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Equity in health care: a Study of health services in a northern regional district of British Columbia Pope, Audrey Elizabeth 1978

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EQUITY IN HEALTH CARE; A Study o f H e a l t h S e r v i c e s i n a N o r t h e r n R e g i o n a l D i s t r i c t o f B r i t i s h Columbia by AUDREY ELIZABETH POPE B.Sc. Pharm. , U n i v e r s i t y o f B r i t i s h Columbia, 1957 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES ( i n the Department o f H e a l t h Care and E p i d e m i o l o g y ) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October, 1978 (c) Audrey Elizabeth Pope, 1978 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Audrey E. Pope Department of Health Care and Epidemiology The U n i v e r s i t y of B r i t i s h Columbia, 2075 Wesbrook P l a c e , Vancouver,Canada V6T 1W5 Date ABSTRACT The p r o v i s i o n o f h e a l t h care and p r e v e n t i v e s e r v i c e s t h a t has evolved i n Canada was based on the concept of e q u a l i t y . W i t h i n any one p r o v i n c e a l l but a few s e l e c t e d groups pay equal p r e p a i d insurance premiums or tax and are giv e n the same b e n e f i t ; payment of the p r o v i d e r f o r s e r v i c e s rendered. The concept of D i s t r i b u t i v e J u s t i c e suggests t h a t those w i t h s p e c i a l needs should r e c e i v e s p e c i a l s e r v i c e s but s e l e c t i v e p r o v i s i o n o f care or s e r v i c e s may gi v e r i s e to f e e l i n g s o f R e l a t i v e D e p r i v a t i o n i n non-r e c i p i e n t s . For a h e a l t h s e r v i c e to be e q u i t a b l e and p e r c e i v e d as " f a i r " t here must be maximal d i s t r i b u t i v e j u s t i c e and minimal r e l a t i v e d e p r i v a t i o n . During a r e s e a r c h p r o j e c t i n the K i t i m a t - S t i k i n e Regional D i s t r i c t d u r i n g the summer of 19 75, i t was found t h a t n o r t h e r n B r i t i s h Columbians viewed t h e i r h e a l t h s e r v i c e s as u n f a i r . They b e l i e v e d they s u b s i d i z e d the care and s e r v i c e s used by southern B r i t i s h Columbia r e s i d e n t s . T h i s study i n v e s t i g a t e s the f a c t o r s i n the h e a l t h s e r v i c e system which a f f e c t the u t i l i z a t i o n and p r o v i s i o n of h e a l t h s e r v i c e s and compares the u t i l i z a t i o n of h o s p i t a l s e r v i c e s o f the K i t i m a t - S t i k i n e Regional D i s t r i c t w i t h three other r e g i o n a l d i s t r i c t s ; Cowichan V a l l e y , North Okanagan and E a s t Kootenay and wit h B r i t i s h Columbia as a whole p r o v i n c e . The comparative r e g i o n a l d i s t r i c t s were chosen on the b a s i s of -demography.,-.- l i f e s t y l e , i n d u s t r i a l , e t h n i c and geographic s i m i l a r -i t i e s and d i f f e r e n c e s . S t a t i s t i c a l t o o l s used were Frequency D i s t r i b u t i o n , Simple and M u l t i p l e Regression. Determinants of access t o care are d i s c u s s e d ; the p e r c e p t i o n of i l l n e s s , convenience c o s t s , f i n a n c i a l c o s t s , a v a i l a b i l i t y o f manpower, programmes and f a c i l i t i e s , s o c i a l and geographic i s o l a t i o n . An examination i s made of the d i s -t r i b u t i o n of power i n the h e a l t h system and the use t h a t i s made of i t by p o l i t i c a l d e c i s i o n makers, government a d m i n i s t r a -t o r s and pl a n n e r s , p r o f e s s i o n a l o r g a n i z a t i o n s , educators and pressure