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The following article is excerpted from A Healthy Society: How a Focus on Health Can Revive Canadian Democracy, by Dr. Ryan Meili. Leaders and Legacies is running a multi-part series based on this book.
The list of social determinants rings true to me and to others who work with the people of Saskatoon’s west side. The majority of our patients are First Nations or Métis. They face challenges in accessing education for themselves, and child care and education for their children. Unemployment, poverty, and dependence on an inadequate social safety net are endemic, in particular for women. Housing is expensive, and often crowded or unsafe. Health care services are limited, and difficult to access. Violence, racism, sexual exploitation, and substance abuse are only a few of the many symptoms of ongoing poverty and social exclusion. The list goes on, and the result is ill health.
The effects of the social determinants on health are readily apparent to those who live and work in underserved communities. They are also supported by studies such as “Health Disparity by Neighbourhood Income,”5 a 2006 paper published in the Canadian Journal of Public Health. This study compared the health of the six lowest-income neighbourhoods in Saskatoon (according to Statistics Canada) with the same health indicators in the rest of the city. The findings were startling. People in the core are four times more likely to have diabetes, four to seven times more likely to get a sexually transmitted illness, and fifteen times more likely to have Hepatitis C. Those in the core also experience significantly higher rates of injury, mental illness, and coronary artery disease.
When the six poorest neighbourhoods were compared with the city’s six most affluent neighbourhoods, the contrast was greater still. If you live in the core, you are fifteen times more likely to contract a sexually transmitted infection, fifteen times more likely to attempt suicide, thirtyfive times more likely to get Hepatitis C, and thirteen times more likely to have type 2 diabetes than if you live in the suburbs. Children in the core are half as likely to have received their vaccinations. With all these increased risks, a core neighbourhood resident is 2.5 times more likely to die in any given year. The infant mortality rate is three times higher in the lowest-income neighbourhoods than in the more affluent neighbourhoods.
To get a sense of income ratios, the average annual family income in the six core neighbourhoods was approximately $30,000 per year, in the rest of Saskatoon it was over $60,000, and in the wealthiest neighbourhoods it was just under $100,000. Forty-four per cent of families in the core live below the low income cut-off line, compared with less than four per cent in the high-income neighbourhoods. People from the wealthier neighbourhoods are more than five times as likely to have gone past grade nine or to have current employment. This landmark study demonstrates clearly the huge disparities in health in Saskatoon and the clear correlation to the social determinants.
Saskatchewan has a reputation for seeking equality, in particular with regard to health. It was the first province to institute what would eventually become Medicare, a national health insurance program designed to ensure that all Canadians would receive health care based on need rather than ability to pay. It is also a reasonably well-off province in one of the wealthiest and supposedly most advanced countries in the world. The discordance between perception and reality represented by this drastic imbalance in health has been a shocking embarrassment for Saskatchewan.
It is, paradoxically, not particularly surprising. We know, and have known for a long time, that poverty is the greatest contributor to ill health. What is new about this study is the way in which it shows, in simple and clear data, just how significant that effect is in Saskatchewan. And the implications are clear, although politically inconvenient: one, poverty and inequality kill; two, governments that stand idly by are complicit in every avoidable illness and premature death.
– Dr. Ryan Meili is a family doctor at the West Side Community Clinic in Saskatoon and head of the Division of Social Accountability at the College of Medicine at the University of Saskatchewan.
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