Can Money Buy You Health? - Region of Waterloo Public Health

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Can Money Buy You Health? The Health Impact of Pov e r t y

Living in poverty can mean the difference between sickness and health

When we use the word ‘health’, we often think about not being sick – but health is so much more than that! While we know that genetics and the choices we make affect our health, our well-being also depends heavily on environmental and societal factors. Not being able to read, being poor, having a low-paying job or being unemployed, living in substandard housing, breathing unclean air, drinking poor-quality water, experiencing high stress, living too far from a grocery store, and feeling isolated or unwelcome in our community are bad for our health and well-being. These individual, environmental, social, and economic factors are called the “determinants of health”. This report is part of a series of reports that looks at how some of these factors impact our health in Waterloo Region.

Poverty is a complex concept. While its most obvious feature is lack of income, there is an equally important social dimension to poverty. In a wealthy nation like Canada, poverty can be understood as the experience of material and social deprivation that prevents people, communities, and whole societies from reaching their full potential.1 Material deprivation means not having enough money to afford the necessities of life. Social deprivation refers to the exclusion and stigma that people may feel by not being able to participate in everyday activities like going for a coffee with a friend or going to a school friend’s birthday party. The worry and stress associated with living on the edge compromises both physical and emotional health.2 Since the dimensions of poverty are complex and subject to interpretation, they are difficult to measure. There is a tendency to understand poverty by relating characteristics (like income level) to outcomes (like occurrence of disease). While this is useful, it is also important to examine the personal experiences of those who live with material and social deprivation.2 The Low Income Cut Off (LICO) is a commonly used measure of low income produced by Statistics Canada. It is a relative measure and reports the income level at which household needs for food, clothing, and shelter will take, on average, a share of after-tax income that is 20 per cent higher than the average family.3 More recently, measures of income gap are being used to add depth to the more common measures. One measure looks at the depth of poverty by measuring the amount of money that a household living in poverty falls short of the LICO.2 Attempts to measure the social deprivation associated with poverty are made by asking questions in surveys about community belonging and social support and by listening to and describing the lived experience of those who are poor.

Describing Poverty in Waterloo Region According to the Statistics Canada after-tax LICO, 7.5 per cent of the population of Waterloo Region was living with low income in 2005.4 In terms of the depth of poverty, the average income of all low-income households in Ontario was $6,900 below the LICO for 2005.5 Low income is well known to exist in certain segments of the population in Waterloo Region more than others. Table 1 illustrates this.

Table 1: Percentage of certain segments of the population in Waterloo Region living under the after-tax LICO, 2005 Population

Percentage living under LICO

Overall population

7.5

Recent Immigrants (1996-2001)

33.5a

Aboriginal households

23.8a,b

Unattached person 15 years and older

21.8

Female-headed lone parent families

20.3

Children under 6

9.8

Male-headed lone parent families

7.7

Source: 2006 Census Statistics, Extracted from SIS on July 21, 2008 a Data not yet available from 2006 Census: source 2001 Census Statistics b Data from Kitchener Census Metropolitan Area only

In 2007, a single person working 40 hours weekly at a minimum wage job ($8.00 in 2007) would earn $16,640 yearly – $4,500 less than the low-income cutoff. In 2001,i 5,510 people in Waterloo Region found themselves living in this situation – working at minimum wage and living below the LICO.7 The implications of living on minimum wage income, as well as levels of income provided by social assistance, can be seen by looking at monthly living expenses for basic needs. Even with minimum wage increases and the recent elimination of taking back the National Child Benefit, some families living on low incomes still do not have enough income to cover their most basic needs. This is illustrated in Figure 1. Urban poverty data from the 2006 census has not yet been released

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Figure 1: Monthly cost of living expenses compared to income, Waterloo Region, 2008‡ Households on Fixed Incomes Ontario Works Ontario Works Man age 26, Mother age 27 living alone with daughter age 7

Ontario Works Father age 36 and mother age 35, daughter age 11 and son age 15

Ontario Disability Support Program Man age 47, living alone

Old Age Security / Guaranteed Income Supplement Woman age 75, living alone

Minimum Wage Father age 36 and mother age 38, daughter age 5 and son age 3 One parent working 40 hours/ week ($8.75/hour)

Income Income

$560.00

$1,226.58

$1,710.00

$999.00

$1,144.29

$1,205.37

Additional Benefits and Credits††

$20.17

$30.75

$61.50

$20.17

$113.92

$897.41†††

Total Monthly Income

$580.17

$1,257.33

$1,771.15

$1,019.17

$1,258.21

$2,102.78



Expenses Rent*

$548.00 (bachelor)

