10 Hserv 482 Canada
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10 Hserv 482 Canada
Learning ObjectivesDescribe plausible reasons for Canada's good standing
in the Health Olympics
List factors that may be involved in the decline in standings over the last decade
My Backgroundborn in Toronto, lived there for the first 23 years of my life,
went to U of Toronto lived a year in Montreal in 1970s as an intern at McGill
Universitylived and worked as a doctor in BC in the 1970sworked for University of Calgary in 1980scared for my father in Toronto nursing home, and BC nursing
homeown land in BC continue to spend much time there
–Vancouver, Lower Fraser Valley, Toronto, Montreal, Edmonton–in the mountains (Yukon, Rockies, Selkirks, Coast Ranges)
Canada comparisons with the USCanada a British Colony from 1700sstrong ties with England continued to recent timessocial welfare contract:
–baby bonus checks–publicly supported education system with no private schools at university level and very few below that
more progressive taxation systemUniversal coverage health care since 1960s1974 Lalonde Report (New Perspective on the Health
of Canadians)LaGuardia and Toronto airports 2002
US Canada Source
Life Expectancy 76.9 79.2 UNDP 2003
IMR 7 6 UNICEF 2000
Health Care Costs/capita (USD) 4187 1783 WHO 2000
Maternal Mortality Ratio 9.8 3.4 OECD
GDP/capita (USD) 29,605 23,852 UNDP 2000
Smoking Prevalence Male 27.6 27 American Cancer Society
Smoking Prevalence Female
22.1 23
Gini 40.1 31.5 World Bank 2000
CEO-Boss/ Average Worker pay ratio
531:1 21:1 New York Times Jan 25, 2004
Teen Births Highest
53/1000
15/30
16/1000
SCF 2004 report
Educational Disadvantage 7th worst 4th best UNICEF Innocenti Research Group
Child Injury Deaths 4th worst 9th worst
Child Poverty 2nd worst 7th worst
Child Abuse Deaths 2nd worst 7th worst
United Nations Human Development Report 2007
77
78
79
80
81
82
83
JapanIceland
SwitzerlandAustralia
SpainSwedenCanada
IsraelItalyFrance
New Zealand
NorwayAustriaSingapore
NetherlandsGermany
MaltaCyprus
United Kingdom
FinlandGreeceBelgiumCosta Rica
Ireland
Luxembourg
United Arab Emirates
Chile
DenmarkKorea
United States
Life Expectancy (years)
510
1520
25
30
HEALTH OLYMPICS 2005
Kaplan 1996 BMJ
BE
TT
ER
HE
AL
TH
MORE EQUALITY
Ross et. al. BMJ 2000
BE
TT
ER
HE
AL
TH
MORE EQUALITY
Highest Life ExpectancyAnd disability free years
Lowest Life ExpectancyAnd disability free years
Life expectancy disparityis 16 years
Metropolitan Income Inequality and Mortality in North America
Siddiqi & Hertzman SSM 2007
74
75
76
77
78
79
80
81
1980 1985 1990 1995 2000
IdahoWashingtonBritish Columbia
Life Expectancy
Williams-Derry 2002
Cascadia2002NW Env Wa
Seattle Magazine August 2007
Infant Mortality: US vs Canada, 1996
Canada US Canada US
Poorest 20%Poorest 20% 6.5/10006.5/1000 ------ SecondSecond 5.25.2 ------ ThirdThird 5.15.1 ------ FourthFourth 4.74.7 ------Richest 20%Richest 20% 3.93.9 ------
OverallOverall 5.2 7.85.2 7.8
Infant Mortality Rates, Status Indians and Other Residents, B.C., 1991-2001
0
2
4
6
8
10
12
14
1991-96 1997 1998 1999 2000 2001 1997-2001
Status IndiansOther Residents
Rat
e P
er 1
,000
Liv
e B
irth
s
Sources: BC Vital Statistics Agency, 1997BC Ministry of Health Planning, 2003
Year
VIOLENCE AND INEQUALITY Daly 2001
LESS EQUALITY
VIOLENCE AND INEQUALITY Daly 2001LESS EQUALITY
Wilkinson et. al. SSM 2007
MORE EQUALITY
Prisoners
Mor
e P
RIS
ON
ER
S
Uslaner 02
TRUST
MORE EQUALITY
Mor
e T
RU
ST
After Willms 1999
Wilkinson et. al. SSM 2007
MORE EQUALITY
Math and Literacy Scores
Bet
ter
SC
HO
OL
Per
form
ance
UNICEF League Table Educational Well-Being
Household Poverty Rates (Household Head Aged 25-64)
