Chapter 2: The Chief Public Health Officer's Report on The State of Public Health in Canada 2010 – Canada's experience in setting the stage for healthy aging

Chapter 2: Canada's Experience in Setting the Stage for Healthy Aging

The proportion of seniors in Canada is increasing more rapidly than that of any other age group and, if population projections remain consistent, there will be a higher proportion of seniors than children by 2015.^{Footnote 9} The World Health Organization (WHO) states that an aging population is a triumph of modern society.^{Footnote 10} A population that has aged shows that social and health practices have been put into place that have extended life and reduced premature deaths earlier in the lifecourse. Over time, Canada has created conditions for a healthy population, in part, due to addressing issues associated with the determinants of health. However, the growth of an aging population requires that Canada find additional ways to maintain and improve the conditions necessary for continued good health in the senior years.

This chapter will take a historical look at some of Canada's many successes and challenges in setting the stage for healthy aging through selected key milestones. It will also highlight certain policies, advancements and difficulties that have influenced the health of seniors over time and point to some broad challenges that lie ahead.

Healthy and active aging

Given that individuals and populations are growing older, all Canadians have a vested interest in creating and maintaining opportunities to age well.^{Footnote 12 Footnote 13} Healthy aging is an ongoing process of optimizing opportunities to maintain and enhance physical, social and mental health, as well as independence and quality of life over the lifecourse.^{Footnote 11 Footnote 12}

A healthy aging approach considers factors impacting seniors but also includes an understanding of how earlier events and experiences can create conditions to influence health and quality of life as individuals age.^{Footnote 10} The approach envisions a society that supports and values the contributions of seniors, appreciates diversity and works to reduce health inequalities. It also provides opportunities for Canadians to maintain independence and quality of life and to make healthy choices across the lifecourse.^{Footnote 10} Interventions, programs and policies that have shown some success or promise in creating conditions for healthy aging will be explored further in Chapter 4.

Aging and the lifecourse

The lifecourse is the path or trajectory that an individual follows from birth to the end of life.^{Footnote 6} This trajectory can change or evolve at any life stage (childhood, adolescence, young adulthood, mid-adulthood and old age) and can vary from person to person depending on the factors interacting to influence health (biological, behavioural, physical and social).^{6 Footnote 14} Both positive and negative factors evolve and interact within and across life stages, ultimately resulting in the positive and negative health outcomes that each individual experiences in his or her lifetime. It is during the earlier years that factors can influence health and have the greatest cumulative impact on health outcomes.^{Footnote 14 Footnote 15} For more information on the lifecourse approach and trajectories, refer to The Chief Public Health Officer's Report on the State of Public Health in Canada, 2009: Growing Up Well – Priorities for a Healthy Future.^{Footnote 6}

Public health uses the lifecourse approach as a tool to understand the links between time, exposure to a factor or combination of factors, experiences and later health outcomes. The lifecourse approach can help identify and interpret trends in the health of populations and the links between life stages.^{Footnote 6 Footnote 14 Footnote 16 Footnote 17} It can also be used to develop appropriate interventions, programs and policies across the lifecourse. The lifecourse approach ensures healthy aging is considered in the context of the entire lifespan, rather than merely as a late-life phenomenon.

Factors that influence health and aging

Many broad factors directly and indirectly influence the health of individuals and communities. Age, sex and heredity are key factors that determine health. Further, individual behaviours can impact health. Although these behaviours are individual choices, they are also influenced by social and economic circumstances. Socio-economic factors called the 'social determinants of health', such as income, education, environment and social connectedness can also influence health.^{Footnote 18-Footnote 21} References to the social determinants of health, collectively and individually, can be found throughout the report.

While these determinants influence health outcomes at every stage of life, the cumulative impact of socio-economic conditions on health outcomes is more apparent as people age. Generally, evidence shows that people with low socio-economic status (SES) have notably poorer health outcomes compared to those of higher SES. Also, the longer people live in stressed economic and social conditions, the greater the impact on their health outcomes.^{Footnote 22} These differences will be discussed further in Chapter 3.

A brief history of Canada's experience in promoting healthy aging

Examining Canada's experience in setting the stage for healthy aging is a complex undertaking. On the one hand, we must consider all of the broad public health improvements for the population as a whole, as well as those specific to children, as these improvements have influenced health and have had the greatest cumulative impact on health outcomes with age.^{Footnote 6} On the other hand, Canada has also made considerable progress on improving seniors' health and well-being and on improving health outcomes later in life.

