‘Town Hall Meeting’
Orientation materials
Demographics
From Greek ‘demos’ the people, and ‘graphe’ writing about or drawing.
Relevant to physicians because population structure
drives the types of patient you will see
(how many kids; elderly; immigrants?)
Main demographic driving forces in Canada:
- Declining birth rates
- Aging of the population
- Immigration
All of these will fundamentally influence
your future medical practice. . .
Declining Birth Rates
Canadian birth rates have fallen to a point below the population
replacement level. All our population growth comes from immigration
Canadian Fertility Rate (Births per Woman),
1871-1996
Average #
births per
woman
Industrialization;
8
urbanization
7
6
5
‘Baby boom’
[ Replacement rate: 2.1 ]
18
71
18
81
18
91
19
01
19
11
19
21
19
31
19
41
19
51
19
61
19
71
19
81
19
91
20
01
3
2
1
0
WW I
WW II
4
The ‘Baby Bust’ is Global
Each woman in the world now has
half as many children as in 1970.
Populations of Russia, Japan, &
several European countries are
already shrinking.
Why the Decline in Births?
Urbanization, lack of space;
Economics of modern work
(contrast with agriculture);
Babies expensive & getting a job
implies attending university, etc.
Source: Health Canada (2005). Changing fertility patterns.
Health Policy Research Bulletin, issue # 10, page 8
So what?
Fewer obstetricians? Empty schools? Time to invest in nursing homes?
Fewer kids initially frees up money, but what happens when their parents get
old? What’s happening in China?
Can lead to social change in terms of ethnic make-up of the population.
Aging of the Population
Our population is aging.
Here is the median age of Canadians:
Year
1998
2016
2021
% aged
≥ 65
12.3
15.9
17.8
(You finish
MD)
Your
5 yr
reunion
So What?
Big demand for geriatricians!
Elderly consume more health care, so costs likely to rise
- Although elderly people may now be trying to stay fit?
There will be fewer working age person to pay the tax bill
for the growing number of elderly: dependency ratios
2041
22.6
25 yr
reunion
Dependency Ratios
Refer to the numbers of working-age people, compared to the number of young and old
who need to be supported by the working age people. It was 59.2 for Canada in 2006,
ranging from 49 in the Yukon to 72 in Saskatchewan
Decline in birth rates initially improves the dependency ratio, so there is more money to
spend on consumer goods . But...
- as the parents grow old (me!), there are fewer working age people (you) to pay taxes
to cover my health care when I am old and need expensive care.
This will be especially hard for poor countries, which will grow old before they grow rich.
At least Canada grew rich before it became old.
The Costs of Care are Driven by the Age of Patients...
Government Health Expenditures per Person per Year,
by Age of Patient, Ontario, 2002
$16,000
$14,000
$12,000
$10,000
$8,000
$6,000
$4,000
$2,000
+
90
-8
9
85
-8
4
80
-7
9
75
-7
4
70
-6
4
-6
9
65
Age of Patient
60
-5
9
55
-5
4
50
-4
9
45
-4
4
40
-3
9
35
-3
4
30
-2
9
25
-2
4
20
-1
9
15
-1
4
10
59
14
<
1
$0
Source: CIHI, 2005, ‘National Health and Expenditures Trends, 1975-2005’
So, what will be the impact of the aging population on costs of care?
Who will pay? What will this do to your taxes?
Ethnic Composition of Canadian Population
From the 2006 Census:
There are 6.2 million foreign-born people in Canada: 19.8% of the population,
but it’s over 28% in Ontario.
Immigrants represent > 200 countries; 70% have a mother tongue other than
English or French.
(12.5% of the U.S. population, and 22% of Australians, are foreign-born)
Between 2001 and 2006, 1.1 million immigrants arrived in Canada
- 58% came from Asia and the Middle East (14% from China)
- about 10% came from Central and South America & the Caribbean
- another 10% came from Africa
- most were working-age
The pattern of immigration has been changing:
- in 1971, 60% of immigrants came from Europe; 12% were from Asia.
- today, 16% of immigrants are from Europe, with growing numbers
from Eastern Europe. More Russians than French now come to Canada
Ethnic minorities are often less well-off than the mainstream population.
Such inequalities can influence health.
Inequalities and Health
During the phase of pestilences & pandemics, health patterns
reflect the absolute wealth of a nation: poor nations suffer the worst.
As countries become wealthier, there are typically growing economic disparities
between people (some get very rich; a lot remain very poor). Some countries
use progressive taxation to transfer wealth to the poor (as in Scandinavia).
Others do this less (U.S.A.) and they retain a wider spread of personal wealth.
An interesting discovery in the
1990s was that overall health
for richer countries varies
according to the level of
disparity in income, more than
the average level of income.
So, being poor in a rich
country is worse than
being poor in a poor country; it
is relative income more than
absolute wealth that counts.
