For my Election Day Blog, I thought it might be appropriate to reflect on the future of our health care delivery system. While we may be consumed by the short-term issues facing our delivery system, today I’d like to focus on some of the rarely-addressed realities that will shape that future.
For the past three years, I’ve acted as their pro bono consultant for the Environmental Health Association of Ontario which advocates on behalf of 300,000+ Ontarians who suffer from multiple chemical sensitivities.
While I’m always advocating for a paradigm shift in health care, it is a significant challenge to get people to actually think differently about our circumstances. Just a couple of weeks before the election was called, a colleague from the Patient Advocacy Team at EHAO handed me a copy of a newly released report, and said, “Please, Ted, if you really want to understand what this country and this province are facing in terms of health status and health care now and in the coming years, read this.”
With a minority government looming in our future, I took a few hours last weekend to finally review this paradigm-shifting report. The report is called Early Exposures to Hazardous Chemicals/Pollution and Associations with Chronic Disease: A Scoping Review, and the person who handed it to me is environmental health pioneer Dr. Lynn Marshall, one of its four co-authors. In August, this report was jointly issued by the Ontario College of Family Physicians, the Canadian Environmental Law Association and the Environmental Health Institute of Canada. It was researched and written by people from the Canadian Partnership for Children’s Health and the Environment (CPCHE) and the Ontario Chronic Disease Prevention Alliance (OCDPA) – two great networks that together comprise more than 35 organizations. The project was funded by a Trillium grant.
Early Exposures authoritatively summarizes a huge pile of top-tier medical and scientific research showing that early exposure to a host of everyday chemicals is clearly associated with the big chronic disease killers and disablers of our time: cardiovascular disease and cardiac birth defects; low birth weight (associated with life long health problems); obesity (associated with CVD, diabetes, and many other chronic illnesses); Type 2 diabetes, Alzheimer’s and Parkinson’s diseases; a new epidemic of neurological developmental deficits; respiratory disease and, of course, many cancers, especially but not only breast, prostate, testicular and childhood cancers (on the right, you can find a link to this report).
We know that there are other such associations, for example, that ‘new’ diseases, such as chemical hypersensitivity, or new types of reproductive disorders (premature puberty in girls, low sperm count and genital deformations in boys) are also strongly associated with toxic exposures in early life. And the list goes on.
You’ve seen reports on these problems often enough in the medical and popular press – stories come out every day. But chances are you’ve never fully engaged with their content and implications.
- You may not know much about specific common chemicals – persistent organic pollutants (POPs) such as dioxins, furans and organochlorines, or about household chemicals such as pthalates, BPA, PBDEs, even about metals such as mercury and lead — and what they do to us.
- You might believe (wrongly) that if a given chemical is in use, somebody in charge somewhere tested it and declared it safe, so you have nothing to worry about.
- You might think (wrongly) that the only bad chemicals come out of smoke stacks or effluent pipes or maybe pesticide cans, but not from your laundry detergent or your personal grooming products or the plastic toys your kids play with or the non-stick coating on your cookware or the additives in your food or the dust bunnies under your bed or even the air ‘freshners’ you can’t get away from any more!
- You’ve probably heard the term ‘epigenetics,’ but have no idea how environmental exposures affect this aspect of our genetic legacy and our health.
And emotionally, you probably don’t even want to think about the implications of what I’ve just said. I don’t blame you. This is difficult stuff. But making like an ostrich won’t help. So have a look at this chart, taken from the Executive Summary of Early Exposures:
SUMMARY OF EARLY EXPOSURES ASSOCIATED WITH
PREVALENT CHRONIC DISEASES OR CONDITIONS:
| Cardiovascular Disease (CVD) |
|
| Cardiac Birth Defects |
|
| Low Birth Weight |
|
| Obesogens |
|
| Type 2 Diabetes |
|
| Alzheimer’s disease |
|
| Parkinson’s Disease |
|
| Developmental Neurotoxicity |
|
Cancer
|
|
| Respiratory Disease |
|
Taken from Early Exposures to Hazardous Chemicals/Pollution and Associations with Chronic Disease: A Scoping Review, 2011.
Go back and a do quick review of the chart above. Do you see how big the picture is? Do you see why we simply can’t ignore this stuff any longer?
