This document discusses poverty and health inequities. It finds that those living in poverty experience significantly higher rates of many health issues compared to more affluent groups. For example, in Saskatoon low-income residents are over 1000% more likely to be hospitalized for diabetes or have chlamydia. A survey found most people agree the poor have worse health, and support policies to strengthen early childhood programs, increase income supplements, and expand disease prevention. The document calls on governments and communities, including faith groups, to work together using evidence-based solutions to improve conditions for daily living and reduce health inequities over time.

1. Poverty is Making Us
Sick:
What Faith Communities Can Do
to Achieve Health and Social Justice
Dr. Cory Neudorf,
Chief MHO Saskatoon Health Region, and
Associate Clinical professor, U of S

2. Introduction: What does it all mean??
Health Disparity – differences or variations
between groups
Health Inequality – implies the need for equality
Health Inequity – implies a value judgement …
things are unfairly distributed
 E.g. equality does not always imply equity. Perhaps some
groups need something more than others (equal service for
equal need)

3. What “determines” Health?
 The fundamental conditions and resources for
health are:
• peace,
• shelter,
• education,
• food,
• income,
• a stable eco-system,
• sustainable resources,
• social justice, and equity.

4. National and International Work on
Health Inequalities/Inequities
WHO Commission on the Social
Determinants of Health Final
Report August 2008 “Closing
the Gap in a Generation:
Health Equity Through Action
on the Social Determinants of
Health”

9. WHO Commission
Recommendations
Three principles of action
1. Improve the conditions of daily life – the
circumstances in which people are born, grow, live,
work, and age.
2. Tackle the inequitable distribution of power, money,
and resources – the structural drivers of those
conditions of daily life – globally, nationally, and
locally.
3. Measure the problem, evaluate action, expand the
knowledge base, develop a workforce that is trained
in the social determinants of health, and raise public
awareness about the social determinants of health.

10. National and International Work on
Health Inequalities/Inequities
 “CPHO Report on the State of Public
Health in Canada” May 2008

11. CPHO Report: Public health in Canada
Source:Dahlgreen, G. & Whitehead, M. (2006). European strategies for tackling
social inequities in health: Levelling up Part 2. World Health Organization.
Factors that influence our health

12. Our health – Life expectancy
Life expectancy at birth by neighbourhood income and sex,
urban Canada, 2001
Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs.
Source: Wilkins et al. (2007), Statistics Canada.

13. Our health – Life expectancy
Source: Indian and Northern Affairs Canada, Basic Departmental Data, 2004.
Life expectancy at birth by sex, Registered Indian and general population,
Canada, 1980-2001

14. Our health – Causes of death
Age-standardized mortality rates for lung cancer
by neighbourhood income, female, urban
Canada, 1971-2001
Age-standardized mortality rates for ischemic
heart disease by neighbourhood income, male,
urban Canada, 1971-2001
ASMR – Age-standardized mortality rate.
Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs.
Source: Wilkins et al. (2007), Statistics Canada.

15. Health behaviours
Source: Statistics Canada, Physically Active Canadians.
Percentage of the general population aged 12+ years who were physically
active by income, Canada, 2005

16. Addressing inequalities
Making a difference to reduce health inequalities involves these priority areas for action:
 Social investment
 Canada can build on its strong policy foundations to further reduce the gap that contributes to
health inequalities
 Community capacity
 Strong communities are critical. Broad social policy and investments are needed to
compliment and support community efforts
 Inter-sectoral action
 All levels of government, the private and non-governmental sectors, and international
organizations can work together towards integrated, coherent policies and actions to effectively
prevent and improve upon health inequalities
 Knowledge infrastructure
 Reducing health inequalities requires building knowledge: better information about specific sub-
populations/regions; a greater understanding of how determinants interact; and stronger
insight into how to apply proven practices from other jurisdictions
 Leadership
 Leadership across all sectors is crucial to reducing health inequalities.

