Reflections on Critical Foundations in Canadian Healthcare: Harsh Realities and Hope

It has been a busy fall both personally and professionally this year. Busy is putting it mildly. A supercharged flu season has had virus cocktails cycling through my household, while simultaneously taking the hospital by storm, especially in the emergency department (ED) and paediatric unit. As outlined in the About Me section of my ePortfolio, in September I also began the Master of Health Studies program with a leadership focus at Athabasca University in order to further learn, grow and develop as a healthcare leader. I have almost completed my first course, Critical Foundations in Health Disciplines (MHST 601), and have been spending time reflecting on the lessons I have learned over the last 13 weeks. This course has challenged me to learn in a new way, to build my online literacy, expand my online/social media presence, and to critically evaluate the current and future states of the Canadian healthcare system, while tackling the uncomfortable realities of inequity and systemic racism that continue to exist. Despite some powerful and painful conclusions drawn, it also brings me hope that we are having the right conversations and heading in the right direction.

Image 1. Washington University of Medicine in St. Louis (Dryden, 2020)

One of my first tasks in this course was a self-audit of my social media presence and professionalism, with an evaluation of how I wanted to exist online moving forward. In my first blog post I outlined how I was in a state of transition, from front-line “raw truths” and hospital advocacy to transformative growth and quiet reflections. Since starting this course my use of LinkedIn has increased and I have networked more with other healthcare leaders, my professional Instagram account posts have remained slow, and I still haven’t started using Twitter with any regularity. I am thankful for the push to create an ePortfolio and blog space, as this is something very much out of my comfort zone and I likely wouldn’t have done it otherwise. I enjoy writing blog posts, and I look forward to using this forum for ongoing professional and educational reflections as I move forward in my leadership journey.

As part of the foundation of this course, I explored the definition and social determinants of health. The complexity of the very definition of what we aim to achieve as healthcare workers was eye opening, as was the realization that many of the multiple levels of influence on health are not (easily) modifiable factors. I found that the Government of Canada (2022) identifies 12 determinants of health:

1. Income and social status

2. Employment and working conditions

3. Education and literacy

4. Childhood experiences

5. Physical environments

6. Social supports and coping skills

7. Healthy behaviours

8. Access to health services

9. Biology and genetic endowment

10. Gender

11. Culture

12. Race / Racism

In a blog post, I explored these in the context of the COVID-19 pandemic in the hospital setting and considered the messaging that was given to stay home, stay safe, socially distance and limit close contacts. I reflected on the fact that many of the patients I saw in hospital during the early/peak stages of the pandemic were unable to follow these guidelines based on conditions of their social determinants of health.

At this point in the course, I further reflect that this messaging likely enhanced distrust in the public health system, which was already prevalent in many racialized communities and those with low socioeconomic status. The Public Health Agency of Canada (2021) echoed these sentiments in a report that pointed to historical trauma and ongoing systemic racism and mistreatment of racialized individuals in our current healthcare system, stating that these factors strongly affect vaccine uptake, especially in Black and Indigenous individuals. If a person has no feasible way of following public health measures and they do not feel that they are being protected in any other way (i.e. adequate ventilation, paid sick days), it makes sense that they would feel undervalued or expendable. Not for the first time during this course, it has me critically evaluating how “universal” our healthcare system really is, and what can be done differently to achieve this universality in the future (tackling systemic racism head-on is a good start).

Building on these earlier concepts, I was challenged to apply a social ecological model of health (SEM) to a relevant health issue in my profession (CDC, 2022). Fueled by my passion for patient and staff safety at my organization heading into the fall/winter surge months, I wrote a blog post applying the SEM to address a question: how can the Ontario health care system better support end-of-life care for people living with chronic conditions in the community? By investigating the multiple levels of influence affecting our patients when they seek our care, I gained a deeper understanding of why individuals living with chronic conditions find themselves returning to our overcrowded ED again and again, especially as they near the end of their lives. The answer to my question is not a simple one (though neither is the question). We as healthcare workers, leaders, and policy makers need to understand the many factors at play affecting our patient's presentation, focus efforts on preventative and supportive medicine in the community, breaking down barriers, inequity and stigma, reversing systemic racism, and above all else, prioritizing honest conversations about chronic conditions, disease trajectory, and patients' true wishes for how they would like to spend the rest of their lives.

After writing my SEM post, the course encouraged me to take a deeper dive into prevalence, funding and management of chronic diseases in Ontario. Through this lens I learned about chronic conditions in a very different way. According to Public Health Ontario (2019), four main chronic diseases (cancer, cardiovascular disease, chronic lower respiratory disease and diabetes) caused almost 64% of deaths in 2015 and led to a cost of approximately $10.5 billion a year in Ontario. The same report noted that chronic disease risk factors are very common in Ontario, citing that in 2015/2016, a mere 12.7% of adults and 7.3% of youth surveyed were found to have none of the risk factors. This underlines the validity of considering chronic disease management strategies as a method to better serve our patients and in turn offload the hospital system in the long run. In order to be effective, prevention and management efforts considering modifiable risk factors would need to also put emphasis on the social determinants of health that affect them.

Figure 1. Causes of death in Ontario (Public Health Ontario, 2019).

