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Pathology of poverty: the need for quality improvement efforts to address social determinants of health
  1. Andrew S Boozary1,2,
  2. Kaveh G Shojania3
  1. 1 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2 Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
  3. 3 Department of Medicine, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Kaveh G Shojania, Department of Medicine, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON M4N 3M5, Canada; kaveh.shojania{at}

Statistics from

A massive body of literature characterises the impact of poverty on health outcomes. In 1817, Rene Villermé, a young French surgeon (and later economist-cum-social commentator), demonstrated stark differences in life expectancy across Parisian neighbourhoods or arondissements.1 This demonstration of disparities in basic health outcomes across income levels helped configure our early understanding of the ‘social determinants of health’. These determinants refer to the conditions in which people are born, grow, live, work and age, including income, housing and education, among others. Even 200 years after Villermé, with so many technological advances both within and outside of healthcare, the unequal distribution of resources across society continues to exert tremendous influence on the health outcomes of individuals and their communities.2–5

Underappreciated impacts of poverty as a cognitive impediment

In this issue of BMJ Quality and Safety, two papers draw attention to just some of the ways in which poverty directly affects the types of issues many in quality improvement (QI) aim to address. In their viewpoint article on the importance of simplifying care when managing chronic diseases for patients living in poverty, Nwadiuko and Sander describe a patient who will regrettably seem all too familiar to many primary care providers.6 The patient, a 52-year-old mother, has chronic medical conditions which include cirrhosis due to hepatitis C, uterine fibroids, hypertension and migraines. She struggles to manage these medical problems while also serving as the primary caregiver of a daughter with bipolar disease, along with nine grandchildren. She has been mired in poverty for years. And, on the day of this clinic visit, her primary care physician learns that she has recently been evicted from her home. Her resilience in simply making it to the appointment is striking enough, yet the authors argue that, as the therapeutic burden for patients with comorbidities has increased, we have failed to …

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