We can’t view health as an exclusively personal matter – it’s a collective endeavour

Perhaps this year you’ve resolved to improve your health. You’re eating better. You’re exercising regularly. You’re staying hydrated, and prioritizing sleep. But have you also thought about what you can do to ensure your friends are healthy too? Your neighbours? Your surrounding environment and wildlife?

No doubt the measures you’re taking are good for you. But regardless of what any one of us does to keep fit and stay well, our risk of COVID-19 and other viruses depends heavily on how many people around us are infected and how close they are, and how much virus circulates in the air we breathe. Likewise, even assuming we have the ability and resources to do so, practising self-care can only protect us so much from countless other health threats, from environmental carcinogens to deadly heat waves to toxic work cultures that induce chronic stress and burnout.

There’s nothing like a global pandemic occurring amid a climate crisis to drive home the reality that our individual health depends not just on our own efforts, but on the health of our communities and ecosystem.

Yet the pandemic has demonstrated how difficult it is to shake the stubborn myth that we are masters of our own health. The phrase “we’re all in this together” quickly gave way to advice from public-health officers and politicians to “assess your own risk,” and consider using “individual public-health measures” as “a personal choice.”

The every-person-for-themselves approach to COVID-19 has driven deep social divides among people trying to protect themselves, either from infection or from a sense of threat to their freedoms. Behind all the debates about face masks, vaccines and the necessity for lockdowns and mandates lies a deeper, more fundamental question: Why should we protect or even care about the health and well-being of others (including those who don’t share our views)?

The reasons aren’t always obvious. But some doctors, researchers and academics say failing to do so could come back to bite us. If we continue to view health as an exclusively personal matter, one that does not require us to also act as stewards of our community and environmental health, it could be to our own detriment, leading to more illnesses, increased burden on our health care system, and greater social costs in the long run.

“It’s kind of a sad state of affairs that we would even ask that question,” said Lindsay McLaren, a professor in the department of community health sciences at the University of Calgary. “We are a collective and there’s no two ways about that.”

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As COVID-19 vaccines began rolling out across the country two winters ago, the biggest challenge wasn’t persuading Canadians to get them. It was having too little supply to handle the crush of people clamouring for doses to protect themselves.

Today, it’s a different story. In spite of calls from public-health authorities to stay up-to-date with COVID-19 vaccines, only 23 per cent of the population have either completed their primary series or received a booster dose in the past six months.

According to an Angus Reid poll in July, at least part of the reason for the low uptake in boosters is that some Canadians feel they don’t provide personal benefit. Twenty-two per cent of respondents said they did “not believe that keeping up with vaccines gives a person protection against either infection or serious illness.”

Toronto epidemiologist Dan Werb says thinking about vaccines as personal protection is a mistake.

“People regularly get vaccinated under the assumption that doing so will directly help them,” he wrote in his award-winning book, The Invisible Siege: The Rise of Coronaviruses and the Search for a Cure. “But vaccines aren’t meant to protect a person from disease – what they are meant to do is protect populations from epidemics.”

Certainly, individuals have died of COVID-19, even after being fully vaccinated. But at a population level, vaccines have prevented as many as 19.8 million deaths from COVID-19 worldwide, according to the estimates of a mathematical modelling study published in The Lancet Infectious Diseases journal in June. Even though vaccines have not reduced infections to the extent many had initially hoped, they have drastically slashed the proportion of people who require hospitalization and lowered the risk of long-COVID.

The difference between personal and population-level protection isn’t just semantics. Consider this, Dr. Werb suggested: Would you rather be the only vaccinated person in the world? Or would you rather have your entire social network, your co-workers, and everyone you encounter vaccinated, except you? (The same concept can be applied to masks, too. The benefit of wearing them is greatest when everyone wears them.)

Vaccination works best, Dr. Werb said, when it’s done on a mass scale. Yet in the early days of the vaccine rollout, the rush to get to the front of the line played out at every level, with those in rich neighbourhoods getting access ahead of those in poorer neighbourhoods. And when wealthier countries were delivering third and fourth doses, many in lower-income countries were still receiving their first. According to the United Nations Development Programme’s Global Dashboard for Vaccine Equity, 72.8 per cent of people in high-income countries had received at least one COVID-19 vaccine dose as of Dec. 21, compared with 29.4 per cent of people in low-income countries.

“That’s a chief reason why we’re seeing the pandemic is still not controlled,” said Dr. Werb, director of the Centre on Drug Policy Evaluation at St. Michael’s Hospital. It’s from these undervaccinated populations that some variants of concern have emerged, he said.

For our own self-interest, we should be doing everything possible to make sure everyone has access to vaccines, Dr. Werb said. “Unfortunately, we, as human beings, have not been able to kind of extract ourselves from the kind of primal greed that has spurred the vaccine hoarding.”