I’ve been writing and speaking recently about the challenges facing Ontario’s health care system – and about possible ways forward in the present and unfolding economic context. In a nutshell, I’ve been saying that we are still just tinkering with changes to a strained, 1960’s-style acute care system, when what we need to create is a wellness and chronic-care system with a much stronger emphasis on disease prevention, homecare and primary care services, as we ensure that our citizens continue to have access to excellent necessary acute care services.
What Early Exposures has so powerfully brought home to me is that our problems with chronic disease and chronic disease care are not just organizational, or structural, or fiscal, in the simple sense of these terms.
In fact, our key health care institutions have no analysis, policy or programs with respect to the some of the biggest causes of chronic disease that even now are honeycombing our society with extraordinary levels of illness, with manifold and far-reaching consequences in suffering and in economic loss.
What this report dramatically demonstrates is that early chemical exposures are the evil gifts that keep on giving and giving. If we remain institutionally blind to these evil gifts, their legacy of illness and disability will get much worse, and we are already staggering under the weight of current levels of chronic illness.
To make matters worse – much worse – here in Ontario a few years ago, the McGuinty government decided to remove the Health Promotion and Disease Prevention Branch from the Ministry of Health and Long Term Care and to create a new and separate silo-ministry for Health Promotion, to which they then also assigned ‘sport’.
However well intentioned this move was, it was not a smart strategic move. The effect of this decision has been to create a small, powerless agency relative to the giant MOHLTC, and to dis-integrate the functions of health promotion and disease prevention – so important in environmentaly-linked conditions — from those of health care. It’s like severing the two hemispheres of a brain. There may be two pieces left, but they’re not working together – they are far, far less than the sum of their parts, and the potential for their close interaction and synergistic capability has been destroyed.
It is government’s job to stay ahead of massive dangers to health, to develop adequate responses and to modernize our approaches to health and health care accordingly. But so far our federal and provincial governments have failed abysmally with respect to chemical hazards. They see the health care crisis as ‘the cost of hospitals’, when the real crisis is what is causing us to become sick in the first place. Rather than upstream prevention measures governments like to focus on all the downstream, high-cost interventions that are necessary because we did nothing to prevent the illness in the first place.
The truth is: we don’t have a Ministry of Health. We have a Ministry of Doctors & Hospitals.
Those familiar with my rants about the healthcare system will know that I often refer to the 30% ‘waste’ in the system – waste in procedures, processes, personnel, etc — that, when judged from a quality-of-care and a patient-centred perspective, take up money, lots of money, but fail to deliver good quality care for people.
But what I have been coming to realize over the past several years, and what the Early Exposures Report has finally cemented in my consciousness, is that we need the kind of system redesign that takes the environmental determinants of health into account and addresses them, all the way through the system. We can’t “fix” our health care problems only within existing programs or paradigms, or only by modern organizational redesign processes like lean thinking and patient experience design.
I talk a lot about patient-centred care. Well, we can’t deliver that if we’re not addressing what’s causing our ill-health, or if we ignore or exclude the myriad of illnesses and conditions that are linked directly to those causes. For true patient-centred are, we need 21st century thinking — which means taking into account, medically and organizationally, the chemical legacy of the 20th century.
Understand that in many cases, this is not about adding net new costs – in many cases it’s about cutting waste and reinvesting savings in more effective and appropriate services.
Consider Ontario’s population of 300,000+ persons diagnosed with ES-MCS (environmental sensitivities – multiple chemical sensitivities), with whom I’ve been working as pro-bono consultant.
These patients live a life of isolation, disability, poverty and suffering due to their life-threatening ailment — yet they are largely invisible to the rest of us. In addition to carrying their own burden of the better-known chronic illnesses, thanks to particular gene/environment interactions triggered by toxic exposures, they have developed a horrible new chemical affliction: they can no longer tolerate many, even most, of the everyday chemicals in that chart you just saw, the ones that have spread into every nook and cranny of our environment and just can’t be escaped anymore.
