Solving Healthcare with Dr. Kwadwo Kyeremanteng

Andre Picard: A Pragmatic Approach to Solving Healthcare

Episode Summary

Key Takeaways -If André Picard could choose what to prioritize to improve Canadian healthcare, what would it be? -“There is no magic formula, first of all,” he says, but there are two things that stand out: 1. We have a sickness care system meant to help the ill. Shovelling more money into it might not be the solution. If he had the choice, he’d put more money into early childhood education and feeding kids at school – measures known to go miles in healthcare prevention. 2. How can we improve the system itself? We need to start with the basics, Mr. Picard says. Bolster primary care; we won’t get far without a good health foundation. - The social determinants of health are a concept Mr. Picard finds himself returning to again and again, especially when discussing vulnerable groups in healthcare. - We have to make an extra effort to reach out to them, he says. To make sure they’re heard; all the medicine in the world isn’t as important as a roof over their head. - Social services in Canada are grossly underfunded, making it all the harder for these groups to seek out help in the first place. - There’s no easy solution to the difficulties faced by indigenous populations. - At the very least, we need to start repairing the damage done by making sure these populations have access to basic necessities like sanitation and clean water. - The looming issue of mental illness is incredibly complex, involving discussions about medical history, economics and politics. - Like with other vulnerable populations, preventative measures are key; we need to prioritize initiatives like Housing First, realizing that these people need homes, social support and income stability just as much as they need treatment. A Closer Look Prioritizing transitions in healthcare - It isn’t easy to choose what to prioritize in our healthcare system. But Mr. Picard offers some insight into where to start. 1. Shovelling money into our healthcare system isn’t always the answer. We need to focus on getting more value for our investment by focusing on specific areas, like prevention. - Early childhood education and making sure children can eat at school – these are the kinds of things that will give us the most bang for our buck. 2. Canada has a sickness care system. We treat the ill. How can we improve the way we do this? The answer may lie in what Mr. Picard calls transitions. - Transitions are the points at which patients move from one institution to another: from the clinic to the hospital, or the hospital to homecare, for example. o It’s at these points, Mr. Picard posits, that we “lose people”. They slip through the cracks, are not followed up with, or not brought to where they need to be. - We need to bolster our primary care system, and make caregivers responsible for seeing patients through a system comprehensively; this disorganization is a fundamental issue in our healthcare system. Humble Origins - What drove André Picard to healthcare journalism? “I stumbled into it,” he says. - An important part of starting his career was covering the AIDS epidemic. Mr. Picard remembers the craziness of the time, during which medical journalism, the drug business and medicine profoundly changed. - An overarching theme in his journalism: don’t judge people. Don’t fall for stereotypes, and make sure to always give individuals the voice they need to tell their story. Healthcare and vulnerable groups - Time and time again, the question of how to help vulnerable populations returns to the social determinants of health. During their discussion, Mr. Picard highlights how all the medicine in the world isn’t as important as giving someone a roof over their head, a sustainable income and meaningful connections with friends. - Despite prevention being a proven way to address these issues, a major concern is that social services continue to be majorly underfunded in Canada; here, we spend about 13% of our GDP on these services, says Mr. Picard, while in Denmark it’s 27%. And you can see the results: better health outcomes, less spending on healthcare. - If we put more money in our communities, they will do better. This is what gives us the greatest healthcare value for our dollar. It’s as simple as that. - Indigenous populations face unique challenges that must first be addressed by acknowledging colonialism’s deep impact on their lives. - To make amends, we have to begin by following the recommendations of the Truth and Reconciliation Commission. - At the very least, it is essential to provide these communities with proper sanitation and clean water, which many still lack. - About 20, 000 people sleep in the streets of Canada every night. Most likely, 90% of them have severe mental illness, Mr. Picard says. - The Housing First initiative is essential. It is impossible to begin treating individuals with complex mental problems without first providing them with a safe home. - Investing in this isn’t just an ethical win; preventing homelessness has been proved to save millions in medical dollars. - We need to fight stigma about mental illness and start treating it as a “brain disease” with a pathophysiological origin. We don’t allow people with cancer to walk the streets without treatment, so neither should these patients. Follow Andre on Twitter: @picardonhealth Further Readings André Picard’s profile page at The Globe and Mail: https://www.theglobeandmail.com/authors/André-picard/ Matters of Life and Death: Public Health Issues in Canada: https://amzn.to/2v9PIXt The gift of death: Confronting Canada's tainted-blood tragedy: https://amzn.to/2v9Q2p9 Today show is sponsored by BetterHelp.com BetterHelp is the largest online counselling platform worldwide. They change the way people get help with facing life's challenges by providing convenient, discreet and affordable access to a licensed therapist. BetterHelp makes professional counselling available anytime, anywhere, through a computer, tablet or smartphone. Sign up today: http://betterhelp.com/solvinghealthcare and use Discount code “solvinghealthcare" Today's show is also sponsored by The House of Pod: A Medical Podcast. A medical podcast with two doctors and a guy named Joe. We answer your questions, cover the latest news, and help pull back the curtain on the world of medicine. Send your questions and comments to hopquestions@gmail.com, or leave a voicemail at 408-444-6623. Listen: https://goo.gl/Uc0MpB Follow them on FB: facebook.com/thehouseofpod & Twitter: @thehouseofpod

