Leave no one behind. That is the tenet of the United Nations’ Sustainable Development Goals – a goal that is increasingly threatened. With the World Health Organization (WHO) dealing with more than 1,500 attacks on health-care infrastructure across 15 countries, more health needs are presenting around the world. Canada’s family physicians must step into the breach.
As a family medicine trainee with a Master’s in global health, I find it necessary to discuss primary care as the foundation not only for individual but also for collective health, and the importance of mobilizing more family physicians to improve it.
Historically, global health has been seen as vaccine efforts and the prevention and treatment of infectious diseases. But infrastructure, whether physical or political, for ongoing health issues and routine check-ups must be optimized. Global health isn’t just institutional organizations that drop in, mobilize a workforce temporarily, and leave. It means equitable access to health care in a timely manner, within a safe place that assesses the whole person. And if we can accomplish this, we can achieve what the United Nations hopes – to leave no one behind.
In 2008, the WHO released its “Primary Health Care: Now More Than Ever,” refocusing attention on the delivery of primary care. The principles had centred on universal coverage, enhanced patient-centred care aligned with public health policies and improved leadership in health systems. However, primary care has been limited by a patchwork approach, with a focus on curative, disease-specific programs primarily funded by donors, but fluctuating with the political and economic status at the time.
As Canadian health-care providers, it is our responsibility to understand where we fit. Our specialty includes advocacy, comprehensiveness and empathy. When we train doctors who treat the whole person, we are more effective in creating an environment that supports collective good health.
Katherine Rouleau, a family physician and Global Primary Health Care Lead with the University of Toronto’s Department of Family and Community Medicine, has contributed to multiple global health projects and says family medicine physicians are ideally situated to improving health outcomes worldwide.
“Family medicine is highly competent, purposeful, integrative generalism – we see everything that comes through the door, establish relationships, take care of problems from cradle to grave, and focus on people, not diseases,” says Rouleau. The value, she adds, is evident in the fact that dedicated training programs have grown considerably over the past 30 years.
“In 1995, there were only about 50 countries in the world that had either a training program in family medicine, a professional association of family doctors or a certification of family doctors. Now there are 155.” The challenge, says Rouleau, is that after their training, family physicians have been placed in academic hospital settings rather than in the community, where it is most needed.
The history of global health has roots in patriarchal, colonial care.
The history of global health has roots in patriarchal, colonial care, in which projects or trials were implemented, care was provided and then withdrawn once the project was complete. But the goals of improving access in the Global South deserve the same level of primary care that we strive to deliver in the Global North.
Rouleau says the family medicine UofT program aims to go against the short-term way of practicing global health “We do not go for two weeks to deliver care at the eye clinic and then come out. We’ve never done this, and neither do we just organize [short-term] electives for trainees. We have resisted this. This is not the work we do.”
For opportunities, residents can choose to pursue an enhanced skills year in global health, but if not, Canadian family medicine core training programs have adapted and are moving toward practicing global health at a local level. It appears in curricula as culturally sensitive care, which is especially important in large multi-cultural centres like Toronto, Montreal and Vancouver, where “think globally, act locally” takes on added significance. All family medicine residents across Canada are required to complete a two-month rural teaching rotation, often in resource-limited and difficult-to-access locations but how can we create more room for global health once a practicing physician?
Many medical schools have associated global and public health departments that hold a wealth of knowledge for clinicians and opportunities for physicians to learn from others from countries around the world. Why wouldn’t we, the people who are the gatekeepers to access to our health-care system, want to support others around the globe to their best health?
Canadian family doctors are already burned out, leaving little energy for additional duties. But family physicians are lifelong learners and are encouraged to advocate for others. And there is no greater form of advocacy than finding solutions for the most disadvantaged populations in an ethical framework, which is education many universities across the country offer.
“If ever there was a reason to invite people in our kitchen, it is because we’re now learning to cook the dishes that the rest of the world knows it needs,” says Rouleau. “So, it doesn’t need to be all Canadian recipe. But we all need the stew, and so let’s create kitchens where we can learn from one another and try different ingredients … for us where we taste each other’s food and go, oh yeah, OK, so how did you do that? And let’s just move it forward. Never before has there been a more compelling reason for Canada to play that role.”
It’s not about Canada having all the answers; it’s about learning from our colonial past and diversifying our future as we move forward. We learn, and hear from others, and that is what every family physician, whether community-based or academic, must know.
We family medicine trainees and practicing physicians must realize our worth and importance in global health because we are in the unique position of caring for every aspect of a patient. It is up to us to help achieve the UN’s goal: using what we know to leave no one, even in places we may have no connection to, behind.
