Canada’s Yawning Health Gap

Connecting the dots between income inequality and ill health

Toba Bryant

A sign photographed near St. Lawrence Market during the Occupy Toronto protests in 2011.

Around the world, increasing concern has come to focus on the health gaps between the rich and the poor. Much research has identified a strong relationship between material advantage and health – a phenomenon now known as the “social gradient” in health.

This social gradient is in turn shaped by the “social determinants” of health - the living and working conditions that people experience such as income, housing, and employment and working circumstances. This idea is not new. In his book The Role of Medicine: Dream, Mirage, or Nemesis?—published in 1976—physician and demographic historian Dr. Thomas McKeown argued that the significant improvements in the health of populations during the 19th and 20th centuries were attributable to changes in social and economic conditions rather than medical advances.

The development of the modern welfare state following the Second World War led to significant improvements in the health and well-being of populations. Through programs such as unemployment insurance (now called employment insurance in Canada), pensions and public healthcare systems, citizens are assured access to resources that ensured a high quality of life and good health. In rich countries, these programs helped increase life expectancy and lower infant mortality rates.

However, the oil crisis of 1973 caused many governments worldwide to reduce social and health spending in order to control national deficits. Governments have since tended to focus less on improving the health of populations and more on austerity measures to balance their budgets. The result: growing social inequalities in income and wealth and in access to necessary supports for the health of their citizens.

Canada is a worrying case in point. In its 2008 report, Growing Unequal? Income Distribution and Poverty in OECD Countries, the Organisation for Economic Co-operation and Development identified Canada as one of the two wealthy nations with the fastest-growing rate of income inequality. This development is also evident in local research that maps growing income inequalities in Toronto’s neighbourhoods.

In his report—“The Three Cities within Toronto: Income polarization among Toronto’s neighbourhoods, 1970–2000”—U of T professor David Hulchanski identifies three distinct “cities,” which differ as a function of income and income growth. City #1—comprising 20 percent of Toronto—consists of wealthy neighbourhoods that experienced an increase of 20 percent or more in their incomes from 1970 to 2005. In City #2—which comprises 40 percent of Toronto—average neighbourhood incomes rose or fell by no more than 20 percent within the same period. City #3—approximately 20 percent of Toronto—consists of neighbourhoods whose incomes declined by 20 percent or more, again within the same time duration. (To view the maps, go to http://tinyurl.com/7rkafhe.)

In February 2012 the Toronto-based Metcalfe Foundation released a report identifying the working poor as being concentrated in Hulchanski’s City #3, which includes North Scarborough. These populations—representing one in five Torontonians—are most at risk for developing chronic diseases due to the direct effects of material deprivation and the stress of living in or near poverty. Both these factors are related to poor diet, lack of physical activity, or tobacco and alcohol consumption, but it is best to view these as maladaptive coping mechanisms rather than lifestyle choices. The take-up of these health-threatening behaviours can be seen as a means of coping with the stress associated with material deprivation (i.e., low income, poor housing, no food security). In other words, the social and economic marginalization experienced by these populations increases their risk of chronic disease and premature death.

But these health inequalities and the social conditions that spawn them are not inevitable, and governments have an essential role in ensuring the security of citizens through redistributive public policies, and intervening in the market. Leaders can adjust employment conditions such as wages and benefits, help create jobs as new employment sectors evolve, provide supports and retraining for workers if their jobs disappear, and make it easier for workers to unionize. Enacting such health-promoting public policies is essentially about providing citizens with the living and working conditions necessary for health. And whether governments decide to enact such policies depends entirely upon whom we elect to represent our interests.

Canadian society is becoming more unequal by the day, and research shows that increasing inequality breeds increasing ill health. But all is not lost. Every four years on election day, we have the opportunity to elect politicians who will act to protect the health of the population. And as good citizens, we must remain vigilant between elections to ensure governments enact public policies that enhance and maintain the health of the population.

As the renowned German doctor, anthropologist and social-medicine pioneer Rudolf Virchow famously stated, in 1848, in his influential weekly medical newspaper, Die Medizinische Reform: “Medicine is a social science, and politics is nothing else but medicine on a large scale.”

Toba Bryant, a former assistant professor of social science at UTSC, is an assistant professor in the faculty of health sciences at the University of Ontario Institute of Technology.