Marked: Poverty Discrimination is a Public Health Issue and the Human Rights Code Can Help

A Meeting of the Minds 

The spheres of public health, the legal system, and social justice collided last year at Pivot when Steph Wiafe, an Epidemiologist, and Nina Taghaddosi, a Registered Social Worker, came together to discuss how Steph’s background in health equity research could contribute to Nina’s research on social condition and human rights legislation in Canada.

When they came together for the first time as people trained in what they thought to be two very different fields, they knew they were going to spend time researching the implementation of social condition protections in human rights legislation in Canada, but what they didn’t know quite yet was how deeply connected their respective professions were in regards to human rights protections.

In the discipline of social work, wholistic approaches to client care are encouraged theoretically, but, on the ground, this framework is not necessarily shared or valued by other service providers that social workers interact with, nor is it a well-resourced initiative. Similarly, in public health and epidemiology, intersectionality and wholistic frameworks to describe, analyze, and address health issues are increasingly applied; however, health research and initiatives that suggest necessary shifts in power to address health disparities are politicized, demonized, or ignored to uphold the status quo of social power.

Pivot staff from varying professional backgrounds, identified the commonalities in their analyses of social condition stigma and poverty discrimination and realized the importance of an intersectoral approach in advocacy, providing a framework to improve health and social equity outcomes in BC.

Linking Social Condition, Stigma and the Structural Determinants of Health

There are several terms we use to describe how poverty impacts people’s health, how the social services, legal and public health fields are connected to each other, and the legal framework for human rights protections for specific identities in BC.

A birds eye view of Social Condition Stigma - A poster laid out like a flowchart

Design by Brittany Garuk

Stigma

“Stigma” is the ancient Greek word meaning “to stick”, and “sticking” in ancient Greek times, was used to “mark or brand” people to socially denigrate them.^[1]

Though we no longer practice the physical marking of people to indicate their social position in our society, our prejudices are marked instead by our use of derogatory labels. In Western, predominantly white culture, we assign labels with attached values to place people higher or lower in the capitalist hierarchy shaping our economic, political and social landscapes. Language is just one among the many powerful tools used to shape our beliefs and how we treat each other, and, unfortunately, the mark of stigma is often a death sentence.

Social Condition

In BC, there are no legal protections for people who experience discrimination based on their socioeconomic status, or, social condition, so we have been building an intersectoral case for amendments to the BC Human Rights Code to include social condition as a characteristic protected against discrimination in the law.

When someone experiences discrimination based on a protected identity under the Human Rights Code in BC, whether their age, disability, and/or ethnic origin, the legal system is their primary avenue to pursuing justice and recompense. However, each province and territory decide what they do and don’t include as protected identities under their human rights legislation, so some provinces and territories protect people from discrimination on the basis of living in poverty while others don’t, including the province of BC.

Social Condition Stigma

So what do social condition and stigma have to do with each other?

Stigma-based discrimination, which can be based on whether someone actually lives in poverty or is just perceived to live in poverty, influences that person’s social condition. This is because being stigmatized results in a reduced level of power and influence, leading to social discreditation, exclusion, and marginalization. Belonging to a stigmatized group with less influence over the decisions that are made in their society means it is less likely that the decisions being made by people holding power will benefit them and, in reality, these decisions often harm people with less influence.

A clear example of the reduced influence and increased harm experienced by people who are stigmatized and poor is the municipal public consultation process in BC. Look through the meeting minutes from any public consultation on proposed developments for health services, social services and housing options for marginalized communities ^[2] and you will witness business owners receiving better treatment from city councillors, with their demands for the exclusion of services for people living in poverty being met time and time again across all municipalities in BC. This happens regularly despite the fact that the health and social services being proposed to serve their communities are often life-saving and required by federal legislation.Former Vancouver city councillor Jean Swanson addressed this issue in 2001 in her book Poor-Bashing: The Politics of Exclusion when she wrote,

Canadians who are poor face poor-bashing when they try to participate as citizens in their community or to consult with government about laws that cause poverty…the poor are often ignored by the people they're working with, and consultation ends up being just another kind of poor-bashing.^[3]

The Structural Determinants of Health and Social Condition Discrimination

Public health is increasingly being viewed through the lens of social justice. Given the well-documented impacts that discrimination can have on the health of individuals, analyzing social condition discrimination and stigma through a public health lens allows for the establishment of a cross-sectoral argument to support legal protections for people living in poverty. Health inequities – disparities in health and wellbeing between people and communities – are intricately linked to systemic social injustices. The social determinants of health framework is widely accepted amongst public health professionals as an intersectional and critical lens of how non-medical-related characteristics, such as income, race, and education, can mediate health outcomes.

While the social determinants of health provide some intersectional analysis of social factors that influence health, they are missing a systemic viewpoint. To truly understand, address, and improve health disparities, we must get to the root of why health and social inequities exist.

The framework of the structural determinants of health allows us to de-individualize health experiences and contextualize widespread systemic health disparities, therefore providing solid ground for exploring solutions and advocating for accountability.

