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  • Photograph by Health Providers Against Poverty

From the clinic to the capital: Advocating for systemic change

More and more in family medicine, health professionals are "prescribing income" to improve the health of their patients, like helping to educate them on things like tax returns.

In this excerpt from Upstream Medicine: Doctors for a Healthier Canada, upstream St. Mike's doctor Gary Bloch speaks to the relationship between poverty and health, and how a focus on income can broadly improve the well being of all Canadians.

Justin Neves: So many social issues have an impact on health. Somewhere along the way you took a particular interest in poverty and low-income populations. How did that come about?

Gary Bloch: I think there are a of couple pieces to that. One – and this is very common to many people who consider themselves progressive or social justice minded – is that you get sucked into an endless number of issues. There is a campaign on everything, and it can become very overwhelming. I have seen people not know how to control that, not know where to pull back, and not know how to focus, and quite honestly not be that effective because they are spreading themselves so thin. So there was certainly a thought in my mind that I would have to focus somewhere, at some point, and couldn’t take on the world completely.

"We could legitimately prescribe every person in these clinics who lived on welfare the full $250 per month supplement based on the diagnosis of poverty, given the health evidence that we have linking poverty with poor health outcomes."

My poverty focus happened somewhat by chance. Soon after residency, I got involved in a campaign to raise welfare rates in Ontario. It was led by the Ontario Coalition Against Poverty, a well-known radical anti-poverty group, not one that traditionally allies with doctors at all. They had decided to start up clinics assessing people for something called the Special Diet Allowance, which provided an extra $250 in monthly income, and wanted to find health professionals willing to staff these clinics. I was part of a small initial group of providers who got involved.

What was amazing about that campaign for us was that as we looked at regulations around the Special Diet program, we realized that they were very loose. We decided that we could legitimately prescribe every person in these clinics who lived on welfare the full $250 per month supplement based on the diagnosis of poverty, given the health evidence that we have linking poverty with poor health outcomes.

"Income is quite honestly a catch-all social determinant of health."

This was a real eye-opener for me. It suddenly gave us a whole new role within anti-poverty social justice movements. This was very much a campaign led by people affected by poverty and living with low income. Suddenly, we were able to directly intervene, to essentially use medical skills to address poverty. Prescribing income was the catchphrase that came out of that work.

Income is quite honestly a catch-all social determinant of health. Low income is common ground for those who experience the most vulnerability and marginalization, and can help us build a more complex analysis of what that means. The other piece is that poverty is something very easy for people to understand. So as opposed to coming in talking about the intersectionality of multiple social issues, we are talking about people living without enough money to survive, or at least to afford to live the kind of lives they deserve to live.

The other lesson that came for me out of the Special Diet campaign was that if we wanted to expand this beyond this initial group of about eighty health providers in that campaign, we would have to be a little smarter about how we messaged and marketed this idea. The subsequent ten years of work have really largely been about that – about repackaging this idea to bring the much broader health world on board.

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JN: There are so many opportunities for doctors, especially family doctors, to engage in this kind of work, not just treating patients’ hypertension and diabetes with medication, but looking at what they are eating and why they are eating that way – tracing these factors upstream. How do we continue to push the envelope and engage more physicians in these kinds of discussions and programs?

"This is the sort of stuff that should be very easily incorporated into front-line practice."

GB: I use two catchphrases here. One of them is using the stages- of-change approach, which is obviously borrowed from the addictions literature, which is the idea that you have to meet people where they are and push them incrementally. So if there are doctors who have never thought about intervening in a social issue in their career, you can’t then expect them to jump out to the front lines of a protest or write a policy paper. But if you can help them start screening patients for low income to find out who in their practice lives in poverty, hopefully that will evolve into them wanting to do something about it.

The other catchphrase I tend to use is a trickle-up approach, the idea being that successful experiences with basic interventions will trickle up into higher order ones, and wanting to deal with the more systemic issues. One of the basic interventions we offer health professionals is a clinical tool on poverty, which is basically a four-page handout but looks like a clinical tool on diabetes or heart disease.

This tool lays out a very simple three-step approach to poverty that can be used by primary-care providers in front-line offices in ten- to fifteen-minute appointments: screening everyone, taking into account the evidence linking poverty and poor health, and very basic interventions to increase income directly through available social programs. This is the sort of stuff that should be very easily incorporated into front-line practice.

Read the whole story, and twenty others in the new book Upstream Medicine: Doctors for a Healthier Canada.

Watch Dr. Bloch speak a few years ago in the TedX Talk below.

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bloch_profile.pngDr. Gary Bloch is a physician at St. Michael's Hospital in Toronto and an Assistant Professor at the UofT's Department of Family and Community Medicine. He founded and chairs the Ontario College of Family Physicians' Committee on Poverty and Health, is a founding member of the advocacy group Health Providers Against Poverty, and helped establish the Inner City Health Advocates in Toronto.

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