The Health of Canadians – The Federal Role
Final Report
Volume Six: Recommendations for Reform
PART VI:
HEALTH PROMOTION AND DISEASE PREVENTION
CHAPTER THIRTEEN
Healthy Public Policy: Health Beyond Health Care
As the Committee has noted in Volume One, it is clear that the health care system is an important contributor to good health.
Services as
widely varied as childhood immunization, medications to reduce high blood
pressure or prevent asthma, and heart surgery all contribute to health and
well-being. In fact, the Canadian
Institute for Advanced Research estimates that 25% of the health of the
population is attributable to the health care system alone (see Chart 13.1).[1]
Obviously, it is important that the health care sector is fiscally
sustainable and continually strives to provide timely services of high
quality. Many of the
recommendations made by the Committee in this report are designed specifically
to achieve sustainability, timeliness, quality and efficiency in health care
delivery, all with the objective of improving the health and well-being of
Canadians.
The remaining 75% of the health of the Canadian population
is determined by a multiplicity of factors outside the health care system.
These factors, which are often referred to as the “non-medical
determinants of health,” include: biology and genetic endowment; income and
social support; education and literacy; employment and working conditions;
physical environment; personal health practices and skills; early childhood
development; gender; and culture.
Throughout its study, the Committee was told repeatedly that, to maintain and improve health status, governments should, in addition to sustaining a good health care system, develop public policies and programs that address these non-medical determinants of health. Such policies and programs encompass a wide spectrum of interrelated activities, ranging from health and wellness promotion, through illness and injury prevention and public health and health protection, to broader population health strategies. These are all components of a healthy public policy:
· Health and Wellness Promotion: these activities are designed to encourage Canadians to take a more active role in improving their health through, for example, exercise and healthy food and lifestyle choices.
· Illness and Injury Prevention: consists of activities directed toward decreasing the probability of individuals, families and communities contracting specific diseases and injuries. Prevention activities seek to reduce unwanted health outcomes by reducing or eliminating associated risk factors. Immunization, early detection of disease through screening programs and reduction of exposure to potentially injurious activities (use of seat belts in the car, fences around pools, safer roads, etc.) are examples of illness and injury prevention.
· Public Health and Health Protection: are intended to protect the health of Canadians against current and emerging health threats. This includes the surveillance and control of disease outbreaks and trends (in both infectious and chronic illnesses) and the monitoring of safety and effectiveness of a variety of products (such as food, drugs and medical devices), as well as environmental health assessments.
· Population Health Strategies: include a wide range of government policies and programs that can influence income redistribution, access to education, housing, water quality, workplace safety, and so on – all major determinants of the health of a population.
· Healthy Public Policy: is a concept that encompasses health and wellness promotion, disease and injury prevention, public health and health protection, as well as population health. Under a healthy public policy strategy, every major action, program and policy of government is evaluated in terms of its implications for the health of Canadians. Healthy public policy requires an intersectoral approach – one that engages the several sectors that are responsible for, or affect, each of the determinants of health.
There is increasing evidence that investing more human and financial resources in promotion, prevention, protection and population health can significantly improve the health outcomes for a given population. In the end, this can reduce the demand for health services and the pressures on the publicly funded health care system.
The Committee was told and is aware, however, that promotion, prevention, protection and population health activities do not claim anything like the close focus and high status that health care has in the eyes of the Canadian public and, obviously, public policy decision makers. Although it is clear that, collectively, the non-medical determinants of health have far greater impact on the health of the population than health care, the fact is that the very positive outcomes from promotion, prevention, protection and population health activities are generally visible only over the longer term, and thus they are less newsworthy. Because they are less likely to capture the attention of the general public, they are less attractive politically.
The focus on wellness was recently addressed by the Government of Newfoundland and Labrador in its five-year strategic health plan. The first goal of this plan incorporates a wellness strategy built on health promotion, illness and injury prevention, health protection and early child development.[2] The Committee applauds such initiative.