groups. The h e a l t h s e r v i c e s i n the K i t i m a t - S t i k i n e Regional D i s t r i c t are d e s c r i b e d with emphasis given to m i s s i n g programmes. The r e g i o n a l d i s t r i c t has a high f a c i l i t i e s - p o p u l a t i o n r a t i o and a low manpower-population r a t i o . The e x p e c t a t i o n s of the r e s i d e n t s of northern B r i t i s h Columbia f o r p r o v i s i o n of h e a l t h care are presented, n o t i n g a c o n c e n t r a t i o n of e x p e c t a t i o n on access to acute h e a l t h c a r e . The planner's e x p e c t a t i o n s , a r i s i n g from elements i n the h e a l t h system are d e l i n e a t e d . Manpower, f a c i l i t y and h o s p i t a l u t i l i z a t i o n data were obtained f o r the f o u r r e g i o n a l d i s t r i c t s and the p r o v i n c e . The h o s p i t a l u t i l i z a t i o n d ata, s e p a r a t i o n s by d i s e a s e o f r e s i d e n t s from h o s p i t a l s within and without t h e i r d o m i c i l i a r y r e g i o n a l d i s t r i c t are s u b j e c t e d to s t a t i s t i c a l t e s t i n g to determine whether access to care i s reduced i n the remote r e g i o n a l d i s t r i c t s . The data are a d j u s t e d f o r the age and sex composition of the p o p u l a t i o n s of each region-.and the p r o v i n c e . There i s no i n d i c a t i o n from the examination of h o s p i t a l u t i l i z a t i o n data t h a t the b a r r i e r s to access to care t h a t e x i s t are e f f e c t i v e i n reducing the access gained. In each of the fou r r e g i o n a l d i s t r i c t s , the numbers of s e p a r a t i o n s i v are higher than expected based on the age and sex composition of the po p u l a t i o n s . A breakdown of the data on the 186 diseases i n t o disease grouping i n d i c a t e s t h a t h o s p i t a l u t i l i z a t i o n i s s i g n i f i c a n t l y high i n some regions f o r p a r t i c u l a r groups of diseases. The r e s u l t s i n d i c a t e a need to examine l i f e s t y l e and environmental f a c t o r s i n the four r e g i o n a l d i s t r i c t s t h a t may be i n f l u e n c i n g h o s p i t a l use f o r these diseases. There are i m p l i c a t i o n s f o r p o l i c y f o r m u l a t i o n and f o r h e a l t h planning a c t i v i t i e s . There i s a need f o r r e g i o n a l d i s t r i c t s to broaden t h e i r area of concern to i n c l u d e h e a l t h s e r v i c e s other than h o s p i t a l s , to c o n t r o l environmental h e a l t h hazards of i n d u s t r i e s , agencies and homes w i t h i n t h e i r boundaries and t o educate the r e s i d e n t s about t h e i r personal r e s p o n s i b i l i t y f o r t h e i r h e a l t h s t a t u s , the s p e c i a l needs of some groups of people, the s e r v i c e s r e q u i r e d to meet those needs and why some s e r v i c e s cannot be^offered l o c a l l y but r e q u i r e r e f e r r a l outside the r e g i o n a l d i s t r i c t . The h e a l t h system which has developed, based on the concept of e q u a l i t y does not provide northerners w i t h a perception of equ i t y or f a i r n e s s . There i s a need to o b t a i n i n n o v a t i v e s e r v i c e s t o meet s p e c i a l needs and t o ensure the people excluded from the e x t r a b e n e f i t are aware of the s p e c i a l needs of those f o r whom i t i s provided. Services which provide a high degree of d i s t r i b u t i v e j u s t i c e and minimize r e l a t i v e d e p r i v a t i o n would r e s u l t i n an e q u i t a b l e and unequal s e r v i c e t h a t could be perceived as f a i r by a l l . V TABLE OF CONTENTS Page ABSTRACT i i TABLE ON CONTENTS . . . . . V INDEX OF TABLES X INDEX OF MAPS x v i ACKNOWLEDGEMENTS x v i i Chapter 1. FAIR SHARES OF HEALTH SERVICES 1 - D e s c r i p t i o n o f Canadian H e a l t h S e r v i c e s 2 - R e s p o n s i b i l i t y f o r He a l t h Care 2 - P u b l i c Funded S e r v i c e s 4 N a t i o n a l Health Coverage 5 S p e c i a l B e n e f i t s . 