Tom, 46 years old and a skilled carpenter, came into my office the other day. He has not worked for the last eight years since he hurt his back in a car accident. He is often depressed and spends days at home, sometimes without leaving his bed. He used up the settlement from the insurance company three years ago, then his savings, and now lives on social assistance, struggling to survive on $600 per month (including his rent). He lives with two other men in a squalid apartment.
I would like to treat his mood with medications and counselling, and I would like him to go to physiotherapy appointments to rebuild the strength he lost after his injury. He would like enough money to move into proper housing, feed himself, and be able to present himself with dignity again. He would also like to be supported in recovering from his physical and mental injuries, and wants nothing more than to get back to work. For him, social assistance has not been so much a safety net as it's been a fish net -- a trap of indignity from which he has been unable to wriggle free.
With the release of the final report of Ontario's Social Assistance Review Commission looming, I see more than ever how relevant a strong, respectful, recovery-oriented, social assistance system could be to the health of my patients who live in the most extreme poverty.
The health research evidence supports the need to improve the lot of people on social assistance. The strong association between poverty and poor health is irrefutable, and has been demonstrated consistently across different periods in history, parts of the world, and groups of people.
But the health needs of people who live on social assistance are at the extreme end of the spectrum.
A report by the Wellesley Institute in 2009 showed that people who live on welfare are at far higher risk of death and sickness than other people who live in poverty. Social assistance recipients were found to have far higher rates of chronic illness. Dramatically, those on social assistance were 18 times more likely to have attempted suicide in their lifetimes.
A reform of social assistance should be judged on its ability to improve the health of the most economically vulnerable Canadians. A health-focused reform would require three essential components. First, a respect for the lived experiences of those who experience extreme poverty. I have yet to meet a patient who is happily living on welfare. Many tell me of the constant weight placed on their shoulders by a system that makes them feel like they have failed themselves and their society, while forcing them to live in extreme poverty.
Second, a focus on recovery from the health impacts of living in poverty, and the disabling conditions experienced by many who live in poverty. This approach, again, requires a shift away from a punitive system towards one that is respectful and nurturing of the abilities of each individual.
Finally, a level of support that allows for a dignified standard of living. Forcing people to live in squalor and survive on less than a pittance only worsens the health impacts of their low income. While this may appear to save money up front, it likely ends up being spent elsewhere, through higher use of physical and mental health services down the road.
Social assistance reform, if done right, can lead to better health for all. As Richard Wilkinson demonstrates in his excellent book, The Spirit Level, the healthiest societies are those with the least income inequality. And these health benefits reach everybody -- even those earning the highest incomes.
By strengthening our social assistance system, and by focusing on a respectful process of recovery for those who live in poverty and outside the workforce, we can take a big step toward becoming a less unequal, and a healthier society.
From my perspective, a person-oriented and recovery-oriented reform of social assistance is the most powerful prescription I could write for Tom and my other patients who live in the destitution forced on them by our current social assistance system.
Gary Bloch is an expert advisor with EvidenceNetwork.ca and a family physician with St. Michael's Hospital in Toronto.