DAY 7: Doing nothing is not an option

There are dozens of ideas for eliminating the health/wealth disparity among our neighbourhoods. Some would take hardly any time at all, while others would take decades. One point of agreement: it is a matter of life and death.

 

By STEVE BUIST

Now comes the hard part.
For the past six days, story after story and number after number in this innovative mapping project have hammered away at the shocking disparities in health that exist between Hamilton neighbourhoods.
The maps, in general, have portrayed Hamilton as a doughnut — a healthy ring around the outside, from Flamborough to the back of the Mountain to Stoney Creek, with a rotten hole centred on the lower inner city.
The message delivered has been clear and consistent: the better your wealth, the better your health.
What we’ve discovered so far is that there are a lot of broken people in Hamilton, people who are broken physically, mentally and financially.
We’ve discovered that some of these people are living with Third World health outcomes and lifespans.
From best neighbourhood to worst across Hamilton, there’s a 21-year difference in average age at death, an appalling gap in a country that prides itself on universal health care.
And we’ve discovered that it takes a lot of money and resources to fix a broken person.
So now what?

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What can be done to raise the floor for those neighbourhoods in Hamilton that have the poorest health outcomes?
And that’s the hard part. Finding solutions is always more challenging than finding problems.
One conclusion, however, seems obvious.
“The current approach is not sustainable into the future, ” said Neil Johnston, a Hamilton health researcher who has collaborated on this project with The Spectator for three years and acted as chief data analyst.
“It’s time to stop thinking about more money, or ‘If only my hospital had a bigger budget we could do more, or if my hospital had more beds we could do more or if we had more doctors who could do more surgeries, ‘” said Johnston.
“Even if we could afford to do it and we had the mechanisms to create it, would it solve the problem? And I think the answer is no, it wouldn’t, because it wouldn’t change the fundamental drivers.
“All it would do is simply expand supply and that supply would be absorbed, ” he noted. Just like adding a lane to the QEW would ultimately have little impact on traffic.
There are two fundamental, but quite different, sets of problems within the health care system, Johnston explained.
One is related to systemic problems and inefficiencies that exist with the delivery of health care. The other relates to the drivers of health care consumption.
“And they require quite different solutions, ” Johnston said.
“You can make the system much more efficient in a number of ways, and you may coincidentally reduce or change demand from the other side, the drivers. But not necessarily.”
The gaping disparities in health across Hamilton have significant financial implications attached to them.
Take, for instance, the five Hamilton neighbourhoods with the highest hospital-related costs and compare them against the five neighbourhoods with the lowest costs.
The Spectator’s mapping project shows the difference between the two groups was a staggering $34 million over the two-year study period.
All that money spent represents “a wasted opportunity, ” according to Johnston.
“We’re quite prepared to spend limitless amounts of money to Band-Aid this, ” said Johnston. “It doesn’t do anything about curing this in the long term.
“The state should nurture the health of its citizens, that’s entirely appropriate. But that’s not what these costs represent.
“It’s a complete revolving door. There’s no improvement in health.”

