Discussions about how to frame social issues in Canada are often left to communications professionals, but so many times it’s the people on the front lines of public service who have a lot to contribute to this endeavour. Take Saskatoon physician Ryan Meili. He has cleverly woven his front-line experiences as a family doctor into a book, A Healthy Society, that attempts to change the conversation about public health care in Canada. Here’s my interview with Ryan about his book and his re-frame.
HENNESSY: You’re a front-line doctor in Saskatchewan and you’ve done something unusual for your profession: you’ve written a book that tells stories about your experiences on the front lines not from a purely medical perspective per se, but with the intention of changing the conversation about the future of public health care. Why did you take this approach?
MEILI: There are two main reasons I took that approach. The first is that I think there does need to be a re-framing of how we talk about public policy in general (including, but not limited to, public health care). Right now there is either a lack of focus, or one that is misplaced, focusing solely on economics without translating that focus into better lives. A focus on health is one that is both closer to home for people, and a more meaningful goal for society as a whole. The second reason is that patient stories bring the policy concepts to life. Hopefully when the reader imagines themselves in the exam room, with a patient in front of them, or imagines themselves in the day-to-day life of that patient, the concepts that follow ring more true. The stories of patients provide the emotional connection to carry the intellectual considerations.
HENNESSY: Let’s open that up a little bit. Currently, the frame for public health care in Canada is: Can we afford it? Does it cost too much? Will it become the monster that ate the budget. Your approach in this book is to move beyond the cost frame. Tell us more about that reframe.
MEILI: The problem with the current frame is it’s about health care, not health. Health care is what we do when we’ve failed to keep people healthy. That will always be necessary to some degree; there isn’t a system that will make doctors, nurses and other health professionals unnecessary, but we can do a far better job at keeping people healthy. The way to do that, is to look at what really makes a difference. Health care is way down the list of what has an impact on health outcomes, the determinants of health. The real differences in health come from income, education, employment, housing, nutrition, social supports etc. By re-framing our discussion of health to concentrate on the social determinants of health, those that government policy can and should be affecting, we move beyond the narrow view of health care crises (wait times, doctor shortages etc.) to consider our real goals. With the health of all as a declared goal for society, we have a way to measure more meaningful outcomes, and make the policy changes that are actually able to have an impact.
HENNESSY: You bring these concepts to life with stories from your work on the front lines. If you could tell one anecdote here to make real the policy shift required, which one would you draw on?
MEILI: This morning I’m thinking about a patient of mine who has me worried, Sherri. I haven’t seen Sherri in a little while and I need to put the word out on the street to get her into clinic. She has HIV, and as a result, her immune system doesn’t fight infections well. For the last few months, she’s had sores on her legs that are getting deeper, with the infection going right into her bones. Without treatment with IV antibiotics, and treatment for her HIV, she’s at high risk of losing a foot, a leg, or even her life. Her story is frustrating, because we know what to do, but we can’t quite reach her. She’s addicted to IV cocaine, which is probably how she got HIV, though it could be from the fact that to support her addiction she has to work the streets. She will come in to the clinic regularly for a while, then disappear, come into the hospital even for a day or two, then disappear. This aspect of being hard to reach is where the story pivots for me. We think we understand her illness and how to treat it, but we don’t, because she’s not sick with HIV and infected leg ulcers. She’s sick with poverty. She’s sick with past physical and sexual abuse. She’s sick with a truncated education and becoming a mother far before she was ready. She’s sick with her whole life. Health care for Sherri is going to be expensive. There’s little question that she’ll end up in hospital, probably multiple times. I hope I’m wrong about that, and I hope we can stop this process before it becomes fatal, but I’ve seen enough people like her to know that that hope is slim. How much better, how much less expensive in the long run, would it be to address the real causes of illness of people like Sherri? By focusing on the determinants of health, and addressing the needs of those who are the most affected, we could have a more cost-effective, more just, and ultimately healthier society, with all of the economic and social benefits that encompasses. We still need the health care for when get sick, but we need to spend a lot more time thinking about how to keep ourselves healthy.
HENNESSY: In your book, you weave these kinds of real life stories with the policy dimensions of social determinants of health, bringing what some might consider dry subject matter to life. You write: “The determinants of health largely refer to a person’s place in society”. I think this relates to the anecdote you just shared. Tell us more about the impact of a person’s place in society and what we can do about it.
MEILI: One of the underlying ideas that informs this book comes from the work of Richard Wilkinson and others around the importance of equality. The evidence suggests quite strongly that societies where there is greater inequality have worse health outcomes. This is obvious for those at the bottom of the socioeconomic ladder, but what is surprising is that those worse outcomes extend all the way up. There is a health gradient, but even the wealthiest in an unbalanced society suffer worse health. The stories of people who are most affected by this inequality bring this into the starkest light, but it’s important to remind ourselves that focusing on the determinants of health doesn’t just mean helping the unfortunate few, it means creating the conditions for greater health for everyone. So what can be done to increase equality? That’s where the policy decisions come in, and many of them must, necessarily, include improving the lot of those currently in the worst circumstances. Making sure that people have adequate incomes - through gainful employment whenever possible and through appropriate assistance levels where necessary – is a good first step. Addressing equity in service provision, by making sure that those most in need don’t have the worst access to education and health care as is the current circumstance, is another important area for investment. Models such as Housing First that emphasize stable, safe housing to enable people to stabilize chaotic lives can have huge impacts on people’s health and well-being. When we do these things, the end result is communities that are safer, more members of society that are actively and productively engaged in the economy, and in the long-term less burden on the social structures (Medicare, social assistance, corrections) resulting in decreased drain on public coffers. All of this while improving people’s lives, makes for a nice mix of doing the right thing and the smart thing at the same time.
HENNESSY: Last question! In your book, you identify the polarizing nature of the political debate in Canada, and how it relates to health care. Universal public health care is such a popular program in Canada, virtually synonymous with what it means to be Canadian, but the vision always included something much broader than emergency health care once you’ve fallen sick. What in your view needs to happen to get beyond the barrier of a polarized political debate and truly change the conversation to valuing health and the prevention of illness, rather than remaining fixated on a debate about a health care system and its costs?
MEILI: Well I could be cheeky and say this book, but obviously it will take a lot more than that. We need voices coming from many directions: academics, political leaders, media, advocacy groups and more that are trained on re-framing the debate towards changes that will actually improve the health of society. There is some benefit of tying this approach to Medicare, given its popularity, though it can be hard for people to make the leap from health care to larger policies that impact the determinants of health. Using patient stories to make that link is one tool, and I hope this work will help others with similar views to make their ideas more accessible to the general public. The long-term hope is that we get to the point where opposition parties, the media, and the public are demanding of governments that the demonstrate just how they are addressing the determinants of health and insisting on meaningful outcomes as a result. Ultimately it’s in that democratic realm where the real change will need to happen. It’s very difficult to make that change in public opinion, but should it happen, it could be the cure for what’s currently ailing the political system.
The Canadian Centre for Policy Alternatives’ Ontario office is pleased to co-sponsor the launch of the book in Toronto on May 29, 2012. To sign up for the event, click here. To get the book, click here.