A Healthy Society
A Better Pancreas

An excerpt from Chapter 2 of A Healthy Society on distribution

One of my first public efforts to make the connection between income in- equality and health was in 2006, when I was asked to speak to the annual convention of the Saskatchewan New Democratic Party about SWITCH, the Student Wellness Initiative Toward Community Health. I was part of a panel that included a young entrepreneur and the publisher of a magazine for Aboriginal youth. The idea was for the party, then in power as provincial government, to celebrate the successes of young people in Saskatchewan.

At SWITCH, students from Medicine, Nursing, Clinical Psychology, Social Work, Physical Therapy, Pharmacy, Nutrition, Dentistry, Kinesi- ology, and more work together, under appropriate supervision, to pro- vide after-hours care and health promotion programming in Saskatoon’s core neighbourhoods. As well as providing much-needed access to care in this underserved area, it is an excellent service-learning experience for the students. They learn in a practical, hands-on fashion about the social determinants of health. Perhaps most importantly, they make meaningful connections with real people, taking these important ideas from the theor- etical to the personal.

As a student, I worked on the establishment of SWITCH, and later spent a year as the project co-ordinator. The government of Saskatchewan was generous in supporting the program, coming on early with funding and helping us establish legitimacy. At the time of the convention our doors had been open for a year, and I was pleased to share some of the successes of the program with our benefactors. I spoke of the hundreds of students on the volunteer rolls, the many different services, and the dozens of com- munity members who access those services at each shift.

But I couldn’t leave it there, on a falsely positive note. The Health Disparity Report,released only a few weeks earlier, gave evidence of growing inequality and the suffering it causes. One of the conditions we see every day at SWITCH, one that people in the core neighbourhoods are thirteen times more likely to suffer from, is diabetes mellitus. Diabetes is the result of the failure of cells in the pancreas to regulate blood sugar. Rather than a proper balance of the fuel that cells need to operate, they have levels that

are damagingly high or dangerously low. The analogy to the maldistribution of resources in our society, and the resulting ill effects on our health, is compelling. Initiatives like SWITCH and Station 20 West, valuable as they may be, treat the symptoms of a much deeper imbalance. Just as the body needs an effective mechanism to ensure that the needs of all its parts are met, with no organs starved or overfed, society needs a mechanism to make sure resources are effectively and equitably circulated. So, tongue-in-cheek, I urged the premier and his party — by enacting policies to more effectively distribute wealth — to become a better pancreas. 

Aside from the risk of sounding ridiculous, I was cautioned by some against this approach. Redistribution of wealth has become a dirty word, even among left-of-centre New Democrats. No one talks about it any more, they said. And they were probably right. We talk about growth and the benefits it brings for all, of how a rising tide raises all boats. But the truth is that, while no one was talking about it, a massive redistribution of wealth had been taking place right under our noses. A small number of people have been apportioned a percentage of the wealth unprecedented in this country. This is the kind of destabilizing growth that undoes development, a disturbing trend for all involved. 

Strong focus on health equity at this year’s CMA - Canadian Doctors for Medicare on the events in Yellowknife


CDM board member Dr. Ryan Meili speaks to media in Yellowknife (Photo courtesy of Libby Davies) 

This year’s Canadian Medical Association General Council marked a sea change in the organization’s direction. Canadian Doctors for Medicare was thrilled with the theme of health equity, and the focus on the social determinants of health.

Dr. Vanessa Brcic, Dr. Bob Woollard, Dr. Ryan Meili and our very own Yellowknifer Dr. Courtney Howard of the CDM board were in attendance at this year’s CMA, along with other members and supporters of Canadian Doctors for Medicare.

Dr. John Haggie, outgoing president of the CMA, took bold steps to move towards entering policy territory not typically addressed by the CMA with a health equity agenda. The CMA’s papers on health equity this year laid out a commendable policy agenda for its future work.

Dr. Anna Reid was installed as this year’s president of the CMA, and we are anticipating another very positive year ahead from the CMA. Read more about Dr. Reid’s perspective on health here.

While the CMA itself focused on an equitable, accessible health care system, the federal government continued to distance itself from responsibility for health care and the guidance of health professionals.

Canadian Doctors for Medicare was deeply disappointed in Health Minister Leona Aglukkaq’s remarks during General Council, and the federal government’s continued insistence on provincial jurisdiction over health care, despite a clear constitutional responsibility to share that jurisdiction. The Minister also made no mention of key areas where the federal government could be supporting health equity, but has retreated from responsibility, through cuts to refugee health, not enforcing the Canada Health Act, and cutting health equity research in its latest budget.

Sir Michael Marmot, the leading expert in social determinants of health, spoke shortly after the Minister, and clearly laid out the evidence, as well as the moral argument, for working towards health equity from a policy perspective. Sir Marmot also joined CDM Vice-Chair Dr. Ryan Meili for the launch of Ryan’s book A Healthy Society at the Yellowknife Book Cellar.

Canadian Doctors for Medicare released its paper Taking Action on Health Equity in Canada, drawing on current research to point the way for the CMA to take further action on health equity, and calling the federal government to account on its absence from leadership on health care. The paper called for the CMA to:

• work with governments to expand capacity in the public, not-for-profit delivery of health care instead of for-profit, private care.
• call for the federal government to return to the table with provinces and territories to negotiate a strong 2014 Health Accord.
• call on the federal government and provinces to develop a national Pharmacare program.
• continue to advocate with other health professionals for the reversal of the cuts to the Interim Federal Health Program.
• advocate that the federal government restore funding to research that addresses the social determinants of health in its 2013 budget.
• demand that the federal government should commit to a stronger role in accountability and enforce the Canada Health Act.

CDM saw some action from the CMA on some of these fronts, particularly during as former CMA president Dr. Jeff Turnbull led a discussion on the federal role in health care. Many doctors voiced the opinion that the federal government has abandoned health care, but that it still has a role. Dr. Turnbull summarized “An overt downgrading of Medicare by our national government would clearly rub against the hopes and expectations of the vast majority of Canadians who see it as our foremost shared national achievement.” We couldn’t agree more.

Canadian Doctors for Medicare looks forward to a continued focus on equity and accessibility from the Canadian Medical Association in the coming year. And it will continue to call on our governments to improve an equitable, accessible public health care system for all Canadians.

