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Health as if everybody counted blog

guest blogger Sarah Giles

guest blogger Sarah Giles

Sarah Giles is a family physician with an interest in remote and rural medicine. She has worked in both the Canadian north and Western Australia. Sarah's interest in refugee health was piqued while working at the hospital on Christmas Island (home of Australia's off-shore detention centre).

So you think you have free health care?

Posted by guest blogger Sarah Giles
guest blogger Sarah Giles
Sarah Giles is a family physician with an interest in remote and rural medicine.
User is currently offline
on Tuesday, 09 October 2012
in CHNET-Works!

Many doctors do not openly discuss the social determinants of health. It's the dirty little secret of Canadian medicine: income makes a huge difference to your health. In the land of "free" health care, living in poverty is still going to have the biggest effect on a patient's health.

At the recent Canadian Medical Association annual meeting in Yellowknife, doctors finally seemed to acknowledge the poverty=poor health situation. Why has it taken so long for doctors to acknowledge the problem? A cynic might say that it is because the vast majority of doctors come from privileged backgrounds, have an income in the top 5% of Canadians, and generally don't care about or understand the poor. A more forgiving person might argue that, coming from such privileged backgrounds and having little to no formal teaching on the subject, many doctors are unaware of the devastating impact of poverty on their patients. And, in fairness, some doctors do not get much exposure to the poor.

A wise physician once told me: "If you don't know your patient's financial situation, you don't know your patient." Truer words have never been uttered. Yesterday I saw a wheezing little boy in clinic. He is a known asthmatic who had not taken his puffers in 3 months. It would have been easy to dismiss the mother as lazy and "non-compliant". Instead, the aunt (who recently gained custody of the little boy), explained to me that she was now looking after 4 children and could not afford the insurance co-pay on these potentially life-saving medications. She didn't qualify for income support and she had insurance – but she still couldn't afford the medications. So much for universal health care.

Patients with low socioeconomic status face a number of challenges within our system. For the homeless, the first challenge is getting a health card. You need a fixed address to get one and then the organizational skills to hold on to it and renew it every few years. Small wonder that the homeless go to the ER more than almost any population – that's the only place they will be seen without a health card.

Let's say that you are on income support or disability. Your health should be good, right? You likely have housing, get your meds covered, and can even access some allied health resources. But can you afford to eat? Studies show that, actually, in Ontario you can't afford to eat a healthy diet on income support. And, even if you could, you likely live in an area where there are lots of expensive "convenience" stores but very few places to buy fresh produce or healthy foods with a short shelf-life. It's much easier to buy crappy food than anything with nutritional value. So, you put on some weight and develop diabetes. Your meds are covered but since your family doctor isn't part of one of those fancy health teams that you get in rich neighbourhoods, you can't access a dietitian because you Community Health Centre hasn't been able to fill the position and all of the other dietitians charge $70 per hour to tell you what you already know – eat better (more expensive and inaccessible) food.

giles-guest-blog-pic-1 giles-guest-blog-pic-2
Healthy foods are available in some low-income neighbourhoods,
but often "it's much easier to buy crappy food."
Photos: T. Schrecker

Now let's pretend that you have developed crippling insomnia. You can't sleep. You got fired from your last job for falling asleep during the day because you couldn't sleep at night. You are now on income support but that's going to run out soon. You are sure you could get back into the work force if you could just sleep six hours per night. You have tried trazodone and amitriptyline – the infamously ineffective sleep aids – but they didn't work. Your doctor now gives you an option: try zopiclone – a sleep aid that works and has little addictive potential – or try clonazepam – a highly addictive benzodiazepine that requires higher and higher doses as your body becomes habituated to it and a drug with considerable street value. The choice is obvious, you want zopiclone. Unfortunately, the provincial formulary will only cover the highly addictive medication with a street value. Zopiclone will cost you at least a dollar a day – a dollar you don't have.

Nobody ever claimed that life was fair. It is intuitively obvious that the more money you have, the more access you have to goods and services. But should money make such a difference that it can determine how healthy you will be or how long you will live? If we, as Canadians, want to continue to be proud of our "universal" health care, we need to make some changes.

