HEALTH CARE * LES SOINS
Stop wasting health care dollars
on dying seniors, physician says
David Helwig D r. Fraser Mustard says health care dollars would be better spent ensuring proper child development than keeping elderly patients alive for a few more days. Speaking in London, Ont., at a conference organized by the Westminster Institute for Ethics and Human Values, the president of the Torontobased Canadian Institute for Advanced Studies criticized the British Columbia government for allowing its health care system to become choked with patients older than 75. "Utilization of health care systems has gone up by a factor of four", he told the meeting. "Basically, the bulk of it is spent extending [by 30 days the lives of] people who are dying." He said the elderly, who used to fill 6% of BC's hospital beds, now fill 25%. "What's the point of putting enormous resources into extending my life 30 days?" Mustard said in an interview. "You're better to put them into a young person who can have 70 to 80 years of high-quality life." Mustard's unique private-sector institute has a broad mandate: David Helwig is a freelance writer living in St. Thomas, Ont.
"What's the point of putting enormous resources into extending my life 30 days? You're better to put them into a young person who can have 70 to 80 years of high-quality life." Dr. Fraser Mustard
it establishes national and international research networks to investigate social, economic and scientific issues vital to Canada's future. His spring presentation in London was a similarly wide-ranging look at the relationship between socioeconomic factors and health status. In particular, Mustard stressed the importance of child development in ensuring health in later life. Mustard argued that "healthy
cultures" tend to be those that allow women to play a key role in society, education and child development. He said such cultures are marked by a strong collective will to permit women to perform such roles and they often make arrangements for working mothers to continue to exercise significant control over the development of their children. "If you look at the developing world, the societies that do this CAN MED ASSOC J 1990; 143 (7)
653
generally have better health statistics than societies that do not. Even if you look at the rich Moslem countries, the oil-rich states, they don't do nearly as well as countries with lower per capita wealth in which women play a key role." In North America, however, he thinks business leaders are often insensitive to women's issues. "I can tell you in talking to corporate heads that 90% of them don't give a damn", Mustard said. "They don't understand it because they're individualistic and freemarket [oriented]." Mustard said he was approached after his presentation by Earl Orser, chairman of London Life Insurance Co., who denied that any such problem existed. "That's nonsense and I'll take him on any day, publicly, with 10 of his colleagues, because I know that data for Canada", Mustard said. "I know the corporate structure of this country, and I know their lack of commitment." Orser was unwilling to discuss the remark with CMAJ. The hygeian concept of human health - health is determined by socioeconomic factors and physical environment - has contended throughout the history of medicine with the aesculapian philosophy that favours treatment and cure, Mustard told the meeting. Until recently, the former remained the dominant influence, resulting in major public health initiatives that gave way only in the middle of the present century to insulin, penicillin and other aesculapian-inspired therapeutic measures.
Mustard believes the relative importance of these two ancient schools of thought is determined largely by the ways nations perceive themselves and their relative prosperity. "I don't know quite how that works yet", he conceded. He said evidence of a relationship between human health and socioeconomic factors can be 654
CAN MED ASSOC J 1990; 143 (7)
found by charting tuberculosis mortality in Great Britain over the past 2 centuries. One sudden dip in the mortality curve corresponds with the introduction of streptomycin, but tuberculosisrelated mortality rates actually started dropping well before the development of such interventions, at least partly because of improved nutrition. "This does show that the changes associated with the industrial revolution in British society have profound impact on mortality and changed the life expectancy of the British population", Mustard said. He used a chart that employed British mortality rates by social class to demonstrate the inequities of human health and the ineffectiveness of publicly financed health care to correct such differences. The chart showed a difference in average mortality of about 19% between upper and lower classes in 1931; this gradient has increased, not decreased, since the 1948 introduction of the country's National Health Service. It had risen to 27% in 1951, to 44% in 1971, and to 60% by 1981. Similar gradients are found elsewhere. In fact, Mustard's institute recently discovered a "perfectly linear" gradient among 550 000 retired men enrolled in the Canadian Pension Plan. "The higher your income, the longer you live after you retire. The lower your income, the shorter your life expectancy. That should stagger all of you when you think about it." Incidentally, the same data suggest that being single places retired men at a substantial disadvantage: the mortality rate for high-income single men was comparable to that of their married counterparts in lower-income categories. What can be done to reduce such inequality? Mustard is intrigued by Sweden. It has a public-
ly financed health care system like Great Britain has, but differences in mortality rates between classes are much smaller. In fact, mortality rates among the lowest classes there are lower than among the highest classes in Britain. Mustard said this is probably related to Sweden's economic prosperity, due in part to its noninvolvement in World War II. Mustard is also interested in Japan, where life expectancy for men has jumped from 66 years in 1960 to 76 years in 1986. "We know they've become prosperous in straight economic terms. Something goes on which is hard to explain, but it does say your social environment may be extraordinarily important." Another interesting issue is the effect of labour policies on health. Disease expression changes dramatically among unemployed people, resulting in higher mortality. This does not seem to happen, however, in countries with adjustment policies that ensure job change doesn't cause dramatic changes in social environment. Japan, West Germany and Sweden have such policies, whereas Canada, the United States and Britain do not. Mustard said humans are currently trying to come to terms with previously unimaginable complexity spawned by the explosive population growth of the past 200 years. "If you put all of human existence on this planet into 1 calendar year the population density, as far as we can tell, was less than a billion until shortly after Christmas. Indeed, the bulk of that rise is on New Year's Eve." This remarkable population increase, which began during the industrial revolution, has resulted in large, complex societies and organizations, Mustard said. He maintained that we should not be surprised that correspondingly complex problems have emerged.-
Stop wasting health care dollars
on dying seniors, physician says
David Helwig D r. Fraser Mustard says health care dollars would be better spent ensuring proper child development than keeping elderly patients alive for a few more days. Speaking in London, Ont., at a conference organized by the Westminster Institute for Ethics and Human Values, the president of the Torontobased Canadian Institute for Advanced Studies criticized the British Columbia government for allowing its health care system to become choked with patients older than 75. "Utilization of health care systems has gone up by a factor of four", he told the meeting. "Basically, the bulk of it is spent extending [by 30 days the lives of] people who are dying." He said the elderly, who used to fill 6% of BC's hospital beds, now fill 25%. "What's the point of putting enormous resources into extending my life 30 days?" Mustard said in an interview. "You're better to put them into a young person who can have 70 to 80 years of high-quality life." Mustard's unique private-sector institute has a broad mandate: David Helwig is a freelance writer living in St. Thomas, Ont.
