Disease prevention: how much progress have we made?
A recent Canadian Institute for Health Information (CIHI) Report obscurely titled Health Indicators 2012 revisits the topic of the impact of prevention on reduced mortality which was first profiled in the 1974 Lalonde Report – A New Perspective on the Health of Canadians. This caused me to go back and reread the 38 year old report to see what it said.
The Lalonde Report is a working paper rather than a blueprint for Canada. It analyzes the principal causes and remedies for premature mortality defined as death before 70 years of age. It places emphasis on reducing premature mortality by reducing environmental and behavioral risks such as pollution, insufficient exercise, abuse of alcohol, tobacco and drugs and poor eating habits. It states that “while it is easy to convince a person in pain to see a physician, it is not easy to get someone not in pain to moderate insidious habits in the interest of future well-being”.
The data used by the Lalonde Report shows that life expectancy at birth was about 73 in 1971 and approximately half of deaths occurred before age 70. In terms of years of life lost due to early death, by this definition the five major causes in order were motor vehicle accidents, heart disease, all other accidents, respiratory diseases and lung cancer, and suicide. Self-imposed risks and the environment were noted to be principal or important underlying factors in each of these causes of death. Interestingly, this 38 year old report notes that “whereas the major problems of the past were acute illnesses, which have a fairly abrupt onset and a finite duration, the major problems now are chronic illnesses, which have a gradual onset and an indefinite duration, and accidents.” This is a fascinating comment given that recent reports on health care in Canada give the impression that chronic illness has just been discovered as being a new problem.
One of the ideas to address this 1974 problem of chronic diseases is “improved ambulatory health centers, with round-the-clock, comprehensive outpatient care … in order that accessibility of care will not be dependent on the individual availability of physicians”. Another is “it may be fruitful for chronic care in clinics and institutions to be provided by nursing personnel trained to carry out procedures and provide counseling in areas now requiring the intervention of a physician”; for both of these excellent ideas we are all these years later just starting to make it happen. A third idea is regional health authorities with the power to plan and manage the health care requirements of a given geographic area”. In Ontario, the regional structure of Local Health Integration Networks (LHINs) has existed for only five years and most commentators would question whether the LHINs really have the power as suggested to “manage care requirements”.
The CIHI Health Indicators 2012 report confirms that Canada has made significant progress in the past 38 years in reducing premature mortality, but it also emphasizes that there is considerable potential for further improvements. Life expectancy is now almost 81 years in Canada and premature mortality (now defined as death before 75 years of age) has decreased in the last 30 years by 45%. The largest cause-specific decline has been 72% related to heart disease. Smoking reduction strategies are identified as one of the major contributors to this improvement with smoking rates declining from almost 50% in 1971 to approximately 20% in 2008. Overall, of all the G7 countries, Canada is currently third best in terms of limiting potentially avoidable deaths with only France and Japan performing better. Looking forward, the CIHI report says that 72% of the current premature mortality (i.e., dying before the age of 75) is avoidable. And of these avoidable deaths, almost two-thirds are preventable particularly by addressing risks associated with tobacco, high blood pressure, obesity, physical inactivity, high blood glucose, high cholesterol, low fruit and vegetable intake, exposure to pollution, alcohol use and occupational hazards.
The CIHI report only makes one passing reference to the Lalonde Report. It points out that the Lalonde Report highlights the “paradox of everyone agreeing to the importance of research and prevention yet continuing to increase disproportionately the amount of money spent on treating existing illness.” After 38 years not much has changed on that front!