The Committee strongly supports the opinion of many witnesses that additional funding in these fields is essential for Canada to develop healthy public policies that focus on improving the health and well-being of the population, rather than concentrating only on curing people when they get sick. Moreover, the Committee believes that the federal government can and must play a leadership role in this area.
In this chapter, the Committee sets out its findings and recommendations with respect to the role of the federal government in promoting healthy public policies. Section 13.1 provides information on trends in disease and injury in Canada. Section 13.2 presents data on the economic burden of disease and injury. Section 13.3 discusses the need for a national chronic disease prevention strategy. Section 13.4 examines the concerns raised with respect to public health, health protection and health and wellness promotion. Section 13.5 discusses the broader context of the determinants of health, and highlights the possibilities of moving toward healthy public policy in Canada.
13.1 Trends in Diseases[3]
During the twentieth century, the application of new knowledge and technology in two key areas – public health (through the provision of clean water and sanitation) and health care – has significantly altered the pattern of disease. The causes of mortality have shifted away from acute, infectious diseases to non-communicable (chronic) diseases (see Table 13.1).
Chronic diseases, such as cancer and cardiovascular disease, are now the leading causes of death and disability in Canada, with accidental injuries the third most common. However, some infectious diseases once thought conquered – such as tuberculosis – are re-emerging as the infectious agents that cause them have developed resistance to antibiotics. Rapid international transport of foods and people also increases the opportunities for the spread of infectious diseases.
TABLE 13.1
LEADING CAUSES OF DEATH (AGE-STANDARDIZED)
Rate per 100,000
|
1921-25 Cardiovascular
and renal disease Influenza,
bronchitis and pneumonia Diseases
of early infancy Tuberculosis Cancer Gastritis,
duodenitis, enteritis and colitis Accidents Communicable
diseases All causes |
221.9 141.1 111.0 85.1 75.9 72.2 51.5 47.1 1,030.0 |
|
1996-97 Cardiovascular diseases (heart disease and stroke) Cancer Chronic obstructive pulmonary diseases Unintentional injuries Pneumonia and influenza Diabetes mellitus Hereditary/degenerative diseases of the central nervous system Diseases of the arteries, arterioles and capillaries All
causes |
240.2 184.8 28.4 27.7 22.1 16.7 14.7 14.3 654.4 |
Source: Susan Crompton, “100 Years
of Health”, Canadian Social Trends, Statistics Canada, Catalogue
11-008, No. 59, Winter 2000, p. 13.
13.1.1 Infectious diseases
In the early 1920s, heart and kidney diseases were the leading causes of death, followed by influenza, bronchitis and pneumonia, and diseases of early infancy. Tuberculosis took more lives than cancer. Intestinal illnesses such as gastritis, enteritis and colitis, and communicable diseases such as diphtheria, measles, whooping cough and scarlet fever, were also common causes of death.
Public health programs, combined with the large-scale introduction of vaccines and antibiotics, have led to a major shift in the pattern of diseases, with a move away from infectious diseases to chronic diseases. Many infectious diseases persist, however. Indeed, Dr. Paul Gully, Director General at the Centre for Infectious Disease Prevention and Control (Health Canada), told the Committee that the death rate from infectious diseases in Canada has increased since 1980.[4] He pointed to seven infectious disease trends that, in his view, threaten Canadians:
· Many infectious diseases, such as AIDS and hepatitis C, persist;
· There are new and emerging infectious disease threats, including mad cow disease and E. coli, as well as the West Nile Virus;
· Global travel and migration can quickly introduce new diseases into the population;
· Environmental changes, such as global warming, deforestation, and tainted water, may increase the spread of infections;
· Behavioural changes, particularly high-risk sexual practices and drug use, can foster the spread of HIV and other infectious diseases;
· Public resistance to immunization could cause a resurgence in, for example, polio and measles;
· Anti-microbial resistance in infectious organisms may reduce the effectiveness of traditional curative measures, such as antibiotics.[5]
13.1.2 Chronic diseases
According to the National Population Health Survey, in 1998-1999, more than half of all Canadians, or 16 million people, reported suffering from a chronic condition. The most common were allergies, asthma, arthritis, back problems, and high blood pressure.[6]
Cardiovascular disease is the leading cause of death in Canada, accounting for 37% of all deaths. Mortality from cardiovascular disease has been declining in Canada since 1970 among both men and women, although more slowly in women. Cancer in its major forms is the second-leading cause of death and is the leading cause of potential years of life lost[7] before age 70 (accounting for over one-third of all potential years of life lost). Cancer is primarily a disease of older Canadians; 70% of new cancer cases and 83% of deaths due to cancer occur among those who are 60 or older. Death rates from cancer have declined slowly for men since 1990, but have remained relatively stable among women over the same period. However, lung cancer rates for women are now four times higher than they were in 1971.