Yellowknife Book Launch with Sir Michael Marmot and Libby Davies
Tomorrow I leave for Yellowknife as a representative of Canadian Doctors for Medicare at the Canadian Medical Association’s annual General Council meeting. The new president of the CMA is Anna Reid, an emergency physician from NWT, with a strong understanding of the Social Determinants of Health, as evidenced in this article.
The keynote speaker at the General Council is Sir Michael Marmot, Chair of the WHO Commission on the Social Determinants of Health and author of Fair Society, Healthy Lives - the Marmot Review. The WHO Commission produced Closing the Gap in a Generation, one of the works I draw upon heavily in A Healthy Society. You can see an excellent interview with Sir Michael here from a recent visit to Canada.
Given this connection, and his particular expertise in the area of the Social Determinants of Health, I’m very pleased to announce that Sir Michael has agreed to speak at a book launch event for A Healthy Society at the Yellowknife Bookcellar, 4:30PM, August 13th. I’m equally pleased to say that Libby Davies, MP for Vancouver East, Federal Health Critic and Deputy Leader of the Official Opposition, will be speaking at the event as well. Ms Davies was kind enough to host me at a previous book event in Ottawa and I’m very much looking forward to seeing her again and getting a chance to discuss further the importance of addressing the Social Determinants of Health at a federal level.
Naturally, I’m very excited about this book event. I’m also quite intrigued to be participating in this year’s CMA General Council. With Marmot as a guest speaker, Anna Reid as president, and the pending release of a CMA paper on Health Equity, there is a real change in the flavour of the organization and its message. CDM has often found itself in opposition to the direction taken by CMA leadership, particularly under previous presidents Brian Day and Robert Ouellet. It’s refreshing to hear Canada’s doctors advocating for a fairer health system and for work to address the upstream factors that impact their patients. Being able to join with the CMA in calling for greater health equity, in a time when the federal government is cutting services and research essential to that goal, is very encouraging. Thinking that there may actually be the critical mass of information on the SDOH and the political will to make change is downright inspiring.

Yellowknife Book Launch with Sir Michael Marmot and Libby Davies

Tomorrow I leave for Yellowknife as a representative of Canadian Doctors for Medicare at the Canadian Medical Association’s annual General Council meeting. The new president of the CMA is Anna Reid, an emergency physician from NWT, with a strong understanding of the Social Determinants of Health, as evidenced in this article.

The keynote speaker at the General Council is Sir Michael Marmot, Chair of the WHO Commission on the Social Determinants of Health and author of Fair Society, Healthy Lives - the Marmot Review. The WHO Commission produced Closing the Gap in a Generation, one of the works I draw upon heavily in A Healthy Society. You can see an excellent interview with Sir Michael here from a recent visit to Canada.

Given this connection, and his particular expertise in the area of the Social Determinants of Health, I’m very pleased to announce that Sir Michael has agreed to speak at a book launch event for A Healthy Society at the Yellowknife Bookcellar, 4:30PM, August 13th. I’m equally pleased to say that Libby Davies, MP for Vancouver East, Federal Health Critic and Deputy Leader of the Official Opposition, will be speaking at the event as well. Ms Davies was kind enough to host me at a previous book event in Ottawa and I’m very much looking forward to seeing her again and getting a chance to discuss further the importance of addressing the Social Determinants of Health at a federal level.

Naturally, I’m very excited about this book event. I’m also quite intrigued to be participating in this year’s CMA General Council. With Marmot as a guest speaker, Anna Reid as president, and the pending release of a CMA paper on Health Equity, there is a real change in the flavour of the organization and its message. CDM has often found itself in opposition to the direction taken by CMA leadership, particularly under previous presidents Brian Day and Robert Ouellet. It’s refreshing to hear Canada’s doctors advocating for a fairer health system and for work to address the upstream factors that impact their patients. Being able to join with the CMA in calling for greater health equity, in a time when the federal government is cutting services and research essential to that goal, is very encouraging. Thinking that there may actually be the critical mass of information on the SDOH and the political will to make change is downright inspiring.

Income from Within

The following is an excerpt from A Healthy Society: how a focus on health can revive Canadian democracy by Ryan Meili (Purich Publishing, 2012). For the next month I’ll be sharing an excerpt a day. To follow the daily excerpts, go to the Healthy Society facebook page or follow @ryanmeili on Twitter, or you can order a copy of the book here. You can also see all the previous excerpts here on tumblr

Today’s excerpt is from the beginning of Chapter 2, Growth and Development. This particular section built upon a blog entry originally posted on the Star Phoenix website and now hosted„ along with a series of other entries on the website of THRP : the Training for Health Renewal Program, a partnership between the University of Saskatchewan and the Mozambican Ministry of Health. I recommend looking through the other blog entries, probably the most interesting of which is Post-Call.

———————

The road to Tevele is red sand and sloppy in the rainy season. The pickup truck bounces in and out of ruts as we head thirty-some kilometres from Massinga to this out-of-the-way rural community, located between the ocean and Mozambique’s national highway. I am travelling with Dr. Gerri Dickson, director of the Centre for Continuing Education in Health, and two teachers from that institution: Cipriano and Flávia, both of whom studied in Saskatoon as part of their teacher training.

The Centre for Continuing Education in Health has a long relationship with Tevele. The núcleo, a group of leaders selected by the various surrounding communities, meets regularly with staff and students from the centre to address the health needs of the people of Tevele. Over the years, they have selected malaria and HIV/AIDS as areas of focus, and have done various public education campaigns and research projects to try to improve prevention and access to treatment.

Núcleo members, many of them quite elderly, walk for miles to attend the meetings. While waiting for those who are late to arrive, we huddle around a fire built in a hollowed-out section of a large tree to take off the morning chill. After morning tea, a group of keen participants starts a raucous gathering song: “a kama wasiya” (time is running out). It’s a classic, well known by the members, and people clap and dance, animating the meeting grounds.

Like the centre, I also have a long relationship with Tevele. On each of my previous visits to Mozambique, I’ve taken time away from clinical work at the hospital to learn more about working with communities to improve health. The members of the núcleo are now old friends, and each visit feels like a family reunion. In 2007, I spent an extra week in the community, holding clinics and trying to improve my grasp of Xitswa, the local language.