■  ■  ■

At first glance, it would seem logical that any discussion about solutions to health problems would focus on the usual suspects — more doctors, more clinics, better access to services, maybe even shorter wait times.
But what if we had a discussion about improving Hamilton’s health that didn’t talk about health at all?
What if we talked instead about things such as income or housing policies?
“We have a hard time grasping this idea that the best health response to poverty is income, ” said Mark Chamberlain.
Chamberlain is a successful businessman — first with Wescam, now as president and CEO of Trivaris — but he’s also chair of the Hamilton Roundtable for Poverty Reduction.
“It’s counterintuitive to say that the best medicine, the best drug, the best immunization just might be income, ” said Chamberlain.
At the very least, Chamberlain said, the minimum wage needs to be raised in Canada, which again might sound counterintuitive coming from a businessman.
“We don’t have a living wage, ” Chamberlain said.
“We have a minimum wage that has no bearing on anything, quite frankly. “It’s just a number. It’s a political number.”
In addition to a better minimum wage, it would also mean increasing payments to those who are unemployed, disabled or receiving Ontario Works.
More than 80 per cent of the people living in poverty in Hamilton are either children, seniors, disabled or the working poor, according to Chamberlain.
“If we were to have a living wage and not a minimum wage that’s way below a living wage, ” said Chamberlain, “if we were to bring our OW and (disability) and EI up to rates where people are not living in poverty while they’re trying to find jobs or be educated, if we simply brought them up to a living wage we wouldn’t have anywhere near the poverty we have and our health outcomes would be significantly better.”
That’s not just a guess on his part.
Look west to the small prairie town of Dauphin, Man., and you’ll find proof.
For four years beginning in 1974, the province of Manitoba and the federal government joined together to fund a unique social experiment.
Dauphin became the town with no poverty.
Every one of the 13,000 residents of Dauphin received a guaranteed annual income support to keep them above the poverty line.
“The counterintuitive part to that is people look at that and say ‘You can’t do that, that’s just paying lazy people not to work, ‘” said Chamberlain.
In fact, quite the opposite happened, as it turned out.
The unemployment rate didn’t jump. Kids stayed in school longer. And more importantly, hospitalization records showed that people lived healthier lives.
Accidents declined, injuries declined and hospitalizations for mental health issues dropped significantly.
“Most people want to do something with their lives, ” said Chamberlain. “They’re not lazy, as it turns out.
“I know lazy people who have worked for me in the past. They get a full salary and they’re lazy. And there are also lazy people who are poor.
“Laziness is not an income issue, ” Chamberlain added. “Laziness is a personal issue. Some people just get away with it better than others.”
Then there are the issues that are less obvious and more insidious, such as building and housing policies that help perpetuate economic segregation within the city.
Last summer, for example, there was an outcry from some Ancaster residents, as well as a city councillor, when a builder proposed putting new, more affordable homes on smaller, 30-foot-wide lots.
The euphemism used by critics was that the smaller lots “would be out of character with that community, ” according to the story, but the reality was more direct — people wanted to protect their property values in a high-priced neighbourhood.
The point here isn’t to skewer Ancaster residents. Self-interest is a powerful guiding force for anyone, regardless of income or social status.
The broader point is to reflect on the difficult questions that bloom from the roots of this dispute.
Why are there such massive economic disparities across Hamilton neighbourhoods? What can be done to change that?
At one extreme, the average value of a home in one inner-city Hamilton neighbourhood near the steel mills is $87,438, according to the 2006 census. That’s not a misprint.
At the other end of the spectrum, the average value of a house in the Flamborough neighbourhood around Carlisle was just over $490,000.
Take a close look at health, social and economic outcomes, and the people who reside in those two neighbourhoods might as well live on different planets.
“Sure, you’re free to go buy that house in the high-priced neighbourhood, ” said David Christopherson, MP for Hamilton Centre, which includes some of Hamilton’s poorest neighbourhoods.
“There’s nothing stopping you — other than maybe a couple of zeroes on the end of your paycheque.”
Terry Cooke, former chair of Hamilton-Wentworth and now president and CEO of the Hamilton Community Foundation, prefers instead to flip the issue around.
“How can we ensure that there is income integration in our neighbourhoods?” asked Cooke. “That’s always a politically volatile subject but it’s one that we have to talk seriously about.”
Cooke is a vocal advocate in favour of mixed-income neighbourhoods throughout the city.
“We make a mistake when we think we can build low-density, purely upscale new communities and not assume that it’s going to compound the problem in the inner city, ” said Cooke.
“The only neighbourhoods that work in the long-term are those that are economically mixed and stabilized by owner-occupied families, ” Cooke added.
The Spectator’s mapping project shows there are six neighbourhoods in Hamilton’s downtown where more than 80 per cent of the residents are renters, not homeowners.
“We have to do some things to stabilize and encourage home ownership by working-class and middle-class people, ” said Cooke.

■  ■  ■

 The sobering message to take away from all this shouldn’t come as any great surprise.

There’s no quick fix.
Fixing people’s health in Hamilton means fixing poverty, and that takes time.
“In a sense, there’s no immediate cure for poverty, ” said Neil Johnston, the project collaborator.
“That’s a generational change, ” he added, “and countries which have been reasonably successful at eliminating it — the Scandinavian countries, for example — have done that literally over generations. With heavy tax burdens.”
But that doesn’t mean all hope is lost.
“Yeah, I despair, but I don’t think these problems are forever, and I don’t think there are no solutions, ” said Dr. Chris Mackie, one of Hamilton’s associate medical officers of health.
What is clear, however, is that there is no single magic bullet that will put all neighbourhoods on an equal footing.
“No one idea or concept, no matter how big it is, no matter how powerful, is going to change things, ” said Mackie.
“Real change comes from a combination of political will, public support, administrative know-how within government, and also contributions and support from the private sector, ” he added. “You need all four of those things working together to make a difference.”
Johnston tosses out a long list of suggestions: economic stimulation, economic incentives, programs in schools, early-childhood education, incentives for pregnant mothers to accept prenatal care, making sure that kids are immunized, even paying incentives to family physicians to do things they may not be doing now, including taking on time-consuming patients, such as the mentally ill.
He freely admits some ideas might work, some might not, and it might take two decades or longer to see real change.
Others, however, reject a scattershot approach, arguing instead that a comprehensive, national strategy for tackling poverty is needed.
“If we do small things, then we can say ‘Oh, I’ve contributed to this, it’s not my responsibility, ” said Dr. Jean Clinton, a child psychiatrist and leading specialist in early-child development at McMaster University. “I think we need to have a collective outrage.
“In my heart of hearts, I believe in the power of one, but what we need is a civic voice altogether that says it’s not enough to do this in dribs and drabs.
“We have a massive social problem here, and what it requires is all of us thinking about how we can stop the gradient from getting steeper, ” she added. “This social-justice issue is a matter of life and death.”
Either way, big initiatives or small, everyone agrees on one point.
Doing nothing is not an option.
“The next big jump is how do we stop talking about equality of opportunity and really creating equality of opportunity, ” said Johnston.
“Because without health, you ain’t got it.”