Episode Notes

Episode Notes

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Episode Transcription

Theodore:                           00:00                     Welcome to Solving Healthcare. We've got Dr. Kwadwo Kyeremanteng with Theodore Kyeremanteng. It's a pleasure to be here. (laughter). And this is with, and the real podcast is with André Picard but let’s get to it man. Yup, yup, yup, yup, yup, yup. Yeah, let's go!

Kwadwo:                             00:21                     Welcome to Solving Healthcare. I'm Kwadwo Kyeremanteng. I'm an ICU and Palliative Care physician here in Ottawa and the founder of Resource Optimization Network. We are on a mission to transform healthcare in Canada. I'm going to talk with physicians, nurses, administrators, patients and their families, because inefficiencies, overwork and overcrowding affects us all. I believe it's time for a better health care system that's more cost effective, dignified and just for everyone involved.

Kwadwo:                             00:57                     Yo, welcome back everybody. Episode 13 and I can't tell you how hyped and excited I am for you guys to hear this. We have the one and only award winning journalist, André Picard on the show today and there's a ton of content in this episode. But one thing I want you guys to really appreciate, is the work he has done to transform healthcare. You're going to hear us talk about his involvement in the AIDS epidemic in the eighties and nineties, and his contributions to the movement. It really is inspiring. But before we dive into that, I want to tell you about our sponsors. We got betterhelp.com. They're an online counseling service that provides efficient, convenient, readily available counseling at your disposal. And what I love about them is that it's in any format, whether that's via phone, whether that's via video chat, whether that's by text messaging; they are there and, they provide high quality counseling that tailors to your needs.

Kwadwo:                             02:02                     Whether that's counseling your teenager, whether it's marriage counseling, it's all available. And I love these guys and they do great work. So if you're interested in signing up, use discount code Solving Healthcare and get 10% off signing up. This show's also being sponsored by the podcast, House of Pod. And can I tell you, I love this crew. Kaveh who I got a bit of a man crush on, Liz and Joe bring it. This is a hilarious medical podcast where they talk about any issues, whether it's screen time or addiction and they just make it a conversation. They make it real; they don't get caught up in the data. It's a real life conversation on these real life issues and I would point people towards Episode 36 a lot of, I know there's a lot of ICU crew out there and they interviewed Jessica Zitter who created the Netflix show Extremist and tons of lessons there in terms of managing end of life care and so on, but I love these guys.

Kwadwo:                             03:02                     Check out their podcast. You could on anywhere that you listen to your podcasts, iTunes, Stitcher, Spotify, they're awesome. Next, I also want to tell you guys about a survey that we're launching alongside of the Resource Optimization Network. And we're just trying to better serve our listeners so it's a two-minute survey. We just want to get a sense of what kind of content you guys want to listen to, come up with some solutions to common problems within your organizations, and so I'll keep an eye out for that. They'll be available by a Twitter, Facebook page, our home site, so put that on your radar. Okay, so today's episode is with the legendary journalist, André Picard and this is the first part of two that we're going to release with our interview with André Picard. We talk about lessons he learned from, you know, the AIDS epidemic.

Kwadwo:                             03:56                     As I mentioned, we talk about the impact of social determinants of health. We talk about how we could better serve the indigenous population and how we could address mental health needs in our country. I can't express the amount of expertise and knowledge André has. He's got 40 years of journalism experience in the healthcare sector. He is an eight time nominee for the National Newspaper Awards, Canada's top journalism prize. He's a past winner of the of the prestigious Michener Award for public service in journalism. He is a five time journalist, his latest book, which is awesome, "Matters of Life and Death: Public Health Issues in Canada." We'll have the links to that in the show notes. In 2002 he received the Sentinel prize of the Pan American Health Organization as the top public health reporter in the Americas. In 2005 he was named Canada's first public health hero by the community and Public Health Association.

Kwadwo:                             05:00                     And in 2007 he was honored as a champion of mental health. Anyway, without further ado, André Picard. André Picard, the one and only, welcome to the show.

