensive hospitalization program designed to fit into the national program in which the federal government proposes to participate at a later date.”⁵² Although Manning’s speeches had mentioned hospitals before, the 1958 speech, with its focal topic of subsidized hospital services, seemed to signal a shift in what public health meant or entailed. That is, prior to 1958, public health as described in Alberta throne speeches included a range of activities and services, of both a preventive and curative orientation, with primary prevention and health protection activities featuring prominently. Starting around 1958, the meaning of “public health,” as used in the Alberta legislature, started to drift downstream.

For instance, the Manning government’s statements about improvements and expansion to “public health” in 1959 and 1961 include provision of hospital care for those with chronic illness, early treatment for children with mental illness, expansion of services for people with diabetes, rheumatic fever, and other illnesses, construction of a new provincial hospital and diagnostic and referral centre in Calgary, and facilities for treatment and education of children with physical disabilities.⁵³

Subsequent announcements focused on establishing a University of Alberta Hospital Foundation, whose funds in 1962 would be used to “augment teaching and clinical research”⁵⁴ including:

[Co-operating with the medical profession] to develop and implement a program of voluntary prepaid medical services.⁵⁵

Establish[ing] a comprehensive program of nursing home care. ⁵⁶

Extend[ing] the benefits under the Alberta hospital plan to include out-patient service at hospitals throughout the province.⁵⁷

Propos[ing] the establishment of a Western Canada Heart Institute and a centre for neurological, renal, endocrine and sensory organ disease, in which the most up-to-date diagnostic, research, and treatment services will be available to our people.⁵⁸

Improv[ing] and simplify[ing] the subsidized health care insurance under the Alberta Health Plan.⁵⁹

Overall, these statements reveal a version of public health, characterized by a focus on treatment, management, and rehabilitation for individuals experiencing illness and on enhancing clinically oriented infrastructure (e.g., diagnosis and treatment); as well as the insurance to support people in accessing those services and activities. Although the Manning government’s throne speeches were not devoid of reference to prevention, they were in the minority during the later years of his tenure (see also the analysis of the sub-code prevention below).

Closing out the Social Credit era was the shorter tenure of Premier Harry Strom (1968–1971), whose throne speeches included only one explicit mention of public health. In 1970, his government’s speech included the following statement: “in other fields of public health, you will be asked to consider legislation for the establishment of a commission on alcohol and drug abuse.”⁶⁰ The focal topic of the proposed legislation as well as the activities envisioned — for example, an educational film on drug misuse — may be seen in hindsight as a sign of a troubling shift toward the individualized and morally infused orientation to health ushered in by the neoliberal era.

Public Health — the Post-Manning Years

Perhaps most notable about Premier Peter Lougheed’s administration, from the point of view of public health, is how infrequently they mentioned the topic in their throne speeches, considering the length of tenure. During Lougheed’s fourteen years in office (1971–1985), his government’s speeches mentioned “public health” only five times, and in fact, one of the longest gaps in Alberta’s history in this regard, 1976 to 1983 (Figure 2.4) was during Lougheed’s tenure.

The Lougheed government’s statements about public health continued earlier threads regarding the need for services in rural or isolated communities, and in 1973 he proposed three new programs to help redress this imbalance: speech therapy services, a mobile dental program, and efforts to enable health units to provide improved services to those with mental and physical disabilities.⁶¹ That same speech referenced initiatives related to drug benefits for seniors, the Alberta Health Care Insurance Plan premium subsidy, and significant amendments to The Nursing Homes Act. Finally, they made reference, in the context of public health, to physical fitness, including their government’s “concern for the health and fitness of Albertans . . . [and the development of] programs aimed at encouraging people of all ages to participate in enjoyable fitness activities.”⁶² In the 15 March 1984 throne speech, Lougheed’s government announced a proposed new Public Health Act, which would constitute a substantial revision from the previous versions (see Chapter 4).⁶³

In 1987, the throne speech of the Progressive Conservative government of Don Getty announced expansion of the province’s immunization program to include haemophilus influenza B, described as “a disease which causes meningitis and other serious infections.”⁶⁴ Although Getty’s speech mentioned other activities and initiatives related to health more broadly, immunization was explicitly connected with public health, thus illustrating the strength of public health’s historical ties to physical (and especially communicable) illness, including the embodiment of those ties in Alberta’s Public Health Act.

