Spending on health care gobbles up the largest share of provincial government budgets — about 40 per cent.
Yet wait times, access to care and health outcomes remain a concern for many Canadians.
Tyee legislative bureau chief Andrew MacLeod takes an in-depth look at the health of Canadians in All Together Healthy: A Canadian Wellness Revolution, and comes up with convincing evidence that the real path to big improvements in our health lies outside the health-care system.
MacLeod marshals research, both Canadian and international, and personal stories to highlight the importance of “social determinants” of health — the factors that have a far greater impact on our health than medical care.
Kids raised in poverty, for example, face far more lifelong health challenges than their more affluent peers, everything from increased risk of diabetes and other chronic illnesses to suicide.
The Tyee explored the issues with MacLeod in this interview.
The Tyee: Let’s begin with an anecdote to illustrate your larger message. I remember the fight against smoking being one of the most visible and, it seems, successful public health campaigns in Canadian history. Several decades ago, smoking was prevalent everywhere across all income groups in Canada, and now it’s pushed to the margins in terms of social spaces and public acceptance. But you show smoking hasn’t gone down among lower-income Canadians, and that among those who do smoke, lower-income Canadians still seem to suffer worse health outcomes than higher income Canadians who also still smoke. Why is that?
Andrew Macleod: That’s right. While the smoking rate has gone down overall in Canada, that’s not true among the bottom 40 per cent of income earners. The thing to remember is that people make choices within a social context. Smokers are more likely than non-smokers to say that they find most days “quite a bit” or “extremely” stressful. As one sociologist I quote in the book put it, “smoking provides an admittedly dangerous but pleasant means to escape the stress of everyday life.” Living with a below average income — struggling to pay for housing, food and other basics — is stressful. Meanwhile, all those things that are making life stressful, such as difficulty affording a healthy diet, are also making it harder to fend off disease. So it’s really social and material factors working hand in hand that determine how healthy an individual is likely to be.
You start the book by noting that Canadian governments have known about the relationship between income and health for half a century, and despite lots of research and brave policy statements from politicians almost nothing has been done that recognizes that relationship. Why have governments failed to act?
When we talk about “health” in Canada, most people tend to understand that as being about doctors, hospitals, nurses and drugs. There’s always excitement about medical breakthroughs and having the technology to fix what goes wrong, and there’s anxiety about having medical care available where and when we need it. That results in a ton of pressure on politicians, from the public as well as people who work in the system, to keep expanding what we spend on health care, even though we already spend more than 40 per cent of provincial budgets on it. I think most people are less aware of how strong the evidence is that better supporting social services, particularly when it comes to helping families raising children, would have a much bigger impact on the average Canadian’s health than spending more on the health-care system would. Without that same kind of pressure from the public, the politicians have been free to ignore it.
A major theme of the book is that our ability to lead healthy lives is determined by forces beyond our control as individuals. And yet in our society we are told that the choices we make as individuals matter, especially here on the health-crazy West Coast. I can imagine some readers saying, “I eat properly, I exercise, I take mental health breaks or do spiritual exercises and I don’t indulge in smoking or excessive drinking, and you’re telling me that my choices don’t matter to my overall health?” What do you say to them, especially when they cite improvements in their own lives?
I’d say keep it up! It’s not that people’s choices don’t matter. They do. If you exercise, eat well, get good sleep and manage your stress, you are going to be healthier than if you didn’t do those things. The point is that across the population some people are much more likely, and able, to make those healthier choices than others are. There’s a need for public policy that doesn’t just tell people to make better choices, but that helps create the conditions and provide the resources that enable individuals to make those healthy choices.
How do you convince those same people that Canadians with lower incomes don’t have the same choices and advantages that they enjoy when it comes to health?
No doubt it can be hard to understand what someone else’s life is like and why they make the choices they do. Throughout the book there are anecdotes from individuals alongside evidence from studies. It should be self-evident that someone living in a tent city and depending on charity to eat is going to have a harder time making healthy choices than someone who lives in a nice home in West Point Grey and who has the means to afford healthy food. When we talk about children growing up in poverty, as some 22 per cent of Canadian children do, we can’t really understand the circumstances of their lives as “choices” that they’ve made. And when we observe that the chances that someone will stay healthy and live longer increase at each step up the income and social hierarchy, it’s clear there’s something more going on.
You show convincingly that people in poor neighbourhoods, communities or towns are sick more often and more seriously and die earlier than people in better off neighbourhoods and communities. For example, those of us who live in the Lower Mainland or on Vancouver Island live longer than people in the Interior or north. Every province would have similar examples. Why isn’t this regional and community disparity obvious to Canadians?
It’s tough to generalize. I think most people in B.C. realize that someone living in the Downtown Eastside of Vancouver is less likely to be healthy than someone in a wealthier neighbourhood. But fewer of us in the cities are likely to have a sense of how people are doing in Bella Bella, for example. People in Nunavut have the lowest life expectancy in Canada. How many of us have been there? And even if you’re there, would you notice that people are less healthy? Maybe, but a lot of the evidence on this is statistical and not so easy to observe casually.
You show that higher incomes correspond with higher levels of health outcomes, including the ability to make what most people might recognize as healthy lifestyle choices. But does raising or flattening out income levels for everyone in society necessarily correspond to higher levels of health for everyone? Do we have examples of that happening historically or in other countries?