The visitors and núcleo members gather under a large mango tree to start the day’s session. The sun comes out and warms us to the point of leaving our jackets in the back of the pick-up. Part of the opening of every meeting is the singing of the national anthem: Moçambique, Nossa Terra Gloriosa, an event that is taken very seriously. Everyone stands at attention, looks straight ahead and sings in a sombre voice. Passersby on the road to town stop and stand until the song is over. This time, halfway through the second chorus, the rain starts anew. This is no drizzle; it’s a tropical, soakto-the-skin-in-seconds downpour. Given the solemnity of the song, no one can run and seek shelter. We grin and bear it, watering pouring down our faces as we finish the final lines of the anthem, then run into the newly built community development centre to start our meeting. While the topic is, as always, the health of the community of Tevele, today we aren’t talking about malaria and mosquitoes. We’re talking about money.

 The most important determinant of health, much more than access to health care, genetics, or culture, is income. The members of the Tevele health núcleo may not have read the latest research on the social determinants of health, but they see every day the way in which the amount of money people have access to shapes their wellbeing and longevity. Every one of them has lost friends and family members to preventable and treatable illnesses like malaria, HIV, and malnutrition. They see how it is the poorest families that suffer the most, see how for the want of a few meticais a child dies at home rather than reaching the hospital for treatment.

 Income is a determinant of health in itself, but it is also a determinant of the quality of early life, education, employment and working conditions, and food security. Income is also a determinant of the quality of housing, the need for a social safety net, the experience of social exclusion, and the experience of unemployment and employment insecurity across the lifespan.

— Dennis Raphael2

One of the younger núcleo members, Senhor Ronaldo, has not been feeling well lately. He has been losing weight and having frequent minor illnesses. His wife had left for South Africa a few years ago and last year she returned. She died a few months later. Many people from the area go to South Africa for work in the mines and other industries there. Coming home sick from South Africa has become synonymous with AIDS. Ronaldo has worked with the núcleo, educating local communities about HIV/AIDS and other sexually transmitted illnesses. He knows very well he should be tested and start treatment if positive, he knows that both testing and treatment are free of charge, but despite that knowledge, he still hasn’t gone for testing. This is not procrastination; he simply can’t afford the 50 meticais (about $2 CDN) to make the trip in one of the battered Toyota pickups that go regularly to Massinga. If he had some form of income beyond what he can grow on his machamba (small farm cultivated by hand) he would be able to access the care he needs. If there were more local income opportunities, perhaps his wife wouldn’t have had to leave for South Africa to make money.

Recognizing how important local sources of income are for their families and their community, the núcleo members have embarked on a program of economic development. With the help of Canadian partners and a group of young people called Zambo ni Zambo (Xitswa for step by step), they have begun a machamba and a carpentry work shop and have recently started to raise chickens. With help from CIDA (the Canadian International Development Agency), they have built a new “centre of competencies” for meetings related to the economic projects and storage of related materials. Proceeds from the project go to a common account to continue development, with a portion going to individuals involved, depending on the work they contribute. Zambo ni Zambo also works with another of the centre’s partner communities, Basso, on a sewing project and a bakery. The underlying idea is to increase the capacity of the community to sustain itself economically. This allows local people to have more access to gainful employment and income for necessities such as travel for hospital care and medications, simple household goods like blankets, and more varied food than what they can grow themselves. It allows them to find this income closer to home, decreasing the disruption to family life and community health brought by migrant work. This goes step-by-step with the health promotion and disease prevention activities of the núcleo, as rather than waiting for help from outside, the people of Tevele start to take charge of their own development. In the long run, these efforts may prove to be what makes a real difference, helping people like Senhor Ronaldo and his family to do better economically and live healthier, longer lives as a result.

Stories like that of Senhor Ronaldo’s bring home just how important economic opportunities are for health. From Mozambique to Canada and everywhere in between, economics is the primary practical human activity. The exchange of goods and services governs much of our everyday life. The economic success of individuals has the greatest influence on their health, far above biology, access to health services, or culture. That success is also a significant source of social stature.

I mentioned earlier that health care is always at or near the top of the list of public priorities. Its main opponent in vying for public concern is the economy. People recognize how important economic success is for physical, mental, and social wellbeing. The list of determinants of health is topped by income and social status, with the position in the economic hierarchy being the single largest factor affecting health. Income also determines many of the other determinants: the ability to afford child care or higher education, safe housing and good nutrition, leisure and exercise, and in many places access to health services. It is little surprise, then, that those at the top of the scale for wealth are there for health as well.

deeannmarie:

Over the last couple of weeks I have received a nonstop series of death threats against me in a variety of forms.

I have been told that I was going to be kicked through a window, my head cut off, and I was going to be killed as I went out to my car or when I went home. They all came from the same person and outside of being heckled when walking home one night, it was all empty threats.

The cause of the threats is complex but there are a lot of mental-health issues there. Our ideas of reality can be somewhat different, but when someone sees their life calling as Batman, you know it’s going to be a long day.

Working at an organization that is a social housing provider, we have an obligation to keep the facility safe for everyone inside it and the community around it. The easiest thing in the world would be to evict troubled clients, who would find themselves on the streets without any supports or help.

Eventually they end up back in jail. By then, however, you have more victims of crimes committed by those who don’t really realize what is happening around them.

Over the years I have repeatedly heard the plea, “he needs help,” but mentalhealth help is really hard to get - even in extreme situations. A couple of months ago a client I was working with attempted suicide and was rushed to the hospital.

He was showing signs of obvious mental-health problems but instead of treating it as a suicide attempt, the doctor treated it as a drug overdose.

He was released in a couple of hours in even worse shape than when he went to the hospital.

The next day I called the health region’s mentalhealth intake line and was told that it was quite common for attempted suicides to be treated that way and there wasn’t much they could do other than recommending he see a family doctor and then get referred to a psychiatrist.

I got off the phone and shook my head; if going to the emergency room doesn’t work and if calling the Saskatoon Health Region’s mental-health intake line does nothing, how does anyone get any mental-health help in this city?

Dr. Anna Reid was recently named the head of the Canadian Medical Association. She talked quite openly about the need for quality housing as making a difference in people’s health. On the flip side, easy access to mental-health care for low income patients would make a big difference in keeping people housed.

The mental-health disorders get people evicted from housing and banned from shelters.

