Saskatchewan health care triage

The health disparity in Saskatchewan's Indigenous populations is staggering, with five times the rate of diabetes, 11 times the rate of HIV and 90 times the rate of tuberculosis. 

"We don't have the longevity that the rest of the population has," said Dr. Veronica McKinney (MD'98), director of Northern Medical Services at the U of S College of Medicine. "For any disease or illness, the rate is worse... The morbidity and mortality rate in some communities is equal to that of Third World countries." 

A division of the Department of Academic Family Medicine, Northern Medical Services (NMS) has been working to provide equitable, accessible health care in the north for more than 30 years. Establishing relationships is one of the key solutions, said McKinney. 

"When you work together, the solutions come forward... We're in the communitites. We go to the births, we go to the wakes, we're with the people in between. We're truly there wil our communities, and that's an amazing gift they give to us, to allow us to be there." 

NMS physicians are in Pelican Narrows, La Ronge, Stony Rapids, La Loche and Île-à-la-Crosse, and they provide services to outposts at up to four different communities outside of those towns. MNS mandates include providing primary health-care services in the north, consultant care and referrals, research and education, and procurement, recruitment and retention of Indigenous faculty at the U of S. 

"Most importantly, we're trying to foster and develop the community voice and support their endeavours to make change for themselves around health and health care," McKinney said. 

On the university level, NMS is working wtihin the College of Medicine to develop the Truth and Reconciliation calls to action, and to indigenize the curriculum. The improved curriculum provides lectures on topics including cultural safety and how history impacts patient-doctor relationships. 

 “When you treat people in the approach we’re asking people to take, it works for everybody. People are more and more not happy with health-care services; they’re looking for a sense of being heard and getting the care they feel they want and need. It’s timely to do this because it speaks to all Canadians and all Saskatchewan people, not just the Indigenous population.”

In the general population, McKinney said there is a “silver tsunami” of older adults, but in the Indigenous population, 50 per cent are 25 years of age and younger. If health policies are geared more towards the general population, they’ll also be more likely to be geared towards the elderly, which is at odds with Indigenous trends. Currently 16.5 per cent of Saskatchewan people are Indigenous, and that number is expected to grow to a third by 2045.

“If we continue to have this kind of health disparity, there’s no way we can manage that,” McKinney said.

Part of the solution will be bringing more Indigenous doctors into the fold, and ensuring there are physician mentors in the community is one way they do that. Many of the Indigenous physicians NMS supports go back to the communities they came from to become mentors.

“It’s a very strong circular process, and it’s a true investment in the community and well worth it to see the benefits.” 

Steven Lewis (BA’72, MA’73), president at Access Consulting, has been working full-time as a health policy consultant since 1999. He’s served on various boards and committees, including the Governing Council of the Canadian Institutes of Health Research, the Saskatchewan Health Quality Council and the Health Council of Canada. He has also headed a health research granting agency, and spent seven years as CEO of the Health Services Utilization and Research Commission in Saskatchewan.

When he thinks about the challenges in Canada’s health-care system, he sees a disconnect between health and health care.

“We tend to think of major health problems in terms of diseases like cancer and heart disease, which are real issues, but many of the diseases and their consequences originate in equality,” Lewis said. “So the system does a pretty good job of dealing with acute health problems—if you walk into an emergency room clutching your chest, you’ll get good service right away—but if you have chronic problems; if you’re a frail, elderly person; if you have some kind of communicable disease where the risk factors include where you live … even a well-nourished system can only patch you up. It can’t really solve the basic problems in poor health.”

It’s easy to agree that primary care should be more effective, but the steps that need to be taken to improve it are less clear. Complicating matters is the natural push and pull of politics, with health care in the crosshairs. When you talk about health, Lewis said, “You do have to talk about politics, but you can also talk basic arithmetic. We can quantify the cost of failure. It’s not like the absence of investment in effective social programs is free money for the rest of us that keeps our taxes down—we pay the consequences of ill health for people. Marginalized people use more health care than non-marginalized.”

Lewis said Canadians need to start moving in an evidence-based direction. The first step is to have conversations about what might be possible with a different approach; the next step is to have public policy backed by adequate resources. And every step along the way will be a small step because health care is a complicated system that can’t be changed overnight. “What are the experiments we need to get underway to start evolving towards a better future?” Lewis asked.

While we still have a long way to go before we’re treating the source of ill health rather than the symptoms, Lewis said there is a growing appetite in primary health care to look at problems more holistically.

“People have identified primary care as the foundation of a system that is more effective and more efficient for decades, but now we’re getting to a point where there’s greater interest to make that a reality. I’m cautiously optimistic something will come of that. It may be an opportunity with the new single health authority, with all its disruption, to rethink some of these issues.”

Ryan Meili (BSc’00, MD’04), a family doctor and Member of the Legislative Assembly for Saskatoon Meewasin, worked as a family physician for 10 years all over rural Saskatchewan, and spent time in Mozambique, but most of his work as a doctor has taken place in inner-city Saskatoon at the West Side Community Clinic. Issues he has witnessed firsthand include some of the highest HIV rates in Canada, and issues related to poverty, such as diabetes, depression, cancer and substance abuse.

“There are lots of elements that weren’t hopeful… but what I am hopeful about is that people are starting to notice,” said Meili. “People are starting to understand we need to do harm reduction. We need to have treatment available for HIV. People are starting to understand the social factor and that health outcomes ultimately have to manifest in political change in terms of choice.”

Meili said his work as a doctor drove his decision to go into politics because he saw the potential to create more far-reaching change as a politician.

“It’s actually political decisions that have the biggest impact … We need to be doing a good job in Regina, and that’s my focus now. I’m trying to create the conditions for people to be healthy rather than spending time with them when they’re already sick.”

Often when politics come up, lines are drawn, and people start seeing red, but Meili said health is something that appeals across party lines. If you take partisanship out of the debate, and look at what is commonly valued in health, you can use evidence to make sound decisions.

“It’s extremely political, but it’s not about a party or an ideology, but what do we want our politics to achieve? What’s best for us all? What better measure than how healthy we are?”

Meili is also the founding director of Upstream, a national non-profit organization located in Saskatoon that aims to spark public conversations and guide recommendations about social determinants of health. The name comes from the analogy that our current health-care system keeps fishing people out of the river instead of going upstream to find out why they’re ending up there in the first place.

Upstream factors include how much money you make, access to healthy food, employment status and access to education. “What actually makes a difference?” Meili asked. “What would have the biggest impact on our health? We usually get stuck thinking about doctors in hospitals and pharmacists and nurses, but health care is only kind of after the fact.”

One way Meili would like to address these upstream health challenges is through a concept called “health in all policies.” The idea is to shift the measure of success in a society to health. Every ministry would be encouraged to make their choices based on what will improve health.

“It requires that you have a whole government approach to improving health rather than leaving everything up to the Ministry of Health,” Meili explained.

Health in all policies started in Europe and is beginning to pop up elsewhere in North America, including in Canadian provinces like Manitoba, Quebec, Newfoundland and New Brunswick.

“You don’t change the whole system, but you change the way you approach your problems … I actually think if we did this right, it would cost less. When you invest in keeping people healthy it's less expensive in the long run than responding when people are sick.”