Welcome to the final entry in Verto’s three-part blog series on the importance of equity in improving health system performance. The series began with an exploration of the history of health system evaluation and the progression of the Triple Aim to the Quadruple Aim, and ultimately, the Quintuple Aim. The series then moved on to a deeper dive into the impetus to add equity considerations into the Quintuple Aim and how doing so can help health systems realize improved clinical outcomes.

To wrap up the series, we present the first edition of Verto Voices, an ongoing conversation where we profile some Verto’s innovative digital health leaders. If you’ve ever wanted to learn more about important issues in healthtech, AI, and health policy this is the place for you. In this installement (full interview available here) we’re joined by Dr. Anderson to discuss the importance of health equity considerations at the point of care and technology’s role in building a more equitable and responsive healthcare system. 

Dr. Michael Anderson is part of the urban Indigenous community in Toronto. He is Mohawk (Bear Clan) and mixed European with family roots in Tyendinaga Mohawk Territory. He serves as the Chief Medical Officer at Verto, practices surgical oncology and palliative care medicine and is the Strategic Lead for Indigenous Health at the University Health Network. He previously served as an Indigenous Cancer Lead and a Surgical Oncology Lead at Cancer Care Ontario. At the Waakebiness Institute for Indigenous Health in the Dalla Lana School of Public Health (U of T), he is a senior researcher with interests in Indigenous approaches to implementation science and Indigenous conceptualizations of death and dying.

Q: Dr. Anderson, you’ve had quite the career. Can you tell us a little bit about your path to becoming a surgeon and what it was like training as an Indigenous healthcare provider?

A: I became interested in surgery probably before medical school. The most impressive thing to me about surgery was the lifelong learning that was built into it.

I had an operation as a teenager and I think the most impressive thing was watching the team round every morning. And the more senior people always teaching the more junior people. And I watched that every day and that was baked into everyday life. So, the lifelong learning aspect of it was really appealing.

The interesting piece of being Indigenous and being in healthcare is of my generation, most of us learned to hide that we were Indigenous. If you were fortunate enough to be able to hide, you did. So, in my training, I would never have openly identified that I was Mohawk. There was another person in my medical school class who was First Nations and he and I both knew who we were and we’d talk about it, but we didn’t let that be open elsewhere. So, it’s interesting being able to be open about being a First Nations person is a product of being more senior and not being vulnerable. And the issue had been when you’re in healthcare, you watch all the stigma that gets applied to different groups of people, in particular Indigenous folks. And when you’re a trainee and you’re a junior, you don’t want that stigma attached to you because the people who are training you and who are perpetuating this stigma are also the people who facilitate your career. And so, it’s interesting, lots of people learn to hide.

I don’t have to hide in part because I am more senior. I don’t have the same vulnerabilities I did when I was a junior trainee.

And I also think the landscape of healthcare is starting to change. There are lots of things where people knew what parts of your identity you were allowed to bring to your profession and what parts you had to hide. And I think that’s becoming less of an obvious barrier now. 

Q:You’ve also worked as a palliative care physician. I know you mentioned in a previous interview that you were drawn to palliative care because of your discontent with how Westernized institutions handled discussions around death. How do you think this manifests in the healthcare system, and why do you think this is the case with Western medicine?

A: It’s interesting. I was in a meeting recently and I heard someone mention that they were the nurse that always got put with the dying patients because they were able to communicate effectively. And I’d actually had that experience a few times in my surgical career where I would be asked to see some family and recall being on call once and asked to go see a family. And I sort of said, “So, what’s the surgical issue?” They said, “Well, there isn’t a surgical issue. Their dad is dying and we haven’t been able to communicate that, so could you go speak to them?”

Death is a part of life. Death is as much a part of life as birth. And yet, healthcare really struggles with it.

The interesting thing to me is if you went back a couple hundred years even, medicine really was palliative care. We weren’t able to cure a lot of things. Cure wasn’t this magical goal. We supported people. We helped relieve suffering.

