In a recent editorial (“Aboriginal HIV Rates Disturbing”) the Winnipeg Free Press expressed concern about the rising incidence of HIV infection in, among other places, Winnipeg’s inner city. There, “social and economic conditions make people easy prey” for HIV infection. The editorial called for a “vigorous response” to these problems.
But rising rates of HIV infection are only the tip of the iceberg. In the inner city all health outcomes, not just the incidence of HIV infection, are worse than elsewhere in Winnipeg. The cause, as for the rising incidence of HIV infection, is the “social and economic conditions”, namely high levels of poverty and related problems.
Health Outcomes and Poverty
The relationship between poverty and poor health is well established, both globally and locally. Locally, for example, Marni Brownell and her colleagues at the Manitoba Centre for Health Policy (MCHP) found in a 2003 study that those living closest to Winnipeg’s low-income city centre were least healthy, while those toward the higher-income outer edges of the city were most healthy. This was the case for the incidence of cancer, heart disease, injury, respiratory illness and virtually all adverse health outcomes.
Similarly, infant mortality in Winnipeg’s lowest income neighbourhoods---primarily in the inner city---is almost three times as high as in the highest income neighbourhoods.
Males born in the lowest-income areas of Winnipeg have an average life expectancy 10 years less than males born in higher-income parts of the city. This is an enormous differential when you consider, as Brownell and her colleagues pointed out in a 2010 book published by the Canadian Centre for Policy Alternatives-Manitoba (CCPA-Mb), that the elimination of all cancers would increase life expectancy by less than four years. Adverse “social and economic conditions”---poverty and related conditions---shorten life expectancy more than does cancer.
Aboriginal people, disproportionately located in Winnipeg’s inner city, are particularly affected by poverty and inequality, with the same adverse health outcomes. Patricia Martens and colleagues at the MCHP have found that First Nations people in Manitoba have a premature mortality rate double that of all Manitobans; a potential years of lost life 2.5 times all Manitobans for males, and 3 times all Manitobans for females; an incidence of diabetes 4 times all Manitobans, and of amputations related to diabetes 16 times all Manitobans; and a hospitalization rate double all Manitobans. The poor health and shorter lives of First Nations people correlates strongly with social determinants of health, that is, the social and economic conditions referred to by the Free Press.
Violence is also a health issue, especially but not only for women. MCHP shows hospitalization rates due to violence are five times as high in the lowest income areas of Winnipeg, that is, in the inner city. This crime-related violence is related to elevated levels of poverty. In 2007 Dennis Raphael, perhaps Canada’s leading authority on the social determinants of health, observed that “one of the most consistent findings to emerge in the literature is that poverty is a key determinant of whether one falls into a life of crime”. Crime is related to violence, and violence is a health issue. As Margaret Haworth-Brockman, Executive Director of the Prairie Women’s Health Centre of Excellence pointed out in that same CCPA-Mb publication: “violence remains a serious women’s health problem, and indeed a public health issue”. And it is related to the social and economic conditions identified by the Free Press.
Educational Outcomes and Poverty
We know too that poverty adversely affects educational outcomes. “Indeed, socio-economic status is the single most powerful predictor of education outcomes”, Brownell and her colleagues have found. High school graduation rates are much lower in the inner city than elsewhere in Winnipeg, confirming that the higher the incidence of poverty, the lower the level of educational attainment. We know too that the lower the level of educational attainment, the higher is the risk of poverty. Brownell and her colleagues, in a 2008 study, found that: “The lack of a high-school diploma remains a significant predictor of negative outcomes: lower earnings, higher rates of unemployment, poorer health, higher rates of reliance on social assistance and higher rates of teen motherhood”. Adverse social and economic conditions reproduce themselves, in the absence of a “vigorous response” aimed at improving those conditions.
The effect of these social and economic conditions on children has been well documented. Raphael, for example, observes that children in poor families: “are more likely to experience greater incidence of a variety of illnesses, hospital stays, accidental injuries, mental health problems, lower school achievement and early dropout, family violence and child abuse, among others”.
In short, the “social and economic conditions” that the Free Press referred to are important causal factors not only for growing HIV rates, but also for poor health of all kinds---heart disease, cancers, mental health problems, respiratory illnesses, accidents, violence, stress.
The Free Press is surely correct in calling on governments to make a “vigorous response” to these adverse social and economic conditions. That means public investment aimed at reducing poverty. Reducing poverty will improve health outcomes. All of us will benefit from the resulting lower health care costs.
The danger is that we will fail to act, as we failed to act to prevent the spread of HIV infection. As the Free Press noted, referring to the failure to respond in a timely fashion to the social and economic conditions promoting the spread of HIV: “The truly disturbing element is that there were years to prepare, to educate and to protect people living in social conditions that make them particularly vulnerable. It didn’t happen”.
There is a lesson to be learned: invest now to improve social and economic conditions in order to prevent worse problems in future. Why does this simple lesson seem so hard to learn?
Jim Silver is co-editor, along with Lynne Fernandez and Shauna MacKinnon, of The Social Determinants of Health in Manitoba, published by the Canadian Centre for Policy Alternatives-Manitoba in 2010.