As an undergraduate student at Universit茅 de Montr茅al, Professor Am茅lie Quesnel-Vall茅e 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.
鈥淭he inverse care law aptly captures the inequity risks that societies face when developing new medications and technologies,鈥� says Quesnel-Vall茅e. 鈥淓ssentially, it means that people with higher incomes, more power, and societal connections are better positioned to access care the fastest 鈥� and that they tend to do so, even though on average, they don鈥檛 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.
鈥淭he most advanced medical technologies won鈥檛 help if people don鈥檛 trust them, especially where need is greatest.鈥�
COVID-19 shed a glaring light on these inequities, and on the need to act. 鈥淥nce 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,鈥� says Quesnel-Vall茅e. 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.
鈥淲e see that play out even in Canada, one of the most vaccinated countries in the world,鈥� says Quesnel-Vall茅e. 鈥淲e'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.鈥�
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-Vall茅e has a deeply personal understanding of how societal conditions shape the 鈥渃hoice sets鈥� that are available to individuals. 鈥淢y 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鈥檚 case, it struck me as even more inequitable, because the salary she brought in paid for her brothers to go to university,鈥� she recalls.
鈥淭hat 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,鈥� 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 鈥渃hoice sets鈥� 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 鈥減oor鈥� health behaviours with individual failures, while neglecting to consider the social conditions in which they occur.
This experience gave Quesnel-Vall茅e an acute sense of empathy for underrepresented populations in universities, and for underserved populations more generally. 鈥淚 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,鈥� she adds.
Building bridges from academia to decision-makers
鈥淎 silver lining of being a first-generation university graduate is that I hadn鈥檛 been socialised to the 鈥渞ules鈥� of university life, so that led me to push some boundaries that I didn鈥檛 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 黑料不打烊 with a joint appointment in Sociology and Epidemiology!鈥� she enthuses.
Quesnel-Vall茅e says we need to address growing social inequalities and fractions in a systemic way in universities, and rethink how we do things. 鈥淲e 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,鈥� 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-Vall茅e 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. 鈥淎t 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,鈥� she adds.
Quesnel-Vall茅e is proud that 黑料不打烊 is a leader in bridging the world of social sciences and humanities with the biomedical side. 鈥淯sually, we bring these populations together once things are through the pipeline and ready to go to market,鈥� 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. 鈥淭he most advanced medical technologies won鈥檛 help if people don鈥檛 trust them, especially where need is greatest.鈥�
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