J. GARY PERLINE DIDN’T CHOOSE TO BE SICK. He didn’t choose to be poor either. But he was. Poverty didn’t make him sick. But it did make him more likely to get sick.
The impact of poverty and other “social determinants” on our health is just one of the hidden truths Andrew McLeod sets out in his new book All Together Healthy: A Canadian Wellness Revolution. They are truths health care policy makers work hard to have us ignore.
They make it sound like good health is all up to us. It all depends on each one of us making the right personal choices. They know it is not true. They know income inequality and other social factors hugely affect—and predict—the choices we will make.
‘My life was fucked before it started’
Consider someone like J. Gary Pelerine. What real “choices” did he ever have. McLeod writes:
"The story of his life included becoming a parent while still a teenager himself, divorce, estrangement from his children, a workplace back injury, hearing loss from working on loud job sites, and a suicide attempt. It started with a childhood lived in poverty in New Glasgow in northern Nova Scotia. “I grew up shithouse poor. I mean poor,” he said, drawing out the “poor” to stress just how poor he meant.
“I used to get off the school bus sometimes, change out of my school clothes into my hunting clothes, and if there wasn’t a rabbit in one of my snares when I got home, back from my trip through the woods, there wasn’t anything on that fucking table for dinner that night, buddy.
"There were four kids in the family and he was working on a farm baling hay by the time he was fourteen. Pelerine wasn’t blaming anyone for how his life had turned out, describing it as a long run of bad luck, but he observed, 'My life was fucked before it started.'
"It’s true that many people make choices that they know are bad for their health. It’s also true that everyone comes from somewhere."
Factors none of us can control
McLeod writes that decades of evidence show that most of what determines a person’s health is beyond the individual’s control. To individualize the problem is to imply that if you are fat, diabetic or sick, it’s all your own fault.
There is abundant evidence, for example, that type two diabetes, which accounts for 90 per cent of cases, is closely tied to income. And yet the fact that the chances a person will become diabetic increase, at each step down the income ladder, is glossed over by Diabetes Canada.
In a 2015 report, the Canadian Institute for Health Information (CIHI) found that despite heavy spending on health care there was still a persistent health outcome divide between rich and poor.
Low income earners still had worse health outcomes overall including everything from mental health, to obesity, infant mortality and smoking. The reality is: not only are poorer people more likely to smoke, they are more likely to get sick from it.
Money even affects the likelihood that cancer treatment will succeed. For the wealthiest people living in Canada’s cities, there’s a 73 per cent chance they will survive five years after they are diagnosed. For the poorest, the five-year survival rate is 61 per cent.
“Put another way,” writes McLeod, “if 100 rich people and 100 poor people are diagnosed with cancer, 12 more of the poor people than the rich will be dead within five years.”
The CIHI’s report argued that major progress on health inequities was unlikely without taking a broader social approach, including boosting people’s incomes. Lower taxes and cuts to social assistance in the mid-1990s had contributed to a widening gap, it said.
Mapping life and death
McLeod points out how health levels skew widely by postal code. It’s concrete proof of the effects of social determinants of health. Simply put: rich neighbourhoods are good for your health and poor neighbourhoods aren’t. We can even map it.
There are thousands of maps online that link life expectancy to where you live. In Toronto, for example, the Toronto Community Health Profiles Partnership has an online map of Toronto neighbourhoods (2006-2008), mapped to show where inhabitants tend to live longer than others.
Factors that make your neighbourhood so important to how healthy you are include the education level of residents, income, having the tax base to support good schools, unsafe or unhealthy housing, access to nutritious food, and opportunities to exercise.
The 2016 My Health My Community survey of people in Vancouver found that the likelihood of someone saying their health was “good” or “excellent” was directly linked to which neighbourhood they call home.
None of this is a secret. Reports by the federal government linking improved social conditions to better public health date back to one written in 1974.
Justin Trudeau made Dr. Jane Philpott his health minister. When Philpott’s daughter entered medical school she posted a blog advising her daughter: “the social determinants of health actually set the stage for all those biomedical actors… Do your part to inﬂuence those social determinants. Speak up when you see the impact of poverty, unemployment, violence and more.”
However, in Trudeau’s mandate letter to Philpott, the words “social determinants of health” were never mentioned.
So, we are today about where former federal health minister Monique Bégin left us in her 2010 forward to Social Determinants of Health: The Canadian Facts:
“What good does it do to treat people’s illnesses, to then send them back to the conditions that made them sick?”
It’s a simple question, massive in its implications. The more our leaders find ways to avoid answering it, the more it becomes obvious we will just have to find our own ways to make them.
The work Andrew McLeod does in All Together Healthy: A Canadian Wellness Revolution will help us find those ways and realize that revolution.
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