6 - Measures of H e a l t h S e r v i c e s 8 - R e l a t i v e Deprivation^ .n,,.-. 8 •- D i s t r i b u t i v e J u s t i c e 9 - E q u a l i t y o r E q u i t y ? 10 - What i s F a i r ? 11 2. WHY THE KITIMAT-STIKINE REGIONAL DISTRICT? 14 - K i t i m a t - S t i k i n e Regional D i s t r i c t 16 Topography 16 - L i f e s t y l e 19 - Methodology . 21 S u b j e c t i v e Data 21 - O b j e c t i v e Data 23 v i 3. ACCESS • 25 - Access • • 25 - Paths and Obstacles 26 - Knowledge of Disease 27 - Knowledge of the System 29 Services 30 - Costs 32 - A v a i l a b i l i t y 34 Perceptions of A v a i l a b i l i t y 36 - The Problem of D e f i n i n g When One Is 111 39 - I s o l a t i o n 41 Dif f e r e n c e s i n Perception of Se r v i c e s Between Providers and Consumers 41 - Geographic I s o l a t i o n 44 - B e n e f i t s 47 - P u b l i c Health 50 H o s p i t a l Services 51 - Medical Care , 54 - Mental Health 55 Pharmacare 57 Dental Coverage 58 - ^Emergency Se r v i c e s 5 8 S p e c i a l Groups 60 E f f e c t on U t i l i z a t i o n 63 The Dilemma o f Access 63 4. POWER IN THE HEALTH SERVICES 67 - D i s t r i b u t i o n of Power 70 Pressure Groups 71 - P r o v i d e r s ' Groups ( I n t e r e s t Groups) 72 v i i Consumer Groups . . >___.J"V . .• .~ 74 J o i n t A c t i o n on Common I n t e r e s t s . . . . . . . 75 - Powers of Government 77 Powers of Delegated Bodies 77 - What Has Been Achieved? " 79 - A New Channel f o r Making Demands: _ The Regional D i s t r i c t . 81 5. DESCRIPTION OF HEALTH SERVICES IN KITIMAT-STIKINE REGIONAL DISTRICT . . 85 - F a c i l i t i e s 86 H o s p i t a l s 86 C l i n i c s , O f f i c e s and Businesses 91 - Manpower 9 3 - Programmes 99 - Acute Care 10 0 A l c o h o l i s m Treatment 101 Ambulance S e r v i c e 102 - Home Care 103 - Mental H e a l t h 10 3 Pl a n n i n g 104 P r e n a t a l Programmes 105 Pr e v e n t i v e Medicine 106 - R e h a b i l i t a t i o n & A c t i v i t i e s o f D a i l y L i v i n g . . 107 Con c l u s i o n 107 6. TWO VIEWS OF SERVICES: PEOPLE'S EXPECTATIONS (PROVISION) AND PLANNERS' EXPECTIONS (UTILIZATION) 109 People's E x p e c t a t i o n s 109 P r o v i d e r s ' E x p e c t a t i o n s . . . . . . 113 I n v e s t i g a t o r ' s E x p e c t a t i o n s . . . 117 v i i i 7. METHODOLOGY FOR OBJECTIVE- DATA ANALYSIS 12 2 Comparison Areas, Geographic I s o l a t i o n . . . . 125 - Methodology - 131 - Data ,. . 131 Methods of A n a l y s i s . 134 C a l c u l a t i o n s o f Expected S e p a r a t i o n s 135 8. IS THERE ACCESS? 142 A v a i l a b l e Resources 142" - H o s p i t a l Bed F a c i l i t i e s 142 - Manpowe r . .145 -' - Hospital" Utrii^'al^iolx- :;. . -. . .-;. -. . . . . 15 3 - Relationships o f . F a c t o r s 158 Regressions w i t h i n Regional D i s t r i c t s . . . . 164 - R e l a t i v e D e p r i v a t i o n 167 • — - Average -Leng.th-.o-f- Stay . . . 169 9 r DISEASE SPECIFIC HOSPITALIZATIONS 172 - O v e r a l l U t i l i z a t i o n by Disease Groups . . . . . . 174 - S e l e c t e d Disease Group U t i l i z a t i o n 175 I n f e c t i o u s Diseases 176 - Mal i g n a n c i e s 180 Mental Diseases 184 Ear I n f e c t i o n s 186 - Heart Diseases 189 - C e r e b r o v a s c u l a r and C i r c u l a t o r y C o n d i t i o n s . . 