André Picard:                     05:14                     Thank you.

Kwadwo:                             05:15                     I have been a big fan for a long time and I apologize for hounding you trying to get you on the show, but I'm super excited to have you on. I know our listeners are excited as well. I want to ask you this. I want you to tell me a bit about your mother and I know that sounds like a random question, but hearing her journey through healthcare I think puts a lot of perspective into some of the struggles that we're seeing in today's healthcare system. So if you don't mind, tell us a bit about your mom.

André Picard:                     05:48                     Yes. I've been writing about healthcare for a long time, more than almost 40 years now. And in the middle of that somewhere my parents, as many elderly people do, started getting sicker and having many conditions that I've spoken often about, my mom in particular, but my father had Alzheimer's, a long journey and my mom had COPD and then some vascular dementia, et cetera. And I always say that was my education, you know, an education I don't wish on anyon. But I learned a lot about the health system by combining my theoretical knowledge with the practical realities of having a parent or parents with chronic health conditions. And you learn a lot going through that and you learn a lot of awful stuff.

Kwadwo:                             06:32                     And like what are some of the things that really come to mind when you think about your parents' journeys through the healthcare system?

André Picard:                     06:41                     Well, I often think the biggest lesson I learned that I always repeat is that, okay, you know, the care is excellent in Canada.

André Picard:                     06:48                     If you're in the right place at the right time, you get fabulous care. That was true of my parents. It's true of almost everyone in the system, but we have a lot of problem with transitions. So every bad thing that ever happened to them happened when they moved from one part of the system to the other. So from the hospital ICU to home with no home care, from home care to a long-term care facility—that wait was painful in many ways for my parents. My mom at the end of life, had a form of dementia, vascular dementia. I kept getting kicked out of her nursing homes because she was quote, unquote violent. Now my mom was about four foot eleven, about 90 pounds. So she wasn't that violent. You know, she wasn't a threat to many people, but she lashed out as many people with dementia do.

André Picard:                     07:36                     She was scared and ended up spending her final days actually in a psychiatric hospital that was being closed down. It was and ironically, the care was superb. There were almost no patients left. She had superb nursing care. But none of her friends came to visit. They were of that generation where, you know, the mental hospital as they called it, was a shameful place to be and she died very, very lonely. And that was something that I found very crushing and devastating, especially as someone who writes a lot about mental health issues. That really drove those points home for me.

Kwadwo:                             08:11                     Wow. I'm sorry to hear that your mom had to go through such an experience. I think it really illustrates quite a few things, in terms of, we could do better in healthcare, and I guess where to start. Like if, so if you had a, you know, a magic wand or you were running the show, where would you put your resources?

Kwadwo:                             08:34                     Like where, what would you want prioritize in terms of improving our current state of health care?

André Picard:                     08:41                     Well, again, I said lots. I'd answer it in two ways. One, well first of all, I'd preface it by saying there is no magic formula. You can invest in a lot of different ways, but I think there are two big priorities. One is people ask me if I had more money for healthcare, I wouldn't put it in healthcare because essentially, we have a sickness care system, so I don't, not sure we need more money for sickness care. So I would put it into early childhood education, feeding kids at school. I think that's where we're going to get the biggest bang for our buck over the long-term. So that's the big picture one. On the more practical level, you know, how do you improve sickness care today?

André Picard:                     09:20                     I think we have to start with the basics. I think we have to, really bolster our primary care system. I always say if you don't have a good foundation for a health system, you know, you built this house of care on a rickety foundation and that's what we've done in Canada. We don't have good access to primary care. It's not organized, you know, no one is taken care of as they are in many systems around the world. Somehow no one is responsible for seeing you through and navigating you through the system. And that's one of our biggest failings — we lose people. People just fall through the cracks. Time after time. I talked before about transitions. So many people get harmed and hurt in those transitions because of a lack of organization. So I always talk about structure. I always say all our problems in healthcare are structural and administrative. We don't really have medical problems. We have fabulous medicine. We're going to have to make it easier for the caregivers to deliver care and easier for the patients to navigate the care system.

Kwadwo:                             10:20                     Yeah, and that's actually come up quite a bit on the show, especially the transitions element and you know, obviously having a family doctor, more engaged or more involved potentially can help out. But what else do you see as a ways of being able to improve these transitions of care?

André Picard:                     10:40                     Well, I guess that we have to say that the system has to become a system. We don't have the system. We have all of these silos that are not really well connected and we see it, you know, where do you see it most strikingly is in our emergency rooms everyday. So we have overcrowded emergency rooms that have nothing to do with emergency. Right? It's all about flow. So there are no beds for people to be admitted who need to be admitted. Those beds are full because we don't have home care. Because there's no home care, we don't have room in long-term care. There's this whole connection and we've got to work all the way up the line or down the line, whoever you prefer to work on that to actually make it a system.

