Doctors link income, education, housing and nutrition to health inequities
The Canadian Medical Association (CMA) held its annual General Council in Calgary this week (August 18-21, 2013). Last summer in Yellowknife, I attended this meeting as a representative of Canadian Doctors for Medicare. It 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 physicians, 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 governments, and physicians, must address the causes of health inequities.
We’ve known for decades 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 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 encouraged doctors to think differently about how they can address the social determinants of health in practice.
This theme has been getting increasing attention through the CMA presidencies of Jeff Turnbull in Ontario, John Haggie in Newfoundland, Yellowknife’s Anna Reid, (and now Edmonton’s Louis Francescutti), and 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 key determinants — 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. They include important general ideas such as strategies to address poverty, housing, food security and the health of Aboriginal people. They also propose more specific changes like Pharmacare, Housing First initiatives, and guaranteed annual income: ideas that could be considered quite radical in today’s political context.
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.
A version of this commentary appeared in the Toronto Star, Vancouver Sun and the Edmonton Journal