To the Editor: Finally! An article in the Journal about health reform that carries no spin and decries further futile experimentation in management. Lewis and Leeder are to be congratulated on their insightful review.1 As they point out, social and environmental determinants of health are far more important to a community’s well-being. This was recognised intuitively as long ago as 1986, with the promulgation of the Ottawa charter,2 and its recommendation that health services be reoriented primarily toward promoting heath rather than delivering acute care per se.

As Lewis and Leeder articulate, the evidence in favour of this line of thinking is actually quite potent.1 However, as they point out, the thing that surprises students and practitioners in public health is why the “bigger picture” has been so difficult to comprehend and act on. Rather than a need for the “stars to be aligned”, perhaps this is the time for stronger advocacy? And while we’re at it, evaluation tools for health promotion programs need to become more sophisticated if we’re going to convince our colleagues, politicians and the community that we’re spending their money wisely. The transformation that Lewis and Leeder recommend is likely generational in its span, but what better time to make a start?