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Diagnosis: poverty

Being poor can actually shorten your life. A new tool is helping doctors query patients about their physical and financial health.

By Susan Peters

Eating at a soup kitchen sometimes lands Shelley Sauvé in the hospital. “I’m anaphylactically allergic to garlic. And sometimes at soup kitchens they have no idea what’s in their food. Sometimes it’s like: Do I eat, and take a chance to end up in hospital where at least they sort of feed me, or do I starve?” says the 42-year-old Winnipegger, only half-joking.

Sauvé is a single mother currently on Employment Insurance. She’s applying for jobs as an educational assistant and works as a substitute teacher. Balancing childcare, job hunting and health problems like her food allergies, asthma, post-traumatic stress disorder and the effects of an old head injury create “lots of stress, all the time,” she says. She knows that a steady job with a good income would improve her health: she’d have enough cash to buy groceries and thereby cut the risk of triggering her allergies in soup kitchens. She’d also have to worry less about the cost of using her anti-allergy EpiPen.

Most health-care providers know from experience that poverty exacts a toll on health. But only recently have provinces begun to encourage doctors to consider their patients’ financial state as a routine part of assessing their overall physical condition. Hospitals, health districts and provinces are developing poverty tools to help doctors diagnose patients more thoroughly and to prescribe non-medical measures that might help alleviate some of the health effects of poverty. Across-the-board buy-in from the medical community and provincial health authorities could significantly reduce high rates of illness and premature death among the economically disadvantaged — and lessen the burden of poverty on the health-care system.

Sauvé’s doctor is ahead of the curve: he already asks if Sauvé has filed her taxes so she can qualify for assistance such as the GST credit and Child Tax Benefits. With the Manitoba Poverty Tool — a 20-page booklet with information on how poverty can be a risk factor in disease, as well as services available to low-income residents, now being distributed to doctors across the province — it’s possible future visits will include conversations about drug benefits, income supports or job-seeker allowances, as well as the usual checks of her blood pressure and heart rate.

The link between income and health is well established. A 1991 study showed that if everyone in Canada lived in a higher-income neighbourhood, men, on average, could expect to live 3.8 years longer than they currently do. By contrast, eliminating cancer would only increase life expectancy by 2.8 years. Men in low-income neighbourhoods die 11.3 years sooner than their counterparts in the better-off parts of town.

Other studies show how much health and income interact on a continuum: the wealthier you are, the healthier you are; conversely, the poorer you are, the sicker you will be. The district health unit in Sudbury, Ont., found the rate of emergency department visits for mental health episodes was 4.4 times higher in the city’s most deprived areas. A Saskatoon report on health disparities found residents of low-income neighbourhoods were four and a half times more likely to have an infant die in its first year. In Hamilton, a 2010 comparison of health indicators in the highest- and lowest-income neighbourhoods found a 21-year difference in life expectancy.

In Winnipeg, residents of the city’s wealthiest areas tended to live 18 years longer than residents living in the poorest areas.

In my hometown of Winnipeg, a 2015 report tracking health and social indicators such as teen births, heart attacks, strokes and diabetes found that residents of the city’s wealthiest areas tended to live 18 years longer than residents living in the poorest areas. When I mention this to Rina and Andrew Hermkens, they just shrug, as if to say I’m not telling them anything they don’t already know.

During an interview, they tell me their life stories, which include being homeless and addicted to crack cocaine. Rina, 47, has Hepatitis C, anxiety and PTSD; Andrew, 51, has survived seven heart attacks, a broken back twice and lupus. The couple now rent a house with Rina’s mother, but in the past they’ve lived in rough rooming houses in some of Winnipeg’s poorest neighbourhoods. They know how poverty takes a toll on health and life expectancy, and describe it in a back-and-forth exchange.

Andrew: “Stress is the number one reason for death. Suicide. Self-destruction. Depression. Isolating yourself.”

Rina: “Even getting a good night’s sleep.”

Andrew: “I mean, how do you sleep in a place all full of bedbugs?”

Rina: “Yeah, and the lady screaming next door.”

Andrew: “Doors are slamming. People coming over. Bang. Bang. Bang. ‘Uh, can I borrow your lighter for a minute?’ Because they ran out of their lighters for smoking drugs. Of course [better-off Winnipeggers] live longer. They don’t have to walk as far, either. They can afford cars.”

Rina: “We can’t even afford bus fare sometimes.”

Fortunately, both Rina and Andrew found good family doctors who understood their addictions; the Hermkens have done their part, too, putting in time, effort and honesty to build solid relationships with their doctors. They both collect disability benefits and say it’s important that doctors understand how to navigate the social programs that may be available for their patients.

“I’m status. Treaty,” says Rina: as a card-carrying status Indian, she qualifies for some special health benefits. “My doctor knows that, so we talk about, ‘Okay, your legs are sore, I’ll prescribe you a brace.’” Their physicians set longer-than-usual appointments to talk about a wider-than-normal range of issues. At a point in Andrew’s life when he couldn’t manage to attend meetings scheduled in advance, his physician simply told him to show up without an appointment.

