Public health pioneer Sir Michael Marmot is preparing for his upcoming role as president of the World Medical Association. I sat down with Dr. Marmot to explore the stories, the evidence and the politics that come into play when doctors are actors for social change.
Experiencing a medical emergency is an incredibly stressful experience for patients and their families. This stress should not be compounded by worries about getting an ambulance bill they can't afford. As physicians, we know the importance of the first few minutes of an emergency situation, and the crucial role of Emergency Medical Services (EMS) in saving lives. And yet ambulance fees remain a significant barrier to people receiving necessary care across Canada.
Saskatchewan is among a number of regions in Canada, such as Manitoba and even our nation's capital, currently experiencing alarming spikes in the spread of HIV. B.C. has an impressive track record for slowing the spread of HIV/AIDs in the province. The B.C. Centre created a Treatment as Prevention strategy which provides widespread access to HIV testing, care, support and treatment. Keys to the strategy's success have been political commitment, programmatic focus, ongoing innovation coupled with monitoring and evaluation, appropriate resourcing and free services (including fully free antiretroviral therapy (ART)).
There is a growing international movement, supported by the World Health Organization, toward "Health in all Policies," an approach that has been adopted by governments around the world. Here in Canada, Quebec has such a policy, and Newfoundland and Labrador is currently exploring this model.
It is perhaps discouraging that the health effects of inequality have not been sufficiently concerning to drive decision-makers to change policies, but a new kind of evidence may make a greater difference. It's not only the people in unequal countries that are sicker, it's their markets as well.
The evidence for the link between factors determined by social policy and health outcomes is crystal clear. Decades of studies have demonstrated that income and its distribution, education, employment, housing, food security and the wider environment have far greater impact than health care in influencing our health.
The road from peace to health is not a one-way street; a healthy society is less likely to find itself fighting. The same conditions that lead to higher levels of illness -- economic inequality, food insecurity, labour unrest -- can also lead to dangerous political instability.
Along with failing to increase affordability and access, private MRIs pose a more insidious threat to publicly-funded health care. The more Canadians believe that they have to pay out of their own pocket for necessary care, the more we will see confidence in and commitment to medicare eroded. We need strategies to improve access to diagnostic technologies that strengthen medicare rather than undermining it.
Beyond Quebec, despite the endorsement of the public health and policy community, a Health in All Policies approach has not found the political will necessary for meaningful change. But the past year offers signs of hope, with governments in Canada from across the political spectrum beginning to see the potential.
Instead of falling for false comparators, how can we have a broader, proactive conversation on the future of Canadian health care? Boston's book highlights how isolated and frustrating the experience of a patient seeking treatment for a life-altering disease can be. She describes much of her frustration as stemming from rushed appointments that left little time for asking questions. What improvements in system efficiency or changes to compensation models would enable physicians to spend more time providing quality, patient-focused care?
Andrea Horwath wants things to 'Make Sense,' Tim Hudak 'Wants a Million Jobs,' and Kathleen Wynne has 'A Plan for Ontario.' One can't expect too much from platform titles, but none of the policy books display a focus on improving the health of Ontarians via bettering their social conditions as a primary driver. This leaves it up to the voters to read between the lines.
Health care is but one element of what makes the biggest difference in health outcomes. Yet political conversations about health still tend to fall into familiar traps. When we talk about health, we return as if by reflex to doctors and nurses, hospitals and pharmacies.
WHO research has found that unpaid volunteers provide the safest blood donations. Among donors, this group consistently has the lowest prevalence of blood borne infections. Secondly, reliance on unpaid donations also plays a critical role in maintaining the supply of blood products. When a country permits paid blood donations, the number of voluntary donors actually decreases.
The elimination of the Health Council only further underlines this movement away from national planning for better outcomes. That the Council's disappearance is part and parcel of a larger strategy of the elimination of the dissenting and unbiased voice -- something that is so needed in a democracy -- is downright disturbing.
The term, health care 'super utilizers' or 'super users,' was first coined by Dr. Jeff Brenner of Camden, New Jersey to describe individuals who, despite very high levels of health intervention and expense, are still suffering from very ill health. His work also outlines the existence of 'medical hot spots' -- specific areas in a community that often incur the highest health bills.