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Drs. Trevor Hancock and Warren Bell share invaluable insights about the inefficiencies of our existing “downstream” mental health care system, and the opportunities provided by an “upstream” approach that better serves individuals, families, workplaces, and communities through prevention and health promotion. Dr. Hancock, a public health scholar, also touches on ‘shit life syndrome’, ‘social prescribing’, Men’s Sheds, the World Happiness Report, and the role of government in post-COVID mental health care. Dr. Bell, a GP and activist for more than 40 years, says doctors need better mental health training, talks about the need for new treatment and funding models, and encourages GPs to speak out about the need for better mental health care in their communities.
This podcast will help you understand:
- Reactive “downstream” approaches vs. proactive/preventative “upstream” approaches to mental health care
- Examples of upstream approaches
- Role of health promotion in prevention-focused mental health care
- Roles of government and GPs in upstream systems
- Impact of COVID-19 in the move toward upstream approaches
- Contributing factors to mental health challenges (shit life syndrome/diseases of despair, adverse childhood experiences)
- COVID-19 and its impact on social justice, social tipping points, and social solidarity
- Upstream approaches to mental health: https://www.thinkupstream.net/upstream_mental_health
- Men’s Shed Australia: https://mensshed.org/what-is-a-mens-shed/
- Social prescribing: https://www.socialprescribingnetwork.com
- Mental Health Commission of Canada: https://www.mentalhealthcommission.ca/English/who-we-are/annual-report/framework-action-2017-2022
- Province of British Columbia: A Pathway to Hope
- Cascade Institute: https://cascadeinstitute.org/
- National Observer: nationalobserver.com
- Vancouver Observer: vancouverobserver.com
- World Happiness Report: https://worldhappiness.report/ed/2020/
- The Spirit Level, New Edition: https://www.amazon.ca/Spirit-Level-New-Equality-Everyone/dp/0241954290
- New Zealand Well-Being Budget: https://wellbeingeconomy.org/new-zealand-announces-wellbeing-budget
- Population Health Reports (Canada): https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada.html
- 2020 Population Health Report (Canada): Addressing Stigma: Toward a More Inclusive Health Care System: https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/addressing-stigma-toward-more-inclusive-health-system.html
- A Healthy, Productive Canada: A Determinant of Health Approach (2009) http://www.phn-rsp.ca/pubs/ssphfr-rfscssp/index-eng.php
- Closer to home : The report of the British Columbia Royal Commission on Health Care and Costs: https://sfu-primo.hosted.exlibrisgroup.com/primo-explore/fulldisplay?docid=01SFUL_ALMA21184019280003611&context=L&vid=SFUL&lang=en_US&search_scope=default_scope&adaptor=Local%20Search%20Engine&tab=default_tab&query=any,exact,0772614261&offset=0
Central Okanagan Foundation supports charities in the areas of youth and family health, arts and culture, education, heritage and history, and the environment. The Foundation’s mission is to contribute to the quality of life in the Central Okanagan through the raising and stewardship of entrusted funds, innovative and diverse granting, and active community leadership.
Dr. Trevor Hancock is an internationally renowned public health physician. His main areas of interest are public health policy and planning, population health promotion, healthy cities and communities, environment and health, healthy and ‘green’ hospitals, and health futurism.
Formerly a professor at the University of Victoria in British Columbia, Canada, he is also a co-creator of the global Healthy Cities and Communities movement and co-founded both the Canadian Association of Physicians for the Environment and the Canadian Coalition for Green Health Care. He is senior editor for the Canadian Journal of Public Health, on the editorial board of Cities & Health Journal, and a weekly columnist for the Victoria Times Colonist.
The Canadian Public Health Association recently recognized Trevor’s outstanding contributions in the broad field of public health with the R.D. Defries Award.
Relevant Articles: Upstream
Dr. Warren Bell has been a general practitioner for more than 40 years. For decades he has advocated for peace, social development, the environment, and the anti-nuclear movement, as well as the integration of healing modalities of all kinds.
He is past founding president of Canadian Association of Physicians for the Environment, past president of Physicians for Global Survival and the Association of Complementary and Integrative Physicians of BC, past president of medical staff at the Shuswap Lake General Hospital, and current president of Wetland Alliance: The Ecological Response (WA:TER). He has written several peer-reviewed clinical pieces and for online publications such as the Vancouver Observer and National Observer.
Warren received a College of Family Physicians of Canada Environmental Health Award and the Queen's Medal for Canada's 125th Anniversary in 1992.
Jo de Vries is a community education and engagement specialist with 30 years of experience helping local governments in British Columbia connect with their citizens about important sustainability issues. She also provides contract outreach services for nonprofits such as the BC Product Stewardship Council and the Mission Creek Restoration Initiative.
In 2006, Jo established the Fresh Outlook Foundation (FOF) to “inspire community conversations for sustainable change.” FOF’s highly acclaimed events include Building SustainABLE Communities conferences, Reel Change SustainAbility Film Fest, Eco-Blast Kids’ Camps, CommUnity Innovation Lab, Breakfast of Champions, and Women 4 SustainAbility. FOF’s newest ventures are the HEADS UP! Community Mental Health Summit and HEADS UP! Community Mental Health Podcast.
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The move toward upstream mental health care becomes possible as more people learn about its social and economic benefits for individuals, families, workplaces, and communities. To that end, please share this podcast with anyone who has an interest or stake in the future well-being of our communities.
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Warren Bell, Trevor Hancock Interview Transcript
You can download a pdf of the transcript here. The entire transcript is also found below:
Welcome to the HEADS UP! Community Mental Health Podcast. Join our host Jo de Vries with the Fresh Outlook Foundation as she combines science with storytelling to explore a variety of mental health issues with people from all walks of life. Stay tuned.
Hey, Jo here. Thanks for joining me this week with my two guests, both doctors and activists, as we paddle the often muddy waters of both upstream and downstream mental health care systems. And yes, the plan is to rock your boat.
Imagine this, you're standing on a riverbank near a village and notice that people are floating by. Some are stressed, others are struggling, and a few have even drowned. You then watch as the villagers set up a rescue operation. But you can't help but wonder why no one thinks to go upstream to see who's pushing these poor people in, or how to stop them. That's the current state of downstream healthcare systems everywhere.
Despite best intentions and the billions spent on services and facilities, many of these reactive systems are chronically overwhelmed, inefficient, and underfunded. And given that mental illness will soon have the largest global impact of all diseases, our current systems are woefully ill equipped to meet escalating needs. So what's the alternative? A proactive upstream approach that focuses on prevention and health promotion.
