1. Genuine Progress Index for Atlantic Canada Indice de progrès véritable - Atlantique Measuring Population Health to Enhance Accountability NSAHO, Dartmouth, 14 November, 2003

2. Pop. health context: Romanow and the 3 burning health policy issues 1) How to treat the sick - supply side 2) How to improve the health of Canadians = outcome measures needed to enhance accountability 3) How to check spiralling health care costs - demand side The next Royal Commission......

3. What kind of Nova Scotia are we leaving our children?

4. What kind of world are we leaving our children? Canada’s premier quality of life More possessions, longer lives But, defining wellbeing more broadly Some disturbing signs

5. Warning Signals: Determinants of Wellbeing Higher stress rates, obesity, childhood asthma Insecurity - safety, livelihood Greater inequality Decline of volunteerism Natural resource depletion, species loss Global warming

6. ‘Healthy’ Economy = Healthy Communities?  More equals better (vs. health as balance). Romanow = 1/3 of equation  Resource depletion as economic gain  Crime, sickness, pollution, make economy grow —because money is being spent.

7. Sending the Wrong Messages  GDP can grow as poverty, inequality increase.  More work hours, stress make economy grow; free time has no value (Statcan. study)  GDP ignores work that contributes directly to community health (volunteers, work in home).

8. Why We Need New Indicators: Policy reasons:  Economic growth = ‘better off’ sends misleading signals to policy-makers.  Vital social, environmental assets ignored.  Preventive initiatives to conserve and use resources sustainably, to reduce poverty, sickness and greenhouse gas emissions, are blunted and inadequately funded.

9. Indicators are Powerful What we measure:  reflects what we value as a society;  determines what makes it onto the policy agenda;  influences behaviour (eg students)

10. A good set of indicators can help communities:  foster common vision and purpose;  identify strengths and weaknesses;  change public behavior;  hold leaders accountable at election time - e.g. Teen smoking as an election issue  initiate actions to promote wellbeing

11. GPI Atlantic founded to address need for better indicators Non-profit, fully independent research group founded April, 1997 Located Halifax. www.gpiatlantic.org Sole mandate is to create good, usable index of wellbeing and progress Pilot GPI projects in Glace Bay, Kings County as model for Canadian communities

12. Measuring Wellbeing In the GPI:  Health, free time, unpaid work (voluntary and household), and education have value  Sickness, crime, disasters, pollution = costs  Natural resources = capital assets  Reductions in sickness, GHGs, crime, poverty, ecological footprint are progress  Growing equity signals progress

13. Valuing a Healthy Population GPI population health reports include: Costs of chronic disease in Canada and NS Women’s health in Canada + Atlantic Canada Income, Equity and Health in Canada / Atl. Can. Costs of tobacco, obesity, physical inactivity, HIV Economic Impact of Smoke-Free Workplaces Value of care-giving in two NS communities New Atlantic region health database

14. Chronic Disease as Cost Prevention = Investment Costs of chronic disease are very high Indirect costs, particularly, are huge Large proportion of costs preventable Disease prevention (esp. dealing with root causes) is cost-effective

15. 5,800 Nova Scotians/yr die from 4 chronic diseases = 3/4 of all deaths in NS (cf 1900) Cardiovascular: 2,80036% Cancer 2,40030% COPD 3705% Diabetes 230+3%+

16. NS: High Rate Chronic Disease NS - highest rate of deaths from cancer and respiratory disease Highest rate arthritis, rheumatism 2nd highest circulatory deaths, diabetes 2nd highest psychiatric hospitalization + Gap with Canada is growing....

17. Chronic Disease Disability 1/4 Nova Scotians have long-term activity limitation - highest in country NS has highest use of disability days 20% have arthritis or rheumatism 16% have high blood pressure 14% have chronic back problems

18. Costs of 7 types non-infectious chronic disease, NS, 1998 60% medical costs = $1.2 billion / year 76% disability costs = $900 million 78% premature death costs = $900 mill. 70% total burden of illness = $3 billion = $3,200 per person per yr = 13% GDP

19. Cost of Chronic Illness in Nova Scotia 1998 (2001$ million)

20. These are under-estimates Exclude diseases: Digestive, cirrhosis of liver, congenital, perinatal/LBW, blood, skin, genitourinary (chronic renal failure), etc. “Principal diagnosis”: e.g. injury/fall vs osteoporosis; diabetes under-reported (complications: blindness, kidney failure, amputations, cardiovascular disease, infections). Diabetes 2 afflicts 4% (38,000) Nova Scotians, disables 3,300, kills 230 - 850

28. What portion is preventable? Excess risk factors account for: 40% chronic disease incidence 50% chronic disease premature mortality Small number of risk factors account for 25% medical care costs = $500 mill./yr 38% total burden of disease = $1.8 bill. (includes direct and indirect costs)

29. A few risk factors cause many types of chronic disease Tobacco - heart disease, cancers, respiratory disease Obesity - hypertension, diabetes 2, heart disease, stroke, some cancers Physical inactivity - heart disease, stroke, hypertension, colon and breast cancer, diabetes 2, osteoporosis Diet/fat - heart disease, cancer, stroke, diabetes

