It’s often said that you can’t put a price on good health.
But as I learned at a conference in Edmonton last month, you can throw good money at northern health care and get very little in return. There must be better ways to improve northern health outcomes. But are we getting any closer to figuring them out?
A pound of cure
First the facts: as has been well articulated by Kue Young and Susan Chatwood, circumpolar health care is expensive relative to regional southern counterparts, particularly in Canada, where Yukon’s expenditures are 1.3 times greater, the Northwest Territories’ 1.7 times greater and Nunavut’s 2.5 times greater than national averages. Indeed, Nunavut has the highest per capita health care expenditures in the world, representing a stunning 30% of the territory’s GDP. Alaska, meanwhile, spends about 1.2 time than the American average, while the northern Nordics spend roughly the same as their southern regions. In some parts of Siberia, health care spending is as high as nine times the Russian average. Greenland, curiously, is an exception, with per capita expenditures at roughly 70% of those of Denmark.
Despite the high spending, health outcomes, measured by e.g. infant mortality and life expectancy, are generally lower than those in southern regions. There appears to be no correlation between health care spending and health care outcomes in the circumpolar north, which should give us all pause.
Neither does geography seem to affect northern health indicators very much. Non-indigenous residents in northern Canada, Alaska, and Scandinavia all have comparatively good health outcomes. Rather, poverty, felt most acutely by indigenous northerners, appears to be the main cause of poor health in the Arctic, and state spending has only a marginal ability to mitigate the consequences of that.
The social determinants of health
This will come to no surprise to public health professionals, who often repeat that health is most significantly determined by your social, economic and behavioral context. Genetics and physical environment also affect status, while access to quality health care determines around 15-25% of health care outcomes. Yet the governing systems we have in place mean it’s easy to funnel public funds into health care, and citizens and health care professionals alike often demand it as a catch-all solution. One doctor from Greenland lamented that they were funded so inadequately compared to Nunavut, despite having better outcomes!
How are these health care dollars being spent? From what I gathered, much goes to import southern labour, both on the administrative and health professional sides, which is all the more expensive as it often requires housing, bonus pay, overtime pay, and incentives to compensate poor working conditions such as professional isolation and understaffing. Another big chunk goes to medical travel, both of patients and health care providers; and the costs of establishing and maintaining medical infrastructure and supplies in small and remote communities.
How health care is organized did not seem to impact results. We were told for example that when Northwest Territories got local control over health care from the federal government 27 years ago, outcomes did not change. The Canadian territories and Greenland have all experimented with extreme decentralization of health services and are now in varying stages of re-centralizing, having found it impossible to administer consistent and quality health care at the micro levels demanded by Arctic geography – health regions trying to provide the gamut of health services for a handful of communities composed of a few thousand people, requiring unaffordable administration and facilities’ overhead with little quality control; the tyranny of economy of scale.
If neither spending nor local control is the answer, what is? Some presentations pointed to the promise of telehealth, which is proven to save money and improve accessibility. But many in northern Canada lamented that they haven’t the internet connectivity to implement high-tech solutions. At any rate connectivity alone seemed to be insufficient in implementing sophisticated telehealth systems, as some, like Iceland with almost perfect connectivity, not having made the required structural and cultural changes to implement it.
On the bright side
Despite the many challenges, there are efficiencies to be had in northern health care, and conference participants were able to hear of many opportunities. But the overwhelming sense I got is that improved northern health outcomes will not be a result of expanded northern health care; rather they will result from expanded northern educational attainment and economic participation. These are not always popular views in a context of cultural and environmental privilege. But the evidence is there: the North’s expansive, state-funded health and social services focus overwhelmingly on addressing the symptoms of social and physical ills. But if poverty is the cause, meaningful employment is the solution.
Another approach may be to ignore all health indicators but one: self-reported satisfaction with quality of life. By this measure, northerners frequently rate their quality of life as good as, and often better than, their southern and non-indigenous counterparts (with the unfortunate exception of Russian indigenous peoples). “Beware this measure”, remarked one esteemed presenter, as it has “no correlation with actual health outcomes”. That seems a backwards way of looking at health. The North’s health care system may be in crisis; so, I hear, is the South’s, with similarly unsustainable expenditures, long wait times, and acute- rather than preventative-centered care. But most Northerners say they are feeling pretty good. We should probably stop trying to convince them otherwise.
Related stories from around the North:
Canada: Website launched to help Inuit living with cancer, Eye on the Arctic
Finland: Study finds lower cancer rates among indigenous Sámi, Yle News
Greenland: Researchers must be honest with Arctic peoples about food contaminants: doctor, Eye on the Arctic
Norway: Nordic diet a heart-smart alternative, Radio Sweden
Sweden: The Sami Health Paradox, Radio Sweden
United States: Examining mental health in Arctic Alaska, Alaska Dispatch News