Health Inequity
Including Social Determinants of Health
Health inequity arises from a combination of many factors, including unfair systems, policies that cause health disparities, poverty, and even personal behaviour. To be clear from the beginning, I am not blaming the person who has poor health. This article will discuss reasons for the variations in the health of individuals within our society.
Poor health is not personal failure. Physiological influences for organic diseases, including inflammatory bowel disease, obesity, and addiction, are real. Also, the function of our bodies influences our health and can cause irritable bowel syndrome, dyspepsia, and other chronic gut issues. Underpinning that, our mental health can affect these processes. Chronic stress and mental health conditions such as anxiety and depression can trigger health symptoms and tangible conditions. Unfortunately, in society as a whole and in some parts of healthcare, individuals who experience these conditions are often dismissed, with their symptoms considered psychosomatic, even though they are very real, and need treatment.
We learn from an early age about good health practices and bad ones. We’re taught to wash our hands, eat an abundance of vegetables and fruits, balance our diets with the latest scientific data, and ensure we incorporate a variety of exercises into our days. How then, can those who live in remote or northern regions and do not have the same access to nutritious foods such as fruits and vegetables as other Canadians, meet this need?
Your ability to access good nutrition, a safe place to live, and even access to transportation, affect your health outcomes long before you as an individual are making informed choices, and even before you are born. Physical, mental, and even genetic barriers can prevent us from making a healthy choice, or from even having an option in the first place.
While evidence surrounding what is genuinely good for us has changed immensely over the years, now we can even nuance our care and lifestyle to our individual genome, if we have access to this information and the will to do so.
Guides around what to eat during pregnancy and how to feed a newborn have evolved and have sometimes led to disasters when product manufacturers jumped into creating baby formula without evidence of what an infant actually requires to grow healthily after birth.1,2 Aside from genetics, the mother’s diet during pregnancy, whether she smokes, is exposed to toxic substances, and a myriad of other factors can mitigate the health of the baby at birth. Then there is the dilemma of breastmilk versus formula feeding. While these things seem like simple and easy choices to make, they are much more complex. This is such a small part of healthcare, but it is a place to start.
Health inequity refers to differences that are unfair or unjust and modifiable. Since we can’t modify every factor that contributes to health inequity, we must rely on human compassion to support those living with these barriers. Let’s dive a little deeper into understanding the social determinants of health that can complicate everyone’s ability to obtain health equity.
Social Determinants of Health in Canada10
Many factors have an influence on health. Our individual genetics, lifestyle choices, exposure to viruses and bacteria, and where we are born, grow, live, work, and age have an important influence on our health. Health Canada has identified specific social determinants of health that are broad-ranging, including personal, social, economic, and environmental factors that determine individual and population health. The main determinants are:
- income and social status
- employment and working conditions
- education and literacy
- childhood experiences
- physical environments
- social supports and coping skills
- healthy behaviours
- access to health services
- biologic and genetic endowment
- gender
- culture
- race and racism
Gender Inequity
From conception through to death, a multitude of factors affect our health. Even your sex can affect your health throughout your lifetime in a variety of ways. A prospective study3 of 9,164 US residents ≥65 years-of-age, demonstrated that health needs were substantially greater among older women compared with men, but women had fewer economic resources to address their needs.
Canada’s Women’s Health Strategy, adopted in 1999,4 with only minor attempts to update it since, identified biases against women in the healthcare system, stating that Canada’s system, not unlike society at large, tends to type-cast women and men based on longstanding traditional roles and attitudes.