To help us better understand how an upstream system works and how it could best serve us in a post-COVID world, I welcome our first guest, who in addition to being a medical doctor is a renowned public health and social policy scholar, and I would argue a salt of the earth kind of guy. Formerly a professor at the University of Victoria in British Columbia, he now advocates for a variety of community health causes. He co-founded the Canadian Association of Physicians for the Environment, pioneered the healthy cities and communities movement, and established the conversations for one planet region in Victoria. He also writes a weekly column on vital community health issues for the Victoria Times Colonist. Please welcome Dr. Trevor Hancock. Thanks so much for joining us Trevor.
A pleasure, good to be with you.
For starters Trevor, for those of us who may not know what public health is, can you just give us a bit of a Coles Notes version and why you're so passionate about it?
Well, I'm a physician and I was trained in the diagnosis and treatment of disease. But I wasn't trained very much about the other end of the spectrum, which is how do you keep people healthy, and that is what public health is all about. So we work to keep populations healthy, and we do so by looking at the environments they live in, the social and economic conditions they live in, as well as their behaviors, the commercial pressures upon them. Obviously, what people hear about right now a lot is infectious disease and COVID, and so on. And that's also part of the work of public health.
So we are all in the business, I guess in a nutshell you could say, if we do our job perfectly, we would put the healthcare system out of business, because no one would get sick. They would live a healthy life until they were at the point of dying, and then they die. So that's what public health is all about. And so why am I passionate about that? Well, because I think if you can prevent people from getting sick, from going through all of the pain and suffering and not just them, but their families and communities, that is so much better than coming in afterwards to fix the problem.
And how does mental health affect overall public health?
I like to remind people that if you look at the WHO definition of health, which is actually as old as I am, it was 1948, it is that it is a state of complete physical, mental, and social well-being. And so actually, two-thirds of the definition is not about physical well-being, which is where we tend to focus. It's about not just mental health, but it's also about social well-being. It's about how we exist within community. And so, mental health has an enormous impact on physical health as well as being good in its own right. And it's very much related to how we fit in or don't fit in with society.
Our society relates to us and we relate to others. And another interesting way to think about this is, I talk to my students always in a discussion we always start with a discussion of what is healthy and what it means to be healthy, and at some point in the discussion, I throw in the idea of healthy death. And there is always a bit of a stunned silence. And then people say, "Well, that doesn't sound right." And I say, "Well, do you know what an unhealthy death is?" And everyone seems to know what an unhealthy death is. And that's not what we want. But if you look at what a healthy death is, it is about being free of pain, but it is also about a whole lot of healthy sort of mental health and social well-being. And so you can actually be healthy in the process of dying. And it's not so much about your physical well-being, which clearly you are dying, but it is about your mental and social well-being.
I heard you on a webinar the other day sharing a quote, and it goes, "Every system is perfectly designed to get the results it gets." So can you tell me more about this as it relates to the health care system in general, and mental health care in particular?
Well, the quotation comes out of the world of systems engineering and more broadly, the world of systems science. And systems are everything from the cells in our bodies or our bodies themselves, to engineering systems like car factories, for example, to communities and societies and natural ecosystems, all of those are systems. And they operate in a way that produces results that they may not have actually been intended to achieve. But more by bad luck than anything else, if you like. Or, if you like through design flaws, they can end up giving you results you didn't want at all.
So in the world of healthcare, and that particular version of the quote comes from an organization called the Institute for Healthcare Improvement in the US, and they were very concerned about the whole problem of adverse effects in health care, and the high rate of deaths from medical error. And essentially what they're saying is, if you've got a high rate of deaths or infections in a hospital or whatever, there's something in the way that that system operates that leads to those results. And it's the same at a wider level about society.
So for example, I talk about the fact that our current economic system is perfectly designed to ravage the earth. And it's also perfectly designed to achieve high levels of inequality, because those are two obvious outcomes of our economic system as well as generating wealth. So it was designed to generate wealth. But it also turns out to be designed to do these other bad things. And the same applies to our mental well-being, to the extent that our mental well-being comes from our social relationships, and our place in society, and the level of inequality, and a whole bunch of other factors. Then we could design a system that would get us better mental health than our current societal and community system does.
So could you then paint us a picture of someone with mental health challenges, trying to navigate first a downstream system and then an upstream system?
Right now we're in the midst of the COVID pandemic. We're seeing, for example, that one of the side effects of the social or the physical distancing has actually been social distancing. So you begin to hear people say, stay physically distant, but socially together. But what's actually happened unintentionally as a result of social isolation is a lot of people are isolated and lonely, and that becomes a major mental health problem for them. So that was not an intention. The intention was to save lives through social isolation and preventing the transmission of infectious disease. But we're creating a mental health challenge.
And then of course, even worse right now in this situation, it's very hard to get them into the care system because there's all sorts of additional barriers to getting into care. So the downstream system, both in mental well-being and even more so, I'd argue, than in physical health is flawed in many ways. It doesn't meet people's needs adequately. An upstream system, on the other hand, is all about how we stop people having those mental health challenges in the first place, so they don't ever have to start navigating the downstream system.
Sounds like a plan!
Well it is, but it's not an easy plan. And of course our whole approach, and we see this in public health in general, is that we don't pay much attention to prevention. We've set up what we call a health care system, which if we're being honest is actually an illness care system. And it is there to care for people when they are sick, whether it's physical or mental. And it was never really designed to keep people healthy. And in fact, if you look at the so-called determinants of health, only about 25 percent of preventable mortality is prevented through the healthcare system. The other 75, 80 percent at least and probably more, comes from everything else in society that's happening.
So partly what keeps people healthy is not the healthcare system in the first place. And within the healthcare system, the whole realm of prevention is vastly underfunded and undervalued. So public health gets about three and a half percent of the total healthcare budget within a healthcare system, which is inadequate. So we have all of these problems about focusing on prevention in the first place, and that applies even more so to mental health. The whole notion of mental health promotion is really relatively recent, the last 20 or 30 years.
So are you aware of any countries or other jurisdictions that have successfully moved to an upstream approach?
It's interesting to look at mental well-being, or things like happiness. There's something called the World Happiness Report, for example. And the World Happiness Report, ranks people on the basis of happiness. And happiness is defined there, both in terms of what they call effective happiness, which is your day-to-day joys of friendship, time with family, or on the other side, the stresses of long work commutes or sessions with your boss and so on, and evaluative happiness, which is about how well you're doing, what's your overall level of satisfaction in different dimensions of life, or how frustrated are you with your place in society.
