Like many governments, the new PEI government now have access to the books and they are likely appalled at the trends behind the healthcare costs. These costs are growing exponentially and will in a few years, drain resources from all other sectors.
That is why they have hired a consultant to look for ways to save money. But I fear that at best, the will find peanuts.
The real issue is to ask the real question. The real question is this: What are the assumptions and hence drivers for the costs? Who are the groups that drive the costs? What are the results on the health of Islanders by what we do?
Here are some quick answers that in themselves offers a direction for policies that may have a chance of reducing the burden.
There are three groups of people that drive most of the costs and of course they are related.
- About 30% of Islanders drive more than 60% of the costs. They drive costs all their lives and as they get older they drive even more
- As we get to 65 our use of the system explodes
- Finally the costs balloon for most Islanders in the last 2 years of life - often exceeding the entire prior lifetime cost per person
What is going on and what can we do about this?
The 30% - This is a modest estimate - are that group of people who also enter school at grade 1 unable to cope, behave and read. They have been wired for helplessness. The critical problem for them that causes a lifetime of health problems is their immune system. If you grow up believing that you have no control in your life, your flight or fight stress process works all the time flooding your body with cortisol. It is this that weakens and finally compromises your immune system.
This is true in all primates.
All of these people are likely to have heart heart disease, diabetes. They will tend to have addictions.
- Impaired cognitive performance
- Suppressed thyroid function
- Blood sugar imbalances such as hyperglycemia
- Decreased bone density
- Decrease in muscle tissue
- Higher blood pressure
- Lowered immunity and inflammatory responses in the body, slowed wound healing, and other health consequences
- Increased abdominal fat, which is associated with a greater amount of health problems than fat deposited in other areas of the body. Some of the health problems associated with increased stomach fat are heart attacks, strokes, the development of , higher levels of “bad” cholesterol (LDL) and lower levels of “good” cholesterol (HDL), which can lead to other health problems!
As this group get older, more and more breakdowns occur and the more ill they become. Their illnesses are chronic and drive huge amounts of healthcare costs.
These people cannot be "cured". The cannot be cured because the cause of their illness is not curable by a pill or by medical treatment. It is driven by their mindset and that is driven by their perceived place in the world. That was largely set in the first 3 years of life.
Everything we do today is "downstream" from the real causes of the problem. To have a chance at helping and also reducing our costs, we have to work in a new way. We have to make the early years a larger focus and we have to look at what does work to help people deal with the underlying cause of their problems.
As AA have shown, and as we are learning with PTSD in the military, the problem is spiritual and can only be remediated by peers acting in groups to provide the support that is required. The actual medication should only be a small part of this process. What works the best is when people are connected to others like them in a safe environment, where they are not judged and where they can help each other.
So what then about the inevitability about as we age, we use more healthcare resources?
Many seniors seem to be walking pharmacies. Are they ill and do all these pills work? What is going on?
First of all, a lot of the pill rolling is new and has been growing exponentially in the last decade. It is rooted in the system that we have. A doctor can only offer less that 10 minutes of her time to a patient. What many of the older patients need is attention. So to make them feel heard, they are given a prescription.
It will be vital to look at the reality of a doctor's world and the incentives that are part of it if we are to make a difference and to give the doctor a life too. They have had to disconnect from their patient and rely on the drug companies. Their costs are so high that they have no alternative.
If I was the Minister I would be making an analysis of the doctor's drivers a critical part of the work.
Secondly, the drug companies have made their fortune in lifestyle drugs. Most of this is based on a bogus idea that you ca cure high blood pressure, high levels of cholesterol etc that are all factors that increase the risk of us dying.
We all know that high levels of cholesterol are bad for us don't we? We in truth there is no correlation between these levels and death. You don't believe me - your doctor doesn't believe me.
This chart is unambiguous. It shows the relative rates of death in the UK civil service for Coronary Heart Disease. On the left are the most senior people - on the right the least. See that there is a gradient. If you are a deputy minister, you will live much longer.
Look at the right hand column. You will see that there are levels of cholesterol, blood pressure, smoking etc but that the largest factor in "unexplained".
We it is unexplained no longer. Sir Michael Marmot's research is now well known in public health circles - but maybe not on PEI!
