Public Health Insight

Healthcare in Canada and the United States: A Brief Comparative Analysis

July 07, 2020 PHI Productions
Public Health Insight
Healthcare in Canada and the United States: A Brief Comparative Analysis
Show Notes Transcript

The United States of America’s multi-payer privatized healthcare system is drastically different from Canada’s universal single-payer healthcare system, but why does the U.S spend more on healthcare as a percentage of GDP compared to Canada? Rose Marcelin joins the Public Health Insight Podcast to discuss the nuances of these distinct healthcare systems and the importance of accessibility, affordability, and equality in determining healthcare quality and ultimately population health outcomes.

If you enjoyed the episode, follow us on your podcast platform of choice and also follow us on social media: Instagram, Twitter, and Facebook. We would love it if you shared your thoughts with us through direct message on your social media platform of choice or by emailing us at ThePublicHealthInsight@gmail.com.

Stay tuned next week when we continue our conversation in the next episode on integrating cultural competence in healthcare as an avenue to address health disparities in vulnerable and marginalized populations. 

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[00:00:00] Sully: Public health is a population-based field of science focused on preventing disease and promoting health. Every week, we will be engaging in interactive discussions and analyses of the latest public health issues affecting you and your communities all around the world. This is the Public Health Insight podcast.

[00:00:24] My name is Sully and I'm here with Will, Gordon , Leshawn, and Ben. 

[00:00:29] Ben: Before we move on its important to note that the views expressed in this podcast are our own and do not represent any of the organizations we work for or affiliated with. 

[00:00:37] Sully: In light of the staggering number of overdose related deaths, harm reduction has been slowly gaining traction as the best method to reduce such health related risks.

[00:00:46] It has been adopted across several jurisdictions and countries across the world to prevent negative health consequences associated with substance use, such as bloodborne illnesses and opioid overdose deaths. In [00:01:00] order to understand the rationale for harm reduction programs, it is essential that we first discuss abstinence-based programs, what they hope to achieve, and then delve into the principles of harm reduction.

[00:01:11] So what is abstinence? 

[00:01:14] Will: So abstinence is the most traditional form of treatment used when dealing with substance abuse or behavioral addiction, things like that. This approach focuses on making sure that clients must completely abstain from whatever behavior or substance that they are addicted to. And it's believed that individuals who have substance use disorders cannot moderate and control themselves in a way that leads to negative consequences.

[00:01:45] Gordon: It's tricky though because like you said, Will, you have to look at abstinence in the context of two different things. You have to look at abstinence from the context of someone who's already addicted to a certain behavior or substance, because you can also be [00:02:00] addicted to things that aren't drugs. Right? So there certain people addicted to things like sex.

[00:02:05] So abstinence comes in also when you haven't yet engaged in that behavior. And in that case, abstinence perhaps is more effective, but we're going to talk a bit, a little bit more about how abstinence might not be the best choice for people who are already addicted to a certain behavior or substance. 

[00:02:24] Ben: The main thing of abstinence, and it's a good point that Gordon raises that there's a spectrum of addiction in terms of where you are at. And I feel as though abstinence is, you could argue that it's good at the beginning, because number one, you never have a person in contact with the addictive source, whatever it may be. But at the same time, I feel like without proper like communication conversation, you're just kinda like making them want to do it more.

[00:02:48] You know, there's like the rebellious aspect of like, oh, you mean, I can't do this. It just makes you want to do it more. So I feel like you have to be kind of cautious when you do abstinence. 

[00:02:55] Gordon: So like you're taught, you're referring to the, the [00:03:00] say no to drugs campaigns going on for a while. 

[00:03:01] Ben: Exactly. So you had to say no to drugs campaigns targeted at children. Um, specifically, uh, children in the way that the media was like, they had like, I think stuffed animals and like, this is your brain on drugs. And it was like an egg on fried on a pan and like, yeah. And like kids would completely miss that point and be like, oh, that's kinda cool. Maybe I should try trucks.

