Social problems are not just social problems. They’re healthcare problems, too.

Issues like housing unaffordability, precarious work, or systemic racism can be directly linked to poor health outcomes. The Coronavirus pandemic has shone a bright light on many of these issues, called social determinants of health: that racialized communities are more likely to contract the virus has been a prominent example. 

These are the principles behind a movement gaining traction in the healthcare world: social medicine. It’s based on the concept that in the Western world, medicine and social services are siloed. This is an ineffective system, social medicine argues, given how interconnected social issues and health outcomes are.

The movement is growing here in Canada. Community health centres across the country have begun offering social services and medical care under the same roof, and doctors often refer patients to social supports, too. The Parkdale Food Centre created some buzz around the concept in 2019 after it launched a program accepting ‘social prescriptions’ for healthy food — allowing clients from outside the centre’s area of service to access its healthy food pantry if they had a prescription from a doctor. 

And most recently, the Gattuso Centre for Social Medicine at the University Health Network in Toronto launched early last year and is now seeing its programs — like a peer support program in emergency rooms and a mobile COVID testing bus — come to life. 

Future of Good Editor Kylie Adair sat down with Sané Dube, who manages community and policy for the centre, and Luwam Ogbaselassie, who works on the centre’s many community-level projects, to learn more about the centre — and the growing movement of social medicine. 

The following conversation has been edited for length and clarity.

Kylie Adair: Let’s start with a simple question: how do you define social medicine?

Sane Dube: Social medicine is not a new concept — it’s something that folks have studied for a long time with an understanding that what impacts people’s health is more than just access to healthcare. It’s the environment that people are living in and other factors that either create barriers or enablers to good health. It’s about addressing health inequities. 

Kylie: How has the pandemic changed social medicine?

Luwam Ogbaselassie: COVID has really exacerbated existing issues in our communities around disparities in health outcomes — along racial groups, along socioeconomic groups, et cetera. But it has also put us — not us as a program, but us as a system [of health innovators] — in a position to work more cohesively with community-based organizations and those in the social sector who have lived knowledge and experience and expertise working with communities. This is work that has been on the minds of those in the healthcare system, but pre-COVID, it might have taken years to build these bridges. COVID has kind of forced the highlighting of these inequities and propelled the work. 

But it has also put us — not us as a program, but us as a system [of health innovators] — in a position to work more cohesively with community-based organizations and those in the social sector who have lived knowledge and experience and expertise working with communities.

Kylie: Are there particular social determinants of health that have been highlighted more than others during this time?

Sané: One thing we’ve been really paying attention to, and something our program has been working on, is housing — just understanding how big a determinant of health housing is. It’s a pivotal factor. If someone’s housing is not stable, we can measure clear lines to their health outcomes. And in the context of COVID, people who don’t have housing have been put at higher risk. Folks who experience homelessness are five times more likely to contract COVID. 

We’re doing a lot of partnerships with community-led organizations. Recently, we launched a mobile bus [for COVID testing] with Parkdale Queen West in Toronto. What has become really clear is that the distribution of healthcare services is a determinant of health, and it has to do with where people live. 

Luwam: Another project we’ve been working on is around food insecurity and working with community-led organizations to ensure that those who have been hindered by COVID in accessing fresh food are getting access to what we call ‘good food boxes.’ These are folks who’ve been identified by the University Health Network as having either been affected directly by COVID or have lacked access to grocery stores, support networks, or other factors that make their access to food more difficult.

Kylie: Is there anything that’s flown under the radar? What’s a social determinant of health people aren’t talking much about, but you wish we were?

Sané: I think people are talking about all sorts of things; it just depends on how much others are listening. Something we’re also focusing on is decent work conditions. We’re thinking about paid sick days, and thinking about what the role of organizations like ours — healthcare organizations — is to actually be pushing for these things as interventions [for better health outcomes]. Another thing that is a huge issue, but, depending on which circles you move in you might not hear much about, is the overdose crisis. Given how severe the crisis is, it’s something that should be talked about way more than it is right now.

