Learning Objectives

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

7. Many studies are on US data, the first two came out in 1996 looking at US states Also associated with income distribution is, low birth weight, homicide, violent crime, work disability, expenditures on medical care, smoking and sedentary activity, ALSO rates of unemployment, imprisonment, recipients of income assistance and food stamps, lack of medical insurance and educational outcomes If you live in Louisiana or Mississippi, the US states with the biggest gap between the rich and the poor, your chance of dying is 50 % greater than if you lived in Utah or Hawaii or New Hampshire. If you control these data for absolute poverty, median income, effect of transfers/taxes, prevalence of smoking, the associations persist You might think it is poverty that is really the key player here, but we have only a weak association between median income and total mortality (r = -0.28), disappears if we adjust for inequality What would happen if we added our neighbors to the north to this graph? Michael Wolfson and Nancy Ross did this Many studies are on US data, the first two came out in 1996 looking at US states Also associated with income distribution is, low birth weight, homicide, violent crime, work disability, expenditures on medical care, smoking and sedentary activity, ALSO rates of unemployment, imprisonment, recipients of income assistance and food stamps, lack of medical insurance and educational outcomes If you live in Louisiana or Mississippi, the US states with the biggest gap between the rich and the poor, your chance of dying is 50 % greater than if you lived in Utah or Hawaii or New Hampshire. If you control these data for absolute poverty, median income, effect of transfers/taxes, prevalence of smoking, the associations persist You might think it is poverty that is really the key player here, but we have only a weak association between median income and total mortality (r = -0.28), disappears if we adjust for inequality What would happen if we added our neighbors to the north to this graph? Michael Wolfson and Nancy Ross did this

11. Metropolitan Income Inequality and Mortality in North America red + on gold octagon, high income inequality and high mortality LONG TERM Canada Reds are Prince George, and Sidney (NS), US: long in US, SE had plantation society organized on hierarchical principles, whereas north had freeholder economy, BNA organized on basis of small freeholders, acting more as free holders on basis of climate E/W Europe would map the same way, W. Europe freeholders, while E. Europe were serfs (Tsars) compared to plantation economy and stayed within social rulebooks for centuries I asked why the difference with Lake Erie and Clyde didn't have great insights Question from Surrey ?health officer (where have parks and income equality) whether this tracks across causes of death, Vietnam War, homicides? Little cause specific mortality data going back many years, would have to try and gather it, Clyde guesses that strongest effect is for cardiovascular disease DID 6 CASE COMPARISONS: Russia:Czech, Baltics:Finland, US:Canada Question about huge differences in life styles US/Canada, work, physical inactivity, rates of obesity, BMI higher in US than Canada, and physical activity higher in Canada, whereas Clyde thought differences were not much, but California had red on map, Ra Ra lifestyles, Kerry state, but not a low mortality state Question: Health care a leading cause of death, John Miller, 1/3 larger than Canada, maybe 1/3 more deaths Need RCT's, manipulating income and health, have social tracking in YVR where a few years ago jacked up income of mothers so could enter work force and see if have a health advantage? red + on gold octagon, high income inequality and high mortality LONG TERM Canada Reds are Prince George, and Sidney (NS), US: long in US, SE had plantation society organized on hierarchical principles, whereas north had freeholder economy, BNA organized on basis of small freeholders, acting more as free holders on basis of climate E/W Europe would map the same way, W. Europe freeholders, while E. Europe were serfs (Tsars) compared to plantation economy and stayed within social rulebooks for centuries I asked why the difference with Lake Erie and Clyde didn't have great insights Question from Surrey ?health officer (where have parks and income equality) whether this tracks across causes of death, Vietnam War, homicides? Little cause specific mortality data going back many years, would have to try and gather it, Clyde guesses that strongest effect is for cardiovascular disease DID 6 CASE COMPARISONS: Russia:Czech, Baltics:Finland, US:Canada Question about huge differences in life styles US/Canada, work, physical inactivity, rates of obesity, BMI higher in US than Canada, and physical activity higher in Canada, whereas Clyde thought differences were not much, but California had red on map, Ra Ra lifestyles, Kerry state, but not a low mortality state Question: Health care a leading cause of death, John Miller, 1/3 larger than Canada, maybe 1/3 more deaths Need RCT's, manipulating income and health, have social tracking in YVR where a few years ago jacked up income of mothers so could enter work force and see if have a health advantage?