Kwadwo:                             11:20                     Yeah, it's so tough. Cause I mean as a guy that's working in the hospital, I see the inefficiencies on a regular basis and I see the issues with siloing. I see the long wait times. And you know, for me, I'd love to see us invest more into things that we know work or even into prevention. And the thing that kills me is how much money and resources go to things that, I don't know, that just seemed to not, that aren't effective. Or like for example, one of the main areas I like to focus on is end of life care and how a lack of communication, a lack of communication, allows for patients to get care that they probably never wanted in the first place. And it's not cheap care. It's expensive care, especially when your patients get admitted to the intensive care unit. So yeah. Any thoughts on how we could be more efficient? I know that's a tough question, but in many ways I feel like there'd be, it would solve many of our issues that we've mentioned so far.

André Picard:                     12:29                     Yes, I think efficiency is not just about money. I think we obsessed a lot about in Canada about how much we spend and not enough about how much value we get for the money we spend. And those are very different things. I think that's where the focus has to be. You know, I hear lots of physicians, especially complaining that old patients want everything, and that, that's not my experience. My experience is patients want to be able to make reasonable choices, especially at end of life. You know, we do, there's gross amounts of over-treatment at end of life. People want to be comfortable. I have the privilege of talking to lots of patients at end of life because of the work I do. And I'm always struck by how rational and reasonable they are. You know, a lot of people say, "Listen, if given a choice between, you know, this cancer treatment and spending a couple of extra weeks or maybe a month with my grandchildren, I want to spend it with the grandchildren. I don't want this extension of life that's artificial and with all these symptoms, etc. I want to know realistically, what are my chances and be able to make reasonable choices." So I think we have to talk to people more seriously, allow, give them the information to make choices and not, not patronize them. You know, too often in medicine where people are taught to try and fix everything and some things aren't fixable. So we have to make people more comfortable rather than trying to fix them.

Kwadwo:                             13:55                     Exactly. And to me, a lot of that is just effective communication. You know, it's really figuring out what the patient's values are and what's important to them and taking that time. Because I think one of the main drivers of some of these issues is the perception or the reality of having that lack of time to address these things.

André Picard:                     14:18                     Yeah. And the communication part obviously is something. I'm in the communication business. I get to speak to lots of med students, a lot of residents about this, and I'm always struck by how little teaching there is about how to communicate with people. And that's such a, that's I think, you know, at least 50% of medicine is just being able to talk to people. And the knowledge is something else. But if you can't talk, it doesn't matter how smart or how talented you are, if you can't communicate that with the patient.

Kwadwo:                             14:47                     Oh amen. And we've talked about this on a previous episode, but literally, you know, their training is like, I give a give a communication lecture to the medical students in their second year. So that's a 50-minute talk. And you know, they go through these practices, these encounters with practice patients, a couple of those. And then you're, you jump in the fire. You start seeing patients and you know, the feedback you get is not always there. And so yeah, like such a huge part of what you do is communicating and, but you know, the teaching, the skill set is not always emphasized in school. Excellent. So let me ask, like, what drove you to do healthcare journalism? Like how did you land this job that you got all these awards for your written books on the topic? Like how'd you get here?

André Picard:                     15:46                     Well, it's actually, I quite literally stumbled into it. I didn't start out covering health journalism.

André Picard:                     15:52                     I actually started my journalism career in university as a record reviewer. That may date me a bit saying records, music reviewer I guess, that was my interest back then.

Kwadwo:                             16:03                     The records are coming back.

André Picard:                     16:04                     Yeah, I know. And I think my old collection is taking on some value now. No, but, so that's how I started. I got interested in the student newspaper because of my interest in music. I was a business student. People are often surprised by that, that I actually have an accounting degree, not any science degree. Because of that, I ended up the way student organizations run. They're always financially troubled. Because I was an accounting student, I ended up being the editor of the newspaper. Because of that, I had to write other stuff. And then I started writing on other topics. And at the time I was in university in the early 1980s was the time of AIDS.

André Picard:                     16:41                     But I started writing about AIDS as we did at that time. And that's sort of been the arc of my career. So for 40 years I've been writing about AIDS. That was my entry point into to healthcare. And I think that that shapes the way I write. I don't write so much about medicine. I write about the politics of health and the policy. And when AIDS started out, it was a very, very political issue. There were no treatments. Oh, there was a lot of discrimination against gay men. Bath houses were being raided. This is the stuff we wrote about. So that's always sort of influenced the way I approach health. I see it as very political, social issue, as much as a medical one.