A 2021 study published in the Journal of Pain,5 explains the vast differences in how someone perceives another’s pain, and that this perception may be subject to systematic biases based on gender, race, and other contextual factors. Such biases could contribute to systematic under-recognition and under-treatment of pain in healthcare. In one of their two experiments, perceivers under-estimated female patients’ pain compared with male patients, after controlling for patients’ self-reported pain and pain facial expressiveness. In the second experiment, perceivers’ pain-related gender stereotypes, specifically beliefs about typical women’s vs. men’s willingness to express pain, predicted pain estimation biases; and perceivers judged female patients as relatively more likely to benefit from psychotherapy, whereas they judged male patients to benefit more from pain medicine. This study identifies a bias toward underestimation of pain in female patients, which is related to gender stereotypes. It also exposes the stereotypical advice to men that they do not need emotional care. The findings suggest caregivers’ or even clinicians’ pain stereotypes are a potential target for intervention in healthcare.
Men are historically the default in health and health research, so women, whose bodies experience diseases differently from men, suffer from healthcare benchmarks not designed to meet their needs.
Women physicians continue to face significant challenges such as pay inequity, sexual assault and harassment, opposition to career advancement, and unconscious bias in the workplace.6 Leading international organizations and institutions are confronting these challenges by creating guidelines, instituting policies, and implementing programming around gender equity and diversity.7 How can we trust a healthcare system that penalizes its own core colleagues to appropriately address the concerns of its female patients?
In its 2018 report,8 Addressing gender equity and diversity in Canada’s medical profession: A review, the Canadian Medical Association states that, “While medical education has begun to include training in social and cultural competency, the limited available data suggest that the Canadian medical workforce does not reflect the diversity of the patients it serves. It has been argued that true social and cultural competency will be best developed through increased diversity of the physician workforce itself. Challenges are amplified for women in medicine who also identify with one or more other determinants of inequity (e.g., racial minority, low socioeconomic status, religious views, LGBTQ2+, disability).”
In a 2021 study published in the Journal of the Canadian Association of Gastroenterology,9 women gastroenterologists display low representation at multiple levels along the career pathway, in fact, the Canadian Association of Gastroenterology has had only two out of 47 (4.2%) women presidents, and other provincial gastroenterology associations ranged from Ontario having never had a woman president to Alberta having the most, but still at only 20%.
Epigenetic Influence
Epigenetics is the study of how your behaviours and environment can cause changes that affect the way your genes work. Newer science shows that what happened to your ancestors before your conception, even for generations before you, could affect you and your health. Trauma your parents and grandparents experienced can affect your health today in the form of unexplained depression, anxiety, fears, phobias, obsessive thoughts, and physical symptoms, which scientists are now calling secondary post traumatic stress disorder (secondary PTSD).
In his book, It Didn’t Start With You,11 Mark Wolynn documents the latest epigenetic research as to how traumatic memories are transmitted through chemical changes in DNA. He also covers the latest advances in neuroscience and the science of language. Trauma can change us for generations. The grief, the suffering, the distress doesn’t always end with the person who experiences it first-hand. The feelings and sensations, specifically the stress response – the way our genes express this stress – can pass forward to our children, grandchildren, and continuing generations, affecting them in a comparable way, even though they didn’t personally experience our trauma.
In her book, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present,12 Harriet A. Washington documents a history of non-consensual, gruesome medical experimentation (abuse) on African Americans from the era of slavery to the present day. This trauma lives on in Black Americans today. Enslaver White persons enjoyed better initial health, better nutrition, and less exposure to environmental pathogens and parasites than did enslaved Black individuals. Denial of care during slavery has left traumatic scars on Black Americans for generations, just as the legacies of the Residential Schools in Canada, and other trauma, have damaged some Indigenous individuals to this day. These epigenetic changes are also prevalent in the offspring of Holocaust survivors. No matter what their race, individuals who lived through abuse of any kind, can pass on their generational trauma.
Sadly, there are insufficient mental health services to help us repair the damages so we can improve our society’s health and work toward healing the generations that follow.
Environmental Contaminants
Childhood exposure to lead can affect health. In a sample of more than 1.5 million people, researchers who published a 2021 study in the journal PNAS13 found that US and European residents who grew up in areas with higher levels of atmospheric lead had less adaptive personality profiles in adulthood (lower conscientiousness, lower agreeableness, and higher neuroticism), even when accounting for socioeconomic status. Their results suggest that even low-level lead exposure may adversely impact personality traits, harming the well-being, longevity, and economic prospects of millions of people.