Life expectancy, 1996
75
Sw
r = -0.81
Nor
74
NL
73
Jpn
Can
Fr
Aus
72
UK
Esp
71
USA
70
Ger
26
31
36
41
More equal
Less equal
Gini coefficient of equality of wealth distribution
So, the population is changing.
But what diseases will you be
treating?
Patterns of disease vary between countries
and evolve over time; many Canadians come
from overseas, so you will see a wide variety
of strange illnesses, and this will also change
while you are in practice.
Let’s begin with the big picture:
Global Patterns of Disease
As societies evolve, patterns of disease evolve and interact with social change.
There are many terms to describe this; here is one:
Stage
Typical health patterns
Typical life
expectancy
Examples
Pestilence &
famine
Malnutrition and infectious
diseases predominate
35+
Sub-Saharan Africa
Receding
pandemics
Improved public health
increases survival; people
live long enough to develop
chronic disease
55+
South Asia; Latin
America; Caribbean
Degenerative
& man-made
diseases
Increased caloric intake,
smoking, etc. Cancer &
cardiovascular disease
65+
Eastern Europe;
Middle East; Urban
India; North Africa
Delayed
degenerative
diseases
Prevention delays onset, &
treatment improves survival;
dementia, osteoporosis, etc.
75+
G-8 countries
Our health has improved remarkably!
One way to describe health is via death rates: the lower these are, the longer people
live on average. But as old people are more likely to die than the young, you would
expect more deaths in an older population. The ‘age-standardized’ rate (red) corrects
for this to give a fair comparison. The fact that the red line declines faster than the
blue shows that we are doing even better than appears from the raw figures.
We all now have half the chance of dying in the coming year as someone did in 1920.
Crude and Age- standardized Overall Mortality Rates, Canada, 1920-2000
14
12
Standardized
Crude
10
6
4
2
20
00
19
90
19
80
19
70
19
60
19
50
19
40
0
19
30
population
8
19
20
Deaths
per 1000
Here
leading
causes
of2004death in Canada in 2004:
FIGURE 1-22were
Number andthe
percentage
of the leading causes
of death, Canada,
Other§ (40,152)
17.7%
Other ischemic heart disease*
(21,186)
9.4%
Heart attack (18,125)
8.0%
Infectious diseases (3,993)
1.8%
Cerebrovascular disease†
(14,626)
6.5%
Diabetes (7,823)
3.5%
Injuries and poisonings
(13,940)
6.2%
All
cardiovascular
diseases
(72,743)
32.1%
Other cardiovascular
diseases‡ (18,806)
8.3%
Respiratory diseases (19,607)
8.7%
Neoplasms (68,322)
30.2%
* Other ischemic heart disease = ischemic heart disease - heart attack.
† Cerebrovascular disease excludes transient ischemic attacks.
‡ Other cardiovscular diseases = circulatory disease – other ischemic heart disease – heart attack – cerebrovascular disease.
§ Other = all causes – [respiratory disease, all cardiovascular diseases, accidents/poisoning/violence, neoplasms, infectious diseases, and diabetes].
Note: Total number of deaths from all causes = 226,584.
Source: Chronic Disease Surveillance Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, using the Vital Statistics database (Statistics Canada).
Note the small number of infectious diseases (<2% of all deaths).
Formerly, these were the leading causes of death. Why the change?
The End of Infectious Disease?
In the years of optimism following World War II, humans seemed to be winning the long
battle against the bugs.
Antibiotics could cure bacterial diseases such as TB and typhoid fever;
Vaccines prevented childhood diseases such as polio, whooping cough, and diphtheria
But...
● In the 1950s, penicillin began to lose its power to combat Staphylococcus aureus;
● New strands of influenza emerged in China and spread worldwide in the 1960s
● The 1970s saw a resurgence of sexually transmitted diseases, leading later to AIDS
● New diseases emerged: Legionnaires’; Lyme disease; Toxic shock syndrome; Ebola
● Antibiotic resistance has become a major problem
Changes relevant to infectious disease:
• Global travel
• Globalization of the food supply and centralized processing of food
• Population growth, increased urbanization and crowding
• Population movements due to civil wars, famines, man-made & natural disasters
• Irrigation & deforestation alter the habitats of disease-carrying insects and animals
• Changing human behaviors, such as intravenous drug use and risky sexual behavior
• Increased use of antimicrobial agents and pesticides hastens the development of drug resistance
Pandemics
A pandemic is an epidemic that crosses international boundaries and affects
large numbers of people over a wide area of the world.
HIV / AIDS is an example and influenza threatens to reach pandemic proportions.
Some History:
The great “Spanish flu” influenza pandemic of 1918-1919 killed between 20 and 40
million people The movements of people after the war helped spread the virus.
The Spanish flu may be the most devastating pandemic in history, although the
Black Death (c.1342) killed a higher proportion of the population.
The world is preparing for a new influenza pandemic.
The minor SARS outbreak in Toronto gave us
a hint of how devastating the impact will likely be.
