Cal Robinson is a PGY2 Pediatrics resident at McMaster University interested in how social determinants of health impact Canadian children.
On November 22nd, 2018, Ontario’s Progressive Conservative government unveiled their planned reforms of provincial social assistance programs, including changing the definition of disability for the Ontario Disability Support Program (ODSP). These announcements have been met with criticism from political and advocacy groups who argue that these represent further cuts to social assistance. Further policy announcements last year included a reduction of the planned 3% increase in social assistance to 1.5% and cancellation of the Ontario Basic Income Pilot, one of the largest minimum income studies ever developed. The Ontario Basic Income Pilot had already enrolled 4,000 low-income individuals across the province. These intended cuts to Ontario’s social assistance programs will have a substantial negative impact on the health of Ontarians, and will particularly threaten the physical, psychological and social wellbeing of Canadian children and their families.
Canada has the third highest rate of child poverty amongst 17 similarly developed countries. UNICEF recently reported the performance of 41 middle- and high-income countries at achieving UN Sustainable Development Goals; Canada ranked 32nd at addressing poverty and had the fourth smallest reduction in child poverty between 2008 and 2014. In Ontario, 1 in 7 children live in poverty and the rates of income inequality, unemployment, social housing waitlists and foodbank usage are rising across the province. Indigenous, immigrant and racialized children are disproportionately impacted by poverty, leading to further marginalization.
Poverty is one of the most important social determinants of health. It is associated with increased all-cause mortality, chronic illness burden, adverse early childhood development, exposure to toxic stress, mental health illness and poor educational attainment. In Hamilton Ontario, one of the sites for the now cancelled Ontario Basic Income Pilot, the local Code Red project showed a difference in life expectancy of 21 years (86.3 years vs. 65.5 years) between rich and poor neighbourhoods. Further, it has been estimated that 20% of Canadian healthcare spending is attributable to income disparities. Addressing poverty in Canadian children has the potential to significantly improve adult health and social outcomes, reducing dependency on social assistance programs. The Public Health Agency of Canada has estimated that every $1 invested in early years may save $3-9 in future health, criminal justice and social assistance spending.
Poverty must be recognized as a modifiable condition, where targeted individual- and population-level approaches have the potential to dramatically improve health outcomes. Current Canadian social assistance programs inadequately address the needs of the population, providing incomes equivalent to 30-80% of the poverty threshold.
Poverty intervention must be founded on achieving stable housing (e.g. Housing First model), food security, adequate income, and safety from crime and persecution. Population-based strategies, such as guaranteed minimum income, have been shown to be effective at reducing poverty and preventing its harmful consequences. This is not a novel concept in Canada, having been first proposed by the Social Credit movement in the 1930s. It was formally piloted in the Manitoba Mincome project of the 1970s; which resulted in fewer hospitalizations, physician visits, accidental injuries, and increased educational attainment, with small reductions on labour markets and work hours. Unfortunately, the project was stopped early after a change in government led to loss of support and withdrawal of funding, limiting the conclusions that could be drawn from the study. Four decades later we find ourselves facing similar circumstances, no closer to addressing the widening poverty gap in our country. Globally, other minimum income research projects have been developed in countries such as Finland, Netherlands, and Kenya.
Helping people to get themselves out of poverty works too. The introduction of Universal childcare in Quebec in 1997 led to a 13% increase labour force participation for women age 20-44 years between 1998 and 2014 (compared to 4% in Ontario), and about $920 million CAD annual government savings (2008 data) owing to less expenditure on childcare tax credits and deductions, increased tax revenue from additional GDP generated, and fewer social assistance claims. The scheme was also shown to improve cognitive outcomes and reduce social inequalities for children of low-income families.
Poverty is an epidemic issue affecting millions of Canadians. It disproportionately affects vulnerable people. Its consequences are far-reaching, extending to effects on physical, psychological, emotional, and social wellness of individuals and families. Poverty permanently harms Canadian children; its neurocognitive and psychological effects further perpetuate the poverty cycle. Although the impact of poverty is multifaceted, it must be recognized by physicians to be a modifiable risk factor for chronic disease and death; comparable to smoking, diet, or obesity. Focused screening can identify at-risk patients and targeted individual interventions, such as assisting with applications for social assistance; disability support or affordable housing; and supporting tax return submission (in order for patients to qualify for available tax benefits and credits) can have a meaningful impact on the social condition and health of one’s patients. Child development accounts (similar to Canada’s Registered Education Savings Plan) have been shown to improve social-emotional developmental outcomes, with greatest effects seen in low-income households. Physicians also have a unique role, with the opportunity to lead and advocate for change in communities, and at provincial and national levels. We must continue to advocate for population-based poverty interventions, such as guaranteed minimum income and universal childcare, as strategies to improve the physical and mental health of Canadians.
Acknowledgment: I would like to thank Dr Gita Wahi for her guidance and for her continued mentorship of McMaster Pediatrics residents, promoting advocacy in child health.