1. David R MacLean MD Professor & Director Institute for Health Research & Education Simon Fraser University A Case for Integrated Chronic Disease Prevention

2. The Challenge of Chronic Disease Barriers to Achieving Better Health Action for the Future

3. Total Number of Deaths: 215,669 Cardiovascular (ICD-9 390-459); Respiratory (ICD-9 460-519); Diabetes (ICD-9 250); Cancer (ICD-9 140-239); Infectious Diseases (ICD- 9 001-139); Accidents/Poisonings/Violence (ICD-9 E800-E999) Source: Statistics Canada, 1997 All Cardiovascula r Disease (79,457) 36% Leading Causes of Death - Canada, 1997

4. Indirect and Direct Costs of Illness Canada, 1993 $ Billions Total $ 157 Billion SOURCE: Canadian Institute for Health Information

5. Total Health Expenditure By Use Of Funds Canada, 1997 SOURCE: Canadian Institute for Health Information HOSPITALS Direct Costs in $ billions Total: $78 billion DRUGS PHYSICIANS OTHER PROFESSIONALS OTHER INSTITUTIONS CAPITAL L OTHER HEALTH SPENDING $25 (31%) $11 (15%) $11 (14%) $10 (13%) $8 (10%) $2 (3%) $11 (14%)

6. Total Indirect Costs of Illness Canada, 1993 $ Billions Total $ 85 Billion SOURCE: Canadian Institute for Health Information

7. Association Between Self Reported Health Status and Health Care Costs Excellent Health 52% Fair Health 37% Poor 11% Self Reported Health Status Health Care Costs

9. Crude rates of hospitalizations per 100,000 population for all cardiovascular disease by age group and sex, Canada, 1996/97. Source: Hospital Morbidity Database, Canadian Institute for Health Information

10. Figure 3-1Proportion of adults who report having heart problems by age group and sex, Canada, 1996/97. Source:Statistics Canada, National Population Health Survey, 1996/97.

11. Figure 3-2Proportion of First Nations and Inuit adults who report having heart problems by age group and sex, Canada, 1997. Source:Assembly of First Nations, National Steering Committee, First Nations and Inuit Regional Health Survey 1997.

12. Proportion of population aged 35 to 64 with self- reported heart disease who have chronic pain, activity restriction, disability, or unemployment, Canada, 1996/97. Source: Statistics Canada, NPHS, 1996/97

13. Age-standardized mortality rate per 100,000 women, Canada, 1969-1997. Age-standardized to 1991 Canadian Population Source:Laboratory Centre for Disease Control; Statistics Canada

14. Age-standardized mortality rate per 100,000 men, Canada, 1969-1997. Age-standardized to 1991 Canadian population Source:Laboratory Centre for Disease Control; Statistics Canada

15. Source:LCDC, Health Canada, unpublished work Number of cardiovascular disease deaths by sex, actual and projected, Canada, 1950-2016.

16. Source: LCDC, Health Canada Number of hospitalizations for cardiovascular disease, actual and projected by sex, Canada, 1971- 2016.

17. Source: LCDC, Health Canada Number of hospitalizations for ischemic heart disease, by sex, actual and projected, Canada, 1971-2016.

18. Number of hospitalizations for cerebrovascular disease, actual and projected by sex, Canada, 1971- 2016. Source:LCDC, Health Canada

19. Cancer Mortality Trends for Selected Sites in Canadian Males Cancer Bureau, LCDC, Health Canada

20. Trends in Cancer Incidence for Selected Sites in Canadian Males Cancer Bureau, LCDC, Health Canada

21. Cancer Mortality Trends for Selected Sites in Canadian Females Cancer Bureau, LCDC, Health Canada

22. Trends in Cancer Incidence for Selected Sites in Canadian Females Cancer Bureau, LCDC, Health Canada

23. Prevalence Of Self Reported Diabetes in Canada By Sex MacLean et al Canadian Heart Health SurveysAge 18 to 74 years

24. Prevalence of Self Reported Diabetes in Canada by Age and Sex MacLean et al Canadian Heart Health Surveys

25. Prevalence of Self Reported Diabetes in Canada by Age of Diagnosis and Sex MacLean et al Canadian Heart Health Surveys

26. Educational Achievement by Diabetes Status in Canadian Males MacLean et al, Canadian Heart Health Survey Elementary : 0 - 6 yrs Some Secondary : 7 - 11 yrs Secondary Completed: 12 -15 yrs University: 16 yrs or more

27. Educational Achievement by Diabetes Status in Canadian Females MacLean et al, Canadian Heart Health Survey Elementary : 0 - 6 yrs Some Secondary : 7 - 11 yrs Secondary Completed: 12 -15 yrs University: 16 yrs or more

28. Self Reported Diabetes Status by Age Group In Canada MacLean et al Canadian Heart Health Surveys

29. Prevalence of Modifiable CVD Risk Factors by Self Reported Diabetes Status in Canada MacLean et al Canadian Heart Health Surveys

30. Distribution of Modifiable CVD Risk Factors by Self Reported Diabetes Status in Canada 3 MacLean et al Canadian Heart Health Surveys

31. Proportion of youth aged 15-19 years who smoke cigarettes daily by sex, Canada, 1977-1996/97. Source:Statistics Canada, catalogues 91-002, vol 7, no. 3; 91-512;91-213. Canadians and smoking: An update. Health and Welfare Canada, 1991. General Social Survey, Statistics Canada, 1991. Survey on Smoking in Canada, Cycle 3, 1994. National Population Health Survey, Statistics Canada, 1996/97.