191 Ce r e b r o v a s c u l a r Diseases 191 C a r d i o v a s c u l a r and C i r c u l a t o r y C o n d i t i o n s . 194 Acute R e s p i r a t o r y I n f e c t i o n s 195 i x D i s c r e t i o n a r y S u r g e r i e s •-.198 Complications o f Pregnancy and D e l i v e r y . . . 199 - r - Complications o f Pregnancy 203 - Complications o f D e l i v e r y 203 - Diseases o f the J o i n t s 205 F r a c t u r e s and Traumatic I n j u r i e s 20 7 - C o n c l u s i o n . 210-10. . POLICY AND PLANNING IMPLICATIONS .215 - Regional~ D i s t r i c t s . . . . . . 215 - Manpower . . . . 218 - P r o v i s i o n o f an E q u i t a b l e S e r v i c e 219 APPENDICES ,,. ,. . . . 22 2 APPENDIX A T o t a l P o p u l a t i o n Changes i n 4 Regional D i s t r i c t s i n B r i t i s h Columbia, 1971, 1973, -1975 223 APPENDIX B C a l c u l a t e d P o p u l a t i o n s o f 4 Regional D i s t r i c t i n B r i t i s h Columbia f o r 1973 by Age and Sex . . 224 APPENDIX C C a l c u l a t e d P o p u l a t i o n s o f 4 Regional D i s t r i c t s i n B r i t i s h Columbia f o r 1975 by Age and Sex . . 225 APPENDIX D M o r t a l i t y Due to Malignant Diseases by Regional D i s t r i c t , . 1973 • 226 APPENDIX E M o r t a l i t y Due to Malignant Diseases by Regional D i s t r i c t , 1974 . 227 BIBLIOGRAPHY 228 X INDEX OF TABLES Table page I. Number of H o s p i t a l Beds A v a i l a b l e i n K i t i m a t - S t i k i n e Regional D i s t r i c t , 19 75. By l o c a t i o n 87 I I . S e r v i c e s o f f e r e d i n Acute Care i n K i t i m a t -S t i k i n e Regional D i s t r i c t , 19 75. By l o c a t i o n •. ... . 88 I I I . Non-Hospital F a c i l i t i e s i n K i t i m a t -S t i k i n e Regional D i s t r i c t , 1975, by l o c a t i o n and type 9 3 IV. H e a l t h S e r v i c e s Personnel i n K i t i m a t -S t i k i n e Regional D i s t r i c t , 19 75, by l o c a t i o n and type 94 V. Comparison o f A v a i l a b l e Beds and Cots f o r Acute and Extended Care i n Four Regional D i s t r i c t s o f B r i t i s h Columbia, 1973 and 1975 . 144 VI. Number and- Number per 10,000 p o p u l a t i o n H e a l t h S e r v i c e s Manpower A v a i l a b l e and P r a c t i c i n g i n Four Regional D i s t r i c t s i n B r i t i s h Columbia, 1975 by Category . . . . 146 V I I . Number and Number per Ten Thousand p o p u l a t i o n of P h y s i c i a n s i n Four Regional D i s t r i c t s i n B r i t i s h Columbia by S p e c i a l t y , 19 75, and T o t a l P h y s i c i a n Manpower, 1973 .148 V I I I . Number and Number per 10,000 p o p u l a t i o n o f Dental Care Manpower A v a i l a b l e i n Four Regional D i s t r i c t s i n B r i t i s h Columbia by Category, 19 75 149 IX. Number and Number per 10,000;. p o p u l a t i o n o f R e g i s t e r e d Nurses A v a i l a b l e and Employed i n Four Regional D i s t r i c t s i n B r i t i s h Columbia by Type o f Work, 19 75 150 X. Number and Number per 10,000 p o p u l a t i o n o f P u b l i c H e a l t h Personnel i n Four Regional D i s t r i c t s i n B r i t i s h Columbia, 1975 152 XI. Number o f Se p a r a t i o n s from'.British Columbia H o s p i t a l s of Residents and Number, of -Expected S e p a r a t i o n s , C o n s i d e r i n g Age and Sex Composition o f P o p u l a t i o n s f o r Four Regional D i s t r i c t s and B r i t i s h Columbia f o r Diseases #1 to #186 and by Year 155 x i Tables (Contd) page X I I . Ratio of Observed/Calculated Separations in- 19-73 f o r 186 Diseases CICDA-8L i n 4 Regional D i s t r i c t s o f B r i t i s h - Columbia . . . 156 X I I I . Ratio Observed/Expected Separations i n 197.5 f o r 186 Diseases .