$829.00 (2 bedroom)

$940.00 (3 bedroom)

$690.00 (1 bedroom)

$690.00 (1 bedroom)

$940.00 (3 bedroom)

Utilities**

Heat & hydro included in rent

$200.00

$235.00

$180.00

$180.00

$235.00

Cost of nutritious food basket (NFB) per month***

$212.04

$276.73

$633.87

$212.03

$148.17

$498.99

Amount of monthly income remaining for other monthly expenses

-$179.87

-$48.40

-$37.72

-$62.86

$240.04

$428.79

Source: The Cost of Eating Well: The Health Impact of Food Insecurity (October 2008). Table design adapted from Halton Region (2007). The Price of Eating Well in Halton Region. † Ontario Works income (basic allowance, shelter, plus Ontario Child Benefit + Canada Child Tax Benefit when applicable) †† Average GST plus harmonized sales tax credit per month (yearly allocation + 12) + Universal Childcare Benefit when applicable ††† Ontario Child Benefit + Canada Child Tax Benefit + GST plus harmonized sales tax credit + Universal Childcare Benefit * Canada Mortgage and Housing Corporation (2007). Private Apartment Average Rents for Kitchener CMA. ** Estimated average cost of utilities for Peterborough on equal billing arrangement, no Waterloo Region data for average utility expenditure for apartments *** Monthly food cost for each person based on weekly cost x 4.33 ‡



Can Money Buy You Health? | The Health Impact of Poverty | 3

In terms of social deprivation, a Canadian study of people who receive social assistance found that those who received social assistance were 2.9 times more likely to report having poor social support.8 Canadian studies which have documented the lived experiences of those living in poverty are not common but there are six which are considered exemplary.2 Those who have lent their voices to these studies speak consistently of economic hardship, inability to participate in everyday activities, the experiences of stress and stigma, the negative impact of their situation on their physical and mental health, and the negative impacts on their quality of life.

Health Impacts of Being Poor The link between living in poverty and poor health has been shown over and over again. In fact, there is conclusive evidence that poverty is not just associated with poor health but is a primary cause of poor health among Canadians.2 The evidence is so strong that poverty may well be the most powerful determinant of health.9 If income levels are viewed as rungs on a ladder, for each step down the ladder to a lower level of income there is a corresponding drop in the health status of the people living at that level of income. Those with the lowest incomes are more likely to develop poorer physical and mental health than those living in better circumstances. There is evidence that childhood development also follows a similar ladder. Generally, children from families with lower income and lower levels of education have higher rates of cognitive difficulties, behavioural issues, hyperactivity, and obesity through childhood.6 But what accounts for these associations? How does poverty cause poor health? Some explain the difference in health as being due to individual lifestyle choices – such as tobacco and alcohol use and low physical activity levels.2 Yet, the evidence is clear that lifestyle choices account for a very small amount of the difference in mortality rates between those who are poor and those who are not. The material and social conditions in which people live their lives account for most of the difference.2 A wide range of health indicators are associated with poverty. Some details for population health, chronic disease, and child health are given below.

Population Health Indicators A study10 which compared neighbourhoods across Canada based on income found that for low income neighbourhoods compared to high onesii: • Life expectancy is five years shorter for men and 1.6 years shorter for women • Infant mortality rates are 61 per cent higher • Low birth weight rates are 43 per cent higher Low birth weight is a very important measure of health status as it is consistently related to the experience of chronic diseases such as heart disease and type 2 diabetes in adulthood.2

For this study, neighbourhoods were divided into fifths (quintiles) based on the number of people living in them who were below the LICO

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Chronic Illness Indicators The same study looked at differences in mortality due to chronic diseases between low- and high-income neighbourhoods. They are reported in Table 2. For each of the chronic diseases studied, only cirrhosis in females and prostate and breast cancer were higher in high-income neighborhoods. For each of the other conditions, mortality rates are higher in lower income neighbourhoods. Table 2: Mortality rates per 100,000 population for some chronic conditions by neighbourhood income quintile, urban Canada, 1996 Gender and Cause of Death Females Uterine Cancer

Males

Low-income neighbourhood

High-income Per cent neighbourhood change

6.4

4.3

50%

Diabetes

13.4

9.1

47%

Mental Disorders

10.1

7.7

30%

Lung Cancer

34.8

27.0

29%

Ischemic Heart Disease

77.0

61.7

25%

Cirrhosis

3.4

3.6

-5%

Breast Cancer

26.6

30.4

-13%

Cirrhosis

16.7

6.7

150%

Lung Cancer

80.1

51.5

56%

Diabetes

21.2

13.5

56%

Ischemic Heart Disease

165.7

126.8

31%

Mental Disorders

10.1

7.7

30%

Prostate Cancer

18.0

24.4

-26%

Source: Wilkins et al, 2002.

