Health Equity – Reality or Politics?

everyone-wins-a-trophy-generationThe need to help animates healthcare. We see a need and work to meet it.

Disparities in health outcomes resonate deeply with us.

The cholera outbreak in London offered clear disparity and a tangible solution. Poor infant and child health in (some) Northern communities offers disparity with no obvious answer.

A solution requires a clearly defined problem. Does anyone know what health equity, inequity or disparity means exactly? Is it something that we know but cannot easily define, like the Caucus-race from Alice in Wonderland?

First [the Dodo] marked out a race-course, in a sort of circle, (`the exact shape doesn’t matter,’ it said,) and then all the party were placed along the course, here and there. There was no `One, two, three, and away,’ but they began running when they liked, and left off when they liked, so that it was not easy to know when the race was over.

However, when they had been running half an hour or so…the Dodo suddenly called out `The race is over!’ and they all crowded round it, panting, and asking, `But who has won?’

This question the Dodo could not answer without a great deal of thought, and it sat for a long time with one finger pressed upon its forehead (the position in which you usually see Shakespeare, in the pictures of him), while the rest waited in silence. At last the Dodo said, `Everybody has won, and all must have prizes.’

Health Equity Defined

Health equity has become the cardinal virtue in many policy discussions. We hear impassioned calls to address it. No action is too outrageous so long as it furthers our goal of health equity and equality overall.

What is health equity?

  • Equality – everyone gets the same pair of shoes.
  • Equity – everyone gets a pair of shoes that fits.

An academic definition (BMJ):

“Equity means social justice or fairness; it is an ethical concept, grounded in principles of distributive justice…

Equity in health means equal opportunity to be healthy, for all population groups. Equity in health thus implies that resources are distributed and processes are designed in ways most likely to move toward equalising the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts. This refers to the distribution and design not only of health care resources and programmes, but of all resources, policies, and programmes that play an important part in shaping health, many of which are outside the immediate control of the health sector.”

One site says

“Once everyone enjoys a similar level of health and well-being, we can focus on preserving fairness by giving everyone the same things: this is equality. As the Pan-American Health Organization puts it, equity is the means, equality is the outcome.”

If you have time, check out Maxwell Smith’s (Toronto) lecture: What do we Mean by Health Equity in Public Health?Assumptions and Theoretical Commitments

Dozens of issues including: genetic predisposition, epidemiological hazards, environmental hazards, geographical factors, work conditions, political or social marginalization or oppression, other social/societal determinants?

“Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided.” Whitehead, 1992, pg. 7

Maxwell tackles strict egalitarianism (equal income, equal healthcare resources, liberty and health) vs. prioritarianism vs. sufficientarianism. He mentions equality of opportunity, resources, well-being, self esteem, knowledge, self determination…

A sense emerges that health inequity is a disparity in health thought to be due to differences in social advantage.  Adherents seem to believe health inequity causes poor health if you belong to an identifiable, disadvantaged group. But bad lifestyle choices cause un-healthiness if you belong to a socially advantaged group.

Health Equity Highlights

  • Outcomes include: life expectancy, social opportunity, well-being, and more…
  • Equity is a normative (moral) virtue rooted in distributive justice.

Advocates of health equity

  • Presuppose the efficacy of social planning to correct health inequity.
  • Believe the state has the right, and moral obligation, to advance health equity.
  • Think that health disparity, being a cardinal virtue, justifies unpopular decisions by government to address health disparity despite lack of a clear definition or solution.
  • Hold a vision of everyone enjoying a similar level of health and well-being.

Medicine, Public Health & Health Equity

Although similar, public health sits apart from the sine a qua non of medicine, the doctor patient relationship.

Medicine is one individual responding to another’s need. Public health is something more and different. Well-intentioned, compassionate people work in both fields. But the motivating ideology is radically different.

I never read public health calling to help individuals in need. Public health preaches distributive justice, not individual charity; population health, not individual compassion.

Politics vs Clinical Care?

We need to champion clinical compassion for its own sake and not let it be used as a lever to promote utopian ideals.

Historical experiments in extreme equality grew from political platforms, political agendas. The righteous indignation voiced against health disparity today often seems less motivated towards meeting individuals’ needs as opposed to promoting old political ideals.