For example, in the case of social condition, the social determinants of health framework would suggest that one’s income, socio-economic status, and housing status (in addition to other factors that comprise one’s social condition) are the underlying factors that contribute to health inequity. On the other hand, the structural determinants of health framework would take this analysis a step further and suggest that social condition stigma and discrimination at interpersonal, institutional, and systemic levels, contribute to large-scale and vast health disparities between social status and income levels. In combination, they have a powerful and immutable impact on a person’s access to healthcare, the quality of healthcare they receive, the affordability of healthcare, and these variables have a direct impact on population health outcomes like morbidity and mortality.

The structural determinants of health framework also provides a link between public health and human rights. Under the United Nations Universal Declaration of Human Rights Article 7, all people are entitled to protection from discrimination, making social condition discrimination protections an issue of public health relevance critical to fulfilling Canada’s commitment to upholding international human rights standards.

We argue that the public health realm should analyze and incorporate the impacts of non-medical factors on patient health. This shift towards root cause explanations for poor social conditions and health outcomes will yield more impactful results than the current widely-used framework of the social determinants of health. Our position is that the social determinants of health as a framework for understanding health outcomes skips over the root causes of public health issues. Pivot urges a shift away from the social determinants of health framework towards the structural determinants of health framework as a necessary step in escaping colonially violent systems that keep communities trapped in generational cycles of intertwined health and social inequity.

The Impacts of Social Condition Discrimination on Health Outcomes

We can further examine and discuss how social condition discrimination and stigma impact the health outcomes of individuals and communities by examining their impacts on clinical and population health levels. In this instance, we refer to the clinical level as patient experiences in healthcare settings (such as hospitals, outpatient clinics, treatment facilities, etc.), and the population level as the health of the public at large (such as community health, health inequities between populations, trends in public health data etc.).

At a population-level, the status quo of healthcare in Canada is designed to be inaccessible and inadequate for people who live in poverty. This is reflected in health data trends showing that low socioeconomic status and living in poverty is associated with decreased positive health outcomes, increased risk of developing and dying from several health conditions, and inaccessible, unaffordable healthcare. Canada’s healthcare systems are designed to re-enforce a dangerous cycle of positioning people who live in poverty to have great difficulty in accessing timely essential care, contributing to the development and worsening of life-threatening health conditions that then go under-monitored or unmonitored completely due to the inaccessibility of care. This cycle also contributes to making poverty inescapable for communities, lasting generations.

a flochart of Continuum of Structural Determinants of Health Outcomes

On a clinical level, patients who experience poverty and low socioeconomic status experience stereotypes, prejudice, and discrimination in healthcare settings from healthcare providers, staff, and even other patients. Stigma and discrimination in healthcare settings can result in direct actions, and inactions, from healthcare workers that impact health treatments and outcomes, such as sub-standard treatment, de-prioritization, and negative interpersonal experiences with healthcare workers. In fact, health research has identified poor quality interactions between health care providers and patients who experience poverty as being one of the main barriers patients face in receiving responsive health care. These discriminatory and stigmatizing experiences can be exacerbated by other characteristics such as a person’s race, gender, sexual orientation, or occupation. For example, in BC Indigenous parents who use drugs and live in poverty routinely report having the family policing system (the “child protection system”) investigate them after seeking healthcare treatment for their substance use. In many cases their children are apprehended by the Ministry of Children and Family Development even when they have been actively seeking support to better the conditions of their families.

There are virtually no protections for patients who experience social condition-related discrimination and stigma in BC, because social condition is not a protected characteristic in the BC Human Rights Code. Patients who experience poverty-related discrimination and stigma in healthcare settings are, therefore, structurally disenfranchised from seeking reparations for their experiences.

Getting to the Root of the Issue

To advance legal protections for people who are impacted by social condition stigma and discrimination, an intersectoral approach between public health, public policy, and the law has the potential to make a considerable impact on the lives of a significant majority of people living in BC, particularly for Indigenous people who have the highest levels of poverty in Canada, with one in four Indigenous people living in poverty.

In 2022, 11.6% of BC’s population (more than 1 in 10 people) was living under the poverty line. BC was the last province in Canada to finally institutionalize a provincial poverty reduction strategy in 2019, and our human rights legislation still does not protect people from poverty discrimination in all protected areas of life as listed in our Human Rights Code. We are behind many other provinces and territories in adapting our human rights legislation to legally protect our most vulnerable populations from discrimination based on the circumstances of their socioeconomic status, including Manitoba, the Northwest Territories, New Brunswick, Quebec, and Newfoundland and Labrador. This is not a new issue for BC; for decades, the BC Human Rights Commissioner’s office, as well as Pivot Legal Society and countless Canadian academics, have been calling for amendments to BC’s Human Rights Code to protect social condition from discrimination.

Given the role that public health has in protecting, promoting, and advancing measures to improve health outcomes and bridge inequities, the public health sector is well-positioned to champion advocacy for social condition and stigma discrimination protections.

To take the necessary steps in this direction, we put forth the following calls to action to public health organizations and decision-makers:

Adopt the structural determinants of health as a primary framework in analyzing health issues, research, trends, data, policies, etc.
Recognize social condition discrimination as a critical concern and threat to public health
Support amendments to BC’s Human Rights Code to protect people from social condition discrimination