The number of people in urban centres who are depressed and who live in lowincome situations is 58 per cent higher than the Canadian average.11 People who experience high levels of food insecurity (which some consider to be a good marker of poverty) are three times more likely to suffer a major depressive episode.12 They also have a higher risk of being isolated, having poor social support, and reporting stressful life circumstances.13,14

Children’s Health Indicators Canadian children living in poverty are more likely to develop a variety of illnesses, be injured, have stunted growth, and experience developmental challenges.15 They are more likely to end up in the hospital, have mental health problems, do poorly in school, and leave school early.16,12 When children grow up in poverty, they carry the effects with them into adulthood. They have a higher risk of health problems throughout their lives, no matter what their circumstances later in life.17,18

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What are we doing? There are three ways in which actions can address poverty.19 They can: • Prevent: stop poverty from happening in the first place • Reduce: increase the proportion of the population with incomes above LICO • Alleviate: improve the quality of life of those who are poor The Region of Waterloo addresses poverty in a number of ways – some of which are presented below. Many of the actions provide support to those in poverty and make a difference in the lives of people in the Region – but they are not aimed at reducing the incidence of poverty. In other words, they will alleviate poverty – but will not reduce or prevent it.20

Direct Financial Assistance to Individuals Living in Poverty • Community Outreach Basic Needs Fund • Income and Employment Support Program (Ontario Works, Planning for Employment, Toward Employment, 30 Ways to Shine, 45+ Program, job search and computer workshops) • Providing affordable housing Community Programs • Access to dental care • Community Outreach Program • Counselling Grants to community agencies • Healthy Babies, Healthy Children Program • Learning, Earning, and Parenting (LEAP) Program • Prenatal Nutrition Program • Peer programming Support to Policy Poverty and Research Initiatives • Research and planning on Homelessness and Housing Stability to support system design and service delivery improvements Networking and Support to Poverty Reduction and Alleviation Initiatives • Provide leadership to the Ontario Public Health Association – Association of Local Public Health Agencies’ Determinants of Health Workgroup • Support and participate in initiatives organized by Opportunities Waterloo Region – a community-based, multi-sector body that sets broad strategic direction for the reduction and prevention of poverty in Waterloo Region

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Finding Solutions Through Policy The traditional role for public health has been to focus on encouraging people to change behaviours which put their health at risk. Research is pointing to the necessity of complementing this with activities which engage the community in addressing broader social policies. Rather than focusing on risk behaviours alone, it is critical to look at and improve the social and environmental conditions in which people live and work. This report has shown that adequate income – as well as housing, food, child care, and education which income is used to afford – is critical to maintaining good health. Since most interventions in these areas fall outside of the mandate of the public health sector – any work to prevent and improve health inequities must involve all levels of government, private and non-government sectors, and international organizations.6 There is consensus among agencies, coalitions, and organizations working on issues of poverty that improvements in the social safety net are needed in order to address the root causes of poverty. These could include: • Improved social assistance and minimum wage rates • Establishing affordable housing policies • Improving employment insurance coverage and benefits • Providing accessible and affordable child care

Resources More information about the Region of Waterloo activities referred to in this report can be found on the website: www.region.waterloo.on.ca The following resources are available online at www.region.waterloo.on.ca/ph (go to Resources and select Health Status and Research Studies and select Poverty), or contact the Public Health Resource Centre at [email protected] or call the automated order line at 519-883-2374. • The Cost of Eating Well. The Health Impact of Food Insecurity (October 2008) • Various brief reports presenting statistics on Poverty in Waterloo Region (Child Poverty, Family Earnings, Government Transfers etc.) The following websites provide more information about poverty issues: • Opportunities Waterloo Region www.owr.ca • Social Planning Council of Cambridge and North Dumfries www.socialplanningcouncil-cnd.org • Social Planning Council of Kitchener-Waterloo http://www.waterlooregion.org/spc/kw • Campaign 2000 www.campaign2000.ca • 25 in 5: Network for Poverty Reduction www.25in5.ca • Make Poverty History Campaign www.makepovertyhistory.org

