Category Archives: Chronic Conditions

Canada’s Healthcare System Today: A Need for Change

About 40 or 50 years ago, Canada’s healthcare system was pretty good. These days it is no longer addressing the needs of Canadians so well. It still provides proper care for people with acute illnesses by way of excellent surgeons, well-trained specialists, and an increasing number of family practice professionals. But by and large, it is not very good at dealing with the four main causes of mortality today – cancer, heart disease, lung disease and diabetes, and the population that is most affected by them, those 65 and over.

One of the great successes of the modern era has been the dramatic increase in life expectancy. People in the developed world lived for an average of 35 to 40 years in 1850 (Reynolds). People born in Canada today can expect to live for more than 80 years (Statistics Canada). This increase is typically common knowledge.

What is less widely known is that the increase in longevity also brought with it an increase in healthy years lived. As late as the 19th century, most people over 40 suffered from one chronic condition or another. Many of these conditions were primarily the result of the infectious disease that they survived as children or young adults. Today, chronic conditions affect most people over the age of 65. So we can describe the improvement from 1850 to now by saying that we have an added 25 years of disease-free life. Of those over 65, 89% have been diagnosed with at least one chronic condition. And in fact, 25% between 65 and 79 years old report having four or more chronic conditions (Public Health Agency of Canada).

The causes of chronic diseases today are different from those of 1850: they tend to occur as a result of lifestyle, environmental or genetic factors, rather than earlier infectious disease. Also, chronic conditions tend to be diagnosed at an earlier stage. When medicare was introduced in Canada in the 1950s and 1960s, chronic conditions often manifested in their acute phase – heart disease as heart attacks, lung disease as cancer and so on, and they were treated in acute care hospitals. Today we diagnose these conditions far earlier. We can identify early stages of the four main chronic killers and we know that early diagnosis is very effective in slowing the progress of these conditions and even reversing them.

Unfortunately our system is not well-structured to keep people with early stages of chronic disease healthy. We do not provide the health education, systematic support for changes in eating habits, and exercise and lifestyle recommendations that would avert the slow development of these chronic conditions. The result has been a tremendous boon for drug companies. Because we have inadequate support in the community for helping people to deal with pre-diabetic conditions, high cholesterol counts, increased blood pressure or reduced lung capacity, our primary care system relies almost entirely on referrals to specialists and to medication.

The result has been that we have an overmedicated population that spends more than $900 per capita on prescription drugs (Lexchin and Gagnon). Another survey found that 76% of people over the age of 65 had taken a prescribed medication in the last two days (Ramage-Morin). We are second only to the United States in our consumption of prescription drugs.

In my next blog entry, I will describe services that are part of the National Health Service in England that have enabled the UK to keep people with chronic conditions healthier, avert institutional care for a longer time and have significantly less drug consumption.

 

Canada. Government of Canada. Statistics Canada. Life expectancy, at birth and at age 65, by sex and by province and territory. Ottawa: Statistics Canada, 2009. Web. 3 No v 2014.

Canada. Public Health Agency of Canada. The Chief Public Health Officer’s Report on the State of Health in Canada 2010. [Ottawa]: Public Health Agency of Canada, 2010. Public Health Agency of Canada. Web. 3 Nov 2014.

Lexchin, Joel and Gagnon, Marc-André. “CETA and Intellectual Property: The debate over pharmaceutical patents.” http://labs.carleton.ca/canadaeurope/wp-content/uploads/sites/9/CETD-Policy-Brief_CETA-and-pharmaceutical-patents_MG_JL.pdf. Oct 2013. 7 pages. Web. 27 Oct 2014.

Ramage-Morin, Pamela. “Medication use among Senior Canadians.” Component of Statistics Canada Catalogue no. 82-003-XPE . Health Reports 20.1 (2009). Web. 3 Nov 2014.

Reynolds, Neil. “Good news: life’s no longer short.” The Globe and Mail 19 Feb 2010. Web. 3 Nov 2014.

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A designated parking space for moving in to long-term care

At Patients Canada, patients and those close to them partner with health care providers and others to help improve patient and family experience.

