2. What’s The BIG Idea? Harvey Skinner Dean, Faculty of Health, York University University of Calgary April 16, 2008 local global

3. Today’s Dialogue Objectives 1.The Challenge  Designing for after the health care system implodes 2. The BIG Idea: “first Health, then Medicine”  keeping more people healthier longer 3. The Opportunity  your fresh thinking for change

4. What is the BIG idea?

6. The BIG Idea “ first Health, then Medicine” Fresh thinking and action for Keeping more people healthier longer by Co-Creating the Total Health System

8. Ten Great Achievements of Public Health in 20th Century  vaccination 4 motor-vehicle safety 4 safer work places 4 control of infectious diseases 4 prevention of heart disease and stroke

9. Ten Great Achievements of Public Health in 20th Century  safer and healthier foods 4 healthier mothers and babies 4 family planning 4 fluoridation of drinking water 4 tobacco recognition and prevention

11. Ten Great Achievements of Public Health in 20th Century Added 25 Years+ to Life Expectancy of People in North America BUT

12. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% Behavioral Risk Factor Surveillance System (BRFSS)

13. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

14. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

15. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

16. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

17. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

18. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

19. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

20. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

21. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

22. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

23. Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

24. (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults BRFSS, 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

25. Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

26. Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

27. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

28. Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

29. 1998 Obesity Trends* Among U.S. Adults BRFSS 1990 - 1998 - 2006 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2006 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

30. Obesity in Canadian Adults CCHS 2004 (measured data)

31. Excess weight (BMI  25) in youth (2-17) Canada, 2004 (measured data) (% Obesity) (7%) (8%) (10%) (9%) (7%) (17%) (13%) (9%) (8%)

32. Childhood Obesity

34. Cuba’s ‘Natural Experiment’   Cuba’s economic crisis of 1989-2000 resulted in reduced energy intake, increased physical activity, population wide weight loss and reduction in chronic diseases   Reduced daily energy intake from 2,899 to 1,863 calories   Physical activity in adults increased from 30% to 67%   1.5 unit shift down in body mass – obesity declined from 14% to 7%   Decline in deaths attributed to   Diabetes: 51%   Coronary heart disease: 35%   Stroke: 20%   All causes: 18% Franco et al. Am J Epidemiology, 2007

35. Ontario Budget Expenditure on Health Care  32 % of Ontario budget ten years ago  46% today  75% by 2023  100% by mid-2030s Based on 2004 budget projections

36. Ontario Government Expenditures $ 79.3 billion in fiscal year ending March 31, 2007 35.7 billion: Health 12.1 billion: Education 10.4 billion: Children & Social Services 9.8 billion: Environment 5.4 billion: Post-Secondary 3.2 billion: Justice 2.7 billion: Transportation

37. Globe and Mail headline April 7, 2008   B.C. intent on tackling issue of funding in health care   Province to defy Ottawa by enshrining fiscal sustainability in medicare laws

38. Health Minister struggling   B.C. Health Minister George Abbott wants to make fiscal sustainability a founding principle of health- care delivery, a measure flatly rejected by his federal counterpart, Tony Clement.   "We will continue to embrace the five principles of the Canada Health Act," Mr. Abbott said in an interview. "We believe we should enshrine sustainability as a principle as well."

39. a framed statement of values   Mr. Abbott said the province has to grapple with escalating costs that are threatening program spending in other areas   Health-care spending currently consumes about 44 per cent of the provincial budget. He said that by 2013 it is expected to chomp through fully half of all B.C. government spending. "Government needs to be conscious of the fact that we have 20 other areas of ministerial responsibility and service delivery besides health care"

40. Critics worry that the sustainability principle will push B.C. toward more privatized health-care services "Adding a sixth principle to the Canada Health Act is opening the door to look at health care through a financial lens for the first time in history," said Leslie Dickout, a campaigner for the B.C. Health Coalition, a group that champions the protection and expansion of universal health care.

41. The Challenges are Large but not Insurmountable

42. The BIG Idea “ first Health, then Medicine” Keeping more people healthier longer   Preparedness: public health threats …   Prevention: tobacco control …   Promotion: active living …   50% premature mortality is preventable   Up to 70% of conditions that patients present in hospitals and clinics are preventable Co-Creating the Total Health System   Access: reducing disparities   Quality, Safety and Effectiveness (outcomes)   Utilization (waste; integration; eHealth)   Global Health: integrated services and delivery

43. first Health then Medicine

44. Fresh Thinking and Action  Reframing: first Health then Medicine  Bottom of the Pyramid (Prahalad)  Co-creation PPP: people, private, public  Global – Local integration  Technology  ???

47. 1. What is the Worst Thing we could do?  Please identify really bad ideas for keeping people healthier longer

48. 2. Now flip the Bad Ideas into good ones?  Pick several bad ideas and transform them into good but still outrageous – way out there -

49. 3. Convergence  Review the good ideas and propose several practical directions and solutions for the BIG Idea

50. Your Take Home Message?

51. Dr. Ida S. Scudder, Founder, Christian Medical College & Hospital, Vellore, India, 1900

52. An Apple a Day: Strategies for Change Penelope Hawe and Alan Shiell 1. 1. Create demand for prevention by measuring, mapping and communicating the distribution of preventive policies & programs 2. 2. Make new investments in evaluation and quality improvement in prevention 3. 3. Open pathways to enable the switch from ineffective programs to effective ones with new customized decision-support tools 4. 4. Create ‘healthy strings attached’ economic incentives to provide prevention policies and supportive environments for health