We already know that air pollution hurts the environment, makes our cities smoggy, smells bad, can damage our lungs, and causes many other ill effects. Evidence shows that it could also increase the incidence of appendicitis. In a study we reported on in the Inside Tract® newsletter, issue 179, published in the Canadian Medical Association Journal,14 researchers gathered information from 5,191 adults in Calgary who had appendicitis, and studied the concentration of specific air pollutants for the seven days leading up to their hospitalization. The air pollutants monitored at these stations include ozone, nitrogen dioxide, sulphur dioxide, carbon monoxide, and suspended particles with aerodynamic diameters of <10μ and <2.5μ. Researchers concluded that short-term exposure to high levels of air pollution could trigger some cases of appendicitis.
Disability
In consideration of disability, we need the ableist rhetoric to stop. While individuals with a disability would like to work, the truth is that often they can’t. We can’t support pushing disabled people into stressing themselves out because an able-bodied person does not understand their disability. Individuals need variable levels of support, and it is not always about income. There is a wide array of unique barriers for those who are disabled, and transportation is one example of this. Importantly, there are many disabilities that we cannot see, including chronic illnesses such as inflammatory bowel disease, liver disease, irritable bowel syndrome, short bowel syndrome, and mental health conditions.
In lesson six of Fareed Zakaria’s 2021 book, Ten Lessons for a Post-Pandemic World,15 he mentions that Aristotle was right, we are social beings. What does this mean for health equity? It means, to me, that we need to care for those around us. Without going to a socialistic extreme, we can care for others while enjoying the unique benefits of a capitalistic system. The downside of our sociability, Zakaria explains, is that we live in congested cities, which led to, among other things, quickly-spreading infections such as that currently being demonstrated by SARS-CoV-2. Variants of the virus are still arising because we have not stopped the initial version from spreading and the more times the virus replicates, the greater likelihood there is of deadly mutations. We are basically stuck with the world we have now and, to improve our health, we have to work together.
Other Influences
There is also a myriad of physical attributes that can affect our health, including birth defects, injury, illnesses, contaminants, and aging. Humans are comprised of 20,000-25,000 genes that work alone and in concert with each other. Our bodies represent so many areas that can have deficits, including our basic senses of sight, smell, touch, taste, and hearing, and yet some scientists suggest we have as many as 21 senses. We also have eleven organ systems, including the integumentary system, skeletal system, muscular system, lymphatic system, respiratory system, digestive system, nervous system, endocrine system, cardiovascular system, urinary system, and reproductive systems. These all communicate with each other, and there are illnesses that can affect more than one of them. We know, for example, that diseases such as multiple sclerosis, Parkinson’s disease, and Fabry’s disease, which are rooted in other body systems, also affect the digestive system.
Bias is another barrier to good healthcare. Despite medical doctors declaring obesity a chronic disease, considerable weight stigma in both popular culture and healthcare still exists, which negatively impacts policymaking regarding prevention and treatment. In a 2021 study published in the journal, Obesity Reviews,16 the authors offer evidence based on obesity treatment, neuroscience, philosophy of mind, and weight stigma to challenge the commonly held beliefs that individuals are free to choose how much they can weigh, and achievement of long-term weight loss maintenance is completely subject to conscious choice. Regulation of hunger, satiety, energy balance, and body weight takes place in subcortical regions of the brain, which are not associated with conscious experience. It’s not about willpower; it’s a disease.
Even with the best healthcare structure, it comes down to the individuals who care for you, and the tests and treatments they have available. In his book, The Secret Language of Doctors,17 Dr. Brian Goldman exposes more than the hospital slang, but the personalities of the doctors and nurses who he captures in their idiosyncrasies. He also exposes the fractures in US healthcare, which begs the question, are we really properly caring for anyone, anywhere?