We always begin by receiving and listening to the experiences that patients and families have. In the last several blog posts, we spoke about parking as a good example of a policy area that can have a great impact on our experience with health care. In this post, I’d like to share an example of a change that happened as a result of hearing about such experiences and then working together with Baycrest Centre for Geriatric Care to make its policies more patient-friendly.

The day of moving in to a nursing home is a particularly stressful time for a family. Ordinary house moves are considered to be among the most stressful times in anyone’s life, but the move into a long-term care facility is even more traumatic for the new residents and their spouses and children. Often the processes put in place for nursing homes admissions can add to the difficulty of this transition. At one point in time at Baycrest, the requirements for moving in a few pieces of familiar furniture to make the new room more home-like made things difficult. It was necessary to call at least three days in advance to make an appointment at the loading dock at the back of the complex. Once there, Baycrest provided no cart and no further help because of insurance concerns. It was also required that the freight elevator be used to bring the furniture to the floor.

This procedure had evolved over some years as a result of multiple efforts at cost control and risk reduction. It had not been developed with any intention of making life harder for people moving in. It responded to a whole series of problem cases, such as equipment breakdowns and demanding families. Baycrest, like most institutions, has had many cost containment exercises and the lack of help might have emerged from one of them. The requirement to move furniture without any help from the institution was further complicated by the lawyers’ instruction not to give out the names of short-term light moving companies that were familiar with the facility. No doubt, this was to avert any liability should something go wrong.

Here was a process that was obviously unfriendly to new residents and their families. When it was brought to the attention of senior staff, they agreed that this was “low hanging fruit” and could be an “early win” for the process of improving resident and family experience.

A series of meetings over several months resulted in changed policies that were not significantly more costly nor more risky and vastly improved the experience of new residents and their families. They decided that families would be given the names of light moving companies if they need help moving furniture into the resident’s room. If they wanted to do it themselves, a designated parking spot had been created at the front door for families who were helping a new resident move in. And residents and families were able to call in advance to get the help of a porter.

We can suggest that this policy or one like it can improve a somewhat traumatic experience by recognizing the need to help new residents and their families to easily move their clothing and small pieces of furniture into their new home.

The more general lesson is that changes in small policy areas like these can make a big difference to people and their experience within the health care system. If you have experiences to share or would like to help design them get in touch with us at www.patientscanada.ca.

Technology helps patients assume a more comprehensive role in medical care

Over the last six months, there has been an extraordinary change in the role of patients in health care and we can hardly keep up. As little as six months ago, the question was, “How can we help patients gain a voice in health care?” We knew that patients should have a voice and that some organizations were beginning to introduce policies and committees to welcome that voice, but what has happened since has far exceeded our expectations.

In the New York Times on April 25, 2014, there was an article that described several devices that empower patients and families to be more involved in their primary care. There are now attachments and apps for smartphones that teach parents how to examine their children for earaches and determine by themselves, or with the online aid of their doctor, whether a visit to the doctor’s office is necessary. techWe already know that the cameras on some phones have become so sharp and clear that photographs of skin conditions can now be diagnosed by dermatologists online without any fancier technology. Now with the otoscope attachment and app, one can create photographs and even videos of the inner ear to check for inflammation. An otoscope is the tool that doctors use to examine the inside of your ear. The picture to the left is of the Cellscope Oto that is attached to an iPhone. Its app will allow almost anyone to examine the inner ear.

This visual otoscope is beginning to be used by doctors to help parents (and medical students) learn which conditions require medical intervention and which do not.

tech1The AliveCor is another recent device/app that allows your smartphone to monitor your heart and interpret the electrocardiogram (ECG). It can also send the ECG to your doctor. It used to be available only by prescription, but can now be purchased online for $199.

As these devices and others like them become more sophisticated and better able to interpret results, they will have a profound effect on the practice of medicine. There is already a website where your photograph can be assessed by a dermatologist for a fee. In the future there will be apps that will be able to crunch the data and do that assessment themselves.

The New York Times notes that this is a continuation of the trend for patients and their families to participate more actively in their own care. Apps are no longer merely ways of communicating with the doctor who has the necessary knowledge and skills to make the diagnosis and prescribe the treatment. Now these tools will enable patients and their families to diagnose the condition and decide by themselves if a trip to the doctor is necessary.

