Income isn't just a determinant of health — it's the determinant of determinants.
Leslie is a single mom who used to live in downtown Toronto. I’ve been her family doctor for a decade. When I met her, she was living with her teenaged son and was in close daily contact with her father. She had her share of health problems, but they didn’t stop her from living her life. Then her breathing troubles began.
Leslie suffers from severe asthma. She uses multiple puffers and has been on and off prednisone (a powerful drug with significant side effects) many times to try to control her symptoms. She’s been seen by specialists and has been in and out of the emergency department dozens of times. But she didn’t have asthma when I met her. It started when the social housing unit she lived in had a flood. Mould grew inside the walls of the building, and Leslie’s health began to deteriorate.
She took photos of the mould and brought them to her landlord. Her doctors, including me, wrote letters of support, trying to get her moved to another apartment or another building. During that time, her physical and mental health deteriorated. She became depressed. Her relationships fell apart. She gained weight and her blood pressure worsened, in part because she couldn’t exercise due to her breathing problems.
"The biggest disease that needs to be cured in Canada is the disease of poverty."
There was a period of time when seeing Leslie’s name on my clinic list meant preparing myself to write letters or fill out forms, and lots of them. Letters to the social housing authority, to her building superintendent, to her case worker. And then, as it became clear that her health wasn’t going to improve, application forms for permanent disability benefits. It took her, and us, two years to get the system to respond to her requests for a new apartment in Toronto’s social housing system. By the time she moved, to an apartment far from her existing community, she wasn’t the same person anymore.
There’s a reason I felt powerless in the face of Leslie’s cough. Leslie wasn’t sick with asthma. She was sick with poverty — and she still is. She was afflicted by a lack of access to appropriate housing and the basic human dignity that comes with being able to make the choices we all want to make to stay healthy.
One of the best ways to help Leslie and other Canadians facing the same challenges can be explained without even a passing reference to health care. But acting on it would do more to improve health than any single other policy our governments could embrace.
Far more than consumption of medical care, income is the strongest predictor of health. Canadians are more likely to die at an earlier age and suffer more illnesses if they are in a low income bracket, regardless of age, sex, race, and place of residence.
There are at least two ways in which income is related to health. First, income allows people to purchase the things that are necessary to survive and thrive, such as nutritious food and safe shelter. Second, income affects health indirectly, through its effect on social participation and the ability to control life circumstances. Put another way, the biggest disease that needs to be cured in Canada is the disease of poverty, and part of the cure is to implement a big idea: A Basic Income Guarantee for all Canadians.
We can eliminate income poverty by ensuring that no one in Canada has an income below what’s needed to achieve a basic standard of living. If we did so, we’d see a considerable improvement in the health of Canadians. The Basic Income Guarantee goes by various names (such as the guaranteed annual income, the negative income tax, and the basic income), and there are different ways to design it. The version I like best works like this: if your income from all sources falls below a certain level, you get topped up to a level sufficient to meet basic needs. That’s it. A true Basic Income Guarantee would ensure that everyone in Canada has an income above the “poverty line.”
The Basic Income Guarantee can’t and mustn’t replace all social programs. We still need good public education, publicly financed health care, quality affordable child care, affordable housing, and reliable unemployment insurance. But it would eliminate the need for the kinds of income support programs that invade people’s lives and limit their choices.
Many existing programs, such as social assistance in Canada or food stamp programs in the United States, are based on a highly paternalistic approach to social welfare. Such systems also require substantial administrative investments — forms have to be filled out, case workers must meet with recipients, people are required to prove that they’ve been looking for work and to account for how they spend their money . . . the list goes on.
"When we try to micro-manage our assistance to people, we insult their humanity and their intelligence. And we don’t help them much at all."
No Canadian has expressed the benefits of the Basic Income Guarantee better than former Conservative senator Hugh Segal. As he’s consistently pointed out, if our tax system topped up everyone who was beneath the poverty line to above it, we’d liberate millions of dollars currently used on provincial social assistance programs. And recipients “would not be treated as dim creatures, incapable of making decisions; they would be treated as human beings trusted to make life choices.”
When I was a resident working at St. Michael’s Hospital in Toronto, Fatou, a young woman who’d recently arrived in Canada from Senegal with no family or other supports, came under my care for her pregnancy. As I began seeing Fatou for her regular prenatal checkups, I became very conscious of her vulnerability. I knew that Fatou was underhoused, moving back and forth between the homes of members of her community and a women’s shelter, and that she was on social assistance. We had long conversations about how to take care of herself in her pregnancy. I gave her printouts with lists of public health dental clinics, local food banks, and charities that provided some basics to low-income new mothers.
However, I became concerned in the middle of her second trimester: Fatou was simply not gaining weight. Her belly was getting bigger, but I could see that the rest of her was shrinking. I sent her for various tests looking for thyroid problems or parasites. Over and over I explained to her how much she had to eat in order to maintain a healthy pregnancy. I told her to make sure she went to the food bank if she couldn’t afford to buy the food herself. I drew little maps of where the food bank was. I found myself feeling frustrated because I was working so hard to help her and felt she wasn’t doing her part to help herself. After weeks of these discussions, she finally broke down crying.