For women it leads them to working the streets and for men it often leads to drug abuse and other crime. The issue isn’t the crime, it’s a lack of treatment options, and no one seems to want to do anything about it. We wouldn’t tolerate this level of care anywhere else in the system.

One issue is a shortage of psychiatrists, available beds, nursing home beds, and a lack of spaces for really hard-to-care-for individuals. It strains everyone across Canada.

Another issue is voter apathy. As voters we care passionately about surgical and emergency room wait times and so they get improved. On a recent trip to RUH’s emergency room, they had signs up telling people that they may be timing your wait in an effort to speed things up. It works. My experience was excellent but the pain from a partially torn rotator cuff is a lot easier to deal with than someone who is struggling with schizophrenia or is trapped in a delusional world of fear.

Saskatchewan Health does a lot of benchmarking. Twenty-one different factors are tracked as part of the 2004 Comparable Health Indicators Report but almost nothing is said about mental health. If it’s not bench-marked, how can we expect change?

Across the country we have seen what happens when we underfund mental-health programs. It leads to an increase of people on the streets, it forces police into becoming mental-health workers, and in some situations it leads to deaths. Mental health is a complicated field but until we start to publicly address how we doing, how is it going to get better?

The bar to get help is too high, takes too long, and people end up too close to the edge. We deal a lot with the symptoms in our society - why not tackle the problem directly?

Read more: http://www.thestarphoenix.com/news/Ignoring+mental+health+costly/7049784/story.html#ixzz22yR46Apr

By Jordon Cooper, The Star Phoenix


Article by my co-worker regarding one of our client’s who desperately needs mental health treatment but just continues to harass and threaten my co-workers and I. We have tried multiple approaches to getting him help. But they all lead to dead ends, forcing us to evict him for our own safety. “Lack of success and no other steps”, is what Jordon sums it up as, which is just horrible.

An Evolving Art - evidence-based decisions in medicine and politics

The following is an excerpt from A Healthy Society: how a focus on health can revive Canadian democracy by Ryan Meili (Purich Publishing, 2012). For the next month I’ll be sharing an excerpt a day. To follow the daily excerpts, go to the Healthy Society facebook page or follow @ryanmeili on Twitter, or you can order a copy of the book here. You can also see all the previous excerpts here on tumblr

The following is a series of excerpts from Chapter 2: Medicine on a Larger Scale regarding developments in medical practice and education and their implications for political decision-making. 

In the past twenty years there have been a number of major conceptual developments in the art of medical practice, and, subsequently, in the way it has been taught, that are beginning to have a major impact on people’s health. These include the focus on social determinants of health, patient-centred medicine, social accountability, and evidence-based medicine.

 The first — and the most profound, in my opinion — is the understanding of the determinants of health described in the previous chapter. While this is an intuitively true concept, and one that was advocated even in the mid-1800s by Virchow and others, it has only become a major focus of health study in the past three decades. Uptake in mainstream medicine has been slower yet, but in recent years it has become a central component of training, and a topic of increasing importance in the profession.

The second is the concept of patient-centred medicine. Once (and still in too many clinics) the rule was Doctor Knows Best. The physician asked the questions he considered important, examined the patient, told them what to take to feel better, and sent them on their way. The result: frequent misunderstanding between patient and clinician, misdiagnoses, prescriptions for treatment the patient was unable or unwilling to complete, and patients allowing responsibility for their health to be the doctor’s and not their own.

One interesting result of this approach is that the definition of success has changed. We now talk about meaningful outcomes. When we know what is meaningful to patients and their families, we can know whether to move ahead with a difficult treatment, or spare the expense and discomfort. The guiding principle is to do what will make the most meaningful improvement in the patient’s quality of life rather than a focus on cure rates, survival times, or adherence to strict guidelines. This humanizing approach, based on what is significant in improving people’s lives rather than an insensitive numerical standard, is an important principle to remember when we discuss political interventions as well as medical. 

The third important notion is that of social accountability. The practice of medicine, the care of the sick, has at its core compassion and attention to those in need. It has also been a profession dominated by social conservatism, economic self-interest, and maintenance of the status quo. The social accountability of faculties of medicine, as defined by the World Health Organization, is: the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public.

This means going beyond the work of treating the sick to understanding and addressing the reasons they are ill. The Parable of the River is often used to illustrate this approach. Imagine you are standing on a bridge. A flailing, drowning child comes floating down the river beneath you. Brave soul that you are, you dive in and swim to shore with the child. Before you can dry off and recover another child comes floating down and you dive in again and bring her safely to shore. A curious crowd has gathered by now. Another child bobs into sight … and another … and another. People take turns fishing them out. It doesn’t take long before someone asks the pertinent question: who keeps chucking these kids in the water? And hopefully they head upstream to find out.

 …

The fourth major advance in medical thought, and perhaps the most significant in changing science and practice, is that of evidence-based medicine. This term, coined by Dr. Gordon Guyatt of McMaster University, describes a paradigm shift in medical practice. For centuries, medicine was a highly developed apprenticeship. Doctors studied and practiced based on what their predecessors had done, anecdotal evidence, conjecture about how things might work, and in later years the recommendations of pharmaceutical salespeople. Clinical science — and, in particular, its standard-bearer, the randomized controlled trial —have allowed us to evaluate tests and treatments much more rigorously. Today’s physicians are expected to have a working knowledge of the analysis of evidence and to remain up-to-date in their field. They are assisted by journals, websites, and other easily accessible tools (such as the phenomenal RxFilesa Saskatchewan government-supported program which offers unbiased analysis of medications based on cost, efficacy, and safety) to ensure that they have the best of science to assist them in the art of medical practice.

The analogy of the past practice of medicine and the current practice of politics is striking. Rather than on the best evidence, political decisions are made based on a polling of their popularity, ideology, and other sorts of best guesses of what might work. What is needed is a move to evidence-based policy. We need to develop the clearest understanding possible of our goals, our meaningful outcomes. We then must understand the obstacles to reaching them, and the actions most likely to have the desired effect. We need to use the best information and examples available to us in order to build a healthy society.