( A )
Market Income
( B )
Col A +
Private Income
Transfers
( C )
Col B +
Universal and
Social Transfers
( D )
Col C –
Taxes
( E )
Col D +
Social Assistance Transfers
Percent Change
Columns A to E
Canada
(1994)
23.9 21.1 15.4 16.6 14.5 -39.3
Sweden (1992)
20.7 20.1 5.0 8.5 3.8 -81.6
US (1994)
23.2 21.0 18.4 20.5 18.9 -18.5
Solo PovertySolo Poverty% of children living below the poverty line, 1990-1992% of children living below the poverty line, 1990-1992
Source: Canada Social Trends, Source: Canada Social Trends, 19961996
• Children in two-Children in two-• parent familiesparent families
Children in Children in solosolo
mother familymother family
SwedenSweden 2.22.2 5.25.2DenmarkDenmark 2.52.5 7.37.3FinlandFinland 1.91.9 7.57.5BelgiumBelgium 3.23.2 10.010.0ItalyItaly 9.59.5 13.913.9NorwayNorway 1.91.9 18.418.4NetherlandsNetherlands 3.13.1 39.539.5CanadaCanada 7.47.4 50.250.2AustraliaAustralia 7.77.7 56.256.2United StatesUnited States 11.111.1 59.559.5
Social Expenditure on Family Benefits as a Social Expenditure on Family Benefits as a
% of GDP% of GDP
• SwedenSweden 2.232.23 11
• FranceFrance 2.132.13 22
• NorwayNorway 1.91 1.91 33
• FinlandFinland 1.901.90 44
• Australia Australia 1.361.36 55
• CanadaCanada 0.510.51 66
• USAUSA 0.22 0.22 7 7
Source: OECD Social Expenditure Database (1998)Source: OECD Social Expenditure Database (1998)
Rank
Q5/Q1 Mortality Ratios
0.75
1.00
1.25
1.50
1.75
2.00
2.25
2.50
2.75
3.00
3.25
3.50
<1 1-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
1971-M
1986-M
1991-M
1996M
1971-F
1986-F
1991-F
1996-F
Age (yrs)
Canada
Mortality by Neighbourhood Income in Urban Canada, Wilkins R, Berthelot JM, Ng E,PPA March 2001
Canada beats USA But Loses Gold to Sweden
0
0.1
0.2
0.3
0.4
USABritain W
GermanyFinland Canada
DenmarkSweden Norway
International comparisons of intergenerational social mobility
Source: Blanden J, Gregg P, Machin S. Intergenerational mobility in Europe and N. America. Centre for Economic Performance, London School of Economics. 2005
Higher columns show that people’s social position is more strongly determined by their parents’ position
Wilkinson et. al. SSM 2007
MORE EQUALITY
Father's and Son's IncomesIf poor in US, stay poor
Mor
e fi
nan
cial
mob
ilit
y
16 nations, 169,776 people
Highest Life ExpectancyAnd disability free years
Lowest Life ExpectancyAnd disability free years
Life expectancy disparityis 16 years
BC/Washington Comparisons BC WA
PUBLIC/ PRIVATE spending, Taxes
Taxes $1700 more Income, property and sales tax
Retail sales tax, property tax and misc. taxes
Public Programs $1000 less per person
Student tuition $1700 more in public universities
Utilities $540 more per family
Life insurance, pensions,
$2300 more per family
BC/Washington Comparisons BC WA
Inequality
Social Assistance More generous Only adults caring for dependent child eligible for 5 years over lifetime
People without health insurance
0 900,000 (16% of population in 1998)
Income inequality (Q5/Q1)
6.2 (1998)
5.2 (1989)
9.2 (1998)
7.0 (1989)
IMR (1989) 4.03 7.0
Minimum wage $7.60 $8 (Can at ppp)
BC/Washington Comparisons BC WA
Working Conditions
Worker's paid statutory holidays
9 days + 2 weeks annual vacation then 3 weeks after 5 yrs
0
Maternity Leave 55% up to $413/week for 50 weeks (15 weeks maternity + 35 weeks parental leave shared with father) compassionate care leave while caring for a dying relative
12 weeks only if working in public sector or for private companies with >50 employees (amounts to 55% of workforce)
2009 WA up to 5 weeks at $250/wk
BC/Washington Comparisons BC WA
Working Conditions
Unionization 30.4% 18.2%
Getting fired, (termination)