Following Getty, during the nineteen-year period from 1988 to 2006, “public health” was not mentioned in the throne speeches at all. Premiers during this time were Getty (until 1992) and Ralph Klein (1992–2006). The next mention of public health came in 2006, toward the end of Klein’s leadership, and was very much focused on health care, when he said, “This session we will set out clear principles to guide the health system, principles that reflect Albertans’ values. They will provide a framework for a comprehensive public health system that fulfills government’s commitment to provide high-quality health services to all Albertans.”⁶⁵ This use of “public health,” refers to publicly funded health care. The ensuing comments focus on “flexibility and choice” in health care, and a “major offensive in the fight against cancer.”⁶⁶

The final mention of “public health” between 1906 and 2017 was by Premier Ed Stelmach’s Progressive Conservative government (2006–2011). In their first year in office, Stelmach’s government declared that there would be “a sustained focus on wellness, injury reduction, and disease prevention combined with efforts to improve productivity and accountability in health care delivery will provide the framework to ensure a sustainable public health care system.”⁶⁷ While that statement could conceivably indicate a broad conceptualization of public health as per the pre-Manning years, subsequent comments suggest otherwise. These include a focus on primary health care and self-management of chronic diseases; improved access to support services and treatment for people living in the community with serious mental illness, and their families; a new pharmaceutical strategy, and intentions to expand long-term care capacity, improve standards, and ensure that facilities and supports are available to seniors as the population ages.⁶⁸ On the other hand, the Stelmach government’s 2009 speech announced an important amendment to the Public Health Act, which was to “lay a solid foundation for improving public health by strengthening the role and authority of the chief medical officer of health in protecting and promoting Albertans’ health.”⁶⁹

There were no mentions of public health after 2009, which included Premier Allison Redford’s (PC) tenure (2011 to 2014), and the early years (2015 to 2017) of Premier Rachel Notley’s New Democratic Party (NDP) term. With respect to the value of hindsight and having adequate time to reflect, we decline to comment on these very recent periods, and hope that future analysis will place them in historical context.

Prevention

Because it is so central to public health, our final consideration in this chapter concerns the concept of prevention, including when, how often, and with what meaning the concept was used in the Alberta throne speech data set.

We performed a keyword search of the entire Alberta throne speech data set (i.e., all 14,193 quasi-sentences, from 1906 to 2017) for “prevent” (which captured iterations, such as prevention, preventing, preventive), and found 139 instances. Recognizing that prevention is not unique to health, we first considered how these 139 instances were distributed across the twenty-five major topic codes representing all areas of public policy. In fact, the largest proportion (n=61, 44 percent) occurred in health (major topic code 3), followed by law, crime, and family issues (n=21, 14 percent, major topic code 12; e.g., “implementing new initiatives to prevent family violence”⁷⁰) and social welfare (n-16, 12 percent, major topic code 12; e.g., “preventive social programs are a high priority of my government”⁷¹). “Prevent” and its iterations occurred fewer than ten times in the other major topic codes. Therefore, across the various policy areas, the concept of prevention was quite strongly aligned with health (which, in itself may help to explain some of the challenges that prompted this volume as a whole; see also Chapter 12), and we restricted our analysis to the health major topic code.

The frequency of reference to “prevent” and its iterations in quasi-sentences coded as health, by decade, is shown in Figure 2.5.

