When the poor have no food

When I give food to the poor, they call me a saint. When I ask why the poor have no food, they call me a communist.

Hélder Câmara

Recently I had an interesting conversation with a family physician colleague. She had just been invited to join a medical school committee that was developing an undergraduate curriculum aimed at educating future physicians about how best to counsel their patients about healthy eating and exercise. The curriculum was case based (presumably to make things more realistic and more fully engage medical students), and the content provided was informed largely by clinical practice guidelines. The curriculum had been developed by non–family medicine specialist colleagues, and she had been invited to join the committee to provide a “family medicine perspective.” My colleague wondered what I thought of the new curriculum.

Not for the first time I was disappointed to find that the real-world generalist perspective on curriculum development seemed to be an afterthought. The case was clearly artificial and driven by the considerations of disease-oriented guidelines, as was the educational intervention itself. Entirely absent, among other things, was a consideration of the profound effect of food insecurity on the health of many of our patients.

A recent study by Tarasuk et al¹ revealed the magnitude of the problem in Ontario and its implications for health. Among the findings was that household food insecurity was a robust predictor of health care use and costs in working-age adults in Ontario, independent of other well established social determinants of health. Further, this effect was seen even when the researchers excluded the costs of prescription drugs covered by the Ontario Drug Benefit plan.

The focus of Tarasuk and colleagues’ study was effects on the health of adults, but what about the effects of food insecurity on children and adolescents? There is good evidence that food insecurity affects roughly 1 in 6 Canadian children and that the effects are both wide ranging and pervasive.² Prenatal iron deficiency in mothers affects neurologic and psychomotor development in children with long-lasting effects including an increased likelihood of attention deficit hyperactivity disorder and other learning difficulties.² Research in the United States reveals that child hunger is also a predictor of depression and suicidal thoughts in late adolescence and early adulthood.³ Inadequate food and nutrition during childhood also means an increased risk of obesity and chronic illnesses in later life.²

How should family physicians respond to such issues?

The April issue of Canadian Family Physician includes a practical guide for family physicians by Goel and colleagues on how to address some of the socioeconomic disadvantages that face many of our patients (page 287).⁴ Their advice includes ensuring that family physicians assess all patients for their income, education, employment, prescription drug coverage, housing, legal needs, mental health, and addiction issues. They outline many opportunities for family physicians to refer patients in need to community resources aimed at addressing each of these areas.

Some have argued that family physicians and other primary care providers should also screen patients for food insecurity and similarly refer them to food programs designed to prevent or alleviate it. But Canada lacks such government-sponsored programs, and ad hoc community-based food banks and other similar programs lack the capacity to alter household food insecurity on a broad scale. As Tarasuk and colleagues state, “Health care providers have little chance of altering patients’ circumstances through referrals.”¹

Also in this issue of the journal is a thought-provoking commentary by Roncarolo and Potvin (page 291) in which they argue that food insecurity in Canada should be viewed as a symptom of a social disease and that family physicians have a role to play in addressing it—not just 1 patient at a time, but by advocating at a policy level to promote social change that will alleviate food insecurity in our communities.⁵ Some might disagree, but it is food for thought.

Hélder Câmara, whose words are quoted in the epigraph above, died in 1999 at the age of 90. He grew up in a family of 13 children, became a seminarian at age 14, and was ordained at 22. He went on to work in the favelas of Rio de Janeiro and eventually became the Archbishop of Olinda and Recife in the impoverished northeastern part of Brazil. He became an outspoken champion of the poor and critic of a succession of repressive military governments and was nominated for the Nobel Peace Prize.⁶

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