This article was originally published in the 2018 Spring Issue, and can be read here.
Author: Julie de Meulemeester, Koray Demir
I stumbled into the Royal Victoria Hospital on a glacial December Saturday, one of those days where your legs resign in protest when you step outside, when you remember that most of the human body is water, and wonder what percentage of you is literally frozen solid at any given time. I was asked to see Noah, a patient with a skin infection, but his chart gave me a sense of a more complicated story. He was homeless and struggling with intravenous drug use, with recurrent skin ulcers and a poorly managed HIV infection. He had visited the emergency department several times in the last few weeks, where he frequently had arguments with the emergency team, who suspected he was seeking opioids and felt unsure about the most sustainable way to manage his diffuse chronic pain. Managing Noah’s acute illness felt like the almost literal Band-aid to end all Band-aid solution metaphors. Perhaps by discharging him and sending him back into the deep cold, we were doing more net harm than good. He would continue to be unwell so long as he was on the streets, so long as he was injecting drugs, so long as he was food-insecure and disconnected from the healthcare system. There are few things in medicine we can really say for sure—but of this, I was certain.
In the global health community, we are familiar with the idea that our social circumstances frame our health outcomes: social inequalities, which translate into health disparities, become unacceptable injustices that we work hard to correct (1). Noah is not a real patient, but his case is based on familiar stories from the dozens of marginalized patients I have seen since starting hospital work. Based on these experiences, I have had to wonder: to what extent do social determinants of health play a role in our immediate Montreal community and Quebec as a whole?
It turns out, unsurprisingly, that they matter a lot. An estimated 35% of Montrealers live with chronic illness, such as heart and lung disease, representing 70% of premature deaths in our city (2). Social and environmental factors are largely responsible for the development of these illnesses; among a number of concerning lifestyle indicators, one in six Montrealers is obese and 20% of the city’s population still smokes cigarettes (3). These discouraging figures are significant for historically marginalized communities, such as homeless Montrealers. Over 3,000 people live on the city’s streets, facing uniquely significant burdens of complex chronic diseases (like HIV and Hepatitis C), mental illness, and substance use (4, 5). Furthermore, the municipal distribution of poor health outcomes is predictably skewed towards disadvantaged parts of the city. The suspicion is that, because of structural reasons— such as low high school graduation, high unemployment, deserts of food and physical activity, and poor connection to healthcare services—life expectancy between wealthier and less fortunate parts of Montreal can be starkly different (6). As of 2011, the least wealthy Montrealers can be expected to live six years less than the wealthiest—the difference could be as wide as eleven years for people from Montreal’s East End versus the wealthier parts of the West Island (5).
Granted, these are precisely the kinds of injustices that inspire us to engage in global health efforts. I wonder, however, how much we are actually doing to improve these health disparities at our own doorstep. In my experience, we have generally focused our efforts within the McGill “bubble,” organizing conferences, lectures, and enough wines-and-cheeses for keen global health students to ironically exceed federal alcohol consumption recommendations (7-9). No doubt these awareness-building and scholarly events are important, particularly for university students. But although there is not any readily available data on how we as a group allocate our resources, it certainly seems that we often neglect engaging closely with the community and working on projects which directly target the social determinants of health.
I am optimistic, however, that this tide is turning: through faculty-led programs and several student initiatives, we, as a McGill community, are taking steps to work directly with disadvantaged populations (10). For instance, McGill’s Global Health Programs trains a rapidly expanding pool of Global Health Scholars, who have been conducting field research in Northern Canada and abroad since 2016. Closer to home, the leaders of the student-led initiatives MealCare and Monthly Dignity have been working tirelessly to distribute food and feminine hygiene products, respectively, to those most in need (11, 12). As student leaders preparing our groups and their budgets for the new year, I think we should be inspired by this trend and be deliberate in our planning to put local disparities front and centre in our efforts. We should remember that collaborative approaches and diversified skill sets are necessary to address complex community needs. In McGill’s healthcare programs, the concept of teamwork is rightfully drummed into our heads. We attend interdisciplinaryworkshops where we learn to explore each of our roles in fictional cases such as Noah’s, and develop plans of care for standardized patients with complex histories (13-15). We also attend the monthly meetings of McGill Association of Students in Healthcare, where we discuss opportunities for cooperation on projects and events.