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Our health isn’t just tied to other people, but to other species as well. And we ignore their welfare at our peril.

Through her work on various infectious diseases (which currently includes a highly pathogenic avian influenza spreading across North America), Toronto virologist Samira Mubareka has come to recognize that nature is not the threat to human health that we often think it is. It’s the other way around. Humans are the threat to nature.

“Most of the major drivers for zoonotic spillover don’t really come from nature. They come from our impact on nature in many ways,” said Dr. Mubareka, who is also an infectious-diseases physician at Sunnybrook Health Sciences Centre.

By disrupting wildlife habitats through various forms of land use, we put ourselves in contact with animals that are natural hosts to viruses, she explained.

An anecdote she has shared in lectures to illustrate this point involves bats in Belize. Clear-cutting forests to make way for cattle farming in one region of the country destroyed the habitat for many bat species, but it allowed hematophagous bats, also known as vampire bats, which feed on blood, to thrive. The introduction of cattle gave these bats an easy food source, leading to the emergence of bovine rabies, she explained.

Here in Canada, even though many Canadians have put the pandemic behind them, the work of Dr. Mubareka and her colleagues suggests it would be unwise to neglect SARS-CoV-2, the virus that causes the disease, in local wildlife. In a study, published in Nature Microbiology in November, she and her team reported finding a highly mutated variant of the virus in white-tailed deer in Ontario that no one had seen before. What’s more, they found evidence of deer-to-human transmission of this variant.

The reassuring news is it wasn’t a variant of concern, as it didn’t spread swiftly between humans. The researchers did not find evidence it infected more than one person.

But what is less reassuring is the potential for infected deer to sicken other wildlife, Dr. Mubareka said. And there’s also the possibility that deer could become a secondary reservoir for SARS-CoV-2. When an infectious disease gets into the wildlife, it becomes a lot harder to control, she said. And if a highly transmissible variant were to change enough within deer to render our vaccines less effective, it could pose a problem if it jumped back into humans.

Understanding the key role humans play in animal-borne infectious diseases requires us to be more considerate about our land use, our travel and consumption habits, and our impact on the environment, Dr. Mubareka said. In this regard, she believes there’s reason to feel hopeful.

“It’s also good news in the sense that it’s up to us then, you know. We have the agency to make changes to improve those things if we decide to look at health in a different way,” she said.

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As a palliative-care physician who provides care to patients experiencing homelessness in Toronto, Naheed Dosani sees the consequences of expecting people to shoulder full responsibility for their own health.

Sure, it’s easy to give patients personal health advice, including to be more active and eat healthy foods. But when you look at the social determinants of health – the factors such as income, labour conditions and where they live, if, in fact, they have anywhere to live – it becomes evident not everyone is able to follow such advice, he said.

“Have you seen what healthy food costs nowadays?” said Dr. Dosani, who works at St. Michael’s Hospital.

Whether his patients are able to exercise, eat well and stay home when sick has implications for everyone else.

For one thing, it can be distressing for health professionals to give patients instructions on how to protect or improve their health, while knowing full well they don’t have the means to follow them, Dr. Dosani said. For clinicians, doing so can lead to burnout, moral injury, compassion fatigue and a sense of powerlessness.

And since we share the same health systems, poorer health outcomes for some can mean less health-system capacity for us all, Dr. Dosani said.

He suggested that ensuring people have equitable opportunities to be healthy could be well worth the cost to society. Imagine, for instance, if we no longer had to address “downstream” outcomes, such as providing shelters and additional health and social services for those who become homeless, which can be expensive, he said, and instead tackled the problem “upstream,” that is, at the source, by making sure everyone had a home and was supported in the first place. The payoffs could be significant.

Similarly, when it comes to COVID-19, he suspected measures such as ensuring people receive paid sick days, wearing masks indoors, delivering boosters and improving ventilation would be less costly than widespread infection, reinfections, a collapse of the health care system and mass disability associated with long-COVID.

“The raw reality is we live in an interconnected world where our health is more connected with each other than ever before,” he said.

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How did we get here, to this place where public health takes a back seat to individual health?

To understand the origins of our modern concept of public health, one must look back to the 19th century. That’s when the sanitary reform movement began, introducing population-based health strategies, such as cleaning up the streets, to tackle rampant infectious diseases, according to Catherine Carstairs, a history professor at the University of Guelph.

One of the most famous stories in the history of public health, she noted, was when London physician John Snow traced a cholera outbreak to a public water pump in 1854, which led to the recognition that cholera is waterborne.

Even early on, there was an element of expectation that people were to take individual measures to control their health, she said. In the 1920s, efforts to fight sexually transmitted infections, previously known as venereal diseases, urged people to “behave in a sexually moral fashion,” and later, vaccination campaigns against diphtheria included posters that shamed parents of unvaccinated babies for allowing their children to get sick, Dr. Carstairs said.

