1. PRESENTER TOOL – REVISED FALL 2013 INCOME AND SOCIAL STATUS

2. OUTLINE Objectives Ted Talk Definitions of income and social status Income and social status as a social determinant of health Global and local impact of income and social status Poverty and primary care Activities/Discussion

3. OBJECTIVES Be able to define income and social status Be able to name the millennium development goal that relates to income and social status Be able to provide 3 pieces of evidence that income and social status affect health Be able to explain to colleagues why an understanding of income and social status is necessary to provide good primary care to patients

4. TED TALK Richard Wilkinson – How economic inequality harms societies (16:55) We feel instinctively that societies with huge income gaps are somehow going wrong. Richard Wilkinson charts the hard data on economic inequality, and shows what gets worse when rich and poor are too far apart: real effects on health, lifespan, even such basic values as trust. In "The Spirit Level," Richard Wilkinson charts data that proves societies that are more equal are healthier, happier societies

5. IN THIS TED TALK FOCUS ON: What health and social problems are affected by income? (life expectancy, infant mortality, math and literacy, homicides, imprisonment, teenage births, trust, obesity, mental illness, social mobility, social capital/involvement in community life) How to countries try to ensure better equality? (difference in earnings narrowed through taxation vs.. more equal earnings across the board) What social groups benefit from better equality in society? (benefits extend across all social classes)

6. GROUP REVIEW AFTER TED TALK…. What health and social problems are affected by income? (life expectancy, infant mortality, math and literacy, homicides, imprisonment, teenage births, trust, obesity, mental illness, social mobility, social capital/involvement in community life) How to countries try to ensure better equality? (difference in earnings narrowed through taxation vs.. more equal earnings across the board) What social groups benefit from better equality in society? (benefits extend across all social classes)

7. DISCUSSION How can we define income? What is social status?

8. DEFINITIONS Income: Financial or material resources

9. DEFINITIONS Social status: The social and economic positions of individuals or groups within society

10. INCOME AND SOCIAL STATUS AS A SDOH Income provides the prerequisites for health... Shelter FoodWarmth

11. SOCIO-ECONOMIC CONDITION AS A SDOH

12. Income provides the prerequisites for health… ShelterFoodWarmth Low income and poverty can… Cause stress & anxiety Limit your choices Influence behaviors

13. IMPACT OF SES ON HEALTH Low Socioeconomic Status = difficulty accessing health care + poorest health outcomes Health status improves at each step up the income and social hierarchy High income determines living conditions such as safe housing and ability to buy sufficient good food The healthiest populations are those in societies which are prosperous and have an equitable distribution of wealth

14. INCOME AND SOCIAL STATUS AS A SDOH “It is one of the greatest of contemporary social injustices that people who live in the most disadvantaged circumstances have more illnesses, more disability and shorter lives than those who are more affluent” (Benzeval, Judge, & Whitehead, 1995, p.1)

15. INCOME AND SOCIAL STATUS AS A SDOH “Poverty can affect health in a number of ways. Income provides the prerequisites for health, such as shelter, food, warmth, and the ability to participate in society; living in poverty can cause stress and anxiety which can damage people’s health; and low income limits peoples’ choices and militates against desirable changes in behaviour.” (Benzeval, Judge, & Whitehead, 1995,p.xxi)

16. DISCUSSION Is is true that income impacts the health outcomes of your patients? Do your patients in the lowest economic bracket experience good health?

17. GLOBAL & LOCAL CONTEXT

18. SDOH – GLOBAL (MDG) Millennium Development Goal 1: Eradicate extreme poverty and hunger http://www.jm.undp.org/files/u80/jpeg%20FILES%20MDG/MDG1.JPG

19. LOCAL CONTEXT It has been known for many decades that the profound improvements in health in Canada and other industrialized countries have been primarily due to the kind of societies in which we live, rather than advances in medicine or health care Low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes, regardless of age, sex, race and place of residence. At each rung up the income ladder, Canadians have less sickness, longer life expectancies and improved health.