As seen in Figure 2.5, references to both public health and prevention were infrequent during the early decades; they appeared equally frequently during the decade 1936 to 1945, and thereafter patterns diverged. While references to public health (grey bars) in the throne speeches peaked during the post-WWII years through the 1960s as discussed above, references to prevent (black bars) peaked later, starting in the mid-1970s. This later peak coincided with Canadian and international health trends, including a growing focus on risk factor epidemiology (e.g., the quest to identify, for the purpose of intervention, individual-level risk factors, primarily for chronic diseases); and the health promotion movement (see Chapter 10). Within a context of growing concern about escalating costs of health care, a strong discourse emerged that encouraged individual responsibility for health as a way to contain costs.⁷²

Objects of Prevention: What Is to Be Prevented?

Looking at the content of throne speech quasi-sentences about prevention sheds light on how, and with what meaning, the term was used over time. First, not surprisingly, there were shifts in what was to be prevented, with the first half of the twentieth century showing strong attention to preventing the spread of communicable diseases⁷³ — in general, and specific to certain diseases such as tuberculosis and polio⁷⁴ — as well as frequent references to general preventive health services.⁷⁵

Later, a shift is apparent toward a focus on preventing chronic or non-communicable illness and injury. Although the first reference to preventing cancer appeared in 1940, the focus on preventing chronic illness and injury began in earnest in the 1960s and continued for the remainder of the data set (until 2017).⁷⁶ In addition to references to illness prevention in general, specific attention was given to alcoholism, mental health problems, cardiac problems, dental problems, injuries, fetal alcohol syndrome, cancer, and risk factors for type 2 diabetes. Among the specific objects of prevention mentioned in this later period, a common one was addictions (variously described using negative language such as “alcoholism,” “alcohol and drug abuse,” “abuse habits,” etc.), which was mentioned in conjunction with prevention at least once during each decade from the 1960s through the early 2000s.

Statements about prevention in the context of communicable disease, while not absent during the second half of the twentieth century, were limited to one reference in 1983 by Lougheed’s government, which says, “in the important area of preventive health, modification of the immunization program has extended protection to Alberta children against seven serious diseases, while a program to provide hepatitis B vaccine to patients and workers at risk of exposure to this potentially serious disease has also been introduced.”⁷⁷ There were two throne speech references to communicable disease prevention by Getty’s government, including one in 1987 announcing expansion of the existing public health immunization program, which said that “the introduction of a new vaccine to protect our children against haemophilus influenza B, a disease which causes meningitis and other serious infections . . . will be administered to two-year-olds throughout the province by the 27 local health units.”⁷⁸ Finally, in 2000, the Klein government announced their intention of “launching a new three-year immunization plan.”

Approaches to Prevention

An additional way to examine trends over time in illness prevention is to consider what it entails or how it would be achieved. Based on the Alberta throne speech data set, there is some indication of a shift over time in this regard.

During the first half of the twentieth century, policy attention to prevention showed alignment with the concept of primary prevention, namely, intervening before health problems or risk factors occur. That is, activities such as expansions to the scope of health protection activities, via amendments to the Public Health Act, and to preventive health service infrastructure, such as travelling clinics in the 1920s⁷⁹ and health units in rural areas in the 1940s and 1950s,⁸⁰ represented efforts to reach all Albertans, thus preventing the occurrence of an array of illnesses.

Later, two shifts in emphasis are apparent. First, whereas early in the twentieth century, prevention was often mentioned on its own (e.g., preventing the spread of infectious and contagious diseases or increasing the number of preventive health units), later throne speeches increasingly contained instances where prevention and treatment were mentioned in the same sentence; for example:⁸¹ preventive and treatment services for alcohol dependence; mental health treatment and prevention; prevention, research, and treatment around addictions; addressing the needs of children affected by fetal alcohol syndrome and finding ways to prevent it; and prevention, detection and treatment of cancer. Although a joint focus on efforts to treat or manage illness in those afflicted, and to prevent new cases, is understandable, this subtle shift in framing suggests a gradual, relative reduction in emphasis on prevention over time.

