Women’s Health in Nova Scotia

Transcript Women’s Health in Nova Scotia

Genuine Progress Index for Atlantic Canada Indice de progrès véritable - Atlantique

Health Measures in the Genuine Progress Index

NZ Ministry of Health Wellington, 22 April, 2008

About GPI Atlantic

• Non-profit, fully independent, research and education organization founded April, 1997. Based in Halifax; Web site: www.gpiatlantic.org

• Committed to development of Genuine Progress Index (GPI): Measuring wellbeing & sustainable development accurately and comprehensively • Towards full-cost accounting: human, social, natural, and produced capital accounts • NS focus ->National and international activities

Origins

• 1st GPI 1995 – Redefining Progress, California • Emerged from critique of shortcomings of GDP based measures of progress (Kuznets warning) • Distinguished from quality of life indicator systems by adding economic valuation • 1995 GPI – single $ number; Statcan critique = starting point for NS GPI (1996) as pilot for Canada. 12 years developmental work.

Basic question: How are we doing? What kind of NZ are we leaving our children...?

Current way of answering that question:

GDP-based measures of progress inadequate and can be dangerously misleading. E.g: • Natural resource depletion as gain • No distinction re what is growing (e.g. pollution, crime [US stats], sickness, cigarettes) • Vital social, environmental assets + value of unpaid work, free time, health, education, equity ignored

Why We Need New Indicators - Policy Reasons:

 More energy use, greenhouse gas emissions, consumption, drug use make economy grow = not the signals we may want to communicate  Preventive initiatives to conserve and use energy and resources sustainably, to reduce sickness, crime, poverty, greenhouse gas emissions, may be blunted, or inadequately funded

Indicators are Powerful What we measure:

 reflect what we value as a society;  determines what makes it onto the policy agenda;  influences behaviour (e.g. students)

Logic not refuted: From wilderness to mainstream: OECD, EU, SNA, CIW

Natural environment Society Economy

That framework addresses question: Are we living sustainably?

Source: Hoggan, James. Globe Presentation: Communicating Sustainability, 2006

The Canadian lifestyle is not sustainable 10 90 We need stricter laws and regulations to protect the environment Canada should set strict national sustainability targets and report back to Canadians regularly on progress.

If everyone in the world lived the consumer lifestyle we enjoy in North America, we would destroy the planet.

Canadians consume more than our share of world resources Protecting the environment usually means sacrificing comfort and convenience Agree Disagree 0 16 17 30 33 67 70 84 83 10 36 64 20 30 40 50 60 70 80

Percentage of Canadians who agree or disagree

90 100

Measuring Wellbeing:

In the GPI…

 Health, free time, unpaid work (voluntary and household), and education have value  Sickness, crime, disasters, pollution are costs  Natural resources (e.g. forests) are capital assets  Reductions in greenhouse gas, crime, poverty, ecological footprint are progress  Growing equity signals progress

Beyond indicators and towards accounting and policy shift… E.g.

• Ideal world: Neither indicators nor economic valuation is required: Social, economic, environmental impacts would be taken into account in all decisions. BUT • GDP is accounting system, not indicator system. While economic growth statistics dominate, economic valuation currently has most impact on policy – strategy not end • Economic valuations = add-on based on physical indicators (report division)

Examples of policy impacts:

• E.g. NS voluntary work worth $1.9 bill/year • Preventable chronic disease costs NS $500m in excess health care costs –> DHPP; costs tobacco, obesity, inactivity –> e.g. HRM planning process; smoke-free legislation • Full CBAs – e.g. Solid Waste; Halifax Harbour cleanup; HRM transportation …. Etc.

• Impact on policy can be indirect (e.g. forests)

The Genuine Progress Index 85 detailed reports to date:

•

Time Use

Economic Value of Unpaid Childcare and Housework √ • Economic Value of Civic and Voluntary Work √ • Value of Leisure Time √ • Working Time and Employment √

Nova Scotia Genuine Progress Index: Components Natural Capital

• Soils and Agriculture (3 =

√

; 2 = …) • Forests

√

• Marine Environment/Fisheries

√

• Water Resources / Water Quality

√

• Energy

√

• Air Quality

√ Human Impact on the Environment

• Greenhouse Gas Emissions

√

• Sustainable Transportation

√

• Ecological Footprint Analysis

√

• Solid Waste

√

Nova Scotia Genuine Progress Index: Components Living Standards

• Income Distribution

√

• Debt and Assets ….

• Economic Security ….