16. Infant Mortality: US vs Canada, 1996 Wilkins shows that Canada's poorest quintile at 6.5/1000 compares with US 7.8, so poorest in Canada did better than US average Wilkins shows that Canada's poorest quintile at 6.5/1000 compares with US 7.8, so poorest in Canada did better than US average

17. Infant Mortality Rates, Status Indians and Other Residents, B.C., 1991-2001

18. Daly 2001Daly 2001

19. Daly 2001Daly 2001

20. Seattle Times April 18, 2007Seattle Times April 18, 2007

22. Uslaner 200Uslaner 200

23. Redrawn by Wilkinson and Pickett in their 2006 submission to AJPH that is from Willms, J. D. (1999). Quality and inequality in children's literacy: the effects of families, schools and communities. Developmental Health and the Wealth of Nations: Social, biological and educational dynamics. D. P. Keating and C. Hertzman. New York, Guilford Press: 72-93. Figure 5.1Redrawn by Wilkinson and Pickett in their 2006 submission to AJPH that is from Willms, J. D. (1999). Quality and inequality in children's literacy: the effects of families, schools and communities. Developmental Health and the Wealth of Nations: Social, biological and educational dynamics. D. P. Keating and C. Hertzman. New York, Guilford Press: 72-93. Figure 5.1

25. Innocenti Report Card 7, Child Well-Being in Rich Countries 2007Innocenti Report Card 7, Child Well-Being in Rich Countries 2007

26. Household Poverty Rates (Household Head Aged 25-64) transfers: things given to individuals, market income, universal transfers, target transfers Private Income Transfers -- includes occupational pension benefits, inter household transfers, and private transfers such as child support (everything but government transfers and taxes) Universal and Social Transfers -- child allowances, unemployment, disability and old age insurance. Social Assistance Transfers -- means tested benefits, such as food stamps, AFDCtransfers: things given to individuals, market income, universal transfers, target transfers Private Income Transfers -- includes occupational pension benefits, inter household transfers, and private transfers such as child support (everything but government transfers and taxes) Universal and Social Transfers -- child allowances, unemployment, disability and old age insurance. Social Assistance Transfers -- means tested benefits, such as food stamps, AFDC

27. Solo Poverty% of children living below the poverty line, 1990-1992 Children in two- parent families

28. Social Expenditure on Family Benefits as a % of GDP

29. Q5/Q1 Mortality Ratios When we break down the effects into age intervals, something important becomes apparent. There has been little decline between 1991 and 1996 in the mortality ratios for men at the bottom fifth/highest fifth and compared to the 1986-1971, an increase, suggesting that recent changes in Canada have hurt the health of the poorest fifth in comparison to the richest fifth Note that the picture for women hasn’t changed as dramatically as for the menWhen we break down the effects into age intervals, something important becomes apparent. There has been little decline between 1991 and 1996 in the mortality ratios for men at the bottom fifth/highest fifth and compared to the 1986-1971, an increase, suggesting that recent changes in Canada have hurt the health of the poorest fifth in comparison to the richest fifth Note that the picture for women hasn’t changed as dramatically as for the men