The second shift in emphasis starts in the late 1970s, with references to secondary forms of prevention. In contrast to primary prevention, which aims to prevent occurrence of disease or injury in the population as a whole, secondary prevention is more downstream in that it aims to “arrest the progress and reduce the consequences of disease or injury once established.”⁸² Examples in the throne speeches include: a provincial plan for cardiac rehabilitation services geared to primary and secondary prevention;⁸³ plans for a comprehensive service that will emphasize early detection and prevention of mental health-related problems;⁸⁴ greater emphasis on preventing illness and injury through a metabolic screening program for newborns;⁸⁵ prevention of illness and injury by expanding screening programs for breast and cervical cancer;⁸⁶ and addressing the needs of those who already have the disease [type 2 diabetes] to prevent and reduce serious complications.⁸⁷ In these examples, the term “prevention” is used to refer to secondary prevention, either explicitly, or implicitly (e.g., reference to screening or early detection), thus suggesting a shift in the term’s meaning compared to earlier periods.

Conclusions

All data sources have limitations. Throne speeches, like other government speeches, have purposes ranging from inspiration to information to political marketing. Nevertheless, throne speech content provides a rich source of insight into legislative priorities and concerns, and it enables systematic coding and comparison over time. The data set allows us to see, from the perspective of successive provincial governments, priorities and concerns emerge and fade over the historical sweep of the Province of Alberta. Thus, without denying the value of deeper historical analysis of the episodes we have described in this chapter, the Alberta throne speech data set provides a valuable survey of the public health landscape in Alberta over time.

A key insight emerged from our analysis of the Manning years of the mid-1940s through the mid-1960s. Premier Manning’s SC government was very concerned with health and spoke of it frequently in throne speeches during their lengthy time in office. However, we detected a shift in the use of the term “public health” during that time. Prior to the late 1950s, “public health” was used, by governments of Manning and others, to describe a range of activities and services of both a preventive and curative orientation. Starting around 1958, the use of “public health” by Manning’s government and others seemed to drift toward an increasing emphasis on treatment, management, diagnostics, and rehabilitation activities within the context of publicly funded medical care. From the current vantage point of widespread confusion about what public health is and does, including a tendency to conflate public health and medical care, it seems that this contemporary confusion may date back to this mid-century shift in usage by Alberta government leadership, which coincided with provincial and national attention to building capacity for hospital and physician services.

Also providing contemporary insight is our analysis of the concept of prevention and how it was used over time in the Alberta throne speech data set. Early in the hundred-year period, prevention was used in the context of efforts to halt the spread of communicable disease and to ensure access to preventive health services for all Albertans, thus conveying a population-wide scope and alignment with primary prevention. Later, we found evidence of declining relative emphasis on prevention, based on its increasing co-occurrence with treatment (which tends to be expensive and appealing to the public) in the same statement, and an apparent drift toward secondary forms of prevention that focused on identifying individuals at risk for the purpose of tailored intervention to prevent further progression of disease.

In terms of the objects of prevention, we saw significant recent focus on certain health concerns, including addictions, especially alcohol and drug dependence, as well as cancer. Although these are important concerns in the Alberta context, it is significant to note that there are many other important health concerns, such as injury and diabetes, that did not receive the same level of explicit attention in the Alberta throne speeches. Health and illness occur in social, economic, political, and moral contexts that shape perceptions of importance and urgency,⁸⁸ including whether or the extent to which they may appear in a government throne speech. Perceptions of importance and urgency may or may not be proportionate to the prevalence or incidence of the problem, with certain illnesses and populations seen as more important or deserving than others.

Collectively, the findings of this chapter shed light on contemporary discourse around the “weakening” of public health in Canada. We have identified subtle shifts in how concepts of public health and prevention have been discussed and conceptualized over time by one source — provincial government throne speeches in Alberta. Our analysis suggests that these concepts have, over time, changed in emphasis, and have in many ways become increasingly indistinguishable from downstream medical care, which is focused on treatment and management of illness at the individual level.⁸⁹ If we wish to strengthen public health as a policy priority, we must find ways to articulate, defend, and advance its core features in a way that aligns with a broad vision of public health (i.e., upstream or root causes of health equity) even if the context is unfriendly.⁹⁰

notes

1. 1 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 (Washington: FrameWorks Institute, March 2014), http://www.frameworksinstitute.org/pubs/mm/albertahealth/.