Kwadwo:                             17:18                     Wow. I mean, you must have learned so much and seen so much during that time. Like I can't even imagine.

André Picard:                     17:26                     Yeah. It was a very, exciting but frightening time. You know, it was one of the, it still is one of the world's biggest epidemics in the history of the world, in fact. As it started out, there were a lot of people very scared and we didn't know what to. People were frightened about sitting on toilet seats. You know, it seems funny in retrospect, but they had no idea what this new disease was. It killed people very quickly. You know, there were no treatments for HIV for many, many years. It was just a death sentence. So it was the frightening time that really an educational time. Then I went as a, I went as a student to work at the Globe and Mail as a summer student and they said, "Oh, great. You know, you know something about AIDS, you've written about this." The mainstream media. didn't really cover it at first, so it was just sort of thrown into my lap and I started covering it there. Which, you know, you have more resources, more readership and then you get more and more knowledge and you kind of, and then I just kind of stuck with it over the years.

Kwadwo:                             18:25                     Wow. I mean what an experience you must have met and developed some amazing relationships covering that topic. Cause, think about what you've seen. You see all these relatively young people dying early and you're seeing the development of the medicines and improving mental care. You're seeing the more openness towards dealing with AIDS patients and HIV patients. Like it must've been like a whole, like a roller coaster ride.

André Picard:                     19:00                     Yeah, it was quite fascinating. We release our reshaping of, I think, of how medical coverage was done. So journalism changed profoundly because of AIDS.

André Picard:                     19:09                     I think medicine changed profoundly. The drug business changed a lot and all of this was the genesis of it was the, the AIDS movement. You know, the people who were infected early were young gay men. They tended to be very educated, very outspoken. And that that was new and medicine didn't know what to do with the patients who talked back and who protested and who said, no, that's not good enough. We want to be treated differently. And I think that the breast cancer movement then rose out of that, took those lessons and became, you know, was more socially palatable women with breast cancer than men with AIDS. But they took those same approaches and they went on to to shape, the healthcare and health coverage as well.

Kwadwo:                             19:54                     That's a really good point actually that I didn't really think about like there's a lot to learn on how to change healthcare because I mean this show's called Solving Healthcare.

Kwadwo:                             20:05                     So we know there's a lot of issues that we're trying to tackle, but if you think about the process or whatever, yeah, the process was to increase awareness, to increase the visibility, to make sure that money was invested to solve these problems. You know, like it's an infinite amount of lessons here.

André Picard:                     20:26                     Yeah. And I think one of the big ones, in the AIDS movement for, you know, it's been 40 years and they're still debating what's the most effective way to bring about change. Is it to work from the inside, to cooperate, or is it to work from the outside and protest and demand more? And I don't think there's a single answer to that question. I think there has to be a bit of both. And those approaches have really benefited us in different ways.

Kwadwo:                             20:51                     Is that how you feel? Is that what you, you know, after doing this for 40 years and seeing different movements and aspects of changes, but you don't feel like there's something that helps more than others?

André Picard:                     21:03                     I think we need both. You know, insiders tend to get complacent and they get comfortable and they always need to be pushed. It's always great to have new types of activists. You know, now there's a lot of activism from the indigenous community and that's, that's great. And I see many parallels there from the gay rights movement 30, 40 years ago. And it's, those things have to, they have to keep coming. We have to be challenged constantly. And to me as a journalist, that's one of the big lessons I think I learned early on, covering AIDS is, don't ever judge people just, you know, accept and listen to their point, you know, don't fall for stereotypes and for assumptions and you learn a lot more.

Kwadwo:                             21:48                     You must've learned a lot about being a patient, seeing them go through all that they went through.

Kwadwo:                             21:55                     Like, because I would imagine that a lot of the little things that we take for granted would be affected. Like I'm just putting myself, you know, in the mid eighties and having being diagnosed with AIDS, and my patients tell me all the time, like, you know, I do ICU, I also do palliative care and you know, being touched, being talked to as an equal and looking them in the eye as I'm talking to them. Like all these little things almost have, I don't want to say, healing properties, but they are impactful.

André Picard:                     22:28                     Oh, they're very, they're profoundly important. So in my last book, I told this story about from the early days of working at the Globe. So one of the first AIDS stories I did at the Globe was someone called in to the newsroom and talked about their partner was in hospital and was being badly treated.