In Ontario, there has been quite a lot of leading edge communications technology to allow doctors to examine patients at a distance. Because of the huge size of the province there are enormous remote areas where there is no easy access to specialists (and other health practitioners). The use of high definition television and tools like the remote otoscope, have allowed doctors to examine and treat patients at a distance for a wide variety of conditions – everything from eye examinations to cancer treatment follow-ups have been done through the Ontario Telemedicine Network (OTN). In fact it has been a leader in medical care among countries with large remote populations. Some of its technology is already beginning to become cheaper and more widely available through smartphones.

At a meeting on April 21, 2014, with a representative of OTN, Patients Canada explored ways to use their technology to increase services not only for remote communities but for populations that find it difficult to travel in rural and even urban communities. Many housebound patients and their families have difficulty receiving services. This new technology can become a way of getting more services, improving continuity of care, and creating stronger partnerships between patients, family members and practitioners. At Patients Canada we have recognized that far more care in the community is needed not only for housebound patients, but for others who have some difficulty accessing the health system. It may be that these new technologies can help to change that by improving communications and enabling patients and families to take on more of the diagnostic role themselves.

Famous patients: Mickey Mantle

In an earlier blog I described the differences between first, second and third class patients. I remembered that I had done a similar piece when Mickey Mantle (October 20, 1931 – August 13, 1995), a famous baseball player, died. The story about his death appeared in the New York Times and is summarized below. It seems appropriate to place him in the Patients Hall of Fame along with Mr. Tillery, a patient whose first name we don’t have, but whose story was presented in Teddy Kennedy’s book about the American health care system. The contrast between the two cases is what should make these two patients famous. In the American health care system, almost 30% of the nation’s entire Medicare budget is spent during patients’ last years of life. (This is probably also true in Canada, lest we become complacent.) Mickey Mantle’s doctors decided to give him a second liver transplant at the age of 63, because they believed there was a 55% chance of Mantle surviving three more years.

Mickey Mantle

The hospital fee for 11 days before the operation was $32,500 (not including doctors’ fees), for assessment of his condition and for cancer tests. The results were negative and it wasn’t until the operation did doctors notice that the cancer had spread dramatically leaving Mantle only a few weeks or a couple of months to live. Had they been aware of the advanced stage of the cancer, the doctors say they wouldn’t have operated. Instead, $20,000 was spent to buy a fresh human liver, plus another $5,000 or more for the
chartered plane. Mantle spent two days in intensive care, probably costing several times the usual $1,000 a day or more that hospitals charge, then another 18 days in the hospital. With anti-rejection drugs and other medication running well into five figures, the hospital bill rose by another $116,000. More tests, drugs and a return to the hospital followed.

Mantle chose to die in a standard hospital room, virtually free of tubes and wires, so the total hospital charge therefore stayed under $200,000. But separate bills for surgeons, pathologists, radiologists, oncologists and gastroenterologists probably equaled the hospital expenses, said Michael Murphy, a health care consultant.

Although it is unclear who paid (Mantle could afford it), keeping Mickey Mantle alive for two and a half months probably exceeded $300,000, (Paraphrased from “Mantle’s Last Medical Bills” by Allen R. Myerson. The New York Times,
Sunday, August 20, 1995.) A companion in the Patient Hall of Fame is Mr. Tillery whose story is taken from Teddy Kennedy’s book on health care in the United States. We don’t have his first name or his date of birth. Nor do we have a photo of him, so we have inserted a drawing of an unknown man, but we do have the story and it is enough to put him in our Hall of Fame alongside Mickey.

Mr. TilleryMr. Tillery, who lived alone, had a complete laryngectomy at the age of fifty-six. He was left unable to speak. Just over two weeks after the operation, Mr. Tillery was sent home from the hospital. He was given a list of specific equipment necessary for his care; namely, a humidifier and a tracheal suction. Given a list of agencies where he could find the equipment, Mr. Tillery was only able to acquire a humidifier, and not a very effective one at that. The suction, he was told, would have to be rented at a cost of $20 a month. Not two days later, Mr. Tillery unable to breathe, woke a neighbor and was sent to emergency. Financially, Mr. Tillery did not have much savings, enough to last him 2 or 3 months, and the $20 necessary to rent the equipment was too much for his stretched budget which already included doctors’ bills. (Paraphrased from In Critical Condition: The Crisis in America’s Health Care, Edward M. Kennedy
Pocket Books New York, 1973.)

