Ryan Meili is a family physician at the West Side Community Clinic in Saskatoon, Head of the Division of Social Accountability at the University of Saskatchewan, founder of Upstream: Institute for a Healthy Society, and a health policy expert with EvidenceNetwork.ca
Recently, I was fortunate to attend the Global Symposium on the Role of Physicians and National Medical Associations in Addressing Health Equity and the Social Determinants of Health held in London, England. The meeting was organized by the Canadian, British and World Medical Associations and had, among other goals, an agenda to assist public health pioneer Sir Michael Marmot in making such issues central to his upcoming role as president of the World Medical Association.
Among the attendees was Canadian Medical Association president Dr. Chris Simpson. I sat down with Dr. Simpson to explore the stories, the evidence and the politics that come into play when doctors are actors for social change.
Ryan Meili: You have an interest in the social determinants of health (SDOH) -- you’ve been talking about it in your presidency, as have the last few Canadian Medical Association (CMA) presidents. On a personal level, why does that matter to you? In your own history, what has drawn you to the idea?
Chris Simpson: There’s one reason that’s more altruistic and noble than the other, but I’ll give you both.
I grew up in rural New Brunswick, in a town that was a “model” town. It was created because a pulp mill was built there, and there was a hydroelectric dam that basically flooded the entire community and they had to build a new community above it. It was populated with a disproportionate number of teachers and engineers and professionals, and there was a time when I was a kid when it was the community with the highest per capita family income in the country, right in the middle of rural New Brunswick. But around it were very poor rural communities, and the contrast was incredible.
When I went to school we all were together, so you'd have these children of university educated engineers and managers making high wages next to more socio-economically disadvantaged kids. And the contrast, I can remember as a kid, struck me as just absurd. It was almost a caricature of the income gap in Canada.
I didn't understand at the time what it was, of course, but I remember being very acutely aware that there was something very odd about the dichotomy.
My father was a teacher, so I was one of the more privileged kids, grew up in a stable home, I had everything you could possibly need to build a good me. But the contrast really informed my views of the world and helped me to develop a sense of responsibility, so that's maybe the more noble reason.
From a health care perspective, it occurred to me recently that as a sub-sub-specialist who does high-tech, very expensive care that probably delivers very little incremental value to a small number of people for a very high price, and, having been very privileged because that's always been valued very highly in our society, the fact of the matter is that, increasingly, I realize that I'm not going to be able to do any of that high-tech medicine unless we find a way to better support the larger number of patients who need low-tech, but equally important care.
I'm not going to be able to do my part of things unless we address the social determinants of health as well, because it ties in critically to the sustainability of our health care system.
So that's why I say it's less than noble, because it seems a bit selfish to say. But I recognize that in a system of finite resources we're investing far too much proportionately in the stuff that I do and in doing so we're going to create an unsustainable system where we're not going to have the upstream stuff or the downstream, it's just all going to collapse.
It didn't take very much for me to see that addressing the social determinants is a critical part of a plan to achieve stability in the health care system, which gives me some hope that it's an easily translatable message -- if we could just find a way to get it out to the population better than we have.
RM: Are you seeing some of that uptake? In the work you do through the CMA, are you seeing that idea of the determinants of health and the importance of it for our patients catching on?
CS: I don't, and I think part of the problem is we're travelling in groups that largely have drunk the Kool Aid, but I know if I go back to my hospital-based colleagues, if I mention any of this at all, they typically do not see how an appreciation of the SDOH ties into their jobs or how it links into their role in caring for patients. We have a lot of work to do.
Family Physicians, I think, get the message very quickly, they don't have to be told or directed or instructed, they just inherently feel it. But in the specialist and hospital-based community, it's still largely a foreign concept. They understand poverty, they understand nutrition, they understand all of that intellectually, but I don't think they always feel it politically or in their gut as something that is or could be their responsibility as physicians.
RM: What do you think would be ways that we could make physicians aware of their role in addressing the social determinants of health, and make it easier to act?
CS: Part of it is the silos; we talk about teams, but in hospitals we're still not there yet. We try to have more interdisciplinary rounds but they're very difficult to organize. As long as we still have a silo mentality, those kinds of questions are going to be someone else's responsibility.
I like the idea of clinical tools and checklists. The surgical world and the procedural world intuitively get the notion of a checklist with safety in mind. I think you could pull out the same kind of sensibility from people if you said, “ok we're going to have a checklist that will pull out the social determinants and barriers.” It could be just a list of 4 or 5 things, that's the kind of thing that could tweak the surgical mindset.
In a very insulated hospital environment, if those issues, like inability to pay for drugs, do come to light by whatever means, then the fix is the social worker. They're right there, you call them up, so you have access to support -- it should be an easy gap to close.
After a heart attack, there are 5 drugs that you have to take - the aspirin, the statin, the anti-platelet, the beta-blocker, and the ACE-inhibitor. I've had on more than one occasion, a conversation with patients saying that, if money concerns come up: “If you have to ration these, if you've got to stop some, this is the order with which I would peel them off.” It seems ludicrous to say that, but to me that's a very practical intervention that is doing some good…It's less good, of course, than an approach that would find a way for them to get all five drugs.
RM: So that's a real-world solution versus an ideal world solution like Pharmacare. I’m wondering what your thoughts are on a first dollar system, with universal coverage removing the necessity for patients to pay for prescriptions at the point of care.
CS: The CMA position has been supporting the Kirby approach - which is some sort of catastrophic coverage. This would perhaps be a good start. But I find the arguments in favour of first-dollar coverage very compelling, personally. I was impressed by the Gagnon report and I love the paper from Danielle Martin and Steve Morgan.
First dollar coverage makes much more sense to me from an effectiveness point of view at the bedside. I've seen just a $12.99 dispensing fee dissuade people from filling their prescription. It's hard enough to get people to take their drugs, let alone having a financial barrier of a few bucks. I'm encouraged by the suggestion and the widespread belief by a lot of people that it can be economically viable to have a 1st dollar coverage system.