André Picard:                     22:44                     So I was in Toronto at the time. I was at St. Mike's hospital and I went over to the hospital to visit this gentleman. And I went into his room and I shook his hand, you know, I introduced myself and he burst into tears. He said, no one's touched me for the week I've been here. They had piled up his food trays at the door. They had a sign on the, on his patient room saying danger, you know, sort of a radioactive sign. That's how AIDS patients were treated at the time. So I just wrote this story very matter-of-factly, how this person is being treated. It was in, you know, we didn't have the internet in those days, but it was on the front page of the Globe. That story is very, very impactful within, you know, the paper hit the doorstep of the hospital and they fixed that immediately. And, and St. Mike's is now, you know, it's known as one of the best places in the world for AIDS treatment. But it didn't start out that way. And it's that kind of those little things you realize, wow, I can, I can make a difference in a person's life and maybe to a few more. It inspires you as a journalist to say, to listen to those stories.

Kwadwo:                             23:52                     That must've been so rewarding to see that you like, you directly had such an impact on so many patients by giving them a voice. Because imagine that patients being in his spot, you know, where you're scared, you got this terminal diagnosis and you're being isolated and you're not feeling loved and you're not feeling respected and um, you come in and giving him a voice, bringing awareness to the, to the issue. I mean that's, this is why I wanted you on the show to be able to talk about ways and innovations and such acts that really can create change in healthcare. And I'm glad you told that story because I think it will mean a lot to a lot of people.

André Picard:                     24:46                     But you know, those things, those things are rewarding, in retrospect. But they're also humbling because you realize you know, for every person you've told their story, there's maybe ten or a hundred others whose stories aren't being told and they might be in much worse condition. This gentleman was, you know, wealthy, very well connected, knew how to call the Globe. I'd get someone over there, you know, a lot of people don't have that privilege. We have to, I think we have to be humbled by this and realize that we're only doing so much and we could be doing a lot more. Giving voice to the disenfranchised is, I think, a really important part of the media and it's, we don't always do it well.

Kwadwo:                             25:26                     Absolutely. I mean, we could talk a bit actually about the vulnerable patient populations. Cause you know, today actually we released a show on one of our residents. She leads a clinic where she sees homeless patients at a church and does preventative medicine and takes blood pressures and checks their blood sugars, like basic care that they might not normally be provided. And I was so proud when I heard this story because I mean, in my opinion, this is a huge problem, especially with the opioid crisis being the way it is. And I know you've voiced some concerns on how we treat our vulnerable patient populations. Any thoughts in terms of next steps or big picture concerns?

André Picard:                     26:15                     Well, I think, you know, over the years another thing you learn when you write about these marginalized and vulnerable populations, it starts with AIDS. But it's the same issues with everyone. You see, you have to, you have to make a little bit of extra effort to reach out and to ensure that people are heard. I learned a lot and I still write fairly obsessively about the social determinants of health. Pretty early on when you start writing about healthcare, you realize that all the medicine in the world is not that important compared to, you know, the basics. Having a roof over your head, having a decent income, having connections with other people is so important for your health, an education, all these, these basic things that we don't think of as health care, are way more important to our health than any amount of medicines.

André Picard:                     27:01                     I read a lot. I think the distinction between social services and health services is a bit of an artificial one, that we should try and get rid of, but we grossly underfund social services in Canada. You know, we spend a lot on sickness care, but we don't spend very much on social programs, on making people healthy and ensuring they don't get sick in the first place. In Canada, we spend about 13% of our GDP on social programs. A country like Denmark spends 27% and not surprisingly, they spend less on sickness care. They have better health outcomes, they have more fairness and equity in their society. And those are things we don't measure often that we don't pay enough attention to.

Kwadwo:                             27:46                     So, André, I couldn't agree more. You know, I think we're seeing more and more studies looking at the impact of social determinants of health. And you know, I really wish it was more emphasized. You know, I think the more I'm doing these podcasts, you realize if you invest early in, you know, in our kids, and our community, it will impact care in the long-term. And as you mentioned, these Scandinavian countries have shown this in the past. And you know, I even, have a colleague of mine, his kid, his school, they, they provide breakfast for kids that can't afford it. And that program was cut. They needed about a $1,000 to operate that program and they couldn't find $1,000. Meanwhile, we spend millions of dollars on drugs that might extend life by three months and we're not invested in our kids? You know what I'm saying?

Kwadwo:                             28:45                     It just blows me away. But honestly, I think this is where if you want to get the most value for the most we should be putting our resources into, into our communities and into prevention and it's tough to see. So we mentioned a bit about the indigenous population. You know, you know, when we were talking about vulnerable patient populations, I don't even know where to start. Where do we start? You know, like this is, we see at the bedside where, you know, younger, they're younger patients that are dying, they're sicker and you know, feel like they're being abandoned in so many ways by our society and by healthcare. What are the solutions there? Like what can we do?

