A prescription for poverty
Recognizing that poor people are at higher risk of illness, a health-care team at St. Michael’s Hospital is offering patients access to social workers, legal aid — and, most important, money
Ten years ago, Dr. Gary Bloch examined dozens of the city’s poor on the lawn before Queen’s Park, and prescribed them money.
Amid the political theatre, he was filling out vague provincial “special diet” forms, which — once in the hands of the patients’ caseworkers — would bump their miserly $500 monthly welfare payments by as much as $250.
“That lit a light bulb — that we could directly intervene in poverty,” says Bloch. “That informed everything that’s come afterwards.”
The provincial government tightened the wording on the forms a year later, requiring doctors to diagnose patients with specific diseases to qualify for the “special diet” money. Bloch and his colleagues with the newly formed Health Providers Against Poverty wound down their massive “hunger clinics.”
They’d made their point: poverty made people sick.
At the time, Bloch was a 30-year-old doctor, treating homeless people in city shelters and drop-in programs. Most of his patients were in terrible shape. He offers an example: a man who’d lived on the street half his life. He had diabetes, had suffered strokes and multiple head injuries, and was an alcoholic. “He was just 42, but he had the body of a 75-yearold, and his brain was veering towards dementia,” says Bloch.
Was he to blame for his current condition? Why didn’t he get a job and cut out the booze? That’s our culture’s predominant view on both poverty and health. But Bloch understood that poverty was like smog — it insidiously causes illness.
The poorest Canadians are twice as likely to develop diabetes as the richest. They’re more likely to suffer from cardiovascular diseases, respiratory illnesses, lung cancer, depression and arthritis. As Toronto Public Health reported in April, poorer young women are more likely to get chlamydia infections.
This is not just because of their lack of money. But it’s all the other things that come with poverty: insecure housing, unstable employment, social exclusion, food insecurity, poor education. In medical parlance, these are now called the “social determinants for health.”
Take Bloch’s homeless patient: "He had residential school, little education, no supports,” he says. “The most I could hope for him was to have a decent meal and move him into something like a palliative care program.”
Illnesses of poverty are hard to treat, once they’ve settled. The answer, Bloch realized, was preventing them in the first place.
He devised a four-page pamphlet for doctors to treat poverty. It advises them to screen for poverty as they do for cancer and hypertension. But in place of medicine or lifestyle changes, his list of suggested prescriptions is applying for government subsidies and benefits.
He delivered the pamphlets to family medical clinics across the city and spoke to doctors and nurses about pov-erty as a disease.
At the same time, Bloch was working part-time at the St. Michael’s Hospital's bustling family and community medicine department. There too, his pa-tients are largely low-income.
Bloch’s treatments there have in clud-ed phoning the welfare office to advocate for a patient’s increased benefits and meeting Toronto Community Housing managers to demand that problems with a patient’s unit be rectified.
When a patient lost her child-care subsidy, Bloch went straight to the city
manager. “She was experiencing depression and was overwhelmed with having to take care of three children, one with a developmental delay,” he explains. “The stress would have put her at huge risk of physical health decline as well.” She got the subsidy back.
You might think of this as social work. Bloch and his mentor Dr. Philip Berger, who ran St. Michael’s family medicine department for 13 years, say it’s an in- tegral role of a physician.
“Doctors have a duty to raise their voices loudly on behalf of their patients who can’t and . . . to hold the government accountable if their policies make patients sick,” says Berger, who now oversees the University of Toronto’s undergraduate medicine advocacy programming.
Bloch comes from a long line of social justice doctors. His grandmother, a ref- ugee who escaped Germany on the cusp of the Second World War, treated the poor in the townships of Port Elizabeth, South Africa. His mother’s medical practice focused on homeless youth in Vancouver. It was at Habonim Dror, socialist-Zionist summer camp, that Bloch formed his politics and penchant for activism.
“We would read Marx and Engels,” says Bloch, now married with three children. “I came into medicine with that analysis.”
On a whim two years ago, Bloch applied to the Ministry of Health and Long-Term Care for money to hire a health promoter within the St. Michael’s family practice clinic — someone whose job would be to help patients access money, serving all 70 doctors on staff there.
To his amazement, the province agreed and funded the position. Health Minister Eric Hoskins said he’s watching with great interest.
“Since then, we’ve seen an incredible explosion of programs,” Bloch says. A social worker was hired to the team. A lawyer recently arrived. A reading program was launched, prescribing books to children at their annual checkups.
An employment program for patients is in the works.
“My hope is, in the medical world, this is seen as core to medical practice,” says Bloch, now 40. “I want poverty to be treated like smoking.”