Today is a National Day of Action for a 2014 Health Accord. With this in mind, we bring you an interview with Ryan Meili, the author of A Healthy Society and an important voice in the debate about the future of medicare in Canada.
Am Johal: In your book, A Healthy Society, you argue that a focus on health can revive Canadian democracy. How so?
Ryan Meili: The book starts with a discussion of the disordered state of Canadian political discourse , from media coverage to the way in which parties present ideas. There is a general lack of focus, a lack of a common project for society. The WHO defines health as not just the absence of disease, but full social, mental and physical wellbeing. In A Healthy Society I propose that health is a useful shorthand for our goals as a society, and one which we can measure our success in reaching.
Such a focus on health must move beyond healthcare to the upstream elements that impact health outcomes: the social determinants of health. Income, education, employment, social supports, housing, nutrition, these are the elements that make a greater difference in health and wellbeing. While these are disparate areas, the common thread of health allows us to address them in an evidence-based fashion.
In A Healthy Society, I take stories from my experience working with patients in inner-city Saskatoon, rural and Northern Saskatchewan, and rural Mozambique, and use them to illustrate the impact of the social determinants of health. I then dig further into specific determinants and ways in which changes in public discourse and the policies that flow from those changes could lead to better lives for my patients and for all Canadians. This leads to a discussion of democratic reforms that could help make the focus on social determinants of health a more effective and engaging tool for social change.
AJ: With governments implementing neo-liberal policies over the last thirty years, there has been a massive erosion of social programs such as employment insurance and a national housing program. How have cuts in these areas impacted the health of Canadians?
RM: These cuts are examples of direct failures to meet key health determinants and improve the wellbeing of Canadians, they also contribute to increased inequality and disparity in wealth. Greater inequality, as demonstrated in research such as that of Wilkinson and Pickett in the UK, results in worse health outcomes not only for the poor, but also for the wealthy. While this is tempered somewhat by economic growth, health and wellbeing outcomes have not kept pace with increases in GDP as demonstrated by the Canadian Index of Wellbeing project. Cuts to key services and government policies that have led to increased levels of inequality, have played a key role in undermining the impact of economic success on health outcomes. Improvements in health will not be reached through health care spending; this trend away from effective, universal social programs has to be reversed.
AJ: What is the role of community health centers in the public healthcare system?
RM: Community health centres, like the West Side Community Clinic where I work, offer an example of health care services that stem from an understanding of the interconnectedness of the determinants of health. Rather than simply providing medical care, they often incorporate multiple disciplines of health services (counselling, physiotherapy, dentistry, social work) with upstream work such as patient outreach, health education programming, and active connections with community services such as addictions treatment or housing authorities. This allows for an approach that goes beyond a narrow medical model of health, and is one key element in moving to a model that emphasizes prevention and wellbeing rather than putting all resources in treatment.
Having community boards also allows CHCs to be more responsive to community needs and to act as gathering points for information about changes in those needs. CHCs are an essential part of a primary health care strategy that leads to more comprehensive and cost-effective care. Of course, however, they can only be partially effective in improving health outcomes if the rest of the determinants of health that are outside their sphere of influence, are not addressed. This is one of the frustrations of working in a setting that offers excellent care but is limited by its scope, and is part of what led me to write A Healthy Society as a means of exploring the upstream changes needed to make good primary health care effective.
AJ: Child vulnerability rates continue to increase across the country. What is the best way to address these issues?
RM: Like any social issue, the causes and responses are multiple and complex. Recognizing healthy children as the goal, and recognizing the impact of the social determinants in reaching that goal, gives us a starting point. From there we can dig into policy choices to improve child health. These could range from improving income supports for low income families, to availability and quality of early childhood development programming, and increased investment in affordable housing.
AJ: Seniors poverty continues to be on the rise particularly in the current economic environment. What are some innovative approaches that can be taken to address the demographic shift that is happening in the country?
RM: Similarly, the issues for any vulnerable group need to be dug into and understood in order to make effective, evidence-based policy changes. A number of the options raised in the Romanow Report, including increased home care and pharmaceutical coverage, could alleviate some of the pressures on seniors, allowing them to stay in their homes longer and be able to afford the medications that can help to keep them out of hospital. This results in decreased costs for the health system, which ultimately should be reinvested in ensuring that the social determinants of health are met for Canadians, young and old.
Unfortunately, excellent evidence-based recommendations such as these have often been left to languish as funds have been diverted to acute care in hospitals rather than preventive or primary care. This is part of why it's so disappointing to see the federal government moving away from the health accord and from establishing national standards in health, rather than applying funds in a targeted fashion to achieve substantial change.
AJ: Policies and programs directed towards the Aboriginal community too often are not culturally sensitive nor are they delivered by Aboriginal organizations. Do you see a shift in health care delivery related to Aboriginal communities. What changes would you like to see?
RM: The transfer of control of health services to First Nations communities has been a mixed blessing. The ability to make decisions about health services offered and to be directly involved in identifying community health needs is a necessary and important step. We can and should involve communities even more in determining the best means to address the health issues they face. Unfortunately, this policy has too often also served as a means for governments to wash their hands of responsibility, including the key responsibility of adequately funding health services. Many bands have seen their health funding frozen at 1990s levels, despite populations that have grown quickly and despite new health challenges that have emerged. This results in an underfunding of key services and worse health outcomes.
A responsible approach to health transfer needs to include transparency not only around decision-making in service provision and human resources, but also around the availability of sufficient funds to provide services. Too often on and off-reserve Aboriginal communities receive services that are less than those received by the rest of Canadians, which, given that they also are over-represented in terms of illness, is exactly the opposite of health equity. Involving communities at all levels of decision-making, including resource allocation, would lead to more effective and equitable service delivery.
AJ: Anything else?
RM: This month marks the 50th anniversary of the introduction of Medicare in Saskatchewan. At that time physicians went on strike, withdrawing their services in objection to universal health insurance. The single-payer, publicly funded system has proven to be a positive development, resulting in high quality services regardless of ability to pay, with physicians recognizing within a few short years that it was a great improvement on the previous system. What has often been lamented, however, is the failure to have proceeded to what Tommy Douglas called the Second Phase of Medicare, where we truly focus on keeping people well, not just treating them when they're ill.
Fifty years later, groups like Canadian Doctors for Medicare advocate strongly for an improved public system and will participate in the July 18, 2012 Day of Action for a 2014 Health Accord. This summer, Doctors for Refugee Care has led protests across Canada against cuts to health care services for refugees. What a glorious change to see physicians taking to the streets in favour of universal care and in defense of the most vulnerable.
One of the reasons for this change is the fact that social accountability, health equity and the social determinants of health have become staples of academic theory and medical education. However, these concepts have not necessarily penetrated into the public consciousness and the media and political discourse.
It's my hope that A Healthy Society, by combining accessible and engaging patient stories with evidence-based reflection on policy options, can be part of bridging that gap between knowledge and practice, and of fueling the political will to reach the Second Phase of Medicare and build a truly healthy society.