2. 2 Robert G. Evans and Gregory L. Stoddart, “Producing Health, Consuming Health Care,” in Why Are some People Healthy and Others Not? The Determinants of Health of Populations, ed. Robert G. Evans, Morris L. Barer, and Theodore R. Marmor (New York: Aldine de Gruyter, 1994); 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), https://doi.org/10.1503/cmaj.170132.

3. 3 “About,” Comparative Agendas Project, accessed 14 February 2019, https://www.comparativeagendas.net/pages/About.

4. 4 Alberta speeches from the throne can be found in Legislative Assembly of Alberta, Journals of the Legislative Assembly of the Province of Alberta (Edmonton, 1963–present, https://www.assembly.ab.ca/assembly-business/assembly-records/journals) and in the Alberta Legislature Library (Edmonton: 1906–present), https://librarysearch.assembly.ab.ca/client/en_CA/public/search/results?qu=u239632&st=TL; speeches from the throne and related data were also extracted from Jack Lucas and Jean-Philippe Gauvin, “Alberta Throne Speeches 1906–2017 (Comparative Agendas Project),” 2019, https://doi.org/10.5683/SP2/0WH5FH, Borealis, V1.

5. 5 Building on original efforts by Frank Baumgartner and Bryan Jones, a master codebook was developed by Shaun Bevan, Senior Lecturer in Quantitative Political Science and Director of Research (Data) for the School of Social and Political Science at the University of Edinburgh (http://www.sbevan.com/index.html). The Canadian arm of the Comparative Agendas Project is led by Jean-Philippe Gauvin at Concordia University (https://www.comparativeagendas.net/canada); Gauvin and a team of other researchers have digitized and coded Canadian federal and provincial throne speeches from 1960–2015. The remaining Alberta Throne Speeches (1906–1959 and 2015–2017) were digitized and coded by Jack Lucas, Associate Professor in the Department of Political Science at the University of Calgary. Data from Lucas and Gauvin, “Alberta Throne Speeches.”

6. 6 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Sessions of the Third Legislature (Edmonton: J.W. Jeffery, Government Printer, 1914); Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Sessions of the Twentieth Legislature (Edmonton, 1985).

7. 7 The master codebook (see note #5) was adapted to the Canadian context by Stuart Soroka, Professor of Communication Studies and Political Science at the University of Michigan (formerly of McGill University). Stuart Soroka, Canadian Policy Agendas Data: Oral Questions (McGill University, April 2009); Stuart Soroka, Canadian Policy Agendas Topic Codebook (McGill University, May 2005). See Stuart Soroka, Erin Penner, and Kelly Blidook, “Constituency Influence in Parliament,” Canadian Journal of Political Science 42, no. 3 (2009).

8. 8 To convey the breadth of the major topic code, we provide the sub-topic codes from the Canadian version of the master codebook (Soroka, Canadian Policy Agendas Topic Codebook, 7): general (includes combinations of multiple subtopics); health care reform, costs, and availability; health care funding arrangements; regulation of prescription drugs, medical devices, and medical procedures; health facilities construction and regulation; mental illness and mental retardation; medical fraud, malpractice, and physician licensing requirements; elderly health issues; infants, children, and immunization; health manpower needs and training programs; military health care; drug and alcohol treatment; alcohol abuse and treatment; tobacco abuse, treatment, and education; illegal drug abuse, treatment, and education; specific diseases; research and development; and other.

