“I’m here for a sleeping pill. I can’t sleep, it’s too cold.”

I have been told by several patients living on the streets that the hardest part is the cold, particularly in Northern Ontario where shelters are scarce. For some, this fate results when years of trauma and tragedy lead to social isolation. It is often accompanied by health struggles. I’ve watched several individuals’ health deteriorate, but with 5 to 10-year wait lists for subsidized housing and barriers, such as systemic racism, we are left to sit and wait.

Homelessness might be the most extreme and visible manifestation of poverty in Ontario, but the impact is much farther reaching. The erosion of social assistance rates and rise in precarious employment, along with the rising costs of living, mean basic necessities are now out of reach for many. Poverty in rural Ontario is deepened by the high costs of food, housing materials, energy, and travel for medical care. We are reminded of this by stories such as Peggy Mills’, whose Hydro was cut off because she could not afford her bills on her annual pension income of $17,000.

The root causes and implications of poverty are even more complex for indigenous communities and individuals. The destructive effects of colonization and the residential school system, which separated children from their families, aimed to destroy their cultural ties, and are widely known for having inflicted physical and sexual abuse, set the foundation for inequality in Canada.

Two decades after the closure of the last residential school, systemic racism perpetuates these inequalities. In 2014, the United Nations’ special Rapporteur on Indigenous peoples in Canada declared that Canada faces a “continuing crisis” and government incentives are “insufficient.” In fact, the Canadian Human Rights Tribunal ruled earlier this year that the federal government discriminates against First Nations children on reserves by failing to provide the same level of child welfare services that exist elsewhere.

The significant negative health impacts of low income, food insecurity, and inadequate housing are seen daily by health care providers and evidenced by research. People with lower incomes are more likely to have medical conditions such as cardiovascular disease and die at a younger age than people with higher incomes. Food insecurity, only one contributor to poor health among people with low income, is more common among those with chronic diseases such as diabetes and hypertension. It is also associated with increases health care utilization and costs.

Poverty affects health through a complex web of influences including material deprivation, chronic stress, and biological mechanisms such as changes in hormone levels. Poverty contributes to the development of medical conditions and also impact one’s ability to access medical care once they arise.

In remote regions in Ontario, where health services are scarce, the health implications of poverty can be costly to treat, creating a cycle that feels impossible to break free from. Consider Mary, who has a medical condition that causes chronic pain and prevents her from working. She cannot afford to travel hundreds of kilometres for physiotherapy or visit the specialist she was referred to because the Northern Health Travel Grant falls short.

Her pain has worsened over time to the point that she cannot walk for more than a few meters. This inactivity likely plays a role in the fact hat her diabetes is difficult to control. She knows she needs to cut down on processed foods with high sugars — fresh produce would be ideal — but they are unaffordable and impractical to keep since she travels to the store by taxi and each trip is costly. Each day she feels more and more discouraged.

The suffering caused by poverty in rural Ontario might be “out-of-sight, out-of-mind” at Queen’s Park, but is repeatedly brought to light by advocates such as Put Food In The Budget. Years of government consultations on housing and poverty, along with marginal changes to social policy, have done little to mitigate the detrimental effect of rising income inequality in Ontario. While a basic income guarantee, currently being studied in Ontario, could reduce poverty, the province needs to take immediate action, such as increasing social assistance and minimum wage, addressing housing and food insecurity, and ensuring equitable access to health and social services across the province. Only then will we be headed toward a healthier Ontario.

Katie Dorman is a family physician in Northern Ontario and member of Health Providers Against Poverty. The names in this story have been changed and the details combine several encounters in various locations, over a couple of years.