"Just cause" or 2 weeks notice after a year of work or 2 weeks pay
"At will"
Income vs. Income Inequality?In Canada, income inequality health relationship is not as strong as in the
US because of other supports that mitigate adverse effects of income inequality
–McLeod 2003: prospective cohort study, SAH 94,96, 98 found low hh income associated with poor SAH, but not inc. ineq. (measured in 91 from census in 53 metro. areas)
–Sanmartin 2003 Labour market income inequality in NA metropolitan areas: more effect in US than in Canada
–Laporte (2003) provincial time-series modeling from 1980 to 1997 look at income and mortality don't find income or income inequality significant but health spending and unemployment predicts mortality better
–Daly (2001) find homicide and inc. ineq. related in Canada as in US, with differences in inc. ineq. Explaining lower rates in Canada when lump states & provinces
Saez 2005
USA Canada Economic Comparisons
Life Expectancy UNDP 1997
Life Expectancy UNDP 1997
73.0
74.0
75.0
76.0
77.0
78.0
79.0
80.0
510
15
2025
30
After-Tax Income Gap is Bigger than Ever for Families Raising Children in Canada (ratio of after-
tax income in deciles 10 and 1, 1976-2004)
Yalnizyan, 2007
7.0
7.5
8.0
8.5
9.0
9.5
10.0
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Earnings
Yalnizyan 2007
Yalnizyan 2007
United Nations Human Development Report 2007
77
78
79
80
81
82
83
JapanIceland
SwitzerlandAustralia
SpainSwedenCanada
IsraelItalyFrance
New Zealand
NorwayAustriaSingapore
NetherlandsGermany
MaltaCyprus
United Kingdom
FinlandGreeceBelgiumCosta Rica
Ireland
Luxembourg
United Arab Emirates
Chile
DenmarkKorea
United States
Life Expectancy (years)
510
1520
25
30
HEALTH OLYMPICS 2005
United States
USA economic pie shares
Share of nation's net worth 2004
Top 1% 34.7%
Next 9% 35.4%
Bottom 90% 29.9%
Source Federal Reserve Board SurveyOf Consumer Finances and ForbesPizzigati, Too Much http://www.cipa-apex.org/toomuch/articlenew2006/April24a.html
US Wealth Distribution 2004
34.7%
35.4%
29.9%
Top 1%Next 9%Bottom 90%
from 1992 to 2004 the wealth share of the least wealthy half of the population fell significantly to 2.5 percent of total wealth
Harvey 2005
Health in CanadaVery good in comparison to US
The result of a historical social contract and redistribution that is not income-based
Not because of health care systemSin (2003) looking at children of very poor vs poor & non-poor families in Alberta had higher rates of asthma ER visits despite universal access (all births 850401 to 880331) followed for ten years
Mu
nn
ell 2
004
Medical Care Act, 1966Passed House of Commons
Insurance rather than national system
By 1971, all provinces ratified
Doctors accepted limitations on their practice –Penticton Hospital Swan Ganz Catheter
Medical care less intervention-based (comparative studies with US on doing less and having better outcomes) current cardiac work-up examples
Influence of Great Depression“if medical care is a contingency left to
each individual to secure as best he can, it becomes a function of the distribution of wealth”
Marsh, Grant, Blackler Health and Unemployment: Some Studies of Their Relationships (1938)
Extra Billing/Two-Tiered System
"Any free country that talks about the democratic process and allows extra billing to become the general rule is denying the basic principles of the democratic process" – Tommy Douglas 1982, introduced Medical Care Act in Saskatchewan in 1962, the first single-payer in Canada
% G
NP
x 1
00
Universal Health Care/Population Health
Manitoba 10 year study: who uses how much care
how this differs by health & ses
Is health care an effective policy tool for reducing inequalities in health?