Patients and the compression of morbidity

It seems to me that living longer isn’t all it’s cracked up to be. Roger Angell, writer with The New Yorker, has provided us with a wonderful, lively and very funny description of what it is like to grow old in this day of healthcare wonders.

His hand is deformed and he says, “if I pointed that hand at you like a pistol and fired at your nose, the bullet would nail you in the left knee. Arthritis” (Angell, par. 1). He goes on to describe his other infirmities including his stents, his artificial hip, the plastic cover for the hole in his heart, and macular degeneration. He concludes, “I’m ninety-three and I’m feeling great. Well, pretty great, unless I’ve forgotten to take a couple of Tylenol in the past four or five hours” (Angell, par. 3).

If we go back to the 16th century, people lived an average of 40 years, but some of them did live to a ripe old age. There were 80 and even 90 year olds as far back as that. Thomas Hobbes (1588-1679), the famous author of the Leviathan,  died at 91.  But he, like most people of his era, began to suffer from chronic disease far earlier – his palsy began in his early 60s and he could no longer write when he was 67.

Thomas Hobbes

Hobbes was an exception: in the 17th century, most people over 40 had one chronic disease or other – many of them as a result of being exposed to an infectious disease earlier in life. Robert Boyle (1627-1691), for example, survived a prolonged fever as a child and again as a young man, and following his second bout of fever was no longer able to speak with a normal voice or write, so that much of his opus was dictated to his various secretaries over his long life. John Locke (1632-1704) was forced to take long rests in the country because of his chronic asthma which flared up in the city. Barely 10% of the population survived past 40 and the vast majority of those who did suffered from one chronic condition or other. People who engaged in manual work, like farmers and sailors, rarely could continue to work after they turned 40, if they survived that long. And what we can tell from this great distance is that they all had serious chronic conditions if they were not killed by infectious diseases.

We might say that the great advance in our time is that today most people over 65 have at least one chronic condition. That extra 25 years may be more indicative of how we are doing than the absolute numbers.

All this is to introduce the topic of compression of morbidity.

In the 1980s, a stated goal of medicine was to keep people far healthier longer and to compress the period of morbidity before death. The idea was that modern medicine would allow people to retain good health and relatively full capacity before a brief illness and death.

Roger AngellRoger Angell’s story gives us a flavor of today’s reality. Since the 1980s just the opposite has happened: there has been a prolongation of morbidity. Standard indicators identify morbidity far earlier and begin treatment with powerful medications and surgical procedures that result in far higher numbers of people like Roger Angell, who live with diabetes, treatable cancer, hypertension, stents, titanium hips and other marvels for very long periods of time.

We have then to reconsider how we think about our objectives and how we provide healthcare to such a population. And to rethink what our objectives are.

Angell, Roger. “Life in the Nineties.The New Yorker 17 Feb 2014: Web.

Unpacking Galenic medicine

This is a good time to introduce you all to the most stable and longest lasting medical theory of all time: Galen’s theory of humours. His theory was grounded in Aristotelian metaphysics. Aristotle, the son of a doctor, used health as an example to illustrate many of his philosophical ideas. For our purposes, two are particularly important: the notion of final cause and the idea of proportionality of elements. In Aristotle’s theory, the purpose or telos of a thing, constitutes one of its causes; just as the final cause of an acorn is to become an oak tree, the purpose or final cause of exercise is health. He also introduces the notion that health is a good balance of the four elements and their properties: “if the disproportion of the hot and cold elements is the cause of ill health, their proportion is the cause of health” (Posterior Analytics Book I, Chapter 13). For Aristotle, medical interventions have health as their final cause, and the rebalancing of the elements as their means.