17. Moving forward
 Foster collective will and leadership
 If Canadians want to be the healthiest population in the world, addressing health
inequalities must become a priority
 Working across sectors and jurisdictions, health inequalities can be reduced
through: recognizing role of prevention and promotion; developing indicators and
measurement tools; recognizing health as a shared responsibility; and engaging
leaders
 Reduce child poverty
 Some of the greatest returns on investment are those targeted to the early years
 Reducing child poverty requires examination of: income redistribution policies and
initiatives required for healthy childhood development; developing better
opportunities for children (e.g. housing, education); targeting interventions for
children at-risk; and adopting best practices from other jurisdictions
 Strengthen communities
 Communities are where all sectors and players can easily converge to establish
local priorities and develop shared strategies for addressing health inequalities
 Enhance Canadian communities by: working collaboratively to support community
efforts; improving access to skills/resources; sharing multi-level data; and
supporting the replication of proven successful initiatives

18. Reducing Gaps in Health:
A Focus on Socio-Economic Status
in Urban Canada
Nov. 2008
A collaboration between the
Canadian Population Health Initiative and the
Urban Public Health Network

19. Saskatoon Analysis of Dissemination Areas by Deprivation Index Quintiles

20. Pan-Canadian, Regina,
Saskatoon and Winnipeg
Comparison

21. Ratio of Age Standardized Hospitalization Rates Between Low and High
SES Groups, Pan-Canadian, Regina, Saskatoon and Winnipeg
2.3
1.9
2.0
3.5
3.8
4.2
4.5
4.7
8.5
1.6
2.8
1.3
1.8
2.5
3.0
3.9
1.2 1.2 1.3
1.6
1.3
1.4
1.9
3.4
2.7
2.42.3
1.6
1.1
2.4
2.2
1.9
1.7
2.2
3.4
6.4
3.43.3
3.4
2.8
2.4
2.0
5.0
2.7
3.0
3.7
3.4
2.1
2.2
1.8
1.9
1.3
0
2
4
6
8
10
Lowbirth
weight
Injuries in
children
Land
tranprot
accidents
Asthma in
children
Unintentional
falls
Injuries Anxiety
disorders
Affective
disorders
ACSC Diabetes Mental
Health
COPD Substance-
related
disorders
Ratio
Pan-Canadian Regina Saskatoon Winnipeg
Source: RQHR presentation on CPHI study

22. Ratio of Age Standardized Self-Reported Health Percentages
Between Low and High SES Groups, Pan-Canadian, Regina,
Saskatoon and Winnipeg0.8
0.9
1.1
1.2
1.2
1.2
1.5
1.8
0.7
0.8
1.1
1.1
1.3
1.6
1.8
2.2
0.8
1.1
1.1
1.5
1.2
1.2
1.6
2.4
0.8
0.8
1.1
1.3
1.4
1.4
1.5
1.8
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Self-rated
health
Influenza
immunization
Overweight or
obese
Activity
limitation
Alcohol binging Physical
inactivity
Risk factors Smoking
Ratio
Pan-Canadian Regina Saskatoon Winnipeg
Source: RQHR presentation on CPHI study

24. Saskatoon neighbourhood analysis boundaries,
excluding industrial and development areas, 2005
Legend
Affluent neighbourhoods
Rest of Saskatoon
Low income neighbourhoods
Source: Saskatoon Health Region, Public Health Sevices

25. Health Issue Rate Ratio (% higher)
Core : Total Saskatoon
Rate Ratio (% higher)
Core : Affluent
Hospitalizations
Suicide Attempts 3.75 (275%) 15.58 (1458%)
Mental Disorders 1.85 (85%) 4.27 (327%)
Injuries and Poisonings 1.54 (54%) 2.46 (146%)
Diabetes 3.98 (298%) 12.86 (1186%)
COPD 1.38 (38%) n/s 1.53 (53%) n/s
Coronary Heart Disease 1.34 (34%) 1.70 (70%)
Stroke 1.33 (33%) n/s 1.82 (82%) n/s
Cancer 0.89 ( no difference) n/s 1.02 (no difference) n/s

26. Physician Visits
Mental Disorders 1.52 (52%) 2.28 (128%)
Injuries and Poisonings 1.35 (35%) 1.91 (91%)
Diabetes 1.71 (71%) 2.11 (111%)
COPD 1.43 (43%) 2.42 (142%)
Coronary Heart Disease 1.12 (12%) 1.44 (44%)
Stroke 0.88 (no difference) n/s 1.58 (58%)
Cancer 0.77 (no difference) n/s 1.00 (no difference) n/s
Prescription Drug Use
Mental Disorders 1.21 (21%) 1.62 (62%)
Diabetes 1.80 (80%) 2.60 (160%)
Health Issue Rate Ratio (% higher)
Core : Total Saskatoon
Rate Ratio (% higher)
Core : Affluent