Social and Human Capital

• Population Health

√

• Educational Attainment

√

• Costs of Crime

√

Next Steps: - (A) Complete detailed, separate components

• Released ’08: Education, HRM transportation + Complete last 3 components by June ‘08 • 90+ detailed reports = Most complete data set available to any jurisdiction in North America to measure wellbeing and sustainable dev’t • Statcan advice – bottom up, methodological, data integrity. Withstand expert scrutiny. Transparency, references.

Next steps – (B) Integration

Now -> policy utility, integration, update: 1. Headline indicators – community (May 08) 2. Database – easily updatable, replicable (Jul.08) 3. Headline indicators – provincial (Sept. 08) • Oct. 08: Major release – Formal presentation to Premier, Government, and People of NS = Landmark moment in evolution of GPI

Therefore communication:

Must speak effectively to 3 audiences:

• Experts (credibility as basis) • Policy audience • General public (use of media) - Infiltration over time vs one big release: Water against a rock (others including govt. cite GPI #s as own; radio talk shows)

Politics and Uptake: Measuring progress is normative

But GPI based on consensus values

• Economic and livelihood security • Health, free time • Educational attainment • Strong and safe communities • Clean environment, healthy natural resources

Political implications

• Non-partisan; Evidence-based decision making • Good news (e.g. waste, air quality, seniors, employment); Bad news (e.g. GHGs, old forests); Improvements (e.g. income dist.) • Consensus on goals, vision. Politics is about how to get there. E.g. GHG reductions, poverty reduction – goal vs strategy • Comparisons: NS, Canada, Provinces, Int’l

Examples of results: The good, the bad, and the ugly…

Unemployment in Nova Scotia (1987-2005)

16 14 12 12 10.2 9.9

10.7

10 12.1

13.1

14.3

13.5

12.2 12.4 12.2

10.5

9.6

9.1

9.7 9.6

9.1

8.8 8.4

8 6 4 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

2005 Provincial Unemployment Rates

4 2 0 16 14 12 10 8 6 15.2

10.8

9.7

Nfld.

P.E.I.

N.B.

8.4

8.3

N.S.

Que.

6.6

5.9

5.4

5.1

4.9

4.8

3.9

6.8

Ont.

B.C. N.W.T. Sask.

Province

Yuk.

Man.

Alta. Canada

Nova Scotia - Gap Between the Rich and Poor (1980-2004)

5.5

5.0

4.5

4.0

3.5

3.0

1980 1982 1984 1986 1988 1990 1992

Year

1994 1996 1998 2000 2002 2004

Gap Between the Rich and Poor - 2004

7 6 1 0 3 2 5 4 6.02

B.C.

5.35

Ont. 5.23

4.64

Alta.

Sask.

4.59

4.51

4.50

4.32

N.B.

Man.

Province

Nfld.

Que.

4.31

3.85

5.12

N.S.

P.E.I.

Canada

Nova Scotia Criminal Incidents per 100,000 Residents (1977-2006)

12,000 10,000 8,000 6,000 4,000 2,000 0 1977 1979 1981 1983 1985 1987 1989 1991 1993

Year

1995 1997 1999 2001 2003 2005

2006 Criminal Incidents per 100,000 Residents

50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 44,074 N .W

32,831 N vt .

22,197 Y uk.

15,276 Sa sk.

12,564 12,325 10,336 B .C

M an.

A lta .

8,698

N .S

7,486 6,780 6,626 6,571 6,251 8,269 P.E

.I.

N .B

Q ue .

N fld.

O nt .

C ana da

Province

Nova Scotia Crimes of Violence per 100,000 Residents (1977 - 2006)

1,400 1,200 1,000 800 600 400 200 0 1977 1979 1981 1983 1985 1987 1989 1991 1993

Year

1995 1997 1999 2001 2003 2005

2006 Crimes of Violence per 100,000 Residents

8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 6,764 6,448 N vt .

N .W

3,007 Y uk.

2,039 Sa sk.

1,598 1,218

1,135

1,101 M an.

B .C

N .S

A lta .

N fld.

851 N .B

849 Q ue .

756 O nt .

756 P.E

.I.

714 C ana da 951

Province

Volunteerism: Atlantic Provinces lead

(formal rate)

10 9 4 2 3 8 5 6 7 1994/95

Nova Scotia Percentage of Population with Asthma (Age 12 and up)

9.3

9.1

7.9

6.5

1996/97 1998/99

Year

2000/01 2003 2005

Nova Scotia Percentage of Population with Diabetes (Age 12 and Up)

0 1 2 7 3 4 5 6 3.6

1994/95 4.6

1996/97 4.4

5.2

1998/99

Year

2000/01 5.5

2003 6.6

2005

Obesity in Canada 1996 - 2005 Percentage (%) of Adults 18 and Older with BMI >30

18 17 12 11 10 16 15 14 13 1 1.