When you look at, for example, the World Happiness Report, which is where those sorts of definitions come from, what you find is the countries that score best on the Happiness Index are actually the high-income countries with a high degree of social equality and trust and quality of governance. And so the top countries in the most, almost most recent 2019 report, here's the top 10. I'll read them for you: Finland, Denmark, Norway, Iceland, Netherlands, Switzerland, Sweden, New Zealand, Canada and Austria. You'll see a pattern there. A lot of Nordic countries, a couple of other European countries, Netherlands, Switzerland, and Austria, and then Canada and New Zealand. United States comes in around 19th on that list.
So that's not a bad measure to my mind of mental well-being is the level of happiness, especially when defined in those broad terms about satisfaction with your place in society, and satisfaction with your relationships, issues of community trust, but also, it gets us into the realm of the quality of governance and the rule of law. So one of the other really interesting things that goes with this is a wonderful piece of work by Pickett and Wilkinson and a book a decade ago called the Spirit Level, where they looked at inequalities in health. And what they did was they ranked high-income countries on the basis of how unequal they were against an index of about a dozen or so social outcomes such as life expectancy, or imprisonment, or obesity, or trust, or social mobility.
And when you look at that index, the most equal countries, the ones with the lowest level of inequality, are also the ones with the best score on the index of health and social problems. And guess what those countries are? Japan, Sweden, Norway, Finland, Denmark, the Netherlands, Switzerland, and so on. Canada's about the middle of the pack and the USA is almost off the screen. So what this is telling us is that there is something about the way that a country is organized. And that's what I mean about every system is perfectly designed to achieve the results you get. In fact, there's a whole chapter in this year's World Happiness Report about why are the Nordic countries so exceptional, and it's really quite fascinating. So what this tells us is that your level of happiness, which I think is as I say quite a good indicator of mental well-being, has a lot to do with not just your immediate social satisfaction and your level of well-being in that personal sense, but also, as the report puts it, the quality of governance and rule of law.
You've talked about some really cool social and medical movements, things like social prescribing. Can you tell us a bit about that?
Well yes, social prescribing is something that started in Britain. They've actually got quite formal about it now. I was a family doctor for four years. And my experience is completely in line with the sort of rule of thumb, which is that about a third of everything that I saw really wasn't a medical problem, it was a social problem of some sort. And so, you can't really, or there wasn't a mechanism that said to people what you actually need is to sit down for a cup of coffee with some friends once a week, to get involved in some way with a local community group, or to have someone drop by and have lunch with you, or whatever. There's all sorts of ways that can happen.
So they actually started a process of social prescribing, which is where essentially the physician or the primary care worker gives you a prescription for some sort of social action. What they do is they refer you to a system, which is actually I think, largely staffed by volunteers that tries to figure out what would interest or engage you, and what would link you to other people. So what are your shared interests, and how can we link you up to other people who share those interests? And it can be all sorts of things.
There's a wonderful program in Australia that's been around for, I don't know 10, 15, 20 years now, and it's called Men's Sheds. And it was set up as a mental health program. But what they were dealing with was particularly older men in trades who were retired, and who might have worked in the factory, or construction, or whatever it may be for years. And then when they retire, they're sort of a bit bereft. And so what they did was they set up what they called a Men's Shed, and they put some basic tools in it, and a coffee pot. And the guys would come around and hang around together and they could make things together.
They would end up doing things like becoming the bike repair shop for the neighborhood, or whatever it may be. But it was a combination of doing something useful, and meeting your peers and doing so in an informal relaxed way. So it wasn't advertised as here's this mental health program you should come to it. It was advertised, here's this place where you can fix things and meet some buddies. And that's an example of self-care that that can be done.
Another thing I've read about, again that was started in the United Kingdom is doctors prescribing plants for their patients.
Well in fact, that touches on another whole really important aspect of mental well-being, which is nature contact. And again, there's been a real explosion of interest in this in the last couple of decades. And we're understanding, first of all, that if you look at the history of Homo sapiens, we evolved in nature. And it's only in a very, very short recent past of the last few thousand years, that we've moved into cities and only really the last couple of hundred years, that we've moved into cities at any scale. But until then, our lives were deeply entwined with nature. And it seems that at a very fundamental level, nature contact is important for our well-being.
And so it's everything from, as you say, having a plant. I mean, one of the things I asked my audiences when we talk about this is how many people have houseplants. Usually, at least two-thirds of the audience have houseplants. And my question to them is why. Why would you have plants in your house? And the obvious answer is because they like it, it makes them feel good. But it's a form of nature contact. So at a deep level, we get that nature contact is important. It's also important in a different way, some of what you were talking about, maybe it's a way to help people start to care. So when you give them a plant, and this has been done with alcoholics for example, who are very bad at caring for themselves, because they don't care. And so you start with giving them a seedling or a plant and say you have to look after this plant.
Another lovely story I like from Wales. I came across this story 30 or 40 years ago. Elderly people who have limited means, and in order to save money for food, they would not heat their house, and they would be getting hypothermia and dying. And the approach that was taken was they gave them budgerigars, which are little pet birds, and they will say this is your budgie and it's going to be your friend and your companion. They're very chirpy, bright birds. They're quite common in Britain, caged birds. And they'd say, "But your budgie is very sensitive to the cold and you can't let the budgie get cold or it will die." And so they keep their room warm. And they wouldn't keep it warm for themselves, they're keeping it warm for the budgie.
So I think all of that whole notion of how do we get people to connect, how do we get people to care? You take the notion of planting again. I mean, we've seen a real growth in the last 20 or 30 years of community gardens, which at one level are about growing things, but on another level they're about social connection. And so there's all sorts of ways, both formal and informal, that we can create connection, and connection is really important because isolation and loneliness are very toxic.
Here's a bit of background from my researcher to set the stage for my next question.
In 2017, the Mental Health Commission of Canada released a five-year framework called Advancing the Mental Health Strategy for Canada. The strategy underscores the need for shared goals among experts, stakeholders, and governments to mobilize change at all levels of care. It also promotes efforts to uphold human rights, improve social inclusion, and eliminate stigma and discrimination.
The strategy highlights the need for governments to be actively involved in the move toward an upstream approach. So Trevor, in that scenario, what is the role of the federal government?