30. Costs of Key Risk Factors, Nova Scotia (2001 $ millions)

33. Socio-economic Determinants of Health Education, income, employment, stress, social networks are key health determinants. These too are modifiable Lifestyle interventions effective for higher income/education groups, not lower - can widen inequity, health gap

34. Health Costs of Poverty Most reliable predictor of poor health, premature death, disability: 4x more likely report fair or poor health = costly e.g. Increased hospitalization: Men 15-39 = +46%; 40-64 = +57% Women 15-39 = +62%; 40-64 = +92%

35. Heart Health Costs of Poverty Low income groups have higher risk of smoking, obesity, physical inactivity, cardiovascular risk = costly NS could avoid 200 deaths, $124 million/year if all Nova Scotians were as heart healthy as higher income groups

36. …delayed child development 31 indicators - as family income falls, children have more health problems, (NLSCY, NPHS, Statistics Canada) Child poverty -> higher rates respiratory illness, obesity, high blood lead, iron deficiency, FAS, LBW, SIDS, delayed vocabulary development, injury+….

37. Highest Risk Groups Single mothers & their children Homeless: longer hospital stay cf low income Unemployed, Aboriginals, migrants, minorities, disabled = Clustered disadvantages (poverty, illiteracy, unemployment, ill-health): “Social exclusion”

38. ……health of single mothers Worse health status than married (NPHS); higher rates chronic illness, disability days, activity restrictions 3x health care practitioner use for mental, emotional reasons = costly Longer-term single mothers have particularly bad health (Statcan)

39. Prevalence of low income- women and men -1997 & 2000

40. Income: Female lone-parent families - 1997 & 2000

41. Trend: Low income rates of children: Single mother families --- 1994-2000

42. Employment of Female Lone Parents 1976-2001

43. Low Incomes : 1991-2000 Single mothers w/out paying jobs

44. The Economics of Single-Parenting Single mothers with pre-school children spend 12% income on child care cf 4% in 2-parent families. In one pocket......... CPI for child care, restaurant good rises faster than wages Robin Douthitt: “time poverty”. Full- time single mothers = 75 hour week

45. Health Cost of Inequality British Medical Journal: “What matters in determining mortality and health is less the overall wealth of the society and more how evenly wealth is distributed. The more equally wealth is distributed, the better the health of that society.” e.g. Sweden, Japan vs USA

46. Costs of Inequality in NS Excess physician use (Kephart) (Small fraction of total costs): –No high school = +49% than degree Lower income = +43% than higher –Educational inequality = $42.2 million Income inequality = $27.5 million = costs avoided if all Nova Scotians were as healthy as higher income / BA

47. If Equality->Health, What are Trends? Average Disposable H’hold Income Ratios, 1980-98

48. Regional inequality = CB requires special attention High unemployment and low-income rates, Much higher incidence of chronic illness, disability, and premature death than Halifax Highest age-standardized mortality rate in Maritimes Highest death rate from circulatory disease, heart disease in Maritimes – 30% above nat.av.

49. Of 21 Atlantic health districts, Cape Breton has highest rates of: Cancer death (231.8 per 100,000) – 25% higher than the national average, lung cancer Deaths due to bronchitis, emphysema, and asthma (9.2 per 100,000) –50%+ higher than the national average High blood pressure– 21.7%, (24.3% women 19% men = 72% higher than the Canadian rate. The next highest rates are in south-southwest Nova Scotia

50. Cape Breton = highest: Arthritis and rheumatism: 31% of women, 23% of men Activity limitation (34%), followed by Colchester, Cumberland, and East Hants counties (30.1%) Life expectancy: 72.8 years for men, and 79.4 for women. (Canada: 75.4 years - men and 81.2 years -women

51. Disability-free life expectancy Cape Bretoners have an average disability-free life expectancy of only 61.8 years, seven fewer than the national average, and the lowest of all the 139 health regions in Canada. This means that Cape Bretoners can expect to live considerably more years with a disability than other Canadians.

52. Potential years of life lost highest number of potential years of life lost due to both cancer and circulatory diseases. Cape Bretoners lose 2,261.9 potential years of life per 100,000 population due to cancer – 41% higher than the national average of 1,603.7, and they lose 1,684 potential years of life per 100,000 population due to circulatory diseases – 65% higher than the national average of 1,020.7.

53. Social Supports Health Canada: “...as important as established risk factors” in contributing to health and medical outcomes, and reducing premature death, depression, mental illness, stress, chronic disability, aiding recovery from illness Family, friends, communities, volunteers

54. Aging - Delay vs Cure Saves $ NS 65+:2001 = 14%; 2011 = 16%; 2036 = 28% 5-year delay in onset cardiovascular disease could save NS $200 million / yr Physically active - lower lifetime illness Nutritional intervention - reduce hospital use 25-45% among elderly

55. “Compression of Morbidity” Fries: “The amount of disability can decrease as morbidity is compressed into the shorter span between the increasing age at onset of disability and the fixed occurrence of death.” (= about 85: analysis of 1900s data) “Successful aging” can preserve independence into old age

56. Disease Prevention is Cost-Effective Investment E.g. Workplace = 2:1 WIC = 3:1 “Smoke-Free for Life” = 15:1 Pre-natal counselling = 10:1 Next Steps....A Chronic Disease Prevention Strategy for Nova Scotia - - the responsibility of all sectors

57. Can it be done?...1900s/1980s...