Reducing the cost of inequality

The health care system struggles daily to manage a large and growing burden of disease. It is the role of public health to reduce that burden, which is why investment in public health is so valuable. But public health is also committed to reducing health inequalities. There are, of course, good ethical reasons to do so — as a country, we believe in fairness and justice. But there are also good pragmatic reasons: the health costs of poverty are very large.

There are many forms of inequality in health, but I will focus on two that are of fundamental importance: health inequalities rooted in poverty and health inequalities experienced by Canada’s Indigenous people.

A 2011 Statistics Canada study of life expectancy at birth for 2005–2007, by neighbourhood quintiles (which tends to underestimate differences), found the gap between lowest and highest income groups to be 4.7 years for men and 2.3 years for women. A study in Hamilton, cited in the CMA’s 2013 report Health Care in Canada: What Makes Us Sick?, found a 20-year gap in life expectancy between the lowest and the highest census tracts.

The situation for Indigenous people is worse, especially among the Inuit. In 2008, the life expectancy in Nunavik was 16.7 years less than for the total Canadian population. A 2010 Statistics Canada report on Aboriginal health found that whereas “life expectancy for the total Canadian population is projected to be 79 years for men and 83 years for women” in 2017, for Métis and First Nations populations it would be five to six years less for men and three to five years less for women, and for Inuit people it would be 15 years less for men and 10 years less for women.

Faced with this deeply inequitable situation, public health looks upstream for answers, to the economic, social and environmental inequalities that some Canadians experience. In the case of Indigenous people, we also look to the impacts of colonialism, racism and what the Truth and Reconciliation Commission of Canada called cultural genocide.

It would be hopelessly naive to imagine that we can remove all inequality — some at least is rooted in our biology, after all. What we can do is ensure that there is no absolute poverty — especially in a society as wealthy as Canada — and tackle inequity, which is unfair inequality that is preventable.

As Kate Pickett and Richard Wilkinson showed in their book The Spirit Level: Why More Equal Societies Almost Always Do Better, the degree of inequality and the steepness of the gradient matters. For a wide range of health and broader social outcomes measured across different countries, the greater the degree of inequality, the worse the outcomes.

This makes poverty very expensive. A 2008 study of the costs of poverty in Ontario estimated the costs to the residents of Ontario to be a staggering $32 billion to $38 billion a year. The authors pointed out that this is the equivalent of 5.5% to 6.6% of provincial gross domestic product.

Included in this total are the additional health costs of poverty. A 2016 report from the Public Health Agency of Canada found that for 2007/08 socioeconomic health inequalities cost Canada’s health care system “at least” $6.2 billion annually — and that was only looking at acute care in-patient hospital admissions, prescription medications and physician consultations. A 2015 report from the Canadian Institute for Health Information found that reducing income-related health inequalities could result in substantial savings for the the health system.

Indeed, one can argue that poverty is so expensive we can’t afford it. Which is why you will see public health supporting Indigenous people across Canada in their struggle for self-determination and joining with anti-poverty groups in pushing to eliminate child poverty, implement antipoverty strategies and consider guaranteed incomes, as Ontario is now testing.

The additional burden of disease attributable to poverty is a self-inflicted societal wound that sickens and kills, overburdens the health care system and costs us all a great deal of money. Removing that burden makes ethical, health and economic sense.