This winter and spring I served as moderator of a traveling road show assembled by the Canadian Medical Association (CMA) in conjunction with Maclean’s. At each town hall meeting across the country teams of local and national experts were assembled to discuss a deceptively simple question: What makes us sick?
It wasn’t really a discussion of germs or viruses or tobacco use. It was an exploration of what has come to be known as the “social determinants of health”—things like insecurity in income, housing or food; lack of education or adequate childcare; teen births, racial discrimination, among others. They may not seem to be purely health issues, but individually, or in lethal combinations, they can and do kill Canadians before their time.
It was a search for bold thinking and fresh ideas, which they found in abundance from the hundreds of audience members who turned out, and from the extraordinary collection of expert panelists on stage—health care workers, social advocates, Aboriginal leaders–who live with the realities every day.
On Tuesday, July 30, the CMA released its report in Ottawa along with a sweeping series of recommendations—from housing and food-security programs to a pilot study of a guaranteed annual income. The ideas are sure to cause discomfit to some of Canada’s political leaders.
“I have to say it was a fascinating, but at times also disheartening, national discussion,” said CMA president Anna Reid, an emergency-room doctor at the Stanton Territorial Hospital in Yellowknife. “In a nutshell, we heard that the biggest barrier to good health is poverty. I do believe that many Canadians do not realize how many of our fellow citizens live in poverty, and how difficult it is for those living in poverty to be healthy.”
By some estimates, 20 per cent of the $200 billion spent annually on Canadian health care can be attributed to socio-economic disparities. The things people don’t have—money, primarily—are what kill them or degrade the quality of their lives. The Hamilton town hall meeting, for example, heard of two city neighbourhoods, one rich, one poor, where the difference in average life expectancy was 21 years.
There are vaccines for diseases like measles, mumps and polio. But how do you vaccinate against poverty? That, in essence, is what the CMA set out to explore in its cross-country consultations and in online discussions on its website.
If the CMA consultation causes a little unease for the ruling class, that can’t hurt. Canada, by any measure, is a middling performer among wealthy countries when it comes to health outcomes or alleviating the damage of social and economic inequality. That was clear, too, in the spirited comments, and heart-wrenching stories shared by audience members at every stop. And by the evident frustration of many of our panelists, who see the problems first hand, and who are all too often thwarted by a system that finances and administers health in isolation from all the thing that make us healthy: education, housing and employment, to name just three.
“The perceived abandonment of responsibility for health care by the current [federal] government was seen as a serious blow to ensuring accountability of how health care is delivered,” the CMA report found.
Among its recommendations was that “a health impact assessment” be part of any cabinet discussions of new policies or programs cuts.
But the reality is that no one level of government can “fix” social and health inequality. Society is us, and the best solutions the consultations heard were usually those that worked across the spectrum, community-based programs that drew from the resources of neighbourhood organizations, and from all levels of government. “There is no one sector responsible for making this happen,” Reid said. “It has to be a joint effort, involving health-care providers, governments, patients and Canadians from all backgrounds and Canadians from all walks of life.”
It means knocking down the silos and bureaucratic fiefdoms that cause one policy in one department to work in isolation, when it really does take a village.
One troubling example raised by Aboriginal panelists and audience members during the Winnipeg town hall were the overlapping and sometimes conflicting federal and provincial services for health, education, housing and other social services for on-reserve and urban status and non-status Indians and Metis people. Chronic education underfunding was denying post-secondary education to a huge cohort of young people, at huge economic and social cost.
There are promising developments. One is New Brunswick’s Economic and Social Inclusion Corporation, a non-partisan Crown corporation with the grand aim of reducing poverty and improving social outcomes. Its 22-member board includes relevant provincial cabinet ministers, an opposition member, business, municipal and social leaders from urban and rural areas and a rotating co-chairmanship that includes a person living in poverty. This spring it played a key role in inspiring changes to the delivery of social services. It is exploring ways to deliver a prescription drug plan to the 70,000 families in the province with no drug coverage at all.
The report’s focus on issues of poverty, housing and education are part of the CMA’s multi-year commitment to advocate for a health-care system that is better focused on patient outcomes, while remaining financially sustainable. It’s a tall order.
“Some people may think that, in looking beyond health care, physicians are treading off their usual path. We’re not really,” Reid said in Winnipeg this winter before a town hall meeting focusing largely on Aboriginal health, social and economic issues. “There is nothing more frustrating than diagnosing a health problem and prescribing treatment for a patient in the knowledge that the cause of the illness will persist.”
After its consultations, the CMA recommends that:
- the federal, provincial and territorial governments give top priority to developing a plan to eliminate poverty;
- the federal government finance a guaranteed annual income pilot program, possibly similar to an experiment in Dauphin, Man., in the 1970s that offered promising returns in health, education and social outcomes;
- there be a greater emphasis on secure housing for people with chronic conditions and affordable housing programs for low- and middle-income Canadians;
- investments be increased in early childhood development;
- comprehensive prescription drug plan be created “to ensure that al Canadians have access to medically necessary drug therapies”;
- there be greater investment in Aboriginal health and education, and fostering of Aboriginal health care providers.
If it all sounds rather utopian, it’s not. Many of these ideas are in place in countries in Europe, which are delivering vastly better outcomes in key indicators including lower rates of infant mortality, chronic disease and chronic poverty, and better longevity and education outcomes.
“It’s a question of compassion and our duty as physicians to bring these issues forward,” said Reid. “For society, it’s also a question of costs, a way to ensuring that we can continue to afford our health-care system.”