Here is Sir Michael in a 58 minute interview making all of this more clear than I ever could. 26.55 is where Marmot goes into detail of the Whitehall study - the most important experiment in health ever undertaken.
Again, it is a gradient of social hierarchy that drives health outcomes. The more control you have, the longer you will live. The traditional health markers are merely guides to the upstream issue of the immune system and how this is affected by the stress of having low control.
If you are interested here is a link to PBS's series on this perspective of health based on Marmot's work and located in Louisville KY where the public health folks are using this knowledge to make a difference.
All the risk factors that the drug companies offer us solutions for are merely indicators of a deeper problem - lack of connection and meaning in our lives. These medications merely costs a lot.
The great malaise of getting older is the risk of losing our identity and meaning. This is especially true for men who have made their work their life.
As in the early years, the real "Cure" is re-connection with others and to being able to make a difference.
Finally we come to the hardest part of all. End of life.
What ever we spend in our lifetime, whether we have been a heavy or a light user of the system, we spend it twice in the last 2 years of life. This is where most of the cost of the system is to be found.
So if we are serious about reducing the trajectory of health costs - we have to look here as the population ages.
Why do we spend all this money in this fruitless exercise of trying to cure death itself?
I think it is because we have indeed made death an "illness" that we should be able to cure.
Again we have separated the spiritual from the physical as we have with all modern medicine. We deny our aging and we deny our death. Families with a dying parent often pretend that their dad will get better and so never talk about the things that they really need to. Their father, afraid and isolated because no one will be straight plays along and hangs on.
So the family and the doctors do anything and everything to keep dad alive a for a few more months. I recall sitting by the bed of an aunt. She was in a coma, two nurses were arguing about how best to attach yet more equipment to her. Her daughter had been creating scenes with the staff telling them that they had not done enough. So her mum died not being held by her daughter telling her how much she loved her but isolated in ICU connected not to the people she loved but to machines. The voices she heard were angry ones of strangers.
This kind of death happens all the time. We are too afraid to accept death - we have made death a failure when it is the inevitable. We have made it into a machine event, when it is surely the most spiritual event of our lives - it is when our lives should have the most meaning.
This is where Hospice enters the picture. Hospice is about dying well. Dying well for all involved. It is on the fringes of the system now but I think needs to be placed in the centre.
There is going to be a revolution in healthcare similar to the one that took place 140 years ago when we learned about germs.
We are learning that the key to most illness is not the disease itself but the immune system. A healthy immune system can fight off most things. A compromised immune system actually makes us ill.
The key to a healthy immune system is to live in a healthy environment. This means less one that is clean etc. Less that we eat the right things and take exercise.
This is a healthy environment. It is where the young are loved up and cared for by a trusting group. It is where the mothers are loved up and cared for a by a trusting group. It is where the adults care for each other.
We are primates. Our immune system is driven by our social environment.
What then could we do on PEI in practical terms to ensure that most Islanders had a healthy life and that this did not cost too much.
The first step for a province is to look not at individuals but to look at what affects populations. Policy can affect populations and groups. Therefore there is the potential of doing something if we take this view.
For the price of reading my blog - a lot less than $300,000 I will talk about this over the next few weeks.
But the one lesson for today - any savings you find by looking at how to make the current system more efficient are chicken shit and will do nothing to help us avoid the crisis that is coming.