Well, if we go back to my earlier comment that something like 70 to 80, maybe even as much as 90 percent, of preventable mortality is prevented through interventions outside the healthcare system, then the federal government has a huge role. It doesn't have a huge role within the healthcare system. It doesn't run health care systems, that's up to the provinces under our Constitution. And it leaves the federal government essentially out in the cold when it comes to healthcare policy, other than what it can persuade the provinces to do often by offering them money, essentially bribe them if you like, to do the right thing where that's necessary.
But outside of the healthcare system, there's a huge amount they can do. And an obvious place to start with that would be, as you say, some of the areas around social inclusion, human rights. We certainly see that, for example, right now with respect to Indigenous people. And there has been over the last decade or two, some slow and much delayed but important steps to recognize Indigenous people's rights and sovereignty. It's still obviously a work in progress. But that has enormous impacts on mental well-being.
There's a very famous study that was done out here in BC, 20 or more years ago now, 30 years ago probably, Chandler and Lalonde in which they looked at First Nations bands, which there are about 200 in BC. And they looked at their suicide rate compared to their level of self-government. And the higher the rate of self-government, the lower the suicide rate. And it was quite dramatic.
So, that applies in particular to Indigenous people, but I think it applies more generally to all of us. Social exclusion, whether it's because of discrimination, whether it's because of being low income, or whether it's because you're an addict or whatever it may be, social exclusion is very toxic. So there is a lot they can do around that. There's a lot they can do. They certainly did it for older people when they raised incomes back in the 70s and 80s. Because living in poverty is not only harmful in a physical sense, but it is in a social sense.
I think that is an area that we really need to be looking at these days, and actually the COVID pandemic has heightened our awareness of that is the economic system, again to go back to a perfectly designed system, it's a system that two-thirds of our workforce now is not really associated with an employer. They are in some way self-employed, or part-time, or temporary. They don't get benefits or many benefits. They have enormous levels of job insecurity, and job insecurity is very bad for human mental and social well-being.
So we need to be looking at, should we be looking at some form of either basic income or at least ensuring that the minimum wage is actually a livable wage, which it isn't right now? Should we be looking at how we can make sure that people have secure jobs with decent pensions? In many ways, going back to the 60s and 70s and the sort of policies we have then. So I think there's a lot of areas economic, social, legal, where the federal government can play a big role, but of course provinces also have to be moving in conjunction with.
Here's some other notable information from my area.
British Columbia is the only Canadian province to have a Ministry of Mental Health and Addictions. In 2019, the Ministry released a roadmap for change called A Pathway to Hope, which outlines the need to shift from downstream to upstream approaches. The 10-year goal is for all British Columbians to enjoy physical, mental, emotional, and spiritual well-being, and to thrive in the communities where they live, learn, work, and play. Short-term goals are to improve wellness for children and youth, support Indigenous-led solutions, better serve substance users, and expand overall mental health care services.
Trevor, you've lived here a long time So, is this doable?
Well, it's certainly doable. We can look at other countries, as I said earlier, look at the Nordic countries in particular, but not just the Nordic countries. If you look at other places that experience high levels of happiness and well-being, a number of them are Latin American countries as well. And there's something about their approach to life there that we need to look at. Costa Rica, for example, often scores quite well on these sorts of frameworks.
I noticed incidentally, it's very interesting, they talk about British Columbians enjoying physical, mental, emotional, and spiritual well-being. The thing they miss there, which is part of the WHO definition is social well-being. I find that an interesting omission and a troubling one. But I think it's doable. I don't think it's doable in 10 years that we can get there. But I think we should have an aspirational goal to get there, even if we don't make it in 10 years, which is not too likely.
What would have to be done first?
Well actually, in a sense, I would say that one of the problems is that there's a whole lot of things that have to be going on all at the same time. I think what might be useful is for the government to go back and look at a report that the Senate of Canada's Health Committee produced, not quite 20 years, about 10, 15 years ago now about creating a healthy Canada. And they recommended that each province set up a population health committee of cabinet, chaired by the premier. And they look at all of the public policies, and think about how to make them good for health.
So if you think about some of the things we've touched on, we've touched on the role of nature, so that gets you the Environment Ministry. We've talked about parks in urban areas, that's the Ministry of Municipal Affairs. We could talk about social housing, which provides security of tenure . Obviously employment and incomes, social assistance, education, food, and agriculture. There's every ministry of government in one way or other touches on people's well-being.
In fact, I have argued for years that we've sort of lost our way that the business of government is not the economy or should not be the economy. The business of government should be human and social development. And that should be what all of government activities are organized around. Now, the federal government and the provinces completely ignored that Senate report. I think they need to go back there.
So I would say the first thing to do is to establish a Cabinet Committee on either population health or well-being, or something. We could look for that matter to New Zealand, which last year released a well-being budget. So they have really focused their whole budget on the well-being of the population. And that is an example that we should be following here.
Costs are a huge consideration for governments everywhere. How do the costs of downstream care compare to those of upstream approaches?
Well, in broad terms, they are less because it's almost always cheaper to prevent something happening then to come in and try and fix it. And that applies not just with respect to health and well-being, it applies to workplace settings, it applies to environmental pollution, you name it. So prevention is always better than cure. And that is something that we've rather lost sight of, both within the healthcare system and within society at large. You can always throw a lot of money at fixing things. And it's popular, it's immediate.
The problem with prevention is several fold. One is if we do it well, nothing happens and nobody notices. And so you're not going to be on the front page. You're only going to be on the front page, if things didn't go well, if things messed up. So you don't hear a lot about measles until there's a failure in the immunization program, and so on. So it's more a matter of deciding where to put your money. And remember that most of that money isn't coming out of the healthcare system anyway. It's actually already being spent in other ministries.
And in fact, there's a very good argument that says that when we continue to increase the healthcare system funding above the rate of inflation, we're actually taking money away from other things that may be more important to health such as housing, access to food, good education, ensuring human rights, building social capital and social cohesion, and community. All of those are much more important for well-being, reducing inequalities. Those are the things that will contribute to our overall well-being. And we need to be sure that we fund those first.
How did you get to be so smart?
Lifetime of experience.
I love it.
The business, nonprofit, and academic sectors also have important parts to play in the move toward upstream care, and we'll explore those in future podcasts. But now I'd like to examine the role of our family physicians, who are often the first points of contact for people struggling with mental health challenges. For that insight, I welcome our next guest who has been a GP for more than 40 years.
A highly esteemed straight shooter, he's advocated for social and environmental health at the local, national, and global scales for decades. With Trevor and Dr. Tee Guidotti, he co-founded the Canadian Association of Physicians for the Environment, and is past-president of Physicians for Global Survival and the Association of Complementary and Integrative Physicians of BC. He's now president of the Wetland Alliance in Salmon Arm, BC. Dr. Warren Bell, thanks so much for being here.