This section will offer a brief historical look at some of Canada's many successes and challenges in establishing a healthy aging population. The following examples illustrate how seniors' health and well-being have been influenced by the evolution of public health. Looking to the past provides a sense of the progress that has been made on seniors' health and the foundation from which future actions can be taken. This should not be considered a complete historical account of all public health advancements. For a more detailed history of public health in Canada, see The Chief Public Health Officer's Report on the State of Public Health in Canada, 2008: Addressing Health Inequalities and The Chief Public Health Officer's Report on the State of Public Health in Canada, 2009: Growing Up Well – Priorities for a Healthy Future.^{Footnote 6, Footnote 20}

1900 to 1950

Before the 20th century, government policy and community interventions did not specifically focus on the health and safety of Canada's seniors but rather strived to improve health and well-being for the population as a whole. Efforts during this period were primarily aimed at combating the many infectious diseases that often affected large proportions of the population. By the early 1900s, waterborne diseases were, for the most part, brought under control with the implementation of water treatment and sanitation standards.^{Footnote 23-Footnote 25} In addition, immunizations – along with food and drug standards – significantly reduced the risk for diseases.^{20 Footnote 26} The recognition of the relationship between social conditions such as education and employment, as well as health and safety, led to improvements in school attendance, living and working conditions, and public infrastructure.^{Footnote 27-Footnote 29} These public health improvements played a large role in advancing the state of public health in Canada and subsequent generations have continued to garner the benefits of these advancements.

By the end of the First World War (1914–1918), social and economic conditions within the country had changed. War-time demand led to more industrial production and a larger urban labour force. Jobs traditionally performed by older adults were replaced with new factories and a younger workforce.^{Footnote 30} However, despite a prospering economy, the effects were not felt by all sectors of society. Canadian seniors could look forward to living longer, but many of those years were spent in lower standards of living and, in some cases, extreme poverty. Due to age and associated health conditions, senior men who had worked throughout their lives were generally unable to continue in the paid labour force. Senior women living in urban areas worked primarily in domestic settings as unpaid caregivers and homemakers. In rural settings, men and women also dealt with the demands of unpaid labour ranging from unmechanized farm work to housework.^{Footnote 30-Footnote 32} As a result, seniors – particularly single or widowed women – were at greater risk for income insecurity and poverty.

Without income security, seniors had limited means of supporting themselves and their families as they aged. Survivor and disability pensions were created for war veterans and their families, but there was still a strong and growing need for assistance for seniors. Fuelled by public support for social reform to help combat poverty and provide assistance to low-income seniors, the Government of Canada appointed a special committee to study the need for a national pension plan, and in 1927, the Old Age Pension Act was passed. The Act set out provisions for granting financial assistance to British subjects 70 years and older who had lived in Canada for a minimum of 20 years.^{Footnote 30}

By the 1930s, Canada was experiencing a state of economic depression. The economy had collapsed, resulting in mass unemployment that weakened social conditions such as housing and food security. As farmers went bankrupt and industries crashed, people lost their homes and livelihoods and it became apparent that many Canadians were struggling to meet their basic needs.^{Footnote 33} Despite the earlier introduction of the Old Age Pension Act, which was initiated to serve seniors in greatest need of financial assistance, eligibility was limited (e.g. Status Indians and immigrants could not apply) and its provisions did not apply to the majority of the aging population.^{Footnote 30} As a result, many seniors were still experiencing lower standards of living and, in some cases, extreme poverty.

1950 to present

Following World War II, several significant public health developments emerged. For instance, the standard of living for most Canadians was on the rise as employment and income levels increased and education and housing standards improved, resulting in better living conditions and nutritional practices. The health of Canadians was even further enhanced with increased childhood immunization against infectious diseases and life-altering scientific discoveries such as insulin and penicillin, which led to treatments for diabetes and infection.^{Footnote 20} Along with improved economic and social conditions, the composition of the Canadian family was changing. More families were having more children and this resulted in a "baby boom" – a period of increased birth rates that started in the mid-1940s (see Figure 2.1).^{Footnote 34 Footnote 35}

Figure 2.1 Crude birth rate in Canada, 1921 to 2007* ^{Footnote 36-Footnote 40}

* Data not available from 1997-1999.
Source: Statistics Canada.

[Click to enlarge Figure 2.1]

The baby-boom lasted until the mid-1960s when it began to wind down due to a shift in social dynamics within the family and the community. During and after World War II, more women entered the workforce and birth control methods became more accessible and effective, making it possible to delay starting a family.^{35 Footnote 41} Also, many people were moving from rural areas into urban areas in search of jobs and a better, more accessible education. Young adults began marrying later and delaying parenthood.^{Footnote 35 Footnote 41} As a result, Canada's birth rate began to decline.^{Footnote 35} The significance of the baby-boom period is most evident today, as the oldest members of this group of Canadians are just starting to reach seniors status and, over time, will represent the largest cohort of seniors in history. By 2038, it is projected that almost 25% of the population will be aged 65 years and older (see Figure 2.2).^{42 Footnote 43}

Figure 2.2 Canadian population, 1978, 2038* ^{Footnote 42 Footnote 43}

* Projected population.
Source: Statistics Canada.