34. Hill 2004Hill 2004

35. BC/Washington Comparisons BC WA

36. BC/Washington Comparisons BC WA

37. BC/Washington Comparisons BC WA To be covered under FMLA (Family Medical Leave Act):Must work for a covered employer (all public agencies; private companies with 50 or more employees within 75 miles.)Must have worked for covered employer for at least 12 months prior, and at least 1250 hours in previous 12 months. Other restrictions apply. http://www.canadaimmigrants.com/maternity.aspTo be covered under FMLA (Family Medical Leave Act):Must work for a covered employer (all public agencies; private companies with 50 or more employees within 75 miles.)Must have worked for covered employer for at least 12 months prior, and at least 1250 hours in previous 12 months. Other restrictions apply. http://www.canadaimmigrants.com/maternity.asp

38. BC/Washington Comparisons BC WA

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

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) Chart 6 pg 25Chart 6 pg 25

44. Yalnizyan 2007Yalnizyan 2007

45. Yalnizyan 2007Yalnizyan 2007

48. USA economic pie shares

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

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

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)

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.

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

66. Baker et al Adverse Events Results Higher AEs in teaching hospitals ? Higher patient acuity Teaching hospitals receive patients at different points in care (small or large community hospitals may not be able to provide care) Complexity of care in teaching hospitals--usu. Several providers, with risk of miscommunication, coordination Patient records may vary across hospital types Lower quality of care

68. DIRECT TO CONSUMER ADVERTISING

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 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%

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. CanadaGovernmentWritingsPOPULATION HEALTHFederalProvincialLocalRegional

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."

96. Tides of Change 7 Key messages 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. 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. Theory and evidence that social and economic processes and the resulting poverty create inequities and chronic disease in society. Vulnerable populations who are affected by inequities: Aboriginal people and African Canadians, single mothers and children living in poverty, seniors, and rural populations. 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. Ask how inequities can lead to chronic disease. Materialist, psychosocial, and political/economic pathways are discussed in the Atlantic Canada context. Recommend strategic directions that must be based on the root causes of inequities in society.

101. From: Christine Post <cpost@pcchu.ca> April 2008 A bit of background.... Our Health Unit did a survey in Nov. '06 which showed that higher income people in our community were less likely to identify things such as housing and income as having an effect on health. We created the 3 TV ads to reach a broad audience and make the link between social policies and health. We made a point of running the ads during the Ontario provincial election campaign in the fall of '07. I'm not aware of any other Health Units who have done campaigns like this, although several are involved in anti-poverty coalitions. My position as a Health Promoter in a "Poverty and Health" program is unique as far as I know. We're hoping to do a poster and either a brochure or newspaper insert later this year to complement the television ads, once the latest income data is released by Stats. Canada, in May '08. Other public information and reports etc... are posted on our website <www.pcchu.ca> under "Poverty and Health". During the campaign this material was linked to our "Hot Topics" opening web page. Thanks for your interest, Christine -- Christine Post, Health Promoter Peterborough County-City Health Unit, 10 Hospital Drive, Peterborough, ON K9J8M1 Tel. (705) 743-1000 Ext. 293 Fax.(705) 743-2897 From: Christine Post <cpost@pcchu.ca> April 2008 A bit of background.... Our Health Unit did a survey in Nov. '06 which showed that higher income people in our community were less likely to identify things such as housing and income as having an effect on health. We created the 3 TV ads to reach a broad audience and make the link between social policies and health. We made a point of running the ads during the Ontario provincial election campaign in the fall of '07. I'm not aware of any other Health Units who have done campaigns like this, although several are involved in anti-poverty coalitions. My position as a Health Promoter in a "Poverty and Health" program is unique as far as I know. We're hoping to do a poster and either a brochure or newspaper insert later this year to complement the television ads, once the latest income data is released by Stats. Canada, in May '08. Other public information and reports etc... are posted on our website <www.pcchu.ca> under "Poverty and Health". During the campaign this material was linked to our "Hot Topics" opening web page. Thanks for your interest, Christine -- Christine Post, Health Promoter Peterborough County-City Health Unit, 10 Hospital Drive, Peterborough, ON K9J8M1 Tel. (705) 743-1000 Ext. 293 Fax.(705) 743-2897