13.1.3 Injury
In 1995-1996, injuries accounted for 217,000 hospital admissions in Canada. By far the highest rates of hospital admissions due to injuries were among Canadians over the age of 65. Falls remain an important cause of injury among seniors and children under 12. Among children, poisoning was the next most important cause of injury-related admission to hospital in 1996. For adolescents and adults under the age of 65, motor vehicle accidents constituted the second most important cause. The vast majority of injuries are accidental (about 66%).[8]
13.1.4 Mental health
The National Population Health Survey of 1994-1995 found that approximately 29% of Canadians experienced a high level of stress; 6% of Canadians felt depressed; 16% of Canadians reported that their lives were adversely affected by stress; and 9% had some cognitive impairment such as difficulties thinking and remembering. Work prepared for the Federal/Provincial/Territorial Advisory Network on Mental Health estimated that about 3% of Canadians suffer from severe and chronic mental disorders that can cause serious functional limitations and social and economic impairment, such as bipolar personality and schizophrenia. This translates into approximately one in every 35 Canadians over 15 years of age.[9]
Mental stress and disorders leading to mental illness can strike at different periods in life. Autism, behavioural problems and attention deficit disorder most commonly affect children. Adolescence is the typical onset of eating disorders and schizophrenia. Adulthood is a time when depression may manifest itself more obviously. Senior years are marred by Alzheimer’s and other forms of dementia, although depression is also often identified in the elderly.
Because of the importance of mental health among Canadians, the Committee will hold specific hearings and table a separate report to present its findings and recommendations to the federal government.
13.2 The Economic Burden of Illness
The only available estimates on the economic burden of illness and injury in Canada were published in 1997 by Health Canada; they apply to 1993. That year, the total cost of illness and injury was estimated to be $156.9 billion, or 22% of GDP. Direct costs (such as hospital care, physician services and health research) amounted to $71.7 billion, while indirect costs (such as lost productivity) accounted for $85.1 billion.
As Table 13.2 shows, the diagnostic categories with the highest total costs were cardiovascular diseases ($19.7 billion or 15.3% of total costs), musculoskeletal diseases ($17.8 billion or 13.8%), injuries ($14.3 billion or 11.1%), cancer ($13.1 billion or 10.1%), respiratory diseases ($12.2 billion or 9.4%), diseases of the nervous system ($9.6 billion or 7.4%), and mental illness ($7.8 billion or 6%). Infectious diseases accounted for 2.0% of the total economic burden of illness ($2.6 billion).
