In 1843, Charles Dickens wrote “A Christmas Carol.” Most of us remember Ebenezer Scrooge and his visits from the Spirits of Christmas Past, Present, and Future. It is the deep resonating voice of the Spirit of Christmas Present that makes me reflect on Christmas 2013. The dialogue between the Spirit and Ebenezer begins:
Spirit: Will you profit from what I have shown you of the good in most men’s heart?
Ebenezer: I don’t know, how can I promise?
Spirit: If it’s too hard a lesson for you to learn, then learn this lesson (he opens his cloak to reveal two small destitute children)
Ebenezer: Spirit, are these yours?
Spirit: These are man’s, they cling to me for protection from their fetters. This boy is ignorance, this girl is want. Beware them both, but most of all beware this boy.
Ebenezer: Have they no refuge, no resource?
Spirit: Are there no prisons, are there no workhouses, are there no prisons, are there no workhouses…
In 2013, some one hundred and seventy years later, the Canadian Medical Association has given a powerful message to Canadians in their report, “What Makes Us Sick?” They argue that poverty is the biggest barrier to good health; that it is the main issue that must be addressed to improve the health of Canadians. It seems ironic that on the eve of the Holiday Season, when families come together to celebrate, share good company over delicious foods, that Charles Dickens’ Spirit of Christmas Present is still with us.
Throughout the winter and spring of 2013, the Canadian Medical Association (CMA) conducted wide-ranging consultations to gather input on Canadians’ views on the social determinants of health. Public town hall meetings were held in Winnipeg, Hamilton, Charlottetown, Calgary, Montréal and St. John’s and were accompanied by an online consultation at www.healthcaretransformation.ca.
The process was framed around four questions aimed at determining what factors beyond the health care system influence health, what initiatives offset the negative impact of these determinants, what governments and health care providers should be doing to address these social determinants, and how equal access for all to the health care system can be achieved.
In every phase of the consultation, four main social determinants of health were identified by participants:
- nutrition and food security
- early childhood development
Several other social determinants of health were mentioned, such as culture, the environment, education and health literacy.
Participants stressed that society, governments and health care providers all have an obligation to address such problems as poverty, inadequate housing and nutrition.
Because the health of indigenous peoples in Canada was seen as being particularly influenced by the social determinants of health, the CMA held a town hall meeting to address the challenges facing Aboriginal people and communities.
Several themes from the town hall meetings were summarized by CMA President Dr. Anna Reid:
- Poverty is the most important issue and must be addressed.
- Poverty can cause multiple morbidities and even influence early childhood neurologic development.
- Mental health issues remain “the elephant in the room” and underlie many of the social determinants of health.
- Governments need to be pressured to take action, but there is a clear role for citizens, physicians and communities to help deal with the problems.
- The capacity of non-profit organizations to help is reaching the breaking point.
- There is a link between a healthy society and a healthy economy.
- Social initiatives need specific funding and should be viewed as investments.
- There is a need to look at why society is willing to accept disparities.
- Social inequities are a major cause of stress and insecurity.
- The medical profession has the authority and voice to take leadership on these issues.
- Canadian society has suffered from a lack of imagination, will and leadership to address social inequities.
- The guaranteed annual income is a compelling concept and can have a positive impact on health outcomes.
- Structural racism keeps Aboriginal people in poverty; this must be addressed to improve health outcomes for these communities.
- The cost of doing nothing is very large, so reallocation of existing spending is important.
Based on the input received, clear areas of action have emerged:
Recommendation 1: That the federal, provincial and territorial governments give top priority to developing an action plan to eliminate poverty in Canada.
Recommendation 2: That the guaranteed annual income approach to alleviating poverty be evaluated and tested through a major pilot project funded by the federal government.
Recommendation 3: That the federal, provincial and territorial governments develop strategies to ensure access to affordable housing for low and middle-income Canadians.
Recommendation 4: That the “Housing First” approach developed by the Mental Health Commission of Canada to provide housing for people with chronic conditions causing homelessness should be continued and expanded to all Canadian jurisdictions.
Recommendation 5: That a national food security program be established to ensure equitable access to safe and nutritious food for all Canadians regardless of neighbourhood or income.
Recommendation 6: That investments in early childhood development including education programs and parental supports be a priority for all levels of government.
Recommendation 7: That governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial–territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies.
Recommendation 8: That the federal government recognize the importance of the social and economic determinants of health to the health of Canadians and the demands on the health care system.
Recommendation 9: That the federal government require a health impact assessment as part of Cabinet decision-making process.
Recommendation 10: That local databases of community services and programs (health and social) be developed and provided to health care professionals, and where possible, targeted guides be developed for the health care sector.
Recommendation 11: That the federal government put in place a comprehensive strategy and associated investments for improving the health of Aboriginal people that involves a partnership among governments, non-governmental organizations, universities and Aboriginal communities.
Recommendation 12: That educational initiatives in cross-cultural awareness of Aboriginal health issues be developed for the Canadian population, particularly for health care providers.
The full report “Health Care in Canada: What Makes Us Sick?” can be found at http://www.cma.ca/advocacy/what-makes-us-sick.
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