32. Prevalence of Daily Smoking Among Canadian Youth Aged 15 - 17 Years by Province Source: Statistics Canada

33. Nova Scotia Adult Smoking Rates (15+) Compared to Manitoba Source: Statistics Canada, Population Health Reports, 1985 - 1999

34. Awareness, treatment, and control of hypertension in Canada The Canadian Heart Health Surveys Joffres et al

35. Proportion of adults who are physically inactive by province, Canada, 1996/97. Source:Statistics Canada, National Population Health Survey, Cycle 2, 1996/97

36. Proportion of adults who are overweight by province, Canada, 1996/97. Source:Statistics Canada, National Population Health Survey, Cycle 2, 1996/97

37. Prevalence of Obesity Among U.S. Adults BRFSS, 1998 15%N/A

38. Source: Mokdad et al., Diabetes Care 2001 Feb;24(2):412 4%4-6%6% n/a Prevalence of Diabetes Among Adults in the U.S. BRFSS 1999

39. INGREDIENT

41. Commonality Of Risk Factors Smoking Unhealthy diet Overweight Sedentary lifestyle Alcohol abuse Psychosocial stress RISK FACTORS Cardiovascular disease Cancer Diabetes Chronic respiratory conditions Mental ill-health MAJOR CHRONIC DISEASES

42. Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged 35-64 years from 1969 to 1995. Mortality per 100 000 population

43. Age-adjusted mortality rates of lung cancer in North Karelia and the whole of Finland among males aged 35-64 from 1969 to 1995 Mortality per 100 000 population

44. Life Expectance at Birth in Canada Source: Statistics Canada

45. Getting Older Population Aged 65 and Over As a Percentage of Population 20 - 64 Source: The Canada Pension Plan Fifteenth Statutory Actuarial Report

46. A Case for Integrated Chronic Disease Prevention The Challenge of Chronic Disease Barriers to Achieving Better Health Agenda for Future Action

47. Barriers to Achieving Better Health In General –The cause and effect relationship with disease prevention, health promotion is less observable, more subject to the effects of externalities –Lack of interest on the part of government leadership and generally within health care system with respect to promotion and prevention –Health policy tends to equate to health care policy –Lack of capacity to develop chronic disease policies and to follow through with scalable interventions

48. Barriers to Achieving Better Health (con’t ) Bureaucratic Issues –Lack of capacity, especially regarding the development of policies and strategies for promotion and prevention –Disconnect among organizational units within health systems at all levels. There is a lack of continuity – little corporate memory –Lack of accountability for outcomes – the bureaucracy concentrates on running good administrative processes –Lack of attention to sustainable financing for promotion and prevention

49. Barriers to Achieving Better Health (con’t ) System Issues –Constant changes of paradigms –Disconnect between research and implementation –Disconnect between specialists groups, primary health care, public health and health promotion systems or structures

50. A Case for Integrated Chronic Disease Prevention The Challenge of Chronic Disease Barriers to Achieving Better Health Agenda for Future Action

51. Need to Develop Appropriate Systems Products Resources Leadership

52. Systems Public Health (broadly defined) –Needs to assume a mandate and leadership role in chronic disease prevention and control –Needs to be restructured with new technical skills and new resources –Needs to be more collaborative with a community capacity building orientation

53. Systems (con’t) Primary Care –Needs to assume a mandate in chronic disease prevention –Needs to be more multidisciplinary with more of a community focus –Need new skills, tools and resources

54. Products - Policies & Programs That are practical and feasible from a management and cost perspective That deliver the preventive dose That build capacity and provide appropriate tools Operate on the basis of appropriate evidence and best practice

55. Resources - People & Money Need to move from reliance research funding to appropriate levels operational funding Need funding to begin the process of realigning system priorities Need new models of program delivery that involve the private and voluntary sectors and other formal sectors such as education and environment

56. Leadership Need to foster the development of champions at all levels Need to enhance the capacity of the health system’s governance structures Need to market chronic disease prevention and health promotion at all levels Need to create demand for preventive services

57. Policy development Advocacy Marketing Capacity building Education – public and professional Community mobilization Dissemination/deployment Resource mobilization Information technology Surveillance Monitoring and evaluation Research … … … Functions Common To Population Health Approaches To Prevention And Control Of Major Chronic Diseases

58. Place in the agenda of the health system Monetize support for prevention “in principle” Arguing the case for financing prevention … but it is not all about money --- > use existing assets The Need for Economic Capacity

59. Conclusions Major Challenges … Infrastructure + Political Will … -Marketing the Health Vision -Policy Development & Implementation -Intersectoral Action -Financing strategies -Use of existing assets … in sink with broader social and economic policies … the problem is not what to do, but how to do it …