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SIX ESSAYS:

POVERTY IS AN INSULT TO OUR VALUES

By MARK CHAMBERLAIN

As Canadians we embrace values of shared responsibility and a collective destiny, and yet more than three million of us live in poverty.
A 2008 national poll found that 88 per cent of Canadians say Canada should try to distinguish itself in the world as a country where no person lives in poverty.
We have fallen far short of this goal as evidenced by the deepening economic disparity in many inner-city neighbourhoods.
Over the past 30 years, we as a city, province and country have made only incremental progress on the overall reduction of poverty. Today, one in nine Canadians still lives below the poverty line. This reality exists despite tremendous efforts by exceptional volunteers, charities, not-for-profit organizations, foundations and government partners.Chamberlain001
Is poverty not a serious enough problem to merit an immediate solution? Is poverty too expensive to fix? Or is poverty simply too complex for us as a community to find appropriate, sustainable solutions?
To the first question, countless reports, longitudinal studies and investigations written over the past 30 years suggest that poverty is sickening — literally.
The total number of individuals affected by poverty far exceeds the number of individuals affected by SARS, H1N1, C difficile and West Nile virus combined, and has far more serious individual and population health outcomes.
As early as 1967, researchers such as Sir Michael Marmot have repeatedly shown that the higher a person’s income or social status, the healthier and longer life that person will enjoy. Reductions in lifespan and other negative health outcomes caused by poverty are catastrophic public health issues.
To the second question, economic cost is an important consideration when mounting a response to a serious health problem; but so is the cost of not mounting an adequate response.
According to a 2008 Ontario Association of Food Banks report, failure to eliminate poverty costs the private and public sectors in Ontario more than $30 billion a year. Put another way, this report states, “In real terms, poverty costs every household in the province from $2,299 to $2,895 each year.”
It takes investment to eliminate poverty. Yet continuing to pay for the negative health and social outcome costs are simply unaffordable.
To the third question, it’s not poverty that is complex, it’s the negative health outcomes caused by poverty that are complex.
The simple steps to reducing the risk of complex personal health issues are being active and eating well. The simple step to reducing the risk of negative health impacts caused by poverty is an adequate income.
With an adequate income, most can afford the necessary healthy food, shelter and discretionary income for their own and their children’s participation in their community. And with some control over your own life comes dignity. Income is a simple prerequisite baseline for both personal and population health, similar to exercise and good nutrition.
Poverty is a catastrophic health issue, it costs us more than $30 billion per year in Ontario, and something as simple as an adequate income can significantly reduce its devastating effects. So why does poverty still exist?
The good news is there are solutions that could eliminate poverty in five years.
A solution to poverty, however, is not dependent on new knowledge; rather it is dependent on a fundamental shift in how we view it and the urgency we place on solving it. First, we need to change the conversation about poverty from “charity” to “health, ” and from “social cost” to “investment in human development.”
Second, the urgency must be driven from our personal and our collective values, not our economics.
It’s about personal values because although 88 per cent of us have stated we want to eliminate poverty, what percentage of us would agree to pay more for a cup of coffee to ensure those serving us had better health as a result of making a living and just wage? It’s about collective values because politics and economics must always have direction, and that direction is set by our collective values.
Do we believe paying individuals a just, living wage for a hard day’s work is critical to a person’s health? Should we provide a combination of adequate income and supports to those who have a barrier to full employment due to a disability? Do we believe in providing adequate transitional support to help those unfortunate to be between jobs? And are we prepared to look at, and even experiment with, broad solutions such as a Guaranteed Annual Income that would ensure every working-age individual receives a living income thereby ensuring a baseline of personal health?
These are fair, just and simple solutions, but they will require courage driven by our values to enact.
Good values have always led good economics. Good values created the economics for immediate and complete responses to SARS and H1N1. Good values are the reason why child labour and slavery were abolished and universal health care and education introduced.
These value decisions did not destroy the economy, rather they strengthened it. If urgency is value driven, then we must act immediately to reflect our values in our government policies, the wages we pay in our businesses, and how we as individuals act to support an adequate income for everyone.
We don’t need a perfect solution, we simply need a better one.
Poverty is an insult to our values.
Why does it still exist?
(Mark Chamberlain is president and CEO, Trivaris, and chair, Hamilton Roundtable for Poverty Reduction.)