The four elements of the pre-Socratics – air, earth, fire and water, provided a metaphysical framework for thinking about matter in general as well as a background for more specific areas such as medicine. Galen’s (c.129-210) theory of medicine was developed from Hippocrates and heavily influenced by Aristotelian thinking. It was closely linked to the four elements. Galen’s four humours – namely blood, black bile, yellow bile, and phlegm, corresponded to air, earth, fire, and water. He also located the humours in appropriate organs, associated them with a developmental process, and connected them to the seasons of the year and to astrology.

The stability and power of the Aristotelian world view was mirrored in the astonishing longevity of its medical offshoot, Galenic or humoral medicine. Like Aristotle’s physics, Galenic medicine remained the dominant western medical framework for almost two millennia. The figure below has been included in various forms and with different degrees of elaboration up to and including the 19th century.

Phlegmatic: cool, calm, self-possessed and unresponsive

Choleric: inclined to anger

Sanguine: courageous and hopeful

Melancholy: gloomy and irascible

According to Galen, a healthy person was someone with a good ratio of the four humours. When they were out of kilter, medical interventions were meant to rebalance them. Diseases could be hot or cold, wet or dry, and cures prescribed hot remedies for cold diseases, wet remedies for dry diseases, and so on. I was startled when I realized that, however unconsciously, we still make use of these ideas when we provide “hot” chicken soup as a remedy for the common “cold.”

The humours were not merely bodily fluids. They referred to people’s character and identity and were also connected to their social and physical environments. This meant that the appropriate balance of humours would be different for different individuals. Because temperament and physiology were considered to be interactive, being angry, for example, could increase the flow of black bile and an increased flow of black bile could also make someone prone to anger. Thus illnesses were called “distempers” and regimens were prescribed to “temper” or harmonize the humours. Many rebalancing interventions that were commonly part of Galen’s prescriptions for regaining health, continue to be prescribed today. For example, changes in climate and adjustments of lifestyle such as diet and exercise.

Most academic doctors practiced some mode of humoral medicine well into the 19th century. Almost all used cupping, purges and bleeds as part of their medical interventions. In fact, some aspects of this remained part of standard practice until the early 20th century after which modern scientific medicine finally gained ascendency. For example, even the very eminent Sir William Osler in his widely used medical textbook, The Principles and Practice of Medicine, includes bleeding as one of the possible treatments for certain conditions such as pneumonia.

Galenic medications remain a part of the naturopathic medicine cabinet. Direct interventions like applying hot cups to create a vacuum and extract poisonous humours (cupping) and digestive tract purges continue to be used. There is not much evidence of curative bleeds which were part of medicine until early in the 20th century. When Gwyneth Paltrow, the movie star, was asked about the four brownish circles on her back, she declared that cupping made her feel significantly better.

A session with a traditional Galenic practitioner usually began with a horoscope which connected the individual patient and the stars. Every individual has a unique horoscope, and therefore a unique character and blend of appropriate humours. The individuation of patients in this way is today mirrored in the individualized DNA that identifies multiplicity of genetic sources of a highly individualized makeup. In both cases, this means that individual modes of treatment must follow from the particular constitution of the individual, whether genetic or astral.

As we’ll see, the highly individualized treatment of individuals gave way in early scientific medicine to a much more chemical mechanical model of healthcare in which diagnosis and treatment became highly standardized.

Reference: Aristotle, Aristotle’s Posterior Analytics, trans. E.S. Bouchier, B.A. (Oxford: Blackwell, 1901). Chapter: CHAP. XIII.: The difference between the Demonstration and Science of a thing’s Nature and those of its Cause.

Competing for patients in a changing system

There have always been many kinds of health practitioners competing for patients. Last week I wrote about the ashipu, priest-healers in Ancient Mesopotamia (about 3500 BC) who diagnosed illness by identifying which god had been angered. Each god was associated with a particular body part, and sacrifices to placate that god would ease the symptoms. These priestly doctors served courtly patients, but even in Mesopotamia there were a variety of health practitioners with different approaches and skills that appealed to the varying needs and resources of patients. The asu were among the other practitioners mentioned in the cuneiform tablets. They appeared to provide hands-on care including the preparation of poultices for wounds, herbal remedies for illness and in extreme cases, they performed surgical procedures to sew up wounds or amputate infected limbs. There were also barbers who pulled teeth and cut hair, and midwives who assisted in births. There were other practitioners who either held special religious beliefs associated with health or who had special knowledge of remedies that differentiated their practice.

