Spend upstream to improve health outcomes

We're sick with poverty. And we have the data to prove it.

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Jared Knoll: Welcome to Upstream Radio, where we dive deep into all the social and economic determinants of health. The source causes of how we live and when we die. I'm Jared Knoll. Last month a team of researchers put out a landmark report examining data on how much healthcare spending really does for our health and well-being compared to social services spending which we put a tiny fraction of resources into by comparison. The evidence tells us that…

Daniel Dutton: Even a small change in that ratio where we move money from health to social has a much larger impact than if we had just put that more money into health spending. So we're not where we need to be in terms of the optimal outcome. 

JK: That's post doctoral scholar Daniel J. Dutton, who undertook the study published in the Canadian Medical Association Journal along with Pierre-Gerlier Forest, Ronald Kneebone, and Jennifer Zwicker. You can read the whole thing on the CMAJ website.

Dutton's background is in economics, where he learned about health economics as a lens to look at the economic incentives that determine whether an individual is healthy. When he transitioned into doctoral work in public health, he first heard people talking about the social determinants of health.

DD: I guess that's when I first heard of them discussed explicitly as the name social determinants of health. I think that a lot of people intuitively understand them without giving them that label.

JK: In your study you point to how trends over the last few decades of health spending have gone up and up dramatically, but social service spending has more or less stayed the same. For such an intuitive thing, have you ever had a moment or an experience that has taught you or given you some insight on why it's taken so long to really start changing things?

DD: That's a great question. So yeah, we do observe that the real healthcare spending per capita, which means we've adjusted for inflation and divided by the number of people in the province is... It's doubled over the past 30 years on average in Canada. And social spending hasn't really moved on average in Canada by a notable amount.

I could speculate that I think a lot of the findings regarding the social determinants of health are not as big picture as the stuff we've done here. So they'll outline that a program or some other sort of government initiative has real benefits for health. So they'll say things like old age security halves the probability of seniors being food insecure. And that's a good result. Everybody understands that, that's good. Except we don't draw the final conclusion that therefore we should take some action on old age security funding. We don't actually connect the dots as well as maybe we should as researchers to an actual actionable item for the government.

So I think that a lot of people in government do understand that there are these social determinants of health, but the rhetoric around health of the population has focused on healthcare spending for so long that it's tough to break free and sort of understand that the government has many levers they can adjust to try and improve population.

JK: Yeah. The former health minister Jane Philpott and the current indigenous affairs minister Carolyn Bennett have both, in our presence, called themselves the the ministers of the social determinants of health. We have them on video in fact.

DD: Oh my.

JK: But as you say they don't... We still don't seem to be taking an earnest approach to crafting policy to match up to the data. How many studies like this do we need to do? How much data? Do you see... Are you optimistic about trends of research that are happening right now with studies like yours in actually compelling action in the near future?

DD: I think that advocacy groups, and let's call it knowledge translation organizations, really make a difference. I think that stuff like what you're doing helps to sort of create a formal understanding amongst general public and researchers about what it is we can do to mitigate the consequences of these social determinants of health on people's health. But I do think that healthcare spending is a political issue in a lot of arenas, and when something becomes a political issue I don't know if all the evidence in the world will make a difference. There's an understanding that evidence based policy isn't as effective as we evidence generators would like to think it is in terms of making a difference. We don't know how much policy in fact is evidence based.

We like to believe that we're contributing to evidence the policy makers need, but in reality it's a complicated pathway. And there are lots of steps involved between writing a research paper and seeing any change in government practice. But I think what our particular paper adds is this understanding that we're not saying you need to find new money, and fund new programs, and then make suggestions for new programs.

What we're showing is small rearrangements within pre-existing portfolios can make a small difference. So instead of the rhetoric around population health focusing on healthcare spending, which it does every time it comes up in the news, we can say, "Look, you're already doing the right things in terms of how to improve population health. You just need to rearrange your money a little bit."

JK: Can you point to any portfolios in particular that you would say would be especially effective to rearrange?

DD: I would love to. I would love to be able to do that.