9. 9 “Lowess” refers to Locally Weighted Scatterplot Smoothing, which is a regression analysis-based tool to create a smooth line through a timeplot or scatter plot, and is particularly useful in situations with “noisy data values, sparse data points, or weak interrelationships.” “Lowess Smothing in Statistics: What is it?,” Statistics How To, modified on 6 October 2013, https://www.statisticshowto.datasciencecentral.com/lowess-smoothing/

10. 10 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Tenth Legislature (Edmonton: A. Shnitka, King’s Printer, 1946), 8.

11. 11 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Tenth Legislature, 8.

12. 12 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fifth Session of the Tenth Legislature (Edmonton: A. Shnitka, King’s Printer, 1948), 8.

13. 13 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth Session of the Eleventh Legislature (Edmonton: Printed by A. Shnitka, King’s Printer for Alberta, 1951), 8.

14. 14 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Twelfth Legislature (Edmonton: A. Shnitka, Queen’s Printer for Alberta, 1954), 8.

15. 15 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth and Fifth Sessions of the Twenty-Third Legislature (Edmonton: 1996 and 1997), 3.

16. 16 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Twenty-Fourth Legislature (Edmonton: 1999), 3.

17. 17 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth and Fifth Sessions of the Twenty-Fourth Legislature (Edmonton: 2000 and 2001), 9.

18. 18 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Fourth Legislature (Edmonton: Printed by J.W. Jeffery, King’s Printer, 1919), 8.

19. 19 An Act respecting the Department of Public Health, S.P.A. 1919, c. 16.

20. 20 An Act respecting Public Health, S.P.A. 1910, c. 17; An Act to amend the Public Health Act, S.P.A. 1919, c. 46; “Public Health Bills are given First Reading,” Edmonton Bulletin, 25 February 1919, Alberta Legislature Library, Scrapbook Hansard.

21. 21 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fifth Session of the Fourteenth Legislature (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1963), 9.

22. 22 Alberta Legislative Assembly, Report of the Special Legislative and Lay Committee Inquiring into Preventive Health Services in the Province of Alberta (Edmonton: 1965).

23. 23 For an in-depth discussion of Alberta’s transition to medical insurance, see, Alberta’s Medical History: Young and Lusty, and Full of Life (Red Deer, AB: R. Lompard, 2008), especially “The Roots of Medicare are in Alberta (1927–1946),” 605–630.

24. 24 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Twenty-Fifth Legislature (Edmonton: 2002), 4.

25. 25 Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH), Toward a Healthy Future: Second Report on the Health of Canadians (Ottawa, Health Canada, 1999), http://publications.gc.ca/site/eng/82290/publication.html.

26. 26 Two possible exceptions to Klein’s otherwise biomedical/behavioral orientation toward health in his 2002 throne speech are about developing community-based health projects under an Indigenous health strategy and taking steps to enhance the health of vulnerable children. However, efforts vis-à-vis those issues could take many forms, and the mere mention of these topics does not necessarily signal a social determinants of health orientation.

27. 27 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Twenty-Fifth Legislature (Edmonton: 2002), 5.

28. 28 The sub-topic codes in the original Canadian codebook (Soroka, Canadian Policy Agendas Topic Codebook) did not work well for our purposes; in particular, the “general” sub-code (300) was large and diverse, and the existing codes did not distinguish between prevention and treatment/management, which we felt was key for our purposes. We therefore developed our own sub-topic coding through an iterative process wherein two team members undertook multiple independent assessments of batches of throne speech quasi-sentences. Once those two team members were consistent in their coding, the coding was applied by a third team member to ascertain consistency and defensibility of coding.

29. 29 John Church and Neale Smith, “Health Reform in Alberta: The Introduction of Health Regions,” Canadian Public Administration 51, no. 2 (June 2008).

30. 30 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the First Legislature (Edmonton: Printed by Jas. E. Richards, Government Printer, 1907), 8.

31. 31 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Fourth Legislature (Edmonton: Printed by J.W. Jeffery, King’s Printer, 1920), 9.

32. 32 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Session of the Sixth Legislature (Edmonton: W.D. McLean, Acting King’s Printer, 1927), 10.