9 1996/97 1 4.

1 1998/99 1 4.

5 2000/01

Year

1 4.

9 2003 1 5.

5 2005

GPI Health Component

• Population health framework, indicators • Socio-economic, behavioural and environmental determinants of health • Costs of chronic disease • Preventable portion – cost-effectiveness of intervention

3 burning health policy issues

1) How to treat the sick - supply side 2) How to prevent disease and improve the health of New Zealanders 3) How to check spiralling health care costs - demand side Conventionally, government focus on (1); now shift to (2) in part because of (3)

Valuing a Healthy Population – the importance of indicators

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

Economic Language:

- 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

1) Costs of Chronic Disease NS:

• Four types of chronic disease account for about 3/4 of all deaths (cf 1900) Cardiovascular - 36%; Cancer - 30% COPD - 5%; Diabetes - 3%+ • Chronic diseases account for 60% medical costs; 3/4 of productivity losses due to disability and premature death; 70% total burden of illness = 13% GDP

E.g.: Cost of Chronic Illness in Nova Scotia

(2001$ million) Circulatory Cancer Respiratory Musculoskeletal Endocrine Nervous system Mental

TOTAL: Hosp.

Doctor

161.6

71.4

21.6

55.9

18.5

55.3

104.2

488.4

26.6

11.8

3.2

20.3

7.2

27.9

17.7

114.8

Drugs

63.6

7.5

16.6

22.0

29.3

19.2

39.2

197.5

Other

137.8

49.6

22.7

53.8

30.1

56.0

88.2

438.1

Total Direct 389.6

140.3

64.1

152.0

85.0

158.5

249.2

1,238.8

Premat.

Death

326.8

427.2

43.4

3.5

43.8

30.0

16.0

890.8

Dis ability

244.4

14.5

78.1

307.2

27.0

158.6

72.3

901.9

TOTAL 960.8

582.1

185.5

462.8

155.8

347.0

337.5

3,031.5

2) 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 • 38% total burden of disease (includes direct and indirect costs)

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

Design cost-effective prevention strategy knowing costs of key risk factors (e.g. Nova Scotia

(2001 $ millions) Deaths Direct Indirect Total Tobacco Obesity Physical Inactivity 1,700 1,000 700 $188 $120 $107 $300 $140 $247 $488 $260 $354

Disease Prevention is Cost-Effective Investment

• E.g. Workplace = 2:1 • WIC = 3:1 (mostly avoided LBW) • “Smoke-Free for Life” • Pre-natal counselling = 15:1 = 10:1 • Brief physician, nutrition, diet counselling – highly effective and cost-effective

3a) Socio-economic Determinants of Healthy Living

• 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 (e.g. St Henri) • WHO: lifestyle related to socioeconomic and environmental conditions. Lifestyle factors explain only 25-30% of premature death

(Adler)

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 (Canada): Men 15-39 = +46%; 40-64 = +57% Women 15-39 = +62%; 40-64 = +92% • Low income = use 43% more physician services than higher income groups

E.g. Excess physician use in NS

(=small fraction total costs)

• Educational inequality = $42.2 million = 17.4% of total • Income inequality = $27.5 million = 11.3% = costs avoided if all Nova Scotians were as healthy as higher income / university

Heart Health Costs of Poverty

• Low income groups have higher risk of smoking, obesity, physical inactivity, cardiovascular risk = costly • Canada could avoid 6,400 deaths, $4 billion/year if all Canadians were as heart healthy as higher income groups

Health costs of child poverty

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

Health costs of unemployment

• Unemployed – high stress, smoke and drink more, less physically active, eat poorly • Higher rates of wide range of physical and mental illnesses (sick 2x as often); more disabilities; lower self-rated health; visit physicians more often than those with jobs • NS cost of u.e. = $4 billion (lost output and taxes + direct payments) + $250-$400 mill. in excess disease, crime, divorce costs • Job creation = good for health

A/c Roy Romanow……:

• “If you’re at the bottom of the

income ladder, odds are you’re going to find yourself at the bottom of the health ladder.”

• “So, if we’re serious about making

Canadians the healthiest people in the world, then we have to be serious about closing the gap between rich and poor.”

Therefore, identify and target highest risk groups

• Single mothers & their children • Unemployed • Blacks and other minorities, native Americans, migrants, disabled....

