Bringing Upstream to the Mainstream

How can we bring everyone in Canada on to the same side, and work toward healthier communities together, for the benefit of all?

In this excerpt from Upstream Medicine: Doctors for a Healthier Canada, Dr. Chris Simpson speaks to the evidence that a fairer, healthier society benefits all of us.

Jon Herriot: What  policy ideas aren’t being talked about enough in the mainstream election cycle that would lead to greater health in Canada?

Chris Simpson: It is not nearly as glamorous to say this, but we need a better structure for having these conversations. Right now, we have ten provinces and three territories, all of which I have to believe have leaders whose hearts are in the right place but have different solutions for slightly different problems. We are far less than the sum of our parts when everybody is working differently and not learning from each other or figuring out how to come together to scale things up.

That is why we believe that the federal government needs to be at the health table, because they are the only ones that can play this unifying role and set national standards, or at the very least present an aspirational goal. For example, if we want to say in five years that we will have the best wait-times in the industrialized world – right now we have among the worst – that can only be done with a national recognition of the problem and national development of a solution. Or if we said we want to be the country that has the fewest number of preventable hospital complications, these things can only be accomplished with a unified voice.

"You can refer them to a social worker, who can sometimes help, sometimes cannot, but I sometimes find myself actually having the conversation saying, “If you can only afford $150 a month, these are the medications I would stop taking first.”"

You can identify any number of upstream or downstream things that need to be fixed, but it cannot be done with strict ideological adherence to this federated model using the constitution as an excuse. Siloism is not the way to fix this stuff, and it is far too Balkanized. Whenever we talk about any issue, we always try to bring it back to “this is the problem, this is what needs to be fixed,” but what are the structures and the organizational levers that we have to make it happen? This federal-provincial divide always seems to be the barrier. David Naylor’s report talked about putting this kind of governance infrastructure in place so that we can address these problems more effectively than we have been doing so far.

We can all say that we want a national pharmacare plan – it’s pretty hard to find a Canadian that doesn’t agree with that – but how can you do that with a federal government that’s not at the table? It’s virtually impossible. We have seen the Council of the Federation make attempts to come together, but they can only pick off the low-hanging fruit, like drug prices. There needs to be a common, unifying force that helps to set those goals and establish accountability in solving them.

JH: You’re a cardiologist in Kingston, Ontario. Why do the social determinants of health matter to your practice even in your acute care hospital setting?

CS: I see patients all the time that, without poverty-reduction screening tools and knowing what to ask, would fly under the radar. I have learned a lot from others about how simple  questions  can really unmask a lot of really important issues. The scenario I see most commonly is in people who, after heart attacks, are recommended to take a cocktail of medications that includes Aspirin, Plavix [a blood thinner], a beta blocker [an anti-hypertensive], ACE inhibitors [another anti-hypertensive], and a statin [a cholesterol-lowering medication].

"The solution, of course, is to make those financial barriers go away."

This is the evidence-based regimen for reducing mortality and improving quality of life after a heart attack. But when you add up the costs of those, if it’s not covered under the drug plan or the Ontario Drug Benefit, then the cost can be $250 to $300 a month. There are a lot of people who simply cannot afford that.

You can refer them to a social worker, who can sometimes help, sometimes cannot, but I sometimes find myself actually having the conversation saying, “If you can only afford $150 a month, these are the medications I would stop taking first.” I actually tell them, “It’s better to take four out of five than none at all, and if you have to drop one, this is the one that is probably going to have the least positive impact.”

It sounds ridiculous that a physician would have to say that, but I have to believe that I am doing good when I recognize the reality of the impact that their social circumstance imposes on them. The solution, of course, is to make those financial barriers go away, but until the financial barriers are gone, the recognition that they are there allows me to deliver at least some beneficial care and hopefully not compromise the ideal too much. It is a stark reminder every day of the impact: the ludicrous realization that we spend tens of thousands of dollars on stents and bypass surgery and all this fancy stuff, and then we let them go, and for want of a few hundred bucks a year, all that work gets undone. It really defies any sense of logic.

Read the whole story, and twenty others in the new book Upstream Medicine: Doctors for a Healthier Canada.


simpson.jpgDr Chris Simpson is past-president of the Canadian Medical Association (CMA) and chief of cardiology at Kingston General Hospital/Hotel Dieu Hospital and Queen’s University. During his term, he continued the leadership of previous CMA presidents in emphasizing the importance of the social determinants  of  health and including this in his advocacy ef forts. As the voice of Canadian physicians to the federal government, his focus on the social determinants of health can leverage a broad spectrum of policy changes that can make a real dif ference to the lives of Canadians. The CMA’s involvement in this work represents an exciting shift in Canada toward upstream medicine becoming mainstream medicine.


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