Lecture 7: Historical trends, health Care and Canadian contributions

1. Lecture 7: Historical trends, health Care and Canadian contributions Geography 346

2. Introduction Poster presentations Set aside �precautionary principle� for the moment Look at Canadian health care system Download article from Chronic Disease in Canada dealing with material deprivation

3. Group Poster Presentation Ideas Complementary/alternative/traditional medicine Climate change and human health Smoking Household chemicals and health Fossil fuels AIDS/HIV in Canada/Africa Organic Foods Genetically Modified organisms: e.g., fish farms Child health issues Pharmaceutical companies Mental health/stress related illnesses Water quality Zoonoses Vegetarianism: Others:

4. On Airs, Waters and Places Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces (for they are not all alike, but differ much from themselves in regard to their changes). Then the winds, the hot and the cold, especially such as are common to all countries, and then as are peculiar to each locality. We must also consider the qualities of the waters, for as they differ from one another in taste and weight, so also do they differ much in their qualities. In the same manner, when one comes to a city in which one is a stranger, he ought to consider its situation, how it lies as to the winds and the rising of the sun; for its influence is not the same whether it lies to the north or the south, to the rising or setting sun. These things one ought to consider most attentively, and concerning the waters which the inhabitants use, whether they be marshy and soft, or hard and running from elevated and rocky situations, and then if saltish and unfit for cooking; and the ground, whether it be naked and deficient in water, or wooded and well watered, and whether it lies in a hollow, confined situation, or is elevated and cold; and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess and given to indolence, or are fond of exercise and labor, and not given to excess in eating and drinking. From these things he must proceed to investigate everything else. Hippocrates (c. 400 BC)

5. Thinking about environment and health Hippocrates 2000 years ago was familiar with person-environment interactions This �ecological perspective� dominated until germ theory in the second half of the 19th century (1850s +). Ideas that microbes invade human bodies and cause alterations that result in disease: Biomedical approaches took hold Scientific revolution

6. Historical Trends John Snow (1854) physician in London working to understand the cholera epidemic Made a connection between the water obtained from a city pump because he found a lot of cases clustering there. He took the handle off the well pump and the rates of cholera declined. Right about the time that bacteria was being discovered.

7. Historical Trends Modern Times: Rene Dubos (1960s) in his book, Mirage of Health said, �Men as a rule find it easier to depend on healers than to attempt the more difficult task of living wisely.� Jacques May � the father of medical geography in the US. He was a French surgeon in Siam (now Thailand). He worked in a hospital in Hanoi and started to question why his patients experienced disease and responded differently than European patients described in textbooks. May progressed to an interest in their multiple infections and the conditions of their lives started searching for understanding in their cultural and environmental conditions that produced and limited their health and disease.

8. Pre- and Post- WWII Capitalist welfare states developed Government intervened more in the economy To assist Fordist modes of production government took on more roles of social welfare provision Most parts of the developed world experienced significant gains in health Eastern bloc countries a lot of variability E.g., Poland there is marked evidence of heavy metal contamination Hungary there are signs of demoralization and loss of control over destiny with effects on health status.

9. Study of University Students Steptoe and Wardle, 2001

10. Health and Wealth nationally, provincially and locally� a nation�s health is influenced by a nation�s wealth or the converse? Health care in Canada is very political Commodity or public good?

11. Challenging the Biomedical Model Thomas McKeown (1978) professor of medicine McKeown looked at mortality between 1838-1970 and concluded: Host resistance was most likely explained by better nutrition than medical intervention or public health measures. Ivan Illich (1976) �iatrogenic illness� E.g., 1880-1920 reduction in infant deaths in the UK the result of social changes: increased spacing between births, prosperity that lead to better living and working conditions Dubos 1960s � evolutionary stimuli coming from built environment

12. Canadian Health Care Provincial and territorial responsibility Governed by Canada Health Act (1984) Guarantees right to medically necessary physician and hospital services 5 principles: public accountability, portability, accessibility, comprehensiveness and universality 1990s health care crisis: 1/3 of budgets Canada spending more than the all countries but the US Escalation of costs, underfunding, inefficiency and ineffectiveness

13. Canadian Health Care Restructuring strategies: Address the importance of health promotion, broader view Alternative physician remuneration schemes Publicly financed competition Curative to preventive/care approach