(.ICDA-8). i n 4 Regional D i s t r i c t s of B r i t i s h Columbia;.. . . . 156 ; XIV. C o r r e l a t i o n C o - e f f i c i e n t s of V a r i a b l e s , Observed and Expected Separations, P h y s i c i a n s , S p e c i a l i s t s and H o s p i t a l Beds i n 4 Regional D i s t r i c t s of B r i t i s h Columbia i n 1973 159 XV. C o r r e l a t i o n C o - e f f i c i e n t s of V a r i a b l e s , Observed and Expected Separations, P h y s i c i a n s , S p e c i a l i s t s , a n d H o s p i t a l Beds i n 4 Regional D i s t r i c t s of B r i t i s h Columbia, i n 19 75 159 XVIv Regression of Observed Separations w i t h Independent V a r i a b l e s : Expected Separations, Numbers of H o s p i t a l Beds, P h y s i c i a n s , S p e c i a l i s t s per 10,000 pop u l a t i o n i n 4 Regional D i s t r i c t s of B r i t i s h Columbia i n 1973 161 XVII. Regression of Observed Separations w i t h Independent V a r i a b l e s : Expected Separations, Numbers of Hospital..Beds, P h y s i c i a n s , S p e c i a l i s t s per 10,000 pop u l a t i o n i n 4 Regional D i s t r i c t s of B r i t i s h Columbia i n 1975 163 XVIII. Simple Regression of Observed w i t h Expected Separations from H o s p i t a l s of Residents of 4 Regional D i s t r i c t s i n B r i t i s h Columbia f o r 186 Disease Categories (ICDA-8) i n 1973 165 XIX. Simple Regression of Observed w i t h Expected Separations from H o s p i t a l s of Residents of 4 Regional D i s t r i c t s i n B r i t i s h Columbia f o r 186 Disease Categories (ICDA-8) i n 19 75 165 XX. T o t a l Numbers of H o s p i t a l Separations of Residents of 4 Regional D i s t r i c t s i n B r i t i s h .Columbia " f o r 186 Disease Categories (ICDA-8) f o r 1973 and 1975 by Loc a t i o n . . . . 168 x i i T ables (Contd) page XXI, XXII, XXIII Average Length o f Stay. for.. T o t a l . Diseases i n 4 •Region4 llvJ0is.tr,icts- i n B r i t i s h Columbia by L o c a t i o n 'arid Year \ . . . 170 I n f e c t i o u s D i s eases: Number of Se p a r a t i o n s from B r i t i s h Columbia.:- H o s p i t a l s and Number of Separ a t i o n s Expected C o n s i d e r i n g Age and Sex Composition o f P o p u l a t i o n f o r 4 Regional D i s t r i c t s and B r i t i s h Columbia by Disease Category and Year 177 S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s o f Ratio o f Observed to Expected S e p a r a t i o n s o f Residents o f 4 Regional D i s t r i c t s i n B r i t i s h Columbia i n 1975 wi t h A d m i t t i n g Diagnoses of I n f e c t i o u s Diseases . • . • 177 XXIV. M a l i g n a n c i e s : Number o f Separ a t i o n s from B r i t i s h Columbia H o s p i t a l s o f Residents and Number of Se p a r a t i o n s Expected C o n s i d e r i n g Age and Sex Composition o f Po p u l a t i o n s f o r 4 Regional Districts and B r i t i s h Columbia by Disease Category and Year 181 XXV. XXVI XXVII S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s o f Ratio o f Observed to Expected S e p a r a t i o n s o f Residents o f 4 Regional D i s t r i c t s i n B r i t i s h Columbia i n 1975 with A d m i t t i n g Diagnoses o f Malignant Neoplasms . . . Mental D i s e a s e s : Number o f Separ a t i o n s from B r i t i s h Columbia H o s p i t a l s and Number of S e p a r a t i o n s Expected C o n s i d e r i n g Age and Sex Composition o f P o p u l a t i o n s f o r 4 Regional D i s t r i c t s and B r i t i s h Columbia by Disease Category and Year 182 185 S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s o f Ratio of Observed to Expected S e p a r a t i o n s o f Residents o f 4 Regional D i s t r i c t s i n B r i t i s h Columbia i n 19 75 with A d m i t t i n g Diagnoses of Mental I l l n e s s 8 Diseases (ICDA #52059) . . . . 