[00:03:20] You know, like that stuff. I might have the opposite effect of what we're doing with, and, you know, history has shown that it kind of has, but, uh, yeah, there, there are some pros to abstinence, but personally I'm not completely convinced. 

[00:03:33] Will: Yeah, those say no to drug campaigns. Um, that kind of reminded me of something we used to have back in elementary school.

[00:03:41] I don't know if you guys have experienced the same things, but I remember we used to have, I think at least a couple of assemblies each year, or like the whole school would kind of go and it would just be a police officer doing like an hour, an hour and a half long presentation on drugs. 

[00:03:57] And not gonna lie, [00:04:00] the main message that I guess the people I, who I, I guess me and my friends kind of took out of, it was not the message, I think that, that the officer was trying to push, which was, you know, kids stay away from drugs, but it was like, oh, look, look at this wide range, spectrum of drugs, you know, it's, there's like different levels of it.

[00:04:19] And I think we got more interested in like finding out more about these drugs then rather than staying away from them. 

[00:04:25] Ben: Mm Hmm. That's a fair point.

[00:04:27] Will: Yeah. Just like tackling onto what you were saying earlier about clear messaging and communication. So like from those assemblies, I feel like that they really missed a ball there with communicating properly. Instead of communicating kids stay away from drugs. It's like, oh, like there's all, it's kind of opened up another door for kids to, to do their own research and look into all these different, cool names. And they have like pictures and everything. 

[00:04:50] Sully: And here, you're assuming that these kids like kind of never been exposed to information about these drugs. And then all of a sudden, a police officer is talking to them about all [00:05:00] these different kinds of drugs and their effects and what they do. 

[00:05:02] Gordon: Yeah. But I'm even thinking, you know, how there's a whole debate about sex education in elementary schools and high schools. Right. So instead of say no to drugs or say no to sex, well, it's almost like it's like maybe tell the children are, you know, the teens, give them the message exactly how it is, type of thing. Instead of trying to scare, is that kind of where you're, where you're getting at help, help people to understand the beast that they're dealing with?

[00:05:28] Will: Kind of, yeah, just felt like that from, from my experience, at least those assemblies was th they, they made it very engaging to have videos of what it was like for people who are on, um, these drugs, but they were these videos weren't done like properly. They were almost like in a way that was that, that got kids thinking, oh, that'd be it's it seems kind of funny. Maybe it would be cool if I tried this kind of thing, the missing the mark when, because it is a, quite a sensitive topic and it was a very important topic. They essentially just didn't cater to like the youth audience [00:06:00] in a way.

[00:06:00] Gordon: Right. It's almost like it would be better to have someone maybe have a, maybe not similar age, but a fairly young person with lived experience kind of share like the dangers, like how it affected their, humanize it a bit. 

[00:06:13] Ben: Or even bringing a person who was actually had experience with drugs versus like a cop who was only on like one aspect of it. Cause you know, what, what you described would you, you would imagine it'd be like the greatest thing. You know, you have a person in the police force working with the community to inform them about drugs and crime, but if it completely misses the mark or you need something more than a one hour conversation, right.

[00:06:34] You know, maybe that's not the greatest way to have that communication. And it's unfortunate. Yeah, everyone's pushing abstinence abstinence. Right? 

[00:06:42] Gordon: Right, right. 

[00:06:42] Ben: So working within that narrative, it's difficult to have effective conversations. 

[00:06:46] Gordon: And it also, it speaks to the kind of criminalization of drugs too. Right. You have, you have an Officer saying, okay. If this is you in 10 years, we're going to lock you up. Exactly, right? Yeah. So it doesn't help either. 

[00:06:59] Sully: [00:07:00] Well, we all recognize that there's a benefit in preventing kids from getting into drugs. And the problem is with the how, but what's the disadvantages of abstinence-based programs.

[00:07:11] Ben: I think it's back to what Gordon says is where you're on the spectrum for addiction. So if you've been heavily addicted to a substance or a certain behaviour, over time, you're going to have withdrawal symptoms because that's just how the brain works. Right. And those withdrawal symptoms are extremely dangerous within themselves.