27. Public Health /
Reportable Diseases
Chlamydia 4.32 (332%) 14.89 (1389%)
Gonorrhea 7.76 (676%) n/a
Hepatitis C Notifications 8.04 (704%) 34.60 (3360%)
Complete MMR coverage
by age 2 yrs
Core 46.4% Avg. 68% Affluent 94.9%
No MMR by age 2 Core 10.7% Avg. 3.5% Affluent 1.7%
Health Status Indicators
Teen Births 4.21 (321%) 16.49 (1549%)
Infant Mortality Rates 5.48 (448%) 3.23 (123%) n/s
Low Birth Weight 1.46 (46%) 1.10 (10%) n/s
All Cause Mortality 1.04 (no difference) n/s 2.49 (149%)
Health Issue Rate Ratio (% higher)
Core : Total Saskatoon
Rate Ratio (% higher)
Core : Affluent

28. Income and Health, selected results
In comparison to high income residents, low income
residents in Saskatoon are:
 1458% more likely to attempt suicide
 1389% more likely to have chlamydia
 1186% more likely to be hospitalized for diabetes
 3360% more likely to have Hepatitis C
 1549% more likely to have a teen birth
 448% more likely to have an infant die in the first
year
Full immunization 46% vs 95% high income

29. Response to data
 Health workers and
general public
 Shock
 Denial moving to
reluctant acceptance
 Anger over degree of
disparity
 Motivation to change
 Inner city Community
& workers
 Less shock
 Anger and despair
 Desire to see action
 Willingness to partner
 Many ideas for change

30. SHR response to data
 Awareness of need to be responsible in the release of
the data
1. Need baseline data on community and staff awareness,
attitudes, willingness to change
2. Need to inform affected groups from community to government
(Communication strategy)
3. Need to have both a Health System action plan and a Social
Determinants of Health Action Plan to announce closely
following the data release
4. Ongoing study and evaluation
 Commitment to keep measuring the issue and effect of
interventions until things change

31. Survey Data Summary
 Baseline survey done to:
Measure public and staff awareness of Health
Disparities
Gauge public receptiveness to possible policy
interventions
 Plan to repeat survey once public
awareness campaign and media coverage
has had a chance to further inform people.

32. Survey Data Summary
 5000 respondents in and around Saskatoon with
representation from Inner city (including
interviews with homeless people and those
without telephones), rest of Saskatoon, and rural
residents.
 Response rate 62%. Representative by age,
income, neighborhood, income, cultural status. F
slightly > M

33. Survey Data Summary
 80% of people agree that the poor are more likely to suffer from
poor health
 However, they tend to assume it is only in areas such as suicide
attempts, diabetes, HIV/STI’s, while they feel there would be no
difference for mental illness, injury, heart disease, breathing
problems, stroke and cancer
 If health status does differ by income, they believe an “acceptable
level” would be:
 0% 49% of people
 10% 12% of people
 25% 17% of people
 50% 20% of people
 >100% 4% of people

34. Survey Data Summary
 91% of people believe something can be done to address this
disparity
 Over 30 policy options were presented for consideration, and the
top three answers were:
 Strengthen early intervention programs for children and youth 82%
 Earning supplements to help people move off welfare 82%
 More disease prevention programs 81%
 Option with the least support:
 More union membership for workers 29%
 More support given when options focused on children:
 More subsidized nutritious food: 62% support
 More subsidized nutritious food for children: 75% support

35. Survey Data Summary
 When asked how they would propose funding
any of these interventions:
 10% raise taxes
 82% redistribute current taxes
 If financial resources are limited:
 41% supported transferring funds from treatment to
prevention (59% against)
 40% support for transferring funds from health
treatment to health creating services such as
education and affordable housing (60% against)

36. Summary
 “Where systematic differences in
health are judged to be avoidable by
reasonable action they are, quite
simply, unfair. It is this that we label
health inequity. …Reducing health
inequities is, …an ethical imperative.
Social injustice is killing people on a
grand scale.” (Marmot, 2008).

37. What Can Be Done by our Governments in
Canada / Saskatchewan?
 Use evidence-based policy options in areas such as:
 Income
 Education
 Employment
 Housing
 Health services
 Aboriginal Cultural Status and governance
..to develop and support an “all of government” approach to
reduce the gap in a generation in our country / province
 Set targets and goals and measure our progress

38. Why Should I Support This?
Some voiced objections…
 Don’t People Get What They Deserve in Life?
 “Freedom to choose is socially determined (rigged). This model has been tested to
destruction over the last few decades. We are motivated by self-interest, but we
are also altruistic, intolerant of unfairness, and made to live in community” Marmot,
2008
 Surely this is not a problem in (Canada, Sask., Regina, Saskatoon, etc)?
 Health Inequity affects us all (social gradient effects, costs of poverty)
 Isn’t it a cultural issue?
 The role of ethnicity disappears once you control for poverty, education, etc.
Interventions need to keep cultural issues in mind in their design and
implementation, but systematic discrimination is the underlying issue we need to
address
 Throwing money at people isn’t going to solve anything. Aren’t we
always going to have poverty?
 It’s not only about assistance rates. Complex problems need elegant solutions.
Supporting approaches that help transition people in need to greater stability and
self-reliance will greatly reduce poverty rates…as it has in other jurisdictions.

