Health in Wealth

"When you look at those people, the one thing that unifies them -- not always but predominantly -- is that they're poor."
"The hospital is a very good system for those acutely ill people who have entitlements and are bright and know how to use it. But when you're chronically ill and you don't have those same entitlements, it doesn't give you very good care. And it's very expensive."
"I think you can address those populations and get better outcomes by doing things differently. By and large, those people have chronic diseases. By and large, they don't have access to the services that you and I would get because of multiple factors, including poverty and class."
"Hospitals recognize that there's not just a health services imperative, but a financial imperative. You save money by doing this and you provide better outcomes."
Dr. Jeffrey Turnbull, chief of staff, The Ottawa Hospital

Dr. Turnbull is addressing the issue of poverty and health, the fact that his hospital sees more frequent use by far of emergency services among the homeless who require mental and physical health services, who suffer from substance abuse and lack of housing services. He speaks of other high-needs patients, like the frail elderly, those with complex chronic diseases, their condition made more complex by mental health or substance abuse issues.

A new study has found that giving homeless people a place to live first, then offering services for other issues such as mental illness and addictions, helps them become self-sufficient. Photograph by: John Lucas/Edmonton Journal , Postmedia News

A number of Canadian studies have definitely established a very direct link between income levels and rates of disease. Wealth equals health; lack of money results in frail health and more frequent calls on public health facilities; expensive to look after because by the time these needy people arrive at a hospital their condition is so far advanced they require far greater interventions; more attention from health professionals, longer hospital stays, expensive medications.

Low-income Canadians become more ill, are more likely to end up in hospital and are far more likely to die at a younger age than their wealthy counterparts. The Canadian Institute for Health Information identified the ailments most closely associated with socio-economic status. Their 2008 study, Reducing Gaps in Health: A Focus on Socio-Economic Status in Canada, explored hospitalization activity in the 15 largest cities of the country, grouping patients into three categories.

Grouping people into three categories the study concluded that those in the lowest socio-economic group were hospitalized for substance-related disorders 3.4 times more frequently as those in the highest income group; more than twice as likely for hospitalization with chronic obstructive pulmonary disease (COPD), diabetes and mental health illness. A larger, long-term Statistics Canada study released in July 2013 established a correlation between income and life expectancy.
               

A new four-year study has found that a housing-first approach to people who are mentally ill and homeless is effective and saves taxpayers money. CBC News

That study followed 2.7-million Canadians between the years 1991 and 2006; once again for comparison purposes the subjects were grouped into five income quintiles. The 16-year study found 426,979 people (16% of the total) had died, leaving researchers to discover mortality rates increased as income levels declined. "Each successively lower level of income had a higher mortality rate", concluded the study.

Low-income Canadians were likelier than wealthier people to die from HIV/AIDS, diabetes, COPD, suicide, alcohol or drug-related diseases. People living in the city of Hamilton's richest-income neighbourhood were found by researchers to enjoy a life expectancy of 86.3 years representing 21 years more than their counterparts living in the same city's impoverished part of town. A 2008 study in Glasgow, Scotland, found a 28-year-gap in life expectancy between the city's best and worst neighbourhoods.

An emerging consensus holds that the health care system can deliver better care and cut costs in the process through the expedient of providing extra social services for people stuck at the bottom of the social hierarchy. The theory bases its assumptions on the fact that those at the bottom -- the sickest, suffering the highest rates of chronic disease -- also represent the greatest users of the hospital system. And it is not necessarily a Canadian phenomenon; this kind of thing crosses all geographic boundaries.

Dr. Atul Gawande, writing in The New Yorker, had this to say of the American system of health care and poverty: "The critical flaw in our health care system ... is that it was never designed for the kind of patients who incur the highest costs." What is true for the United States is true also for Canada. Hospitals were established to react medically to emergency situations; they are less adept in managing complex, chronic diseases. The examples are given of a homeless man battling alcohol addiction who also has a brain injury.

Another of a older woman suffering from heart disease, obesity and diabetes unable to afford healthy food, and the 70 year-old man who lives alone and copes with COPD and  high-blood pressure, with no family doctor. These people arrive often at the hospital for emergency care. High needs patients like these, according to the Ministry of Health, represent five percent of Ontario's population, yet consume two-thirds of the health-care budget.

The province has launched a new program to address these issue, called Health Links, which encourages hospitals, family doctors, long-term care homes and community groups to engineer a useful coordination of the care of such high-needs patients for the purpose of reducing the number of emergency department trips and hospital re-admissions. Once established, the Health Links program will identify such high-needs patients to ensure each has an individualized care plan.

"Even if you were to make a modest, ten percent improvement -- some of these people have 30 or 40 visits to the emergency department in a year -- it's a huge, huge savings, particularly when you multiply that across the province."
"If we can get it right for them, we can bring down costs for the health care system."
Chantale LeClerc, chief executive officer of the Champlain Local Health Integration Network, Ottawa regional health authority