Delighted to be here Joanne.
I know that a good portion of your practice involves psychotherapy and supporting patients with mental health challenges. Why is this so important to you?
It's important to me for two main reasons, Joanne. The first is that many many studies have shown that mental health issues are a prominent part of primary care. People walk in to doctor's offices with anxieties and depression and sadness, and mixed up feelings about all sorts of stuff, ambivalence. And by not addressing that we we miss an important part of the needs in the community. The second reason is that, from the start when I was in training, I became aware of an affinity for this kind of work and pursued it with some extra training, and worked for a year in a psychiatric outpatient department in Montreal at McGill. And so it became part of my practice early on, and it's been there ever since.
And what do you think is the link between physical complaints and mental health challenges?
Well, the division between them is artificial. So I guess one could say the link is inherent. People who have physical illnesses always have some kind of psychological impact from that, and people who have psychological disturbances often have physical conditions that result from that. So the two are indissolubly linked. I think it's probably more that that makes them important. You can't really address one without the other.
I have done psychotherapy while sewing up somebody's laceration in the emergency room. They didn't perceive it as such because they just thought it was, we were chatting away, but we were chatting away about important issues in their life. So I see it as an integral part of everything that a family physician does.
That's great. So in our existing downstream system, how are GPs limited in the services they can provide to people with mental health challenges?
It's an interesting situation in Montreal in Quebec when I first started to practice. Psychotherapy was accepted to be carried out by family physicians. And it became in fact the focus of my office practice. I worked in emergency rooms and other settings as well, but in my office, it was almost exclusively psychotherapy and in-depth psychotherapy, a form called anxiety-provoking psycho-dynamically based psychotherapy. And I came to BC and discovered that a family physician was only allowed to do four sessions per year per patient. And you're not actually supposed to talk about mental matters.
You're supposed to talk about sort of physical illnesses and how you adapt to them. I approached every governing body in the province and they all said the same thing. So I ended up just doing the psychotherapy on the same rate of return as I would get from a regular visit, which was a bit of a reduction, substantial reduction actually, but I felt it was important to do and that's why I continued doing it for many years.
How many physicians do you think are prepared to go that route?
Very, very few, even psychiatrists among psychiatrists, there are very few psychiatrists who still actually talk to patients in depth in a form that is leading to insight and the development of tools to deal with psychological and physical problems.
So that's where those patients would then go to psychologists or therapists or whatever.
Psychologists are positioned, generally speaking, positioned outside the healthcare system, and you have to pay from your own pocket to see them. That was another reason why I ended up doing what I'm doing, because at least part of my fees were covered by the medical services plan. So there are some complexities in this area, and the jurisdictional authorities kind of divide it up.
But certainly I have found over the years, that bringing in the element of people's minds and their emotional responses to addressing physical conditions, or even just on their own, the psychological aspect of their problems, has been a very productive thing to do. I've had patients referred from other practitioners, for example, on a regular basis, sometimes formally, sometimes informally. But I think word got out in the small town that I live in that this was available. And so people would sort of turn up at my office and want to talk about what they're going through.
So if GPs are limited in the services they can provide in a downstream system, what is the potential for GPs in an upstream system? How can they best support their patients that way?
Well, that's a very important issue. In fact, support for upstream interventions all the way from the training process that doctors go through all the way up to specialized practice, the training is very limited in terms of looking at, say, community-based measures that could enhance a person's mental health, addressing how people's relationships come to play on their mental state. Most of this is kind of considered outside the purview of the typical family physician's practice, and I think it's unfortunate, and I hope it changes at some point. But it doesn't seem to be doing that right now.
We're still doing the, where we've got into this pattern of one problem per visit, for example, a lot of physicians do that. And that is utterly contrary to the kinds of things that psychological problems present, because they cover different areas of a person's life from the physical to the mental, to the social, to the community-based issues. So it's a shame, but that's how it happens right now.
So from your perspective, as a GP, what would the perfect upstream system look like?
Well, it would have physicians integrated into community-based issues. In other words, instead of just seeing one patient at a time in our offices, you know, the door closes and we ask questions about their physical functioning, sometimes their mental function, but mostly it's limited to just physical functioning. That's both inefficient and it's definitely downstream.
On the other hand, if physicians present themselves in the community, they join organizations, or they engage in practices that are associated with good health, if they speak about these issues in the community, if they model these behaviors in the community, all these are ways to act pre-emptively to strengthen community resilience, which then flows on to enhance individual resilience. So there are lots of things that physicians can do, but often it means stepping outside the office enclosure and out into the community.
So let's bring Trevor back into the conversation. From what I understand, the ideal in mental health care is a fully functional upstream system supported by robust health promotion. So Trevor, what is health promotion and why is it so vital?
Well, health promotion is one of the core functions of public health, and public health includes illness and injury prevention, so things like wearing your seatbelt or getting your immunizations. It includes health protection. That's things like preventing pollution, chlorinating the drinking water, things that we do to whole communities and societies. And then health promotion. And health promotion has been defined as the process of enabling people to increase control over and improve their health. And that applies both at a personal level and at a collective level.
So it's really a process of empowerment, how do you enable people to have more control over their working conditions, for example, so that's why unions are very important. And that's why it's important not to have these sort of insecure part-time temporary jobs with no benefits. But inorder to get out of that system, you have to have a combination of organizing by workers together, with support from government and legislation, to require employers to behave in certain ways just as we do for occupational health and safety.
But it is also about, a lot of the work I've done over the years has been the notion of healthy cities and healthy communities. What is the role that municipal governments play, and what is the role that citizens of cities and communities play in creating the conditions for good health in their community? And that is everything from clean streets and good policing, to parks, to clean water, to sanitation. If you look at most of what municipal government does, it's about improving health and well-being and the quality of life.
And interestingly enough, if you look at national and provincial governments, they tend to measure progress in terms of GDP, did the GDP go up, did it go down. I don't know any municipalities that measure progress using GDP. Municipalities generally measure progress through measuring quality of life, and that's their main focus. And actually, the federal and provincial governments need to learn from municipal governments about how to govern for quality of life and well-being, because I think they generally do a better job of it than the federal and provincial governments.
Warren, how would a system rich in targeted health promotion improve your patient's mental health?
