I attended the annual meeting of the Canadian Medical Association (CMA) as a representative of Canadian Doctors for Medicare last year. The meeting was not at all what I'd expected.
The CMA, as a professional association representing doctors, has often been seen — fairly or unfairly — as working primarily for the interests of the physicians it represents with patients and health equity appearing at times to be an afterthought. This impression was particularly prevalent during the presidencies of Brian Day (2007-8) and Robert Ouellet, (2008-9), both vocal advocates for privatization (and owners of private, for-profit health care facilities) who used their tenure to advocate for greater private payment for essential health services.
As someone who had come to view the organization with some degree of distrust, the Yellowknife meeting was like stepping into a ‘bizarro’ CMA. The keynote speaker was Sir Michael Marmot, who brought the challenging message that "inequality is killing on a grand scale" and that it is the role of governments, and physicians, to address the causes of health inequities.
We've known for decades, through Dr Marmot's famous Whitehall study and many others that health care is only one element in determining health outcomes; a far less influential factor than income, education, housing, nutrition, and the wider environment. However, this information has had little impact on how medicine is practiced, and this can be frustrating for doctors, uncertain of how to translate this understanding from the conceptual to the clinical.
A paper released by the CMA at that Yellowknife meeting on the role of the physician in achieving health equity tackled the issue head on, and encouraged doctors to think differently about how they can address the social determinants of health in practice.
This theme of addressing the social determinants of health, one that has been getting increasing attention through the medical association presidencies of Jeff Turnbull in Ontario, John Haggie in Newfoundland, and now Yellowknife's Anna Reid, was taken a step further with the recent release of "Health Care in Canada: What Makes Us Sick". The result of a series of town halls across Canada, this report underlines the degree to which four determinants in particular - income, housing, nutrition and food security, and early childhood development - influence the health and wellbeing of Canadians.
It also goes a step further, proposing a dozen recommendations on how to address these determinants. These are significant enough that it's worth posting them here in their entirety.
Recommendation 1: That the federal, provincial, and territorial governments give top priority to developing an action plan to eliminate poverty in Canada.
Recommendation 2: That the guaranteed annual income approach to alleviating poverty be evaluated and tested through a major pilot project funded by the federal government.
Recommendation 3: That the federal, provincial and territorial governments develop strategies to ensure access to affordable housing for low- and middle-income Canadians.
Recommendation 4: That the “Housing First” approach developed by the Mental Health Commission of Canada to provide housing for people with chronic conditions causing homelessness should be continued and expanded to all Canadian jurisdictions.
Recommendation 5: That a national food security program be established to ensure equitable access to safe and nutritious food for all Canadians regardless of neighbourhood or income.
Recommendation 6: That investments in early childhood development including education programs and parental supports be a priority for all levels of government.
Recommendation 7: That governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial–territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies.
Recommendation 8: That the federal government recognize the importance of the social and economic determinants of health to the health of Canadians and the demands on the health care system.
Recommendation 9: That the federal government require a health impact assessment as part of Cabinet decision-making process.
Recommendation 10: That local databases of community services and programs (health and social) be developed and provided to health care professionals, and where possible, targeted guides be developed for the health care sector.
Recommendation 11: That the federal government put in place a comprehensive strategy and associated investments for improving the health of Aboriginal people that involves a partnership among governments, non-governmental organizations, universities and Aboriginal communities.
Recommendation 12: That educational initiatives in cross-cultural awareness of Aboriginal health issues be developed for the Canadian population, particularly for health care providers.
Pharmacare, Housing First, a national food security program and guaranteed annual income: these are ideas that could be considered quite radical.
They would certainly be outside of what most Canadian politicians would openly discuss as options. And yet, here they are, coming from what is thought to be one of the most conservative professional organizations in the country. Why? Because whatever self interest may influence physician politics, the purpose of the profession is still, at its heart, to work for the best health outcomes for patients. The weight of the evidence for the social determinants of health, and the need for creative, system-wide policy changes to address them, is simply too great to ignore.
In Yellowknife, Sir Michael Marmot was kind enough to offer a few words of introduction at the local launch of my own book that deals with the social determinants of health, A Healthy Society. I was honoured that he had read the book. He did, however, take umbrage with one section of the book, in which I quoted Dr. Dennis Raphael who has described the social determinants of health as a concept existing in a “Phantom Zone,” well known to academics but failing to make the leap into the consciousness of decision-makers or the general public. Marmot said that disconnect no longer applies, and cited the CMA meeting as an example that these concepts are becoming mainstream and could influence policy.
I hope he's right, and I think this paper from the CMA is a remarkable piece of evidence that the tide of public and professional opinion is turning in this direction. There is still, however, growing inequality in Canada, there are still housing and homelessness crises in many Canadian cities, food insecurity — especially among First Nations and Métis people — is a chronic problem, and early childhood development programs are inconsistent and inadequate across the country.
In other words, there is still a lot of work to be done to make sure that recognition of the role of social factors in determining health outcomes translates into action that improves the lives of Canadians. Listening to the voice of Canadian doctors and following the recommendations outlined in "What Makes Us Sick?" would be a healthy start.
Ryan Meili is a Saskatoon-based family doctor and health equity advocate. He is currently the head of the Division of Social Accountability at the University of Saskatchewan's College of Medicine. Follow Ryan on Twitter @ryanmeili.
The opinions expressed in this paper are those of the author, and do not necessarily reflect the views of the Broadbent Institute.
Photo: Sara Star NS. Used under a Creative Commons BY-SA 2.0 licence.
