An Even More Modest Proposal


How many of you remember being presented with Jonathan Swift’s ‘A Modest Proposal’ in English 101? It was a not so subtle satire of 18th century British treatment of the Irish, in which he hyperbolically –and anonymously- suggested that the Irish might be able to ease their economic distress by selling their children for food to English gentry. It was clearly so outrageous and inflammatory that it was intended to make the readers see how wrong the then-prevailing treatment of fellow human beings could be. To alter, in other words, the perspective, and facilitate the shift to a different world view. To allow people to see what they had hitherto ignored and perhaps make them want to improve it.

My own modest proposal is less preposterous and certainly not satirical, but it does fly in the face of what we in the richer nations have come to expect and accept: only the use of professionals in our health system; and discount: the adjunctive use of non-professionals to help with some aspects of that care. It was engendered by a segment in an October 2016 PBS program and has intrigued me ever since: http://www.pbs.org/newshour/bb/can-ordinary-citizens-help-fill-gaps-u-s-health-care/ The idea that health care is becoming increasingly expensive and that even with universal coverage, there are still a lot of gaps that are unlikely to improve even with the addition of more doctors and nurses. Training and equipping them is expensive, and still does not usually solve the problem of their accessibility to those most in need –the poor and disadvantaged in our societies.

Professionals are viewed as part of a power structure that is often alien to a population all too frequently ignored, isolated and denigrated by the mainstream. Issues of cultural safety frequently play a role in this –lack of understanding and respect for cultural or economic disparities may make them unwilling to engage with professionals until the problem is untenable or even irremediable. Prejudices don’t need to be stated; they are too often felt. So the idea that there may be bridges into this demographic –keys, however counterintuitive, that could unlock barred doors- is worth exploring.

The idea of using trained volunteers to talk to those in society that are often ignored until in extremis is certainly not new. Think of the ‘barefoot doctors’ working in rural villages in China, for example. Or, ‘In sub-Saharan Africa, community health workers have long formed the backbone of health systems, filling in gaps where doctors and nurses are in short supply.’ The key concept for the acceptance of these para-medical workers, of course, was the relative lack of other facilities and professionals to fill them.

So why should we, in our relative affluence, consider the use of non-professionals? Especially here in Canada where, in 2003 at least, there were 2.14 doctors and 9.95 nurses per 1000 population? Perhaps in Malawi, where there is 1 doctor per 50,000 people (2004) the need is more readily apparent, but Canada…?  Well, it seems to me that the gap is not so much one of professional numbers as engagement. As one of the patients interviewed in the PBS program said of the volunteer that talks to her about her severe diabetes condition: ‘With your doctor, you don’t really want to say what you eat, so I’m able to tell her like, really, if I’m not going well, or, you know, if I sneaked and cheated. I tell her the right things, and she helps me.’

In other words, the volunteer is not attempting to take the place of the doctor or nurse and give medical advice, but is acting almost as a translator of patient concerns that are not verbalized in front of the doctor or nurse. We sometimes forget the power discrepancies on display between doctor and marginalized patient.

The addition of trained community volunteers should not be seen as a threat to the professions, but rather as a helpful, and essential, adjunct to expand the reach of healthcare beyond its present boundaries. Nor should it be seen as creeping multi-tiered medicine with the poor being relegated to substandard care –swept under a carpet where they can be safely ignored until they become seriously ill and show up in Emergency Departments across the land -an expensive way to provide health care, not to mention wellness-promotion. It is simply not cost-effective, no matter the system.

The volunteers can be used to penetrate the layers and develop relationships with people who otherwise might not seek help until they had no other choice. Help them to know when to seek professional advice. Check to see if they are following whatever recommendations were given; make sure they take their medicines as directed. Emergency care is expensive and its facilities limited; timely, early intervention is both preferable and, ultimately, more humane. I know that our Social Service is already doing a sterling job in this regard -especially in our larger cities- but they are stretched pretty thinly nowadays; I would think they might appreciate a little help. Doctors and nurses in the various walk-in community clinics or in smaller towns could suggest clients who might benefit from some additional help, and the word would spread from there… As I have suggested, there are layers within layers to penetrate in a neighbourhood.

And if we agree that the volunteers would be better prepared and more useful if they received an appropriate basic training course to equip them for what they are likely to encounter, why not fund this? For that matter, why not pay them? Or am I being naive?

It’s a modest proposal, though… Isn’t it?

 

 

 

 

 

 

 

 

 

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