= Clustered disadvantages (poverty, illiteracy, unemployment, ill-health): “Social exclusion”

Inequities within provinces: Averages misleading

• Intra-provincial disparities: – largest cities closer to national pattern than to own “hinterlands.” E.g. Halifax unemployment less than national average and comparable health profile (cf Cape Breton) • Low income areas with highest unemployment and lowest socioeconomic status have worse patterns of chronic disease, disability, and premature death

Labrador: high Aboriginal population: unique profile

• Infant mortality = 17.2/1,000 live births (St. John’s = 5.6) • Low birth weight = 6.8% - highest in Atlantic.Can

• Suicide = 19.2/100,000 (Nfld=7.3=lowest in Can) • Injury deaths = 40/100,000 (St. John’s = 16) • Lung cancer deaths = 73/100,000 (Nfld-50) • Respiratory deaths 50% higher than Cdn. rate • Life expectancy = 74.9 (Can=78.3) - lowest Atl.Can

• PYLL=7,432/100,000 (St. John’s = 5,205)

Labrador: 36% men, 30% women are daily smokers

Pathways to health material and social/psych

E.g. Nfld, PEI – lower incomes, wealth, BUT • Lowest crime rates • Lowest stress, depression levels • Strongest voluntary sector • Highest mental health, self-rated health, functional health

Social supports provide buffer in Atlantic Canada

• Social networks may play as important a role in protecting health, buffering against disease, and aiding recovery from illness as behavioural and lifestyle choices such as quitting smoking, losing weight, and exercising. – See: Mustard, J.F., & Frank, J. (1991).The Determinants of Health. (CIAR Publ. No. 5)

BUT... Doesn’t a successful

preventive strategy just defer costs to older ages?

• NS 65+:2001 = 14%; 2036 = 28% • e.g. Philip Morris’ Czech Republic study • prevention hard to sell: –Successful prevention = nothing happens –Costs won’t be diverted from health care

Prevention saves $

• “Compression of aging:” delays costs, preserves independence into old age: – 5-year delay in onset cardiovascular disease could save US $100 billion / yr – 5-year delay in hip fracture could save $7.3 billion / yr – Physically active - lower lifetime illness – Nutritional intervention - reduces hospital use 25%-45% among elderly

“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

3b) Environmental Determinants of Health

• Air and water quality directly affect health (e.g. OMA study on excess mortality and morbidity due to smog, poor air quality; Walkerton) • Climate change & resource depletion have health consequences • Chemicals, toxins in the environment – incl. 2nd hand smoke (NL – 12% exposed in home) • New categories of illness – multiple chemical sensitivities, environmental illness

NL: 2nd-hand smoke exposure on most days in the last month, regions, 2001

New population health strategies can:

• address root causes rather than individual behaviours alone • support more equitable distribution of public and private resources • emphasize costs: reducing poverty and inequality can cut health costs • include all levels and sectors of government – including outside the "traditional" health domain

In sum:

• Tracking health includes socio-economic and environmental measures – low-income & unemployment rates, literacy, stress, crime, social supports, air and water quality, etc… These directly affect health status/outcomes • E.g.: Measuring healthy living – e.g. healthy weights + costs of obesity and cost effectiveness of interventions

4) Healthy Living Trends, NL, 05

Canada NL East Central West Labrad

2 nd hand Smokers

8.7

11.9

21.3

22.6

11.4

11.1

14.4

12.6

21.2

24.0

27.4

Active

26.5

21.2

20.8

20.3

23.9

21.0

Inactive Fr-veg 5+

46.7

41.2

53.2

52.9

23.0

NA 55.8

49.8

56.7

NA NA NA

Obesity (BMI = 30+) – NL (2005)

• Canada • NL • Eastern • Central • Western • Labrador 15.7% 24.6% 24.6% 29% 20% 23.4%

Is obesity a “cost”, or is it good for the economy?

• Americans spend more than $100 billion a year on fast food = 44% of all food service sales • Fast food, candy, sugared cereals = 1/2 of $30 billion annual food industry advertising in U.S. (Kelloggs spends $40 million /year to promote Frosted Flakes alone)

Overeating contributes to economy many times over

• Excess foods grown, processed, advertised, transported, warehoused, sold • Diet drug and weight loss industries then add $35 billion to US economy • Liposuction = leading form of cosmetic surgery in US = 400,000 operations / year = up 62% in 2 years = a growth industry

Obesity-related illness

• Costs U.S. $118 billion / year (Colditz) now exceeds smoking; but doctor, drug, hospital costs make economy grow • More than 50% diabetes 2 due to obesity • Type 2 diabetes grown 5-fold globally since 1985 from 30 to 150 million (17 million in US). WHO predicts 300 million by 2025

In the words of the pharmaceutical industry:

“The type 2 diabetes market will double to $17.2 billion in 2011, reflecting sustained, robust annual growth of 7% from 2001 through 2011”

• Consumption of oral diabetic drugs will grow five-fold from 2001 to 2011

Eli Lilly - $119 bill. firm

• Announced construction of world’s largest factories devoted to single drug (insulin) = $1/2 bill. plants in Virg. and PR (11% of PR population has diabetes) • Lilly global insulin sales up 16% in 2001 Humalog (Virg, PR) up 79%; Actos up 61% from 2000 (2001 sales = $901 mill) • James Kappel (Lilly): “You’ve got to be

in diabetes.”