Examine 1986 health care use in Winnipeg, and ten years later
Health characteristics (life expectancy, prevalence of chronic disease, rates of avoidable hospitalization) in 1986 and 1996
Effect of downsizing hospital system (24% bed closure over that period)
Roos 2006
Roos 2006
Web of Influence
“To conclude, a universal health care system is definitely the right policy tool for delivering care to those in need, and for this it must be respected and supported. However, investments in health care should never be confused with, or sold as, policies whose primary intent is to improve population health or to reduce inequalities in health. Claims to that effect are misleading at best, dangerous and highly wasteful at worst.”
Chapter 5, Universal Medical Care and Health Inequalities: right objectives, insufficient tools. Roos, Brownell, Menec (2006). Oxford University Press.
Guyatt, G. H., P. J. Devereaux, et al. (2007). "A systematic review of studies comparing health
outcomes in Canada and the United States." Open Medicine 1(1): e27-36.
High Quality Studies
Low Quality Studies
Resulting favoring United States
2 3
Results favoring Canada
5 9
Mixed or equivocal results
3 16
stay < 24 h, obstetrics, transfer, cardiac arrest on arrival and subsequent death, rehab, psychiatric
Baker et al CMAJ 2004 Figure 1
Baker et al Adverse Events Results7.5% of patients had ≥1 Adverse Event (AE)
–51% surgery, 45% medicine
–Errors of omission and commission
–16% of AE's resulted in death
36% highly preventable (score >4)
AEs resulted in longer stays, temporary disability
–5% resulted in permanent disability
9250 to 23750 deaths from AEs were preventable
–~ 64% not preventable total deaths 34900 to 98700
Death associated with AE in 1.6% of patients with similar hospitalizations in Canada Adjusting
for sampling strategy
Baker et al CMAJ 2004
Baker et al CMAJ 2004
Baker et al CMAJ 2004
*Weighted to account for the total number of charts per hospital and the total number of hospitals per type per province.†Adjusted for 8 comorbidities plus age and sex
Baker et al Adverse Events Results
Higher AEs in teaching hospitals
1. ? Higher patient acuity
2. Teaching hospitals receive patients at different points in care (small or large community hospitals may not be able to provide care)
3. Complexity of care in teaching hospitals--usu. Several providers, with risk of miscommunication, coordination
4. Patient records may vary across hospital types
5. Lower quality of care
DIRECT TO CONSUMER
ADVERTISING
Direct to Consumer Advertising DTCA: 3 types
Disease-awareness advertisements–Prompts consumers to talk to providers about treatment without expressing brand preferences
Reminder advertisements –States name of product, strength, dosage, form and price but may not mention production's indication or make claims about effectiveness
Product-claim advertisements–Includes indication and effectiveness –Allows manufacturers to associate claims with particular brands
Direct to Consumer Advertising DTCA: PRODUCT CLAIM type
Product-claim advertisements–Begun in US in 1982 in Readers Digest and required product labeling information to be presented as in medical journals
•Moratorium from 1983 to 1985 as FDA consulted
–Began again in Sept. 1985 and by 1987 spending $35 million annually on DTCA–Required major side effects and contraindications
Broadcast advertisements began late 1980s
Spending $380 million in 1995, $790 million in 1996
US growth in DTCA1997: required major statement about risk 4 sources
– Toll-free telephone service– Concurrently running print advertisements or brochures– Consumer's health care provider– Web site
2005 spending of $4.24 billion (11 times that of 1995)
1996-2004: DTCA grew from 9% to 16% of total expenditures on drug promotion (including retail value of professional samples)– Excluding samples: 19% to 27% by 2005
DTCA spending to exceed doctor advertising by 2011
DTCA vs drug marketing to doctors1996-2004:
DTCA Expenditures increased 408%
"On the basis of an analysis of 49 brands that were the subject of DTCA between 1998 and 2003, IMS Management Consulting concluded that the return on investment from DTCA is "nearly unprecedented in terms of the positive sales response generated."