Station 20 West: a community-based approach to

addressing the determinants of health

The following is an excerpt from A Healthy Society: how a focus on health can revive Canadian democracy by Ryan Meili (Purich Publishing, 2012). For the next month I’ll be sharing an excerpt a day. To follow the daily excerpts, go to the Healthy Society facebook page or follow @ryanmeili on Twitter, or you can order a copy of the book here. You can also see all the previous excerpts here on tumblr

Chapter 1, p.22 re: Station 20 West

At the time of this decision (a decision by the SK government to rescind funds granted to the construction of Station 20 West, see article below for further detail), I was working as a family physician at the clinic that was meant to relocate to Station 20 West. While working on the west side as a student, a resident in Family Medicine, and later as a practicing family doctor, I became quite excited about the potential of this project and was deeply disappointed by the cancellation of funds.

Clinical work in underserved areas offers many joys: the sense of community, the easy humour and relaxed attitude of many of the patients, and for me a sense of purpose, as I am often able to connect with people in real need and offer them meaningful support. The frustrations are many as well. Every day, whether I’m working in Northern Saskatchewan, rural Mozambique, or in my neighbourhood, I see patients whose problems are not merely physical, but political. They stem from a lack of safe or appropriate housing, a lack of education, or from simply not having enough money to access the basic necessities of life. People don’t get sick when they come into the clinic or show up at the hospital; their problems can’t be solved there, either. They get sick in their real lives: at home, at school, at work, and at play. Station 20 West was a project designed to meaningfully address the factors that play such an important role in determining longevity, illness, and quality of life: the determinants of health.

To understand more about Station 20 West see the video from WolfSun productions at the top of this post, the article from Briarpatch magazine below, and the video of my talk during the community march to save the project embedded below. A later post will trace the process by which the community banded together to raise the funds and complete this project that is so essential to addressing the social determinants of health.


Full steam ahead

Station 20 West, Saskatoon’s innovative engine for

urban renewal, is back on track

Station 20 West is not just a model of an innovative community-based response to endemic poverty and the ill health that results from that poverty; it’s also an example of a community rallying around a good idea and bringing it to fruition, overcoming significant challenges in the process. The good idea was to launch a multi-use community economic development initiative that would help address the gross inequalities that exist in Saskatoon. Thanks to the overwhelming support of the community, the project is now back on track after nearly being derailed by the provincial government.

The shocking news of Station 20 West’s potential demise blindsided a community that was already reeling.

Saskatchewan’s largest city, according to a groundbreaking 2006 study, contains the sorts of extreme health disparities between rich and poor neighbourhoods generally associated with cities in much poorer countries. As shocking as the study’s findings may have been, the current provincial government’s response was even more surprising. Shortly after coming to power, and one year after the study’s release, the Saskatchewan Party government announced in March 2008 that it would be withdrawing already-promised provincial funding for Station 20 West, a project in Saskatoon’s core that was specifically geared towards addressing these health disparities and the lack of basic services. Nine months after the funding was pulled, however, the project is going ahead despite the resistance of the provincial government.

According to “Health Disparity by Neighbourhood Income,” published in theCanadian Journal of Public Health in November 2006, residents of Saskatoon’s core neighbourhoods are 15 times more likely to contract a sexually transmitted infection, 15 times more likely to attempt suicide, 35 times more likely to get Hepatitis C, and 13 times more likely to have type 2 diabetes than residents of other neighbourhoods. With all of these increased risks, a core neighbourhood resident is 2.5 times more likely to die in any given year. The infant mortality rate is three times higher than elsewhere in the city.

Saskatoon’s core is the most economically disadvantaged area of the city and has been without access to a full-service grocery store for many years. This lack of services contributes to the poor health of the neighbourhoods. Community organizers have long recognized that a broadly based, multifaceted approach to addressing poverty is the only way to reduce the shocking health disparities within the city. It was in this context that Station 20 West was born.

Station 20 West was the product of collaboration among a number of community-based organizations. It was to serve as a one-stop service shop addressing issues such as health, food security and economic development in the core neighbourhoods. Station 20 West was to be located next to 56 new affordable housing units and a branch of the public library, and was to include a broad range of services including a community health clinic, a student-run after-hours clinic, a dental outreach clinic, offices for several community-based organizations, a university outreach education centre and a member-owned co-operative grocery store. These were all to be housed in a building that would meet the highest level of LEED (Leadership in Energy and Environmental Design) certification. The expanded clinical services, alongside community economic development organizations and access to good, affordable groceries would have gone a long way toward addressing the health needs of the core.

In recognition of the importance and quality of the Station 20 West initiative, and having extensively vetted it, the provincial NDP government dedicated $8 million to the project in its spring 2007 budget.

In March of 2008, however, the recently elected Saskatchewan Party government informed Station 20 West board members that the dedicated funds were being rescinded. The justifications – given only after the fact – spoke of insufficient community consultation or involvement of First Nations and Métis organizations, as well as ideological reluctance to support a “private” grocery store with public funds. Premier Brad Wall dismissed the project as a “mall development.”

The Wall government’s ill-considered decision to rescind the funding for Station 20 West shocked the people of Saskatoon, triggering a firestorm of criticism of the decision and a groundswell of support for the threatened project. In April 2008, in one of the largest demonstrations in Saskatchewan in decades, over 2,500 protesters took to the streets to show their support for Station 20 West. 

Determined that the project would go ahead in some form, the organizers scaled it back to reflect new financial circumstances and launched an energetic fundraising campaign to make up the remaining shortfall. The rapidly formed Friends of Station 20 West group recruited thousands of online members in a few short days, many of whom came out to subsequent meetings and continue to organize fundraising and awareness campaigns.

The organizers have unveiled a more modest Station 20 West plan, one which will cost a great deal less ($3 million, rather than $13 million) but will still host a number of services. The Good Food Junction and Café, the Child Hunger and Education Project, the Quint Development Corporation, Heifer International and the Elizabeth Fry Society will all be housed in the space, as originally envisioned. The new building will still be LEED certified, though at a lower classification of environmental sustainability. It will still boast an outdoor stage and container gardening. While the clinical and educational services will be missed, the remaining partners, alongside the affordable housing and library next door, will still enjoy a synergy where their efforts are enhanced by the other services that have chosen to co-locate.

Some progress has also been made in rebuilding some of the relationships damaged during the period immediately following the removal of the funds. The Station 20 West board met recently with representatives of the Saskatoon Community Clinic, the membership of which changed significantly in recent board elections. An expanded West Side Community Clinic will likely locate nearby and will continue to work in positive partnership with Station 20 West. The board is seeking to partner with more First Nations and Métis groups. An Outreach Education Centre for the University of Saskatchewan is also being proposed for the new building.