TABLE 13.2
ECONOMIC BURDEN OF ILLNESS BY DIAGNOSTIC CATEGORY, 1993
(In Millions of Dollars)
|
|
DIRECT COSTS1 |
INDIRECT COSTS |
TOTAL COST |
|||
|
|
Percent |
Cost |
Percent |
Cost |
Percent |
Cost |
|
Infectious/Parasitic Cancer Endocrine/Related Blood Diseases Mental Disorders Nervous System/Sense Cardiovascular Respiratory Digestive Genitourinary Pregnancy Skin/Related Musculoskeletal Birth Defects Perinatal Conditions Ill-defined Conditions Injuries Well-Patient Care Other |
1.8 7.3 3.0 0.6 11.4 5.1 16.7 8.6 7.5 5.1 4.6 2.0 5.6 0.7 1.2 4.2 7.1 6.2 1.2 |
786 3,222 1,334 274 5,051 2,252 7,354 3,787 3,326 2,248 2,025 892 2,460 305 551 1,851 3,122 2,741 549 |
2.2 11.6 2.5 0.2 3.3 8.6 14.5 9.9 3.4 0.9 0.8 0.1 18.0 0.4 0.4 3.0 13.2 0.0 7.1 |
1,857 9,845 2,086 173 2,787 7,321 12,368 8,393 2,920 786 690 122 15,328 334 332 2,517 11,222 0 6,040 |
2.0 10.1 2.6 0.3 6.1 7.4 15.3 9.4 4.8 2.3 2.1 0.8 13.8 0.5 0.7 3.4 11.1 2.1 5.1 |
2,643 13,067 3,419 447 7,839 9,573 19,722 12,181 6,247 3,034 2,715 1,014 17,788 639 883 4,368 14,343 2,741 6,589 |
|
TOTAL |
100.0 |
44,130 |
100.0 |
85,123 |
100.0 |
129,253 |
A total of $27.6 billion in direct
costs were not classifiable by diagnostic category.
Source: Laboratory Centre for Disease Control (Health Canada), Economic
Burden of Illness in Canada, 1993. 1997, pp. 10-11.
13.3 The Need for a National Chronic Disease Prevention Strategy
These statistics suggest that chronic diseases are not only the leading cause of death and disability in Canada but account for the largest proportion of the economic burden of illness. Moreover, information given to the Committee indicates that about two-thirds of total deaths in Canada are due to the following chronic diseases: cardiovascular disease (heart and stroke), cancer, chronic obstructive lung disease (bronchitis and emphysema) and diabetes.[10] More specifically:
· Cardiovascular diseases, including coronary artery disease and stroke, are responsible for 38% of all deaths among Canadians each year, and are one of the leading reasons for hospitalization.
· Cancer is the second most important cause of death in Canada, responsible for 29% of all deaths each year, and accounting for almost one third of potential years of life lost.
· Chronic obstructive lung disease is the fifth most common cause of death in Canada and is the only cause of death that is increasing in prevalence. Asthma is the most common chronic respiratory disease of children; it is the leading cause of hospital admission and school absenteeism among children in Canada.
· Over one million Canadians live with diabetes. It is a major cause of coronary heart disease and a leading cause of blindness and limb amputations. Among Aboriginal Canadians, the prevalence of diabetes is three times as high as among other Canadians. In total, diabetes accounts annually for about 25,000 potential years of life lost.
During its study, the Committee was told repeatedly that most chronic diseases are entirely preventable. Moreover, a report prepared by Terrence Sullivan, Vice President and Head, Division of Preventive Oncology, Cancer Care Ontario, indicates that many chronic diseases – particularly cardiovascular disease, cancer, chronic obstructive lung disease and diabetes – share common causes. More specifically, poor diet, lack of exercise, smoking, stress and excessive alcohol intake – all lifestyle issues – are recognized as the leading social/behavioural risk factors for these diseases. These risk factors are also often associated with other physical and physiological states that elevate the risk of chronic disease – including overweight/obesity, high blood pressure/hypertension, high blood cholesterol/-hypercholesterolemia, and glucose intolerance/diabetes.[11] If reduced or eliminated, these common lifestyle risk factors would greatly lessen the prevalence and economic burden of these chronic diseases.
The fact that the vast majority of Canadians are exposed to one or more of these common risk factors[12] suggests that the overall health status of the population could be substantially improved by a stronger focus on chronic disease prevention, in parallel with controlling infectious diseases. In recognition of this fact and the potential for joint action, major national health organizations (Canadian Cancer Society, Canadian Diabetes Association, Heart and Stroke Foundation of Canada, Canadian Council for Tobacco Control, Coalition for Active Living, and Dieticians of Canada) have recently come together with Health Canada to form the Chronic Disease Prevention Alliance of Canada (CDPAC).