Inequalities in Health
Michael Marmot, Ph.D. / New England Journal of Medicine, v.345, n.2 12jul01
Michael Marmot, Ph.D., University College London, London WCIE 6BT, United Kingdom
WALK the slums of Dhaka, in Bangladesh, or Accra, in Ghana, and it is not difficult to see how the urban environment of poor countries could be responsible for bad health. Walk north from Manhattan's museum district to Harlem, or east from London's financial district to its old East End, and you will be struck by the contrast between rich and poor, existing cheek by jowl. It is less immediately obvious why there should be health differences between rich and poor areas of the same city. It is even less obvious, from casual inspection of the physical environment, why life expectancy for young black men in Harlem should be less than in Bangladesh.1
Geographic variations in health within rich countries arc substantial. White men in the 10 "healthiest" counties in the United States have a life expectancy above 76.4 years. Black men in the 10 least healthy counties have a life expectancy of 61 years in Philadelphia, 60 in Baltimore and New York, and 57.9 in the District of Columbia.2 The 20-year gap in life expectancy between whites in the healthiest counties and blacks in the least healthy is as big as differences between countries at very different stages of economic development. The best off are like Japan; the worst off hover around the level of Kazakhstan and Bangladesh.3 The low life expectancy in poor countries may be the result of starvation, infected water, and poor sanitation. The low life expectancy of people who live in poor areas within rich countries is not. The major contributors to excess deaths among men in Harlem are circulatory disease, homicide, and infection with the human immunodeficiency virus.4
Does the social environment have a role in generating differences in health between residential areas? Is health status worse in poor areas because poor people live there, or are there features of the environment that might predict ill health over and above the socioeconomic characteristics of the residents?5 In this issue of the Journal, Diez Roux and colleagues suggest that the answer to both questions is yes.6 These investigators show that individual socioeconomic characteristics, particularly income, are related to the incidence of coronary heart disease, with poorer people having a greater incidence of disease. In addition, they divided neighborhoods into groups on the basis of household income and other socioeconomic characteristics, separately for blacks and whites. Among whites, as among blacks, the worse off the neighborhood, the higher the incidence of coronary heart disease. By bringing together two levels of analysis communities and individual residents - Diez Roux et al. show that socioeconomic characteristics of communities, in addition to individual characteristics such as income, education, and occupation, are related to the incidence of coronary events.
Is poverty at the root of the associations between ill health and the socioeconomic characteristics of both individuals and neighborhoods? The relation is not that simple. There are poor countries that achieve good health at low cost. Life expectancy in China, Sri Lanka, and Kerala (a sizable state in southern India) exceeds 70 years, despite their having gross national products in 1994 of less than $1,000 per capita.7 Contrast this with Harlem, where there was a median family income in 1990 of $24,174 yet a probability of only 37 percent that a black man would survive from the age of 15 years to 65 (as compared with the U.S. average of 77 percent for white men ).4 Poor people in the United States are rich by world standards, but they have worse health than the average in some poor countries.
Poverty is more complex than simply a lack of money. According to Diez Roux et al., the most affluent group of black neighborhoods (containing approximately a third of the black study subjects) had about the same median household income as the worst-off group of white neighborhoods. The worst-off-whites had a higher incidence of coronary events than the best-off blacks. Yet for both blacks and whites, there was a social gradient in the incidence of coronary events: the worse off the neighborhood, the higher the incidence. Thus, inequalities in health are not confined to poor health among the most deprived. Studies by my colleagues and me of British civil servants, known as the Whitehall studies,8,9 demonstrated that among white-collar workers, none of whom were poor by any usual standard, mortality and morbidity followed a social gradient -with higher rates as the social hierarchy was descended. The lower the grade of employment, the higher the mortality from coronary heart disease, from all causes, and from most other major causes of death.
We have, then, to explain not only why the poorest members of rich societies have higher rates of disease, but also why health follows a social gradient. It is all too easy to assume that either advances in understanding of the molecular basis of disease or broader access to higher-quality medical care will solve the problem of disparities in health. This is unlikely. In the United States, as in Britain,10 the magnitude of the gap in health has increased - that is, the slope of the relation between education and mortality has grown steeper" and the advantage of healthy counties in terms of mortality has widened.2 Whatever hypothesized genetic factor may be conjured up to explain the plight of people in disadvantaged circumstances, it could not have changed in a few years. If research on the genome is to help us understand inequalities in health, it will have to clarify how genes interact with environmental influences.
What of differences in medical care? One oft-cited comparison is that the social gradient in mortality is similar in Britain, where there is a National Health Service, and the United States, which is without one. Universal provision of health care may still hide differences in access and utilization. The fact that there are socioeconomic differences in medical care does not mean that these are the cause of differences in morbidity and mortality.
Health might also be a determinant of social position, rather than the reverse. For this factor to account for differences between neighborhoods, it would have to be argued that sicker people migrate to poorer neighborhoods - something that is plausible, but unlikely to be the primary explanation.