[Click to enlarge Figure 2.2]

Post-war, Canadians experienced unprecedented gains in real income, which primarily benefited younger Canadians who made up the majority of the workforce. Many Canadians nearing retirement had experienced limited opportunity to save for their retirement, due to having lived through years of economic hardship and war.^{Footnote 8} As a result, they were more likely to be food insecure and live in inadequate housing, which put their health and well- being at even greater risk. By this time, poverty among seniors had become a significant concern in Canada.^{Footnote 30 Footnote 33} Many of the social initiatives up until this time were directed at the overall population and not at seniors. In fact, across the country, within both the public and private domains, there was a lack of initiatives that benefited the aging population. In view of that, a number of federal programs and policies to support seniors and improve their quality of life were introduced, including broad social investments such as:

• Old Age Security (OAS), which was Canada's first universal pension. Introduced in 1952, it aimed to financially assist retired Canadians, including Status Indians, who were experiencing a significantly lower standard of living than other age groups within the general population;^{Footnote 30}
• the Canada Pension Plan (CPP) and the Quebec Pension Plan (QPP), which were introduced in 1966 as employment-based pension plans that were portable from job to job. Both plans provided all employed Canadians with protection against loss of income as a result of retirement, disability and death;^{Footnote 44-46} and
• the Guaranteed Income Supplement (GIS), which was introduced in 1967, as a measure to further reduce poverty among seniors and assist those who needed to retire before they could benefit from the CPP.^{Footnote 30 Footnote 44}

These programs were initiated to provide working Canadians and their families with income for retirement, improve eligibility of financial assistance for seniors in greatest need and as measures to enhance quality of life.^{Footnote 8,Footnote 30} Until the mid-1960s, the age of eligibility for OAS was set at 70 years; however, it was gradually lowered to 65 years between 1966 and 1970.^{Footnote 8} Over time, Canada gradually moved away from clearly defined age-based retirement. Flexible retirement options were introduced in the CPP and some provinces passed labour and human rights legislation that protected against mandatory retirement (with the exception of specific occupations that have a set age limit).^{Footnote 8,Footnote 47} This meant that Canadians entering their 60s could consider a variety of employment and retirement options. Income benefit programs were introduced in many provinces beginning in the 1970s. For example, the Ontario Guaranteed Annual Income System (GAINS) and the Alberta Seniors Benefit Program both aimed to provide support to seniors and ensure a guaranteed minimum income in addition to federal benefits received under OAS, CPP and GIS.^{Footnote 44,Footnote 50} The introduction of these income assistance programs, along with the establishment of workplace pensions, helped to reduce poverty among seniors. With these additional income benefits, standards of living improved and health and well-being were enhanced. Subsequent generations of retired Canadians and seniors have continued to benefit from these programs.^{Footnote 8,Footnote 51}

By the 1950s, the science of gerontology had received more attention, particularly as a means of raising awareness and promoting research and education in the area of seniors' health and well-being. In the following decades, organizations were created within Canada to promote the health of seniors through science-based research, education and advocacy. These included the Canadian Association on Gerontology (1973), the Canadian Geriatrics Society (1981), the Canadian Gerontological Nursing Association (1985) and the Canadian Academy of Geriatric Psychiatry (1991).^{Footnote 52-Footnote 54}

Increased longevity among seniors due to public health improvements and social investments led to an aging population that was healthier, older and more numerous than in previous generations.^{Footnote 10 Footnote 55} Access to acute hospital services was guaranteed through the Hospital Insurance and Diagnostic Services Act (1957), while the Medical Care Act (1966) afforded access to insured medical services.^{Footnote 56} Additionally, medical advances in health technologies and pharmaceuticals improved the speed and accuracy of diagnosis, reduced pain, facilitated rehabilitation and survival, and improved the independence of individuals coping with chronic diseases and injuries.^{Footnote 57} These public health initiatives, together with immunizations, contributed to a decline in many infectious diseases.^{Footnote 26} Nonetheless, injuries and non-communicable diseases such as cardiovascular disease, cancer, arthritis and diabetes, were common causes of disability and death.^{Footnote 8 Footnote 10 Footnote 55 Footnote 58} Although risk factors had been identified for these diseases, early interventions to prevent and/or reduce risk were minimal.^{Footnote 8 Footnote 55}