[00:07:26] So you can't just suddenly go cold Turkey, like it's literally impossible. Your body's going to shut down. You're going to have certain cravings, et cetera, et cetera. So abstinence in that sense won't work unless you fill it with something else. And we've seen that with other, um, addiction based programs is that often social connection is used in order to combat those withdrawal symptoms.

[00:07:47] So for example, um, for AA, I know that if you're having these symptoms, you are linked with a person. And no matter what time of day, if you're feeling like you need a drink, you just call that person up and they don't judge you [00:08:00] usually like, I mean, well, obviously they don't judge you, but usually they don't say no to drinking.

[00:08:04] They're just like, what do you want to do? Where are you going to go? How are you feeling? Just talking and having that connection in of itself fights off that addictive craving. 

[00:08:12] Leshawn: That's a great point. And I think one of the difficulties with abstinence-based approaches is that in a lot of, I guess, community service settings or social housing settings, individuals are actually required to be abstained from drug use while accessing these services.

[00:08:27] And as you mentioned, abstaining from drug use, for example, for someone who's been taking drugs, their whole life is a very difficult thing, and there's a lot of health effects, physical dependency, um, negative consequences that occur with that. And it's also important to point out the fact that abstinence is very difficult, right.

[00:08:46] And especially coming from certain backgrounds, you know, there's environments that you're, you're grown up in that kind of perpetuate the ongoing use of substance abuse, unstable housing, financial instability, and the lack of social support. [00:09:00] So in addition to stigmatization and shaming behaviors associated with drug use.

[00:09:05] Ben: Yeah. And that's, that's the tough point with shaming and stigmatization, because you'd think that if a person was going through drug or alcohol abuse, your immediate reaction is to get them help, but the very like, uh, consequences of them having that abuse, you know, they're, they're drunk, they don't listen to, they may be violent, et cetera.

[00:09:21] It makes you want to like, uh, socially distance yourself away from them. Right. So it's a really complicated situation where you want to help. But you can't. And then at the same time, because they're not getting that social connection from you, they end up spiraling further and further down that addiction.

[00:09:36] Gordon: Yeah. Yeah. I think preventing problematic use of any substance or behavior is a kind of a two part discussion. So in health promotion, you want to prevent people from engaging in behaviors or habits that kind of jeopardizes their health. So in that case, you want to educate people about the dangers [00:10:00] associated with drug use, including opioids, so that they don't go on it.

[00:10:05] People who tend to use substances, um, there's usually an associated underlying mental health condition. So it's important that people are educated, you know, if they are feeling anxious or depressed that there are supports out there other than going to drugs in the first place. And if they do go to drugs, you want it to kind of be under the care of a physician, hopefully who has their best interests.

[00:10:28] Right? So with that said, now you have people that are already addicted to drugs, and that's a different discussion where abstinence is not very successful. 

[00:10:37] Sully: So because abstinence only focuses on one aspect of addiction, which is just to get you off it. It ignores all the other aspects, which is the negative consequences in terms of health, social aspects.

[00:10:52] So there is a gap there, and that's why harm reduction arrows to fulfill that gap as a response where [00:11:00] we should talk about first as well as harm reduction.

[00:11:02] Leshawn: So harm reduction is an evidence-based client centered approach that seeks to reduce the health and social harm associated with stuff that we discussed, like addiction and substance use. So this approach also doesn't necessarily require people who use substances from abstaining from them. 

[00:11:20] Gordon: It's important to note that harm reduction is not specific only to substance use, harm reduction has also been used in other high risk behaviors, such as unprotected sex, where, you know, condoms have been used to kind of prevent the transmission of, um, sexually transmitted infections, things like wearing seat belts when you're driving a car, um, you know, you don't discourage people to drive a car, but then when you, if you do drive, wear a seatbelt, because it can help save your life if you're in an accident. So in general harm reduction is essentially a set of principles that can keep someone safe while engaging in potentially harmful behavior. 

