Dr Gary Bloch cycles to work.
Through Regent Park, Moss Park, Alexandra Park, some of Canada’s oldest and largest social housing projects, and into Toronto’s downtown core. To his clinic by St Mike’s Hospital and a multidisciplinary family practice that houses a unique team of people he says it would be impossible to work without. There are Karen and Gordon, the income security health promoters. There’s Johanna, the lawyer. There’s Cian, the community engagement specialist. There’s a literacy program.
That’s because doctors alone can’t medicate the illness of poverty.
“It’s been a decade of reframing the conversation. Of shifting the way doctors think about social determinants of health. Of understanding that the evidence is irrefutable: poverty deserves to be treated like a disease.”
The work of “prescribing money,” which is how—from TEDx Talks to CBC Radio, from The Toronto Star to The Globe and Mail—many Canadians have read or heard about what Gary Bloch and his team do, is in many ways beguilingly simple. The first step is just “screening everyone,” says Gary. “Ask your patients if they have difficulties making ends meet at the end of the month. You would be amazed what you learn if you ask the right questions.” Too often, thinks Gary, physicians just don’t have a picture of their patients’ social state.
Once you’ve gathered that baseline information, he insists, factor poverty into clinical decision making: “You can’t understand people’s health risks without knowing their social conditions.” Indeed, according to a clinical tool developed by Gary for primary health care providers, and supported by the Ontario College of Family Physicians, poverty is directly associated with higher rates of cardiovascular disease, diabetes, mental illness, cancer, hypertension, and even infant mortality. Understanding this evidence should change the way physicians approach their patients’ health. These risks demand the third step: intervention.
About intervention, Gary Bloch is more introspective. He knows it can be hard. He calls for physicians to listen to what their patients are asking for, to mobilize and advocate against poverty, to push forward conversations about transformations to systems that perpetuate poverty. To practise as part of a team of people who can assist patients, in very practical ways, to access additional finances and resources. Someone might, for instance, be eligible for Old Age Security income supplements or, if your patient is indigenous, they might not have tapped into Non-Insured Health Benefits. Doing so could result in a few new precious extra dollars a month to access better food. “Upping the income of someone who lives on social assistance, even if just by a few hundred bucks a month, can be transformative,” notes Gary.
Upping social assistance through a “prescription” was how Gary Bloch first got into the business of treating poverty.
“In 2005 the Ontario Coalition Against Poverty discovered a little-used program in Ontario’s social assistance regulations—doctors were able to prescribe a special diet allowance to people living on welfare.” All the prescription required was a doctor to say the allowance was needed.
It was a game changer from Gary’s perspective: “Imagine increasing your monthly income from $506 to $750. We were working in church basements and out of public libraries. Our biggest clinic was at Queen’s Park. We had 40 prescribers. We served over a thousand patients in one day.”
In 2006, the provincial government tightened the regulations, creating a very specific list of diagnosable illnesses for which a specific diet could be prescribed. “Poverty wasn’t on the list,” notes Gary, wryly.
The experience with the Ontario Coalition Against Poverty, with “prescribing against poverty,” fueled something in Gary Bloch that had been simmering for quite some time. “I’ve always been involved in activist circles. My undergraduate degree was in African and colonial history at McGill. My medical school mentors were advocates and activists who gave me hope … [they too] lived their ideals.”
What Gary realized, and what he’s since devoted his practice to, was that physicians could play a key role in social change.
“As a society, we’re heading in the wrong direction,” observes Gary. “There is this ongoing erosion of social supports, a flattening of people’s incomes who are living on the lowest economic margins. Our governments are austerity focused, but this means cuts to families and individuals, a move away from government responsibility.”
“Physicians,” notes Bloch, “often sit in that top 1% [income bracket].” But that makes physicians perfectly positioned to push forward discussions about addressing poverty: “we’re not acting out of self-interest,” says Bloch, but are instead expanding conversations about wanting a better, healthier world.
At St Mike’s, these conversations are expanding beyond a few doctors. They are expanding to a true team approach to treating social issues. From many disciplines and many backgrounds. Overseen by the Social Determinants of Health Committee. It is unique. It is exciting. Even groundbreaking. And it is moving responsibility for these interventions to a larger, more complex, and farther-reaching part of our health care system.
Gary’s cycle to work takes him through more than just social housing projects. “I bike past homeless shelters and poverty centres, past homeless people and streams and streams of other people. Past the economic power centre that is Toronto’s financial district. The evolving life of this city gives me a lot to think about. You see so much stuff.”
That “stuff” is fuel for Gary Bloch, fuel in efforts to “bring the powerful voice of physicians and health teams into discussions about poverty. This cuts across political lines. The evidence is beyond challenge. Economic disadvantage is a determinant of health. We need to shift the conversation. It’s urgent.”
PHOTOS (CLOCKWISE FROM TOP RIGHT): Dr Bloch cycling to work through the streets of Toronto, Ont.
Dr Bloch with Karen Tomlinson, income security health promoter.
Dr Bloch in front of the Good Shepherd shelter and in the community.
PHOTOS (CLOCKWISE FROM TOP LEFT): Team meeting with (clockwise from left foreground) Cian Knights, Danyaal Raza, Melinda Glassford, Laurie Malone, Gary Bloch, Karen Tomlinson, Jacqueline Chen, Gordon Soplet, and Courtney Ruddy. Dr Bloch in a makeshift shelter in downtown Toronto. The St Michael’s Department of Family Medicine Social Determinants of Health Committee: (back row) Melinda Glassford, dietitian; Courtney Ruddy, clerical staff; Nav Persaud, family physician; Andrew Pinto, family physician; Gordon Soplet, income security health promoter; Jackie Campbell, clinical leader manager; Caroline Jeon, resident physician; (front row) Johanna MacDonald, lawyer; Karen Tomlinson, income security health promoter; Danyaal Raza, family physician; Gary Bloch, family physician; Aisha Lofters, family physician; Katherine Rouleau, family physician; Cian Knights, community engagement specialist. Dr Bloch in the community.
PHOTOGRAPHER: Laura Bombier, Toronto, Ont
Footnotes
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro d’avril 2016 à la page e218.
The Social Determinants of Health Committee of the Department of Family and Community Medicine at St Michael’s Hospital in Toronto, Ont, has been in existence since 2013. Its goal is to support health team interventions into social risks to individual and community health. Dr Gary Bloch is a family physician and the committee’s Chair.
The Cover project The Faces of Family Medicine project has evolved from individual faces of family medicine in Canada to portraits of physicians and communities across the country grappling with some of the inequities and challenges pervading society. It is our hope that over time this collection of covers and stories will help us to enhance our relationships with our patients in our own communities.
- Copyright© the College of Family Physicians of Canada