The shift in Western medicine has been the notion of curing things. And I suspect some infections.

We cure pneumonias that we didn’t use to. We cure infections that we didn’t use to.

In the cancer space, which is where my first home was, the goal is cure. We don’t cure everybody. When we don’t cure people, and that’s the goal, medicine often provides poor care after that or has a challenge providing care because the goal was cure.

The palliative care is sort of beautiful in that the goal is: “I will walk with you through this journey, whatever it becomes.”

So, reframing the goal allows people to refocus their care. That always felt like a bit of a disconnect when we weren’t achieving the goal of cure. How were we refocusing to, “I will still support you.” I think healthcare has a long way to come in how it approaches death. I actually think, interestingly, the pandemic really exposed that and has started the journey.

Palliative care teams got embedded in all sorts of places. They weren’t pre-pandemic emergency departments.

The magical tool of palliative care isn’t the different drugs we use. It’s usually the conversations we have. Being comfortable with the conversations is important.

I used to find when I would watch medical trainees, trainees were uncomfortable with having dying patients. The patients would feel uncomfortable. We would mirror to them, “You should be uncomfortable with this. So be uncomfortable.”

As people get comfortable with the conversations, we find that families and patients are also comfortable with them. So we get a lot of things mirrored back at us. As we get comfortable with it, people are comfortable talking with us.

Q: Your professional involvement within various Indigenous communities in Ontario is very apparent. The decision to identify can be a difficult one for some Indigenous folks; was there a particular point in your career that was the catalyst or call to action to advocate for and work with these communities?

A: Funny enough, part of it is, for me, has been being in a place like Toronto. I identify as Mohawk. My family’s community is Tyendinaga. I actually identify more as part of Toronto’s urban Indigenous community. And that has been a wonderful awakening for me. Toronto’s community is diverse. I live and work and socialize with Mohawk people, but I also socialize with Cree people and Métis.

The team I work with at UHN, we often thought we were quite representative of what Toronto looks like. Our team has someone who’s Anishinaabe, someone who’s Haudenosaunee, and someone who’s Mi’kmaq. So we look like Toronto. So the diversity of Toronto has been a really bright spot, and it’s actually opened a lot of possibilities.

So, yeah, I actually found that the community I most identify with is Toronto’s Indigenous community. 

Q: When we look at population health and think of Indigenous communities in Canada, it’s apparent that Indigenous groups experience some of the worst health outcomes in the country and North America. What do you think are the most significant systemic barriers to health equity for these groups?

A 5: Probably because the real barrier is not what most people believe it to be. If I talked to many of my colleagues, they would say that the access to care barrier for Indigenous folks is geography.

They’d say, “Well, you live far away.” And part of that’s perpetuated because so much research is done on remote communities.

Why is it done on remote communities? Because it’s easy to define that this community is. When it’s a fly-in remote community, it’s obvious this is almost all First Nation people.

In the city, we become hard to find.

How do you identify a population of Indigenous folks in a city like Toronto? If you don’t know how to, we’re hard to see. So the challenge is people think the barriers are geography. Most Indigenous folks in Canada live in urban spaces. In Ontario, 80% of us live in urban spaces. Our access to care gets worse when we get into urban spaces, not better. Geography isn’t the issue. It’s systemic issues. A lot of them, the only plain way of saying it is systemic racism. There are clear barriers.

The interesting challenge is pointing out to people that it’s not always about saying, “Well, there’s individual racism. There’s systemic racism. There’s things baked into the system that often we go through every day and we don’t see. They’re just part of our background.” I find once people see it, once their eyes are open, then they can’t unsee it.

It’s the things that are every day that are baked in. It’s the language we use.

There’s certain language in healthcare that we think is okay, but the reason it’s problematic is you realize we don’t apply it to everybody.

We use terms like noncompliant.

