White Coat, Black Art·Dr. Brian's BLOG

The health cost of being poor

People living in low-income neighbourhoods are at higher risk of dying from preventable diseases than people in more affluent circumstances. But it's reversible.
A homeless person is seen in downtown Toronto in 2018. Disadvantaged patients with limited financial resources use fewer preventive and outpatient services than those with higher incomes. (Christopher Katsarov/The Canadian Press)

Canadians pride themselves on having a health-care system for everyone. But an editorial published Monday in the Canadian Medical Association Journal (CMAJ) says the system is failing people with low income. 

This happens in several ways, say the authors of the editorial, Dr. Andrew Boozary, executive director of health and social policy at University Health Network in Toronto, and Dr. Andreas Laupacis, CMAJ's editor in chief.

First, publicly funded health care in Canada covers only certain services. Prescription drugs are inconsistently funded in Canada. Coverage of physiotherapy is almost non-existent. Home care coverage is inadequate. So is counselling for mental health problems.

For many Canadians, employee benefits make up the shortfall. Those with lower incomes do without simply because they can't afford them. When they do have coverage, disadvantaged patients with limited financial resources use fewer preventive and outpatient services than those with higher incomes.

Poverty also leads to insidious barriers even when services are "free." For instance, they might not be able to afford the cost of transportation.

Income disparities lead to predictable shortfalls in health. A recent report from Ontario found that only 54 per cent of women living in the poorest neighbourhoods got screening for cervical cancer. By comparison, more than 67 per cent of women living in the most affluent urban neighbourhoods got full screening for cervix cancer. Disparities like that are true for colorectal cancer screening too.

Discrepancies affect survival

Studies show that people who live in well-off parts of Canada have better access to family medicine than people who live in areas that are less advantaged.

These discrepancies affect survival. In Ontario, between 1993 and 2014, the likelihood of dying from a preventable cause more than doubled among people living in the province's poorest neighbourhoods.

Indigenous people are among the vulnerable Canadians. Approximately one-third of the people who use shelters are Indigenous. That's according to research by the Canadian Alliance to End Homelessness. People with physical and mental disabilities are twice as likely as other Canadians to live below the poverty line. Up to 45 per cent of people who are homeless are living with some sort of disability.

Single mothers are also on the list of those whose health is disadvantaged. One in five single mothers live in poverty. Racialized families are more likely to live in poverty, and racialized women tend to earn less money. According to one estimate, two million seniors who were receiving the Guaranteed Income Supplement were living on an annual income that was below the basic standard of living.

Canada ranks poorly on social spending

As the editorial states, when compared to other countries, Canada ranks relatively poorly in spending on social programs. A 2018 study published in the Journal of the American Medical Association found that Canada ranked 10th out of 11 well-off nations in terms of public spending on health expressed as a percentage of total national GDP.

That article pointed to other disturbing trends. Canada placed second only to the U.S. in newborn and infant mortality.

In London, about 200 people are sleeping rough every night and more than 5,000 people are on the waiting list for rent-geared-to-income units. (Andrew Lupton/CBC)

A paper published last week in CMAJ argued that Canadian social programs have changed relatively little over the decades despite substantial transformations across society. These include increased migration and cultural diversity, changing family structures and gender roles, as well as changes to the economy and globalization. 

The editorial calls on the federal government and the provinces to do more to address those inequities. For instance, Canada needs to consider a guaranteed annual income. It needs to understand that health and social services are interconnected.

Other countries are making strides. The U.S. has proposed a national interagency council on the social determinants of health. Earlier this year New Zealand released a budget promising more money for mental health, Indigenous peoples and poverty reduction. Iceland and Scotland have expressed interest in similar policies. Canada must invest more in evaluating these sorts of policies here.

Instead of trailing other well-off nations, Canada should be leading the way. It's the right thing to do. Given the cost of health care, it's also the smart thing to do, as prevention costs far less than managing serious and avoidable chronic diseases. 


Dr. Brian Goldman is a veteran ER physician and an award-winning medical reporter. As host of CBC Radio’s White Coat, Black Art, he uses his proven knack for making sense of medical bafflegab to show listeners what really goes on at hospitals and clinics. He is the author of The Night Shift and The Power of Kindness: Why Empathy is Essential in Everyday Life.


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