The surviving cuneiform tablets tell us a little about some of the laws that regulated practitioners. According to the tablets, if a high status person lost a hand as a result of surgery, the asu was at risk of having his own hand cut off. In other cases, he paid their owners to recompense them for the death of a slave. These regulations suggest that the ashipu may have had higher status than the asu and had been in some rivalry with them. Their higher status may have helped them argue for increased regulation of their rivals by invoking penalties for failures in practice; there is no mention of consequences to ashipu for their failures. Although other practitioners are mentioned in the tablets, not much is said about them which suggests that their status was lower than that of the two predominant groups.

We live in interesting times. Today, scientific medicine predominates in the academic and political world, but there remain a plethora of other practitioners who are thriving and providing a wide variety of care. Many of the ancient practices continue to this day – everything from cupping to purging. There are also a great number of practitioners who concentrate on nutritional cures, relaxation therapies, herbal remedies and so on. In fact, to understand the pervasiveness of alternative medicine, one only has to go to the large chain supermarkets who now offer organic foods and a wide variety of food supplements that are not part of the pharmacopeia of orthodox medicine. In fact, organic food is the fastest growing segment of Canada’s food industry.

Last year when I gave a talk at the Canadian College of Naturopathic Medicine, I learned that their four-year program is full. Since 1995, the graduating class has mushroomed from 25 to 125 students. A significant number of Canadians consider a naturopath to be their primary doctor. Naturopaths see themselves as being largely involved in the promotion of wellness and the prevention of disease, and when they do deal with illnesses, it is with conditions that are often difficult for orthodox medicine to treat such as chronic digestive complaints, pain management, chronic fatigue and so on.

Recent articles in the orthodox medical journals suggest that the growth of this segment of healthcare has not gone unnoticed. It seems that the age old rivalry between these groups has re-emerged. After decades of ignoring these issues there has been a spate of articles that suggest the uselessness of vitamin supplements, and even the possible deleterious effects of vitamin D. A closer look shows that what the articles say is that if one eats a well-balanced diet, supplements are not necessary, but they are certainly not harmful. The amount of Vitamin D that would hurt you is far in excess of any normal dose. Nonetheless, these pieces of research seem to be part of an argument for increasing the regulation of nutritional supplements, which of course could then not be offered by non-medical practitioners. These warnings are oddly disproportional to the lack of widespread coverage of the damaging side effects of prescribed drugs, which are regulated.

Three Theories of Health and the Mortality Shift

The Mortality Shift that began in the 1850s and continues to this day in the industrialized world is marked by a constant increase in life expectancy at birth. For many centuries, life expectancy was about 35 years, while today it is between 77 and 85 years and rising in almost all industrialized countries. The table below is an example drawn from available data that shows the changes in life expectancy in the United States, Canada and the United Kingdom over the last 90 or so years despite depression and war.

The explanation for this change is still being debated.  I will review three of the main positions.

  • Increased life expectancy is primarily due to medical science
  • The increase is due to advances in public health
  • The increase is due to a complex interaction of many factors, primarily non-health

Each of these explanations has had a strong successive influence on health policy over the last century. In all of them life expectancy at birth has stood as a surrogate for the health of a population. The three views state that the changes are due to medical science, to public health and to a broad range of determinants of health. Let me briefly describe each of them.

Scientific Medicine Results in a Healthier Population

A strong argument was made for the impact of medical science on population health.  Many histories of medicine have claimed that the major scientific advances in medicine in the 19th century resulted in the dramatic reduction of surgical mortality through the introduction of ether in the 1850s, and the promotion of sterile operating environments by Joseph Lister in the 1860s. These innovations also helped to reduce infant and maternal mortality through more scientific childbirth with fewer infections, for both mothers and infants. The discovery of the causes of infectious diseases by Robert Koch and Louis Pasteur led to the development of vaccines that saved the lives and increased the longevity of large numbers of children. Finally, the introduction of penicillin and its widespread use during World War II confirmed the incredible contribution of medicine to a healthier and longer lived population.

