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CHCs: The Answer to the Questions

8 years ago

Keynote Address
Chatham-Kent Community Health Centres
Annual General Meeting
24 November 2011 

I would like to thank the board and staff of CKCHCs for inviting me to be a part of this important occasion.  This is, in my view, one of the more interesting regions of the province of Ontario, the mainstream white population leavened by the indigenous First Nations of Caldwell, Munsee- and Moraviantown-Delaware, Chippewa and Oneida, the black descendants of those delivered by the underground railroad, and the francophone communities of  Essex, Kent, Lambton. Je peux vous confesser que je ne connais presque rien de l’histoire de la présence francophone enracinée ici dans la région sud-ouest de cette province.  Ma famille vient il y a soixante ans des cantons de l’est au sud de Montréal, l’emplacement de la naissance de mon père – mais les histoires sont distinctes, n’est-ce pas?  Et peut-être, j’imagine, les idiomes, la vocabulaire, je ne sais pas. Je tiens à vous remercier sincèrement pour votre invitation à faire partie de cette occasion très importante à cette communauté des communautés.

You have either the advantage or disadvantage, not sure which, of getting me right after I have fallen off a plane from a war zone.  In more than 22 years of such work, I know that it changes my perspective, discombobulates, breaks open new avenues for understanding the world in which we live.  In many ways, I see my own country more clearly from a distance. But I arrived home in a certain fashion this time, that helps to connect the dots – by ambulance – direct from plane to hospital to Community Health Centre, my CHC, East End in Toronto, and, eventually, home.

South Sudan handed me something in my final days there that is with me still, as yet undiagnosed.  So I would ask your forgiveness in advance if I have to either dash out precipitously or finish this sitting down.  I am not contagious, in case that thought had occurred to you.  No, not to worry, it’s all mine.

I’m quite certain that this is more for my benefit than yours but I would beg your indulgence to tell a couple of stories, for me, building a bridge between where my brain still is and my body finds itself.

Faidah has just given birth.  She is lying in what passes for a hospital in Lankien, Upper Nile State.  At just short of full term, she weighs about 37 kilos; she is 15 years old.  The baby has, according to local custom, been placed on a grass mat on the floor, not held or suckled, but placed on the floor.  This is Faidah’s third pregnancy.  The first died after a few days, the second was stolen by cattle raiders, re-branded with the facial scars of the raiding tribe and sold to one of those husbands suffering the twin misfortunes of a barren first wife and insufficient cow-wealth to purchase a second.

Though the RN who delivered the baby doesn’t have an explanation for the apparently odd custom, we are thinking that it might have to do with the fact that one in every seven girls and women die in childbirth; one in seven babies dies in the first few years of life:  why get attached to something that may go away? Sickened, killed, stolen, what does it matter how.  The husband stops by to see the results then leaves, perhaps most poignantly of all, without a single gesture of affection or gratitude for her labour.  It’s her job, after all.

In this village, there are no sanitary napkins, no diapers, no toilets, no medications, no health care except for this feeble field hospital run by MSF (Médecins sans frontières).  Women are barely able to connect what happens monthly with the production of babies – their purpose in life.  They come to the MSF tent in fear that they have lost a baby when it is only the monthly cycle.  Here a woman is meant to be either lactating or pregnant, with enough strength left over to tend livestock, cultivate the family plot, cook, clean, and look after the children that have managed to survive.

Child lies on street in South SudanOutside of urban centres, the economy is not currency-based and so the fact that more than 90% of the population lives on less than half-dollar a day doesn’t have a lot of meaning.  The only currency that matters is cattle.  Children wear the rags inherited from older siblings; and school is not an option in vast reaches of this country where the literacy rate is the second lowest in the world.

There’s something about being out of one’s country, out of place, out of one’s comfort zone and into a place that challenges everything that one carries around as normal. You begin to walk with a limp.