Faith Bodnar, the new coordinator of the project, says that “While the size of the building and the scope of the project have changed, the concept and the dream have not.” The project will forge ahead because the original concept was solid and the need for such an intervention persists. Community support for the project includes major donations from the Saskatchewan Union of Nurses and Canadian Union of Public Employees – $100,000 each – as well as a donation of $500,000 from an anonymous Saskatoon corporate donor. Perhaps more impressive is the $225,000 already raised from hundreds of individual donors. These financial contributions show that the people of Saskatoon have not abandoned Station 20 West or been deterred by its tribulations. A capital campaign is now under way to raise the remainder of the $3 million by February of 2009, with construction set to begin in May of 2009. There is still a long way to go, but organizers are confident that Station 20 West is back on track.

Bait and Switch

In a previous note I said I was going to be posting the entire book, excerpt by excerpt, hoping to share the content widely, get more people interested, and generate discussion. The plan was to also enhance the book content with images, videos and related articles.

I neglected to clear this first with the folks at Purich Publishing, however, and they raised valid concerns about copyright and access issues related to their business model. So, with sincere apologies to Purich and to those of you who had started to follow the blog, I won’t be posting the entire book after all.

What I will be doing, however, is posting a series of smaller excerpts from the book, tracking through the main topic areas, and continuing to seek out the added material to expand on the reader’s experience. In that spirit, today’s post features, instead of a book excerpt, an article I published in Briarpatch magazine in 2010 that outlines the core argument of the book, and the TEDx Regina video above which gives you a rundown of the style and substance of A Healthy Society in 12 minutes and 43 seconds. 

In sickness and in wealth

Unmasking the social determinants of health

Briarpatch Magazine, Sept 9, 2010 (see original article here)

“Politics is nothing else but medicine on a larger scale.”

—Rudolf Virchow, 1848

In Canada and around the world, the health of the poorest people is far worse than the health of the richest – and new evidence suggests we all suffer as a result. In order to address the fundamental unfairness of this situation, we need to completely rethink not just how we do health care, but how we do politics.

Canada is one of the wealthiest nations on the planet, but the gap between the rich and poor is widening, and rates of child poverty and homelessness are on the rise. Aboriginal people, immigrants and women continue to suffer elevated rates of illness. Epidemics of drug abuse, diabetes, obesity,HIV/AIDS and other diseases closely related to poverty are resulting in lost lives and wounded communities. Meanwhile, human actions are seriously harming the wider environment that supports us; this in turn harms humans. These problems are fundamentally political, but those who raise objections to the current state of affairs, who suggest that there must be a different way of organizing ourselves that is to the benefit of all, are dismissed as naive and ignorant of economic realities. The question before us all is, how can we move beyond this impasse? How can we organize ourselves to make rational decisions for the benefit of all, rather than allow the powerful to raid the commons for their own narrowly conceived self-interest?

The difficulty here is not a failure to understand the extent of our difficulties; it is the lack of a focus, an organizing principle for change. We must state our goals clearly if we wish to reach them. We need a clear objective that will inspire people from diverse circumstances to work together for a greater good.

What I propose is that we have that focus already. It is simply a matter of understanding, articulating and acting upon it. The focus is health: the health of individuals, the health of communities, the health of democratic institutions.

People care about health. It’s part of our assumed common ground, one of our few truly shared values that transcends class, colour and political ideology. Our conversations are rich with references to health. If you ask expectant parents if they’re having a boy or a girl, the answer is inevitably, “we don’t care, as long as it’s healthy.” When neighbours and friends are ill we go out of our way to help them. If people fall on hard times a common encouragement is “at least you have your health.” We speak of healthy relationships, healthy attitudes, healthy economies and healthy appetites. We toast to one another’s health. These familiar expressions reflect our unconscious preoccupation with our common vulnerabilities, hopes and fears: we know, deeply, that health – physical, mental and social – is a necessary condition for the full enjoyment of life.

Read More

Buying Smokes for my Patients



The following is an excerpt from A Healthy Society: how a focus on health can revive Canadian democracy by Ryan Meili (Purich Publishing, 2012). For the next month I’ll be sharing an excerpt a day. To follow the daily excerpts, go to the Healthy Society facebook page or follow @ryanmeili on Twitter, or you can order a copy of the book here. You can also see all the previous excerpts here on tumblr.

The development of a society, rich or poor, can be judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health.

Commission on the Social Determinants of Health Closing the Gap in a Generation1

Buying Smokes for my Patients

Maxine just turned twenty, but walks like she’s ninety-one. I suppose that’s because she’s closer to death than most ninety-one-year olds. You’d walk slowly, too, if that’s what lay ahead. While she’s been on the street since she was thirteen, hooked on IV cocaine and morphine for nearly as long, she has only had HIV for two years, three at the most. For some reason she, like many of the growing number of people infected with HIV in Saskatoon, is a rapid progresser. This means that, rather than taking years for her infection to progress to the immune suppression of AIDS, it happened very quickly. There are a few theories out there: different genetic capacity to respond, unique strains of the virus, or just poor underlying health. The truth is, we don’t quite know why. What we do know is that she’s in really bad shape — what many doctors would call, in back rooms and unprofessional asides, a train wreck.

When I first met Maxine, she came in with florid thrush, a rip-roaring pneumonia, and a prescription for prophylactic antibiotics she never intended to fill. I instantly recalled the hospital in Mozambique where caring for young men and women who arrive emaciated and scared, fast approaching the end of their lives, is a daily occurrence. Maxine’s is the worst case of AIDS I’ve seen walking a Canadian street. I told her she was sick enough to go into the hospital, but she had just been discharged for the umpteenth time. She wouldn’t say much, just told me she wanted antibiotics and nutritional supplements. The last thing she wanted was to go back into the hospital.

Three months later, the word on the street is that Maxine wants help. She’s getting weaker and sicker, and finally recognizes she’s in trouble. She comes into the clinic and falls asleep on the exam table. She is deathly thin, and under my stethoscope her lungs sound like a rubber boot being pulled from the mud. I call the Infectious Disease service and Internal Medicine at Royal University Hospital. They know her well; she’s done this before. She gets sick enough to need some help, she is admitted, she gets a bit better, hates the hospital, misses the drugs, and bolts. Reluctantly, they agree to give her another try.