185 x i i i T ables (Contd) page XXVIII. XXIX. XXX. XXXI, XXXII XXXIII, Diseases o f the E a r : Number o f Se p a r a t i o n s from B r i t i s h Columbia H o s p i t a l s o f Residents and Number of Se p a r a t i o n s Expected C o n s i d e r i n g Age and Sex Composition o f P o p u l a t i o n f o r 4 Regional D i s t r i c t s and B r i t i s h . C o l u m b i a by Disease Category and Year 187 S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s o f Ratio o f Observed t o Expected S e p a r a t i o n s o f Residents o f 4- Regional. D i s t r i c t s i n B r i t i s h Columbia i n 1975 wi t h A d m i t t i n g Diagnoses o f Ear I n f e c t i o n s Diseases o f the Heart: Number of Separations from B r i t i s h Columbia H o s p i t a l s o f Residents and Number o f Separa t i o n s Expected C o n s i d e r i n g Age and Sex Composition o f P o p u l a t i o n s f o r 4 Regional D i s t r i c t s and B r i t i s h Columbia by Category and Year 187 190 S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s o f R a t i o o f Observed to Expected S e p a r a t i o n s o f Residents o f 4 Regional D i s t r i c t s i n B r i t i s h Columbia i n 19 75 with A d m i t t i n g Diagnoses o f Heart Diseases , Ce r e b r o v a s c u l a r and C i r c u l a t o r y D i s e a s e s : Number of Separ a t i o n s from B r i t i s h Columbia H o s p i t a l s and Residents and Number of Separa t i o n s Expected C o n s i d e r i n g Age and Sex Composition o f P o p u l a t i o n s f o r 4 Regional D i s t r i c t s and B r i t i s h Columbia by Disease Category and Year 190 192 S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s o f R a t i o o f Observed t o Expected S e p a r a t i o n s o f Residents o f 4 Regional D i s t r i c t s i n B r i t i s h Columbia i n 1975 with A d m i t t i n g Diagnoses o f C a r d i o v a s c u l a r D i s e a s e s r 193 XXXIV. S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s o f R a t i o o f Observed t o Expected S e p a r a t i o n s o f Residents o f 4 Regional D i s t r i c t s i n B r i t i s h Columbia i n 19-75 wi t h A d m i t t i n g Diagnoses o f Ce r e b r o v a s c u l a r Diseases 193 xiv Tables (ContcU page XXXV. XXXVI XXXVII, XXXVIII, XXXIX. XL. XLI, Acute Respiratory I n f e c t i o n s : Number of Separations from B r i t i s h . Columbia H o s p i t a l s of Residents and Number of Separations Expected Considering Age and Sex Composition of Populations f o r 4 Regional D i s t r i c t s and B r i t i s h Columbia by Disease Category and Year 196 S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s of Ratio of Observed to. Expected Separations of Residents of 4 Regional D i s t r i c t s i n B r i t i s h Columbia i n "1975 w i t h Admitting Diagnoses of Acute Respiratory I n f e c t i o n s 197 D i s c r e t i o n a r y Surgery: Number of Separations from B r i t i s h Columbia H o s p i t a l s of Residents and Number of Separations Expected Considering Age and Sex Composition of Population f o r 4 Regional D i s t r i c t s and B r i t i s h Columbia by Disease Category and Year S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s of Ratio of Observed to Expected Separations of Residents of 4 Regional D i s t r i c t s i n B r i t i s h Columbia i n 19 75 with Admitting Diagnoses of D i s c r e t i o n a r y Surgeries . S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s of Ratio of Observed to Expected .Separations o f Residents of 4 Regional D i s t r i c t s i n B r i t i s h Columbia i n 19 75 wi t h Admitting Diagnoses of D e l i v e