Every day I am confronted with one more piece of this South Sudanese reality that leaves me shredded, wordless.  I have a new video camera, acquired with the intention of recording by some other means since my words are inadequate to the task.  But the images, now loaded for viewing on my computer are blurry, opaque.  Foreigners with cameras are suspect and a South Sudanese walking companion is required, a pontifex, facilitating a gentle entry over the threshold of lives so unlike the one I live.

I crawl out from underneath the mosquito netting, weary from a short night.  Sometime after midnight, in a part of the world where the whole notion of ‘pets’ is ludicrous to imagine, a cat fight broke out, punctuated by small bodies flung or falling below my window.  The thumps on the paper thin walls are impressive, the feline screams more than sufficient to keep sleep at bay.

I bend over to dodge my clothesline’s still-damp laundry to find something clean to wear.  The Nile water that emerges from the tap is the colour of urine.  Last evening, I tossed my dishes to soak in a plastic container, its label, President’s Choice mesclun mix, dulled by frequent use.  This morning, they are covered in a thin, reddish-brown silt.  Ah, the children, the children, who drink from, play and wash in these waters that bear cholera, leptospirosis and schistosomiasis, wringing their little bodies dry of life.

Philippines Street CatsAs I make my way out into the streets of the capital, Juba, I encounter one of last night’s feline warriors, the skinny black-and-white denizen of the patio whose diet seems to consist mostly of cockroaches.  She looks rather worse for wear, bloody spots on her neck and legs, bluish skin showing where there used to be fur.

Animals are kicked around here, beaten, scavengers in the streets and garbage dumps.  The lives of children seem hardly much better, thousands living on the streets of Juba, tens of thousands dying each year from dysentery and diarrhoea, hundreds, if not thousands, killed or kidnapped, caught in the cattle wars, turned into soldiers or scooped up by raiders, in an endless cycle of revenge.

The route between my bed and the venue where a group of South Sudanese, Muslims and Christians, women and men have been gathering for the last few weeks is captivating, every block of the dirt road filled with life: frolicking children draped in ragged clothing play in the mud puddles – more like little brown swimming pools – left by the evening rains, some very young ones already conscripted into the task of child-care, a younger sibling strapped against wee bodies.  They wave and squeal, ‘Morning!’ – no matter the time of day.

Small corner shops are doing a brisk business with a diverse clientele of women, men and children, dressed variously in brown polyester shifts, knee-length black or ankle-length white djalabiyas, shorts, trousers, SPLM or UNHCR or USAID or White Bull or  Independence Day t-shirts, some barely hanging on at the shoulders.  On the return journey in the evening, restaurant meals, bicycle and boda boda repairs, haircuts and hair-styling are happening, often out front of the small, ramshackle shorefronts, the dust of the road mixing with shampoos, automotive oils, lentil soups and plates of foule.

So why these stories? What does all that have to do with here and now, the province of Ontario’s health-care system and its jewel, Community Health Centres?  The contrast is stark, no doubt, beyond stark.  Hardly recognisable as being the same thing.

I recall hearing interviews with people following the G-20, which my city hosted a year and a half ago, people who had immigrated to Canada from countries ruled by repressive régimes.  They said, ‘You think this is repression?  You haven’t seen anything!  Quit whining!’

Many who arrive on our doorstep believe themselves to have arrived in the land of milk and honey, where health care is based on, not just citizenship, but human dignity.  Maybe they might advise us similarly:  ‘You think you have problems with your health-care system? You don’t know problems!  Quit your whinging!’

There was an episode of All in the Family, perhaps in the early 1970s, when Gloria was preparing to announce to Meathead that she was pregnant.  I was no young thing, already in University, and I remember asking my father why was she so terrified?  Why did she not want to tell Meathead?  Well, pre-natal, labour and delivery was going to cost $300.   Sure enough, the prospective Dad blew up, the thought of the bills obliterating any warm thoughts of impending fatherhood.  I remember feeling as if I were visiting the zoo, peering through the bars of the cage at the strange creature on the other side wondering why they do the things they do.

