The Impossible Case of Disease Damage and Poverty

The impact of poverty on health is well-recognized. The World Health Organization website suggests that 1.2 billion people in the world live in extreme poverty. In Canada, 4.9 million (1 in 7) people live in poverty and this costs Canada as a nation between $72 and $84 billion annually (according to the Canada Without Poverty website). The most vulnerable members of society include those living with disabilities, single mothers, Indigenous populations, elderly individuals and racialized communities.

So if you are wondering why this depressing topic makes it into a Rheum Report - it's because poverty is inextricably linked to health outcomes – and this was demonstrated in a disturbingly convincing way this morning in the second plenary at the ACR. Edward Yelin (Abstract #1958) presented data from the UCSF Lupus Outcomes Study, which recruited lupus patients from 37 states in 2003 and followed them until 2015 with annual telephone interviews. The poverty status of each participant was evaluated annually in surveys based on household income and family size, and starting in 2009, the BILD (Brief Index of Lupus Damage) (a validated measure of disease damage) was administered.

Out of 783 respondents in 2009, 94% were female, 35% non-white, and 15% were living in poverty. Evaluating the impact of poverty in a dose-response way, this study found that those in poverty had greater increases in damage, particularly those in continued poverty. This was followed by worse damage in those with variable periods of poverty during the study period, whereas those without poverty had less damage. For those who exited poverty, the damage score changes were more similar to those who were never poor.

When asked why poverty has such an association with damage outcomes in lupus patients, several reasons were proposed including the finding in the study that those in poverty who lived in areas of concentrated poverty had more damage. Moreover, stress levels in those in poverty were twice as high as for those not in poverty.

This session was sad since suggestions by the presenter on how to fight poverty (e.g. advocacy, health vouchers) were proposed but he stated they were unlikely to happen with the recent political change. Although there are significant limitations in generalizing my own patient experiences to the same conclusions of this study – I actually can, and I think many rheumatologists can. Whether we are thinking about lupus, rheumatoid arthritis or psoriatic arthritis (or perhaps any chronic disease) , the patients who do worse include a significant proportion who are living in poverty – and we are not always addressing the impact of this in clinic. Nor are we usually in a position to do so.

This session was important, however, if only to increase awareness and have all attendees take the message home and work locally to tackle the problem of poverty and health with others who may have the skill set to effect change such as social workers, government, specialists, and general practitioners as a start. Focusing on the most vulnerable (e.g. minorities, indigenous peoples) would be an important place to start.

More reports from ACR 2016