The Canadian healthcare systems are simply inadequate to meet the complexities of human physical needs. Evolving science is helping us combat obsolete ideas of health and the complex causes of disease and disorder.
Governments’ Role
The Canada Health Act is Canada’s federal legislation for publicly funded healthcare insurance. It sets out the primary objective of Canadian healthcare policy, which is “to protect, promote and restore the physical and mental wellbeing of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”
On April 1, 1984, the Act replaced several federal hospital and medical insurance acts and consolidated their principles by establishing criteria on public administration, comprehensiveness, universality, portability, and accessibility. Its aim is to ensure that all eligible residents of Canada have reasonable access to insured health services on a prepaid basis, without direct charges at the point of service.
In his book, Chronic Condition,18 Jeffrey Simpson wrote that most of our public healthcare problems in Canada go back to its creation and suggested, in 2013, that it needs a huge overhaul. Canadian Healthcare creators did not give sufficient thought to which countries it was patterning itself after and once the plan was adapted to our existing diverse federal, provincial, territorial responsibilities, they left many essential things out of the Act.
Thus, our entrenched, complex web of systems, that never completely integrate, means that many of our needs fall between the cracks. The system is failing us and significantly exposes the social determinants of health. How can we have good health if our healthcare system fails us when we need it?
Canadian Healthcare Falls Short with Medications
Remarkably, Canada is the only developed country with a national framework for publicly-funded healthcare that does not include universal drug coverage.
The GI Society has been active in this area, and you can find information on our website about the impending drastic changes to the Patented Medicine Prices Review Board,19 which are important for the supply chain of medications in Canada. There are too many bodies that assess and reduce the prices of pharmaceutical medications in Canada. I won’t go into full detail here, as we have covered many examples on our website, but they include, in summary:
- Health Canada considers evidence from clinical trials submitted by pharmaceutical manufacturers to decide if a drug or biologic is safe and effective for sale.
- Patented Medicine Prices Review Board operates under the Patent Act and is an independent quasi-judicial federal body with a dual mandate, which is 1) Regulatory: to ensure that prices charged by patentees for patented medicines sold in Canada are not excessive, and 2) Reporting: to report on pharmaceutical trends of all medicines and on research. Things are changing here!
- Canada’s Drug Agency (CDA) conducts drug reviews in two streams: the Common Drug Review (CDR) and the pan-Canadian Oncology Drug Review (pCODR). CDA is an independent, not-for-profit organization responsible for providing healthcare decision-makers with objective evidence to help make informed decisions. Quebec also has L’Institut national d’excellence en santé et en service sociaux (INESSS) for health technology assessment.
- The pan-Canadian Pharmaceutical Alliance (pCPA) is a joint provincial, territorial, federal body that manages the process of private negotiations with manufacturers to find acceptable, undisclosed, drug prices, eligibility criteria, and risk sharing arrangements (rebates, expenditure caps, etc.).
- Once a pCPA negotiation is complete, each provincial, territorial, or federal public drug plan decides whether to include the drug in its list of covered medications (formulary). Private medication insurance is managed differently.
- Recognizing this patchwork of how medicines are covered, the Canadian Government formed the Canada Drug Agency and, on April 1, 2021, announced the head of the Transition Office who will be overseeing the development of a national formulary, which is a comprehensive, evidence-based list of prescribed drugs that will support consistent patient access to treatments across the country.
We have intense control and management of pharmaceutical products in Canada, and this can mean that individuals who need medications cannot get them. Canadians face lengthy delays in access to medications when compared with the US and the European Union. In a Fraser Institute Blog from May 13, 2021,20 the authors report that of the 218 drugs approved in both Canada and the US between 2012/13 and 2018/19, approval was granted a median 289 (average 469) days earlier in the US. Of the 205 drugs approved in both Canada and Europe, approval was granted a median 154 (average 468) days earlier in Europe.
Our collection of redundant systems is making things worse for Canadians. We do need that overhaul!