It’s not as if my father hadn’t tried to educate me.  I recall when he first placed on the kitchen table in front of me the bill for our – I’m a twin – birth.  I do not know if he were trying to instill in me a sense of appropriate gratitude for my parents’ suffering; perhaps I had displayed a bit of the ingrate at the still tender age of nine and half.  At any rate, ninety-eight dollars.  The bill was $98.00.  At the age of six weeks, I was back in hospital for a stay of some several days with what my mother insisted was an errant diaper rash that had travelled well beyond its usual confines to cover most of my body.  Dad had the bill for that one, too.  I can’t remember the amount.  However, I do recall my mother asserting that, whatever the cost, it was worth it – her rest, not my cure.

On the spectrum that has South Sudan at one end, at the other, there has to be a centrifugal force, a model of excellence that inspires, that, in many ways returning to the roots of the village health promoter, provides a goal for health care that is within the realm of the possible.

Safe Steps PosterNot the high-tech heroics but the community-based, holistic, patient-centred, illness-prevention, health-promotion, equity-seeking care that keeps people out of not only hospitals but courts and prisons, gangs and drugs, early motherhood and unnecessarily-early long-term care, out of dialysis, out of debt, out of isolation, out of addictions, out of despair – and into community kitchens and unemployment support, lactation circles and anger management, traditional healing and holy smoke, walking gaggles and fitness flocks, table talk and support groups of all sorts.

I’m from tobacco country not too far down the road from here and so I am long familiar with ‘temporary workers’ – except we called them ‘transients’ back then.  It was an epithet, as I recall, describing the wave of mostly young Québecois who slept in the park until they could find work – and the only somewhat improved accommodation provided by the workers’ bunkies.  Over lunch in the kiln yard, it was a great place to practise the French of my Québec-born and -raised father.

These days, they are, as they say, ‘off-shore’; a class of workers who take the jobs, I am told, that our children will no longer take.  I recall in the early days of the first wave of CFHTs and CHCs in this area of the province and the identification of seasonal workers as a population for attention.  It is so good to see these dreams come true!  You are their health-care providers and their advocates, building bridges between employers, employees and the community in which you all live.

As manager for Centre Development for the Association of Ontario Health Centres during the early expansion years, I was struck by the novel kinds of collaborations already underway in existing CHCs around the province.  I’d been around CHCs long enough to expect the extraordinary – not your average doctor’s office or walk-in – partnerships with the local hospital, the women’s shelter, Native Friendship Centres, the schools, the CCAC, Meals-on-Wheels, other local health-care providers, long-term care facilities, children and youth services, addiction and mental health services, immigrant and settlement organisations.

Community Cuts PosterBut then I came across and continue to encounter the truly novel:  partnerships with the barber, the local beauty school, the grocery store, the skate-board park, the car dealership, the police, faith communities,  and programmes that help you to learn how to manage your budget, re-imagine your relationship with food,  manager your anger, dance the foxtrot, learn to meditate or do yoga, meet your neighbours, other diabetics or recovering addicts or teen mums just like you, know yourself better, find support for change, employment counselling, legal aid and a new chance.

Do you know just how truly unique the Ontario model is?  As AOHC began to plan our first-ever international conference, along with the Canadian Alliance of Community Health Centre Associations and the U.S. National Association of Community Health Centers – we quickly began to realise that, though we all called our centres the same thing, we were stumbling over language differences, same words but meaning something different in each context.  CHCs in other Canadian provinces would not meet AOHC’s criteria for membership with respect to community governance.  CHCs in the States are a medical model, lacking the programming that is so central to our model – that looks at the person as multi-facetted, located in a home, a family, a community and whose health is determined by a whole host of conditions in which we are born, grow, live, work and age, including the health system.

Some of you may have been at that conference in June.  My main responsibility for the conference was to support all of the aboriginal pieces, from the opening ceremony, smudge, drumming, song and prayer to the staging of tipi and sweat lodge and the healing circle.  What an amazing close to my nine years with AOHC, including the months leading up to the conference, working with the Aboriginal, First Nations and Métis members of our larger constituency.  It was a lesson for me in sitting quietly, waiting for the spirit to move, waiting until the shape of what we were to do emerged.  ‘A disruption is what we want,’  finally surfaced in the course of one of our weekly planning teleconferences.  ‘Like throwing a stone into the swamp; the clear water below breaks the surface, rippling over the pond.’

