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Health – Mortality is the wrong place to look now – Look at “Disability”

Most of our health statistics still focus on mortality. This is a left over of the time when infectious disease was what concerned us the most. Infection kills quickly. It was the correct focus to have when this was the battleground.

But today infection has largely been pushed into the corner and we face instead long term chronic illness that takes years to kill but that can and does disable us – making it impossible to work or even look after ourselves. On PEI the average man becomes disabled by 65 and lives for 9.6 years in this state. This is where the real costs are to be found. Costs to each of us as we are unable to earn or cope with daily life. And costs to us as a society – for medicine can only keep us ticking over.

This group do die at the latest in their 70’s. Leaving another group the Very Old who have been fit and active all their lives. Why is another question for later. But this group too reach a stage when they too become disabled and this is where the costs and the burden mount. For their families and for the state. Until now there have been so few of these that we could afford to shelter them in institutions. But with so many that will live well into their 90’s in the pipeline – we will not be able to afford this.

Ironically, the worst thing we can do for people like this is to institutionalize them. Their health collapses when they have all control and role taken away. But as I am finding with my own mother, medicine can keep us ticking over for decades.

CIBC and VAC have worked for over 15 years on reducing the load on their medical systems.

Together they offer a useful model for how any population might look at its own load issues. Load being defined here as the impact of those people that become disabled by illness and live a long time. For the most important cost drivers in any health system are not mortality or morbidity but disability. It is disability and not acute illness that drives the costs. Once we understand this term, many options open up for us to reduce costs and increase care.

  • Disability Load = incidence X duration of reduced capacity.
  • Disability rate – has to be addressed though policy, better support for wellness activity, working conditions etc.
  • Reduced capacity – person perceives that they cannot fulfill their full function.  More likely to seek medical care and as a result drive other benefit costs.

The total population contains two Disability risk segments. The “Young” aged up 65  and the “Very Old” aged 75 – 110.

The Young increasingly develop chronic illness such as Type 2 Diabetes. This segment becomes progressively more ill until they are disabled and require both ongoing treatment and social support sometimes for decades. We call these diseases, the Diseases of Modern Civilization

Diabetes drives many other conditions including cardiovascular disease. On PEI adults in 2006 with diabetes had to be hospitalized much more often than those without it. 16 times more often for lower limb amputations. 6 times more often with kidney disease. They had 5 times more heart attacks. 4 times more heart failure. 3 times more strokes. They stayed 3 times longer in hospital. Had 2 times more visits to physicians and 2 times more to specialists

Most diabetics don’t just take one medication, but several. A typical regimen for an adult diabetic after a couple of years of treatment and following the dietary advice of the American Diabetes Association includes Metformin, Januvia, and Actos, a triple-drug treatment that costs around $420 per month. Two forms of insulin (slow- and fast-acting), along with two or three oral medications, is not at all uncommon

The real societal problem is not that we die of these diseases but that we that suffer from them. All or concerns in the past have been mortality. But with this large and growing group of people, the issue becomes not mortality but care.

Diet is at the core of this epidemic. Most of the information related to diet today is at least misleading or even wrong. A new understanding of our evolutionary past shows that grains, the core of the recommended diet, are in fact the pathway to insulin resistance and so to this family of diseases.

Social Status and Managerial Culture then act as an amplifier on vulnerable people. Those in organizations with the least amount of control will have a mortality rate 4 times greater than executives with more control and status.

The breakthrough then in costs and care are that diet and issues of managerial culture can be positively affected by social intervention.

The issue of control and social status is the vector for Load in the very old as well. Social Intervention works best here as well.

The  “Very Old” aged from 75 – 110. This group has usually avoided the chronic illness and has remained well and independent until they become too frail to live on their own. But if they are institutionalized, they tend to lose their health and then can also live for many years.

Currently we just treat these groups medically. CIBC and VAC treat them socially to great effect. They can prevent, reverse and mediate the illness. I will offer up 2 case studies to show you how.

CIBC – the under 65 set

VAC – the over 75 set

Is there a better model out there for better health outcomes that uses the health care system less? Yes there is!

How do you take Marmot’s information about how social status affects our health and use it to make a positive difference in the workplace? This is how you can.

When I left CIBC, one of Canada’s largest banks, 17 years ago the most prescribed drug in the plan was Prozac – an anti depressant. The bulk of the staff were women in clerical roles – at the bottom of the hierarchy with the least amount of control. Why were they so depressed and what did this mean? Our healthcare costs were exploding. The plan cost $200 million then and our projections showed that it would cost $500 million in ten years. Why was this? After all working at the bank did not expose workers to a risky or dangerous workplace.

What Dr David Brown and our team discovered was that everything that Dr Marmot had predicted  The bank’s highly bureaucratic culture – very top down and controlling towards those at the bottom such as the fron line female staff – was creating waves of debilitating disability. You see this in any organization where the work is tightly controlled – why teachers are now so stressed. The social stress in the workplace was driving the incidence of disability. (BTW do you see the link back to the family too? – lack of “Voice” and too much control set up social stress and so too much cortisol)

Until then, we, at CIBC, like everyone else had treated this resulting illness by using the medical system. We had intervened to great the symptoms of the illness and disability. We found the key stressor that drive the cortisol and then the breakdown in health and the incidence of disability.

For David Brown’s historic achievement was to look upstream from the disability itself and look at the social and cultural drivers that caused it. In short, it was stress – social stress caused by the overall culture and made worse by some managers in particular – that set the staff up to become ill. David’s great work was to find ways of identifying the hotspots early and intervening socially to mediate the cultural tension. The results have been amazing.

My sense is that this model can be replicated in any health system. Here below the fold is what we did.

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  • matt: isn't the "sugar" in soda high fructose corn syrup? why do y...
  • Caroline Cooper: Hi Rob, Nice to see you're writing again. I have been thi...
  • Patrick Meadows: People, can and have lived solely on meat. Eskimos go months...
  • ike: Maybe you veggies need to eat meat so your brains can develo...
  • robpatrob: Of course - but we are talking much more recently here about...
  • Rob: "I come from Northern European stock. My genes are the most ...
  • Gemma: Don't forget regular exercise! Prevention is better than cur...
  • Daniel: Nothing can live on just meat. Carnivores such as cats and s...
  • robert: Your retarded, so why is it most vegans need pills as vitami...
  • Dario McNut: It is true that erectile dysfunction can be associated with ...
  • robpatrob: Google Richard Wrangham - His book is on Amazon - much more ...
  • A Question: Thanks for this video! Half of the urban women who had a raw...
  • robpatrob: Great questions - thanks. Just as 300 years ago a few misfi...
  • Garfield: I really like the parallels too...I live like this also. Twe...
  • nj: Rob, check out the chart here for a broader perspective on a...

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