33. 33 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Ninth Session of the Eighth Legislature (Edmonton: A. Shnitka, King’s Printer, 1940), 8.

34. 34 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Session of the Eleventh Legislature (Edmonton: A. Shnitka, King’s Printer, 1949), 9.

35. 35 Malcolm Ross Bow and F. T. Cook, “The History of the Department of Public Health of Alberta,” Canadian Journal of Public Health 26, no. 1 (1935).

36. 36 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Session of the First Legislature (Edmonton: Jas. E. Richards, Government Printer, 1906), 14; Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the First Legislature; An Act respecting Public Health, S.P.A. 1907, c. 12; “The Last Legislative Oratory for 1907,” Edmonton Journal, 15 March 1907, Alberta Legislature Library, Scrapbook Hansard.

37. 37 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Fourth Legislature (Edmonton: Printed by J.W. Jeffery, King’s Printer, 1920), 9.

38. 38 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Session of the Fifth Legislature (Edmonton: Printed by J.W. Jeffery, King’s Printer, 1922), 12.

39. 39 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Sixth Legislature (Edmonton: Printed by W.D. McLean, King’s Printer, 1929), 8.

40. 40 An Act to amend The Public Health Act, S.P.A. 1929, c. 36.

41. 41 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Sessions of the Eighth Legislature (Edmonton: A. Shnitka, King’s Printer, 1936), 11.

42. 42 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Session of the Ninth Legislature (Edmonton: A. Shnitka, King’s Printer, 1941), 10.

43. 43 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Ninth Legislature (Edmonton: A. Shnitka, King’s Printer, 1942), 7.

44. 44 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Sessions of the Tenth Legislature (Edmonton: A. Shnitka, King’s Printer, 1945), 10.

45. 45 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Sessions of the Tenth Legislature, 10.

46. 46 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Sessions of the Eleventh Legislature, 9.

47. 47 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Tenth Legislature, 8.

48. 48 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Session of the Twelfth Legislature (Edmonton: A. Shnitka, Queen’s Printer for Alberta, 1953).

49. 49 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Sessions of the Eleventh Legislature, 9.

50. 50 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Thirteenth Legislature (Edmonton: Printed by A. Shnitka, Printer to the Queen’s Most Excellent Majesty, 1956), 7.

51. 51 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Thirteenth Legislature (Edmonton: Printed by A. Shnitka, Printer to the Queen’s Most Excellent Majesty, 1957), 7.

52. 52 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth Session of the Thirteenth Legislature (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1958), 5–6.

53. 53 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fifth Session of the Thirteenth Legislature (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1959), 6; Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Fourteenth Legislature (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1961), 4.

54. 54 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth Sessions of the Fourteenth Legislature (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1962), 4.

55. 55 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fifth Session of the Fourteenth Legislature, 3.

56. 56 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Session of the Fifteenth Legislature (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1964), 6.

57. 57 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Fifteenth Legislature (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1965), 4.

58. 58 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth and Fifth Sessions of the Fifteenth Legislature (Edmonton: Printed by L.S. Wall, Printer to the Queen’s Most Excellent Majesty, 1966), 4.

59. 59 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fifth Sessions of the Fifteenth Legislature (Edmonton: Printed by L.S. Wall, Queen’s Printer, 1967), 5.

60. 60 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Sixteenth Legislature (Edmonton: Printed by L.S. Wall, Queen’s Printer, 1970), 5.

61. 61 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Seventeenth Legislature (Edmonton: Printed by the Queen’s Printer for the Province of Alberta, 1973), 8.

62. 62 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Seventeenth Legislature, 8.

63. 63 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Twentieth Legislature (Edmonton: Printed by the Queen’s Printer for the Province of Alberta, 1984), 5.

64. 64 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Twenty- First Legislature (Edmonton, 1987), 8.

65. 65 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Twenty- Sixth Legislature (Edmonton, 2006), 7.

66. 66 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Twenty- Sixth Legislature, 7.

67. 67 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Twenty- Sixth Legislature (Edmonton, 2007 and 2008), 7.