The second day of the conference, the 800 participants arrived to discover the ‘disruption’, a circle opened up in the midst of the large auditorium that then quietly filled with Aboriginal, First Nations, Métis people and some mainstream, followed by an elder from Shkagamik-we, who trawled the circle with her stories and her questions, a fishbowl experience, demonstrating to the silently attentive observers, a meaning of holistic health care that mostly eludes mainstream providers – seeing the person as a complete entity, the sum of its spiritual, emotional, mental, physical parts – the soul impacted by shame, the body by housing, employment and food insecurity, the mind by addictions and stress and trauma.

Long ago, it seems, we gave up on the value of the generalist, breaking up all sorts of things into their hermetically-sealed component parts – whether academic studies or disciplines or media or engineering or health care – atomising us all and presenting ourselves as kidneys or knees or hearts or stomachs or livers or colons or eardrums or brains, knowing more and more about less and less.

For more than forty years, CHCs in this province have been bucking that trend.  A woman comes into your CHC, having fallen down the stairs and fractured her kneecap.

How did you fall down the stairs?

I tripped at the top of the stairs.

How did you trip?

Well, I was drinking.

Do you know why you were drinking?

I’m depressed, I guess.

Do you know why you are depressed?  Anything going on I should know?

I lost my job.

Oh my; what kind of work were you doing?

On a shop floor, working with heavy machinery.  The vibrations hurt my teeth.  My teeth are rotting…  I was taking off sick all the time.  So they fired me.

Let’s say this same woman goes into the local emerg.  The kneecap is treated as best as one can treat a fractured kneecap.  And she is sent home…  home to her depression, her oral pain, her comfort-seeking in alcohol, her unemployment, her isolation.  And she begins the revolving door that is so much of our health-care system.  This is not to diss EDs or walk-ins or any other part of the health-care system; they have their role, those areas in which they are without equal.  But there are many things for which they are ill-suited, inefficient and wastefully expensive.

At the CHC, a true story, she is immediately triaged, referred down the hallway to the mental health and addictions counsellor, the physiotherapist and the oral health worker; she joins the unemployment support group, the fitness group and the community kitchen group and receives support filling out ODSP forms.  Today she is more herself than she has ever been in her life, healthy, employed, in a new relationship, reconciled with her daughter, volunteering at the CHC and serving on the board’s advisory committee.

Sisterhood of the PhoenixI have a neighbour by the name of Chuck.  He is a resident of the ex-offenders’ transition house two doors down from me.  He has been almost two years free of alcohol but continues to smoke despite the COPD that shortens his breath and his step.  He is 50 but looks 60.  We help one another out.  I kept telling him to go the three blocks south to the CHC and put himself on a list.  It never happened.  ‘Why bother?’ he would say. Those people don’t understand addictions; they don’t get it, they just preach.’

But one day recently, he was out raking leaves and he told me that he had met an outreach worker from the CHC at the foodbank and she was issuing invitations to a Saturday lunch programme for recovering addicts.  He had gone and he couldn’t believe what he encountered.  He felt welcomed, understood, embraced and more hopeful than he has felt in a long time.  Told you so, Chuck. : )

After  three years, Chatham Kent Community Health Centres of Walpole Island,  Wallaceburg and Chatham are creating your own stories, your own roster of changed lives, your own catalogues of hope and renewal.

George Smitherman, then-Minister of Health and Long-Term Care once called Community Health Centres the provincial health-care system’s ‘best-kept secret’.  He said that at a 2005 press conference in Scarborough when he announced the close-to-doubling of the numbers of CHCs serving Ontario’s most vulnerable populations.