The problem is our data is extremely aggregated and our next step is of course disaggregating these values. So oftentimes when people talk about healthcare spending they break it down into things like hospitals, and physicians, and drugs, and mental health, and public health. And we're kind of hoping that we can do that activity here, and talk about what forms of social spending or health spending have very high marginal returns to these population health metrics.

And I think that's the last part where we can say, "Look, an increase in social spending will improve population health and here's one program that's particularly effective right now." And we're sort of hesitant to say how much spending should increase by, because frankly we haven't observed what happens when there's a big increase in social spending over time, because we just haven't had any. So we've only had these tiny changes, and that's all we can really speculate on.

JK: We have to ask ourselves as citizens, as members of communities, what do we want our society to be like? Do we wanna take care of each other? That's the essential principle, the fundamentally Canadian value that our healthcare system is founded on. But we know more and more, with increasingly mountainous evidence, that our historical approach of throwing money downstream isn't working. We need a strong healthcare system, but our resources will go a lot further if we adjust the ratios. We don't necessarily need to spend more. We need to spend more wisely.

DD: The healthcare system is there to catch you when you fall, with respect to a health outcome of some kind. You have a bad health outcome, you go to the doctor and hopefully it's taken care of. I think the social services sector could operate in that same fashion.

When we talk about, for example, homelessness, we're starting to have a growing understanding of homelessness, not as sort of a behavioral characteristic, or an individual level phenomenon. We know that there are factors operating on individuals, and some individuals fall into homelessness, and yet the incidence of homelessness is different across cities. So there must be something about the system that's operating on people that government could take action to mitigate. And we talk about housing subsidies, for example, as the kind of thing that will mitigate the poor consequences of social determinants of health that are operating on people.

So the government might not be able to address those large social determinants of health better to operate on a person by the time they get to the point where they might be homeless, but they could mitigate the result, they could take away that bad consequence of actually becoming homeless, which we know is affiliated with all these bad health outcomes.

JK: How long were you thinking about this study, and how did you initially come up with how you were gonna do it?

DD: So there is American literature and international literature from Europe looking at this same sort of relationship. Social spending and healthcare spending on population health outcomes. And I think that in Canada we sort of look at American evidence and we say something like, "oh yeah, that's a delightfully American result, that more social spending would actually improve their health. Thank God we have a public healthcare spending and a strong social security net. We won't have that problem."

But in reality, if you live in Canada and think about these things, you know that we have issues. So we thought, "I wonder if that relationship that we observed internationally throughout Europe and in the United Sates is true here at this very macro level." Luckily somebody who already works here, Ron Kneebone and his research associate, her name is Margarita Wilkins, put together... They compiled government spending data at a very aggregate level from the fiscal year ending in 1981 to the fiscal year ending in 2014. And that's what we took when we were trying to study this issue.

Without the existence of those guys and their data set, this paper never gets written and we never know this answer. So this is kind of the unglamourous work of compiling a data set, really paying all the dividends for people who weren't involved at all. And I think that... My personal view is that when we talk about the social determinants of health, when we talk about population health, there's a certain type of person who will only listen to numbers.

So you can say in words what is happening, and they will intuitively believe you, but if you show them a number and that number is 5%, for some individuals, for some reason that really strikes to their core, and now it's serious... Now we're talking about something serious as opposed to before they thought, "Oh yes, that phenomenon is probably real and important. We should act upon it." But it doesn't really trigger them in any way.

JK: Yeah, that's why we've always taken the approach of basing everything in evidence. We may amplify, and boost, and translate with human stories, but without the evidence, you're never going to see the policy action. That's why we were so excited to see this study come out this week. And we need more and more of this analytical, hard number-based data where we can point to and say, "look, this is how we should be doing it. Look at the numbers.” You can't argue with that.

DD: As somebody who does purely quantitative work, I love hearing that, of course, of course I love it. I wanna frame that quote.

However, I appeared on the news, CTV Winnipeg, and I watched... I did, let's say, 10 minutes of an interview, and then they had some stock footage of me walking around the office and sitting at my desk and looking like I was busy. They used approximately one second of me talking, and the rest of the news segment was about an individual in Winnipeg who utilized a woman's shelter, or a homeless shelter. And I thought to myself, "This is what makes it real for a lot of people too." So I think that much like... Oh, look at this, much like the balance between social and healthcare spending, we have to balance these quantitative analyses with real story.

