The most powerful social determinant of health

I am surely biased, but I feel very lucky to live in our beautiful Canada. There is nowhere else in the world that I would rather live or work. With that said, I find the wealth inequality in our country deeply disturbing. The wealthiest 10% of Canadians accounted for almost half (47.9%) of all wealth in Canada in 2012, while the least wealthy 30% accounted for less than 1% of all wealth.¹

In medical school, we learned that health services play a relatively small role in a person’s health status and that the social determinants of health, such as employment, education, environment, sex or gender, and culture, to name a few, also play a role.² Perhaps the most powerful social determinant of health is income. All of us have seen too many patients who could not afford their medications, a healthy diet, or a proper place to live—and how this affected their health status. We have wished we could do something about it. It turns out we can.

Dr Gary Bloch is a family physician who works in downtown Toronto, Ont. Several years ago he was working in his personal practice and finding ways to optimize financial benefits for his patients. He eventually developed an inventory of benefits that might be available to his patients: income benefits, food supplements, and telephone and transportation subsidies. This was the beginning of what later became known as the Poverty Tool.³

The Poverty Tool was originally developed for Ontario but it has been adapted for all provinces. It can be incorporated into electronic medical records so family doctors can use it in their offices. In Manitoba, where I live and work, the provincial government has picked up on this effort. The program they created is called Get Your Benefits. If a patient responds positively to the screening question “Do you have difficulty making ends meet at the end of the month?” he or she is given a list of potential resources and services to help with such tasks as filling out tax returns, applying for pharmacare, and applying for the Employment and Income Assistance or Old Age Security programs. Some of the people who are eligible for social or financial support also struggle with taking the necessary steps to secure those benefits. This tool tries to address that gap.

This story would not be complete without addressing a couple of the elephants in the room. First, isn’t the work of family doctors complex and time consuming enough without having to worry about our patients’ income and food security? We all know that a simple 10-second question can lead to a long and involved conversation and probably more forms to fill out. I have only partial and imperfect responses for that. The first is that the Patient’s Medical Home model emphasizes the importance of working in teams with other health care providers. This is important work but work that is ideally referred to another member of the Patient’s Medical Home team, preferably a social worker. I know that most practices do not have social workers on board yet, but that is something that we can advocate for. In the meantime, primary care nurses, home care coordinators, and clerical staff can also be helpful in this work.

My second partial response is that since becoming familiar with Dr Bloch’s work, my personal energy for filling out those dreaded forms has changed. I sometimes question the power of many of the medications I prescribe. However, when I can help someone access a disability tax credit or more suitable housing, I feel like I am having a measurable effect on his or her health status. Now when I teach residents and they come out of the patient interaction with a form to be filled out for the patient, I tell them that that is one of the most concrete ways we will be able to help that patient this year.

The second elephant in the room goes back to my opening paragraph about the economic inequality in our country. If we thought about our communities the way we think about our families, we would never structure our society like this. If we had a family member with a disabling physical or mental health condition, we would never decide to allocate to that person the worst housing, the worst food, and the lowest income, but that is what we do in our society.

Once again, it falls to family doctors to adapt and try to address gaps in our imperfect system. That is part of what makes us so special and important. I would like to thank Dr Bloch for his country-changing work and his contribution to helping us serve our patients.

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