An irrefutable evidence base demonstrates that socioeconomic conditions—in particular poverty and inequality—impact health. In health care we call these conditions ‘social determinants of health’ (SDOH)—a term that describes the downstream health impacts of multiple forms of systemic inequity.
In the context of a society, culture and health system that focus on the individual, it is critical to recognize that these problems are systemic in nature. These conditions are thus sometimes called ‘structural violence,’ and include:
- Ongoing colonization and perpetuation of systems breeding powerlessness,
- Rising income inequality,
- Lack of affordable housing,
- Exploitative labour markets,
- Punitive and stigmatizing social welfare and disability support systems,
- And more.
Socioeconomic problems such as these do not belong to the individual patients that bear the burden on their health. Nor do systemic problems respond to outdated prescriptions of personalized lifestyle interventions—which falsely presume the individual, with enough vigour, can overcome systemic oppression. Rather, systemic inequities and poverty funnel steeply downstream into the publicly funded health care system where the most vulnerable can land, and where we observe the health impacts of poverty.
In the last decade, progressive thinkers in Canadian health care have been increasingly asking the question: How can we address poverty-related needs of people accessing health care services?
Upstream and systemic conditions will simply not be addressed by downstream investment in biomedical services. Among peer countries, Canada ranks last in social spending relative to health care spending, which drives up health care costs. Neglecting increasing poverty and inequality is a recipe for unsustainable health care—an unfortunate outcome that is often spun into an argument for a two-tiered system.
We are overdue to look squarely at the SDOH and what we can do in health care. Inspired by a public policy discussion on basic income hosted by the BC Alliance for Healthy Living earlier this month, I offer three important considerations:
1. Degrading human dignity impacts health
The economic argument for poverty reduction is clear, but we see in health care what is more plainly obvious and compelling: the argument for human dignity. The deeply colonial, broken and inaccessible “poverty policing” that occurs in the current welfare and disability support systems have negative health impacts. Various papers and reports describe the impact of discriminatory systems, which for too long have perpetuated the shameful trend of labeling the poor and marginalized as undeserving. I invite anyone who believes that any person is undeserving of food, housing, or opportunity to thrive and contribute to contact me for a conversation: let’s talk.
Systemic inequities and poverty funnel steeply downstream into the publicly funded health care system.
Primary care clinics in several provinces in Canada have built capacity to address poverty and SDOH head-on when patients come to the doctor’s office, and we should be doing the same in BC. At the St. Michael’s health team in Toronto, the primary care team has hired an income security promoter—who connects patients to income and social programs to address SDOH—and is studying its impact. In BC, on the other hand, we rely primarily on few social workers in the system or exceptional community initiatives like the RICHER Social Pediatrics program, or a resource connection program co-developed by PainBC and Basics for Health Society, two provincial non-profit organizations. Adequate patient support to meet SDOH needs must not be the exception; support for patients to meet basic needs must happen within, not outside of BC’s health care system.
As a family doctor, I’m very aware that there is only so much that medical care can do to help a person who can’t afford basic needs to survive. We need support for patients to meet their basic needs; ignoring this need and letting doctors dance around it is costly—and, undeniably, it is not patient-centred.
2. Poverty interventions are ACE interventions
Disability, mental illness and experiences of adversity in childhood and throughout life, are ubiquitous in populations suffering from poverty, isolation and homelessness. For those who need a diagnosis in order to act, this is a clear call to action from the health sector.
In November of 2017 at the BC Summit on Adverse Childhood Experiences (ACEs), health professionals were motivated by the mountain of evidence describing ACEs as risk factors for poor health. Researchers developed a questionnaire in which ACEs could be known and measured; making a social problem measurable was a great mobilizing force. However, several astute ‘people with lived experience’ and concerned conference attendees asked: How does it help to label people “at-risk” based on their experience of adversity? What will you do to intervene and support their resilience?
Educators and advocates have explained how trauma—adverse childhood experiences included—are about a person experiencing unsafe, overwhelming and isolating experiences. Ongoing structural violence perpetuates this pattern. Therefore, efforts to provide present-time safety are the most critical intervention.
Put simply, healing cannot happen and safety cannot be experienced if a person cannot meet their basic needs for food, shelter and belonging. ACE interventions are, quite simply, poverty interventions.
3. Universal programs are an important foundation
At the BCHLA policy discussion, we learned about Ontario’s Basic Income pilot project, which will study the impact of more predictable and respectful income support for people living in poverty (Note: the income top-up is set at 75% of the poverty line, so this is not a study of the impact of a truly adequate livable income).
At the poverty line (or 75% of it, or even 200% of it for that matter), many services remain unaffordable for most people; consider housing, medication and childcare costs to put that in perspective. A basic or guaranteed income, implemented as soon as possible, would be a critical correction to begin to dismantle the discriminatory, punitive and broken social welfare system in BC. However it is only one step towards poverty reduction.
A fair income program must not allow governments off the hook for, or take the place of, other universal programs that patients depend on for their health (pharmacare, primary care and mental health), for their families (child care, elder and caregiver support, and housing), and for belonging (community and cultural programs, and so much more). If we dare look beyond a four-year political term, these public programs are cost-saving and economy-boosting measures. Further progressive policy (such as fair taxation and increasing private sector accountability for social and environmental externalities) can also help with this.
Put simply, healing cannot happen and safety cannot be experienced if a person cannot meet their basic needs for food, shelter and belonging.
Support for people marginalized by current policies of oppression and colonization must include person-to-person support. People must be seen, heard and respected. Systemic change—including essential public services and basic income support—must provide the foundation for this support so that people can live with dignity, rather than systemically endorsed shame and isolation.
We can build on the foundations of creating a more efficient welfare system, and build on the momentum to address ACEs. But our first step should be a guaranteed or basic income in BC, implemented immediately, to replace the thoroughly broken welfare system that yields ongoing daily discrimination and harm. No economic argument should eclipse the health and human benefits of such a program.
We must not shy away from ambitious policy in BC that will promote human dignity. These are the building blocks of a healthy society, and we all stand to benefit.