She explained that she’d been going to the food bank, but that she’d had to throw out most of what she got there. It all came in weird boxes and she couldn’t figure out what it was or how to prepare it — boxes of macaroni and powdered cheese, cans of ravioli, and other items that were essentially unrecognizable to her as food. She didn’t know what to do with it. And she was too ashamed to say so; instead, she went hungry. Had she been given a bag of rice and a bag of beans, Fatou would have known what to do. Better yet, if she’d been given the money she needed to live on, she could have purchased and prepared food herself.
I remember this case with shame. I did too much talking and not enough listening. I also remember it as a powerful illustration of how wrong we are as a society to think we know better than people themselves do about how to spend their money. When we try to micro-manage our assistance to people, we insult their humanity and their intelligence. And we don’t help them much at all.
Basic Income Guarantee pilots have been done all over the world. The single Canadian example was carried out in Manitoba. In the 1960s and 1970s, the extent of poverty among seniors and other groups across North America was becoming a significant concern. South of our border, building on the momentum of President Lyndon Johnson’s “war on poverty,” the Office of Economic Opportunity ran four Basic Income Guarantee experiments; and in Canada, Prime Minister Pierre Trudeau’s Liberal government decided to launch its own. The newly elected Ed Schreyer, Manitoba’s first ever NDP premier, volunteered the province as the site for the experiment.
In 1974 the project was introduced in Winnipeg and in the small farming community of Dauphin. They called the experiment Mincome. The purpose of Mincome was to determine the effect of offering a guaranteed income on work effort. Would people quit their jobs? Would the costs of the program balloon as people dropped out of the workforce? In Winnipeg, a small proportion of the total population was chosen to participate. For comparison, participants were matched to people just like them who continued to use the existing set of social programs. In Dauphin, they tested a different model: everyone who lived in the town of ten thousand received the same guarantee.
A comparator group of people was selected from nearby communities to complete various surveys but did not receive support. In Dauphin, any individual who had no income from any source would receive an income of approximately 60 percent of the Low Income Cut-Off (the unofficial poverty line). As their earned income increased by one dollar, benefits would be reduced by fifty cents until they disappeared entirely. The unanticipated high levels of unemployment in the years following meant that more families sought more assistance than anticipated.
When Mincome researchers approached the federal and provincial governments for more funding, they found that priorities had changed. Provincially, in 1976, the Schreyer government lost to the Sterling Lyon Conservatives, who weren’t interested in helping out a struggling NDP research project. The families continued to receive support, but the research aspect of the project came to an end. Not long after Mincome ended in Dauphin, scholars from the University of Manitoba dug into the data to examine the work outcomes for Winnipeg participants.
"The reduction reflected a decrease in health care use across the entire population."
Much like their U.S. counterparts who scrutinized results from the American experiments, they found very little reduction in the number of hours people worked in response to having a guaranteed income. In other words, the fear that the money would impel people to stop working wasn’t borne out.
Two groups, however, did reduce their hours worked: married women who used the income to “buy” themselves longer maternity leaves (which at the time were in the four- to six-week range) and “young, unattached males” who reduced their work effort substantially and stayed in school instead. Most of the remaining Mincome data sat in boxes in a warehouse for over thirty years.
Enter Dr. Evelyn Forget, a health economist at the University of Manitoba. In 2006, she decided it was time to learn about the impact of Mincome in Dauphin. Using databases only now available in the twenty-first century, she was able to reconstruct the story. The Forget research team compared the outcomes of people who lived in Dauphin to people with similar characteristics who lived in similar communities in other parts of Manitoba at that time.
The results were striking. Before Mincome came along, residents of Dauphin were 8.5 percent more likely to be hospitalized than people like them in the neighbouring communities. But by the end of the program, this hospitalization gap had completely disappeared. Mental health visits also declined, both in hospital and in family doctors’ offices. Overall, the reduction reflected a decrease in health care use across the entire population of Dauphin. This is known as the “social multiplier effect”: if something is good for many of your neighbours, the positive effects spill over to you as well.
The Basic Income Guarantee isn’t a pipe dream. In Canada, we already have one for seniors: Old Age Security and the Guaranteed Income Supplement. We also have one for families with children, called the Canada Child Benefit. Taken together, they essentially offer a Basic Income Guarantee to around one-third of the Canadian population.
What is left now is to close the gap so that every Canadian can be protected from the health effects of poverty. By dissolving some programs, recouping some of the savings from other parts of the health and social services systems, saving on administration, and investing some of our collective wealth, we could design a Basic Income Guarantee that would deliver a huge return on investment.
Excerpted from Better Now: Six Big Ideas to Improve Health for All Canadians, by Dr. Danielle Martin, on sale January 2017 (published by Allen Lane, a division of Penguin Random House Canada). Adapted with permission, first published in Chatelaine.
Dr. Danielle Martin is a family physician and vice-president, medical affairs and health systems solutions, at Women’s College Hospital in Toronto.