An overarching theme throughout this entire course was encouraging conversations about uncomfortable truths within our healthcare system as it relates to inequity. I found an interesting article by Clark and Preto (2018) about the concept of vulnerability, in which they described groups deemed "vulnerable" to health inequities based on impact of social determinants of health: Indigenous people, people with low income and level of education, people living in rural and remote communities, and individuals who have immigrated to Canada. The authors outline the nuance and sensitivity of this subject, explaining that stigma and power dynamics can complicate matters, with the ability to worsen inequities rather than equal the playing field, as is the intent. They go on to challenge readers to consider that "vulnerable" doesn't mean worse or less-than, and language is important, as is the understanding that it is necessary to address inequities for vulnerable populations without shame.

I chose to focus further on low-income populations, as I have seen firsthand the difference in health outcomes for aging seniors living in poverty vs those with accessible, steady income late in life. It is important to note that according to the 2016 Canadian Census, over 20% of racialized Canadians were considered low-income rather than approximately 12% of non-racialized individuals (OCASI, 2022). Health Quality Ontario published a report in 2016 exploring the impact of income on health outcomes in Ontario. The report described clearly that individuals with lowest incomes had worse health outcomes than individuals with high incomes. Smoking rates, amount of physical activity, and fruit and vegetable intake were all significantly impacted by income. The hospitalization rate for people living with conditions that can be managed in the community were 2.5x higher for low-income individuals compared to high-income individuals. The realization that income has such a direct impact on an individual's health and access to quality healthcare was profound. I found this powerful related TEDx talk video with a refreshing perspective by a Toronto physician, considering poverty as a disease and addressing it as such in the context of healthcare.

Video 1. Dr. Bloch TEDx video.

Fittingly, the last focus of this course was on future directions of healthcare. I found a report from Shaw and colleagues from the University of Toronto (2020) about the future of healthcare with respect to technology and equity. This report summarizes five discussion topics from a symposium held one year prior:

1. Access to technology is not universal, which can cause further healthcare inequities if not addressed.

2. Technology is not the solution to every issue currently in healthcare (the authors discuss social determinants of health, impact of poverty and homelessness for example).

3. As new technology is developed and healthcare's technological future takes shape, equity deserving groups and vulnerable populations should be considered as key stakeholders in decision making

4. The needs of patients and their caregivers should be the main focus of digital healthcare

5. Digital healthcare needs to consider information sharing throughout the healthcare continuum and serve to close the gap in communication between different sectors which currently exists. Systemic issues such as antiblack and Indigenous racism also need to be addressed.

The authors go on to urge the Ontario Government to take action by addressing social determinants of health and inherent inequities in healthcare delivery in order to realize a new, digital, inclusive healthcare system in Ontario for the future. I find this is an excellent summary of important considerations moving forward and brings many of the learnings of this course together.

Starting a post-grad degree 10 years after finishing physiotherapy school has been an exciting, challenging balancing act. This first course was set up in a way that allowed for discussion and deep reflection about the ways in which our healthcare system falls short, and the extent of systemic inequities that exist. We have a LONG way to go before actively addressing social determinants of health and being able to achieve anti-racism in our country in any area of focus. These conversations are the tip of the iceberg. As frustrating as it is that parts of the country fail to acknowledge our current reality, I find that the effort of starting this work is genuine and widespread in this country. The fact that these discussions are embedded in course content for healthcare leaders (and are being had regularly on leadership calls in my organization) brings me hope. Technology allows for widespread sharing of powerful messages and opinion pieces in a way that didn't used to be possible. It is getting harder to ignore the systemic issues we face. There is a lot to be discouraged about as a healthcare worker right now, and there is a lot to be fearful of heading into the winter months-- but there is a lot to be hopeful for as well.

References

CCO and Ontario Agency for Health Protection and Promotion (Public Health Ontario). The burden of chronic diseases in Ontario: key estimates to support efforts in prevention. Toronto: Queen’s Printer for Ontario; 2019.

Center for Disease Control and Prevention. (2022, January). The social-ecological model: A framework for prevention. Retrieved on October 19, 2022, from https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html.

Clark B, Preto N. Exploring the concept of vulnerability in health care. CMAJ 2018;190:E308–9.

Dryden, Jim. “Podcast: Racism as a Public Health Issue.” Washington University School of Medicine in St. Louis, 1 Nov. 2022, https://medicine.wustl.edu/news/podcast-racism-as-a-public-health-issue/.

Health Quality Ontario. Income and Health: Health Equity in Ontario. Toronto: Queen’s Printer for Ontario, 2016.

“New Fact Sheets Show Growing Racial Disparities in Canada.” OCASI, https://ocasi.org/new-fact-sheets-show-growing-racial-disparities-canada.

Public Health Agency of Canada. “CPHO Sunday Edition: The Impact of Covid-19 on Racialized Communities.” Canada.ca, Government of Canada, 21 Feb. 2021, https://www.canada.ca/en/public-health/news/2021/02/cpho-sunday-edition-the-impact-of-covid-19-on-racialized-communities.html.

Shaw, J., Chandra, S., Gordon, D., Bickford, J., Fujioka, J., Yang, R., Griffith, J., Gibson, J., & Bhatia, S. (2020, September). Digital Health Technologies for More Equitable Health Systems: A Discussion Paper. Toronto; Joint Centre of Bioethics University of Toronto.

YouTube, 18 July 2013, https://youtu.be/FLRT0bvaz98.