These folks have become like aliens in their own atmosphere. Many suffer with levels of poverty and homelessness that are just mind-boggling. Check out the link below for the photo essay on their lives that appeared in the Sept. 17th New York Times Sunday Review for an immediate and visceral education: http://www.nytimes.com/interactive/2011/09/18/opinion/sunday/20110918_OPINION_ALLERGYGOBIG.html?ref=opinion#1
Ontario’s population of persons already diagnosed with this illness grew from 217,000 in 2005, to over 300,00 in 2010. That’s the bad news. The good news is that early intervention, and even intervention at levels of great severity, can make a tremendous difference. But we don’t intervene here in Ontario. Our health care system barely recognizes that these folks exist and offers them no treatment, or any other medical and social supports along the normal continuum of care. We have no billing code for them, and no clinical facilities. So their numbers multiply as they get sicker and sicker as the consequences of their illness ripple out into society,
Does this medical shunning at least keep our costs down? Is there, as one civil servant once put it to me in a macabre formulation, a ‘business case’ for this medical irresponsibility? Turns out that it’s just the opposite — Ontario’s official blindness to these people has been costing this province hundreds of millions of dollars in waste — through inappropriate physician utilization costs alone.
Because the condition is a ‘multi-organ system’ one – affecting some or all of respiration, vision, digestion, liver, kidney, gastro-intestinal, neuro-musculatory and brain function, sleep, immune and endocrine function — people who have it, often without an accurate diagnosis and certainly without the necessary supports and treatment, get sick a lot. And so they go from one doctor to another in search of medical help, and they do it for years.
In fact, a study done at the Environmental Health Clinic at Women’s College Hospital, the one, tiny, diagnosis-only facility the province does fund, showed that physician utilization rates by clinic patients prior to their diagnosis with ES-MCS was 8 times – that’s right, 8 times! – higher than that of average Ontarians, but with wrong diagnoses and no treatment they just get sicker.
By contrast, in Nova Scotia, where the only treatment clinic for ES-MCS in Canada exists, outcome studies show that after one only year of low-tech, low cost treatment, physician utilization rates of clinic patients (which are lower to begin with than in Ontario since referral is faster and awareness among physicians greater) return to the Nova Scotia average, and the system realizes major savings by providing appropriate and effective physician services.
In our great province, recent estimates suggest that we are paying a whopping $400 million dollars a year for largely inappropriate, sometimes harmful, physician services for persons with ES-MCS. That’s right, nearly half a billion dollars so that people can get sicker and sicker.
Back-of-the envelope estimates also suggest that for a fraction of that money, allocated to the right services and treatment at the right time (i.e. an appropriate continuum of care), and system-wide awareness and protocol development, Ontario could save perhaps 80% of that, get excellent health outcomes, and prevent much disability — thus preventing a cascade of horrendous consequences, including economic hardship and loss of productivity. Here is a leveraged action waiting to happen.
Think about it. With respect to ES-MCS alone, the savings that would be realized by a health leadership that is willing to take the blinkers off and modernize our health care system would be tremendous. Resources would be freed for effective and hopeful re-investment. Strengthening public health programs that are designed to reduce environmental harms and educate about early warning symptoms of chemically-linked illnesses, including in schools and communities, would certainly be an example of a “leveraged action” that such savings could fund — with major pay-offs long into the future.
Let me end my Election Day Blog by saying that whoever the new Minister of Health is, and whatever happens on other fronts in health care, we need to strongly encourage her or him to move forward on a few measures right away. These measures include:
- Fix the waste and the suffering in the ES-MCS file immediately: Just before the election was called, funding for recommendations for the right health services was finally being discussed at senior levels. Let’s get that funding flowing and address these issues.
- Reintegrate into one ministry and strengthen the health promotion function within the Ministry of Health and Long Term Care — so that all crucial functions and components are working together.
- Work with ES-MCS patients and leaders in the field of environmental health (including the authors of the Early Exposures Report), to lead in devising multifaceted policies and processes to ensure that what we are learning about the environmental hazards to our health, can be addressed in meaningful ways throughout our health care system.
So, as we go off to vote today to set the course for the future, we really ought to reflect on the type of leadership and the kind of thinking that takes us beyond the short-term concerns of minority governments and instead, includes the type of paradigm-shifting perspectives that our health system leaders – at all levels – must now address.
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