Social accountability at the macro level

Join or create an organization to advocate both with and on behalf of communities

There are many recent examples of successful macro-level advocacy by physician organizations. Canadian Doctors for Refugee Care⁹ is a striking example, as its varied efforts, from street activism to court challenges, led to the reversal of cuts to the Interim Federal Health Program, which provides health care coverage for refugees and refugee claimants in Canada. Canadian Doctors for Medicare has established itself as a leading voice in championing a high-quality universal health care system and has been instrumental in bringing the idea of pharmacare to a national stage.¹⁰

The voice of physicians can also be influential on issues less obviously related to health care; for example, the Canadian Association of Physicians for the Environment lent credible expertise on health effects to the successful effort to see coal phased out of power production in Ontario and Alberta.¹¹

For individual physicians, supporting organizations such as these is an excellent way to contribute to, as well as to learn skills from those experienced in, macro-level advocacy.

Engage with medical, health care, and social service organizations to provide organizational advocacy for improved social determinants of health

Our professional organizations are influential among policy makers and among physicians. Subgroups like the Poverty and Health Committee of the Ontario College of Family Physicians or the Social Accountability Working Group (of which the authors for this series are members) of the CFPC can help to organize these representative bodies to put greater emphasis on the role of the profession in macro advocacy.¹² The aforementioned campaign on refugee health was aided considerably by the support of professional organizations, including the CMA, the Royal College of Physicians and Surgeons of Canada, and the CFPC. Individual members can also make their concerns known to the leadership of such organizations, which exist to represent our concerns.

Advocate for remuneration arrangements and funding that incentivizes addressing social determinants of health care

There is some danger in this recommendation, as it brings the issue back to what could appear to be a self-serving advocacy role. However, recognizing that certain models of payment and practice allow for more time and support for advocacy is essential to creating that space. Such advocacy must be tied to the desire to design remuneration in ways that incentivize the best practice for patients. In that context, it can be an important place for physicians to speak up for a better system as a means to facilitate care for underserved populations and patients with complex needs.

Collaborate with other organizations to establish broad intersectoral support for healthy public policies that address upstream determinants of health

The voice of physicians can also support the work of partner campaigns and organizations. One example is Upstream, a national organization dedicated to reframing political discourse around the social determinants of health (www.thinkupstream.net).¹³ While not an organization of physicians, it uses the voice of health care providers and the stories of patients to make the case for policy changes that will improve health outcomes, and the voice and experience of physicians is key to that message.

The voice of physicians has been influential in support of campaigns on specific issues such as paid sick days¹⁴ or raising the minimum wage.¹⁵ One example is the recent decision by the Ontario government to pilot a guaranteed basic income; this has largely been led by the Basic Income Canada Network¹⁶ but has been greatly assisted by support from the CMA⁶ and by concerted outreach from Ontario doctors to the Minister of Health and Long-Term Care, Eric Hoskins.¹⁷ Physicians can also lend their voices to support community groups fighting for justice, such as Black Lives Matter or Idle No More, recognizing that discrimination is a considerable determinant of health.

Advocate for increased focus on and exposure to social determinants of health in undergraduate and postgraduate medical education

The movement for social accountability in medical education has brought a greater understanding of the need for medical learners to be exposed to the social determinants of health. This is reflected in the Future of Medical Education in Canada projects (undergraduate and postgraduate) led by the Association of Faculties of Medicine of Canada, in which social accountability plays a prominent role.¹⁸ Advocacy has also been included as a CanMEDS¹⁹ and CanMEDS– Family Medicine²⁰ competency for medical learners. However, the concepts surrounding health advocacy remain challenging to teach and are often labeled as the “soft stuff,” both in curricula and in the minds of students and residents. Increasing classroom content and, more important, giving greater opportunities for service learning that incorporates a meaningful understanding of and actions on the determinants of health is necessary. An example of this approach can be found in the Making the Links Certificate in Global Health at the University of Saskatchewan in Saskatoon and other global health concentration programs that offer advanced learning opportunities for students interested in global health and advocacy.²¹

Rudolf Virchow famously said that politics is medicine on a large scale.²² Advocacy at the macro level is an opportunity for physicians to use their knowledge and influence to make that true—to create a politics actually in service of the health of the public. When macro efforts are seen as complementary to efforts at the meso and micro levels, we see that the inverse of Virchow’s dictum is true: medicine is politics on a smaller scale.²³ Our practice and its outcomes are bound up in the political realities that manifest in the social determinants of health. Using our skills and voices to make change at the macro level is a natural extension of the call to service of the profession. Our 40-year-old patient, Diana, who has multiple medical conditions and was recently diagnosed with cervical cancer, has been connected with local resources and has inspired you to engage in making healthy changes in your community.^1–3 Building on these successes, you wonder how you can help patients like Diana on a broader scale.