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10 Hserv 482 Canada. Learning Objectives Describe plausible reasons for Canada's good standing in the Health Olympics List factors that may be involved.

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Presentation on theme: "10 Hserv 482 Canada. Learning Objectives Describe plausible reasons for Canada's good standing in the Health Olympics List factors that may be involved."— Presentation transcript:

1 10 Hserv 482 Canada

2 Learning Objectives Describe 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

3 My Background born 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 University lived and worked as a doctor in BC in the 1970s worked for University of Calgary in 1980s cared for my father in Toronto nursing home, and BC nursing home own land in BC continue to spend much time there –Vancouver, Lower Fraser Valley, Toronto, Montreal, Edmonton –in the mountains (Yukon, Rockies, Selkirks, Coast Ranges)

4 Canada comparisons with the US Canada a British Colony from 1700s strong ties with England continued to recent times social welfare contract: –baby bonus checks –publicly supported education system with no private schools at university level and very few below that more progressive taxation system Universal coverage health care since 1960s 1974 Lalonde Report (New Perspective on the Health of Canadians) LaGuardia and Toronto airports 2002

5 USCanadaSource Life Expectancy76.979.2UNDP 2003 IMR76UNICEF 2000 Health Care Costs/capita (USD)41871783WHO 2000 Maternal Mortality Ratio 9.83.4OECD GDP/capita (USD) 29,60523,852UNDP 2000 Smoking Prevalence Male 27.6 27American Cancer Society Smoking Prevalence Female 22.123 Gini40.131.5World Bank 2000 CEO-Boss/ Average Worker pay ratio 531:121:1New York Times Jan 25, 2004 Teen BirthsHighest 53/1000 15/30 16/1000 SCF 2004 report Educational Disadvantage7th worst4th bestUNICEF Innocenti Research Group Child Injury Deaths4th worst9th worst Child Poverty2nd worst7th worst Child Abuse Deaths2nd worst7th worst

6 United Nations Human Development Report 2007




10 Highest Life Expectancy And disability free years Lowest Life Expectancy And disability free years Life expectancy disparity is 16 years

11 Metropolitan Income Inequality and Mortality in North America

12 Siddiqi & Hertzman SSM 2007

13 Life Expectancy Williams-Derry 2002

14 Cascadia 2002 NW Env Wa

15 Seattle Magazine August 2007

16 Infant Mortality: US vs Canada, 1996 Canada US Canada US Poorest 20%6.5/1000--- Second5.2--- Second5.2--- Third5.1--- Third5.1--- Fourth4.7--- Fourth4.7--- Richest 20%3.9--- Overall5.2 7.8 Overall5.2 7.8

17 Infant Mortality Rates, Status Indians and Other Residents, B.C., 1991-2001 Rate Per 1,000 Live Births Sources: BC Vital Statistics Agency, 1997 BC Ministry of Health Planning, 2003 Year




21 Wilkinson et. al. SSM 2007 MORE EQUALITY Prisoners More PRISONERS


23 After Willms 1999

24 Wilkinson et. al. SSM 2007 MORE EQUALITY Math and Literacy Scores Better SCHOOL Performance

25 UNICEF League Table Educational Well-Being

26 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) 23.921.115.416.614.5-39.3 Sweden (1992) 20.720. US (1994)

27 Solo Poverty % of children living below the poverty line, 1990-1992 Source: Canada Social Trends, 1996 Children in two-Children in two- parent familiesparent families Children in solo mother family Sweden2.25.2 Denmark2.57.3 Finland1.97.5 Belgium3.210.0 Italy9.513.9 Norway1.918.4 Netherlands3.139.5 Canada7.450.2 Australia7.756.2 United States11.159.5

28 Social Expenditure on Family Benefits as a % of GDP Sweden2.231 Sweden2.231 France2.132 France2.132 Norway1.91 3 Norway1.91 3 Finland1.904 Finland1.904 Australia 1.365 Australia 1.365 Canada0.516 Canada0.516 USA0.22 7 USA0.22 7 Source: OECD Social Expenditure Database (1998) Rank

29 Q5/Q1 Mortality Ratios Age (yrs) Canada Mortality by Neighbourhood Income in Urban Canada, Wilkins R, Berthelot JM, Ng E,PPA March 2001

30 Canada beats USA But Loses Gold to Sweden

31 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

32 Wilkinson et. al. SSM 2007 MORE EQUALITY Father's and Son's Incomes If poor in US, stay poor More financial mobility

33 16 nations, 169,776 people

34 Highest Life Expectancy And disability free years Lowest Life Expectancy And disability free years Life expectancy disparity is 16 years

35 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

36 BC/Washington Comparisons BC WA Inequality Social AssistanceMore generous Only adults caring for dependent child eligible for 5 years over lifetime People without health insurance 0900,000 (16% of population in 1998) Income inequality (Q5/Q1) 6.2 (1998) 5.2 (1989) 9.2 (1998) 7.0 (1989) IMR (1989)4.037.0 Minimum wage$7.60$8 (Can at ppp)

37 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 Leave55% 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

38 BC/Washington Comparisons BC WA Working Conditions Unionization30.4%18.2% Getting fired, (termination) "Just cause" or 2 weeks notice after a year of work or 2 weeks pay "At will"

39 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

40 Saez 2005

41 USA Canada Economic Comparisons


43 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

44 Yalnizyan 2007


46 United Nations Human Development Report 2007

47 United States

48 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 Survey Of Consumer Finances and Forbes Pizzigati, Too Much from 1992 to 2004 the wealth share of the least wealthy half of the population fell significantly to 2.5 percent of total wealth

49 Harvey 2005

50 Health in Canada Very good in comparison to US The result of a historical social contract and redistribution that is not income-based Not because of health care system Sin (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

51 Munnell 2004

52 Medical Care Act, 1966 Passed 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

53 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)

54 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

55 % GNP x 100

56 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)

57 Roos 2006


59 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.

60 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 23 Results favoring Canada 59 Mixed or equivocal results 316


62 stay < 24 h, obstetrics, transfer, cardiac arrest o n arrival and subsequent death, rehab, psychiatric Baker et al CMAJ 2004 Figure 1

63 Baker et al Adverse Events Results 7.5% 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


65 *W eighted 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

66 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



69 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

70 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

71 US growth in DTCA 1997: 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

72 DTCA vs drug marketing to doctors 1996-2004: 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%

73 Morgan 2007

74 US spending on DTCA & US-Canada Difference in per-capita drug expenditures US - Canada Drug $ US DTCA $

75 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%

76 Canada Government Writings POPULATION HEALTH Federal Provincial Local Regional


78 Provincial



81 Determinants of Health 1 Income and social status 2 Social support networks 3 Education 4 Employment and working conditions 5 Social environment 6 Physical Environment 7 Biology and genetic endowment 8 Personal healthy practices and coping skills 9 Healthy Child Development 10 Health Services 11 Culture 12 Gender

82 Alberta Determinants of Health 1 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."













95 Tides of Change Atlantic Canada

96 Tides of Change 7 Key messages 1.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.





101 Safe and affordable housing Nutritious food

102 Safe and affordable housing Nutritious food


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