Wednesday night September 15, 2021, Matt Galloway, host of CBC’s The Current,* set up at the Old School Community Gathering Place in Musquodoboit Harbour to produce an extraordinary and sometimes heartbreaking show about the problems facing rural healthcare, in Nova Scotia and across Canada. For more than two hours, we heard testimony about both problems and solutions from patients, survivors, doctors, nurses, social workers, and community volunteers.
The most challenging testimony about policy came from people who argued that solving the problem was much more than just throwing more money at the existing system of medical care. As Einstein famously pointed out, we cannot solve such large-scale problems by looking for solutions within the framework in which our society created these problems.
And the speakers agreed that the first step in creating a new framework was to recognize what several called “the social determinants of health.” Chris Parsons, the provincial coordinator of the Nova Scotia Health Coalition, said that in adopting universal health care, the country had made a huge promise to all Canadians, that everyone would have access to good medical care. However, good medical care is not the same thing as good healthcare, which includes access to and support for housing, food security, and mental health.
The inadequacies of many other social programs have in effect collapsed onto the healthcare system, which was never designed, staffed, or funded to deal with the negative consequences of not providing access to services in these other areas. Instead of medical care being part of a larger system of social support, our medical professionals end up having to address the combined effects of all these ills.
A host of volunteers have stepped up to staff non-profits (including the Old School) as well as working within hospitals and nursing homes. In many communities, these volunteers are the people directly dealing with homelessness, food security, and mental health, and providing much of the preventive care, including workshops on healthy nutrition, mental health, stress reduction, and the like.
What’s needed, both in the volunteer community and in the current medical system, are ways to offer people a team-based, “wrap-around services” approach that integrates attention to all the social determinants of health.
But what would such a system look like? As it happens, the New Yorker magazine published an article at the end of August about just such a system in Costa Rica that has produced impressive results. In his article, Dr. Atul Gawande, a Harvard Medical School professor and a New Yorker staff writer, answers the question, “Costa Ricans Live Longer Than We Do. What’s the Secret?” Costa Rica is not a wealthy country. Its per-capita income is only one-sixth of the U.S., and its per-capita health care costs are far lower.
Gawande shows that Costa Rica has achieved such good results because it developed a team system that integrated medical care with public health. In Costa Rica, every person has a local primary-healthcare team that includes a doctor, a nurse, and a trained community-health care worker. The teams make regular, scheduled visits to every home in their area. There is a geo-referenced electronic file on most households that includes not only medical updates but notes on living conditions. And the cost of this type of program is much less per capita than what Canada spends.
Models for such an integrated teams approach exist in rural healthcare clinics in some parts of Canada, where medical care is only part of the services offered. And from the very challenging stories we heard on The Current, access to follow-up care, preventive measures, including nutritional support, mental health services, more social workers and adjunctive therapies can improve the poor prognosis for the current system.
Finally, one of the things that was striking from those who spoke was the powerful aversion to any suggestions that the solution to the current situation was to privatize. The private system will peel away patients who can pay and the medical staff who could serve them, leaving the public system with fewer staff and greater challenges from ill patients with multiple concerns. You only must look across the world’s longest non-militarized border to see the inhumaneness of a public/private system.
Is developing the wraparound, team-based community-serving approach too expensive? Consider the imminent cost of a collapsed system.
*You can listen to the archived program on the CBC website at: https://www.cbc.ca/radio/thecurrent/the-current-s-forum-on-access-to-health-care-and-fixing-the-system-for-patients-and-workers-alike-1.6177056