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This is the first of two articles commissioned by CHN on public health in Canada. Coming soon… 'A day in the life of a public health unit'.

The average person living in a Canadian town or city usually doesn't think about public health, much less know local provincial and municipal public health officials by name…

Sometimes it takes a crisis to make us appreciate the importance of public health. But the truth is that every day, public health officials are working to keep us healthy in cities and small towns across Canada-though the demands on those working in rural and northern Canada may be quite different than those on their urban counterparts.

The mandate of public health departments is disease prevention and health promotion. In crisis-free times, many of us take their work for granted even though they have a direct impact on everything from immunization programs, breastfeeding support and oral health promotion to food poisoning, substance abuse prevention and water testing.

And Canada's public health system just got a whole lot stronger. The Agency will have two main pillars, Winnipeg and Ottawa, and will work with a network of specialized centres across the country.

Health is determined by many factors, including the social and physical environments where we live. These factors are referred to as 'determinants of health'. How these factors combine in our lives can determine whether we will be healthy or not. (Public Health Agency of Canada - Population Health Approach)

For example, the 2004 report from the Canadian Population Health Initiative (CPHI), called Improving the Health of Canadians examines the tendency of Canadians to have poorer health at low levels of income.

Public health benefits all Canadians, yet public health workers in rural and northern Canada sometimes have jobs with quite a different focus from those of their counterparts in the southern half of the country.

All sorts of factors play into these differences-everything from population density and education levels to the cultural mix. Even the weather of a particular area has an impact. In a city like Toronto, for example, where the weather can go from one extreme to the other, hypothermia, hyperthermia, slips, falls and unintentional injuries are more of a public health concern than in, say, Vancouver, according to Dr. Perry Kendall, the provincial health officer for British Columbia. Restaurant food safety is also much more of a public health issue in an urban setting, where there are large numbers of restaurants with varying standards of hygiene, Dr. Kendall adds.

			What does a Public Health Unit do?
			It's almost quicker to list the things a public health unit doesn't do. The mandate of public health is health promotion, health protection and early detection of health problems. Among the many areas that mandate covers: Food and water safety Environmental issues such as toxic waste handling, air pollution, second-hand smoke Rabies Public sanitation Tuberculosis screening for immigrants to Canada Vaccinations against major communicable diseases Home visits for new mothers Education about tobacco use, nutrition, physical activity, injury prevention, birth control, sexually transmitted diseases, breastfeeding and reproductive health Screening for breast and cervical cancers

About 30 per cent of Canadians live in rural or remote areas of the country. While they share many areas of health concern with Canadians in urban areas, they also have additional realities. Among them: a potentially harsher climate, transportation ability and distance considerations, sparser population and different demographics. As a result, in more isolated communities, for example, seniors, at-risk infants and people with physical or mental disabilities may find it harder to access the services they need. And according to the Canada Safety Council, farming is one of the most hazardous industries, with farm injuries responsible for more than 130 deaths and 1,200 hospitalizations each year.

Of course, there are many issues shared by both northern and southern Canadians; some are simply more concentrated in urban areas-larger numbers of sexually transmitted diseases, clusters of HIV, a bigger sex trade, more injection drug use. Even between large urban areas, there can be differences. Dr. Kendall, who has worked in public health in both Toronto and Vancouver, is in a good position to make comparisons. In Vancouver, for example, drug use is mainly concentrated in the downtown east side area while in Toronto it's much more diffuse.

In southern parts of the country, there is also more cultural diversity, which presents different challenges for public health workers. "People come to this country with different expectations and different patterns of living and different cultural norms," says Kendall. "If you're trying to develop a prenatal program in a big city, you have to analyse behaviours of women in different cultures." Public health workers also find that some groups in greater need of dental services are people who have come from a country with varying dental hygiene practises. In addition, in any area-northern or southern, urban or rural-with large populations of people who make periodic visits to their native countries, there will likely be higher rates of tropical diseases such as malaria.

In the north, public health issues are influenced by the fact that there are larger Aboriginal populations. The 2004 report called Improving the Health of Canadians states that Aboriginal peoples' health is worse than that of Canadians as a whole. While they are making some gains, the study found that, on average, First Nations and Inuit peoples in Canada live 5 to 10 years less than other Canadians due to serious social, economic and environmental conditions.

• "Compared with the rest of the Canadian population, First Nations and Inuit have higher suicide and infant mortality rates. Aboriginal peoples also have three times the rate of diabetes and 16 times the rate of tuberculosis.
  
  
• On reserve First Nations peoples have injury rates that are four times the rate of that of the Canadian population as a whole."
  (Improving the Health of Canadians, Canadian Population Health Initiative, 2004)
  

The study identifies new research that suggests that "cultural continuity" and community control are factors in the health of Aboriginal peoples. For example, a 1998 study by British Columbia researchers Christopher Lalonde and Michael Chandler found that the First Nations communities in British Columbia that have more community control over schools, and health and other services have much lower youth suicide rates than other communities. Kendall notes that people who stay on reserves may end up healthier in general than those who migrate to big cities. "It's not related to income or employment but rather to cultural integrity."

Northern public health workers have fewer dollars than their southern colleagues to spend on preventive health education and yet, with only small chapters of other agencies such as the Heart and Stroke Foundation or the Canadian Cancer Society, the job is left pretty much up to public health. At the same time, the north is a population with a large burden of preventable chronic disease. Lung cancer, for example, is the leading cause of death in Ontario. From the mid-1960s to the mid-1990s, according to the Ontario Cancer Registry, the rate of new lung cancer cases was consistently higher in northern Ontario than in southern Ontario-likely because of higher smoking rates in the north. One area in which urban areas excel is that of environmental smoke tobacco controls. In fact, notes Kendall, there is a "five to 10-year gap in response to tobacco between south and north."

			What are the Key Determinants of Health?
			Income and Social Status Social Support Networks Education and Literacy Employment/Working Conditions Social Environments Physical Environments Personal Health Practices and Coping Skills Healthy Child Development Biology and Genetic Endowment Health Services Gender Culture From Public Health Agency of Canada

Despite all the challenges in providing northern public health services, Cherry Lawrance, director of the Northwestern Ontario Health Unit in Sioux Lookout, is proud of what public health workers are able to accomplish. Few families have to drive more than an hour to access to public health services. "Those services are available to all of the mandatory programs-vaccine promotion, chronic disease prevention," she says. They have been able to maintain sexual health clinics and have instituted needle exchange programs as one of a number of services that are linked with parallel services in urban centres.

Then there are differences in public health workers' ability to deliver services. For example, Lawrance's unit, which is 290 km northwest of Thunder Bay, maintains 11 offices to cover 19 municipalities in a geographic area the size of France, sparsely populated with 87,000 people. Twenty per cent of those people are First Nations who live on or off reserve. Transportation and advertising are both expensive, so much of the communication is carried out by radio. According to Lawrance, the Internet has a huge impact on northern communities-possibly more than in urban areas-by not only providing an instant method of communication but also access to a whole global source of health information, for both consumers and health professionals.

Let's not wait for another crisis to pay attention to our public health system. Public health touches us all, from the tiniest baby to the oldest member of the community in urban and in rural settings and from north to south. Public health is a vital service that works to keep us healthy and prevent disease and injury.

To learn about programs where you live, call your local Department of Health. For information on national initiatives in public health, visit the website of the Canadian Public Health Association.