HOPEFUL HAMILTON IS COMMITTED, GENEROUS

By DR. CHRIS MACKIE

Money can’t buy me love — but it can buy health.
It’s one of those ugly facts of life. Rich people live longer, healthier lives than the poor.
In public health, it has become a cliche that the lower your income, the more likely you are to get sick – from infectious diseases such as tuberculosis or chronic diseases such as diabetes, heart disease and lung cancer.
Last year’s H1N1 pandemic could not have highlighted this more clearly. True, the virus put a strain on the health system here in Hamilton, but fortunately deaths were rare.
By contrast, H1N1 devastated communities that face more severe poverty. On reserves in northern Manitoba, whole communities became ill, and many people died. Mexico, where the swine flu virus originated, was overwhelmed.
Death tolls were much higher than in Canada, owing largely to poor nutrition and housing conditions that made it easy for the flu to spread.
So why is there such a variation in health even here in Canada, where access to health care is free to all?
If we are all using the same health care system, why are our poor so much sicker? The answer is that health care only accounts for about 25 per cent of health, maybe less.
Social and economic factors are far more important. Income is linked to health through access to adequate nutrition, housing, education, child care and personal health behaviours._GMY9545
My first experience working in a First Nations community was in a nursing station in Lac Brochet, a tiny, remote reserve in northern Manitoba. Most people lived on social assistance of one form or another, well below the poverty line.
While a fortunate few in “Lac” had reasonable housing, many lived in plywood shacks with no running water. With families of eight to 12 crammed into two rooms, viruses and bacteria spread fast.
Milk cost $14 for a two-litre jug, but potato chips were cheap — so adequate nutrition was hard to come by. Less than a quarter of adults had high school diplomas.
It was hard to see people living that way. As a medical student, all I could do was treat the illness that I saw. Throat, skin and lung infections were very common in my patients, and many did not live long enough to experience diseases such as heart disease.
At the time, I didn’t know that the community had the highest rate of tuberculosis in the world. TB infection indicates poor overall health and is closely linked to poverty. At over 100 times the Canadian average, TB was more common in Lac Brochet than in the slums of South Africa.
Here in Hamilton, we are a lot more fortunate than the people living in the Third World conditions of Lac Brochet. No one has to live five or six crammed to a room. Virtually everyone has access to clean running water, and healthy food is much more readily available.
But as this Code Red project shows, we still have huge differences in health between neighbourhoods.
This is upsetting, but not surprising. Your neighbourhood is closely linked with your income, so the relationship with health outcomes should be expected. And while income differences within Hamilton are nothing like the differences between Hamilton and Lac Brochet, they are still enough to produce most of the differences in health that we see in Code Red.
Nutrition, child care and education represent some of the pathways linking income and health in Hamilton. Think of how much cheaper sugary, fatty, salty foods are, and what people on low incomes can afford.
Try to find high-quality child care at an affordable rate, and consider how important those early years are for building a strong base of learning and development for a child’s future.
University tuition rates have skyrocketed. How hard would it would be for a family living on minimum wage to send their children to McMaster?
While virtually everyone in our city is better off than the majority of people in Lac Brochet, we still have huge gaps in health between our rich and poor for reasons such as these.
Fortunately, there is hope here in Hamilton.
We live in a city where people are willing to put time, effort and money into caring for those who are less fortunate. We have made a collective commitment to make Hamilton the best place to raise a child because we recognize that happy, healthy children are more likely to grow up into happy, healthy adults, and more likely to build a happier, healthier community.
And this commitment is not just on paper. Hamiltonians donated almost $5 million to the United Way last year, and the Hamilton Community Foundation invested another $3.4 million in poverty reduction, strengthening neighbourhoods and protecting our environment.
Last year at a Hamilton Timeraiser event, young adults committed more than 3,000 hours of volunteer time — a small fraction of the volunteer work being done in our city, but a big indication of how willing we are to give help when asked.
The municipal, provincial and federal governments are all contributing as well, but they need our help as citizens. Good political leadership doesn’t come out of thin air — but it will come when the people demand it. Politicians need us to support their efforts to improve the economic conditions of those less fortunate.
If you care about improving the health of people who are less fortunate, take the time to get involved in the political process by contacting your representative or speaking out in whatever way you can.
(Dr. Chris Mackie is one of Hamilton’s associate medical officers of health and an assistant professor in McMaster University’s Department of Clinical Epidemiology and Biostatistics.)