In addition to this new strategic alliance, there are also several important nation-wide chronic disease initiatives, such as: the Canadian Diabetes Strategy, Canadian Heart Health Initiative, Canadian Cardiovascular Disease Action Plan, Canadian Strategy for Cancer Control, and many other federal/provincial/territorial joint initiatives.
However, the Committee was told that there is a need to integrate, coordinate and strengthen all these diverse initiatives into a national chronic disease prevention strategy. According to Sullivan, Canada should build from the knowledge, success and failure of the existing initiatives to push the agenda forward with renewed vigour.[13]
In addition to better integration of the various current initiatives, there is a need for:
· Increased federal leadership, including political leadership and sustained financial and human resources.
· Development of a common vision across all the major chronic disease organizations, leading to a set of specific goals and objectives.
· Partnerships with the provinces/territories and stakeholders in private sector and non-government organizations.
· Surveillance systems for chronic disease and associated risk factors that will also track progress toward the attainment of strategic goals.
· Greater investment in prevention initiatives that are tailored to regional differences.
The national chronic disease prevention strategy should incorporate a combination of public education efforts, mass media programs and policy interventions. These interventions should be implemented through multiple settings (primary health care, education system, workplace, community) and address the need of various priority populations (e.g., Aboriginal Canadians, rural communities, women, etc.).
The direct benefits of a national chronic disease prevention strategy would be substantial, encompassing the avoidance of unnecessary premature disease, enhanced population health status, improved productivity and reduced health care costs. Estimates are that over a ten year period the decreased health care costs resulting from reduced utilization of hospital and doctor services could be as much as 10%.[14]
The Committee agrees with many witnesses that now is the time for the federal government to lead a national initiative to reduce the prevalence and economic burden of chronic disease in Canada. In our view, the federal government is particularly well suited to assume such leadership, given its long-standing role in health promotion and disease prevention and its legislative authority with respect to health surveillance and health protection.
While we feel that the federal government must act as a leader, it is important to collaborate with provincial/territorial governments, the private sector, and voluntary health sector partners – if we are to effect the needed changes. Therefore, the Committee recommends that:
The federal government, in collaboration with the provinces and territories and in consultation with major stakeholders (including the Chronic Disease Prevention Alliance of Canada), implement a National Chronic Disease Prevention Strategy.
The National Chronic Disease Prevention Strategy build on current initiatives through better integration and coordination.
The federal government contribute $125 million annually to the National Chronic Disease Prevention Strategy.
Specific goals and objectives should be set under the National Chronic Disease Prevention Strategy. The outcomes of the strategy should be evaluated against these goals and objectives on a regular basis.
13.4 Strengthening Public Health and Health Promotion
A report produced for the Committee by Dr. Joseph Losos, Director of the Institute of Population Health (University of Ottawa), states that public health/health protection often functions silently as the sentinel for health – through monitoring, testing, analyzing, intervening, informing, promoting and preventing – until something happens unexpectedly. In such instances (such as: Walkerton, food-borne outbreaks, infectious disease outbreaks, increasing chronic disease clusters), the crisis and profile of public health incidents quickly reach major proportions. Perhaps most important, often this occurs at a great cost in human suffering, possibly death and financial expense for often preventable occurrences.[15]
According to the Canadian Medical Association Journal, a major problem with public health interventions is that funding is low, often unstable or inconsistent. The result is that the public health care infrastructure in Canada is under considerable stress.[16]
Another major barrier to effective public health is fragmentation: all provinces and territories have separate public health legislation. The federal government also has direct statutory responsibilities for regulatory aspects of public health (e.g., disease surveillance, food and drugs, devices, biologics, some environmental health, consumer products). This welter of regulatory authority results in complex negotiations among the various “players” and less than optimal coordinated activity. Such fragmentation limits the effectiveness of public health efforts and results in a lack of clear accountability and leadership. In the view of many experts, there is an immediate need for strong federal leadership to rectify this unhappy and less-than-productive situation.[17]
Similarly, government funding for health promotion is very low relative to spending on health care. In addition, health promotion is practised both by governments and non-government organizations. While most of these efforts have proven effective, their fragmentation has resulted in a poorly coordinated or integrated health promotion infrastructure. More important, no health goals have been set nationally for health promotion as there have been in the United States.[18]
The Committee believes strongly that programs and policies with respect to public health, health protection and health and wellness promotion are critical to enhancing the health of Canadians. We believe that a coordinated and integrated approach is needed and that, once again, the federal government can and should play a leadership role. We believe also that more funding is needed in this area. Given its statutory authority with respect to health protection and its long-standing role in health promotion, the federal government should devote more funding to health protection and promotion. Therefore, the Committee recommends that:
The federal government ensure strong leadership and provide additional funding to sustain, better coordinate and integrate the public health infrastructure in Canada as well as relevant health promotion efforts. An amount of $200 million in additional federal funding should be devoted to this very important undertaking.
