What I learned in the emergency room
Emergency rooms: the last line of social safety net defence
Due to a family health scare, I saw my fair share of emergency rooms in 2019 and it’s left me with wholehearted respect for all health professionals.
From the intake nurses deftly assessing who needs to be admitted stat, to the doctors who are the epitome of calm, cool and collected, right down to the support staff who are the backbone of the system.
On our first trip to the ER, while my family member was being cared for on a hallway gurney inside the emergency room, medical staff rushed into a curtained-off room where an agitated man was violently spitting on the nurse and yelling profanities.
On our second trip to the ER, as my family member lay on a gurney in the hallway adjacent to the waiting room, I noticed a man slouched over in a wheelchair, appearing to be writhing in pain. A police officer was casually standing nearby.
Next thing I know, the hospital’s security guards are sprinting and asking: “Where’d he go?” I looked, and the guy in the wheelchair had given them the slip.
You see a slice of everything in the ER waiting room: socially isolated frail elderly patients, a child fighting for life after being struck by a vehicle, families gathered around loved ones.
Emergency rooms are the last line of defence in Canada’s fraying social safety net, “where you see the pathologies of poverty play out,” says Dr. Andrew Boozary, executive director of health and social policy at Toronto’s University Health Network (UHN).
In this Think Upstream Plan B podcast with Ralph Benmergui, Dr. Boozary points to the determinants of health that are shaped through policies like an inadequate minimum wage or lack of affordable housing.
“We see the downstream effects,” Dr. Boozary says. “The erosion of public space or social fabric that has been happening at a worsening degree.
“These are pieces that we can’t shirk. I think we have to ask hard honest questions about what we’re really willing to accept—what it looks like to maintain whatever quality of life that we would think as human and humane.”
His gaze is on the neglected poor:
“Income is one of the major drivers of health and wellbeing,” he says.
For Dr. Boozary, it means disentangling social determinants of health from social needs. He’s a big proponent of a basic income guarantee from a health care standpoint. He also advocates for greater investments in social services and a more integrated health and social service approach.
At UHN, they’ve decided to set aside a $10 million parcel of land that will be dedicated to building affordable housing near a Toronto hospital to address homelessness and improve health outcomes in surrounding neighbourhoods.
As Dr. Boozary tells Ralph: “I think it’s really important to not overlook the structural pieces that from the moment of birth really shape people’s opportunities … and underscore the resilience within these communities.”
He calls it a moral choice, because policy, by design, discriminates against and stigmatizes poor people. The solution lies in partnerships, in “a collection of communities coming together on these issues … for us to see any change,” Dr. Boozary says, calling for greater innovation within the health care system.
“Even within 10 years of having Medicare, the Lalonde report [in 1974] was pretty clear that for us to realize health outcomes … and really maximize wellbeing as a society, that the social determinants, the social factors, have to be addressed and integrated.”
“Physicians are the natural attorneys of the poor”: A doctor takes an Uber and discovers why a patient never returned for a follow-up assessment: working poverty.
The poor face higher likelihood of dying from preventable causes: “The arbitrary silos between health and social services must be reconsidered,” write Dr. Andrew Boozary and Andreas Laupacis in the CMAJ.
Medicare inertia: “Canadian social programs have changed relatively little over the decades since their establishment, despite substantial transformations in the social and economic fabric of the country,” write Marcello Tonelli, Kwok-Cho Tang, Pierre Gerlier-Forest in this CMAJ article, Time for Health in All Policies.
Working towards equity: Uprooting the hierarchical medical culture to tackle power imbalances.