André Picard:                     29:38                     Yeah, so again, I don't think there's a magical solution. This is, that's a problem we've created over hundreds of years. It's not going to be solved overnight. Right? I think the starting point is a recognition of the realities. So if you look at the, you know, the good a place to start as any, is the Truth and Reconciliation Commission or the recommendations they've made. And some of those are pretty basic. It's just realizing that the source of the problem, like colonialism, how that has created these, you know, the perfect storm for people to be sick. So I've written a lot about this, how you couldn't imagine if you are trying to create an evil, a form of killing people, you couldn't do better than what Canada has done. This creation of reserves, underfunding, isolation, stripping people of their language and culture, taking children away and sending them to schools.

André Picard:                     30:30                     You, you can't imagine a better way of destroying culture. So we have to work on rebuilding that. So that's the first step is to stop doing the bad stuff. And I think we're getting there. Then we have to start repairing. So things like making sure communities have basic sanitation and water. It's, you know, beggar's belief. But the reality is hundreds of communities in Canada just don't have clean drinking water. They don't have sewage, they have honeypots, so they collect their waste in plastic bags and a truck comes around once a week and picks up their human waste. And that's in Canada. One of the wealthiest countries in the world. So we have to deal with that really basic stuff and quickly. And make sure kids get an education, that we deal with discrimination. You know, the daily realities that indigenous people face are the ones we have to tackle first.

Kwadwo:                             31:24                     Yeah. And it's so sad when you think about this is our country and as you mentioned, it's a first world country and we're still seeing these issues. I mean, I have a colleague, Mike Kirlew, who should be on the show soon talking about when they're treating patients, they worried about running out of oxygen tanks. They might not have all the medications or antibiotics that they might need to treat patients. And this is in our own country. You know, it's, it's mind boggling.

André Picard:                     31:54                     And he does, he does fabulous work up in Sioux Lookout. But I think the flip side of it too is we can't let ourselves be, you know, I think for too long we've kind of thrown up our hands and said, "Oh, the problem's too big. Oh, it's too horrible. It can't be fixed." So I think we also have to realize that there's a lot of good going on in indigenous communities.

André Picard:                     32:12                     We write about a few very poor ones, but there are lots where the communities are thriving, where they're doing really well. They're educating their young people. They have great health clinics, they've brought in midwives so people don't have to be shipped out to give birth. So there's a lot of positive stuff. We can't focus, you know, we in the media tend to focus on the bad stuff a little too much and I think that's important. But at the same time we can't forget that there's a lot of good, a of sharing is going on between indigenous communities and learning and copying things that are working well in other communities. So I think there's a lot of hope there. This is also a generation, a lot of young people, you know, the indigenous community is very, very young, compared to the mainstream Canadian community.

André Picard:                     32:57                     More than half the people in indigenous communities are under the age of fifteen as opposed to Canada where about half of us are over the age of 40. So it's a very, very different demographic and we have to give those that younger generation some hope and I think there's a lot of hope there to be glommed onto.

Kwadwo:                             33:16                     What about mental illness? This is a topic that we've touched on quite a bit on this show that we feel or I feel is under-served and underappreciated. I'm wondering, any thoughts in terms of how we could do a better job at addressing mental illness in general? And then maybe even talk about, this might segue naturally into, into some funding issues, but yeah, maybe any thoughts in terms of our approach to mental illness?

André Picard:                     33:47                     Yeah, so I'll start with, I'll try and start with the positive. So the positive in 30, 40 years that I've been covering this, it's changed quite dramatically.

André Picard:                     33:55                     So things are getting much better. There's a recognition that we have to deal with, with mental illness. I think one of the important things, is we have to stop making this artificial distinction between mental and physical health. I like to call mental illnesses, brain diseases like liver disease or heart disease. We have brain disease. We have to attack that stigma part of it. I think we have to recognize why we have some of the problems we do. So if we go back to the beginnings of Medicare. One of the oddities of our Medicare system is when we started funding hospitals publicly in the 1940s and fifties, we excluded psychiatric hospitals. They were considered part of the jail system, the penal system. So they got grossly underfunded, literally the money dried up. We've released people into nothing. So we had this policy of deinstitutionalization, which, you know, decades later we're still paying the price for. Canada has one of the highest rates of homelessness in the developed world, the homeless. Everyone who lives in our streets, about 20,000 people a night in Canada, sleep on our streets. Probably 90% of them have severe mental illness. So we have to tackle that at the root. We have to ensure that people get the care that they deserve. You know, imagine if we had 20,000 cancer patients in the streets every night. No one would tolerate that. I mean, you have to just have the same attitude that this is not acceptable and we have to deal with them. So sorry for ranting.