13.5 Toward Healthy Public Policy: The Need for Population Health Strategies
As described above, the term “population health” is used to describe the multiplicity and range of factors that all contribute to health. These many factors encompass both the medical and the non-medical determinants of health. The concept of population health is not new. Indeed, for almost 30 years, Canada has played a leading role worldwide in elaborating the concept of population health:
· In 1974, the then federal Minister of Health, Marc Lalonde, released a working document entitled A New Perspective on the Health of Canadians. This report stressed that a high quality health care system was only one component of a healthy public policy, which should take into account human biology (research), lifestyle and the physical, social and economic environments. The Lalonde report was extremely influential in shaping broader approaches to health both in Canada and internationally. At the federal level, it led, among other things, to a variety of social marketing campaigns such as ParticipAction, Dialogue on Drinking, and the Canada Food Guide.
· In 1986, the report Achieving Health for All, released by the then federal Minister of Health, Jake Epp, led to the initiatives related to Canada’s Drug Strategy, the Heart Health Initiative, Healthy Communities, the National AIDS Strategy, etc.
· In 1989, the Canadian Institute for Advanced Research (CIAR), then headed by Dr. Fraser Mustard, proposed that the determinants of health do not work in isolation but that it is the complex interaction among determinants that can have the most significant effect on health. This work, along with more recent findings by Dr. Mustard, has, among other things, led to the development of the joint federal and provincial/territorial initiative on early childhood development.
· In 1994, the population health approach was officially endorsed by the federal, provincial and territorial Ministers of Health in a report entitled Strategies for Population Health: Investing in the Health of Canadians.
· In September 2000, all Ministers of Health agreed to give priority to action on the broader, underlying conditions that make Canadians healthy or unhealthy.
There is increasing evidence on the impact of the determinants of health on the health status of Canadians, particularly with respect to the socio-economic determinants. For example, the Second Report on the Health of Canadians[19] pointed out that:
· Low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes;
· Large disparities in income distribution lead to increases in social problems and poorer health among the population as a whole;
· Canadians with low literacy skills are more likely to be unemployed and poor, to suffer poorer health and to die earlier than Canadians with high levels of literacy;
· Canadians with high levels of education have better access to healthy physical environments and are better able to prepare their children for school than people with low levels of education. They also tend to smoke less, to be more physically active and to have access to healthier food;
· Studies in neurobiology have confirmed that experiences from conception to age 6 have the greatest influence of any time in the life cycle on the connecting and conditioning of the brain’s neurons. Positive stimulation early in life improves learning, behaviour and health right throughout the lifespan;
· Aging is not synonymous with poor health. Active living and the provision of opportunities for lifelong learning are particularly important in maintaining health and cognitive capacity in old age;
· Despite reductions in infant mortality rates, improvements in education levels, and reductions in substance abuse in many Aboriginal communities, First Nations and Inuit people remain at higher risk than the Canadian population as a whole for illness and early death;
· Men are more likely to die prematurely than women, largely as a result of heart disease, fatal accidental injuries, cancer and suicide. Women are more likely to suffer from depression, stress, chronic conditions, and injuries and deaths resulting from family violence;
· Older Canadians are far more likely than younger Canadians to have physical illnesses, but young people report the lowest levels of psychological well-being.