[00:11:59] Will: Right. And [00:12:00] just to add on to what you were saying earlier, Gordon, about harm reduction being used in sex. Um, not only does it prevent the transmission of sexually transmitted infections, but also it helps reduce the rates of unwanted pregnancies. And there has been a lot of studies showing that, especially in developed countries, if you're comparing, in schools, you're comparing between abstinence only sex education vs. safe sex education. Um, these safe sex programs and education programs, which are classified as harm reduction programs, um, had been found to drastically decrease risky sexual behavior, prevent sexually transmitted infections, and also reduce the rates of unwanted pregnancies. While, um, abstinence programs, it doesn't appear to actually affect any of these three indicators.

[00:12:47] Sully: What I'm understanding from this is that the overarching goal of harm reduction is to prevent the negative consequences of any risky behaviors such as substance use or driving the car is actually a risky [00:13:00] behavior. So you need the seatbelt to prevent, you know, harmful injuries when in an accident and preventable deaths.

[00:13:06] So harm reduction is everywhere in our lives, so it's nothing new, but what it hopes to do right now is to make it more of a pragmatic solution to the opioid crisis. 

[00:13:18] Ben: Yeah. I love the pragmatism of the harm reduction approach because it's very against what we've already tried, which was the war on drugs. And we saw that we lost that war completely and embarrassingly.

[00:13:31] So harm reduction is basically you recognize that substance use is inevitable in a society. Drugs are going to be out there. And there's far more people funding the use of drugs in our society versus trying to get rid of them. So it's necessary to take a public health oriented response to minimize the potential harms. It's there. We can't fight it from being there, but we can help individuals once it's there. 

[00:13:53] Leshawn: Yeah, exactly. In addition to that, the pragmatism aspect of it, it also considers more [00:14:00] humane values. So a lot of the harm reduction approach actually looks into meeting the person wherever they are in their substance use journey, and working with them in that sense. So individual's choice is considered, there's no judgements applied on individuals who are using substances. And this essentially respects the dignity of the people who are using these substances. 

[00:14:22] Gordon: Yeah. And focus on harms is the last principle of harm reduction. And it basically looks at the substance use, uh, of a person as secondary to the potential harms that may result from the use.

[00:14:33] And essentially what that means is if someone is addicted to drugs, And they're trying to stave off withdrawal, for example. They might be more inclined to use a dirty needle to inject the drugs. And we know that if you use a needle that hasn't already been used by someone else, you can transmit, um, diseases like HIV and hepatitis.

[00:14:54] When you look at the big picture of harm reduction, we, we laid out some brief examples. I think [00:15:00] when I in doing public health, I didn't really know what harm reduction was. I knew about, you know, safe sex education, um, and things like that. But what are some other examples of harm reduction that people may not necessarily think about? 

[00:15:14] Leshawn: Wearing bike helmets while riding your bike 

[00:15:16] Ben: consuming water while drinking alcohol.

[00:15:20] Gordon: Another one too is, um, from the pharmacy perspective is, um, using a nicotine patch, uh, to help someone quit smoking. So basically you're swapping out smoking for the nicotine patch, which is a safer way to consume, I guess, nicotine. 

[00:15:36] Ben: There are certain types of things that could be classified as harm reduction that often might result in risky behavior.

[00:15:44] For example, what I'm thinking of is helmets. People wear helmets, and you could argue that that's harm reduction because you know, you prevent injuries. But leads to riskier behavior because people think they're more protected than they actually are. So is that an element of harm reduction that we should be wary about?

[00:15:59] Gordon: So [00:16:00] that's a good point, but I think it's like individual topic to topic because as Will had mentioned that, you know, safe sex programs versus abstinence-based programs did not lead to an increase in risky behavior regarding sex. So I think there might be examples where people may engage in more risky behaviors if the harm reduction principles are emphasized.