Provincial and non-insured health benefits (NIHB) formularies are set by a bunch of experts sitting in a room. The formulary, to those of us in practice, seems to be arbitrary. There is no explanation as to why one drug is covered and another is not. Recent drug shortages have made life even more difficult as drugs that I would commonly substitute in for a short drug are often not on formulary (for instance, amitriptyline is covered but we couldn't get any; gabapentin is not covered for anything other than seizures so I had nothing to give my patients with neuropathic pain). I'm not sure why we need ten drugs in one category covered when we could have three instead, buy in bulk, and use those savings to incorporate other drugs into the formulary.

Provincial and NIHB formularies need to help doctors decrease addictions to opioids and benzodiazepines. They could do this by covering medications that are currently believed to be less addictive. For instance, I can prescribe OxyNeo (the new version of Oxycontin) until the cows come home but prescribing a long fentanyl patch or long acting codeine requires special forms. Doctors can prescribe massive doses of narcotics but need a special license to prescribe the meds required to help people break their addictions (Suboxone and methadone). Certain non-steroidal anti-inflammatory drugs (NSAIDs) require special permission but massive doses of benzodiazepines don't raise flags in the system. Private insurance fills these gaps for many patients, but creates a two-tiered system.

When poor people get injured their lack of access to out patient allied health services (such as physiotherapy) and non-addictive medications decreases their chances of returning to the work force. If outpatient allied health services were easily available to patients, they would be able to get off of income support faster and be less likely to remain in chronic pain.

Imagine if the thousands of people off work for mental health reasons were able easily to access free psychological help? In Ottawa, the going rate for a psychologist is $160/hr. I know of very few people who can afford this. If they could afford it, many people could remain in the work force or stay off of the streets. Instead, we rely on NGOs to provide care that should really be universally available.

In short, I'm sick of being a doctor who sees such discrepancies in the availability of care, medication, and overall health status between the poor and the rich. I am glad that the CMA is finally taking note of the problem – but how are we going to address it? Having the current Canadian government pull the social safety net out from under those who have the most precarious balance is not going to help matters. Is it only a matter of time before I recommend that patients find a way to get sent to jail so that they can get the medication, rehab, and care they require? There has got to be a better way.

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The Unkindest Cut

Posted by guest blogger Sarah Giles
guest blogger Sarah Giles
Sarah Giles is a family physician with an interest in remote and rural medicine.
User is currently offline
on Thursday, 05 July 2012
in CHNET-Works!

In the face of the Harper government's proposed cuts to refugee health care, there has not been a massive outcry from the nation's doctors. Certainly, we have heard from a vocal minority of individuals, such as the 80 doctors who briefly occupied cabinet minister Joe Oliver's Toronto office on May 11, 2012 and those who participated in a national day of protest on June 18, 2012 (about 400 people in Ottawa and others scattered across the country), but, in general, the response from doctors has been underwhelming.

First, it's important to highlight that the major associations of health care providers (Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, College of Family Physicians of Canada, Canadian Nurses' Association, Canadian Dental Association, Canadian Pharmacists Association, Canadian Association of Optometrists and Canadian Association of Social Workers) have signed a position statement in which they have asked the federal government to rescind some of the proposed cuts to the Interim Federal Health Program (IFHP). IFHP, for those who are unfamiliar with it, is a program that provides health care funding from federal coffers until a refugee is eligible for coverage under provincial programs.

Despite the federal government's assertion that IFHP provides refugees with "superior health care" in comparison to other Canadians, the program only actually provides essential and emergency health services to treat and prevent serious medical conditions such as prenatal care, some vaccines, and essential prescription medications should a refugee be unable to afford such items. Yes, eyeglasses and a few other services such as limited physiotherapy are provided, but the program is not overly generous as is quite similar to programs for Canadians on income support programs.

The federal government naïvely suggests that its proposed cuts will save Canadians $100 million. Refugee health problems will not go away; instead, they will fester untreated until they become a medical emergency that lands these vulnerable people in the emergency room.

