What’s The BIG Idea? Harvey Skinner Dean, Faculty of Health, York University

1. What’s The BIG Idea?Harvey SkinnerDean, Faculty of Health, York University global local University of Calgary April 16, 2008

2. Today’s Dialogue Objectives • The Challenge • Designing for after the health care system implodes • The BIG Idea: “first Health, then Medicine” • keeping more people healthier longer • The Opportunity • your fresh thinking for change

3. What is the BIG idea?

5. The BIG Idea“first Health, then Medicine” Fresh thinking and action for Keeping more people healthier longer by Co-Creating the Total Health System

7. Ten Great Achievements of Public Health in 20th Century • vaccination • motor-vehicle safety • safer work places • control of infectious diseases • prevention of heart disease and stroke

8. Ten Great Achievements of Public Health in 20th Century • safer and healthier foods • healthier mothers and babies • family planning • fluoridation of drinking water • tobacco recognition and prevention

10. Ten Great Achievements of Public Health in 20th Century Added 25 Years+ to Life Expectancy of People in North America BUT

11. Obesity Trends* Among U.S. AdultsBRFSS, 1990 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% Behavioral Risk Factor Surveillance System (BRFSS)

12. Obesity Trends* Among U.S. AdultsBRFSS, 1991 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

13. Obesity Trends* Among U.S. AdultsBRFSS, 1993 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

14. Obesity Trends* Among U.S. AdultsBRFSS, 1992 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

15. Obesity Trends* Among U.S. AdultsBRFSS, 1994 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

16. Obesity Trends* Among U.S. AdultsBRFSS, 1995 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

17. Obesity Trends* Among U.S. AdultsBRFSS, 1996 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

18. Obesity Trends* Among U.S. AdultsBRFSS, 1997 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

19. Obesity Trends* Among U.S. AdultsBRFSS, 1998 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

20. Obesity Trends* Among U.S. AdultsBRFSS, 1999 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

21. Obesity Trends* Among U.S. AdultsBRFSS, 2000 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

22. Obesity Trends* Among U.S. AdultsBRFSS, 2001 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

23. Obesity Trends* Among U.S. AdultsBRFSS, 2002 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

24. Obesity Trends* Among U.S. AdultsBRFSS, 2003 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

25. Obesity Trends* Among U.S. AdultsBRFSS, 2004 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

26. Obesity Trends* Among U.S. AdultsBRFSS, 2005 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

27. No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Obesity Trends* Among U.S. AdultsBRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

28. No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Obesity Trends* Among U.S. AdultsBRFSS 1990 - 1998 - 2006 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1998 1990 2006

29. Obesity in Canadian Adults CCHS 2004 (measured data)

30. Excess weight (BMI  25) in youth (2-17) Canada, 2004(measured data) (% Obesity) (17%) (8%) (7%) (9%) (7%) (8%) (10%) (9%) (9%) (13%)

31. Childhood Obesity

33. Cuba’s ‘Natural Experiment’ • Cuba’s economic crisis of 1989-2000 resulted in reduced energy intake, increased physical activity, population wide weight loss and reduction in chronic diseases • Reduced daily energy intake from 2,899 to 1,863 calories • Physical activity in adults increased from 30% to 67% • 1.5 unit shift down in body mass – obesity declined from 14% to 7% • Decline in deaths attributed to • Diabetes: 51% • Coronary heart disease: 35% • Stroke: 20% • All causes: 18% Franco et al. Am J Epidemiology, 2007

34. Ontario Budget Expenditureon Health Care • 32 % of Ontario budget ten years ago • 46% today • 75% by 2023 • 100% by mid-2030s Based on 2004 budget projections

35. Ontario Government Expenditures$79.3 billion in fiscal year ending March 31, 2007 35.7 billion: Health 12.1 billion: Education 10.4 billion: Children & Social Services 9.8 billion: Environment 5.4 billion: Post-Secondary 3.2 billion: Justice 2.7 billion: Transportation

36. Globe and Mail headlineApril 7, 2008 • B.C. intent on tackling issue of funding in health care • Province to defy Ottawa by enshrining fiscal sustainability in medicare laws

37. Health Minister struggling • B.C. Health Minister George Abbott wants to make fiscal sustainability a founding principle of health-care delivery, a measure flatly rejected by his federal counterpart, Tony Clement. • "We will continue to embrace the five principles of the Canada Health Act," Mr. Abbott said in an interview. "We believe we should enshrine sustainability as a principle as well."

38. a framed statement of values • Mr. Abbott said the province has to grapple with escalating costs that are threatening program spending in other areas • Health-care spending currently consumes about 44 per cent of the provincial budget. He said that by 2013 it is expected to chomp through fully half of all B.C. government spending. "Government needs to be conscious of the fact that we have 20 other areas of ministerial responsibility and service delivery besides health care"

39. Critics worry that the sustainability principle will push B.C. toward more privatized health-care services "Adding a sixth principle to the Canada Health Act is opening the door to look at health care through a financial lens for the first time in history," said Leslie Dickout, a campaigner for the B.C. Health Coalition, a group that champions the protection and expansion of universal health care.

40. The Challenges are Largebut not Insurmountable

41. The BIG Idea“first Health, then Medicine” Keeping more people healthier longer • Preparedness: public health threats … • Prevention: tobacco control … • Promotion: active living … • 50% premature mortality is preventable • Up to 70% of conditions that patients present in hospitals and clinics are preventable Co-Creating the Total Health System • Access: reducing disparities • Quality, Safety and Effectiveness (outcomes) • Utilization (waste; integration; eHealth) • Global Health: integrated services and delivery

42. first Health then Medicine

43. Fresh Thinking and Action • Reframing: first Health then Medicine • Bottom of the Pyramid (Prahalad) • Co-creation PPP: people, private, public • Global – Local integration • Technology • ??? • ???

46. 1. What is the Worst Thing we could do? • Please identify really bad ideas for keeping people healthier longer

47. 2. Now flip the Bad Ideas into good ones? • Pick several bad ideas and transform them into good but still outrageous – way out there -

48. 3. Convergence • Review the good ideas and propose several practical directions and solutions for the BIG Idea

49. Your Take Home Message?

50. Dr. Ida S. Scudder, Founder, Christian Medical College & Hospital, Vellore, India, 1900