Despite the available evidence, no jurisdiction in Canada and no country in the world has designed and implemented programs and policies firmly based on a population health approach. The fact is that there remain significant practical obstacles to the design of concrete programs that can be sustained over the long haul.
In the first place, the multiplicity of factors that influence health status means that it is extremely difficult to associate cause and effect, especially since the effects of a given intervention are often obvious only after many years. Because political horizons are often of a shorter-term nature, the long timeframe for judging the impact of policy in this area can be a serious disincentive to the elaboration and implementation of population health strategies.
Furthermore, it is very difficult to coordinate government activity across the diverse factors that influence health status. The structure of most governments does not easily lend itself to inter-ministerial responsibility for tackling complex problems. This difficulty is compounded several times over when various levels of governments, together with many non-governmental players, are taken into account, as they must be if population health strategies are to be truly effective.
Although many difficulties are associated with developing an effective population health approach, the Committee believes it is important for Canada to continue to strive to set an example by exploring innovative ways to turn good theory into sound practice that will contribute to improving the population’s health status.
Ideally, the Ministers of Health in all Canadian jurisdictions would take on the role of “champions for population health” and advocate health as the major consideration in all initiatives, irrespective of sector. This would lead to the development throughout Canada of a truly “healthy public policy.”
In a subsequent report, the Committee will set out its findings and recommendations on the potential for, and the implications of, healthy public policy in Canada.
[1] Volume One, p. 81.
[2] Minister of Health and Community Services, Healthier Together: A Strategic Health Plan for Newfoundland and Labrador, September 2002 (www.gov.nf.ca/health/strategichealthplan).
[3] Most of the information contained in this section can be found in Volume Two, Chapter Four, “Disease Trends”, pp. 45-55.
[4] Dr. Paul Gully, Brief to the Committee, 4 April 2001, p. 2.
[5] Dr. Paul Gully, op. cit., p. 5.
[6] Dr. Christina Mills, Brief to the Committee, 4 April 2001, p. 4.
[7] The internationally recognized indicator of “potential years of life lost” refers to the number of years of life lost when a person dies before a specified age, say age 75. A person dying at age 25, for example, has lost 50 years of life.
[8] Federal/Provincial/Territorial Advisory Committee on Population Health, Toward a Healthy Future – Second Report on the Health of Canadians, Ottawa, 1999, p. 19.
[9] Kimberly McEwan and Elliot Goldner, Accountability and Performance Indicators for Mental Health Services and Supports: A Resource Kit, prepared for the Federal/Provincial/Territorial Advisory Network on Mental Health, Ottawa, 2000, p. 30.
[10] Advisory Committee on Population Health, Advancing Integrated Prevention Strategies in Canada: An Approach to Reducing the Burden of Chronic Diseases, Discussion Paper, 10 June 2002.
[11] Terrence Sullivan, Preventing Chronic Disease and Promoting Public Health: An Agenda for Health System Reform, August 2002.
[12] An analysis from the 2000 Canadian Community Health Survey indicated that 65% of Canadians showed more than one risk factor for chronic disease.
[13]
Terrence Sullivan, op. cit., p. 7.
[14]
Terrence Sullivan, op. cit., p. 10.
[15] Dr. Joseph Losos, Promotion and Protection of the Health and Wellbeing of the Population – Vision of Federal/National Roles, 4 September 2002, p.1.
[16] “Public Health on the Ropes”, Editorial, and Richard Schabas, “Public Health: What is to be done?”, Canadian Medical Association Journal, Vol. 166, No. 10, 14 May 2002.
[17] Dr. Losos, op. cit.
[18] Dr. Losos, op. cit., p. 1.
[19] Federal/Provincial/Territorial Advisory Committee on Population Health, Toward a Healthy Future - Second Report on the Health of Canadians, Ottawa, 1999.