Here's a quick (fictional) example of how this program will cost Canadians more money and cause refugees' health to deteriorate. Havinder is a refugee who is an insulin-dependent diabetic who has been stable on his medications for some time. On July 2, he runs out of insulin but cannot afford to buy more. He tries to drink more water and walk more to decrease his sugar levels, but as the week goes on, he feels worse and worse. He is unable to attend work because he is lethargic. He can't sleep because he is urinating every thirty minutes. He develops a terrible headache that he can't shake. Havinder goes to bed on July 7 and on July 8, his wife can't wake him up. An ambulance is called; he is taken to the local emergency room where he is quickly diagnosed with an advanced case of diabetic ketoacidosis. He is admitted to the ICU and remains in hospital for two weeks. The federal government refuses to pay for his care, so the provincial government (which is responsible for hospital funding) is forced to cover the cost of the two weeks in hospital as there is no way that Havinder can pay the twenty thousand dollar hospital bill. Havinder is discharged home with prescriptions that he cannot afford to fill and the cycle starts all over again.

The health care providers in the hospital understand that Havinder's entire $20,000 hospital stay could have been avoided with a $20 vial of insulin. They appreciate that Havinder has had a needless brush with death and that there may be some permanent sequelae. The hospital staff, at least in the short term, will still get paid. They may shake their heads at the insanity of policies behind the new policy, but it won't affect their finances until provincial taxes go up to cover the short fall in hospital budgets.

Doctors working in refugee health clinics around the country will be forced to evaluate how they can continue to provide services when they will no longer be paid by the IFHP. They will wonder whether there is a point to seeing patients who will never be able to afford the services and treatments that the doctors will recommend. They can treat pneumonias and prevent infectious disease with drugs and vaccines – but how can doctors do this when there isn't any funding available to procure such items? They will know that having unvaccinated refugees will cause a significant public health risk through the erosion of "herd immunity".

So, doctors certainly understand that the health of refugees, and indeed the health of the general public is at risk with these proposed cuts, but very few of us are actually actively speaking out or protesting. Why is this?

First, we must examine those who become doctors in Canadian society. We know from many studies that doctors overwhelmingly come from high income earning families. Most, though certainly not all, doctors have never had to consider forgoing a prescription in order to buy food. Most doctors were accepted into medical school by doing well in undergraduate classes and not rocking the boat. Most doctors are people pleasers who have gone to great lengths throughout their training to jump as high as humanly possible when commanded to – often without thinking about why they were asked to jump in the first place. The medical establishment rewards with promotions and positions of power those who do not threaten the status quo. There are very, very few (at least openly) radical doctors. Perhaps those doctors who occupied Mr Oliver's office are the only politically active doctors in the entire Greater Toronto Area?

Or maybe doctors feel beaten down. We are essentially civil servants – the provincial government sets our wages, tells us whether or not there is funding for another hip replacement surgery, and dictates that we are not eligible for vacation pay, benefits, or pensions. In Ontario, doctors have just received a substantial pay cut and they were not able to participate in that decision making process. Maybe we just feel that governments are not listening to us.

Doctors have used the term "evidence-based medicine" for some time. We try to use science to dictate our practice rather blindly doing what has worked in the past. If interventions are shown to be expensive and ineffective, we do our best not to use them. W why are Canadians, especially doctors, willing to endure non-evidence based politics. We know that the cuts to the IFHP will hurt the most vulnerable members of Canadian society. We can guarantee that provincial health costs will rise far more than the supposed savings at the federal level and yet, very few of us are raising hell about the issue.

We need to stop depending on our organizational bodies (the Canadian Medical Association, RCPSC, etc.) to represent our patients' rights. We need to stand up and demand that the federal government protect our most vulnerable patients. Our organizational bodies look after doctors' concerns and will put out the odd position statement to support patients, but it is not their primary responsibility. We, who are educated and well compensated, need to press everyone we know to stop this disastrous change in policy. This cut makes no sense on any level – be it fiscal or compassionate. Let's rally the troops and help keep Canada a place where we are proud to live and practice.

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