MADE-IN-HAMILTON POVERTY-HEALTH SOLUTION

By NEIL JOHNSTON

Outrage is the word I select to best describe my reaction to this series and what it reveals about our community. That such a waste of human potential and its consequences to our health, justice and education systems can reach the point it has requires radical change.
It is not simply a moral priority. The chasm between neighbourhoods in the downtown core and the suburbs in determinants of health and health-service use is perhaps the most important reason why Hamilton will never be able to regain the prosperity it enjoyed 40 years ago.
No matter what is achieved in attracting business investment to Hamilton, it will have little real value unless we simultaneously invest the same energy to eliminating disparities in the determinants of health in our community. Success in that endeavour will probably take a generation to take full effect.Neil Johnston.JPG
If I had to pick out one statistic that truly appalled me, it was the percentage of low birth-weight babies born in Hamilton. Fifteen years ago when the Ontario government set out to “restructure” the province’s hospitals, I was asked by the Hamilton hospital CEOs of the time to create profiles of health-service use in Hamilton similar to those used for this series. At that time, the low birth-weight percentage was roughly 7 per cent. Two years ago, it was near 8 per cent.
So all of the investment growth in our health-care system that has occurred over that time does not appear to have improved one of the most important determinants of lifetime health.
There are many fine programs aimed at improving pregnancy outcomes and many dedicated people doing what they can, but unless a systemic long-term commitment is made by the province and civic leaders to reduce poor pregnancy outcomes, with very clear accountability for achievement of policy targets, the problem will continue.
We don’t have to invent something. There are many good examples of systemic approaches to prenatal care in other countries as well as elsewhere in Canada. Band-Aid programs that sound wonderful in political speeches won’t cut it.
We have built a health care system in Hamilton that we can be rightly proud of, one that should be the envy of many communities in Canada. We have access to medical, nursing and therapy specialists without equal, and our hospitals achieve outstanding outcomes.
Given Ontario’s current financial situation and the growing proportion of tax revenues spent on health care, it’s worth asking if our health system is sustainable as it is. The answer is: probably not.
At the very least, that should provoke some serious questions about how the “health system” currently operates.
Our hospitals and emergency rooms have become the default option for managing problems that are fundamentally social in origin, and in many cases beds are filled by people with no better alternative to meet their needs.
So the most expensive health care resource we have — designed to provide acute care and restore people to health — becomes, in many cases, a nursing home.
In Hamilton, few hospital beds remain empty at any time, and health care professionals are forced to compete for them when they are. Huge advances have been made in surgical and diagnostic procedures such that many patients do not require a hospital bed.
However, the decision to send a patient home should not be influenced by an ongoing lottery for bed access. There is a social component to this as well because those who have family support and are capable of understanding their discharge instructions may run the risk of being discharged too early for their own good.
Our hospitals are not to blame for this situation, they are victims of the complete incoherence of social policy in Ontario; and the fix requires that the health, social welfare, and perhaps justice systems undergo radical change driven by explicit policies and accountabilities. There will be savings if this occurs, but it requires a generational commitment.
One obvious area for innovation is the pathetic track record for adoption of information systems in the health and social welfare systems.
If our banks were run like the health system, they’d be sending runners between branches with transaction slips or perhaps using carrier pigeons. The problem in the health system is that if there is no timely transfer of clinical information between and among health-care providers, people die.
In the absence of coherent provincial leadership, it’s worth asking if improvements can be achieved in Hamilton with civic leadership. I believe they can.
The leaders are already here. The motivation should be recognition that Hamilton’s future economic success will be fostered by improving the health of our people.
Who will pick up the torch?
(Neil Johnston is a health mapping expert who is a professor in McMaster University’s Department of Medicine, a researcher with the Firestone Institute for Respiratory Health and a collaborator on the Code Red project for the past three years.)