Sample spending increased 144%
Drug sales representative contacts increased 224%
Morgan 2007
Morgan 2007
US spending on DTCA & US-Canada Difference in per-capita drug expenditures
US-Canada Drug $
US DTCA $
DTCA US/CANADA COMPARISONS
DTCA Expenditures increased 408%
"On the basis of an analysis of 49 brands that were the subject of DTCA between 1998 and 2003, IMS Management Consulting concluded that the return on investment from DTCA is "nearly unprecedented in terms of the positive sales response generated."
Sample spending increased 144%
Drug sales representative contacts increased 224%
CanadaGovernment
WritingsPOPULATION HEALTH
FederalProvincial
LocalRegional
Provincial
Determinants of Health1 Income and social status2 Social support networks3 Education4 Employment and working conditions5 Social environment 6 Physical Environment
7 Biology and genetic endowment8 Personal healthy practices and coping skills9 Healthy Child Development10 Health Services11 Culture12 Gender
Alberta Determinants of Health1 Income and social status
"countries with the greatest differences between the richest and poorest tend to have poorer overall health status than societies which are both prosperous and have an equitable distribution of wealth"2 Social support networks
"Caring and respect are derived from strong social networks which improve one's sense of well-being and appear to act as a buffer protecting against health problems." 5 Social environment
"Goes beyond friends and family and extends to the broader community in which a person lives and works. It includes a sense of cohesiveness within society from its values to its institutions to informal giving."
8 Personal healthy practices and coping skills
"There is increasing understanding that personal decisions are greatly influenced by the socio-economic environments in which people live, learn, work and play." 9 Healthy Child Development
"Healthy child development is a powerful determinant of health. How a child develops is greatly influenced by their physical and social environment." 11 Culture
"particularly for those who are a part of a cultural group that is not the dominant one in the area in which they live and work." 12 Gender
"Gender refers to the societal roles placed on the sexes that influence behaviors, personality, attitudes, and power and influence on society that may be on a differential basis."
CITY
Tid
es o
f C
hang
e A
tlan
tic
Can
ada
Tides of Change 7 Key messages1. Health is conceptualized as physical, mental, and social well-being rather than as the
absence of disease. We then discuss the current tendency of chronic disease prevention strategies to focus on changing individual risk behaviours, despite evidence that changing to social and economic root causes could be more effective.
2. The scene in Atlantic Canada by reviewing statistics for the three categories of chronic disease: noncommunicable, communicable, and mental health. We also include main regions facing inequities within the provinces.
3. Theory and evidence that social and economic processes and the resulting poverty create inequities and chronic disease in society.
4. Vulnerable populations who are affected by inequities: Aboriginal people and African Canadians, single mothers and children living in poverty, seniors, and rural populations.
5. Importance of place; neighbourhood, community, region, etc., in creating inequities and points out that inequities in society affect the entire population, not just the poor. We look briefly at cultural and social context, geographic areas, and income distribution.
6. Ask how inequities can lead to chronic disease. Materialist, psychosocial, and political/economic pathways are discussed in the Atlantic Canada context.
7. Recommend strategic directions that must be based on the root causes of inequities in
society.
Safe and affordable housing
Nutritious food
Safe and affordable housing
Nutritious food
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