By Jim Silver

Manitoba’s health care system is undergoing major changes. Many Manitobans fear that the changes are more about saving money than improving health, and that privatization of parts of the health care system may be a slippery slope towards the erosion of our treasured single-payer public health care system.
Completely absent from the health care discussion is any consideration of the social determinants of health. There is now a vast literature across the world about the social determinants of health. This literature provides evidence that our health is determined not only by bio-medical considerations, and our lifestyles—whether we smoke, or exercise, or are overweight, for example—but also by a range of socio-economic factors. The social determinants of health literature makes it clear that a population’s health is in large part a product of socio-economic factors related to people’s location on the income scale.
Those of us who have relatively high incomes are statistically much more likely to be healthy than those of us who live with low incomes. Another way of saying this is that being poor makes us sick. The poorer we are, the more likely we are to be sick.
Manitoba Centre for Health Policy data show that virtually all forms of health issues—cancers, heart disease, respiratory disease, kidney and liver disease, accidents, infant mortality, longevity, for example—are worse in the lower income areas of Winnipeg and Manitoba, than in the higher income areas.
It follows that if we were serious about wanting to improve Manitobans’ health—which would in turn lower the costs of health care—we would implement policies that improve the socio-economic circumstances of those at the bottom end of the income scale. Such policies would include, for example: building sufficient numbers of social housing units to meet the needs of the poorly housed; making enough childcare spaces available so that parents could improve their education or seek gainful employment; increasing the availability of adult education and literacy so that the very high numbers of Manitobans with low levels of education could make improvements in their lives; funding job creation strategies that have proved effective for marginalized, low-income people so that they can become self-supporting; increasing the minimum wage so that those who are working can earn a wage sufficient to support their families. There is overwhelming evidence that these policies, if implemented consistently over time, would make large numbers of people much healthier. But we are not implementing such policies. A large part of the reason is that such policies run counter to the ideology—the political belief system—of the current provincial government.
Instead of implementing such policies, the provincial government is limiting and even cutting funding to many such measures, while focusing almost all of its health care effort on re-organizing various parts of the health care system—the system that responds to peoples’ needs after they become sick.
No doubt the health care system needs improvements. Making improvements ought to be a constant in such a large and complex system, although such steps as allowing private diagnostic clinics to open in Manitoba can hardly be seen as an improvement, since they pull scarce resources from the public system and—consistent with that same ideology—eat away at the public system, adversely affecting those many who are sick but can’t afford to pay.
But to concentrate only on what happens after people become sick brings to mind the story of the person who sees someone drowning, and pulls her out of the river, and then sees another person drowning and pulls him out of the river, only to see another person drowning and then another and another. Finally, exhausted from responding to these emergencies, the person decides to go upstream to see who or what is pushing all these people into the river.
Poverty and its many adverse consequences, and the ever-widening gap between the rich and the rest of us, are pushing people into our hospitals and emergency rooms. If the provincial authorities spend all of their efforts re-organizing those hospitals and emergency rooms, and fail to deal with those socio-economic factors that we know are major causes of poor health, they are not acting on the basis of the evidence.
Ideological blinders appear to be preventing the current provincial government from seeing the overwhelming evidence that being poor makes people sick, and that to improve health outcomes requires policies that address the socio-economic circumstances of those at the lower end of the income scale.
The provincial government ought to take off those blinders, take a look upstream, and deal with the factors that are pushing people into emergency wards and hospitals.

Jim Silver is a professor in UW’s Department of Urban and Inner-City Studies, and a co-editor, along with Lynne Fernandez and Shauna MacKinnon, of The Social Determinants of Health in Manitoba, Second Edition (Winnipeg: Canadian Centre for Policy Alternatives-Mb, 2015).