WE NEED COURAGE TO CONFRONT OUR MISTAKES

By TERRY COOKE

We are separate and unequal. Over the past 40 years, Hamilton has become an economically segregated community, divided by income and geography.
Concentrated poverty is the moral challenge of our generation.
Steve Buist and researcher Neil Johnston’s groundbreaking Code Red clearly shows that Hamilton is losing ground economically, and compounding its problems by limiting where our poorest citizens can live, go to school and work.
But beyond a sense of human compassion and concern about the health costs of inner-city poverty, why should you even care? If your family is fortunate enough to live in one of our better neighbourhoods and you generally avoid spending time in the inner city, does it even affect you?
North American urban experience and years of research confirms that poverty anywhere is bad, but concentrated poverty spreads, undermining economic growth, property values, health and educational outcomes across entire regions.
How did we get here? The decline of Hamilton industry started the downward economic spiral for much of our North and east ends. Our uncompetitive tax rates discouraged new private-sector job creation. Working families who glued together older neighbourhoods left to escape pollution and find careers elsewhere.
One-way streets created virtual highways in older areas, moving large volumes of traffic quickly from downtown to the suburbs, with little appreciation for their negative impact on local neighbourhoods and businesses.
Regional government in the 1970s further fuelled middle-class flight, providing the financing and infrastructure for low-density suburban housing. Developers targeted “exclusive” middle and upper-class buyers, and local planning policies largely prevented smaller, affordable units or residential-care facilities for people with lower incomes or disabilities.
But instead of trying to stabilize home ownership and focus on brownfield remediation to create new jobs in older neighbourhoods, we mostly abandoned the North End to illegal apartments, absentee landlords and public housing. We used tax dollars to subsidize residential sprawl and build suburban business parks unreachable by public transit.
This restricted housing options for people with low incomes and high needs in neighbourhoods that were already struggling. Suburban growth pressure was not unique to Hamilton, but it had more devastating results here than in more progressive cities that avoided segregating the poor.
Syracuse University professor Gerald Grant recently published an important book called Hope and Despair in the American City (Harvard University Press, $29.95). It contrasts the abysmal performance of neighbourhoods and schools in Grant’s native Syracuse, N.Y., with the more positive experience of Raleigh, N.C. While Raleigh integrated every school by family income levels, and gave their teachers the tools to innovate, Syracuse continued to concentrate poor kids together in the inner city.
In 1998, Raleigh set a goal to have 95 per cent of grades 3 to 8 students proficient in math at a time when a majority of inner-city kids were failing. Today, a mere 12 years later, they are at 91 per cent.
Meanwhile, Portland, Ore., with a rusting manufacturing base similar to Hamilton’s, dramatically restricted sprawl and focused its redevelopment around Light Rail Transit, renewing mixed-income older neighbourhoods and creating new jobs in small knowledge-based businesses. Today, Portland is a stunning example of economic rebirth and diversification.
There are lessons for Hamilton in the very different experiences of Syracuse, Portland and Raleigh. Syracuse was unwilling to talk about the uncomfortable facts of neighbourhood and school segregation. Portland and Raleigh relished the clash of ideas and civic engagement, and accepted the need to make fundamental changes to achieve income diversity in schools and neighbourhoods.
To end the cycle of poverty in Hamilton, we must be willing to have a blunt conversation about our neighbourhoods and our neighbours, about our schools, about the health of our citizens and the magnets we need to glue investment into place.
Looking at the sobering evidence presented in the past few days, you may ask if I am filled with hope or despair. The answer is hope, tempered by the hard reality of the work ahead. And here, the Hamilton Community Foundation and citizens of Hamilton have some stories to tell.
Six years ago, the foundation had the foresight to make poverty its priority, working with partners to establish the Poverty Roundtable and Jobs Prosperity Collaborative to attack poverty at its roots. HCF also directly funded many initiatives that give us cause for optimism.
Let me tell you about just one.
Planning teams that include service providers and many local residents are working to improve the quality of life in eight challenged Hamilton neighbourhoods. These “hubs” are becoming “one-stop” service centres to address poverty effectively by offering critical supports while building neighbourhood capacity.
Perhaps most importantly, civic engagement in the neighbourhoods is expanding. Local citizens are taking ownership of where they live and making positive changes.
But to change the overall trajectory of our city, we must do more than just support and build capacity in neighbourhoods and schools that remain economically segregated “poverty traps.”
We need to find the courage to confront our past planning mistakes and take a different path, committing to a future where all of our schools, neighbourhoods and workplaces integrate people of all income levels to begin reversing the devastating consequences of concentrated poverty.
Hamilton needs to become more competitively attractive to private-sector jobs that pay living wages. We must continue pressuring senior levels of government to provide a guaranteed annual income for those who require social assistance.
A west harbour Pan Am Stadium, Light Rail Transit and full-day GO service create a remarkable opportunity to leverage massive capital investments to begin transforming Hamilton’s inner-city neighbourhoods into healthy, sustainable and more economically integrated places.
Working together and facing up to some hard truths, I believe that we can overcome the challenge of concentrated poverty and make Hamilton the best place in Canada to raise a child.
(Terry Cooke is president and CEO of the Hamilton Community Foundation and former regional chairman of Hamilton-Wentworth.)