r y Without Complications 199 199 201 Complications of Pregnancy: Number of Separations from B r i t i s h Columbia H o s p i t a l s of Residents and Number of Separations Expected Considering Age and Sex Composition of Populations f o r 4 Regional D i s t r i c t s and B r i t i s h Columbia by Disease Category and Ye ar S t a t i s t i c s from Frequency D i s t r i b u t i o n and t - t e s t s o f Ratio of Observed to Expected Separations of Residents of 4 Regional D i s t r i c t s i n B r i t i s h Columbia i n 1975 w i t h Admitting Diagnoses of Diseasess of Pregnancy 202 202 X V T a b l e s CContd) X L I I . X L I I I X L I V . XLV. X L V I . XL V I I , p a g e C o m p l i c a t i o n s o f D e l i v e r y : Number o f S e p a r a t i o n s f r o m B r i t i s h . C o l u m b i a H o s p i t a l s o f R e s i d e n t s a n d Number o f S e p a r a t i o n s E x p e c t e d C o n s i d e r i n g Age an d S e x C o m p o s i t i o n o f P o p u l a t i o n f o r 4 R e g i o n a l D i s t r i c t s a n d B r i t i s h C o l u m b i a b y D i s e a s e C a t e g o r y a n d Y e a r . . S t a t i s t i c s f r o m F r e q u e n c y D i s t r i b u t i o n a n d t - t e s t s o f R a t i o o f O b s e r v e d t o E x p e c t e d S e p a r a t i o n s o f R e s i d e n t s o f 4 R e g i o n a l D i s t r i c t s i n B r i t i s h C o l u m b i a i n 19 75 w i t h A d m i t t i n g D i a g n o s e s o f C o m p l i c a t i o n o f D e l i v e r y 204 204 D i s e a s e s o f t h e J o i n t s : Number o f S e p a r a t i o n s f r o m B r i t i s h C o l u m b i a H o s p i t a l s o f R e s i d e n t s a n d Number o f S e p a r a t i o n s E x p e c t e d C o n s i d e r i n g Age a n d S e x C o m p o s i t i o n o f P o p u l a t i o n s f o r 4 R e g i o n a l D i s t r i c t s a n d B r i t i s h C o l u m b i a b y D i s e a s e C a t e g o r y a n d Y e a r . . S t a t i s t i c s f r o m F r e q u e n c y D i s t r i b u t i o n a n d t - t e s t s o f R a t i o o f O b s e r v e d t o E x p e c t e d S e p a r a t i o n s o f R e s i d e n t s o f 4 R e g i o n a l D i s t r i c t s i n B r i t i s h C o l u m b i a i n 19 75 w i t h A d m i t t i n g D i a g n o s e s o f D i s e a s e s o f t h e J o i n t s 206 206 F r a c t u r e s a n d T r a u m a t i c I n j u r i e s : Number o f S e p a r a t i o n s f r o m B r i t i s h C o l u m b i a H o s p i t a l s o f R e s i d e n t s a n d Number o f S e p a r a t i o n s E x p e c t e d C o n s i d e r i n g Age a n d S e x C o m p o s i t i o n o f P o p u l a t i o n s f o r 4 R e g i o n a l D i s t r i c t s a n d B r i t i s h C o l u m b i a b y D i s e a s e C a t e g o r y : a n d Y e a r S t a t i s t i c s f r o m F r e q u e n c y D i s t r i b u t i o n a n d t - t e s t s o f R a t i o o f O b s e r v e d t o E x p e c t e d S e p a r a t i o n s o f R e s i d e n t s o f 4 R e g i o n a l D i s t r i c t s i n B r i t i s h C o l u m b i a i n 1975 w i t h A d m i t t i n g D i a g n o s e s o f T r a u m a t i c . . . " I n j u r i e s 209 209 xvi INDEX OF MAPS . page MAP i , REGIONAL DISTRICT OF KITIMAT-STIKINE 15 MAP 2 LOCATION OF HEALTH FACILITIES IN KITIMAT-STIKINE REGIONAL DISTRICT 90 MAP 3 MAP, OF BRITISH COLUMBIA SHOWING LOCATION OF 4 REGIONAL DISTRICTS . . .... . . . 