Furthermore, there was increased demand for care and services for seniors due to multiple factors, including shifting cultural values and family dynamics, and better, more accessible employment and education opportunities that led to increased numbers of working families moving to urban areas or greater distances away from their elders.^{Footnote 10} As a result, many programs have been launched in recent decades to help seniors remain independent as they age by offering homemaking services such as meal planning and preparation, light housecleaning and laundry services. Long-standing organizations such as the Victorian Order of Nurses have expanded their services to include home care, personal support and community services.^{Footnote 59} And a number of provincial home care programs have also been established across the country. In addition, health services for Canadian veterans were improved with the introduction of the Veterans Independence Program (VIP) in 1981. A national home care program, VIP is provided by Veterans Affairs Canada to help clients remain healthy and independent in their own homes or communities.^{Footnote 60}

Supporting healthy aging in the home and community also required better standards of care and safety.^{Footnote 10} Most homes were not designed to meet the changing needs of seniors and many seniors could not afford or physically carry out the renovations needed to make their homes safe and functional. Changes to building codes dating back to the early 1940s, such as the National Building Code of Canada, played an important role in setting standards to promote health, safety, accessibility and injury prevention for seniors and have been updated in recent decades to reflect current risks and safety requirements.^{Footnote 61} Home improvement programs, such as the Residential Rehabilitation Assistance Program for Persons with Disabilities and the Home Adaptations for Seniors Independence program, were launched by the Canada Mortgage and Housing Corporation (CMHC) to assist low-income seniors and households with home renovations, such as accessibility modifications and home adaptations.^{Footnote 62 Footnote 63} Additionally, recognition of the growing need for supportive housing arrangements for seniors led to an increase in the development of private and public retirement homes and long-term care facilities.

A work in progress

In the 21st century, attention to issues concerning seniors has continued to gain momentum. Governmental and non-governmental organizations have been formed in Canada to encourage and promote healthy aging and to advocate for seniors' issues in areas such as falls and related injuries, mental health, abuse and neglect, social connectedness, healthy living, and care and services. In addition, the National Advisory Council on Aging (NACA) (1980) was established to assist and advise the Federal Minister of Health on issues related to aging and quality of life for seniors.^{Footnote 51 Footnote 57 Footnote 64} In 2007, the National Seniors Council was established to advise the Government of Canada on all matters related to the health and well-being of seniors.^{Footnote 65} Internationally, there has also been greater awareness of the issues facing seniors (see Textbox 2.1 International action on aging).

A large part of this increased momentum and support for seniors over the last few decades can be attributed to the growing realization that the demographics of the population are changing. Canada, like many other countries around the world, is experiencing significant growth in its population aged 65 years and over.^{Footnote 12 Footnote 51} Furthermore, Canada's seniors are not a homogenous population and issues related to seniors' overall health and well-being may vary depending on historical social and economic conditions, place of residence (urban, rural or northern areas), gender, and ethnocultural background.^{Footnote 51} For a brief look at how these factors have impacted Aboriginal health, see Textbox 2.2 Historical influences on Aboriginal Peoples health.

While Canada has made great strides in implementing public health initiatives to maintain and improve the health of Canadians as they age, considerable challenges remain. The continued prevalence of unhealthy lifestyles and chronic diseases threaten the physical and mental health of the population. The significance of age-related chronic diseases and their prevention and management will be an ongoing concern – not only for today's seniors but for those in future generations.^{Footnote 12}

There are real environmental, systemic and social barriers to adopting healthy behaviours. One of the challenges in moving forward will be for Canadians to find ways to live healthier lives by staying socially connected, increasing their levels of physical activity, eating in a healthy balanced way and taking steps to minimize their risk of injury.^{Footnote 12} Additionally, the health and safety of seniors has been, and will likely continue to be, jeopardized by extreme weather events, infectious disease outbreaks, water contamination and seasonal influenza. This points to the need for emergency preparedness measures that integrate senior-specific considerations to reduce the risk of injury and death.^{Footnote 80 Footnote 81} Canada also requires age-friendly environments and opportunities for seniors to be socially connected and make healthy choices that will enhance their safety, independence and quality of life.^{Footnote 12 Footnote 82 Footnote 83}

Looking ahead, Canada will need to consider ways to integrate healthy aging into the lifecourse experience. Healthy aging is not simply about seniors; it is an issue that affects all age groups and generations. In order to ensure Canadians are healthy for as long as possible, all Canadians must have opportunities at all stages of their life to have, maintain and enhance good physical and mental health.

Summary

Canada has made progress in improving the health outcomes of its citizens. Today, most Canadians are living longer and living many of their years in better health. Many initiatives have been put in place and evolving social and economic conditions have resulted in adaptation and change. Regardless of these successes, challenges remain and will continue to emerge. Chapter 3 will explore the current health status of Canada's senior population from four perspectives – physical health, mental health, economic well-being and social well-being – including factors influencing their health.