As I leave Raj’s bedside, I encourage him to eat something while he’s here in the emergency department. He’s having some dental pain, and I want to reassure both myself and Raj that his nutrition status isn’t in any acute danger before he leaves the ER.

He tells me he isn’t hungry. I insist that he try. Fine then, he says. I’ll take a tuna sandwich and two apple juices. He knows what’s on offer, since he’s been here before.

This is part of what we do in the emergency department.

Raj (not his real name) is familiar with our ER menu because he is often hungry, since he is poor. He is poor because he survives on social assistance, and social assistance doesn’t go very far in Toronto, where the shelter system is overburdened and the average cost of an accessible bachelor apartment is $1,200.

Raj’s teeth hurt because he’s in dire need of dental care, which is hard to access if you are poor. Toronto Public Health provides dental care to children, seniors, and eligible impoverished adults; there may be cuts to this service as TPH faces a billion-dollar budget cut over the next 10 years.

I saw Raj last week as well, when he arrived at the ER intoxicated. He struggles with alcohol addiction, as do thousands of other Ontarians. Access to alcohol in Ontario is becoming easier, with new deregulation announced this month. I don’t know how this will affect Raj, if at all, but I cannot imagine it will make his life easier as alcohol becomes more readily available in corner stores and at earlier hours.

Raj is not unique. On any given day, a small number of the patients seen in our ED are high-frequency users, many of whom have complex social concerns. The sandwiches they eat are served with the hefty price tag of hundreds of public dollars spent for each emergency department visit.

Addressing Raj’s problems, and the problems of so many of my patients, requires real commitment from governments to support the social determinants of health – the social, economic and environmental factors that determine individual and population health. Instead, the government has promised cuts to public health, education, legal aid and social services.

Last week we ran out of sandwiches. I found myself scrounging the cupboard for a last box of off-brand cereal so that I had something to offer Raj in the ER. I cannot fix his housing, nor his dental pain, nor his poverty. That day, I couldn’t even address his hunger. As an ER doctor, I find this deeply morally distressing.

With this budget, the Ford government is chopping up the safety net meant to be supporting the most vulnerable members of our communities. Meanwhile, they expect that the hallways of our emergency departments and wards won’t only fill further, as patients lose access to the social and preventive supports that are meant to keep them healthy.

We’ve already run out of sandwiches, Doug. How are our patients, providers and system going to cope now?

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