To break down the barriers to accessing medications and care, we must look at things with an equity lens, says McGill’s Amélie Quesnal-Vallée.

As an undergraduate student at Université de Montréal, Professor Amélie Quesnel-Vallée learned about a concept in health services research called the inverse care law – it set her career in motion and continues to define the work she does today.

“The inverse care law aptly captures the inequity risks that societies face when developing new medications and technologies,” says Quesnel-Vallée. “Essentially, it means that people with higher incomes, more power, and societal connections are better positioned to access care the fastest – and that they tend to do so, even though on average, they don’t need care as much as people in less privileged positions.”

Canadians are often surprised to learn that this occurs in Canada, even though our laws uphold the principle that equitable access to care should be driven by medical need and not these other social factors. But this is also a more global problem, because in any society, people who are in less privileged positions also tend to be in worse health, so this inverse care law will exacerbate existing inequities if it prevents or delays those individuals from accessing scarce medical resources.

“The most advanced medical technologies won’t help if people don’t trust them, especially where need is greatest.”

COVID-19 shed a glaring light on these inequities, and on the need to act. “Once we start to observe patterns of inequality, especially structural inequalities, like racial inequalities, we cannot turn away and pretend like they’re merely the product of individual choices,” says Quesnel-Vallée. And these inequalities can result in barriers to care, like the stringent cold chain requirements (e.g., refrigeration at minus-70 Celsius) that precluded mRNA vaccines from being administered in many resource-poor countries (and even some locations in Canada), or indeed any vaccines requiring multiples doses when people must travel long distances to seek care.

“We see that play out even in Canada, one of the most vaccinated countries in the world,” says Quesnel-Vallée. “We’re lagging on booster shots for reasons that don’t just have to do with availability. When you must take time off work to make an appointment, that’s not very available to certain populations in more precarious employment. We need to face those barriers head on.”

Family histories and social conditions can pave the path to equity-focused research

Growing up herself in a third-generation single-mother household, and as the first woman among her relatives to have graduated from university, Quesnel-Vallée has a deeply personal understanding of how societal conditions shape the “choice sets” that are available to individuals. “My grandmother and mother often told me that they would have wanted to pursue further studies, but they had to start working straight out of high school to help their mothers financially. In my grand-mother’s case, it struck me as even more inequitable, because the salary she brought in paid for her brothers to go to university,” she recalls.

“That means that I never took for granted my university education, because I also had to help my mother financially and pay for my tuition. But thanks to the immense privilege I had of growing up in a province that has made important steps towards greater equity, like free post-secondary (CEGEP) education, highly subsidized university education, and staunch support for gender equity, to name only a few, I was still able to do it,” she says.

Her studies in sociology gave her the tools she needed to understand these structural forces, and she transmits these insights to her undergraduate students. A key pedagogical goal of hers is to help them realize that their individual choices occur within constrained “choice sets” that are largely determined by their social contexts, the norms they have internalised based on their social position and associated expectations. This is particularly important in population health because those in more privileged positions can be quick to associate so-called “poor” health behaviours with individual failures, while neglecting to consider the social conditions in which they occur.

This experience gave Quesnel-Vallée an acute sense of empathy for underrepresented populations in universities, and for underserved populations more generally. “I think that if everybody had a little bit more self-awareness about how our structural positions shape our perspectives, we would have much more compassion for others and the choices they’re making within their constrained choice sets,” she adds.

Building bridges from academia to decision-makers

“A silver lining of being a first-generation university graduate is that I hadn’t been socialised to the “rules” of university life, so that led me to push some boundaries that I didn’t even know existed. For instance, in my PhD thesis in sociology, I drew heavily on social epidemiological work because it was pertinent to my question. And that worked, because not only did I win the American Sociological Association Dissertation, but I got this amazing job at McGill with a joint appointment in Sociology and Epidemiology!” she enthuses.

Quesnel-Vallée says we need to address growing social inequalities and fractions in a systemic way in universities, and rethink how we do things. “We cannot continue in silos where the scientists are in their wet labs, developing the best product, the best medical science, while social scientists and legal scholars are out in the field. We need to bring historically underserved populations in from the start to improve their trust in science and medicine,” she says, adding that education is one of the best places to start to embed principles of equity, diversity and inclusion into research and innovation in the health sector.

Quesnel-Vallée is doing her part in driving pedagogical innovation by running a cutting-edge training program developed in partnership with decision-makers in private, non-profit, and governmental organizations. This program, the Consortium on Analytics for Data-Driven Decision Making (CAnD3), is designed to respond to the demand for data science and applied research skills in population research among these partners, which increases the employment opportunities of our graduates and improves the capacity in these organizations to conduct evidence-informed decision making. “At CAnD3, we both teach equity, diversity and inclusion (EDI) principles, and we live by them in our hiring and recruitment, and I just know that this will result in the most sustainable impact,” she adds.

Quesnel-Vallée is proud that McGill is a leader in bridging the world of social sciences and humanities with the biomedical side. “Usually, we bring these populations together once things are through the pipeline and ready to go to market,” she says, adding that bringing underserved populations in contact and collaboration with researchers and decision-makers throughout the process will lead to better input and outcomes. “The most advanced medical technologies won’t help if people don’t trust them, especially where need is greatest.”