We need a clear definition of what we hope to achieve by promoting health equity. Vague sermons about distributive justice mean nothing without concrete ends. If we cannot define what we hope to achieve, maybe pontificating about equality is nothing more than political ideology dressed up as ‘health’?

 photo credit: hotmeme.net

Doctors’ Blame & Shame – Ontario Bill 29

Steve ClarkThe Toronto Star loves Steve Clark.  The Conservative MPP sings from the Star’s hymn book with his Bill 29 – An Act to Amend the Medicine Act, 1991.

Clark crusades on total transparency. He calls for full reporting of all complaints against physicians, all deaths reported while under their care; including complaints and deaths from other jurisdictions.

Transparency – what could be more wholesome?

The public deserves to know about every single death.  It’s condescending to think the public needs protection from the facts. The public needs protection from nefarious physicians. If there’s any chance the information might help one patient, the information should be public. Right?

Blame and Shame for Death

Who gets attributed with a patient’s death?

When a patient dies of cancer, does the family doc who knew the patient for years get labelled? How about the surgeon who operated 2 weeks before?  Maybe the intensivist?  The palliative care doc?

Or should it be the naturopathic doc who attended to the cancer for 18 months before the patient sought medical attention?

Physicians who practice palliative care will have a high number of patient deaths.  Does that make them bad doctors?  Even if a palliative care doc is a murderous physician, how would the public know based on the reports?

Would Bill 29 encourage physicians to care for the very sick, those in greatest need? Most attempts to rescue the dying rest on slim hope. Shall we reward these deaths with blame and shame?

Blame and Shame for Complaints

Many patients write complaints, not just thoughtful people from the Toronto Star.  Often, patients with major mental health challenges have the most time to craft complaints.  Aside from the obvious ones, many complaints require investigation to reveal that psychosis, delusion, or other cognitive challenges determined the content.

Many complaints focus on things out of MD control: wait-times, legislated reporting to the Ministry of Transportation (patients hate this!), no beds available in the emergency department…

Blame and Shame – Help or Harm?

The most important question is How will this impact patients?  Will Bill 29 improve quality and safety?

The Patient Safety and Quality Improvement group from Duke says,

“This ‘shame and blame’ approach leads to hiding rather than reporting of errors, and thus is the antithesis of a culture of safety. Recent efforts have tried to change this—to encourage people to report problems rather than hide them, so they can be addressed.”

The World Health Organization writing on safety cultures notes that blame and shame does not work.  It does not improve safety.  The Canadian Patient Safety Institute says the same thing.

Here’s one of dozens of academic articles suggesting better alternatives to blame and shame – Relationship between safety climate and safety performance in hospitals.

Healthcare wrestles with creating safe places for providers to talk about ways to improve care by sharing their concerns without fear or shame. Bill 29 takes us back decades.

What’s been your experience? Does a culture of blame and shame improve performance anywhere?

 photo credit: steveclarkmpp.com

Terrorism, Canada, Crisis

1023 Shooting 284.JPGOur minds spin. Our world marred.

Watching terrorism in Canada, we take comfort knowing security forces live for this.  They exist to manage emergencies.  We expect they will be there when we need them.

We watch armoured vehicles mobilize on Parliament hill.  A medic performs CPR on an honour guard. Police in black facemasks and ballistic vests point revolvers at rooftops as politicians dive into tank-like trucks.

We need Canadians in uniform.  We honour their commitment and sacrifice. As civilians we never understand the toughness required to run into danger to protect our freedom, our way of life. If asked, we would do almost anything to support them.

Canadians inherit pioneering toughness. New Canadians know courage, risk and resourcefulness coming to a new country, a new life. Third and fourth generation Canadians know grit when death and financial ruin were realities of climate and landscape. Perhaps some heritage Canadians have never known vital challenge – never needed self-sufficiency – but they are few.  Canadians know how to manage.

Crisis reveals the limits of our system, and it gives government reason to take more control.

Living in the North requires confidence to take personal control in crisis.  A nanny state that turns Canadians into undeserving recipients of state beneficence insults the fabric of Canadian identity.  It undermines the core nature required to thrive in the North. But in national crisis, we risk compromise of identity for state solutions.

Terror on Parliament Hill. Ebola threatening. Acute care overwhelmed.

Canada will emerge stronger from all of this. Thank God for soldiers who sacrifice for us, for our way of life. Let’s hope our leaders avert crisis without crushing our freedom, our passion, and our Canadianism in the process.

photo credit: nationalpost.com