[00:16:21] But I think we have to look at the individual. Um, so for example, nicotine replacement therapies and smoking, I don't think people smoke more when they use nicotine patches. So I think it may be in some instances, um, it does. And maybe in some it doesn't, but I think it just, it just goes to reemphasize that public health research is very, very difficult for those listening who are into maybe more applied kind of research where you can kind of test hypothesis and there's no real ethical violations behind it. You can't really randomize someone to an unsafe car without a seatbelt to someone, you know, [00:17:00] so you kind of have to look at history and see if the thing you're trying to prevent, if the policies that you kind of implemented, reduced or had the intended effect.

[00:17:08] So that's kind of, unfortunately, in public health, that's the only way you'll know if something worked as if you tried it. 

[00:17:14] Sully: So, wait. That, well, that brings me to the question. I mean, is there any weaknesses associated with harm reduction, the principles of harm reduction? Like what does it not do? 

[00:17:24] Will: I think a weakness of harm reduction is that it doesn't target the issues at its core, you know, like for example, um, related to the addictions or substance use. Harm reduction, the concept itself doesn't address the underlying mental health implications or other life course events that might've led to the current use. But what it does is that it provides, um, almost like a safety net.

[00:17:49] So individual who is using these substances are able to do so safely so that when the time is right, they are still alive, let's say to be able to, um, progress [00:18:00] towards abstinence. 

[00:18:01] Ben: So what you are saying is that it deals with more of the acute problem of overdoses versus the more long-term solution of rehabilitation.

[00:18:09] Will: Right. Exactly. Yeah. It's, it's, it's a very much, it doesn't tackle it at the core, but it prevents related deaths from happening essentially.

[00:18:17] Leshawn: I think also a part of the harm reduction narrative is that you work with someone where they are at. And the eventual goal is to help them access other services to maybe adjust those problems. 

[00:18:29] Will: Right. But, but those services are outside of the harm reduction scope, are they not? I'm sure, like if you, for example, if you go to a harm reduction, um, like a safe consumption site, it's the individuals trained at the safe consumption site are not trained psych uh, psychiatrists, who are able to diagnose underlying mental health.

[00:18:46] Gordon: That is true. However, however, some of the more, I guess, the safe consumption sites that have decent funding and stuff, they actually have connections to health care and treatment services. 

[00:18:57] Leshawn: Yeah. There's a couple of different variants, I guess. [00:19:00] There's um, for example, you mentioned supervised consumption sites.

[00:19:03] One variant of those supervised consumption sites can actually be integrated within health systems where something like accessing different healthcare services would be more feasible, but then that you have supervised sites that are maybe more standalone, in those cases. Um, they'll, there'll be a harder case to make in terms of referral to different services or integration with patient care.

[00:19:26] Gordon: Yeah. Just to get back to what Will was saying, at its core, the basic principle of harm reduction does not address those other underlying factors. What you need is you need to implement kind of supplementary interventions along with harm reduction, uh, in order to get people from where they're at to maybe where they want to be.

[00:19:46] Sully: I wouldn't say supplementary, it's more like programs that work in tandem with harm reduction to make all these other services more accessible and that's where we're harm reduction comes in. 

[00:19:57] Okay, so that brings me [00:20:00] perfectly to, uh, another issue then. So we pitched the problem as in it's a harm reduction versus abstinence issue, but are they mutually exclusive? 

[00:20:10] Gordon: Getting all philosophical Sully.

[00:20:12] Sully: Ay ay that's the point. 

[00:20:15] Gordon: Yeah. I'm not sure. I'm not sure because I guess one of the long-term goals of harm reduction is that eventually the person in need of these various harm reduction strategies, and one of the examples that we'll get to is, um, substance use the ultimate longterm goal is that the person will no longer have problematic use of a drug. 

[00:20:37] Right. So it's not necessarily the drug use itself is that the drug use is problematic for their daily functioning. Right. So one of the long-term goals would be to address problematic use. However, there are certain harm reduction strategies such as, um, Buprenorphine or Suboxone, where basically it's another opioid where someone who's maybe addicted to something like Heroin would go on [00:21:00] prescription Buprenorphine.

