By W.S. Croson and D.J. McCulloch, HealthStats Inc.
Almost 50 years ago, in 1968, Canadian Prime Minister Pierre Trudeau called on Canadians to help create “A Just Society” where no one “should be entitled to superfluous or luxury goods until the essentials of life are made available to everyone” and that “those regions and groups which have not fully shared in the country’s affluence . . . be given a better opportunity.”
Pragmatically, he also recognized that “most people take it for granted that every Canadian is assured a reasonable standard of living. Unfortunately, that is not the case.”
Fifty years later the effects of income inequality are still evident. In its 2013 RHA Indicators Atlas, the Manitoba Centre for Health Policy (MCHP) at the University of Manitoba identified that:
“Residents of lower income areas have significantly higher mortality rates and higher prevalence of physical and mental illness. Their results are either not improving over time or are improving at a slower rate than for residents of higher income areas. As a result, the health gap is getting even wider.” Similar findings have been found and documented in jurisdictions across Canada for some time and have been illustrated by measures of disparity applied to health indicators data from the Canadian Institute for Health Information (CIHI).
The relationship between wealth and health has been known and documented for some time.
The World Bank states:
“Poverty is a major cause of ill health and a barrier to accessing health care when needed. This relationship is financial: the poor cannot afford to purchase those things that are needed for good health, including sufficient quantities of quality food and health care.”
Moreover, the connection between poverty, low income and poor health has been well understood by primary healthcare providers.Traditionally the focus of healthcare has been addressing downstream issues (i.e., treating health conditions that have already arisen) as opposed to addressing upstream issues (i.e., treating underlying causes before health conditions arise). This is particularly true in developed countries like Canada.
Research efforts often consider income as part of a collection of socio-economic determinants that influence health. To measure these relationships, researchers use two measures of deprivation: material and social.
Material deprivation encompasses elements such as income, employment and education. Social deprivation reflects relationships among people, such as partnership status, living arrangements (i.e. alone or otherwise), stability (i.e. length of time living in one place).
MCHP has developed what it calls a socioeconomic factor index (SEFI) to reflect social determinants of health that is closely aligned with aspects of material deprivation. In 2013 MCHP reported that between 2001 and 2006 the overall SEFI index showed increasing inequality, as did income alone and the index of material deprivation. While SEFI is a Manitoba-specific measure, efforts by other organizations such as the Public Health Association of Canada, CIHI through the Canadian Population Health Initiative, and Citizens for Public Justice indicate persistent and deepening disparities.
In 2015 as a follow-on to the Millennium Development Goals adopted through the United Nations, the Sustainable Development Goals (SDGs) set out a framework to “end poverty, protect the planet, and ensure prosperity for all,” specifically to:
- end poverty (Goal 1)
- end hunger (Goal 2)
- ensure healthy lives and promote well-being for all (Goal 3)
- promote inclusive and sustainable economic growth, employment and decent work (Goal 8)
- reduce inequality within and among countries (Goal 10).
There is an emerging sense that promoting employment and decent work (Goal 8) may be increasingly difficult in our rapidly evolving world. Economic trends across the globe, including the developed world, suggest that stable work opportunities commonly found a generation or two ago are diminishing. There are reasonable arguments that implementation of basic income would improve overall population health by compensating for precarious employment, reducing poverty and mitigating other social determinants of health.
It should also be kept in mind that poverty and low income are not the only issues to address to achieve better health. A further finding from the MCHP research indicates that despite apparent disadvantages reflected by material deprivation, there may be mitigating advantages to be derived from social cohesion, as reflected by the inverse relationship seen on the social deprivation index. This would be important to remember in relation to addressing income as a factor related to health.
As the MCHP suggests, a sense of community supports wellbeing. There is also a body of research and action that supports the provision of adequate housing as part of the equation to establish stability and well-being, especially among those in vulnerable and marginalized circumstances.,, The issues of access to information and health literacy are also important.
The renowned epidemiologist, Sir Michael Marmot, summarized his 2002 paper, “The Influence of Income on Health,” with a question: “would income redistribution matter to health?”
Relying on comments by Angus Deaton (2015 Nobel Laureate in Economics), Marmot states that “income redistribution would improve overall health by relieving the fate of the poor more than it hurt the rich.” He adds that lack of income may hinder “social participation and receipt of services”, which are heavily dependent on income. This links the dimensions of material and social deprivation identified previously. In his concluding remark, Marmot asserts:
“A policy of not redressing this [material deprivation and restriction on social participation and opportunity to exercise control over one’s life] through the tax and benefit system, linked to lack of investment in public goods that brings the benefits of richer communities to all, will damage health.”