Well, I can answer that question by saying that it already does. For example, there are other community organizations. The Family Referral and Resource Center in our town is a place where people can go for education about skills that they may not have, basic skills like cooking. It doesn't seem like teaching somebody how to cook food for themselves is, apart from the nutritional value, a health-giving process. But actually, for people who feel inadequate in the cooking department, it's such a basic requirement for a person's life, it actually gives them a sense of mastery. And the more people have a sense of mastery in their lives, the more they can function properly.
In addition, there's the whole social support system through Ministries of Social Services. I'm personally a great fan of the guaranteed living wage approach. And as you may know, Ontario recently implemented a pilot project in this area. It was unfortunately cancelled, but before it was cancelled, a survey was done of the participants in it. There are some thousands, two or 3000 people involved. And some of the stories that they told were clearly indicative of drastic improvements in mental health.
I recall one young man who felt marginalized and lost and confused about his life, and basically rejected by society, who when he started to receive a living wage, his whole attitude changed. He went back to school but most important, he felt really nurtured by the society and the community he lived in. And when you feel that way, in your own home community, it opens doors in your mind to be able to pursue more creative and ambitious processes. And that's exactly what he was doing. And that was just one example.
But, you know, the so-called social determinants of health and the environmental determinants of health, the first are relationship-based, the second are based on generating what we could loosely call a clean environment, a clean and natural environment. Those things doctors can be very active in pursuing, and in fact, the work of the Canadian Association of Physicians for the Environment has been all around that latter subject trying to make a more healthy and robust environment the option available to everybody, because that does induce better health.
Let's talk about a few other things that contribute to our overall need for mental health care. Trevor, I've heard you talk about shit life syndrome, which I understand is the British equivalent to what are also known as diseases of despair. Tell us about that.
Well, the notion of shit life syndrome came out of, I think, a British GP about 20 years ago. And it actually goes back again to a point I was making earlier that about a third or so, roughly speaking of what you see in primary care, is actually social problems not medical problems. And what he was saying is, you know, people would come in with their injuries or their illnesses or whatever, but when you really dug into it, it came out of the fact that they were having a pretty shitty life, that they were unemployed or working part-time, they lived in an unpleasant or dangerous area. I mean it's very apparent, you know, when you move into an area that's not good, you can feel it.
And in the US, they've been focused in the last 10 years or so on this notion of diseases of despair. And what they've seen is a considerable spike particularly among middle aged, low-income, white population, a considerable spike in deaths from suicide, alcohol use and drug use. So much so, in fact, that it's actually reduced life expectancy in the US. It's also started to do so here in BC, that's particularly because of the opioid epidemic. And they've called these things diseases of despair. And, there's been quite a lot of work done on that.
What you've seen in those populations is their jobs have gone to Mexico, or to Asia somewhere, and they don't have a job, they don't have a social role. And particularly in the US where you have a very weak social safety net and very little help for people. We're seeing that right now again with COVID, they fall into despair. And when you're despairing, then you're going to use drugs, you're going to use alcohol, you're going to be suicidal. And, it stems to a large extent from economic factors that are driving us.
Again, as I say, the economic system that supports those kind of economic policies, that export good manufacturing jobs, they're doing it to generate wealth for shareholders, but they also are perfectly designed to result in the diseases of despair. So we have to change our economic system to one that actually produces good physical, mental, and social well-being which this one is not designed to do.
So in an ideal upstream system, are these diseases of despair primarily prevented?
Yeah, it's easier to prevent them when you have an upstream approach. You create the circumstances for somebody to thrive rather than undertaking an intervention to make them thrive. It's assuming that there is an inherent drive to be productive and creative in pretty well everybody. And if you give them an opportunity to be that way, then they will take that opportunity. If it's a genuine offer, it's not just, you know, we'll do this for now. But then we might take it away later sort of thing. And I have seen people when that's been available to them really start to thrive.
And I remember one woman who was very, very unhappy and depressed, who got on the committee to establish a new community center, and she just threw her heart and soul into it, and it transformed her. Her family physicians, they don't see her anymore because she was so unhappy before but now she's doing something she feels is really productive. And I believe that was the last time she really needed direct care for her psychological suffering.
Before we pick these amazing brains any further, I want to thank the Central Okanagan Foundation for the funding needed to launch this podcast. COF contributes to the quality of life in the Central Okanagan region of British Columbia, by supporting charities focused on youth and family health, arts and culture, history and heritage, and the environment. We wouldn't be doing this without your help, so thank you so much. And if you as listener would like to support our charitable work, you'll find donation and sponsorship info at freshoutlookfoundation.org.
Another thing you both talked about is ACEs or adverse childhood experiences. Warren, can you tell us a story about how childhood trauma can impact mental health, and how the resulting mental health challenges can be mismanaged in our current downstream system?
I'm thinking now, I had a case a long time ago of an eighty year old gentleman came to see me, only a couple of times. And he described constant and irremediable stomach upset. And every remedy that'd been offered him, which was sort of for symptom relief, had been unsuccessful. This is probably 30, 35 years ago. He started talking about it, I said, "Where did this come from?" He says, "Well, I've had it since I was a kid." And I said, "Well, what happened when you were a kid?" And he said, "Well, my father used to beat me all the time with a belt", and described a situation in which his teacher had put her hand on his back one day and he'd winced, and she'd been surprised and she'd take him off to a private place to say, "Show me your back" and he showed her his back and it was covered with welts from his father's beating. And she'd send a note to the father saying, if I ever see evidence of this happening again, I will report you to Social Services, something like that.
And the outcome of that was his father beat him almost to death and said, "If you ever tell anybody again about this, then I will kill you literally." And in addition, his father was having a relationship with a neighbor, the neighbor's wife, and this man as a young boy was compelled to watch his mother sitting beside him on the sofa while this was going on. And he had borne this thing through his whole life.
He eventually faced his father off when he was in his teenage years, but he'd never had this addressed. He never talked about it to anybody. Nobody had ever asked him if anything like this had happened. And the result was that he essentially had this disability, if you like, follow him wherever he went. And heaven only knows how it affected his interactions with other people and his sense of pleasure and satisfaction in life, but he certainly bore a burden that had a profound influence on the course of his days, and it was just a sad situation. That's an example of how something not addressed becomes a lifelong burden to bear.
Trevor, how does an upstream system work to prevent these adverse childhood events from happening, or mitigating them as quickly as possible when they do occur?
Well, it's interesting that the notion of adverse childhood events is a relatively recent focus about the last couple of decades. And the work out of, for example, a recent report from the Centers of Disease Control in the US looked at that, and the model or the framework that they propose, again interestingly enough, is to a fair extent an upstream focus. So you can wait until an adverse childhood event has happened, and those are essentially around living in poverty, and living in unstable households, and living in the presence of parents who can't cope, and who abused physically, mentally, or neglect. Those are the sort of adverse childhood events we're talking about.