“This sort of blaming in public health is nothing new,” she said, but she noted it began to accelerate in the 1970s, when chronic diseases became the leading health issue and public recognition of the harmful effects of smoking grew.

In Canada, this push for people to take responsibility for their own health was also tied to the implementation of medicare, Dr. Carstairs said. Universal health care came with sticker shock, leading the federal and provincial governments to seek ways to save on costs. Part of the answer involved encouraging Canadians to adopt healthier lifestyles with the promotion of exercise, nutrition and avoiding smoking, she explained.

“It’s all very nice to promote exercise,” she said, but it can take a harmful turn when people start blaming others for their illnesses if they don’t exercise.

From a sociologist’s perspective, University of Alberta professor Amy Kaler suggests the tendency to view health as an individual responsibility stems, in part, from a world view that regards people as consumers, who are defined by their choices. This has implications for our concept of freedom, she explained, because if you see yourself as a consumer, the highest exercise in freedom is being able to choose what you consume.

Dr. Kaler argues for a different definition, one for which freedom means participating in the creation of a society in which everyone can live out their fullest potential.

“Arguably a society where people aren’t dying young from preventable causes and people aren’t sort of stuck inside because they’re at risk if they go outside is more of a free society than a society in which there are no laws and no rules and people do what they want,” she said.

According to Dr. McLaren, the community health sciences professor at the University of Calgary, the pandemic has reinforced a very narrow vision of public health. Dominant discussions have focused either on health care, including hospital capacity, testing and biomedical treatments, or individual behaviours. Both are critically important. But what gets overlooked, she said, is a third pillar, what she refers to as the political economy of health.

“That is where you think about health as really having to do with where you are situated within a society and an economy and how much power you have,” she explained.

In a wealthy country, everyone should have the material and social foundations needed to have a good life and participate with dignity in society, she said. “We have more than enough money and capacity to make that happen, but we haven’t.”

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What would treating health as a collective endeavour look like?

The idea of achieving health for everyone may seem lofty. But Dr. McLaren emphasized there are practical examples of works in progress.

The approach taken by the country of Wales was to legislate long-term thinking. Under its 2015 Well-being of Future Generations Act, all public bodies are required to consider the impact of their decisions on the prosperity, health and equality of the country’s future citizens.

For example, a proposal to build a new relief road to a major motorway was scrapped, since it did not meet the bar for long-term gain, according to Sophie Howe, who was appointed as future generations commissioner to hold public authorities to account. Wales has also issued a moratorium on all road building and lowered the speed limit across the country, Ms. Howe said.

Measures such as these are as much health interventions as they are transportation policy, she said, as they help reduce deaths from air pollution and car accidents and increase the physical activity of the population.

“We can’t divorce our actions now from what happens to those yet to be born,” she said. However, acting for the good of future generations doesn’t always require making difficult sacrifices either. She said in many ways, as in the transportation example, it also benefits the health and well-being of those living now.

Finding ways to achieve collective health may not only lie in future-thinking, but in re-examining how we relate to the world.

At Thompson Rivers University in Kamloops, Indigenous health researcher and professor Rod McCormick studies traditional healing and wellness practices.

While there is a lot of diversity among them, many Indigenous peoples embrace a philosophy captured in the expression, “All My Relations,” Dr. McCormick said. (It’s also the name of his research centre.) This concept extends beyond one’s immediate relatives to one’s extended family, community and the natural and spiritual world, he said. “The idea is you really need your relations if you’re going to be healthy.”

Dr. McCormick, who is Mohawk, said elders have shared with him the notion that a person becomes sick when they are disconnected from these elements. As a trained counselling psychologist, he has seen this firsthand in his work with depressed and suicidal youth in Yukon and B.C., who have withdrawn from their peers and family. Often, he said, he has found that through traditional ceremonies, reconnecting with their land, communities and spirituality helps these young people get better.

“You’ve got to be connected because that’s who watches out for you and that’s where you get your sense of empowerment and belonging,” he said.

In other words, mental, physical and spiritual health does not happen in isolation.

None of this means you should abandon your goals for taking better care of yourself. But achieving health means taking better care of your surroundings and those around you, too.

Ultimately, the rationale for acknowledging that none of us can attain or sustain health on our own is not just about cost-effectiveness or preventing epidemics and future pandemics or saving the planet – though it does include all of those things. People have a moral responsibility, too, to take care of one another, said Dr. Dosani, the Toronto palliative-care physician.

In a world rooted in the values of justice and equality, “we wouldn’t just focus on becoming healthier as individuals because that’s not the point,” he said. “We would focus on caring for the health of others because it’s also the right thing to do.”