This may be of interest. It will be published in Canadian Family Physician.
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Canadian Family Physician, in press
Increasing Poverty Threatens the Health of All Canadians
Dennis Raphael, Ph.D.
Department of Public Health Sciences
University of Toronto, Toronto Canada
Correspondence to: Dr. Dennis Raphael, Department of Public Health
Sciences, University of Toronto, McMurrich Building, Toronto, Ontario, M5S
1A8. Tel: (416) 978-7567; fax: (416) 978-2087); e-mail: [log in to unmask]
Increasing Poverty Threatens the Health of All Canadians
It is one of the greatest of contemporary social injustices that
people who live in the most disadvantaged circumstances have
more illnesses, more disability and shorter lives than those who
are more affluent (1, p.1).
The profound improvements in Canadians' health the past century
are primarily due to advances in living conditions and physical and social
environments. Improved health care also played a small (estimated at 10%)
but important role. Yet, wide disparities in health continue to exist among
Canadians and these persist independent of access to health care.(2)
Lifestyle choices do not explain disparities in health. Lifestyle
issues such as tobacco and alcohol use, body mass index, and activity
account for a rather small proportion of variation in mortality rates. The
factors that actually account for most of the variation in health are called
social determinants of health.(3)
Health Canada outlines income and social status, social support
networks, education, employment and working conditions, and physical and
social environments as social determinants of health. This editorial focuses
upon the health effects of poverty; a situation that profoundly affects the
presence and quality of many of these health determinants.(4)
Poverty and Its Effects on Health
In this paper, level of poverty is defined as the percentage of
Canadians living with pre-tax incomes below the Low Income Cut-Offs
established by Statistics Canada. These cut-offs -- based on family and
community size -- identify individuals living in "straitened circumstances."
Poverty is lacking the material resources that allow meaningful participation
in society rather than having enough to merely survive.(5) By 1996, the
Canadian poverty rate rose to 18% and the children's rate reached a 17-year
peak of 21%. The wealthiest Canadian province, Ontario, experienced
increases in children's rate from 11% in 1989 to 20% in 1996 and Toronto now
has 38% of its children living below these cut-offs. Latest figures indicate a
slight improvement in national and provincial poverty rates.(6)
Canadians, Britons, and Americans in the lowest income groups
have higher incidences of a range of diseases and likelihood of death from
illness or injury at every age.(7) Poor children in Canada show higher
incidence of illness and death, hospital stays, and injuries, and lower levels
of mental health and school achievement.(8) It is conservatively estimated
that 22% of premature years of life lost in Canada can be attributed to income
differences; a value close to the impact of heart disease or cancers.(9)
How Does Poverty Affect the Health of Canadians?
Poverty prevents people from achieving the prerequisites for
health, such as shelter, food, warmth, and the ability to participate in society.
Living in poverty also causes anxiety and stress associated with uncertainty
that can damage people's health. And lack of income precludes people from
making the kinds of behavioural choices that support health.(1)
Poverty provides individuals with material and social insults that
accumulate over the life course. Periods during which people's health are
especially vulnerable to these disadvantages include fetal development,
nutritional growth and health in childhood, entering the labour market, job
loss or insecurity, and episodes of illness.(10) Those in poverty also
experience lack of control over life circumstances, a factor that predicts
illness, and experience distress over their lack of material resources.(11)
The Widening Gap Study
A recent British study defined the parameters of how poverty
influences health.(12) Using premature mortality rates (death prior to age 65)
the 15 "worst health" and 13 "best health" constituencies in Britain were
identified. The one million in the worst health areas had a 2.6 greater
mortality ratio than those in the best health areas. Health differences were
seen as resulting from an accumulation of material disadvantages reflecting
differing economic and social life circumstances. Striking differences among
health areas existed in rates of infant mortality, school failure, post-school
qualifications, unemployment, disability, and long-term illness. A key finding
was that magnitude of health inequalities increased over time in response to
increasing income disparities. Health differences systematically widened in
Britain -- paralleling increases in income inequality -- over 20 years of
Conservative party rule.
Findings that "Childhood and adult social circumstances make
independent contributions to the risk of dying" indicate that the health
consequences of children and families living in poverty will be manifest for
the entire next generation in Britain.(13, p.142) To extrapolate, the magnitude
of Canadian increases in child and family poverty pose significant population
health risks and threaten the viability of the health care system.
Social Safety Nets Weaken as Poverty Increases
Increasing poverty occurs in conjunction with the reduction of social
safety nets. In Canada, government policies of reducing program spending,
decreasing eligibility for benefits, and reducing amount of benefits, served to
both increase incidence of poverty and remove the means by which those in
poverty sustain themselves.
Canada has been in the mid-levels of nations in spending on the
social safety net; an important determinant of health for all individuals, but
especially the poor. Canada's move towards reduced spending on services
and supports occurred simultaneously with the increase in levels of
poverty.(14)
Poverty Effects Spill-Over to the Whole Population
The British Medical Journal (BMJ) editorializes: "What matters in
determining mortality and health in a society is less the overall wealth of that
society and more how evenly wealth is distributed. The more equally wealth
is distributed the better the health of that society."(15) Societies with greater
incidence of poverty show higher mortality rates across the entire population.
For example, after decades of rapidly increasing economic inequality, the
most well-off in Britain now have higher adult male and infant mortality rates
than the least well-off in Sweden.(16) Also, the well-off in economically
unequal American communities have more health problems than the well-off
in relatively equal communities.(17) This spill-over effect is due to the
weakening of social infrastructure and declines in social cohesion and civic
commitment.