That was a Friday, and I was out of town for the weekend. When I arrive to see her on Monday morning the internal medicine team is about to discharge her. Her CD4 count, a measure of the immune cells that defend against infection, is four. It should be at least 400. The HIV viral load tells us how active the virus is in her system. More than 100,000 is considered too much; hers is three million. However, her pneumonia has improved, she’s not ready for the antiretroviral medications that must be taken every day without fail in order to avoid increasing resistance, and the normal functions of an acute ward have been reached. She doesn’t make it easy to help her, either. She swears at the nurses, refuses to take pills or have blood work. When the security guard assigned to keep her in line takes her for walks, she bums cigarettes, hides them in her gown and smokes them on the ward. She takes as much time and attention as the rest of the patients on her ward combined, and the nurses and medical staff are exasperated.

Despite her misbehaviour, she tells me she wants to stay. I visit twice a day, sitting on the edge of her bed and talking with her about the future. She says she wants to get on methadone and off the streets. She wants to take the antiretroviral medications to get her immune system working again. She is refusing to leave the hospital. The idea that, as health care providers, we might have security guards escort this young girl who is dying of AIDS to the street is against all we stand for.

So we don’t. After a long discussion with the medical team, we agree to try a little longer. Give her a week and see how she does. Because, despite the frustrations of bed shortages, extra workload, and chances that are cachectically slim, we know these are the moments that define us as a profession. Even when the odds are long, we cannot walk away from someone who is so clearly suffering. So we’ll try for another week. Get the methadone doc to see her, get psychiatry involved, and social work, and nutrition, and anyone else we can think of, make our boundaries clear and try once more.

We know the hospital is no place for Maxine. But the system has no better place. Most drug rehab programs won’t take people on methadone; none of them will take someone who needs to start it. The waiting list to get started can be several months and requires people with numerous social and economic barriers to jump through multiple hoops that seem designed to keep them out. So in the gap between wanting to kick the drugs and having the personal and social capacity to do so, they’re dumped back on the streets to start from scratch.

On the second or third night of this experiment in patience, I go up to see Maxine. The nurses are frustrated; she’s still sneaking smokes into her room. She constantly demands that security take her for walks. She fights meds and blood work. But she’s still there. She’s taking her methadone. She tells me again she wants to stay, she wants to get better. The nurses think that maybe if she had her own cigarettes they could help her set a schedule and stay out of trouble. Maybe if they print her off more of the crossword puzzles she likes she’ll stay busy. In many ways she is older than her twenty years. In others she’s truly a child.

The next morning I go in to see her. I’ve got a couple of books of crossword puzzles and a pack of Player’s Light. I never thought I’d buy a pack of smokes for a patient, but in this case “first do no harm” takes a back seat to the immediate fight for her life.

I go up to her room to deliver my gifts and talk to her some more. She’s gone. The night before she got frustrated, left the hospital, scored some drugs, shot up and showed up in emergency in bad shape. The line was crossed and she is not welcome in the hospital any more. She can come to see me at the clinic the next week — we’ll always see her — but the glimmer of hope is significantly dulled.

The last time I saw her, just before I stopped working at the clinic she trusts, she was repeatedly wearing out her welcome at the brief detox centre. I told her I hoped she’d at least come in and take her medications and see the other doctors there. She said goodbye, and thank you, and gave me a heartbreakingly innocent hug. 

The cigarettes stayed in my freezer for a long time. I thought the next time I was invited to a sweat lodge ceremony, I’d bring them as my offering of tobacco and say a prayer for Maxine. It turned out I didn’t get the chance — at least not while she was still alive. A few weeks after I left the clinic to work in rural Saskatchewan, she was hit by a car, shattering her pelvis. While in hospital she contracted pneumonia again, and this time she couldn’t recover from it. She died just before her twenty-second birthday.

It’s easy to get distracted by the pathology of Maxine’s story, to think that it’s a story of viral invasion, of fractured bones and infected lungs. These physical details, however, are distractions from the real disease. They are symptoms of what Dr. Stu Skinner, a Saskatoon infectious disease physician who specializes in HIV, refers to as the “End Stage of Poverty.”

Maxine’s life was hard from the beginning. She grew up in an environment of poverty, dysfunction, and abuse. Her mother had spent most of her own childhood in a residential school; she hadn’t seen what it was like to be a parent and wasn’t very good at it. Maxine never knew her father. Instead, she knew the attentions of various boyfriends and extended family members who abused her physically, sexually, and emotionally throughout her childhood. She had a baby before she reached Grade 9 and never returned to finish high school. In many ways she never got a chance to be a child, and at the same time never matured to be an adult.

 Such a broken life, such an inherently tragic existence, provokes serious questions about our society: questions about the prevention and treatment of disease, about poverty and services for vulnerable people, about education, and about justice. What often escapes our attention when considering the tragic story of one individual is how intimately it is connected to all of us, to the collective decision-making process that is electoral politics. It is politics that decides whether young women like Maxine live or die. Ultimately, our political choices are to blame for the large number of people who slip through the cracks.

There is strong evidence that our current political choices aren’t working for everyone. In Canada and around the world, the health of the poorest people is far worse than the health of the richest, and new evidence suggests we all suffer as a result. In order to address the fundamental unfairness of the situation, we need to rethink not just how we do health care, but how we make decisions as a society.

Economic growth and advances in health care have increased the life span, health status, and quality of life of people all over the world. Yet there are many people, in poorer countries and within wealthy nations, who do not experience the benefits of this progress. Canada is one of the wealthiest nations on the planet, but the gap between the rich and the poor is widening, and rates of child poverty and homelessness are on the rise. Despite Canada’s self-image as a welcoming and equal nation, Aboriginal peoples, immigrants, and women continue to suffer more illness than the rest of the population. The cost of post-secondary education has risen to levels that are unaffordable for many. Epidemics of drug abuse, diabetes, obesity, HIV/AIDS, and other diseases closely related to poverty result in lost lives and wounded communities. Meanwhile, human actions are harming the wider environment that supports us; this, in turn, harms humans. These problems are fundamentally political, but those who raise objections to the current state of affairs, who suggest that there must be a different way of organizing ourselves that will be to the benefit of all, are dismissed as naïve and ignorant of economic realities.

