The Health Advocate Role (cont.)

Preparing future physicians for socially responsive practice

Why Health Advocacy?

The Romanow Report proposes “sweeping changes” to make the healthcare system “more responsive and efficient as well as more accountable to Canadians.” This has raised important questions concerning the education of health professionals,  particularly within the context of recent discussions in Canada around primary care renewal and ensuring the provision of necessary services to disadvantaged populations. In Canada, approximately 1.6 million individuals live in poverty; and child poverty is highest in BC, with nearly one in four children living below the poverty line. Chronic poverty has harmful effects on children’s health, with socioeconomic status being a key determinant of health out- comes and of the appropriate use of health services. In their detailed examination of the in- equities in health and healthcare experiences among disadvantaged or vulnerable populations, Shi and Stevens broadly define vulnerability to include various social, economic, political, environmental, and biological conditions that prevent people from protecting their own needs and interests. Vulnerable populations experience worse health outcomes, higher rates of morbidity, and barriers to care; inappropriately use health services; and have little control over the conditions that contribute to their circumstances.

Healthcare practices and policies that fail to consider ways of addressing disparities and the healthcare needs of marginalized populations are unlikely to have the desired impact on health outcomes. Reducing health disparities and promoting equity for vulnerable populations in Canada is thus an essential imperative underlying the Canada Health Act. Yet, inequities continue to influence and plague the health of Canadians and the Canadian healthcare system. A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health indicates that, although improving socio-economic conditions is essential, health services can play a key part.understanding social inequity and maldistribution of wealth are thus two vital aspects of understanding ill health and disease. Most of the resources we have provided here are an attempt to do this.

In order to act within the capacity of health advocate, physicians and physicians-in-training need to ac- knowledge and appreciate the role of the social determinants of health. As educators we must also take the time to critically evaluate our own experiences and understanding of social determinants and how it impacts health status.

Below we offer problem-based case studies and resources to aid medical educators better integrate the concept of health advocacy into the curriculum.

Teaching Health Advocacy: Starting Points

In our experience, teaching and learning about HA is most successful using a participatory approach, that is, by working closely with our communities, medical residents and students in developing key learning objectives and outcomes. The aim is to create educational opportunities that will enhance the learners’ knowledge and skills around the social determinants of health, health promotion, principles of social justice and advocacy, and effective community engagement strategies. The intent is to nurture a sense of social responsibility and social accountability for responding to the inequities in healthcare and the needs of those people in society who are rendered vulnerable because of various social, economic, political, environmental, and biological influences that prevent them from protecting their own needs and interests.

Using a participatory and inclusive process, begin with opportunities for dialogue and discussion. Create several opportunities for residents to discuss HA initiatives and how the curriculum can best foster opportunities for social awareness and responsibility. Convene faculty, residents, staff, and clinicians to collectively examine issues, conduct literature searches and environmental scans, develop priorities, explore partnerships with community-based organizations, and consult with health authorities.

The first session may begin with a small group of faculty and residents identifying HA related issues within your discipline, what existing initiatives are underway at the local and national levels, and how to get involved. For instance, there are several opportunities and efforts underway in the areas of maternal and child health, inner city health, mental health, child rights, men’s health, access to care, trauma, homelessness, adverse outcomes, and medical errors - these are just a few examples.

Charity vs. Social Justice approaches to HA

Explore the differences between charity conceptions of HA with one based in social justice. Many HA efforts tend to take an almost exclusively charity based approach – providing services or relief to people who are in desperate need. Charity based HA activities tend primarily to be based on the “good Samaritan” concept – providing resources, time, knowledge, and clinical service to vulnerable people. A charity based approach is not only difficult to sustain, it creates a dependency relationship. Charity approaches can be seen simply as band-aid solutions that do not address the root problem of health disparities. A social justice approach, on the other hand, requires residents to focus their efforts on understanding and working to change the structural or institutional factors that contribute to inequitable conditions. HA within a social justice framework enables an equal and collaborative partnership with communities; develop mutual capacity to address the root causes of systemic social inequity and disparity; and focuses on building social capital.