Virtual Care
The evolution of virtual care intensified during the COVID-19 pandemic and this modality will not go away. There are positives and negatives to this. The absence of in-person care can still be a detriment to healthcare, and yet it is an enhancement that is long overdue for certain circumstances. While there is still a big leap before we realize care from The Doctor, an Emergency Medical Hologram Mark I, from the television series Star Trek: Voyager, artificial intelligence is also emerging in healthcare. For humans to care for humans, we need all our senses and, with virtual care only, some illnesses will go undetected.
In a 2021 report published by Canada’s Drug Agency, the authors point out that we need new regulations regarding the provision of virtual visits (e.g., phone, text messaging, video conferencing) to uphold equitable access to publicly funded healthcare as mandated by the Canada Health Act.21 They agree that virtual visits are a way of providing healthcare to patients in their location of choice, using technology, and that the use of virtual visits has the potential to overcome many of the barriers associated with in-person care, including improved access, convenience, and cost savings. Other barriers that virtual care does not address include reliable access to an internet-connected device, technology literacy, and language obstacles.
Size Matters
Budget size for your jurisdiction’s portion of Canadian publicly-funded healthcare matters. The fact that our public plan doesn’t cover pharmaceuticals except in specific situations, matters. Former British Columbia Health Minister, George Abbott, wrote in his book, Big Promises, Small Government, about the negative effects of budget cuts on those living in poverty or children of the disabled, who were abruptly no longer eligible for preventative dental benefits, among other things.22
Economic freedom relates to health quality and even the size of the jurisdiction you live in matters, if it’s too big or too small, you could be at a disadvantage. Among the most interesting and robust findings of a 2021 Fraser Institute publication is that there appears to be an “optimal” population size for subnational jurisdictions that maximizes overall economic freedom, which is about 9.5 million people. Beyond that point, overall institutional quality begins to decline, and this decay starts at even lower population levels for the economic freedom subcategory of taxation.23 Economic freedom affects your health.
Action
The Public Health Agency of Canada established the Canadian Council on Social Determinants of Health to work with leaders from different sectors on the social determinants of health and improve health equity. While they have produced resources and tools that you can find online,24 we have a long way to go.
Conclusion
Healthcare is rooted in ancient medical and philosophical teachings, from the well-known practices of Hippocrates of Kos in the fifth century BCE in Classical Greece, to varying concepts of health throughout the world over time. Our ancestors realized that maintaining good health and fighting illness are related to natural causes and that health and disease cannot be dissociated from any particular physical and social environments nor from human behaviour. We can and must do better today.
At a Canadian Medical Association meeting I attended in Yellowknife in 2012, Dr. John Haggie said, “Our universal healthcare system is a defining attribute of what it means to be Canadian. We must strive to ensure that, no matter where you live, Canadians can access comparable levels and standards of healthcare.” He was completing a whirlwind term as president of the Association, and added, “Canadians see an opportunity for all levels of government to exercise leadership and collaborate to transform healthcare to make it focused on the needs of patients. Our healthcare system originated through collaboration; it is time to bring it back at all levels.”
Dr. Haggie’s thoughts resonate with me. We need to work together to improve healthcare and address the social determinants of health within our fractured systems.
Healthcare in Canada is about in the middle of the road as far as systems go in developed countries. It is far from perfect. It has gems; it has albatrosses. I have personally seen amazing input from the patient community that has helped drive meaningful change in the way we care for individuals. If we want health to be a priority, we need to address the social determinants of health, which include the areas mentioned above. It all works together. We have personal and societal responsibilities to ensure a good outcome.
We also need to cut each other some slack. We don’t know what another person is going through. Some days, for some, even getting out of bed is a challenge. Let’s be kind, and let’s continue to improve healthcare. We can do this if we’re all a little more thoughtful.
And if you’re going through life feeling good, looking good, and you’re gainfully employed, you could have significant advantages in the social determinants of health. Enjoy!