Many. It’s true of most countries, to a point, that as they get richer on average people get healthier. Beyond a certain amount though it becomes a question of how that wealth is distributed, which is why people in the United States are no healthier than people in Costa Rica, even though the United States is much richer. One of the classic examples is from Britain, where during the decades that the two world wars took place the country saw significantly faster gains in life expectancy than it did before or after. Researchers attribute the gains to a narrowing of income differences and a sense of shared purpose. We’ve seen the opposite happen too, where countries going through turmoil or where inequality is growing see bigger health gaps and declining life expectancies. That’s what’s happening in the United States today, where the life expectancy of working-age men has been dropping in recent years.
Canadians are both proud of and anxious about our health-care system. You write with gratitude about your family’s own critical experiences with it, but you also note it’s under great strain and doing poorly compared to some of the other wealthy countries. Is that a surprise to Canadians?
It shouldn’t be. The Commonwealth Fund has repeatedly found that compared to our peers, with the notable exception of the United States, we’re spending a lot and getting worse outcomes. We’ve had endless rounds of reports and commissions on the state of health care and its future. There are often stories in the news about hallway medicine and incidents where the system has failed. The push for a national pharmacare plan has made it clear that our drug coverage is worse than in many other countries. There’s lots the health-care system does very well, but it’s obvious to anyone paying attention that there’s room for improvement.
You note that much of the money spent on health care in Canada is wasted. You use prostate cancer screening using the PSA test as an example, noting that despite all the money spent and all the anxiety it produces for men undergoing the screening, it saves almost no lives. Can you explain that?
We tend to assume that more care is better care, but that’s not always the case. While there’s much that happens in health care that’s well supported by evidence, sometimes a particular treatment or test will be of little benefit, or worse, it may come with some risk of harm. There are many reasons why people might want it anyway. Perhaps it’s been promoted by the company that makes it or by a patients’ group. Maybe they feel having it will give them peace of mind. From the doctors point of view, they might provide it to appease the patient, or out of habit, or even out of fear of being sued if they don’t. The group Choosing Wisely Canada recommends people ask whether they really need any particular test, treatment or procedure. They need to know what the downsides may be, whether there are simpler and safer options, and what happens if they do nothing. From a public policy point of view, any money that’s wasted on unneeded medical care could be better spent on other social services that really would make a difference to people’s health.
Where else can we save money in health care, and how easy or hard would it be?
One of the main points of the book is that adverse experiences in childhood are connected to a long list of outcomes that it would be better for both the individual and society to avoid. The worse a person’s childhood is, the more risk there is of everything from obesity and diabetes to substance abuse and suicide. If we really want to get upstream and prevent illness, it means doing more to support people who are raising children. It would take pressure off the health-care system and save money, but only in the long term. It requires looking ahead a generation at least. The challenge of course is that governments and politicians tend to instead be thinking in terms of the annual budget and the four-year election cycle.
Where should we be spending more money on health care?
We shouldn’t be spending more on health care. We already spend about 11 per cent of our GDP and 40 per cent of provincial budgets on it. I do think there are areas where the system could do more, including the need for a national drug plan, better access to mental health care and dental care for children. There’s a good argument that improving care for seniors would take some of the pressure off hospitals and emergency rooms. Overall though, the discussion needs to be around how to better spend the money we’re already dedicating to health and what are the things that we can do outside the health-care system that have the potential to help more people stay well longer.
Asking individuals to consider social and economic determinants for health might be intimidating to some people. The very phrase “social determinant” might sound fancy or bureaucratic. And many people feel that there’s little that we can do against these larger forces that affect our lives, and that a campaign “for better health for everyone” seems like a big topic that could go in many different directions. How do you motivate Canadians to act politically for better health? What can they do to bring out a healthier Canada?
I deliberately tried to keep the use of the phrase “social determinants of health” to a minimum. It can be a useful shorthand, but I agree that for many people it sounds like jargon. Instead I tried to present information and stories that illustrate the issue in a way that’s accessible. People can easily understand that some people are healthier than others and that it’s interesting to dig into why that is. As a writer I don’t see my job as motivating people to take any particular political action, but I do want to provide the information they need to understand what’s going on and how things could be different. My hope is to widen the discussion around health, which may in the long run lead to change, but it’s entirely up to people what they want to do with it. I would suggest too that if we adopt a perspective that public policy decisions should all be made with an eye on how they will affect the health of the population, then we’ll start making small changes that will eventually add up and get us where we need to go.
You write that based on your family background, with parents working in health care and pharmacology, you were set for a similar career pathway but instead got sidetracked into journalism. Do you ever regret not following up on a health-care career?
Not at all. I feel lucky to have a job where I can talk with people, read, think, explore ideas and write. It suits me. There are lots of medical people out there who talk about the frustrations of having few opportunities to address the underlying causes of illness. As a reporter, there are opportunities every day to contribute to public discussions we need to have.
‘All Together Healthy: A Canadian Wellness Revolution’ is published by Douglas & McIntyre and available in stores and online now.
https://thetyee.ca/Culture/2018/05/14/Prescription-Better-Health-Canadians/?utm_source=weekly&utm_medium=email&utm_campaign=140518
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