20. LOCAL CONTEXT Poverty acts like a disease… Just like high blood pressure, diabetes, cholesterol: Puts sufferers at risk of high morbidity and mortality through various pathways (increased risk of CVD, diabetes, depression, cancer) No other cause accounts for all the elevated risk At extremes it can cause direct harm Groups that move out of poverty experience a decrease in disease Children who have lived in poverty have increased health risks as adults The finding is consistent across time, geography, and different populations

21. LOCAL CONTEXT Only 47% of Canadians in the lowest income bracket rate their health as very good or excellent, compared with 73% of Canadians in the highest income group Low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes, regardless of age, sex, race and place of residence At each rung up the income ladder, Canadians have less sickness, longer life expectancies and improved health

24. LOCAL CONTEXT Studies suggest that the distribution of income in a given society may be a more important determinant of health than the total amount of income earned by society members. Large gaps in income distribution lead to increases in social problems and poorer health among the population as a whole

25. LOCAL CONTEXT There is strong and growing evidence that higher social and economic status is associated with better health. In fact, these two factors seem to be the most important determinants of health.” Public Health Agency of Canada (2004)

26. POVERTY AND PRIMARY CARE

27. WHY SHOULD FAMILY DOCTORS CARE? As family doctors we deal with preventative care...In fact, Income is now a part of the Preventative Health Care Checklist Forms that we use in family medicine Knowing that income and social status have such a profound effect on health therefore matters in our everyday work Advocating for our patients and finding ways to help them overcome income and social barriers is key to good health Recognizing the additional health risks of patients living in poverty is crucial in our everyday work

28. PRIMARY CARE How do differences in income, “where we are in relation to one another” matter for primary care?

29. POVERTY AND HEALTH Income: Increasing poverty is seen to go hand-in- hand with increasing income inequality Poverty directly harms the health of those with low incomes while income inequality affects the health of all http://www.povertyandhumanrights.org/docs/incomeHealth.pdf

30. POVERTY, INEQUALITY AND HEALTH No examination of the health effects of poverty can ignore the relationship between economic inequality and poverty Societies that are economically unequal have higher levels of poverty http://www.povertyandhumanrights.org/docs/incomeHealth.pdf

31. SOCIO-ECONOMIC STATUS AND HEALTH Those with very low socioeconomic status have the most difficulty accessing health care and usually experience the poorest health outcomes Those of higher socioeconomic status experience ready access to health care and increased opportunities for engaging in health-promoting behaviours and therefore have better health outcomes Is this true for your patients? Do your patients in the lowest economic bracket experience good health? http://cbpp-pcpe.phac-aspc.gc.ca/topic/determinants/5/page/1mes

32. CANMEDS ROLES: HEALTH ADVOCATE

33. QUESTION What is the low income cut-off for a family of four in Toronto before tax?

34. POVERTY IN CANADA Income is now a part of the Preventative Health Care Checklist Forms that we use in family medicine What is the low income cut-off for a family of four in Toronto before tax? ( $41,198) Cut-offs change depending on where you live (rural vs. urban, population size) Gary Bloch MD CCFP St. Michael’s Hospital DFCM Assistant Professor, DFCM, UofT

35. ARGUMENTS FOR ADDRESSING POVERTY IN PRIMARY CARE Argument 1: This is required by the fundamentals of family medicine (health advocate, communicator, resource to a defined community) Argument 2: Poverty is a major risk factor for disease so requires intervention Argument 3: Poverty is a disease and warrants treatment like any other Gary Bloch MD CCFP St. Michael’s Hospital DFCM Assistant Professor, DFCM, UofT

36. HOW CAN FAMILY DOCTORS INTERVENE AND ADVOCATE FOR THEIR PATIENTS WITH LOW INCOMES? Gary Bloch’s Poverty Tool – delineates ways to advocate for patients

42. PREVENTATIVE CARE CHECKLIST

43. ACTIVITY Imagine you are a single person on Ontario Works. Your receive $592 per month. Write down your usual monthly expenses excluding rent. Calculate how much money you would have left for rent once you had taken care of all other expenses in a given month. What kind of monthly income is needed in Toronto for someone to meet their basic needs (food, shelter, electricity, transport)? What is the minimum amount you could live on per month with your current rent/mortgage? What months are most expensive in Toronto?

44. ACTIVITY - DEBATE “Doctors to Governments: Tax us. Canada is worth it!” Doctors For Fair Taxation http://www.youtube.com/watch?v=o_GsqskLvaw Debate: Be it resolved that doctors as health advocates, should pay higher taxes

45. ACTIVITY Divide into groups of 4 Brainstorm ways in which Canadian family doctors can advocate to enhance equality: a)On behalf of their patients? (disability forms – WSIB/ ODSP/CPP, welfare supplements – transport/medical supplies/special diet, tax forms-child benefits, old age security and guaranteed income supplement, disability benefits, social worker referral) a)On behalf of society? (fair taxation, advocate for public services and systems, advocate for income equality, ensure employees have benefits)

46. ACTION PLAN After today’s workshop, make a list of tangible action plans to implement in your respective practices.