One of the things I also tell my students is public health is all about asking the question why. There was a wonderful introduction to the first Canadian rapport on population health back in the 1990s. And it had a little story about why is Johnny in the hospital. And it was a series of questions. Why is he in hospital? Because he cut his foot. But why did he cut his foot? Because he was out playing and stepped on some glass? Why was there glass there? Because this was an abandoned site, and on, and on, and on. And each question takes you further up the chain of causation. And turns out that Johnny was living in a neglected, downtrodden, poor neighborhood with an unhealthy environment and lots of neglected areas, and so on.
So what this CDC report says is that you have to look at these upstream generational impacts. A perfect example would be what we see with high rates of suicide among indigenous youth. And in order to understand that you have to look at indigenous social determinants of health. And what they tell us, and this is the work of my colleague Charlotte Loppie and others, is that those adverse social conditions and adverse economic conditions are rooted in several hundred years of colonialism, and racism, and colonization, and dispossession. And that's why asserting the rights of indigenous people and their sovereignty over their land is so important, and important in so many ways. I already mentioned the famous Chandra and Lalanne study on suicide, but it also extends to care of the land.
So we've seen the Wet'suwet'en hereditary chiefs, for example, opposing the construction of a pipeline through their territory. And that's partly about asserting their sovereignty, but it's also about their right to protect their land and the land of all of us in the process. I have a friend Shannon Waters, who's an Indigenous public health physician in the Cowichan region of Vancouver Island, and works for Island Health, but also with the Cowichan Tribes. And she actually just gave a talk for an NGO I've set up called Conversations for One Planet Region. And her talk was entitled, Sovereignty Becomes Sustainability.
And she argued that essentially that connection of Indigenous people not just here but around the world to the land is part of their vital identity. In protecting their land, because they are the land is the way they think of themselves, that in protecting the land, they are living sustainably. And we have much to learn from that I completely agree. When we came as the Europeans and took the land and confined people to reserves, we were undermining the vital, cultural aspect or core to their being. And on top of that, we then set out to destroy their culture, to ban traditional ceremonies, to ban the languages even. Do you wonder why we have high rates of mental health problems in Indigenous people across the country? Why we have high rates of youth suicide, just look at what we've done. So those adverse childhood events are rooted in hundreds of years of colonization, and dispossession, and discrimination.
You both mentioned COVID-19. And we couldn't have this conversation without talking about its impacts on our mental health as individuals, and in families, workplaces, and communities in Canada and around the world. So what from your perspective are the key systemic challenges you're seeing magnified as a result of COVID? And who do you think should step up to the plate to mitigate these challenges?
Well, I think one of the challenges we've seen, which I touched on before is isolation and loneliness, particularly for older people, particularly for those in care homes and residential care. The interesting thing is we're also seeing, I think to some extent, the flip side of that. People are beginning to appreciate the importance of social connection. And I and others I know, we're getting together online, to just sit around and chat and have a beer each in our own home, but instead of going to the pub and having a beer, we're doing it from our homes. People are seeing the importance of family and community and connection. So I think there's some good things come out of that.
I think that there's a whole focus on where did this come from in the first place? And what is it about the way that we organize society that makes it spread so rapidly? And the level of international connection, the level of international travel, but also importantly, the extent to which our society, our civilization now intrudes into nature and interacts so deeply with nature. So COVID is just the latest of a whole series of emerging infectious diseases that come to us from our intrusion into and interaction with nature, which is increasingly pressured.
So I think, interestingly enough, it's highlighting the impact we have on the environment. So people are actually saying, "Wow, I can see the mountains, I can hear the birds, I can smell the roses." Pollution levels have gone down, air quality is improved. So it's also highlighting the price we pay for the kind of life we live. And I think over the longer term, we may start to look at this and say, well, is this really how we want to keep leading our lives or is there a better way?
Warren, what are you hearing from your patients?
I'm hearing a great deal. It's very hard because our offices has been re-jigged. So the chairs in the waiting room are six feet apart, everything is wiped down, hands are sanitized. If I examine somebody, I wear a mask and I only have one chair in one corner of my room, and another chair in the other corner and my chair is six feet away. And so everybody starts talking about it almost as soon as they come in the door. People are a mixture of anxious, skeptical, and confused. Those are the three most common reactions.
The plethora, the absolute tsunami of information, some of it reliable, some of it not, much of it conflicting, is so extensive that people are just, they're hungry for dispassionate, tempered, equilibrated information. And so I spent a lot of time trying to pass that kind of information on. Of course, I have to read widely so that my comments are accurate, but I'm actually surprised sometimes how knowledgeable, how common sensical people are when they think about COVID-19.
I do know for a fact that the physical distancing, that takes place as recommended by public health authorities, is in many, many lives extremely challenging, not just doing it but experiencing the sense of fragmentation among their peers, essentially a sense of being cut off. We are a species that likes to connect to one another and touching one another is a very common thing. And I've for years, especially with elderly folks, you know, a hand on the shoulder or a hug if they're going through some difficult experience is a very powerful tool. And having that taken away, has been a huge challenge. And I know that patients find that difficult as well, they talk about it all the time. So there's a lot of anxiety, a lot of confusion, and then some sense of sadness and depression and isolation.
I've noticed there's been a lot of discussion lately about social justice. For example, fair wages for essential workers, not only now but in the future. Also talk about social tipping points where if enough people adopt a new behavior, it becomes a social norm. And social solidarity is growing as well, meaning that people are communicating and collaborating their way through this pandemic, in positive, innovative, and thankfully, in compassionate ways. Warren can this formula, say social justice plus social tipping points equal social solidarity? Can this formula be applied to other challenges such as climate change?
Yeah, we live in interesting times don't we. My favorite term is that the COVID-19 situation is offering us training wheels for dealing with these other future and more compelling problems, because it's showing us how to be cooperative across nations, and among nations, and around the world, across scientific disciplines that political voices are being informed by science rather than just political priorities. People are doing things for other people on an unprecedented scale. They're being selfless and altruistic.
These are all qualities that we need to amplify and extend. If we're going to deal successfully with things like the climate crisis, and with reducing plastic pollution, we all have to do something there to make it happen. And we're learning how to do some of that with COVID-19. So there is, I think, a silver lining in this particular cloud, that if we're good, and we pay attention, we emphasize and underline it in red ink, it can serve us very well in dealing with these other and more compelling issues.