The successes of scientific medicine in the late 19th century was probably the greatest influence in the development of our current healthcare systems which are built around hospitals, medical schools and research facilities.

Better Public Health is the Main Basis for a Healthier Population

The Miasma Theory of Illness was the theoretical frame for the Sanitarian movement led by Edwin Chadwick. It was falsely believed that foul smelling air and dirty water contained pollutants that caused diseases like cholera, typhoid fever, and even the Plague. Chadwick devoted a good part of his life to improving sanitary conditions in England, and in 1848 he succeeded in getting the first public health act passed in England. This was followed by the construction of new sewer systems for London and other cities in the late 1850s, and the passage of a much stronger public health act in 1875. Many current public activities like the development of policies related to food inspection and labelling, anti-smoking legislation and so on are in that tradition.

Advocates for increased public health have argued that these and other public health measures were more responsible for a healthier longer lived population than medical interventions. This view was one of the bases for the Lalonde Report which led to great changes in public policy and population behaviour in the 1970’s and later. Today, many argue with some justification that anti-smoking legislation has had a greater impact on the reduction of cancer and heart disease than the billions of dollars spent on medical research.

The Social Determinants of Health Argument

More recently scholars of the Mortality Shift have argued that the most cogent explanation for the great increase in life expectancy was that the period that began in 1850 was one where general prosperity led to increased earnings and better living conditions for large numbers of people in the developed world. Although medical care and public health measures did contribute to a healthier population, both were less critical than improved housing, better working conditions increased education and similar factors that resulted in people living longer.

Advocates for the social determinants of health view argue that there is good evidence that tuberculosis was decreasing as a result of less crowded housing well before medical intervention began, and that the reduction of mother and infant mortality was on the decline because of better maternal nutrition. Holders of this view also believe that healthier populations have greater income equality. In many countries income disparity was reduced during the period of increasing life expectancy. However, income inequality has been increasing for the last 40 years without any reduction in life expectancy. Many who hold this view are beginning to think that life expectancy at birth may not be such a good surrogate for the health of a population.

My next blog will focus on how our health care system came to be.

How normal aging has changed

Here is the bad news.  As we age our bodies change: our skin becomes less elastic, our hair thins, we lose as much as two inches in height by the time we are 80, we lose muscle mass, and some of the mineral content in our bones. Our senses become less acute: most of us need glasses by the time we are in our 40s, and it becomes more difficult to hear the high-frequency sounds of human speech. We sleep less long and not as deeply. Our metabolism slows and we need less food. Our brains become smaller with less blood flowing through them; some memory loss is normal. Our organs also change: most of them become less efficient and more vulnerable to extremes of activity or diet.  Male sexual response times slow and women stop ovulating. The pace of aging varies not only because of differences in one’s genetic makeup but also because of income, social status, education and many other determinants of health. Heart problems, arthritis, lung disease, chronic digestive issues and their associated problems are much more common as we age. Dealing with such conditions is a significant part of the normal aging process.

There are many ways in which the health status of humans has changed over the centuries. For example, we know that for many centuries life expectancy at birth was between 30 and 35. There was a very high rate of infant and child mortality. Many deaths were due to infectious diseases – typhoid fever, cholera, small pox among others. In fact, if you lived to the age of 20 your chances of surviving to 60 were pretty good.

The critical point for me is that in previous eras almost everyone over the age of 40 had one or more chronic diseases.  For example, while doing some work on seventeenth century philosophy and science, I found that many of the famous philosophers and scientists of the time, such as John Locke, Robert Boyle and Thomas Hobbes, all suffered from chronic diseases from quite early on.  Many of these conditions were the consequence of infectious diseases that they had survived as children or teenagers. By the time they were 40, they and their peers were considered to have entered old age. Still death was not usually a result of chronic conditions – at all ages the greatest risk of dying was from the big killers, like cholera, tuberculosis, and other infectious diseases.