"What's the point of putting enormous resources into extending my life 30 days? You're better to put them into a young person who can have 70 to 80 years of high-quality life." Dr. Fraser Mustard
it establishes national and international research networks to investigate social, economic and scientific issues vital to Canada's future. His spring presentation in London was a similarly wide-ranging look at the relationship between socioeconomic factors and health status. In particular, Mustard stressed the importance of child development in ensuring health in later life. Mustard argued that "healthy
cultures" tend to be those that allow women to play a key role in society, education and child development. He said such cultures are marked by a strong collective will to permit women to perform such roles and they often make arrangements for working mothers to continue to exercise significant control over the development of their children. "If you look at the developing world, the societies that do this CAN MED ASSOC J 1990; 143 (7)
653
generally have better health statistics than societies that do not. Even if you look at the rich Moslem countries, the oil-rich states, they don't do nearly as well as countries with lower per capita wealth in which women play a key role." In North America, however, he thinks business leaders are often insensitive to women's issues. "I can tell you in talking to corporate heads that 90% of them don't give a damn", Mustard said. "They don't understand it because they're individualistic and freemarket [oriented]." Mustard said he was approached after his presentation by Earl Orser, chairman of London Life Insurance Co., who denied that any such problem existed. "That's nonsense and I'll take him on any day, publicly, with 10 of his colleagues, because I know that data for Canada", Mustard said. "I know the corporate structure of this country, and I know their lack of commitment." Orser was unwilling to discuss the remark with CMAJ. The hygeian concept of human health - health is determined by socioeconomic factors and physical environment - has contended throughout the history of medicine with the aesculapian philosophy that favours treatment and cure, Mustard told the meeting. Until recently, the former remained the dominant influence, resulting in major public health initiatives that gave way only in the middle of the present century to insulin, penicillin and other aesculapian-inspired therapeutic measures.
Mustard believes the relative importance of these two ancient schools of thought is determined largely by the ways nations perceive themselves and their relative prosperity. "I don't know quite how that works yet", he conceded. He said evidence of a relationship between human health and socioeconomic factors can be 654
CAN MED ASSOC J 1990; 143 (7)
found by charting tuberculosis mortality in Great Britain over the past 2 centuries. One sudden dip in the mortality curve corresponds with the introduction of streptomycin, but tuberculosisrelated mortality rates actually started dropping well before the development of such interventions, at least partly because of improved nutrition. "This does show that the changes associated with the industrial revolution in British society have profound impact on mortality and changed the life expectancy of the British population", Mustard said. He used a chart that employed British mortality rates by social class to demonstrate the inequities of human health and the ineffectiveness of publicly financed health care to correct such differences. The chart showed a difference in average mortality of about 19% between upper and lower classes in 1931; this gradient has increased, not decreased, since the 1948 introduction of the country's National Health Service. It had risen to 27% in 1951, to 44% in 1971, and to 60% by 1981. Similar gradients are found elsewhere. In fact, Mustard's institute recently discovered a "perfectly linear" gradient among 550 000 retired men enrolled in the Canadian Pension Plan. "The higher your income, the longer you live after you retire. The lower your income, the shorter your life expectancy. That should stagger all of you when you think about it." Incidentally, the same data suggest that being single places retired men at a substantial disadvantage: the mortality rate for high-income single men was comparable to that of their married counterparts in lower-income categories. What can be done to reduce such inequality? Mustard is intrigued by Sweden. It has a public-
ly financed health care system like Great Britain has, but differences in mortality rates between classes are much smaller. In fact, mortality rates among the lowest classes there are lower than among the highest classes in Britain. Mustard said this is probably related to Sweden's economic prosperity, due in part to its noninvolvement in World War II. Mustard is also interested in Japan, where life expectancy for men has jumped from 66 years in 1960 to 76 years in 1986. "We know they've become prosperous in straight economic terms. Something goes on which is hard to explain, but it does say your social environment may be extraordinarily important." Another interesting issue is the effect of labour policies on health. Disease expression changes dramatically among unemployed people, resulting in higher mortality. This does not seem to happen, however, in countries with adjustment policies that ensure job change doesn't cause dramatic changes in social environment. Japan, West Germany and Sweden have such policies, whereas Canada, the United States and Britain do not. Mustard said humans are currently trying to come to terms with previously unimaginable complexity spawned by the explosive population growth of the past 200 years. "If you put all of human existence on this planet into 1 calendar year the population density, as far as we can tell, was less than a billion until shortly after Christmas. Indeed, the bulk of that rise is on New Year's Eve." This remarkable population increase, which began during the industrial revolution, has resulted in large, complex societies and organizations, Mustard said. He maintained that we should not be surprised that correspondingly complex problems have emerged.-