[00:21:01] And then Buprenorphine is more slow acting and it doesn't give you the same high. So these people are able to go and function in society. So you can't really say those persons are abstaining that at that point, they're abstaining from problematic use of the drugs, but they're going through medication assisted therapy in order to function in society.

[00:21:21] So I don't know if abstinence is necessarily like maybe it's on a continuum, but there's also some harm reduction pathways in which abstinence is not a part of. I think that's the way I see it. 

[00:21:33] Leshawn: So just going back, it's like harm reduction, like we mentioned, is, is a client centered approach. And so I think we have to consider the fact that if an individual, if their goal is to abstain from a certain drug for example, then that would be kind of their end point, for example. Whereas someone else, their goal may not be to abstain completely. And like you mentioned, maybe it's a more manageable situation where it doesn't lead to [00:22:00] adverse outcomes in their everyday lives. 

[00:22:02] Will: It's, it's interesting because the two terms, harm reduction versus abstinence.

[00:22:06] I think if you look at it from the angle of harm reduction. Harm reduction like you guys feel like you guys mentioned can encompass abstinence as part of the, the group, I guess the process. But if you look at it from the perspective of abstinence, I think the term itself to abstain from something means to fully give up and not indulge in whatever substance or activity.

[00:22:29] So I find that from, if you're looking at it from the angle of abstinence, the two can never be related because. Right. So it's really depends on which perspective you're looking at. 

[00:22:39] Leshawn: Perspective. Right? That's a good point, Will. 

[00:22:41] Gordon: Just to double down on that, abstinence is very difficult to achieve as Leshawn had said earlier as well, because abstinence is relative to a period of time.

[00:22:50] So you can be drug-free for two years. And then a lot of cases where people who abstained from drugs often relapse, right? So if you relapse, [00:23:00] you're no longer abstinent and then you kind of have to start the cycle all over again. 

[00:23:03] Leshawn: And even with that, I think there's a lot of dangers in starting up again. Right. Because you know, your, your tolerance essentially goes down at that point.

[00:23:11] And if you're taking the same amount of the substance you're taking, when you initially were starting, that leads that could lead to an overdose event. Right. 

[00:23:18] Will: But my biggest thing I think with, with abstinence, um, I think it's the issue of relapsing, right? So if, if you have this concept where individuals are, you know, in order to be classified as a successfully undergoing this treatment, let's say of any abstinence based program and, and like, don't get me wrong.

[00:23:38] I'm I'm not a hundred percent familiar with like the specifics. I'm there might be programs out there, which, you know, is like ease slowly easing into some abstinence. Not too sure. But anyway, if your whole program is focused on, you know, abstaining from the substance and the behavior and an individual feels like every time that they relapse, the sense of guilt sense of [00:24:00] failure is perpetuated. 

[00:24:01] Gordon: Stigma. 

[00:24:01] Will: You know, Yeah, exactly. It's, it's just all these negative feelings and emotions, and these things are kind of perpetuated each time an individual fails. I'm sure that's, that's that's gonna lead to some other adverse mental health implications.

[00:24:17] Gordon: It's almost like abstinence based programs criminalizes relapses. You know what I mean? It's, it's almost like, you know, maybe you were on a program, like you said, Will, where are we will help you with housing and stuff? And the moment you do take drugs again, your, your, your drug test comes back. You're out of the house. So you're being criminalized for, you know, relapsing because of your addiction.

[00:24:40] So I think in that way, abstinence-based programs can cause a lot of problems. 

[00:24:45] Sully: Yeah. There's a lot more to talk about, but, well, we got to wait for part two where we talk about uh safe consumption sites and the, the way they work, what they try to address. And we'll, we'll have a [00:25:00] constructive, critical conversation about that.

[00:25:01] So, stay tuned. 

[00:25:02] Ben: Find out on the next episode of PHI. 

[00:25:07] Sully: Thank you for listening to the Public Health Insight podcast, your go to space for informative conversations, inspiring community action. If you enjoy our content and would like to stay up to date, follow us on Instagram, Facebook, Twitter, and LinkedIn.

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