It is 10 a.m. on a typical Monday at St. Paul's Emergency Department - all the stretchers are already full. The ambulances are filling the driveway, the line-up at triage is growing and the staff is struggling to make space for new patients and to see them as quickly as possible.

I look around the waiting room and see the various faces of humanity: The old and weak, the young and restless, the injured, and the lonely. The overhead speaker crackles and I hear, "Over-capacity protocol level one," which alerts the entire hospital that the Emergency department (ED) is in trouble-again.

This happens almost every day. I have to wonder what we would do if there were ever a true disaster. The reality is that we struggle daily to deal with these normal surges. ED overcrowding is a serious problem and its primary causes are not due to nonurgent patients, as is often thought, or to inefficient operations. Rather, ED overcrowding is a symptom of a system-wide problem with access to care that requires system wide solutions.

The ED is the barometer of the healthcare system as a whole-the canary in the coalmine, so to speak. The question is not whether there is a problem or not, but why. This is an enormously complex question with no easy answers. Part of the answer is that over the last several decades the role of hospital-based emergency care has evolved significantly. EDs continue to focus on providing urgent and life-saving treatment but have also taken on increasingly complex roles, such as providing a social safety net, providing primary care, public health surveillance, and disaster preparedness to name a few.

While the demands on emergency and trauma care are increasing, the capacity to meet these needs are not. A recent report by Ontario Hospital Association's Expert Working Group categorizes the causes of emergency department overcrowding into two groups: Lack of inpatient bed availability and lack of integration between community and hospital.

The same conclusion has been described in many other reports including The Institute of Medicine's report on Hospital Based Emergency Care, and the U.S. General Accounting Office's 2003 report on Hospital Emergency Department. However, I think they all present too narrow a view. We have to go further in the analysis and broaden our lens to arrive at the root causes of the problem, beyond the mechanics of the healthcare system.

Undoubtedly we need to develop more efficient, integrated and better healthcare delivery models but, ultimately, we have to look at macro forces of demographic changes and the multi-factorial determinants of health-biologic, psychologic, social, ecologic and spiritual. More and more patients with complex multi-system diseases are being seen in our EDs; the highest rate is now in the 75 and older age group-a rate that has increased more than 50 percent since 1992. It is projected that by 2031, approximately 25 percent of Canada's population will be over the age of 65 years, double the current proportion of 13. The question is: How are we going to deal with this?

The ED is the final common pathway for many people and many conditions. When someone's health fails and their condition deteriorates they end up in the ED; if the health system fails-whether from inadequate primary care, complications from medications or procedures, or being discharged and sent home too early- they end up in the ED. If the societal safety net fails-whether from inadequate housing or social welfare programs, or environmental  degradation leading to ill health, for example-they end up in the ED. From this standpoint, I have always thought that the ED represents an interesting vantage point in which to view the weaknesses of not only the healthcare system but also society at large.

As a doctor working in an inner city ED, one cannot help but have a real appreciation of the breadth of illness and dysfunction that can exist, as well as its relationship to socio-economics, education and policy. One should, then, naturally begin to think about the root causes of disease and illness and the determinants of health.

I am reminded by something I read in Geoffrey Rose's seminal paper "Sick Individuals and Sick populations." He wrote: "Why did this patient get this disease at this time?" He goes on to say that it is an integral part of good doctoring to ask not only: "What is the diagnosis, and what is the treatment?" But also to ask: "Why did this happen and could it have been prevented?"

In the ED, we restart hearts, stitch up wounds, give fluids, and provide other life-saving interventions, but I always wonder whether we could have intervened earlier. Could we have done something further upstream in a person's life to change the trajectory of their journey? Without a multi-dimensional approach to health and wellness, I wonder whether we are making enough of a sustainable impact in many of these people's lives. I also believe, as many people do, that a major paradigm shift needs to occur-from an illness-centered, provider-focused system to a more integrative, client-focused and holistic view of health and wellness.

We have better and increased understanding of the molecular basis of disease; improved diagnostic capabilities and treatment; biotechnology; unprecedented communication and connectivity in the world; continually evolving methods to collect and interpret complex data; and an increasing understanding of the inter-connectiveness of mind, body and spirit, and our environment. I feel that there is a tremendous opportunity, perhaps more so now than ever, for us to improve the health and well-being of ourselves and our global community, but we have to think broader and deeper.

Lawrence A. Cheng MD, MPH is the Physician Operations Leader for the Department of Emergency Medicine at St. Paul's Hospital in Vancouver, BC, and Clinical Associate Professor at the University of British Columbia.

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