None of this is news. Most people are well aware of the situation, and many are moved to action. The overall response, however, is fragmented, confused, and ineffective. The question before us all is, how can we move beyond this impasse? How can we organize ourselves to make wise decisions for the benefit of all?

Politics and public discourse, the field that should be responding to such pressing societal concerns, flounders instead from crisis to crisis. Parties and public figures bounce around the political and social spectrum in reaction to events or public opinion. The key issues of the day are decided more by the news cycle than any rational understanding of priorities. Ideas are presented by extreme opposite views in debate rather than in a search for common ground. Political reporting is dominated by scandal to the exclusion of substance, and, as a result, we are unable to focus on real issues. The agenda of governments seems to be either hidden or absent. From day to day the top stories change from an international conflict to a far-off natural disaster, from the rising or falling loonie to a record lottery jackpot, with no discernible pattern of progress or failure. In this fragmented experience of history and the present, all of us have a hard time recognizing what is really happening, what a government has done, or what it ought to do.

The problem is not a failure to understand the extent of our difficulties; it is the lack of a focus, of an organizing principle for change. An undeclared objective will not be realized; we must state our goals clearly if we wish to succeed in reaching them. In the absence of a societal project that advances the wellbeing of all, it is only natural that different groups will use politics cynically for their own gains, and that people will find it difficult to decipher the mixed and ever-changing signals. Without clear common goals, we have increasing polarity and discord. If we are to make anything of this mess, we must find something we agree on and work toward it. We need a clear objective that will inspire people from diverse circumstances to work together for a greater good.

What I propose is that people have already chosen that focus. It is simply a matter of recognizing, understanding, articulating, and acting upon it. The focus is health: the health of individuals, the health of communities, the health of democratic institutions.

People care about health. It’s part of our assumed common ground, a truly shared value that transcends class, colour, and political ideology. Our conversations are replete with references to health. If you ask expectant parents if they’re having a boy or a girl, the answer is inevitably, “We don’t care, as long as it’s healthy.” When neighbours and friends are ill, we go out of our way to help them. If people fall on hard times, a common encouragement is, “At least you have your health.” We speak of healthy relationships, healthy attitudes, healthy economies, and healthy appetites. We toast one another’s health. These familiar expressions reflect our unconscious preoccupation with our common vulnerabilities, hopes, and fears: we know, deeply, that health — physical, mental, and social — is a necessary condition for the full enjoyment of life.

This focus on health is reflected in public life as well as private, particularly in the heated political debates around health care and health spending. Health care and health are very different things, but health care is the policy area most obviously linked to health, and the attention given to it is an identifiable surrogate for this deeper preoccupation. With rare exceptions, health care is the number one issue of importance in Canadian polling, an unusual constant in the tumultuous sea of public opinion. Accordingly, health care spending takes up the largest portion of provincial budgets. There have been many who have complained about this, saying that an inordinate focus on health takes away from other important areas such as education, justice, and infrastructure spending. In a way they’re right — our focus on health care at the expense of other important aspects of public life is disproportionate. But the problem is not that we care too much about health, it’s that we are doing so in an incomplete and reactive fashion. Our approach tends to be palliative rather than preventative; we focus too much on what to do when our health fails, not on how to make sure the conditions are in place for more people to thrive, to stay healthy. If we truly want a healthy society, we need to build a political movement with health as its focus. 

1        Commission on the Social Determinants of Health, Closing the Gap in a Generation: Health equity through action on the social determinants of health. Final report of the Commission on the Social Determinants of Health (Geneva: World Health Organization, 2008), p. 3.

Determining Health (Preface)


The following is an excerpt from A Healthy Society: how a focus on health can revive Canadian democracy by Ryan Meili (Purich Publishing, 2012). For the next month (or so) I’ll be sharing an excerpt a day. To follow the daily excerpts, go to the Healthy Society facebook page or follow @ryanmeili on Twitter, or you can order a copy of the book here. You can also see all the previous excerpts here on tumblr.

The protection of the people’s health should be recognized by the government as its primary obligation and duty to its citizens.

Dr. Norman Bethune1

A man as thin as a skeleton sits coughing in a tent near the hospital latrine, patiently taking his tuberculosis treatment and hoping he doesn’t have a drug-resistant strain. A father’s support makes all the difference for a young woman struggling to stay off of street drugs while waiting for cancer treatment. A five-month-old girl the size of a newborn is brought into hospital by her father, who has been feeding her canned milk since her mother died. An elderly man is sent to a nursing home an hour’s drive away from where he’s lived with his wife for 60 years; they can’t manage at home with his dementia, and there are no long-term spaces available nearby. Having lost their home to flooding, a family wonders how it will care for a physically disabled child. A Dene elder goes into a diabetic coma and dies at home waiting for the ambulance that was busy with a car accident on the gravel road leading to her reserve. A doctor in a wealthy suburb prescribes an anti-depressant to a man who has been having trouble sleeping and concentrating; she wonders whether she should be taking them as well. Having lost his job due to an economic downturn, a middle-aged man is forced to choose between his children’s school fees and his blood pressure medications.

Income, education, employment, housing, the wider environment, and social supports: these, far more that the actions of physicians, nurses, and other health care providers, have the most impact on our health. If Norman Bethune was correct, and the greatest role of government is protecting the health of the population, then it is in these areas that our public policy must have its greatest emphasis.

In A Healthy Society, the stories of patient experiences lead us into a discussion of health and its role in determining our political direction, our collective decisions. With health as a commonly held goal, the drive for better human health can be a shared mission for society. When people understand just what it is that really makes a difference in people’s health — the determinants of health — it leads us to realize just how great a role politics plays in deciding the health of all of us. A renewed focus on health offers hope to change a political climate that has bred scepticism and mistrust among the public.

To begin, I will lay out the case for putting health front and centre in our public discourse — in how we organize politically, in how we plan, and in how we judge the success of our actions and our political representatives. In the following chapters, I will discuss the concept of social determinants of health in greater detail. Before doing so, I will pause briefly in the field of medicine and the health sciences to explore some emerging ideas that could be usefully applied to politics. We will then examine the current predominant focus for our society: that of economic wellbeing. This will be followed by the exploration of a number of specific health determinants, and end in a discussion of democratic reforms that could help reshape the way we organize ourselves to create a truly healthy society.

1 A. Clarkson, Norman Bethune (Canada: Penguin Group, 2009).