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Public Health 99 Regina Street South Waterloo, Ontario N2J 4V3 Phone: 519.883.2000 Fax: 519.883.2241 www.region.waterloo.on.ca/ph This report was prepared by Judy Maan Miedema. For more information call 519.883.2004 ext. 5297 or e-mail [email protected]

References 1 Townsend, P. (1993). The international analysis of poverty. Milton Keynes: Harvester Wheatsheaf as cited in Raphael, D. (2007). Poverty and Policy in Canada: Implications for Health and Quality of Life. Toronto: Canadian Scholar’s Press Inc. 2 Raphael, D. (2007). Poverty and Policy in Canada: Implications for Health and Quality of Life. Toronto: Canadian Scholar’s Press Inc. 3 Canadian Council on Social Development. (1994). Canadian Fact Book on Poverty. Retrieved from: http://www.ccsd.ca/pubs/archive/fb94/fs_povbk.htm September, 2008. 4 2006 Census Statistics, Extracted from SIS on July 21, 2008 5 Statistics Canada (table 202-0805, last updated on: 2008-04-18) 6 Butler-Jones, D. (2008). The Chief Public Health Officer’s Report on the State of Public Health in Canada. 7 Region of Waterloo. (2008) Region of Waterloo Council Report SS-08-030. Living wage policy impact assessment for the Region of Waterloo: Preliminary considerations 8 Vozoris, N.T., and Tarasuk, V.S. (2004). The health of Canadians on welfare. Canadian Journal of Public Health 95(2): 115-120 9 Ontario Physicians Poverty Work Group. (2008). Why Poverty Makes us Sick: Physician Backgrounder. Ontario Medical Review, May 2008 10 Wilkins, R., Berthelot, J.-M., and Ng, E. (2002). Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Health Reports, 13 (Supplement), 1-28 11 Smith, K.L.W., Matheson, F.I., Moineddin, R. and Glazier, R.H. (2007). Gender, income, and immigration differences in depression in Canadian urban centres. Canadian Journal of Public Health, 93(3) May/June 2005 12 Che, J. and Chen, J. (2001). Food security in Canadian households. Health Reports. 12(4). P.18. Ottawa: Statistics Canada. 13 Vozoris, N.T., and Tarasuk, V.S. (2003). Household food insecurity is associated with poorer health. J. Nutr. 2003 Jan:133(1) 120-6 as cited in Ontario Physicians Poverty Work Group. (2008). Why Poverty Makes us Sick: Physician Backgrounder. Ontario Medical Review, May 2008 14 Siefert, K., Heflin, C.M., Corcoran, M.E., and Williams, D.R. (2004). Food insufficiency and physical and mental health in a longitudinal study of welfare recipients. J Health Soc Behav. 2004 Jun; 45(2): 171-86 as cited in Ontario Physicians Poverty Work Group. (2008). Why Poverty Makes us Sick: Physician Backgrounder. Ontario Medical Review, May 2008 15 To, T. Guttmann, A. Dick, P.T., Rosenfield, J.D., Parkin, P.C., Tassoudji, M., Vydykhan, T.N., Cao, H. and Harris, J.K. (2004). Risk markers for poor developmental attainment in young children: results from a longitudinal national survey. Arch. Pediatr. Adolesc. Med. 2004 Jul;158(7):643-9 as cited in Ontario Physicians Poverty Work Group. (2008). Why Poverty Makes us Sick: Physician Backgrounder. Ontario Medical Review, May 2008 16 Kidder, K. Stein, J., and Fraser, J. (2000). The Health of Canada’s Children; a CICH profile. 3rd ed. Ottawa, ON: Canadian Institute of Child Health as cited in Ontario Physicians Poverty Work Group. (2008). Why Poverty Makes us Sick: Physician Backgrounder. Ontario Medical Review, May 2008 17 Davey Smith, G. (2003). Inequalities in Health: Life Course Approaches. Bristol, UK: Policy Press as cited in Ontario Physicians Poverty Work Group. (2008). Why Poverty Makes us Sick: Physician Backgrounder. Ontario Medical Review, May 2008 18 Raphael, D. Farrell, E.S. (2002). Beyond medicine and lifestyle: addressing the societal determinants of cardiovascular disease in North America. Leadersh Health Serv 2002 15(4):1-5 as cited in Ontario Physicians Poverty Work Group. (2008). Why Poverty Makes us Sick: Physician Backgrounder. Ontario Medical Review, May 2008 19 Government of Newfoundland and Labrador. 2006. Reducing Poverty: An Action Plan for Newfoundland and Labrador. Department of Human Resources, Labour and Employment. 20 OPHA (2008). Joint Working Group on Social Determinants of Health (Volume 1)

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