CHCs are no longer quite so secret but, while the pundits and the politicians, both federal and provincial, continue to talk about and raise anxiety about the ‘sustainability’ of the health-care system and the need for an ‘adult conversation’ about alternative financing options, with endless talk about the importance of health promotion, CHCs are over on the sidelines, jumping up and down, ‘Hello!  Here we are!  We are the answer to your questions! To saving dollars, to using physicians better and more cheaply, to reducing poverty, to saving on hospital stays, long-term care, emerg, unnecessary diagnostic tests, unnecessary pharmaceuticals, integrated home care… ’  Yet when the government talks about primary health care, rarely, if ever, do CHCs appear in their PowerPoints or talking points.

How do we change that dynamic?   How do we get the province to prioritise CHCs as the answer to so many of our day’s questions, both federal and provincial, with respect to health care?

A little less than four years ago I was invited to apply for the in-house position of Manager, Policy and Government Relations.  Against my better judgement, I did so.  I went to some of those pricey seminars on how to be good at ‘GR’.  They gave me hives and I used the handouts for kindling the evening’s woodstove fire.  If I got to be good at it at all, it was because I came to realise that there are good people at Queen’s Park who want the same things as I do, as we do.  I just may disagree on how they’re going about it.

In the last couple of years, it was hard to begin any conversation, whether with political staff or bureaucracy, without the other side of the table saying, ‘As you may have noticed, we have a deficit, a large deficit.  We have no money.’

‘Oh, but we do,’ I’d say.  ‘Lots of it. About $110 billion.  And you get to make choices about how to spend those dollars, our dollars.  And you could make some different choices.’

Our appeal to government was this:  a Health-in-All policy that requires all of government to pass every expenditure decision – whether transportation or education or natural resources or corrections or municipal affairs, whatever – even those decisions that were meant to be income generators – through the lens of health equity:  does this expenditure take us closer to or further away from our goal of health equity?  Will it advance or impede the economic, social, cultural, civil, environmental health and well-being of the people of this province?

Bottom Dollar BudgetingUnder that lens, many of our government’s budget decisions would not pass muster, corporate tax cuts being perhaps the most egregious; nor would income-generators such as Mixed Martial Arts and online gambling make the cut.  The income generated is a false economy that fails to acknowledge the price paid in both dollars and social capital depletion.

Sometimes I think we all suffer from short-term memory loss – we forget that the Golden Age of Capitalism is behind us, the 1950s and 1960s – when productivity was high, economic growth was steady and shared equitably amongst the population, corporate profits were high as were corporate taxes, creating a burgeoning middle class, and generational leaps of prosperity.  Economic decisions since then have turned back the gains of that post-war period, now replicating disparities not seen since 1929.  Rising GDP is meaningless if it’s collected into the hands of fewer and fewer people.   It’s not the wealth created that makes for well-being, it’s the distribution of that wealth that makes for societies made up of people who feel secure – in the best sense of that word, safe, confident and engaged.

It makes me think of what Denise Brooks, former President of AOHC said at the 2008 annual conference:

Poverty is the biggest health risk we face.

Poverty is a political choice.

Poverty is an unacceptable human condition.

If these are political choices, then they can be unmade, made differently, prioritising differently, enabling not just the reduction of poverty but its eradication.  Why not.

CHCs can be key tools in the re-creation of a more equitable society. CHCs are not about charity:  they are about justice, right relations, affirming the humanity of all, equally valuable, equally deserving of the best health care we have to give; assuming that we all have something to learn from those from the margins of our society who come through our doors.

What you are doing so amazingly here in Chatham Kent is multiplying gradually across this province.  With dollars redirected from a prioritising of sickness care to a prioritising of health promotion and illness prevention – where you lead the pack – we can have a CHC in every community in this province.

Every day you are ‘being the change you want to see in the world’.

Every day you are giving people a new chance at life – a Fresh Start,

Rebounding,

Rising,

Craving,

Stepping Up,

Climbing,

Conquering,

Imagining, Believing, Achieving,

Empowering.

Congratulations!  I am so proud to be a part of your story.

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