Moreover, our healthcare curriculums contain immediate and longitudinal components of public health education. During the very first day of medical school, we gather into our small groups to discuss the case of Maggie, an Indigenous woman with diabetes, marking the beginning of ‘Block A’—an entire month focused on public health. As well, in their fourth year of studies, nursing students even get the opportunity to build partnerships with underserved communities and initiate health promotion projects (16). However, to date, there have been too few projects enabling students to bring all these curricular components to fruition in the real world. The year 2017 marked the founding of the Community Health and Social Medicine (CHASM) Incubator, which matches deserving projects with funding and mentorship (17). The program received 14 applications from students of all academic backgrounds, but only three could be accepted into the program—demonstrating the wealth of knowledge and willingness to participate in meaningful collaborative projects among McGill students.
Surrounded by these exciting developments and opportunities, we should commit to directly engaging with social determinants of health. Let us identify global health leaders in all healthcare programs who can work synergistically to initiate, support, and advocate for interdisciplinary projects. Let us be culturally sensitive when working with marginalized groups and follow the mantra of ‘nothing about us without us.’ Let us be diligent and intelligent in investing our resources to serve the most pressing needs, and be accountable by carefully monitoring our outcomes. Let us partner with experienced faculty as well as graduate and professional students across disciplines to broaden our efforts. Our projects will be richer and more impactful because of it. In 2018, let us roll up our sleeves, get to work, and do as much good as we possibly can.
- Wilkinson, R., & Marmot, M. (2003). Social determinants of health: the solid facts. 2nd edition(Rep.). Retrieved
- Direction de santé publique de l’Agence de la santé et des services sociaux de Montréal. (2014). La santé des Montréalais : les maladies chroniques et leurs déterminants selon l’enquête TOPO 2012(Rep.). Retrieved from
- CBC News. (2015, July 7). Montreal Homelessness Count finds 3,016 homeless people in city. Retrieved from http://www.cbc.ca/news/canada/montreal/montreal-homelessness-count-finds-3-016-homeless-people-in-city-1.3141007
- CATIE. (n.d.). HIV in Canada: A primer for service providers. Retrieved from http://www.catie.ca/en/hiv-canada/3/3-1
- Statistics Canada. (2015, November 30). Life expectancy. Retrieved from http://www.statcan.gc.ca/pub/89-645-x/2010001/life-expectancy-esperance-vie-eng.htm
- Leblanc, M., Raynaud, M., Lessard, R., Léa Roback Research Centre, & Health surveillance in Montréal sector (SÉSAM).
(2012). 2011 Report of the Director of Public Health: Social Inequalities in Health in Montréal. Progress to Date. (Rep.). Retrieved:https://publications.santemontreal.qc.ca/uploads/tx_asssmpublications/978-2-89673-131-2. pdf
- Tremblay, M. (2014, September 22). Bursting the bubble: Why McGill students should engage with Quebec. The McGill Daily. Retrieved from https://www.mcgilldaily.com/2014/09/bursting-the-bubble/
- Gunning, G. (2017, November 28). McGill Quebec Studies: Maintaining an international university’s local roots. The McGill Tribune. Retrieved from http://www.mcgilltribune.com/opinion/mcgill-quebec-studies-maintaining- an-international-universitys-local-roots-112817/
- Canadian Institute for Substance Use Research and BC Centre for Excellence for Women’s Health. (2012). Drinking Guidelines: Supporting health and life. Retrieved from http://www.heretohelp.bc.ca/factsheet/drinking- guidelines-supporting-health-and-life
- Global Health Programs. (n.d.). Key Programs. Retrieved from http://www.mcgill.ca/globalhealth/research/key- programs
- MealCare. (n.d.). Reducing food and energy waste, one meal at a time. Retrieved from https://www.mealcare.org/ our-impact/
- Carr, E. (2017, December 6). Monthly Dignity provides hygiene products for women in need. The McGill Tribune. Retrieved from http://www.mcgilltribune.com/student-living/monthly-dignity-bridges-the-gap-between- mcgill-and-montreals-womens-shelters-120417/
- McGill University. (n.d.). IPEA 500 Roles in Interprofessional Teams. Retrieved from https://www.mcgill.ca/ study/2017-2018/courses/ipea-500
- McGill University. (n.d.). IPEA 501 Communication in Interprofessional Teams. Retrieved from https://www.mcgill. ca/study/2017-2018/courses/ipea-501
- McGill University. (n.d.). IPEA 502 Patient-Centred Care in Action. Retrieved from https://www.mcgill.ca/study/2017-2018/courses/ipea-502
- McGill medical students launch health-related incubator. (2017, November 16). Retrieved from http://publications.mcgill.ca/medenews/2017/11/16/mcgill-medical-students-launch-health-related-incubator/
- McGill University. (n.d.). NUR1 432 Community Health Nursing Project (4 credits). Retrieved from https://www.mcgill.ca/study/2017-2018/courses/NUR1-432