Town Hall MeetingOrientation materials

DemographicsFrom 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- ImmigrationAll of these will fundamentally influence your future medical practice. . .

Declining Birth RatesWhy the Decline?Urbanization, lack of space; Economics of modern work (contrast with agriculture);Babies expensive & getting a job implies attending university, etc. The Baby Bust is GlobalEach woman in the world now has half as many children as in 1970.Populations of Russia & Japan are already shrinking. 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? Whats happening in China? Can lead to social change in terms of ethnic make-up of the population.

Aging of the Population(You finish residency)10 yr reunion30 yr reunion

The Costs of Care are Driven by the Age of Patients... Government Health Expenditures per Person per Year, by Age of Patient, Ontario, 2002So, 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 PopulationFrom the 2006 Census:There are 6.2 million foreign-born people in Canada: 19.8% of the population, but its 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 CanadaEthnic minorities are often less well-off than the mainstream population. Such inequalities can influence health.

Inequalities and HealthDuring 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. A crucial 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.

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. Lets begin with the big picture:

Global Patterns of DiseaseAs societies evolve, patterns of disease evolve and interact with social change. There are many terms to describe this; here is one:

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.

Note the small number of infectious diseases (

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 diphtheriaBut... 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 problemChanges 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

PandemicsA 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 AdvancesMedical 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.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

Prevention StoriesPreventing health problems before they arise may seem unexciting work for a physician, but it makes practical sense, economic sense, and moral sense. Some examples: 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?

ImmunizationImmunization 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 5In 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 ManpowerBelgium has twice as many physicians per 1000 population as Canada. Canada is also lower than the US, Australia and UK 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)In the early 1990s the Ontario government reduced enrolment in medical schools and residency programmes.

Annual gains & losses in staff

Health Care CostsOntario 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

Will throwing money at it help? Expenditures & Health OutcomesThe 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.So, will paying doctors more make them work harder, or will they say Thanks! and go play golf?Is life expectancy the best health indicator? What would you suggest?Compare Cuba with the US. How does Cuba do it?

Primary Care:Percentage of all Family Physicians accepting new patients, Ontario 2007%Source: College of Physicians and Surgeons of Ontario. MD Dialogue, April, 2008

ConclusionsThe 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?