Counting it wrong – why the context matters

• So long as we count growth in fast food and diabetes industries as good news for the economy, the health policy agenda will be difficult to shift • So long as we use economic growth statistics as the primary measure of social wellbeing, we won’t give population health and prevention (including good nutrition) the attention they deserve

Counting it right: Obesity as serious cost

• Obese (BMI >30) = 50-100% increased risk of death (all causes) cf healthy weight • Overweight = higher premature death rate even if no smoking, otherwise healthy (American Cancer Society - 1 million subjects) • Second-leading preventable cause of death in US (Joann Manson - Harvard) and now most expensive (Rand)

Health Impacts

• BMI >30 = 4x diabetes; 3.3x high blood pressure; 56% more likely have heart disease; 2.6 times urinary incontinence; 50% less likely rate health positively (Statcan) • Association with some cancers, gallbladder disease, stroke, asthma, arthritis, thyroid problems, back problems, sleep disorders, impaired immunity, depression, etc.

A “Global Epidemic” (WHO)

• Obesity increased 400% in the western world in the last 50 years.

• Underfed and Overfed: The Global Epidemic of Malnutrition: “ for the first time in human history the number of overweight people in the world now equals the number of underfed people, with 1.1 billion each.” March, 2000, Worldwatch Institute, Washington D.C.

Unequal distribution not food scarcity is the problem

• 80% of world’s hungry children live in countries with food surpluses; 36% Brazilians, 41% Colombians overweight • 50%+ US, UK, Germans overweight; 50%+ Bangladesh, India children underweight • U.S. - 20% children overweight or obese (50% increase since 1980); Nearly 1/5 U.S. children “food insecure” (USDA)

Underfed and Overfed

• The hungry and the overweight share high levels

of sickness and disability, shortened life expectancies, and lower levels of productivity - all of which impede a country's development

• Among the overweight, "obesity often masks nutrient starvation," as calorie-rich junk foods squeeze healthy items from the diet. In Europe and North America, fat and sugar now account for more than half of total caloric intake • But few doctors give nutrition counselling –

Low-income, poorly educated, elderly = higher rates overweight, obesity Percent of Canadians who believe that low-fat foods are expensive, 1994-95 41

40 40

37 35 33 31

34 32

29 27 25 lowest low-middle middle upper middle highest

Overweight- by Education and Age (20-64), Canada, 1997 (%) 45

36 36

30 29 29

15 10 5 0 < H ig h sc ho ol H ig h sc ho ol C ol le ge U ni ve rs ity A ge 2 0 24 A ge 2 5 34 A ge 3 5 44 A ge 4 5 54 A ge 5 5 64

Costs of obesity – 8 Provinces

• Obesity: 56% diabetes 2 in NS attributable to obesity; 37% hypertension; 22% heart disease; 24% gallbladder disease; + stroke, cancers (colorectal, endometrial, post menopausal breast), arthritis etc. • Obesity costs NS health care system = $120m/year (6.8% budget) + $140m indirect productivity losses = $260m • 39% N.S. overweight (BMI = >27)

50% Nova Scotians are inactive (2005). Only 21% physically active

(CCHS) (3 kcal/kg/day), age 12+, 2001 (%) 30 26 27 25 21 21 21 23 20 20 17 16 17 17 15 10 5 0 C an ad a N fld PEI NS NB Q ue be c O nt ari o M an ito ba Sa sk Al be rta BC

T R E N D S:

• % exercising regularly in NS now stagnant after improvement in 1990s (63% inactive 1994, 52% 1998, 50% now). • Improvement among women but decline among men (43% inactive 1998; 48% today; cf 60%->52% fem). Gap closing fast • All 4 Atlantic provs rank below Cdn average • Obesity = more than doubled; childhood asthma, obesity up sharply

Obesity Trends* Among U.S. Adults BRFSS, 1985

Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. BRFSS – Behavioural Risk Factor Surveillance System - CDC

Obesity Trends* Among U.S. Adults BRFSS, 1986