Kwadwo:                             35:28                     No, that's perfect. It honestly though, I mean, I couldn't agree more like we, you know, see it's January and it's, Let's Talk Bell month. We've, you know, locally champions like Daniel Alfredsson has voiced, you know, how we got to reduce the stigma of mental illness. And, I know I do feel like we're getting there, but, I still feel like it's like when we're in a first world country like Canada where, you know, we were, we say we're going to cover universal, we have universal health care. Yet. You know, if there's a child that needs to be assessed for whether it's anxiety, depression, or an adult with a similar problem, many of our citizens have to pay out of pocket to be able to be seen by a psychiatrist or psychologist, for example. And to me that's, I don't want to say it's a crime, it's just, it's a, it's a barrier. You know, and I just, if we're going to take this as seriously as we should, I think we should do a better job in supporting it.

André Picard:                     36:38                     Yeah. It's definitely a barrier and it's inefficient. And it's ineffective and we, you know, we shouldn't be doing that for any number of reasons, but we have to recognize the history of that and fix it. Realize why this problem exists and then address it. The other part of it, I think too, you mentioned things like Bell Let's Talk, Daniel Alfredsson. Those initiatives are important. They're important to get people talking, but I think we pay much too much attention to people with not very severe mental illness. I'm not, I don't want to underplay the fact that someone can be depressed, but it's the people with very severe, almost often intractable or untreatable illness of people we see in our streets, they just need a disproportionate amount of care. And that's, we don't focus enough on them. I don't think we focus enough on the sickest of the sick. We kind of take the low hanging fruit too often.

Kwadwo:                             37:31                     Yeah. I wonder, like part of me is thinking how complicated and difficult of an issue that can be. Cause you know, you get your mentally ill whether you've got schizophrenia, you are like, you know, you may or may not be compliant. Did you run away from home? You live on the street and then to try and get you situated back into society, that's a tough road, you know. And I do hear you though. Like it would be these are the people that need our help the most. But man, there's, there's so many layers there.

André Picard:                     38:12                     Yeah, there's a lot there. But you know, we have, we have good research. We know one of the most important things for people with severe mental illness is to have a home. You know, the Housing First Initiative Canada has done some fabulous work there. It just hasn't been expanded enough. There's some really fascinating bioethical debates. I've written many columns over the years about whether people have a right to be sick? You know, do you have the right if you have schizophrenia, are you allowed to refuse treatment and live in squalor puts your life at risk every day? Is that a right or is that a failure of society? And I don't think these are easy questions, but I think we have to not shy away from talking about them. Over the years I talked to talk to so many families with you know, people with their loved ones living on the streets trying to kill themselves or overdosing on drugs every day. And they feel so powerless to not be able to help them. And again, they wouldn't have that problem if they had cancer, you know, whatever. We would treat them whether they want to be treated or not. And we don't have that same, we have this sort of self-righteous civil liberties attitude about some stuff that I don't think is appropriate.

Kwadwo:                             39:22                     Hmm. That's fair. I'm just, I'm brainstorming out loud in terms of real ways that that change could happen or like even we were trying to improve on how we approach mental illness today based on what we've done so far and, the awareness that's happening now. Like what could we do? Is it a resource thing where we should be emphasizing our time? Like, I guess I'm not, it's not clear my mind what we could do to fix this now. You know what I'm saying?

André Picard:                     39:53                     I think it's about priorities. I don't think it's about resources. There's few, there are a few things that are more expensive than having someone live in the streets. Right? They are. They're a great burden on the, they ended up in the emergency room a lot. They end up in the courts. They end up in jail. Homeless person costs our society about $110,000 a year. They're very, very expensive. Imagine if we spent that money a little smarter. And that's what initiatives like housing first are about. You can give someone a home or reasonable place to live. You can give them oversight. You don't, a lot of people with severe mental illness need oversight. A nurse, a social worker, but once they're in place, so much easier to give them the other things, and we can do that for a fraction of the cost. You know, we can debate this economically. We can debate it ethically because there's no question we can, we can do better on a number of counts.

Kwadwo:                             40:42                     Absolutely.

Kwadwo:                             40:47                     Yes. Thanks for joining us on Solving Healthcare. That was our first of two parts with André Picard. If you want to follow André on Twitter, he's @picardonhealth. If you want to follow us on Twitter or on Facebook or Instagram or at Kwadcast, any comments, please send them to Kwadcast99@gmail.com we really appreciate your input and I can't wait for you all to hear the next episode. So stay tuned and thanks for listening in guys. Peace.