My electives adventure all started by securing a spot with the University of Toronto’s Health of the Homeless elective, and building the rest of my schedule around it. Even knowing what we do about the connection between social determinants (such as income, housing, race, and gender) and health, I had never seen another medical elective specifically designed to address the populations most in need of medical services.
Inner City Health Associates (ICHA) is a group of over sixty physicians dedicated to providing care to those who truly need it most – those without housing, without income, without identification, and often with complex health struggles for which they have been repeatedly refused care. Our existing system has been carefully built to ensure that those who could stand to benefit most from health care are effectively barred from accessing it. For example, even in our “free” Canadian healthcare system, care is extremely difficult to access if you do not have proper identification, like a provincial health card. However, in order to access a health card, you need proper identification… Hang on a second. Something isn’t adding up…
ICHA docs see this paradox and work to correct it through education and advocacy at all levels of the system (the public, policy makers, and other healthcare professionals), reminding people of the undeniable connections between things like income, housing, and health.
Higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.
— World Health Organization
I say “remind” because we first learn about the social determinants of health as early as UNICEF Halloween presentations back in Grade 1 (or if you’re evangelical by trade, then World Vision sermons before you were even out of the womb), where we are taught that poor kids are sick and need our help. Crude and incomplete, but built around an important truth: Poverty contributes to a lack of health. And many factors contribute to poverty. “The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels” (World Health Organization, 2017).
When I am one of the privileged wealthy (and by that, I mean I can read, have stable housing, food in the fridge, safe drinking water, and a physician who won’t refuse to see me because of my housing/sexual orientation/age/illness), I need to look at how I am contributing to – or at the very least, not working to change – those factors contributing to other people living in poverty.
And this is what moved me most about the ICHA docs. Their ultimate goal is for public perspective and the Canadian healthcare system as a whole to shift towards a system that is truly equitable, accessible, universal, portable, and comprehensive (hmmm… sound familiar?) So ICHA docs are dynamic teachers in the hospital, devoted mentors of medical students, passionate advocates on Parliament Hill, and constantly working with policy makers to encourage systems level change (I myself had the privilege of attending a breakfast meeting with the Law Commissioner of Ontario to discuss a new policy of palliative care). But in the meantime, if they cannot convince others to join them in providing quality care to those who need it most, they just go out and do it themselves.
For example, I worked with 2 physicians at a refugee health centre, a tiny room nestled within a shelter for newly arrived refugees. For many who have arrived in Canada fleeing persecution, there is a lag between when they arrive here and when they have their court hearing to actually receive their refugee status (ironic, because these individuals have been experiencing persecution for years, but are only recognized as a refugee once they are safe in a country defined as free from persecution). This lag, which can be many months, is a time of immense vulnerability for these folks, since they are not only fleeing immense trauma, not only adjusting to a new culture and climate, and not only trying to accomplish the daily tasks of living we all must do (families have to eat, kids have to get to school, spouses occasionally want to talk), but if they get sick, accessing healthcare can be immensely complicated (remember the ID/health card shenanigans described above??) Furthermore, it’s not just the usual pneumonias and UTIs that can get them down. Many come from countries where immunizations were unreliably accessible and where certain infectious diseases and genetic conditions are much more prevalent. When you are focused on daily survival in a refugee camp, screening for genetic blood conditions may not seem high on the list of priorities. But when you trying to live peacefully in Canada with hopes of surviving past age 45, suddenly that condition takes on a new importance.
In every new clinic I worked in (and I had the privilege of working in many… too many for a single blog post!), I made a point to ask the physician “How??” How did they end up here? How did they get the funding, the building, the equipment organized? How did they make it a reality to provide care to a population where literally no care existed? And their answer was almost always the same. They’d shrug and say something along the lines of, “Well, I knew it had to be done… so I just did it.” For the incredible docs at the refugee clinic, “just doing it” included rummaging in the basement of the major TO teaching hospital for discarded but still usable supplies. It meant 2 docs carrying each end of an old examination table to get it up the street from one clinic to this one. It meant these same 2 guys coming in at midnight after their workday to paint the new clinic room themselves. It meant them going to hospitals and administrative boards and other physicians and saying, “It would help so much if you could provide funding and staff. But if you can’t, we’re going to be doing this work anyways.” They continue to volunteer their time one day a week to provide healthcare to undocumented refugees who simply could not receive care anywhere else, and they also donate their money earned on other days to an emergency fund for their families who cannot afford their prescription medications.
I met psychiatrists who literally went into ditches and bus shelters to provide emergency mental health care where it is so desperately needed most. I worked with a palliative care doc who zips around Toronto in his little car, bringing comfort, dignity, and company to beautiful people who would otherwise be dying alone in back alleys and basements because they were refused care everywhere else. I carefully stepped around and over bodies jam-packed into a shelter common room to get to a woman so ill with uncontrolled diabetes that she could not come up to the clinic to be examined. On my first day working with one doc, they handed me a copy of their own personal Manifesto of a Revolutionary Practitioner.
“I only realised at age 60 that I needed to articulate my vision for practicing Medicine,” they told me. “I hope you will write your own much sooner than that.”
As a skilled professional, so much has come to me – opportunity, education, mentorship, social standing, income (one day!) Have I worked hard for it? Absolutely. But me working hard is not the point. We have put barriers in place to stop people who need care from coming to us. So the time has come for us to go to them.
What can we practically do? Most importantly, start to notice our own reactions to people who are homeless, poor, struggling with health problems. These are not the people we should be uncomfortable having in our hospitals – these are the people who most need care. Next, take the opportunity to start conversations with friends or families who may talk about the vulnerable people in our communities less than kindly. Heck, send them to read this blog! When you vote, look at how your representative talks about things like housing, access to clean water, autonomy for Indigenous populations. We know that upstream action ultimately is most profitable for all involved (sorry guys, “trickle down economics” isn’t a thing; actually, the opposite is true**), so make sure we’re supporting policies that will support all of us. And ultimately, I want to remember the ICHA docs: If something needs to be done, maybe we just need to do it.
In other words, if you find yourself painting a clinic at midnight, give me a call – I’d love to join you 🙂
** The IMF and the OECD have found that there is an inverse relationship between the increasing income share of the wealthiest and overall economic growth. If the income share of the top 20 percent increases by one percentage point, GDP growth is actually 0.08 percentage points lower in the following five years, suggesting that the benefits do not trickle down.
— Shimman & Millar, 2017