Thinking large and small in the inner city

A roof over our head. Enough to eat. Income and decent work to support a life.  These are a lot more important to our health than pharmaceuticals and hospitals.

In this excerpt from Upstream Medicine: Doctors for a Healthier Canada, Upstream thinker and ally Dr. Ritika Goel explores some of her experiences as an inner city doctor in Toronto.

Zachery Hynes: Thinking about the social determinants of health, what forces do you see most affecting the health of your patient population?

Ritika Goel: I would say income and housing are probably the biggest social determinants I see in the general population of homeless men and women. We know that income is the number one determinant of health, and I have certainly seen the impact of even the difference between people being on social assistance, where they are only receiving around

$600 a month through Ontario Works, which is welfare, and then we are able to get them onto the Ontario Disability Support Program, and then they are accessing about $1,000 a month.

"How many people would perhaps be doing so much better in their mental and physical health if they just had a place to stay at night?"

I think of a young man in his late twenties, of Indonesian background, who has been my patient for a few years now and has bipolar disorder. He always presented to me in a very chaotic manner. I saw him several times when he was manic, either just as he was hospitalized or just after he was hospitalized, and I remember the tremendous difference I saw in him when he got housed.

It was incredible; it was like I was seeing a different person. He even said to me, and I was impressed at his insight, “You know, when you saw me before, that was who I had to be, because I was on the street. I was in the shelter. I was living that life. I was using. I was gambling. I was just in that space.”

Somehow, I think being housed provided him the stability to see himself in a different light and to be able to think of a different life for himself. Even as we talk about bipolar disorder as a disease, we rarely talk about it as something that can be influenced that dramatically by housing.

It makes me wonder how many people we are inappropriately treating. Obviously, pharmaceutical treatment has its place, but how many people would perhaps be doing so much better in their mental and physical health if they just had a place to stay at night?

ZH: It makes me think of triple-therapy, how we wouldn’t prescribe one-third of a drug regimen we know to be effective. But in a sense, that’s what we’re doing by treating an illness like that with pharmaceutical therapy alone.

RG: It’s a similar story with patients who are refugee claimants. In Canada, when you arrive and make a refugee claim, you get put into the refugee shelter system, but people are not able to get a work permit for several months.

"Sometimes the best treatment is getting your immigration status."

So I see people having just arrived in this new country; they’re in a shelter, they’re on welfare, they have this refugee claim, and they don’t know what is going to happen. When their claim has been accepted, and they’ve gotten housed, they have a work permit, and now they’re starting to work, and they’re starting to get their permanent residency with a plan to bring their family over – it’s an incredible transformation in the levels of anxiety and insomnia, depression, suicidal thoughts, and even the manifestations of post-traumatic stress disorder (PTSD) like nightmares and flashbacks.

You see this dramatic change in people once they know that they are in a safe place that they can now call home permanently, and that they are able to begin their new life. Conversely, you’ll see the people whose immigration situation gets dragged out over years and years, and they can’t ever feel completely settled and calm because they don’t really know what’s going to happen. Sometimes the best treatment is getting your immigration status.

For more from Dr. Ritika Goel, check out this fourth episode of Upstream Radio on employment security and the precarious future of work in Canada.

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




ritpic.jpgDr. Ritika Goel is a family physician working with marginalized populations in inner-city Toronto, and a passionate advocate of health equity in Canada through her writing and public speaking. She serves as board member and volunteer physician at the Scarborough Community Volunteer Clinic for the Uninsured, serves on the Ontario College of Family Physicians’ Poverty and Health Committee, is a founding member of Students for Medicare, and serves on the board of Canadian Doctors for Medicare.

Connect upstream.