“A 41 year-old woman with no documented medical history or family history of disease presents to you complaining of occasional chest pains on exertion. How many would order a stress test to rule-out cardiovascular disease?” asks Dr. Gary Bloch, to a captivated audience of resident physicians currently in training at an academic learning day – a few hands go up.
“Now how about if she were a smoker or had high cholesterol?” – several more hands go up. “Now how about if I told you she earned less than $12 000 per year through part-time work, while renting a $600 per month bachelor apartment?” While some more put their hands up, many in the group look at each other, unsure of how this information would impact their diagnostic decision-making.
Dr. Bloch, a family physician at Toronto’s St. Michael’s Hospital and a founding member of Health Providers Against Poverty (HPAP), is an advocate for poverty screening. “Just as screening is important for other conditions or risk factors, like smoking, high cholesterol or domestic violence, so too is screening for poverty,” he says. Dr. Bloch and HPAP have been instrumental in producing a primary care intervention tool on poverty that is now endorsed by the Ontario College of Family Physicians and will likely soon be made available to every Family Physician in the province of Ontario for use in clinical practice.
How do healthcare and poverty interrelate? Why bother with poverty reduction as a health intervention? Because everyone should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, education or ethnic background. We know that families struggling to get by face considerable barriers in making healthy lifestyle choices, and people’s health is significantly affected by the quality of their homes, jobs and schools. In Canada, where I am a resident physician in Family Medicine, low income has been shown to account for 24% of person years-of-life lost, second only to 30% for neoplasms, out of all potential causes of illness. I suspect things are probably not so different in the United States. Dr. Bloch points to a growing body of research evidence showing the impact of financial struggle on the risk of a variety of diseases (this research is largely Canadian, so US statistics will differ, though the themes are likely similar):
- Cardiovascular disease: there is a 17% higher rate of circulatory conditions among the lowest income quintile versus the average
- Diabetes: prevalence among the lowest income quintile is more than double the rate in the highest income quintile
- Mental Illness: the suicide-attempt rate of those living on social assistance is 18 times higher than higher-income individuals
- Cancer: low-income women are less likely to access screening interventions like mammograms or Pap Smears
- Development: infant mortality is 60% higher in the lowest income quintile neighborhoods
Regardless of this compelling evidence, why is there a need to screen for poverty? “Simply because we don’t know which patients live in poverty and if we don’t ask, we won’t find out,” says Dr. Bloch. Since the recession of 2008, many hard-working people have been squeezed out of the middle class. A November 2011 report by Wider Opportunities for Women entitled, “Living Below the Line,” highlighted the fact that nearly half of Americans struggle to make ends meet. It is clear that having full-time, year-round employment and health insurance does not guarantee that a family doesn’t have to struggle to get by. In these tough times, those who live in poverty are not only those patients on Medicaid.
There is a lot physicians can do to give all of our patients the chance to live healthy lives. We can connect patients with organizations and resources that will assist them in maximizing their incomes. Dr. Mark Ryan, a family doctor working with underserved populations in Richmond, Virginia, explains “We can ensure patients participate in any federal, state and local programs that provide assistance, including WIC (Women and Infant Children supplemental nutrition program), food stamps, general relief programs, etc. We can also guide patients towards faith-based and other non-governmental non-profit organizations whose missions include supporting low income individuals and families.” He also points to the value of including a social worker as part of the treatment team. Physicians that screen for poverty are in a unique position to provide opportunities for interventions that can increase income and thereby provide our patients with the opportunity to make healthy choices, while advocating for government policies that can raise the bar for everybody.
I look forward to the day when screening for poverty as a risk factor for health becomes the standard of practice in every setting, whether it be in the emergency room, on the wards of a hospital or in primary care clinics.
Naheed Dosani is a family medicine resident. Both he and Jeremy Petch write at Healthy Debate, and can found @NaheedD and @jeremypetch respectively, on Twitter.