MAKING CONNECTIONS BUILDS A HEALTHY CITY

By MURRAY MARTIN

Hamilton is a city of contrasts. Geographically sliced into upper and lower city, divided into rural and urban, rich and poor, it is a community obliged to build bridges to connect those contrasts.
I look at Hamilton’s North End and downtown, an area plagued with high poverty and low levels of education. Here is an opportunity to examine what bridges can do, and the necessity to build them.
Hamilton General Hospital, one of Hamilton Health Sciences’ family of health care facilities, is an integral part of this community, and a clear example of how contrasts must work to bridge poverty with possibility.
Renowned for innovation in cardiac and stroke care, a regional centre for trauma cases, and a global leader in health research, how does such a hospital also focus care on the population within walking distance of its doors?
It’s a strong-hearted community with proud new and established immigrants, but it is also an area dotted with homeless shelters, a regional jail, people suffering addictions and those with severe mental health issues.
These are the unfortunate connections of poverty and health. How do people think about staying healthy when they are worried about shelter? Where does nutrition fit into a meal that is based, by necessity, solely on cost? How do you pay for medication with no health plan and only sporadic work? Where do you get a persistent cough checked without a family doctor?
These problems exist in the inner city because it offers cheaper shelter (although often still expensive for those living in poverty), and we see the health fallout at the General.
We see it in patients who have multiple complications because a problem has been left to deteriorate. We know that poor living conditions help to create those complications — for instance, a stroke is made worse by poor diet and lack of medications.
We see it in the emergency department as “frequent flyers.” These are the people who walk through our emergency doors multiple times through the year.
It’s not a huge number, maybe a few dozen, but they keep coming back — some averaging two to three times per month and, occasionally, it’s two to three times per week. We do our best to keep these people healthy, but we’re doing it in an environment intended as the last resort, not as it should be in primary and preventative care.
Ankle pains, addictions, poison, toothaches, rashes. These are some of their complaints. But sometimes it’s not that at all. Sometimes a nurse will spot a face seen many times before; she’ll offer juice, a sandwich and a smile. The visitor leaves feeling better, without a medical exam. He was just seeking connection.
Sometimes, at the General, the connection is a nurse finding a blanket to cover the person using a hospital chair as a bed on a cold night; sometimes it’s giving away a pair of shoes from the free “Clothes City” hospital closet, created when staff realized this population needed clothing.
Is this what hospitals are for? Not on paper. Not by government regulation. But by community responsibility, yes.
It’s why our hospital staff has built bridges with the community — connecting with Claremont House, a centre helping homeless people with alcoholism, because we know sometimes addictions can’t be fixed, aren’t a matter of hospital care, but are a part of long-term and palliative care. It’s why we’ve connected with local shelters, so that we can understand that not everyone has a proper home to go to when they leave a hospital and still need attention.
These connections are invaluable in our community, but they are only a part of the solution. I’ve seen much of this before, in my years in Vancouver as CEO of Vancouver Hospital and Health Sciences Centre, and I know it’s not enough. Vancouver’s notorious Downtown Eastside is awash in issues of poverty, homelessness, and addiction and mental-health problems.
Through the years, millions of government dollars have been dropped into the area in revitalization and rehabilitation programs, in the many efforts to try to fix the situation.
But quick, reactive programs are not an answer. Nor is it about a huge hit of money.
We need commitment from all levels of government to recognize and identify areas such as Hamilton’s downtown and North End as worthy of long-term, systematic programs to help improve the lives of those suffering from having too little.
Hamilton is exceptionally good at building connections, at developing a strong voice for those too weak to be heard. We need to use that voice to continue to tell this story, and to help build long-term solutions.
We are doing our part, but we need governments to take a lead role to ensure sustainability.
(Murray Martin is the president and CEO of Hamilton Health Sciences.)

