Almost immediately after starting to help them claim income assistance benefits, Bloch saw a positive impact on his patients’ health. Now he’s advocating that health practitioners across Canada help impoverished patients increase their income by helping them claim income assistance benefits they are entitled to but may not be receiving.
It seems obvious that having more money can translate to a healthier lifestyle. But in the world of public health, it’s taking time for the idea to take hold, particularly as it pertains to dealing with low-income communities. It’s not technically a doctor’s job, after all, to assist someone in filling out an application for disability assistance. The more Bloch speaks publicly about his findings, however, the more doctors realize how important income is to the overall health of their patients, and especially how poverty impacts health.
As British Columbia continues to face the highest poverty rates for both children and adults in the country, Bloch’s message has never been more pertinent. A family physician with St. Michael’s Hospital and chair of the Ontario College of Family Physicians’ Committee on Poverty and Health, Bloch recently shared his perspectives with Megaphone.
Megaphone: Why did you decide to treat poverty as a disease?
Gary Bloch: Throughout my career, I have worked predominantly with people who live in poverty, and I have seen, over and over again, the kind of health conditions that affect people who live in poverty. It became obvious, quite quickly, that the traditional medical approach was not enough such as counselling about good diet or prescribing the recommended drugs. It just didn’t seem to cut it.
People didn’t seem to get better, people didn’t seem to believe they were going to get better, and people knew that [simply eating more nutritious food or taking new medication] wasn’t the right intervention for them. It felt like something was missing. It pushed me to think beyond what the traditional medical approach taught me to do and the most obvious piece that jumped out
MP: How does the stress related to poverty affect peoples’ health?
GB: I tend to see people in my office with chronic health conditions such as diabetes, heart disease, lung disease, different cancers, as well as acute health conditions. People come in with those conditions in a more severe state by the time they come and see me, and they come in younger.
The fact that I have seen it over and over again shows that there is something going on there, and it presses me to say, “What can we do? How can we as doctors start to treat this, beyond just putting band-aids on these problems?” And that’s obviously where we start to talk about moving upstream, about finding the root cause of these conditions, and again poverty keeps pushing its head up.
MP: British Columbia has the highest child poverty rate in Canada, at 11.3 per cent. Research has shown that poverty has a particularly strong impact on young peoples’ health. What are you seeing?
GB: When you look at the evidence around poverty in kids, it brings an increased sense of urgency about how to deal with poverty as a health issue. Kids who are poor tend to have a higher prevalence of asthma, tend to get sick more often, tend to miss school more often because of illness, and tend to have higher instances of behavioural issues.
Research has shown that kids who grew up in poverty show an increased prevalence of heart disease later in life. Just the fact of having grown up in poverty put them in that risk, and decades later, whether they still live in poverty or not, they still felt the health impacts of having grown up in poverty. That is pretty scary stuff when it comes to dealing with childhood poverty, and definitely raises a sense of urgency.
MP: You prescribe income to deal with these health impacts. What does that look like at your clinic?
GB: Once we accept that poverty is a disease we need to figure out what the treatment is, and the most obvious treatment to me is looking at increasing peoples’ income.
One piece is just to get patients to fill out their tax return, because the impact of that can be huge. We’ve seen people gain thousands of dollars a year in benefits just by accessing those basic benefits available through the tax program. Many people in poverty don’t fill out those tax returns because they figure, “I’m not paying tax returns, so what’s the point?”
Another piece is knowing the high impact benefit programs, such as child benefits and disability benefits. When you sit down with someone and piece together their history, it opens up doors like you wouldn’t believe and can lead to thousands of dollars in increased benefits.
For someone to go from basic welfare supports onto disability supports is almost a doubling of income, and that process is wholly dependent on a healthcare provider doing a good job on filling out an application. That’s the kind of thing I’m talking about in terms of prescribing income—and I’ve got to say there is very little that is more satisfying about my job than helping someone double their income. I see the benefits immediately.
When people go from programs like welfare to disability, which doubles their income, I see them come back and their mood is better, they look brighter, their stress levels are down, they are eating better, they are taking care of themselves better, and their general sense of well-being improves and it happens almost overnight, within a couple of months of being on that increased income.
The most advanced idea of prescribing income is at my practice at St. Michael’s Hospital in Toronto. We have now hired someone specifically to help low-income patients increase their income, an income security specialist. This is not something you see generally in health settings, but this is a Ministry of Health funded position, and very explicitly its goal is to help improve income. We are studying this, so hopefully the research will come out and we will see what kind of impact it has, and if it works then perhaps this kind of thing will start to spread beyond where we are now.
MP: Are you seeing other physicians pick this up?
GB: There has been a really strong response in the physician community, and we are in an upswing stage right now. Every doctor hears their patients’ stories about what it means to live in poverty and knows that poverty affects health. What everyone doesn’t necessarily accept is whether or not it is a physician’s role to deal with that poverty and that’s the piece we are pushing. Part of the reason that physicians don’t assist with poverty is because they don’t know what to do with it, so what we are offering is a set of very easy-to-implement tools, and that’swhere we start to see physicians and other health providers respond.
I think this is a sign that this is etching towards the mainstream. Are we quite there yet? No, but we are on our way. Proving there is a health impact is not an easy thing to do. We look at things like our income security specialist and ask, ‘Is there a difference in income outcomes and health outcomes to patients who have access to these types of physicians, and those similar patients that don’t?’ I think that type of evidence, if it shows a positive impact, will really start to push this agenda farther in the medical community.
MP: You have been consistent in saying that these clinics are necessary, but there also needs to be a change in government policy to effectively address poverty. How can you mobilize doctors to challenge governments to make these changes?
GB: I’ve always been explicit about the fact that I don’t think physicians prescribing income is the answer to poverty. I think it helps those individual patients, which is wonderful: it helps the patient/physician relationships, and in a small way improves health in those settings. But the bigger statement it makes to physicians is that poverty is something that should be on our plate, and this is an issue we should be advocating.
My hope is that physicians will move towards pushing for the higher levels of governmental changes that we truly need to deal with poverty. Poverty is a structural issue, it’s a societal issue, and it’s something that needs to be dealt with big-level programs and big-level changes. What we have seen with other big issues that were once considered social and were then taken on by the medical community—smoking is a big one—is that having doctors and other health providers push them has a huge impact. I hope the healthcare community will treat poverty in that way, and I would like to see doctors speaking with government, speaking with policymakers, and collaborating with anti-poverty advocacy groups from all different sectors.
I hope that the more this is accepted in mainstream medicine, the more we will see physicians speaking up about these issues in a very strong way. I think that that will have an impact.
You know, for whatever reason, when doctors speak, people, society, and governments seem to listen.
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