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In Thomas McKeown 1979 study 'Tortoises 1 Hares 0: How Comparative Health Trends between Canada and the United States Support a Long-term View of Policy and Health,' the reasons as to why Americans on average enjoy better health standards than their Canadian experts have been examined and contrasted to the 1960s when the two countries enjoyed roughly similar life expectancies. He studied mortality and its putative determinants as they unfolded over the decades. This study demonstrated that the factors that led to large decline in mortality from the major infectious diseases of antiquity were not founded on healthcare interventions as expected. Factors that attracted attention were economic growth, rising living standards and improved nutrition. This shift is foundational to population health and a motivating factor of health determinants that are not specifically designed to support health or fight disease.

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An analysis done revealed three key conclusions. First, greater economic well-being and spending on healthcare did not yield better health outcomes. Canada was ragging behind in economic growth, high unemployment and less spending on healthcare which far outstripped America in mortality reduction. The second finding was that public provision and income redistribution trump economic success where population health is concerned. In contrast to economic growth and health expenditure, the time trends of changing public expenditure and income redistribution correspond to relative changes in health status and the relative steepness of the economic gradient in both countries. The third finding was that the gradual development of public provision represents the build-up of social infrastructure that has long-lasting effects on health status. Public provision and economic redistribution are products of the evolvement of the institutional landscape. Despite the periods of high unemployment, the Canadian health status continued to improve. Canada has been doing better in economic redistribution even through unemployment protection which represents the extent to which wages and benefits accrue to individuals, even in times of unemployment. Therefore, there is need for more focus on the introduction and evolution of the institutional differences. The historical and the dynamic approach applied reveals what path we need to take in our search for better health.

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