14. Canadian Health Care 1991 Minister of Health: arguing for a shift from curative to preventive care: ��it is infinitely cheaper for us to stop a child from ever starting to smoke than it is to treat somebody who contracts cancer. It is infinitely cheaper for us to educate people on how to avoid contracting AIDS than it is for us to provide services to them once they become infected with the disease. It is infinitely cheaper for us to prevent drug abuse and alcoholism in Canada than it is to treat the problem once it has occurred.�

15. Canadian health care Finding the balance? Oscillations between preventive and curative historically Resource allocation decisions �.loss of welfare programs and cuts to education What are the consequences? 1974 Lalonde Health Field Concept -Individual risk factors vs structural conditions in the society, economy and environment - cautions about victim-blaming

16. Canadian health care 1987 Ottawa Charter for Health Promotion Conditions and resources for health are: -peace -shelter -education -food -income - a stable ecosystem - sustainable resources -social justice, and equity

17. Determinants of Health ~50% social and economic environment/lifestyle ~10-25% physical environment Up to 25% health care Remainder biology and genetic endowment

18. BC Health Goals Living and Working Conditions Employment Unemployment rate-not much change Income assistance-improving Decision latitude at work-no data Income Low income rate-not much change Income assistance rate-improving Income inequality-not much change Housing Housing need � no recent data (likely worsening) Individual Capacities Healthy Child development Learning opportunities Healthy choices: Smoking-improving Drinking-worsening Phys act-not much change Teen pregnancy-improving

19. Inequalities Wilkinson (1996) argues that what matters most is not whether you have a smaller or larger home or better or lesser care but what these differences mean socially and what they make you feel about yourself and the world around you.

20. Determinants of health inequalities % of income spent on basic necessities: food, shelter and clothing ___________________________________ Low income Poor housing Unemployment Townsend et al. (1988) material deprivation --Car ownership, household tenure (own or rent), overcrowding Wilkinson (1996) attempts to bridge the gap between income inequality and mortality and life expectancy by looking at the role of social relationships and civic society �social capital�

21. Whitehall studies, Black Report (Popay et al., 1998) a clear mortality gradient across employment categories of English civil servants threefold difference in mortality between low and high excess mortality is not just related to the cumulative effect of conventional risk factors e.g, exercise, obesity, smoking and blood pressure Whitehall studies have also sought to incorporate psychosocial factors within and outside the world of work into the analysis (Marmot et al., 1991).

22. Whitehall I and II studies The Whitehall studies also moved beyond cross-sectional data to explore longitudinal data�changes in mortality over time. A lot of work/emphasis also currently going into the quality of social relations e.g., idea that better social support and social integration leads to better health outcomes and reduced mortality.

23. Inequality in a Canadian Context Health Canada: 47% of Canadians in the lowest income bracket say they have good-excellent health compared with 73% in the highest income group Low income Canadians experience more illnesses Whitehall studies show that income distribution in a society is more important than total income earned large gaps in distribution or steep gradient lead to increased social problems and poorer health 1990-2000 wealthiest 10% of Canadians increased their income by $ 23,000/person Annual income of poorest 10% of Canadians increased by $ 81/person.

24. Health in Canadian Communities Infectious diseases vs chronic conditions and disabilities LE ranges from 65.4 years in Nunavik, PQ to 81.2 in Richmond, BC. In Richmond, the smoking rates and obesity rates are the lowest in the country (9%, 6%).

25. References Burke, M. and H.M.Stevenson (1998) Health and Canadian Society: Sociological Perspectives, 3rd edition, edited by D. Coburn and C.D.�Arcy and G.M.Torance, U. of Toronto press. Marmot, MG, G. Davey Smith, S Stansfield, C. Patel, F. North, J. Head, L White, E. Brunner and A. Feeney (1991). �Health inequalities among British civil servants: the Whitehall II study, Lancet, 337, 1387-93. Popay, J. G. Williams, C. Thomas and T. Gatrell (1998) �Theorizing inequalities in health: the place of lay knowledge.� Sociology of Health and Illness, Vol 20 no 5 p 619-644. Steptoe, A. and J.Wardle (2001) Health behaviour, risk awareness and emotional well-being in students from Eastern Europe and Western Europe, Social Science and Medicine, 53, 1621-1630. Wilkinson, R.G. (1996). Unhealthy Societies: The Afflictions of Inequality. London: Routledge.