68. 68 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Twenty- Sixth Legislature, 7.

69. 69 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Twenty- Seventh Legislature (Edmonton, 2009), 9.

70. 70 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth Session of the Twenty-Second Legislature (Edmonton, 1992–1993), 7.

71. 71 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Nineteenth Legislature (Edmonton: Printed by the Queen’s Printer for the Province of Alberta, 1981), 6.

72. 72 Fran Baum, The New Public Health: An Australian Perspective (Oxford: Oxford University Press, 1998); Mervyn Susser, “Does Risk Factor Epidemiology Put Epidemiology at Risk? Peering into the Future,” Journal of Epidemiology and Community Health 52, no. 10 (October 1998); 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 (August 2011).

73. 73 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Session of the Sixth Legislature, 10; Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth Session of the Sixth Legislature (Edmonton: Printed by W.D. McLean, King’s Printer, 1930), 8.

74. 74 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Eighth Session of the Eighth Legislature (Edmonton: A. Shnitka, King’s Printer, 1939), 7; Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Twelfth Legislature (Edmonton: Printed by A. Shnitka, Queen’s Printer for Alberta, 1955).

75. 75 Many of these references to prevention were in the context of references to public health by the Aberhart government (1940–1943), and the “post-war public health program” by the Manning government (1944–1946 and 1949–1950). Lucas and Gauvin, “Alberta Throne Speeches.”

76. 76 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Ninth Session of the Eighth Legislature (Edmonton: A. Shnitka, King’s Printer, 1940), 9.

77. 77 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Session of the Twentieth Legislature (Edmonton: Printed by the Queen’s Printer for the Province of Alberta, 1983), 7-8.

78. 78 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Twenty- First Legislature (Edmonton: 1987), 8.

79. 79 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. First Session of the Sixth Legislature (1927); Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Sixth Legislature (1928); Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth Session of the Sixth Legislature (1930); and Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Eight Session of the Eighth Legislature (Edmonton: A. Shnitka, King’s Printer, 1939).

80. 80 See note #74.

81. 81 Lucas and Gauvin, “Alberta Throne Speeches.”

82. 82 Public Health Agency of Canada. Glossary of Terms. https://www.canada.ca/en/public-health/services/public-health-practice/skills-online/glossary-terms.html. Last modified 18 December 2022.

83. 83 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Seventeenth Legislature (Edmonton: Printed by the Queen’s Printer for the Province of Alberta, 1973); Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth Session of the Eighteenth Legislature (Edmonton: Printed by the Queen’s Printer for the Province of Alberta, 1978), 4.

84. 84 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Sessions of the Twentieth Legislature, 8.

85. 85 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Third Session of the Twenty-Fourth Legislature (Edmonton: 1999), 3.

86. 86 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Fourth and Fifth Sessions of the Twenty-Fourth Legislature (Edmonton: 2000 and 2001), 9.

87. 87 Legislative Assembly of Alberta, Journals of the Legislative Assembly of Alberta. Second Session of the Twenty-Fifth Legislature (Edmonton: 2003), 8.

88. 88 Samantha King, Pink Ribbons, Inc. Breast Cancer and the Politics of Philanthropy (Minneapolis: University of Minnesota Press, 2006); Kirsten Bell, Darlene McNaughton, and Amy Salmon, “Introduction,” in Alcohol, Tobacco, and Obesity: Morality, Mortality, and the New Public Health, eds. Kirsten Bell, Darlene McNaughton, and Amy Salmon (New York: Routledge, 2011).

89. 89 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); Michael Hayes, et al., “Telling Stories: News Media, Health Literacy and Public Policy in Canada,” Social Science & Medicine 64, no. 9 (May 1, 2007), https://doi.org/10.1016/j.socscimed.2007.01.015.

90. 90 Lindsay McLaren, “In Defense of a Population-Level Approach to Prevention: Why Public Health Matters Today,” Canadian Journal of Public Health 110, no. 3 (2019).