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Poverty is at root of heart disease

Dennis Raphael - SPECIAL TO THE STAR

Based on what we see, hear, and read in the media, the causes of heart
disease are biomedical imbalances in our body caused by faulty lifestyle
choices. This message is reinforced by the pamphlets we receive from
health-related organizations and theresearch funding announcements
made by government agencies.

The "it's your own fault" message about the causes of heart disease is still
being
given despite the rapidly growing body of research that finds that the economic
and social conditions under which people live are the major factors determining
whether they fall prey to heart disease. And it is these precursors of heart
disease,
such as living on low income, lack of shelter and food and shortage of health
and
social services that are showing ominous increases among Canadians.

More specifically, many large-scale studies find medical and lifestyle factors
account for small amounts of variation in the incidence of heart disease as
compared to income level. Heart disease is the ailment most associated with low
income among Canadians and several extensive follow-up studies show that heart
disease is reliably predicted from adverse childhood circumstances regardless of
one's life income status in adulthood.

When these findings are combined with the studies that show the minimal
success of lifestyle changes in reducing the risk of heart disease among those
most at risk, one must seriously question the entire approach toward reducing
the
illness.

The most recent estimates are that 23 per cent of all years of life lost prior
to age
75 in Canada can be attributed to income differences and the greatest proportion
of these years lost are caused by heart disease. Were all Canadians' rates of
death
from cardiovascular disease equal to those living in the wealthiest quintile of
neighbourhoods, there would be more than 6,000 fewer deaths each year from
heart disease.

In Ontario, the Institute for Clinical Evaluative Sciences tracked
hospitalization
rates for heart attack, congestive heart failure, angina, and chest pains in
Ontario
from 1992/93 until 1996/1997. The place of residence for each patient was used
to identify them as being from neighbourhoods that were ranked from highest to
lowest in income. The hospitalization rates for the lowest income neighbourhoods
were 69 per cent higher for heart attacks, 65 per cent higher for congestive
heart
failure, 97 per cent higher for angina, and 121 per cent higher for chest pain
than
those in the highest income of Ontario neighbourhoods.

At the same time as media and health organizations continue to focus on
biomedical and lifestyle risk factors for heart disease, there is documentation
of
the increasing numbers of Canadians being moved into low-income status and the
weakening of the social safety net. As of 1991, Canadians enjoyed remarkably
lower heart disease and total death rates than our neighbours to the south. Our
poverty rates were also much lower than our American neighbours and Canada
was in the mid-level of nations in the percentage of tax revenues allocated to
spending on the social safety net, an important determinant of heart health for
all
individuals, but especially those living on low incomes.

But since 1991, income inequality has increased in Canada and a move toward
reduced spending on services has occurred simultaneously with an increase in
numbers of Canadians living on low incomes. And living on low incomes has
severe consequences for people. Besides suffering actual material deprivation,
there are psychological costs associated with not having sufficient income on
which to live.

Living on low income creates uncertainty, insecurity and feelings of lack of
control over one's life - these are all conditions that have powerful effects on
health. The National Population Health Survey found that among Canadians in the
lower third of the income distribution, 47 per cent reported seeing the world as
meaningless, events as incomprehensible and life's challenges as unmanageable.
The comparable figure for the highest third income group was 26 per cent.
Similarly, people in the lower-income group were also 2.6 times more likely to
have a low sense of control over their lives than the higher income third of
Canadians (31 per cent vs. 12 per cent).

Since the research literature indicates that societal features such as the
number of
people living on low income and lack of services are the greatest influences
upon
the heart health of the population, three questions must be asked. Why is it
that
the Canadian media and health institutions are so neglectful of these
influences?
What will it take to shift attention to the factors that either support heart
health or
lead to heart disease? Are we prepared to live with the health consequences of
subjecting so many of our neighbours to health-threatening living conditions?

Dennis Raphael is an associate professor at the School of Health Policy and
Management, Atkinson Faculty of Liberal and Professional Studies, York
University.

This material is taken from the report "Inequality is bad for our hearts: why
low income
and social exclusion are major causes of heart disease in Canada" which will be
released
September 20. It will be available at http://www.yorku.ca/wellness/heart.pdf.