A great shift in mortality began in the industrialized world in the middle of the nineteenth century.  Longevity was increasing and many of the diseases of aging were starting later in life. Today, we hear that “60 is the new 40.” And it is. This rapid increase in life expectancy is continuing, as is the delay in the onset of age related morbidity. One can describe the changes of the last several centuries in terms of this delay of the onset of the diseases associated with aging.  If in the 1600s almost everyone over 40 had one or more chronic diseases, now almost everyone over 65 is affected.  If old age began at 40 in the 1600s, we can say that it now begins at 65.

Some of the main features of the mortality shift are the reduction of maternal and infant mortality, and the elimination of many communicable diseases. Infant mortality in the developed world has dropped by almost a hundredfold from more than 10% to almost 0.1% over the last 150 years.  Maternal mortality which was about 500 for every 100,000 births is now about 12. Deaths from diseases like small pox, cholera, typhoid fever tuberculosis and other communicable diseases have virtually disappeared in Canada and other developed countries. The recent WHO atlas of morbidity tells us that in Canada 89% of deaths are due to non-communicable chronic diseases. Competing explanations of the Mortality Shift have greatly impacted health policy, some of which I will review in the next blog.

How should a healthcare system respond to an aging population?

We all agree that the population of Canada (and of other industrial countries) is getting older. People are living longer and the birth rate is dropping. As a result, the average age of the population is rising. We have long recognized that our society must make adjustments for this change and we have introduced some effective economic and social policies to avert the impoverishment of our older population; however, our healthcare system has responded less well to this demographic change: despite the fact that they have become the heaviest users of the system, the system has, if anything, become less friendly to them and their caregivers.

There is a great disparity between the different responses to an older population. The social and economic responses have been relatively strong and the healthcare response has been disappointing. What are some of the indications of this disparity, and why is the disparity so great?

It is economically easier for people to live after retirement because we have been encouraged to save for old age through both mandatory and voluntary pension contributions; we have increased the age of retirement and, in some cases, have eliminated mandatory retirement altogether for people who want to continue to work. We also have more developmental support, and educational and leisure services for older people. These economic and social adjustments have occurred over a long period of time with both positive and negative outcomes that affect not only older people but the rest of the population as well. For example, the disappearance of mandatory retirement and increased longevity has made it more difficult for young people to enter certain parts of the works force; the increased wealth of the elderly has created the first generation of relatively independent older people who do not have to depend on their offspring to support them economically in their old age. This is evident in some of the statistics on the economic status of older people:

1. The fastest growing segment of the population are the over 85s

2. People over 65 have the lowest debt load of any segment of the adult population

3. In recent years the largest increase in debt has also been of the over 65s as they are increasing their expenditures

It is at first somewhat puzzling how poorly the healthcare system has accommodated to an older population. We know that older people have very different health need, particularly less dramatic intervention and more support. However, many of the conditions associated with aging have been characterized as diseases, even though a large number of them are in fact a natural consequence of getting older, rather than the result of a particular pathology. As a result, healthcare services appear to remain quite narrowly focused on hospital and specialist care, and in some cases people must have an acute episode before any serious consideration is given to their care. Families faced with aging parents have great difficulty in finding services that suit their needs beyond the most basic medical and nursing care; suitable supports for aging in one’s home still require great effort and remain hard to come by.

A great proportion of Canada’s healthcare dollars are spent on a relatively small part of the population – elderly people who are kept in acute hospital for long periods of time because of inadequate long term care. Once discharged this group of patients are often at high risk of returning to hospital frequently in a kind of revolving door syndrome. In Canada it has been determined that 5% of the population uses something like 20% of the funding for healthcare, and this group of elderly people are a large part of that population. In the United States there is a similar problem of mostly older people who return to hospital within 30 days of discharge, which means a great deal of energy is being focused on this population. The objective is to improve their transitions of care to keep them out of hospital once they are treated, and so far there has been no great and clear success in these efforts.

At Patients Canada we think that this problem has deep roots and we are exploring it slowly. We think that much of the problem is related to the kind of healthcare system we have created, to its focus, the kinds of strengths it has and how resources are allocated to it. I’ll continue to review these issues in the coming weeks and I encourage anyone interested to add their feedback or comments.