Canadian mortality rates in 1991 were strikingly lower than the USA
as was degree of income inequality.(18) But inequality and poverty is
increasing in Canada. Table 1 shows the cumulative effects of varying social
policy orientations on population health by illustrating where Canada falls on
a number of health determinants and outcomes as compared to a nation with
a market (USA) or welfare state (Sweden) orientation.(19-21)
insert table 1 about here
Physicians' Responses to Poverty
The BMJ editorialized: "Doctors fought nuclear weapons, now they
can fight poverty."(22) Public health practice usually limits itself to delivering
programs to those in poverty.(23) One exception is the Montreal Medical
Officer's report that stated "Inequalities in health and well-being can be
traced back to socioeconomic inequalities, that is to the harsh living
conditions which marginalize so many of our fellow citizens, not only limiting
their access to essential goods, but depriving them as well of any meaningful
role in social life."(24, p.60)
In 1995 the CMA Board of Directors stated "Governments should
give high priority to public policies that take account of the broad range of
determinants of health, and proposed legislation should be routinely
reviewed for any impact on the health of individuals and the community."(25)
A number of resolutions were passed in CMA Council during the early 1990's
regarding the health effects of poverty, but follow-up with the CMA revealed
little resulted from these motions.
The Canadian Paediatric Association recently called for government
action to address poverty, but also with little result: "The health problems
associated with poverty include a greater likelihood of low birth weight,
inadequate nutrition, poor school performance, injuries, disabilities, and even
death. This all contributes to increased insecurity, stress and social isolation
-- all factors that have a profound impact on the emotional health of
children."(26)
At St. Paul's and Mount Saint Joseph Hospitals in Vancouver, St.
Michael's and St. Joseph's Hospitals in Toronto, and Montreal Children's
Hospital, family medicine has recognized the importance of poverty as a
health issue. The Ontario College of Family Physicians reported on "Access
to Health Care for the Marginalized: A Challenge for Family Medicine" and the
College of Family Physicians of Canada was involved in the "Removing
Barriers II: Keeping Canadian Values in Health Care" initiative.(27,28) These
efforts could be supplemented by family physicians and their associations
encouraging further development of inner city health care initiatives and
developing models of care that better respond to situations of poverty.
Focussing Upstream
Family physicians and their associations can also help to have
policy makers to consider how their decisions can either increase or reduce
poverty. They can encourage policy dialogue at local, provincial and national
levels on the health effects of poverty.
A range of policy options are available from Canadian and British
sources on how to address poverty. The Canadian Growing Gap report calls
for restoring funding to social and health services, assuring a fair taxation
system, and increasing financial and other supports to those in poverty.(29)
The British Acheson Inquiry has many recommendations for reducing
poverty. The main theme is monitoring the effects of government policy
decisions to assess their impacts on creating inequalities in resources
among citizens.(30)
Conclusion
In Canada, policy decisions are being made that impact the health
of the population. Empirical evidence would suggest looking to Scandinavian
and other European nations for ideas on addressing health determinants
such as poverty. Instead, our leaders seem to be looking to the USA for
answers. Are family physicians prepared to join in these policy debates?(31)
Table 1: USA, Canada, and Sweden Rankings on Various Indicators as
Compared to Other Industrialized Nations
(Ranking: 1 is most positive rating)
Measure Canada USA Sweden
Income Inequality (1992) 11 of 18 18 3
Child Poverty (1996) 17 of 23 22 1
Elderly Poverty (1990) 4 of 17 15 5
Wages (1996) 15 of 23 13 6
Unemployment (1996) 7 of 10 2 8
High School Drop-Outs (1996) 16 of 17 17 10
Youth Suicide (1992-1995) 16 of 22 15 10
Youth Homicide (1992-1995) 19 of 22 22 5
Infant Mortality (1999) 10 of 29 17 2
Life Expectancy (1999) 3 of 50 21 3
______________________________________________________________
Sources: Various international reports (19-21).
References
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Britain by M. Shaw, D. Dorling, D. Gordon & G. Davey Smith. Social Science
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inequalities and policy in Britain. Bristol (UK): The Policy Press; 1999.
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what can be done? Bristol (UK): The Policy Press; 2000. p.141-158.
14.Hurtig M. Pay the rent or feed the kids: The tragedy and disgrace of
poverty in Canada. Toronto (ON): McClelland and Stewart; 1999.
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19.UNICEF Innocenti Research Centre. Innocenti Report Card No. 1, June
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population. Montreal (PQ): Direction De La Sante Publique; 1997. On-line at
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25.CMA Board of Directors. The role of physicians in prevention and health
promotion. Ottawa (ON): Author; July 15, 1995. On-line at
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27.The Ontario College of Family Physicians. Access to health care for the
marginalized: A challenge for family medicine. Toronto (ON): Author; 1998.
On-line at http://www.cfpc.ca/ocfp/commun/publitns.html.
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(ON): Faculty of Medicine. On-line at
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29.Yalnizyan A. The growing gap: A report on growing inequality between the
rich and poor in Canada. Toronto (ON): Centre for Social Justice; 1998.
Available at http://www.socialjustice.org.
30.Acheson, D. Independent inquiry into inequalities in health. London (UK):
Stationary Office; 1998 . On-line at http:// www.official-documents.co.uk/
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31.Raphael D. Health effects of New Right policies. Policy Options, October
2000, 57-58.
Our Web Sites have information and reports from all of our Quality of Life
Projects!
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Dennis Raphael, Ph.D.
Associate Professor
Department of Public Health Sciences
Graduate Department of Community Health
University of Toronto
McMurrich Building, Room 308
Toronto, Ontario, CANADA M5S 1A8
voice: (416) 978-7567
fax: (416) 978-2087
e-mail: [log in to unmask]
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