Although the term ‘pandemic’ is usually reserved
for communicable diseases, do you think there
may be merit in applying it to other health
issues: obesity; poverty?
Medical Advances
Medical developments such as vaccination, antisepsis, antibiotics, high-risk
obstetrics... have all
profoundly affected patterns of morbidity and mortality.
However, be aware that most actions of doctors help patients who already have
an illness, rather than alter the underlying pattern of illness in the population.
The basic determinants of health and illness lie outside of medicine and include
factors like sanitation, work environment, poverty, war, etc. Some of these are
addressed by public health, which is often supported by legislation.
1200
Death rates (per million) from Measles, in children < 15
England & Wales, 1850-1975
1000
800
600
Immunization
began
400
200
0
18
50
18
60
18
70
18
80
18
90
19
00
19
10
19
20
19
30
19
40
19
50
19
60
19
70
The impact of public
health (rather than clinical
medicine) is seen in the
decline of diseases
such as measles or
tuberculosis, which
were largely eliminated
before the development
of effective immunization
1400
Prevention Stories
Preventing health problems before they arise may seem unexciting work for a physician,
but it makes practical sense, economic sense, and moral sense. Some examples:
The decline in motor vehicle collisions has been a major Canadian success story:
Dental Caries
Following fluoridation of
the water supply, dental
caries have declined by
over half.
So, what can doctors do to contribute to such efforts?
Immunization
Immunization counts as one of the greatest achievements of medicine.
In terms of lives saved, there is no rival.
Compare the pre-immunization era to today. For the USA:
In 1921, diphtheria caused 207,000 deaths. In 1997, only 5
In 1941, measles caused 894,000 deaths. In 1997, 135.
In 1952, polio caused 21,000 deaths; in 1997, there were none.
And the list goes on...
Do you think that people should have the right to
refuse immunization?
So the health care system (including
public health) is critically important,
even if by no means the only
influence on health patterns.
How healthy is our health care
system?
Health Manpower
Physicians per 100,000 population, Ontario, 1995-2005
In the early 1990s the
Ontario government
reduced enrolment in
medical schools and
residency programmes.
190
185
180
175
170
165
160
1995
1996
1997
1998
1999
2000
On the left of the diagram, MD supply was not
keeping pace with the growing population
2001
2002
2003
2004
2005
Belgium has twice as many
physicians per 1000
population as Canada.
Canada is also lower
than the US, Australia and
UK . Why?
Here, increased medical school
capacity began to pay off
Increased medical school enrolment means that the number of Ontario physicians is
growing slowly. It is keeping pace with the population growth, BUT ...
- the aging of the population will imply increased demand for care
- the average age of doctors has risen by 10 years since 1995; many will retire soon
- new doctors do not work as long hours as in the past (a growing % are women who
have other responsibilities)
Annual gains & losses in staff
1. Migration of Physicians between Canada & U.S., 1996 - 2006
400
200
0
Left
Returned
-200
-400
Net
-600
-800
1996
1998
2000
2002
2004
2006
2. Nurses in Ontario, 1998 - 2007
1500
1000
500
0
-500
-1000
1998
2000
2002
2004
2006
Health Care Costs
Ontario total government expenditures in 2002 were $83.9 billion;
Health care expenditures $32.8B (39%)
Largest cost component was hospitals, at $14.8B (45% of health budget)
Physician services cost about $7B (21%)
Fastest growth in cost in recent years is for drugs: double digit growth rates
Figures for
Canada
(billions of $)
Will throwing money at it help?
Expenditures & Health Outcomes
The link between national
health care spending
and level of health is
curvilinear.
Among poor countries,
expenditures quickly
reduce infant mortality
and this greatly extends
average life expectancy.
But once infant mortality is
low, increasing expenditures
have less effect.
Compare Cuba with the US.
How does Cuba do it?
Is life expectancy the best health
indicator? What would you suggest?
So, will paying doctors more make them work harder,
or will they say “Thanks!” and go play golf?
Primary Care:
Percentage of all Family Physicians
accepting new patients, Ontario 2007
%
45
40
35
30
25
20
15
10
5
0
38.4
36.3
31.7
20.2
16.5
11.5
9.6
10
2000 2001 2002 2003 2004 2005 2006 2007
Source: College of Physicians and Surgeons of Ontario. MD Dialogue, April, 2008
Conclusions
The curative role of medicine will always form the central core of the profession.
But we can predict quite accurately which people will get sick,
what it will cost to treat them, and how their disease could be prevented.
So, it makes sense to prevent,
especially where we cannot cure.
Many of the diseases people suffer from are brought on by a combination of
personal behaviours, environmental conditions, poverty and ignorance.
These are not strictly speaking “medical” issues, so we must debate
how far doctors should get involved in tackling these challenges.
Does the public have a right to expect that you, as a doctor, should devote
your time to helping patients, and society, address such problems?
How broad should be the mandate of the physician in contemporary Canada?