And then, we know that this pandemic will have long lasting impacts. So, what happens in a few months from now when we start to reduce COVID supports, but people still need, for example, food security support? I don’t know if we’re planning on a big enough scale. 

Kylie: What are the barriers to addressing these kinds of social challenges at scale?

Luwam: The fabric of the healthcare system in Canada is quite siloed. Something we’re trying to do is really centre the voices of community-led organizations, recognizing and respecting the knowledge and expertise our partners have in their communities. In all of our initiatives, we seek to partner with community initiatives, and I don’t know how much of that is popular discourse at the moment [in healthcare spaces]. 

Sané: This is one of the things that makes our healthcare system so strong — to have different people doing different things, with different resources behind them, and different approaches to their work. It’s not necessarily a bad thing that there are so many different players. What we’re interested in right now is bridging the gaps between the players. We think about the social medicine team as a connective tissue. 

Kylie: How do you build those bridges in your work?

Sané: It’s really about the guiding principles that we use every day. We are really aware of the effects of huge systemic issues. We pay attention to: what is the legacy of systemic racism in healthcare? How has this impacted what these programs look like? We are participatory and co-designed, meaning we talk to community members. We make sure that all of our planning is deeply informed by the communities, and rooted in the communities they’re working in. The quick answer is: we ask questions.

Luwam: [Practically speaking], we also link healthcare to community supports. For example, we link folks who might me leaving the emergency room with supports beyond their stay in the emergency room. So it’s a whole holistic approach that not only addresses the medical issue, but also the challenges a person may be facing post-their time in hospital. But being at UHN is so crucial, because it gives us a venue to reach folks who are accessing healthcare at a hospital setting and really building those connections after their time in the healthcare system. 

Kylie: What are the biggest challenges you face in moving social medicine forward?

Sané: I think one is creating room for a different way of moving through the world — it can be hard to change big systems. But the biggest challenge is just that resources are finite. We’re in a pandemic and there is only so much that can go to any one thing. There are many programs we’ve seen the benefit of and we’d love to fund on a bigger scale, but resources are finite so we have to prioritize. 

You also always run the risk of, if you’re not implementing programs in the right way, of reproducing the very harm you’re working against. I don’t know if it’s a challenge, but it’s definitely something we keep in the back of our minds as we do this work. How do we do this work in a way that does not further marginalize people who already face so many barriers?

You also always run the risk of, if you’re not implementing programs in the right way, of reproducing the very harm you’re working against.

Kylie: What are some things you consider in working to make sure your programs don’t remarginalize participants?

Sané: I’ll give you an example. One of the programs we’re supporting right now is bringing in peer workers — folks with lived experience — who are supporting work in emergency departments. It’s important to really give thought to this, because what you don’t want to produce is a dynamic where the expertise and knowledge that these workers bring is undervalued simply because of the different qualifications. So it’s really important to build a program that values their contributions, that adequately compensates them for their work, and that also creates safety and safe working conditions. That really means paying attention to the programming you’re building and making sure that the right people are at the table as you’re designing it. There’s a real risk of doing harm to people in the pursuit of doing good. 

Luwam: Something that’s important is really meaningful engagement. That’s a term that gets thrown around a lot — what does it really mean? Are we really actually listening to the voices of those who have worked with peers for years before we thought that peers could be a benefit in our emergency departments? We prioritize understanding and learning from those who’ve been doing this work for years before us, and really listening and learning. 

Kylie: How much of social medicine has to do with policy advocacy — pushing for better governmental policy responses to the social determinants of health?

Sané: Social medicine as a discipline, as a practice, always pays close attention to the policy landscape that we’re working in. There’s a lot of on the ground work that’s happening here at UHN, but there’s also a lot of contribution to conversations about what good policy might look like. I think that with time, I don’t know what our policy work will look like in the future, but we’re very aware that this is an important part of the work. To change a bigger picture, you need to have bigger picture conversations. 

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