JK: So we know social spending is good for the well-being of our communities, but why should you and everyone else care enough to stand up and hold our leaders to really take action and change this? Health.

Monika Dutt: Health is something that everybody identifies with. You know your own health, you know the conditions that you might have, you know your mother has asthma, your grandfather might have heart disease.

JK: That's Dr. Monika Dutt, national advocate for social spending on the broader determinants of health like housing, food security and education, who's been a medical officer all over Canada, is currently a family physician in Wagmatcook First Nation and former chair of Canadian Doctors for Medicare. She's also the executive director of Upstream. This study is just one more piece of undeniable evidence of what kinds of policies our leaders should really be enacting for the better health and well-being of all Canadians. I asked Dr. Dutt how we can connect this to the real world health impacts of our community members.

MD: Having the evidence is always one piece of trying to make change, it's often far from the only piece that's needed, but if you don't have that, it makes it much harder to advocate for good policies that influence health, so it's definitely a vital piece of the work that we do.

JK: We see from the Canadian Index of Wellbeing studies that they have done, and we'll have that linked for listeners as well, that while we have all of this healthcare spending, our well-being, our happiness, our health hasn't gone up all that much over the last few decades. Do we have evidence from this study and from the rest of the research done over the years that social spending could have a better impact on that?

MD: We absolutely do. And I think you've referred to the Canadian Index of Wellbeing as one excellent measure of how we're doing in terms of health in a broad way. We also have seen other not so positive changes around income inequality, which we know is connected to health, and that's been worsening. We know food insecurity for the most part is increasing, we know that we're seeing more poverty.  

But at the same time, we have also seen changes when there is a conscious investment in social spending. And a recent example is Newfoundland and Labrador where they do do have a comprehensive poverty reduction strategy, and when they put into place pieces like increased income assistance rates along with a number of other measures, they have seen changes in terms of poverty rates in Newfoundland and Labrador. They have seen changes in terms of food insecurity.

So we know both the evidence is there to connect different areas to poor health, whether it's poverty, whether it's food insecurity, we know those are connected to poor health. But we do also have evidence from in Canada as well as in other parts of the world that connect good public policies that think about health and having those be put in place and actually see that they do improve health.

JK: So what advice then would you have for someone starting out in the medical field that wants to make as profound an impact on the health of Canadians as they possibly can? Where would you advise them to concentrate their efforts and their energies?

MD: Healthcare professionals, healthcare providers can have a very strong influence on policy. We know that nurses are some of the most trusted professions, physicians are somewhat high up there too, politicians tend to be lower down in the pack. And so we know that healthcare providers are listened to, and one of the reasons for that is that we can bring the stories of the people that we see every day, that we work with every day, and make some of those connections to policy.

We can also act as allies and advocates for the communities that we're in and that we live in and that we work with. So I would say that going into those professions, it's essential that we keep in mind that we can have an influence both of course in a clinic or a hospital, but beyond that, we could also have a far greater community and population level impact.

JK: So you're a highly educated, very intelligent person who's done work seeing the importance of research and data and evidence your whole career, but even with all that background, you can be shown charts and graphs that show the connections between things like food security, income and health outcomes, data on climate change versus asthma and forest fires. But just honestly, openly, does that... How does that drive you and move you compared to having a patient in the office telling you their own personal story?

MD: I think they both speak to different parts of my brain, but definitely having a patient in front of you, having a person in front of you, I can think of numerous people... I had a patient who... He actually right up front told me... He had shoulder pain from a long ago injury that had prevented him from working. And he’d had a good income, he had been supporting himself and his family, and then it all just fell apart after that. And he was struggling, and he's on social assistance, and he was trying to pay his rent.

And what he said to me when he came in for... The appointment was for pain control, to talk about pain control for his shoulder. But he actually said to me that, "my shoulder really hurts, but I'm sick with poverty. It's not just my shoulder, it's far beyond that." And he said that to me, and he realized that, and he lived it every day because he knew he couldn't pay for just his day to day expenses. And it's even more frustrating for him because he had been completely self sufficient and quite content with where he was.