The idea that poverty is a health risk is gaining traction in some key sectors, including the College of Family Physicians Canada and the Canadian Medical Association. Medical students at the University of Toronto and the University of Manitoba now learn about poverty tools in their course work.

Poverty tools are already in use in several Canadian jurisdictions beyond Manitoba, including British Columbia, Alberta, Ontario and Nova Scotia. A six-page handout developed for British Columbia’s Kootenay Region in 2014 ranks poverty as a health-risk factor along with more traditional conditions such as hypertension, high cholesterol and smoking, and describes how this might play out in the examination room. If, for example, a healthy 35-year-old presents no standard diabetes risk factors but lives in poverty, the physician might order a diabetes screening test anyway. It goes on to link poverty with a higher risk of cancer, cardiovascular disease, mental illness, asthma, infant mortality and low birth weight.

Poverty tools also recognize that reducing the health risks of poverty often requires non-medical interventions. Most versions offer information on resources to which physicians can direct their patients — for example, rent-supplement programs for seniors or referrals to low-cost dental clinics or addiction treatment services.

In provinces where poverty tools have not yet been developed, the philosophy behind them already enjoys considerable support in the medical community. “I’m more likely to discharge a child who’s in the hospital from an asthma flare if I know that patient is living in a well-insulated home with no mould, it’s smoke-free, there’s good childcare to watch if the patient has more problems and they can afford their prescriptions,” says Dr. Sarah Gander, a pediatrician at Saint John Regional Hospital in New Brunswick. “Otherwise I might keep the patient in hospital for a few days longer or see them back more frequently. If the trigger for asthma is mould, the child might need better housing.” Gander has been meeting with provincial officials to explain why New Brunswick should adopt a poverty tool. With preliminary approval, the next step would be continuing education for doctors in the province.

Manitoba’s version of the poverty tool, called “Get Your Benefits,” is presented at a December 2015 meeting of Manitoba anti-poverty activists held at the Winnipeg Harvest Food Bank. Noralou Roos, a University of Manitoba professor who specializes in public health, tells the group about working with organizations such as the United Way to list resources like homeless shelters in three Manitoba cities. The tool is already being given to high school guidance counsellors, Roos says. “Now I’ll turn it around and ask you. How can we distribute this widely?” Sitting patiently on black metal folding chairs, the audience offers suggestions: give copies to nurses, pharmacists, social workers at libraries, public housing buildings with health centres. A college instructor volunteers her community planning students to work on the project. Someone suggests commerce students can do taxes. One member of the audience worries that the tool is “hard to understand. You need a point person at every food bank to explain and advocate for the tool.” Another person in the audience retorts: “As a low-income person, I’m insulted that people think this will be hard to understand. Just get the info out there.”

Poverty tools are not without their critics — even among the poor. Iris Yudai, for one, doesn’t want her doctor asking about her finances. The 70-year-old retired Winnipegger has a limited income from CPP, OAS and GIS, but she has always managed her money well. “It’s none of their business how much money I make,” the widow says. Yudai doesn’t think more money would automatically improve her health, but admits that matching the cost of deductibles for the medication she needs to her income bracket would make a difference.

Effectively treating the health consequences of poverty requires more than a pamphlet. To do it properly, already cash-strapped health-care systems may have to fund a range of new programs and jobs.

Another problem: effectively treating the health consequences of poverty requires more than a pamphlet. To do it properly, already cash-strapped health-care systems may have to fund a range of new programs and jobs. Consider the approach taken by the family medicine department at St. Michael’s Hospital in Toronto. In 2013, the hospital hired two health promoters with experience in social work and financial empowerment, a lawyer and a children’s literacy staffer. Not every hospital has the resources to tackle the issue on this scale. St. Michael’s does and also has the research capacity to evaluate outcomes. The data on what works (and what doesn’t) can be expected in three years.

The first program of its kind in Canada, the effort is spearheaded by family physician Dr. Gary Bloch, a long-time anti-poverty activist who developed Canada’s first poverty tool. He believes most doctors want to help their low-income patients, but getting them to flex their collective muscle to push for changes that would enshrine poverty as a medical issue may take some persuading. “I think until you have doctors truly on board, you won’t really get the system to shift,” says Bloch.

For now, the poverty tool is an idea that’s spreading slowly, province by province, one hospital, one clinic, one examination room at a time.

In Nelson, B.C., family physician Dr. Lee MacKay has been using a poverty tool with patients for a year and a half. As a specialist in diabetes, he tells patients about the impact of stress on the disease and asks if they can afford their medications and treatments. “Ideally things like proper housing and nutrition shouldn’t necessarily be the purview of the family doctor,” he observes. “[But] we are the people who end up dealing with everything that has an impact on our patients’ lives.”

In addition to queries about their diet, exercise and family history, his patients increasingly hear this question: “Do you ever have trouble making ends meet at the end of the month?”

Susan Peters is a journalist in Winnipeg.

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(Photo: cuatrok77/Flickr via Creative Commons)

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