Affluent people rarely get labeled noncompliant. Noncompliant gets attached to racialized people, people who are economically challenged. It gets applied unevenly. When we say things like frequent flyers in an emergency department, that term gets used a lot, but what we’re missing is people who are using EDs frequently, which is true in the Indigenous community, have low connection to primary care. They’re using EDs frequently because they don’t have other resources. So the language we use in healthcare actually is part of the problem, because we’ve normalized it so much we don’t see that. We don’t see that we don’t apply language evenly.

So the challenges are often what’s just baked into the system, and the way to ultimately improve it is to start to open people’s eyes to it. I think there’s another side, certainly around, Indigenous issues, which is that we constantly have a focus on our deficits, and that precludes people seeing all the strengths in our communities. We have tremendous strengths in how we know, we think, we live our lives.

But they rarely come through because we’re always framed around the deficits. It gets in the way of seeing where the strengths are. I actually find once you start to expose the strengths and then actually use them, you start to change the conversation.

Q: You’ve spoken about the importance of stable housing, and how that drives improved health outcomes, and that holds true especially, I think, here in Toronto. I know the University Health Network has partnered with the city and other organizations to create the Social Medicine Supportive Housing Project. Can you tell us a little bit about that project and how it came to be, and perhaps where it’s headed?

A: Yeah, it’s a real recognition that one of the key determinants of health is housing, and not just health, but our ability to provide health care.

We saw that there’s groups of people who use an awful lot of emergency resources a receive episodic care. And the challenge they have is that they have complex health conditions, and they’re precariously housed. They don’t have a stable housing situation. 

The ability to provide health care at home, to service people with resources, with nursing, etc., is impossible when your address is changing or you don’t have a stable address. We know that housing is one of the biggest factors in health outcomes. And we see groups of people who are constantly using emergency departments because we’re unable to serve them. So the theory here is that if we house people with complex health conditions, we’ll be able to serve them at home in the community.

That’ll reduce the reliance on emergency department visits and improve outcomes, because the truth is emergency departments are all about episodic care. There’s no continuity. It’s, “what’s the crisis today? What do I need to manage?” When we look at providing ongoing care, supporting people in their home, they are set up much better. When you don’t have that stable home, I can’t do the other part of it. So that’s the theory. And the truth is Toronto is not unlike any major North American city right now where we have sizeable groups of people who are unhoused.

It doesn’t matter what medications I prescribe, what services. If you don’t have housing, all the other stuff I’m doing is, you know, it’s almost impossible to demonstrate its impact.

And so one of the goals of the program is to reduce disparities in health equity through evidence-based interventions. And so the Social Medicine Supporting Housing Project is a perfect example of something intervention.

Q: What do you think technology’s role is towards advancing health equity?

A: I often think health equity needs to be framed a little differently. The way it often gets framed as giving people something, as supporting them, gets pushed back around people. Why are they getting something everyone else doesn’t? So I think the framing has to be a little different, which is, equity is actually trying to bring people to the same place. It’s trying to overcome deficits that are baked into the system. 

The first piece of that is having to have some visibility into where the deficits are. So when we talk about digital health, digital health often gets designed by people who are health literate, digital literate, people who already understand.

We need to remember to actually talk to and surface the voices of the people who aren’t digitally literate, who aren’t necessarily health literate. Hearing their voices allows us or informs the technology we build.

Too much of healthcare is built for people who are well connected, and we resource people who are well connected.

We don’t hear the voices of the people who aren’t experiencing good access to care. And I think that that translates also into the digital space, that we need to hear from people so that we overcome barriers like, not everyone has access or funds to have a smartphone. So where can we meet people?

If I can’t meet everyone technologically where they’re at, well, how can I take people who do understand and use technology and allow them to use technology to free up resources to meet people who may not be as technologically literate or may not have access to the same technology, essentially redeploying resources effectively.

There’s an awful lot of things we can do around digital equity. I think one of the first ones is understanding what that equity looks like.

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Stay tuned for future entries in the Verto Voices series where we will dig into the role of AI in transforming care delivery.