THE FIX? PARTNERSHIPS, LEADERSHIP, URGENCY

By CHRIS MURRAY

There is a significant body of research that supports the relationship between health and wealth. Access to proper housing, good food, jobs that pay a living wage or more, education and literacy, environment and recreational opportunities are just some of the social determinants of health that have an impact on the success of people and neighbourhoods. Municipalities that respect these variables and work collaboratively to reach positive gains in all areas will be more successful than those that do not.
Closer to home, it’s clear that family incomes vary considerably among neighbourhoods in the lower city of Hamilton and those in other parts of this community. Add to this the fact that our population is aging, and baby boomers will be mostly retired in 10 years, and it makes you worry about how lower household income and higher health care demands will affect quality of life.
If that’s not enough, residential growth in the last 30 years has dramatically surpassed commercial and industrial development to the point where approximately 82 cents of every property tax dollar collected today comes from the residential taxpayer. As troubling as this is, having a grasp of the problem is the first step in finding a lasting solution.
So when asked by many how do we find ourselves with such extremes in the health of our community, and how can we solve it, I think about what I have learned in the past 16 years as a planner, manager, director and now city manager. As the former director of housing, I saw first-hand the challenges people face when having to “live” on Ontario Works.
The east-end McQuesten neighbourhood, for example, sticks with me to this day. I attended a neighbourhood planning group meeting in 2007 to gain a better understanding of resident concerns. The high level of frustrations they expressed left some uncomfortable, and afterward yielded expressions of pity for the rough but fair treatment I received.
Make no mistake, they felt ignored and were adamant that the city needed to do more than listen to them. It needed to act. More importantly they told me that we needed to become a partner — one that didn’t impose our answers on them, but rather developed solutions with them.
This resulted in a series of 90-day work plans that we committed to — some of these involved simple things such as better lighting and signage in the neighbourhood, for example. As a result of that meeting, residents began to feel empowered, and in turn took it upon themselves to organize a community garden, weekly shuttle service to the grocery store and even fundraise for playground equipment (which was installed last year).
I’ll never forget meeting one woman who had immigrated from Iran. She had attended a neighbourhood forum, and was listening quietly to her neighbours and city staff talk about new program ideas for helping people get to know each other and work together. When I asked her what she thought about this, she smiled and said “my husband and I just want a job.”
An old friend of mine once said “to a hammer, all problems look like nails.” Hammers and nails have their place — as do programs — but for many having a well-paying job that allows a person to provide their family with good food, a safe home and education is vital.
Those conversations shape my thinking today. It led me to begin to focus our organization, to strengthen partnerships with other stakeholders, to break down walls that occur in every organization and to challenge staff. When I took this position as city manager, I committed to council and senior management that we would align our efforts and develop priorities.
This past year, we developed a Corporate Priority Plan that will provide us with an integrated approach to achieve our goals. Approved by council last December, the plan documents the challenges we face in the lower city and the need for co-ordinated action. It also identified two major themes we must focus on: community prosperity (more living-wage jobs and growth in the nonresidential assessment base) and sustainable service delivery (services citizens need, value and can afford). As a city we know confronting our challenges will require a command of relevant issues, planning, active involvement of the public and private stakeholders and, where warranted, the involvement of experts in areas of particular interest. That is why we need to continue to work together — as a community, we are blessed to have gifts such as McMaster University, Mohawk College, Redeemer University College and world-class medical facilities.
The leadership of these institutions together with our school boards, nonprofit organizations, police and the private-sector partners must share more of a common purpose. Let the Pan Am Games serve as a clock by which we time our actions to see if our neighbourhoods that need attention can be improved.
Only together can we come up with the solutions that will change our community. I don’t want to leave the impression that we are waiting for that change. Change has already begun and will continue, but it requires constant effort, re-evaluation and the input of new ideas.
We must work with a sense of urgency. Ten years will go by in a flash.
(Chris Murray is city manager for the City of Hamilton.)

 

10 IDEAS: A STARTING POINT

An ounce of prevention is worth a pound of cure, as these suggestions illustrate.
It costs far less money to stop a problem from developing rather than treating it after it has arrived.
Here are 10 ideas that could ultimately improve the health of Hamiltonians — and save money for taxpayers:
1. Provide incentives to young, pregnant at-risk mothers to encourage them to show up for regular prenatal care visits to help reduce Hamilton’s rate of poor pregnancy outcomes. The incentives could be direct, in the form of financial compensation; or indirect, in the form of merchandise and food vouchers. The costs are meagre compared to the lifetime cost of poor pregnancy outcomes to the health care and education systems.
2. Undertake a scientific study that examines the differences in health outcomes and costs between those people in the lower central city who don’t have a family physician and those who do. Identify the factors that cause people to either not have — or not visit — a family physician. Determine the best approach that could be developed to reduce the number of people who don’t have access to a family physician. After a period of time, re-examine the numbers and evaluate if there has been any improvement in health outcomes and costs. When a person shows up in the emergency department and reports no family physician, set up a program that matches those people with a family doctor.
3. Provide better financial incentives to physicians to encourage them to take on patients with mental health issues. Payments to physicians for patients with mental health problems need to recognize that these patients often present time- consuming, complex cases.
4. Create a high-profile, made-in-Hamilton model that mimics Calgary’s 10-year plan to eradicate homelessness, and create public awareness about the need for such a program.
5. Implement funded breakfast programs at every elementary school in the city. At the very least, every elementary school in the lower-central city should have a funded breakfast program. Currently, the province provides just 15 per cent of the funding for breakfast programs and the rest must come from fundraising. “We have had comments from teachers that the teaching process is a lot easier after the kids have taken part in the program, ” said Tammy McDonald, a senior social planner with Hamilton’s Social Planning and Research Council. “The kids concentrate better and they’re more attentive.”
6. Antismoking medication, which is currently not covered by the province, should be provided at no cost to those who want to use it to quit smoking.
7. Extend the evening and weekend hours for walk-in medical clinics in the lower central city, which could help reduce costly visits to hospital emergency departments. According to Ontario’s health ministry, each emergency room visit in Hamilton costs taxpayers $259.
8. Make physical fitness or physical education mandatory for each year of elementary and secondary school. Obesity rates are skyrocketing and people who are active young in life have a greater chance of remaining active later in life.
9. Create a one-stop access program for comprehensive health and social care for the elderly that mimics the CHOICE (Comprehensive Home Option of Integrated Care for the Elderly) model in Edmonton.
10. Raise the country’s minimum wage for workers to a living wage. “It’s going to take a national strategy, ” said David Christopherson, MP for Hamilton Centre, a riding that includes some of the city’s poorest neighbourhoods. “Municipal governments aren’t in a position to deal with changing your income. That’s something that has to come at a national level.”

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