MD: And so that, to me, just really makes it real, it makes the data real, it makes the policy discussions real, it just really makes it so that you understand why it's so important to try to change some of the conditions that we live in. I know as a physician, I do come from a different background, and I don't have to think about a lot of those issues.

But I do live in a place where in Cape Breton there's extremely high child poverty. There's high family poverty, there's First Nation community that doesn't have water that they're able to drink. These are all really very real issues for the people I see every day. And so that's what makes all the other work tangible. It makes it meaningful.

JK: That's such a powerful way to look at it all. How do you see Upstream as having a role in that context?

MD: Upstream has played a range of different roles. I think we're unique in that although some of our work is similar to other sectors, say public health and other similar places that connect health and some of these broader social, economic, environmental issues, as a non profit, as a smaller organization, we can be more responsive, we can take chances on things that others might not be able to.

And so what we've done is we've been able to be involved in specific policy issues, for example around this idea of health in all policies, which is integrating health into any policy decision that's being made. We've been able to work on issues around income inequality and primarily on income issues such as a living wage.

We've been able to use different digital platforms to bring out a lot of these issues, whether it's through blogs that make research more understandable, whether it's through podcasts, whether it's through social media. And we've also been prominent enough that we can still connect with policy makers, both at municipal level, even provincial and federal, we've been able to make those connections.

So I'd say Upstream's role has been able to make all of these links, and do so in a way that's innovative and exciting and attracts people and generates excitement, and that's made us really strong. And people have noted that across the country, and people now come to Upstream for support in work that they're doing because they see that we're able to do what we're doing so successfully.

JK: It really is an exciting time, isn't it?

MD: It is.

JK: We've got Closing the Gap coming up in just a couple of months, our yearly conference in Ottawa on April the 6th. Listeners can go to ctg18.eventbrite.ca to sign up for that either in person or live viewing via live stream. What do you see as the biggest benefit of that conference?

MD: In the past, we've covered a range of different topics and I think that was really vital as this idea of policies being connected to health is gaining more and more traction. And we wanted to show that there is all of these different links to community well-being, to individual well-being. This year, what we've decided to do is focus more on reconciliation and health, given that there is so much public discussion now around our colonial history and how that connects to health of people today in Canada.

JK: So the first Closing the Gap was very specific, Action in Health Equity was the title, the tagline. The next year, sort of inviting everyone, just Better Health for All. What does The Next 150 mean?

MD: It's picking up on a theme that... It's not something that we've created. Many other people have voiced this idea, but the idea that... Of course we just had our 150th anniversary as a nation. And that 150 years and the starting of Canada was based on colonialism, was based on displacing peoples who had long lived on the land that settlers came to. And so the idea is that now we're looking forward.

We've had 150 years that did continue to have a lot of these negative systems and events that have led to poor health amongst other outcomes. So now as we try to look forward, what could the next 150 years look like and beyond. But that's kinda the idea that we're wanting to look forward, recognizing that there had been not so good events in the last 150 that we as a nation, or many of us as part of this nation, have been part of either explicitly or implicitly. And we want to change that going forward.

JK: There's nothing stopping us from doing just that. We're standing up, your neighbors are standing up. We can collectively decide that we won't accept intolerance and injustice anymore. There are shockwaves throughout the world right now to say no more to ignoring science and evidence on climate change and environmental devastation and so many other things. No more tolerance for the systemic mistreatment and abuse of women and minorities. A wise person named Marie Francois Arouet once said that everyone is guilty of all the good they did not do. It's now our chance and our duty, 150 years in, to finally say no more to colonialism and no more to pervasive structural injustice in our country.

Join us and your neighbors in Ottawa on April 6th and 7th with First Voice advocates like Tanya Talaga and Jessie Thistle, leaders like Jane Philpott and Jagmeet Singh, and experts like Sarah Jama and André Picard to say no together. Visit ctg18.eventbrite.ca for early bird tickets while they're still available. And if you aren't able to be there, be sure to sign up for the live stream and catch every bit. Thanks so much for listening, and don't miss our deep dive into housing and homelessness later this month. Be sure to like, follow and subscribe to Upstream Radio so you don't miss it. I've been Jared Knoll. Until next time, keep thinking Upstream. 

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