Dr Jeffrey Turnbull: Addressing the Social Determinants of Health in a new Health Care Environment

Dr. Turnbull's talk last week at the Desmarais Building was the first in the University of Ottawa's President's Lecture Series. Dr Turnbull spoke to a full house of physicians, scientists, University faculty, students and stragglers like us. No surprise there.

I have been very impressed with Dr. Turnbull's work, especially at the Ottawa Mission, and was eager to hear him speak. Since his topic was the social determinants of health, and given that he serves the same population we sometimes see in the Library, I thought it would be valuable to hear his impressions and recommendations. This post is therefore a bit outside the scope of this blog in some ways, but very much not outside the scope in others: one of my primary interests has always been Library outreach to marginalised populations. You'll see that several of Turnbull's points below have implications for libraries: how can we appropriately (and best) support the health of all people in our communities through our collections, services and programs? With the below in mind, why not ask them?

Dr. Turnbull structured his talk around the "Top 6 ways to stay healthy:"

1. Don't be hungry:
   In a country in which 868 000 Canadians use the food bank every month, many live great distances from a grocery store (on foot), many cannot afford fresh fruits and vegetables (see Ottawa Public Health's "The Price of Eating Well"), and those living in shelters may not have access to a kitchen to make their own meals, proper nutrition is still a tremendously large problem.
   
   
2. Live in a nice community:
   There will be 1000 people sleeping in shelters in our city tonight. Very shortly, the shelters will begin putting out the mattresses in chapels, hallways and washrooms for the night; it's only October and they are already doing this (it's not even winter yet!). For those who do have a home, 3.1 million of them cannot afford their housing, and another 1.3 million are living in subsidised housing. There is a 21 year difference in average life expectancy between the poor and the rich; in cramped shelter quarters, it's easy to see how infections and illnesses can be spread quickly.
   
   
3. Get a good education:
   There is a 25% illiteracy rate in the poorest bracket of Canadians; there is a 31% illiteracy rate on reserves in Canada. For more information, see ABC Canada's Adult Literacy Facts and a 2006 CBC News Indepth report. As CBC says, "Nearly 15 per cent of Canadians can't understand the writing on simple medicine labels such as on an Aspirin bottle, a failing that could seriously limit the ability of a parent, for example, to determine the dangers for a child." And as ABC Canada observes, "Literacy proficiency improves chances of employment, builds self-confidence and enables discussions and actions that affect the welfare of individuals and their community."
   
   
4. Get a good job:
   6% of Ottawans don't actually make enough money to live in Ottawa. Many are living on the poverty line, or below it, while supporting their families.
   
   
5. Get good health services:
   21% of homeless people in Ottawa shelters are HIV-positive; 80% have Hep C (for more general numbers, see Ottawa Public Health). There is a higher risks of contracting disease in Ottawa shelters, and in many of our poorer areas; in fact, the incidence of TB is lower in Bangladesh than it is on some Canadian reserves.
   
   
6. But above all else, be wealthy:
   "The commodity of your wealth is your health," Turnbull says; "Money can't buy happiness, but it can certainly buy your health." In fact, the biggest predictor of health is your economic status.
   

So what are the implications of the above Top 6 list, and the attendant issues in Ottawa, for health care?

• Isolation = social stratification. There are increased risks when people are crammmed in confined spaces together, resulting in diferential exposure of certain groups... We act surpsied when there is higher incidences of illness among certain populations, but isolating those populations together has increased the risks for them.
• The idea of health care as a public service: This is one way of "levelling the playing field," but is it sustainable? The current health care system was not designed for the 21st century: it was designed on an acute care model, except now we see increased needs for chronic care, and increased numbers of chronic care patients. Observes Turnbull, "we use the chronic care sector as the default for meeting acute care needs."
• Accessibility: ever waited for lab results? It takes awhile, and that's in an urban area, never mind in a rural area or on a reserve. Compared to other first world countries, "we are a bottom-of-the-pack perormer," despite high spending on health. In fact, health spending gobbles up funding that could perhaps better be routed to preventative measures, such as improving social or educational services, which would in turn improve health ("I just put myself out of a job"). As Turnbull phrased it, "healthcare is the monster eating everybody's lunch!"
• The CMA wants to mobilise Canadians to "press for transformative chaneg to Canada's healthcare system," including 5 pillars of change: "building a culture of patient-centred care, providing incentives for enhancing access and improving quality of care, enhancing patient access across the continuum of care, helping providers help patients, and building accountability at all levels."
  
• Our Canadian emphasis on equity of access to and delivery of health care expresses our values, ensures human rights are protected, and saves money (for more information about the economic consequences of health inequality, see "The economic burden of health inequalities in the United States").
• We should thus shift this debate away from a conversation about providing charity towards a conversation about protecting the rights of citizens (who are entitled to protection, as enshrined in law and with respect for their human rights).
• The outcomes of treatment in this manner include improved compliance, appropriate use of medical services (hospital, EMS), and a 64% reduction in risk behaviours, including substance abuse.
  

Dr. Turnbull spoke about the Ottawa Inner City Health program (of which he is co-founder and Medical Director). You can read a full history of the group here, but as Turnbull explained, it was born out of concern that, while many homeless people were using health services on disproportionate levels, their health needs were still not being met. The co-founders began to ask, what about other related services that the homeless clients might need, such as judicial and social services, etc?

As Turnbull concluded, Canadians can "do better," can serve homeless and marginalised groups better. The model that he envisions is to make the services a homeless person receives "equal to what an individual family would get in their home." It is our collective responsibility to advocate for health equality by advocating for "informed social policy decisions, effective health delivery systems for prevention and care, anti-poverty measures, direct health care services, and positive social change through healthy public policy."

I was fortunate to have a chance to speak with Dr. Turnbull after his talk, and let's just say we have a possible partnership up our sleeves......

A great event.