In Vancouver last month Ryan Meili presented his wild idea - changing the frame and redefining how we measure the success of our country - at the Transforming Society: 5 Wild Ideas for a Better Future event hosted by Changemakers Vancouver, Upstream, and Next Up.
Watch the video or read the transcript below to understand why looking upstream to the root causes of ill health is essential to building a healthy society.
Tonight I want to start by asking you to imagine that you’re standing at the edge of a river. And you see a kid floating by, and that kid is struggling, drowning. Now you’re a pretty brave person, so you haul off your shoes, and you dive into the water, and you bring that kid to shore. Which is wonderful - you've saved a life - it's great. But then, before you're even dry, the next kid comes floating by and so you've got to dive in again, and then comes along kid number three, and four and five. You're calling everyone you know to come haul kids out of the river. Eventually, hopefully, one of you will be wise enough to say, "Who keeps chucking these kids in the river?" and they'll head upstream to try and find out.
We spend most of our time dealing with the symptoms of illness and not the root causes
This classic story is an analogy for how we approach health in general. We spend most of our time dealing with the symptoms of illness and not the root causes. So what's really chucking the kids in the river? When we look at what makes the biggest difference in whether we'll be ill or whether or well - whether our lives will be long or short - it's these, the social determinants of health.
Ranked according to their impact on our health outcomes, you can see that health services where we usually concentrate is further down the list, and really what matters is how much money you make, whether you have a living wage, whether you have access to good housing, whether childcare is available, whether you have access to good nutritious food.
Now this list is maybe even a bit obvious - I find it's better to flesh it out a little bit. I work in an inner-city clinic in Saskatoon. I live in the same neighbourhood. And more days than not, as I walk to work, I run into someone who I'll call Crystal. Every time I see Crystal, it makes my day, because she's got a big wave and a big smile, and always has something funny to say. It makes my day, and it breaks my heart, because I'm not seeing her in the clinic, I'm seeing her on the street corner, which is a bad thing because she's quite sick. She has HIV and her CD4 count, which tells us how well she can fight infections is really low - around 10 - and it should be up around 1,000.
So as a result, she comes in once in a while to clinic, when she gets extra sick - when she's got a pneumonia - but she isn't able to take the antiretroviral medications that we know would make a difference. And the reason for that is that she's not really sick with HIV, she's sick with poverty. Sick with a truncated education, sick with never having had stable housing, sick with the abuse she suffered as a child, and the abuse and marginalization - she's first nations - of her people over generations and generations. As a result, anything we do in a clinic isn't really going to make a difference. To respond to her health issues, we need to be thinking about how to get her enough money to live, how to make sure she's got a good place to stay, how to get her access to supports to help deal with the addictions that resulted from the trauma in her life.
Our current frames are about economics as the primary goal, about austerity rather than abundance
The causes of her ill health are political - so the solutions have to be political as well. But in order for us to make better political decisions, we need space for good decisions to happen. To have social movements that are transformative, to give the younger set a better deal, to have a culture that actually feeds us instead of drains us, to have a living wage - we need room within our frames, and our current frames don't allow this. Our current frames are about economics as the primary goal, about austerity rather than abundance. So what I'm proposing for Upstream and other work is the idea of a new frame - changing the terms of the argument to health. And I like to think of it though the World Health Organization definition - not just the absence of illness, but full physical, social and mental wellbeing.
Isn't that a pretty amazing model for a society - what you really want you province your country to be trying to achieve? That frame is there for us - it's something that already matters to us. In fact this wild idea might seem like a pretty mild idea, but when you start to shift the measurement of what is success in our society, it really changes the space of what options are possible and shrinks the space of what damaging decisions can be made.
In order to improve the lives of the people I work with, we need social change, but in order to have social change, we need a new frame
It also does something really great. If you look back at this list, the social determinants of health, if you consider health as our destination, what we're trying to achieve as a society, this is the roadmap of how we're trying to get there. This tracks on to ministries and departments throughout government. It really gives us a guide of where we need to take action in order to have the better health that we want. We were asked to talk a bit about our personal challenges in this work. For me, the tension always comes to this discussion about how we frame politics is so important - but right now, I have sick patients. I wasn't in clinic yesterday because I came out here to speak with you folks. There are kids in the river right now, and that's really frustrating because I want to be doing this framing work, but I also want to be there to help.
The reason I do this, the reason I step away from the bedside in the clinic to do this work, is because of the more serious frustration, which is seeing folks like Crystal coming back over and over again with the same illnesses and giving them a little bit of help with medications or advice but sending them back into the situation that made them sick. In order to improve the lives of the people I work with, we need social change, but in order to have social change, we need a new frame. As Lakoff said - reframing is itself social change. It's the upstream thinking required for upstream action for better downstream results.
Changing the political landscape isn't something that happens overnight. It takes many years, many voices, many stories. And that's why we've started Upstream
Changing the political landscape isn't something that happens overnight. It takes many years, many voices, many stories. And that's why we've started Upstream. It's a national non-profit organization dedicated to shifting this frame, to building a healthy society. So what I'd ask you to do tonight is check it out, find out more about Upstream, help make it better - bring your stories and your ideas to this movement, and lastly - we're heading into an election year; let's not make the social determinants of health an election issue - let's make it the frame through which we view the platforms, the parties, the promises of everyone, and say - we want to know how what you're suggesting you'll do will improve our lives in a real way. Because politics is at the root of many of our problems - it can be at the root of our solutions as well.
Crystal's life has changed because of the introduction of a Housing First program that now has her in a stable place to live. She's taking her meds; she's got more support with addictions; She's doing so much better, and I actually see her more now than I do on my walk to work. And that to me gives me hope - there's so much we can do if we start to invest Upstream rather than just responding to illness as it occurs.
Ryan Meili is founder and Executive Director of Upstream, a Family Doctor, author of A Healthy Society: How a Focus on Health can revive Canadian Democracy and Assistant Professor at the University of Saskatchewan. Ryan also serves as vice-chair of the national advocacy organization Canadian Doctors for Medicare, is a Broadbent Institute Fellow and an Evidence Network Expert.