The usual explanation for inequalities in health is lifestyle. There are clear socioeconomic differences in smoking and other unhealthy types of behavior that are risk factors for coronary artery disease. Yet controlling for these factors had little effect on the socioeconomic differences in coronary heart disease in the study by Diez Roux et al. The first Whitehall study of British civil servants had a similar finding.2 Something in addition to socioeconomic differences in smoking, physical activity, hypertension, diabetes, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and body-mass index must be responsible for the differences in the incidence of heart disease.
The extent to which inequalities in health are the result of material or psychosocial factors is also uncertain.12,13 We do not know the extent to which social circumstances influence disease pathways through exposure to physical, chemical, and biologic agents, or through the mind. My own view is that the mind is a crucial gateway through which social influences affect physiology to cause disease. The mind may work through effects on health-related behavior, such as smoking, eating, drinking, physical activity, or risk taking, or it may act through effects on neuroendocrine or immune mechanisms.14
There is evidence to support this view. In the Whitehall II study, for example, we examined a psychosocial characteristic of work, termed "low control" - meaning that an individual worker had little control over his or her daily activities in the workplace. We showed that it was an important predictor of the risk of cardiovascular disease and that it had an important role in accounting for the social gradient in coronary heart disease and depression.9, 15 Looking outside work, we also showed that people who reported feeling low control at home and over life circumstances in general had an increased risk of depression; this was particularly apparent among women in low-status jobs.16
Psychosocial factors might also apply to communities. Living in a disadvantaged community may be bad for health because of lack of access to amenities, which in turn may affect access to healthful foods, to opportunities for physical activity, and to medical and other services. In addition, insecurity, fear of crime, suffering from the effects of a low position in the socioeconomic hierarchy, and lack of social support are all features of disadvantaged communities that might increase inequalities in health.
Describing the social gradient in morbidity and mortality in terms of "inequality" draws attention to the fact that death and illness are related to social inequalities. Perhaps this is why a conservative government in Britain in the early 1990s abolished the term "inequalities" in health and replaced it by the blander "variations." One of the first things a Labour government did in Britain was to restore "health inequalities" to the language and to the health agenda and to ask what could be done about them.10 In the United States, the subject has become known as "health disparities." As research develops, it will become important to ask the question of how an understanding of health disparities might help correct some of the problems of deep-seated social inequalities. The findings of Diez Roux et al. suggest two potential targets of intervention: enhancing the social and psychological resources of individual people, and improving the duality of neighborhoods and communal life.
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2. Murray CJL, Michaud MC, McKenna M, Marks J. U.S. patterns of mortality by county and race: 1965-1994. Cambridge, Mass.: Harvard Center for Population and Development Studies, 1998:1-97.
3. -the World Bank. World Development Report 1999/2000. New York: Oxford University Press, 2000.
4. Geronimus Ni" Bound J, Waidmann TA, Hillemeier MM, Burns I'11.
Excess mortality among blacks arm whites in the United States. N Engl J Med 1996,335:1552-8.
5. MacIntyre S, Maciver S, Sooman A. Area, class and health: should we be focusing on places or people? J Soc Policy 1993;22:213-34.
6. Diez Roux AV, Stein Merkin S, Arnett D, et al. Neighborhood of residence and incidence of coronary heart disease. N Engl J Med 2001;345:99 106.
7. Sen AK. Development as freedom. New York: Knopf, 1999.
8. Marmot MG, Shipley MJ, Rose G. Inequalities in death - specific explanations of a general pattern? Lancet 1984;1:1003-6.
9. Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 1997;350:235-9.
10. Acheson D. Independent inquiry into inequalities in health report. London: The Stationery Office, 1998.
11. Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med 1993;329:103-9. (Erratum, N Engl J Med 1993;329: 1139.
12. Lynch JW, Davey Smith G, Kaplan GA, House JS. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ 2000;320:1200-4.
13. Marmot M, Wilkinson RG. Psychosocial and material pathways in the relation between income and health: a response to Lynch et al. BMJ 2001; 322:1233-6.
14. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med 1998;338:171-9.
15. Stansfeld SA, Head J, Marmot MG. Explaining social class differences in depression and well-being. Soc Psychiatry Psychiatr Epidemiol 1998;33. 1 9.
16. Griffin JM, Fuhrer R, Stansfeld SA, Marmot MG. The importance of low control at work and home on depression and anxiety: do these vary by gender and class? Soc Sci Med (in press).
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