39. What Can the Church do to
Reduce the Gap?

40. Why Should the Church be Interested
in the Community’s Health?
 The church:
 is a major “intersectoral partner” in the effort
to improve health at both the individual and
community level
Serves as an important social support
mechanism for many people
has a mandate in achieving a balance
between evangelism and social justice (ref.
John Stott)

41. Why Should the Christian be Interested
in the Community’s Health?
 A follower of Jesus Christ must use his
actions as their guide (WWJD)
 Christ clearly cared about individuals’
physical, emotional, and spiritual health
 Christ gave many admonitions to his
followers to care about and influence
societal issues such as poverty, justice,
equity, gender equality, war, etc.

42. God’s View on Poverty
 2000+ verses in the Bible relating to how
God feels about poverty and justice

43. What can I do?
 Give (globally and locally)
 Pray
 Live responsibly
 Volunteer
 Be aware
 Share God’s passion for the poor
 Advocate

44. Ideas for local action
 In all these areas, do things individually, in
a small group, as a congregation,
denomination, and as the Church
(collectively with other congregations from
many denominations) in your city,

45. What Can I / We do?
 Give (globally and locally)
 to organizations working in low income areas, or
working to deliver programs for those in need (and not
just to “Christian” organizations and causes)
 support changes in government programming aimed
at reducing the gap, even if it affects your taxes!
 Support fundraising initiatives (capital needs) in areas
such as affordable housing, improved health
promotion & disease prevention, and primary care in
areas of need, etc

46. What Can I / We do?
 Pray
 For justice
 For spiritual renewal
 For people/groups in need, and individuals you
encounter
 For God’s Kingdom to come “on earth as it is in
heaven”
 For a heart that feels what God feels for the poor

47. What Can I / We do?
 Live responsibly
For sustainability, and in order to afford to
help others in greater need
Spend Wisely – where do you shop? Do you
(indirectly or directly) encourage local
business re: ethical practises, fair trade,
involvement in being part of the local solutions
by supporting them if they do?

48. What Can I / We do?
 Volunteer
Your time, and your skills, to agencies
working to reduce the gap
Be a mentor or find ways to invest in others
using your area of education, work, or interest

49. What Can I / We do?
 Be aware
 Learn about health disparity and the social
determinants of health – globally, and here at home
 Share your findings with others at home, in your
neighborhood, at your workplace, your place of
worship
 Challenge stereotypes and misconceptions when you
hear them, and inform others about workable
solutions

50. What Can I / We do?
 Share God’s passion for the poor
How much thought/time do we spend on this
issue compared to the time God devotes to it
in the Bible? Compared to other issues we
think important and the relative time devoted
to those in the Bible?
Take the “Micah challenge” as God requires
of us in Micah 6:8 “do justice, love mercy,
walk humbly with your God”

51. What Can I / We do?
 Advocate
 Write letters to decision makers, demonstrate, talk to
your friends and neighbours about the need to
change
 Meet with your city councillor, MLA, MP and express
your concerns and your support for change
 Talk to those in your sphere of influence about the
issues and possible solutions
 Support Saskatoon’s Action Plan on Poverty

52. Ideas for local action
 Adopt a capital project in the community to support (e.g.
Station 20 west, a new primary care clinic for the inner
city, a comprehensive clinic for HIV positive people and
their families
 Use your space for clinics and services during the week
 Support micro loan cooperatives (micro finance) for
women starting small businesses out of their homes in
the inner city
 Encourage members (especially youth) to do a “mission
year” (and perhaps start Mission Year Saskatoon!) or
Urban Promise Saskatoon
 “Speak” (www.speak.org.uk) advocacy and prayer

53. Conclusion
 The current economic crisis is no reason
to delay our response. In fact, our
challenge is not to draw back from our
ambitions, but to make them more urgent!
UK Prime Minister Gordon Brown, Nov 2008