Wealth begets health: Why universal medical care only goes so far
TheGlobeandMail.com – news/national/our time to lead
Nov. 12 2013. André Picard – Public Health Reporter, Montreal
Canada is at a crossroads. A gap has grown between the middle class and the wealthy. Now, that divide is threatening to erode a cherished Canadian value: equality of opportunity for all. This article is part of The Globe’s Wealth Paradox series, a two-week examination into how the wealth divide is shaping Canada’s cities, schools, social programs – and even its national sport.
Every two weeks, Virginie Ralamboarisoa visits her local community health clinic, where she gets a prenatal checkup from a nurse and chats with the nutritionist.
Then, the 22-year-old receives her regular “prescription” – coupons for free milk, eggs, orange juice and vitamins.
Ms. Ralamboarisoa, an engineering student who recently dropped out of university for lack of funds, estimates the coupons save her about $60 a month in groceries and keep her from relying on food banks, where the offerings are less nutritious. “I don’t know how I would have a healthy baby without OLO,” she says.
OLO is the French acronym for oeuf-lait-orange (eggs, milk, oranges), a long-standing charitable initiative to ensure that low-income mothers-to-be in Quebec get adequate nutrition. The program is meant to bridge a gap in Canada’s much-envied universal health care system – while prenatal medical care is readily available, mothers-to-be with low income often can’t afford nutritious food to help their babies reach healthy birth weights.
A devilishly simple initiative, it has helped reduce the number of low-birth weight babies by half in the low-income neighbourhoods where it operates. About 13,000 of the 88,000 children born in Quebec each year are OLO babies.
Universal health care has long been identified as one of the reasons the effects of income inequality are not seen as vividly in Canada as in countries such as the United States. While it has done much to improve outcomes – Canada enjoys one of the highest life expectancies at birth – experts say that medicare is only part of the answer, because medical care is only part of the overall health picture.
As income inequality rises, people of lower and middle incomes are getting squeezed. That has implications for our health system: Low-income earners are less likely to have a family doctor or receive early treatment for health problems, even though care is available.
Their poorer health takes a toll on the economy through lost productivity, and adds costs to an already overburdened health-care system. One study estimates that if those in the bottom 20 per cent of income earned as much as those one step higher on the income ladder, the savings to the health system would be $7.6-billion a year.
The figure suggests that if income inequality continues to rise, health-care systems will feel the financial pressure – at a time when governments around the country are trying to rein in the growth in health spending to eliminate fiscal deficits.
“The biggest health problem in Canada is not heart disease or cancer or mental health, it’s inequality,” health policy analyst Steven Lewis said last week in a keynote address to the Family Medicine Forum, the biggest meeting of doctors in the country.
Virtually every measure of population health – from child mortality to rates of cancer, cardiovascular disease and traumatic injury – is worse in poor areas than in wealthier ones.
Canadians with an income of $15,000 or less have three times the risk of developing diabetes than those who earn more than $80,000.
Similarly, the risk of dying of cancer within five years of diagnosis is 47 per cent higher in the low-income group than the high-income one.
It is not simply a question of the poor and everyone else. Health tends to increase all the way up the income scale. People living in poor neighbourhoods have a 37 per cent greater risk of suffering a heart attack than those in wealthier areas. But those in middle-income neighbourhoods have a 21 per cent great risk than residents of the richest areas. Most health problems follow a similar gradient.
And what is notable is that, in all these cases, people receive similar medical treatment in all income groups – so it is not access to health care that is the issue, but rather the underlying causes of disease.
Research published in the Canadian Journal of Public Health shows that, over the last several decades, the health outcomes of mothers and children have improved, but the disparities between rich and poor have remained. Consider that, compared with the highest income group, in the lowest income group the rate of stillbirths is 24 per cent higher, the infant mortality rate is 58 per cent higher and cases of sudden infant death syndrome are 83 per cent higher.
Children born to low-income parents are twice as likely to end up in special education classes and three times as likely to suffer mental health problems than those in the highest income group. They’re also twice as likely to drop out before completing high school.
The same disparities exist in life expectancy. Statistics Canada found, for example, that at age 25, life expectancy varies between the highest and lowest income groups by 7.1 years for men and 4.9 years for women.
“We know that poverty … is bad for health,” says Élise Boyer, director-general of Fondation OLO, the charity that has overseen the maternal nutrition program since 1991. “That’s especially true before birth so we try to level the playing field a bit for at-risk children.”
Just as important as the healthy food it provides, the program draws pregnant women to services and pulls them out of the social isolation that goes hand-in-hand with poverty, so smoking rates fall, and do cases of postpartum depression, while breastfeeding rates increase. But Ms. Boyer is the first to concede that: “Helping pregnant women and their babies is not enough. It’s just one link in the chain.”
Others are looking at broader measures to try to mitigate the impact of inequality on health. In a recent report entitled Social Inequalities In Health, Dr. Richard Lessard, director of Montreal Health and Social Services Agency, proposed a number of steps, starting with hiking the income of the poorest in society using social programs and tax measures. Encouraging active transportation, such as walking, biking and using transit, affordable housing, better access to daycare and supporting community groups and grassroots programs like OLO – especially those aimed at children – were also highlighted.
Physiologically, the damage done by poverty – absolute and relative – is believed to be caused principally by stress, which can affect brain development, cause heart damage, and can even alter DNA.
Dr. Gary Bloch, a member of the Ontario College of Family Physicians’ committee on poverty and health, says low income is an independent risk factor for poor health, one that has as great an impact as smoking. By some estimates, if poverty was listed as a cause of death, it would be the second-biggest killer in Canada after cancer.
Some of the best-known research on inequality was done by Sir Michael Marmot, a professor at University College in London. He tracked civil servants in the U.K. and found that mortality rates correlated perfectly with social status and income – in other words, the lowest paid died much younger. (Later he also headed a blue ribbon international commission on the social determinants of health for the World Health Organization, which examined the impact of inequality on health on a global scale.)
Michael Wolfson, the former assistant chief statistician who now holds the Canada research chair in population health modelling, found the same results in this country’s civil servants, but also asked a key question: “Why do socioeconomic status gradients in health persist in a society with apparently equal access to medical care?”
The answer was pretty straightforward: Medical care does not have nearly the impact on our health as we tend to think.
In fact, many researchers estimate that medical care accounts for only 25 per cent of health outcomes, while another 25 per cent is related to genetics and fully 50 per cent depends on the socioeconomic determinants of health like income, education, housing, physical environment and community engagement.
Ms. Ralamboarisoa, for her part, knows that her financial situation will have a real impact on her child. “I’m hoping that this is temporary, that we can get back on our feet so the baby can have a good life. But sometimes people just need a little help.”
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