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January 26, 2011

Health care is not enough, Dr. Jeffrey Turnbull says

Reuel S. Amdur

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"We should be investing some of the money we spend on health for social services instead, for prevention." Of course you would expect something like that to come out of the mouth of a social worker, but the speaker was no social worker. It was Dr. Jeffrey Turnbull, president of the Canadian Medical Association. "I'm dealing with the swamp," he said, "and nobody's draining the swamp."

Turnbull, the Ottawa Hospital Chief of Staff and co-founder of Ottawa Inner City Health, has focused his career on the health needs of the poor and dispossessed, both in Canada and overseas. 

In a talk at Carleton University before a conference on urban poverty, he identified poor health with social inequities and lack of the social determinants of health.  “75% of health outcomes are influenced by other things than health care,” he observed. 

“Health care is the monster that is eating everybody’s health,” as governments are spending huge parts of their budgets on health care.  “We are doing less for health if we spend it all on health care.”  As it is, “We are paying for ineffective care, not delivering value for dollars.” 

To illustrate some of the social factors affecting health, Turnbull observed that “700,000 Canadians go to food banks, and the food they get is not of a quality recommended by the Canada Food Guide.” 

He also noted that 300,000 Canadians seek accommodation in shelters each night.  “And that,” he noted, “does not include couch surfers and those sleeping rough.”  Couch surfers are people who move in temporarily with someone who has a room or an apartment for a night or more and then moves on to another person’s place, with no longer-term stability. 

Turnbull pointed to the poor health on the reserves, with tuberculosis rates that are actually higher than they are in Bangladesh.  As well, 30% of those on reserves are illiterate.  In the general population, of the people in the lowest one-fifth of the income distribution, 25% are illiterate.  Illiteracy, of course, makes it very hard to find a job.  And even people who have a job may find themselves in dire straits.  “Six per cent are underemployed; that is, they earn too little to meet day-to-day requirements.”

Looking at heath outcomes, Turnbull told the audience that average Canadian life expectancy is 80 years.  However, in Nunavut it is only 67.  Among the homeless, only one-third ever reach 75.

We spend $170,000 to $225,000 a year on each person who is chronically homeless, “and they get not very good care,” he charged.  One cause of this mess is the policy of deinstitutionalization, which threw vulnerable people out on the street and into the correctional system. 

In the Ottawa City Health program, which is focused on a housing first approach with supportive services included, the health care system is saved $750,000 a year, and the quality of care is good, serving the mentally ill and the addicted. 

He decried the attitude that meeting the needs of the poor, the mentally ill, and the addicted are to be met by charity.  They are all, he declared, “entitled to protection” as a right of citizenship. 

The biggest challenge in dealing with homelessness is provision of housing, but housing alone is not enough.  There should be supportive housing for those with special needs.  “It is hard,” he pointed out, “to provide services if they do not have stable housing.” 

“Not providing needed services costs society a lot more money than providing them.” Commenting on the federal focus on building more prisons, he charged that this is “not helpful, not thoughtful.  30% of the prisoners are mentally ill, and they are put in a place where they do not get very good care.”  Turnbull did not comment on the Conservatives’ description of the prison system as “Club Fed.” though well he might.

The Canada Health Act has five basic principles: public, non-profit administration; comprehensiveness; universality; portability from one province to another; and accessibility. Dr. Turnbull would add other principles.

He would like to see, for example, the guarantee of patient-centred care, along with a guarantee that care is sustainable and equitable.  Equity would be not just in terms of access but also in terms of outcomes. For such equity to be achieved there would need to be income redistribution and provision of augmented services to those at the bottom of the income scale.

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