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Poverty increases the risk of disease. But the reason why a low income can have such a dramatic effect on health is not clear.

After more than a decade of intensive research, we know that many factors conspire to link income and health — some of which are obvious, such as stress and poor access to healthy food.

Earlier this year, Stephen Hwang (pictured below right) exposed a surprising new factor.

Hwang, a professor in the Department of Medicine, led a study that found family doctors’ offices are more likely to give first-time appointments to patients with a high income than those with a low income.

“Even though family physicians in Canada’s single-payer health care system have no economic incentive to discriminate based on socioeconomic status, we found that some offices favour people who have higher income,” said Hwang, who is also a scientist in the Centre for Research on Inner City Health of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital.

Hwang’s team contacted 375 doctors’ offices in Toronto posing as either a bank employee newly transferred to the city or as a welfare recipient. Those presenting themselves as bank employees were almost 80 per cent more likely to get an appointment.

The study was the first in Canada to find discrimination based on economic status — a phenomenon that Hwang, who works half a day per week at a homeless shelter, had long suspected was real.

Richard Glazier, a professor in the Department of Family and Community Medicine, recently found evidence of another income-linked determinant of health: neighbourhood walkability.

Glazier (pictured below right) and colleagues showed that recent immigrants living in areas less conducive to physical activity — those with few amenities and recreational facilities, where travel by car is common — had a threefold risk of developing diabetes.

“Poor walkability and low income can create a perfect storm that raises the risk for diabetes, particularly among recent immigrants,” said Glazier, who is also a scientist in the Centre for Research on Inner City Health of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital.

Peel and other regions around Toronto have begun to identify and make changes to low-income neighbourhoods with poor walkability, based on the work of Glazier and his colleagues.

“Zoning changes that allow for more density and commercial space encourage people to walk when running errands, rather than drive, and can quickly turn an unhealthy neighbourhood into a more active one,” said Glazier. “The progress has been encouraging.”

By exposing some of the indirect ways that low income negatively affects health, ��˾��ֱ�� researchers are helping to ensure marginalized populations can access the health care they need.

Jim Oldfield is a writer with the Faculty of Medicine at the University of Toronto.