The Canadian Medical Association's 145th annual meeting is taking place this week. In one of the most anticipated proceedings in recent memory, the who's who of health policy will be gathering in Yellowknife. Yes, Yellowknife. And with the mantra of the meeting being health equity, there may have be no better backdrop in Canada.
The Northwest Territories (NWT) embodies much of the income inequality quagmire. On the surface, it has experienced rapid economic growth and its residents lay claim to the highest GDP per capita in the country. Things aren't as rosy when you mind the gaping divide in housing, income and education. It is a region plagued by criminal offenses, substance abuse, and mental health afflictions. Disconcertingly enough, Yellowknife highlights the ills of income inequality on a population level.
We can be pretty safe in believing that health and wealth are mutually dependent. But there's some reason to believe that widening distances on the rungs of income can act as social pollution, refusing to spare those at the top or bottom.
As would only be fair, one of the world's foremost experts on society and health will keynote the meeting. Sir Michael Marmot, the white knight of social determinants, undoubtedly provides the human and scholarly element the issue of inequality deserves. His landmark Whitehall Study, which investigated the effects of social position and death rates amongst British Civil servants, widened the discussion of health beyond poverty alone. To Marmot, it is a question of empowerment. And many are hoping that he will give "Canada the kick" as seen in Inception. There may be no better person to articulate Canada's barriers to better health outcomes, understanding that these are composed of harsh realities.
The previous era's greatest gains in life expectancy came from various technologies and drugs (particularly in cardiovascular disease), creating significant inroads for what medicine could do for the patient. The CMA should be commended for signifying that this era's gains will rest on the vitality of a society and its distribution of benefits (health and alike). How we choose to do this will ultimately define our generation's contribution.
The concept of income inequality and health may currently be in vogue, but it's not altogether new. The literature has known this for a little while now. Louis Rene Villerme noted the large gap in health status between rich and poor Parisian arondissements in as early as the mid-1800s. But as is too often the case, progress ebbs and flows with political will. While a great deal of public attention has been placed on health system spending (and rightfully so), how exactly do we make gains in efficiency and equity? Like most numbers in public policy, a lot of it matters on how you count things. And there is some evidence to this.
A recent paper by Elizabeth Bradley underscored the shortcomings of fractioning health care from the total umbrella of social spending. Her team found that industrialized countries with the best health outcomes didn't spend the most on the health care sector per se. Rather, they had higher levels of aggregate public spending.
Quite neatly, she distilled it down to a ratio. The societies that spent more on other social services (such as education, housing and old age support) in relation to conventional health care had their citizens live longer and performed better on a bunch of other outcomes. When speaking of fixing health care, Bradley brought the costs that follow the social determinants into the equation.
North Americans love decking their homes out in Ikea. Yet when faced with the prospect of higher levels of social spending, many claim they'd prefer not to live in Sweden.
If we are able to contain health care costs within a single-payer model and direct savings to other public sectors, we may be closer to nailing the concept of value. Equitable health systems have demonstrated to be more sustainable ones. And by investing in our social institutions, schools rather than prisons, we may begin to witness synergistic returns to population health. We are all better off once social pathologies become part of the diagnosis.
Even with all the parliamentary feel and order that encompass general council meetings, the CMA is not a legislative body. Tackling many of the issues that foster growing inequities will require courage on behalf of federal and provincial governments. Continuing to cut at a sluggish public education system may only strain our health system in response. A robust welfare state may be unpalatable to some, but we cannot overlook the fact that we spend less, dollar for dollar, on our very own citizens than many peer countries.
On the matter of a healthier society, some of it goes back to an old Lincoln adage:
We should do together what we cannot do as well for ourselves.
Especially under the midnight sun, and in the face of trying economic times.
*All views in this post are strictly of the writer and do not necessarily reflect those of any affiliated institutions or boards*
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