I know you know each other well, but in summary, I'd like you to answer these questions for our listeners. Warren, as a GP and an activist, what would you like to say to Trevor knowing that he's on the leading edge of public health in Canada and beyond?
When I first got to know Trevor, it was because of the things he was writing in the medical literature, and I do remember an article he wrote about social marketing. The notion of using advertising and public relations techniques to promote things that were beneficial for humankind, and in the context of what we're talking about now, also beneficial for the ecosystem and its integrity and robustness. And I think, Trevor, if I was to suggest that there's something to consider, it would be to continue doing this social marketing process to put yourself out as you already have done on many occasions and in many different situations. Put yourself out and shamelessly promote the ideas that have been close to your heart and your mind for many years, because that's really critically necessary.
The big picture has to be discussed whenever we're talking about the little picture. You know, the phrase acting locally but thinking globally, I mean, it applies precisely in this context. We are part of the global ecosystem, and so everything we do locally affects it. And, Trevor, you're a paragon of expressing those kinds of ideas. And you should do it as much as you do or more for the rest of your life.
And Trevor, as a public health and policy scholar, what would you like Warren to know about GP's roles and influences in the move toward prevention and health promotion?
Well, knowing Warren as well as I do, I know he does so much of this. I mean, I guess I'd like to say that Warren is kind of the poster child, poster boy for this. He's always done a lot of prevention and he's always been interested in holistic and alternative medicine, and in being active and engaged in his community. I think that the system that we have is not really designed for that. So Warren is kind of the exception to the rule. Warren in a sense is swimming against the current to do what He does. But I think we need to redesign our primary care system to make it the heart of the healthcare system, which it isn't.
Primary Care, for example, is devalued in society. And in the healthcare system, you're only really successful if you're a specialist, and you know all about the heart or the brain or the whatever, the kidney. But the people who are really important to health are the primary care people and the public health people who are looking at the whole person and the whole community, and they're much more important. We have not as a society valued them sufficiently, we have not as a healthcare system valued sufficiently. So we need to redesign the system to focus on that role, and prioritize that role, and to reward that role.
As we near the end of the episode. I'd like to bring us back to the title, mental health care systems, downstream losses versus upstream wins. I'd like each of you to share briefly what you think about the following. First, the greatest loss or challenge of a downstream approach, Trevor?
Well, it's too little and it's too late.
It's expensive and inefficient.
Wearing my Fresh Outlook Foundation hat, I'd like to add that the downstream system results in lost potential and lack of fulfillment for not only individuals, but families, neighborhoods, workplaces, and communities in general.
What's the greatest barrier to a transition from downstream to upstream approaches?
The greatest barrier is that we have built a downstream system and so to try and redirect energy and resources from downstream to upstream approaches is a problem. The other great barrier is that the upstream approaches lie outside the healthcare system.
A focus on acute care.
Can you expand on that?
There's a royal commission in BC called the Seaton commission, Judge Seaton was presiding over it, and I sent in a submission, but I got the documents from the BC Government on acute care, and then health promotion and prevention. And the size of the documents was extremely important. The one on acute care was probably an inch and a half thick, and very dense. The one on health care prevention and health promotion was probably about three or four millimeters thick, and lots of pictures. It was very eloquent, how much money, and how much emphasis, and how much time and effort is put into acute care and how little is put into health promotion and prevention. It really should be very different. It should be not necessarily the other way around, but there should be at least an equal emphasis on health promotion prevention.
I'd have to say the greatest barrier is a lack of communication, collaboration, and innovation among people from all sectors, ages, cultures, genders, and abilities. Okay, now the greatest win or opportunity, of an upstream system?
Be part of a whole of society approach, which is what we need, you would have more people having more health at less cost.
I think that's pretty easy to say that the best, the greatest win is better health in the global sense of health, physical, and mental health.
For me, the ideal outcome would be robust and resilient communities realizing their social, cultural, environmental, and economic potential. I know I sound like a broken record on that, but I really believe that 50,000 foot perspective is really important if we're then going to hone in effectively on individuals and smaller groups of people. Your personal commitment to being the change we want to see in this field?
My personal commitment is simply to keep doing what I'm doing, which right now that focuses, particularly on our local community and how we become a one planet region. I retired a couple of years ago, and in thinking about particularly my writing career, and I've done a lot of writing, published a lot of book chapters, a lot of articles, I now write a weekly column.
Writing that weekly column has made me realize that we've actually done a very poor job of communicating with the general public, about the work of population and public health and what we do, as opposed to communicating with fellow academics and professionals and students. And so my other commitment is I am stopping academic and professional writing, and I'm planning over the next couple of years, in a few years, writing two or three books for the general public about the work of population and public health, healthy cities, health, planetary health, those sorts of ideas.
So my commitment in the area of moving care upstream is to act as a model and an advocate. A model by doing things that I think other people should do that are good for the ecosystem and for mental health, and as an advocate, to stand up and say, I think this is what we should do. And here are the reasons why I say that being a public presence in the community as a physician, and advocating for mentally healthy and physically healthy behaviors is a really constructive way. And I think I would recommend it to every one of my colleagues as a way to make an impact.
I promise to continue these conversations about community mental health through Heads Up podcasts and virtual summits, so we can all be healthier and happier. Thank you again, Trevor and Warren, for sharing your incredible insights, ideas, and passions. I've admired you both for years and have loved this opportunity to get to know you better, and to share your wisdom with people wanting to mobilize positive change in the world of mental health care.
Thank you for having me. It's been a pleasure. And I look forward to being part of the conference in the fall.
Well, thank you very much, Joanne. It's been delightful to be part of this interview in this future podcast. And I really wish you and the Fresh Outlook Foundation well for the work it's doing, the conferences that you've organized in the past, and the ones that you'll be organizing in the future. It's a very valuable presence in the advocacy and social transformation community where a lot of us realize there's a lot of work to be done. I think we're both grateful to you for doing this work. Thank you.
For more on Trevor's work and his weekly columns, visit trevorhancock.org. Warren's insights can be found at nationalobserver.com and vancouverobserver.com, two major online independent news sources. You can also find detailed shownotes on our website, which will provide links to all of the reports that we've mentioned.
And thank you so much for listening. If you liked what you heard, visit freshoutlookfoundation.org for more podcasts, and to check out our virtual Heads Up Community Mental Health Summit. As Winnie the Pooh says, I'm lucky to have something that makes saying goodbye so hard. So instead, I'll say be healthy and let's connect again next week.