Problem-Based Case Studies

Case Example 1

Mr. Dalek Novak immigrated to Vancouver from the Czech Republic in 1994. He initially was employed in the building industry and eventually was able to sponsor his wife and four children to join him in September 1999. Adjusting to life in Vancouver proved difficult for the rest of his family, particularly his wife Anicka, who spoke little English. She spent most of her time at home, occasionally heading out to the local park. By September 2000, Anicka no longer left the house and had very little contact with people outside of her immediate family. Things become more difficult for the family as Dalek lost his job in 2002, and he was repeatedly between jobs for the next five years. The family struggled to make ends meet.

On December 29th, 2008 Anicka was found alone, disoriented in the local park, and inappropriately dressed for the cold weather. In the emergency room, the attending physician, resident, and nurse became concerned when they found that there was no history of Anicka accessing the medical system in Canada, and to make matters worse, they were unable to contact her family.

Questions

1. How would the competencies listed under the CanMEDS Health Advocate Role help physicians respond effectively to this case (at the individual level, community level, and population level)?
2. What actions should be taken to address Anicka’s current situation?
   • What should be done on December 29th, during the following week and in the months to come?
   • What physician will follow up in the New Year? Why? How?
3. What social support systems are available to help the Novak family?
4. What is the role of (lost) relationships in bringing forth and treating Anika’s disease?

Case Example 2

Two generations of the Radcliffe family have worked in the automobile industry of southern Ontario. Scott and Debbie Radcliffe joined the General Motors plant in Oshawa, Ontario straight out of high school in 1986. Working with General Motors ensured that both Scott and Debbie received full health insurance, retiree medical coverage, and pensions.

In late 2006, the Number 1 plant in Oshawa was cancelled resulting in the loss of 1,000 jobs; amongst those newly unemployed were Scott and Debbie Radcliffe. The effects of unemployment were devastating; there were limited job opportunities for the couple. Debbie finally secured a job at the local grocery store, and Scott remains unemployed. He and his unemployed work buddies get together almost every day drinking and lamenting about the circumstances they find themselves in.

Scott is admitted to emergency one afternoon complaining of chest pain. Scott is overweight, borderline alcoholic, and has started smoking again.

Questions

• What recommendations would you make to this task force? Consider education and retraining opportunities, financial assistance programs etc. ?
• What recommendations would you make about having the Task Force engage Scott and his buddies directly in their deliberations? Consider the direct health benefits on all cause mortality of patients having a sense of agency?
• What resources would you access to ensure your opinion was evidence-based? ?
• What actions would you take once you returned to your practice?

Case Examples 3

Take a moment to read the CodeRED Series that appeared in The Hamilton Spectator, by Steve Buist. The series reflects over three years of research carried out jointly between the Spectator and researchers affiliated with Mcmaster University. The series offers several real case studies that you can use to think about your role as health advocate. We have adapted one of the sections in the series and included it here to give you an introduction.

Health disparities by neighbourhoods

Two neighbourhoods, separated by just five kilometers: they might as well be worlds apart. Between these Hamilton neighbourhoods, representing two ends of the spectrum, there’s a difference of 21 years in average age at death. If it were a country, one of the neighbourhoods would rank 165th in the world for life expectancy, tied with Nepal, just ahead of Pakistan and worse than India, Mongolia and Turkmenistan. The huge gap in life expectancies across the city is one important piece of a much larger story concerning the health of Hamilton’s neighbourhoods. It reflects the great divide between the poor and the prosperous.

Read the rest of CodeRED (http://www.thespec.com/sections/codered).

1. How would the competencies listed under the canMEDS Health Advocate Role help physicians respond effectively to this case (at the individual level, community level and population level)?
2. Consider the following quotes from Rudolph Virchow, arguable the 19th century father of cellular pathology: “Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution. The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” “It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation. Physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.” How does this help inform your obligations and work in this regard?
3. What responsibilities do physicians have to engage in the political process on behalf of their patients?

Conclusion

With this e-booklet we have sought to introduce medical educators to the concept of health advocacy and how it might be integrated into medical education and both postgraduate and undergraduate levels. We have reviewed HA literature, profiled Canadian physicians engaged in health advocacy, provide pedagogical approaches and external resources as a means of encouraging further activity in this area. This e- booklet is by no means exhaustive and it is our hope that it will serve as a platform for dialogue and a space where physicians, teachers, learners and policy makers can share their experiences.

Beyond its immediate purpose to serve the teaching needs of medical educators, we envision that this e-booklet could be an educational tool for medical institutions, community based organizations and patient support groups. We invite readers to share it far and wide and only ask that you cite it as our work.

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