In this excerpt of Upstream Medicine: Doctors for a Healthier Canada, Upstreamist Danielle Martin has some big ideas about how to improve Canadian health.
Vivian Tam: How has working with your patients shaped your understanding of the way that upstream factors like income, housing, and food security affect people’s health?
Danielle Martin: For all healthcare workers and physicians, the upstream determinants are where we bump up against the limits of our own training. If we’re honest, most of us experience the importance of the social determinants of health when we experience frustration about our own inability to help our patients stay healthy or get well, because there are some things for which our medical tools are not useful.
"As long as we have an inequitable set of social determinants, we will need to rely in part on a strong, publicly funded healthcare system to provide a cushion for people."
So we mostly experience it as frustration, and for many of us that can become a driving force in the work that we do.
VT: How has that frustration fueled your work, as a health advocate, clinician, and educator?
DM: Most of my work has been in the area of healthcare systems, as opposed to the social determinants, but we know that equitable access to healthcare is a determinant of health. It probably determines about 25 per cent of health. My view is that, although the social determinants are incredibly important and require our collective advocacy, one of the things that can help to equalize inequities in the social determinants is a strong, equitable, publicly funded healthcare system.
A publicly funded healthcare system serves as a redistributive tool in a community or society where access to the social determinants is inequitable and imperfect. As long as we have an inequitable set of social determinants, we will need to rely in part on a strong, publicly funded healthcare system to provide a cushion for people.
VT: You’ve previously proposed three big ideas to transform the healthcare system: a universal pharmacare system, choosing medical interventions wisely, and a basic income guarantee. How did you arrive at these three targets in particular, and what has progress been like since you first proposed them?
DM: The three ideas have now evolved into six ideas, and I’m writing a book about them. These things evolve over time. For starters, none of these are my ideas. They are not concepts that I came up with; they are my “picks” as I scan the policy landscape for the concepts that I think would have a big impact on the health of Canadians and are within the realm of the achievable in the short-to-medium term.
Any given advocate will likely name different targets, so these may not necessarily be the best or most important, but they’re the ones that I’m most engaged with and where I think the biggest impact is to be had.
The first relates to the implementation of universal pharmacare in Canada, or the notion that we should be bringing prescription medicine under medicare, and I think we are seeing quite a lot of movement on that file right now. Where it will land, I don’t know. The growing numbers of healthcare providers and physicians in particular who have been active on this file have helped to bring the issue into the public eye, and I’m thrilled to see that.
"What I like about the basic income concept is that it is both a realistic and achievable solution to poverty in Canada."
Improving stewardship is a notion that has been gaining traction in the Canadian medical community through the Choosing Wisely Campaign, and I know that medical students are becoming leaders in this conversation. Patients and citizens, as well as healthcare providers, need to work to reorient our system to ensure that the tests, treatments, and interventions we use are actually likely to improve health.
After all, that’s the purpose of a healthcare system. If we can do better in this regard, not only will the quality of care improve, our system will be more sustainable.
Basic income is not a new idea; we all know what an important determinant of health poverty is, and many more impressive advocates than I have advocated for it. What I like about the basic income concept is that it is both a realistic and achievable solution to poverty in Canada, and it is a means of raising the conversation about the determinants of health and the importance of income to the health of Canadians.
It seems to be under discussion: we’ve heard provincial politicians from quite a few provinces talk about running pilot projects, and mayors from a number of different communities across the country have raised the possibility as well, so we may yet see a basic income pilot taking place in Canada in the next year or two.
See Danielle at Closing the Gap '16 below, and hear her on Upstream Radio here.
Danielle Martin is a family physician and vice president, Medical Affairs and Health System Solutions, Women’s College Hospital, and a member of Upstream's Advisory Board.
Vivian Tam is a final-year medical student at McMaster University and McMaster’s senior representative to the national Government Affairs and Advocacy Committee.
Cover photo by Jon Bonar.