130 x v i i ACKNOWLE DGEMENTS Th i s study, l i k e o t h e r s , would not have been completed without the h e l p o f many people. I should l i k e t o acknowledge the a s s i s t a n c e I was given f o r i t has meant a g r e a t d e a l to me. F i r s t and foremost, the members of my t h e s i s committee: Dr. A.O.J. C r i c h t o n , who helped me formulate and d e l i n e a t e the concepts of e q u i t y i n the e a r l y stages; Dr. R.G. (Bob) Evans and Dr. R.B. Splane, who c o n t i n u a l l y encouraged me to " f o r g e ahead" and whose h e l p i n a n a l y z i n g the data and exchanging ideas was much g r e a t e r than I had envisaged when they agreed to a s s i s t me. They r e a l l y have been most h e l p f u l . The data on h o s p i t a l s e p a r a t i o n s were c o l l e c t e d by Dr. D.O. Anderson and the l a t e Margaret Wertz o f H e a l t h Manpower Research & Development, U n i v e r s i t y o f B.C. Wendy Manning s u p p l i e d me w i t h a good d e a l of source m a t e r i a l as w e l l as encouragement. Dr. Annette /Stark-- p r o v i d e d a s s i s t a n c e i n the l a t e s t a g es. The K i t i m a t - S t i k i n e Regional D i s t r i c t a s s i s t e d me i n s e v e r a l ways; they employed me one summer i n a p r o j e c t from which- t h i s study evolved; they c o n t r i b u t e d towards the t y p i n g expenses. In a d d i t i o n , John Pousette, S e c r e t a r y -T r e a s u r e r of K i t i m a t - S t i k i n e Regional D i s t r i c t s u p p l i e d me x v i i i w i t h i n f o r m a t i o n about the e f f e c t s o f the economy on the area d u r i n g the p e r i o d under study. There are many f r i e n d s and classmates who s u p p l i e d encouragement and r e a l a s s i s t a n c e . Outstanding among them are C a r o l Gray, Rosemaree G e n t l e s , Lynn H a r r i s , Diane Layton, Margaret McPhee, Ted Myers, M i k k i Naruse, Pat N o r f i e l d , Sarah Y a r i e and a g a i n , Wendy Manning. F i n a l l y , my f a t h e r , who i n h i s 90th year, taught stroke-handicapped f i n g e r s to operate a c a l c u l a t o r f o r me and my s i s t e r , Doreen must be mentioned f o r both the r e a l and q u i e t support and encouragement they have g i v e n me. xix TO S.D. HAROLD POPE and the memory of A.A. ARTHENA POPE c o n t i n u i n g sources o f i n s p i r a t i o n and joy Chapter 1 FAIR SHARES OF HEALTH SERVICES Northern B r i t i s h Columbians view th e i r health services as unfair. This unfairness i s related to the r e l a t i v e geographic i s o l a t i o n and to the inconvenience they frequently experience when obtaining health care. Objective measures of health care and health services w i l l show that i n some instances, t h e i r subjective view that they receive an unfair share of these services and care i s correct, but that i n other cases t h e i r view i s not v a l i d . In these l a t t e r cases they have rather more service than people l i v i n g i n the urban south of the province. Amongst the Non-Native population, despite u t i l i z a t i o n differences, the use of current health l e v e l measures of the people (the outcome of the health system) as indices, does not e s t a b l i s h that unfairness e x i s t s . Rather, the unfairness i s i n d i f f e r e n t i a l costs of access to health care manpower and f a c i l i t i e s (through-put factors i n the health system). This i s not always shown by the u t i l i z a t i o n of health care factors. 2 DESCRIPTION OF CANADIAN HEALTH SERVICES In a p l u r a l i s t i c s o c i e t y such as Canada's, the h e a l t h s e r v i c e system r e f l e c t s the value s of many d i v e r s e groups with sometimes c o n f l i c t i n g aims and b e l i e f s . The components of t h a t system are the r e s u l t of complex b a r g a i n i n g aud n e g o t i a t i n g between the i n t e r e s t e d groups. Together they comprise the complicated and i n t e r - c o n n e c t e d system which enables Canadians by and l a r g e t o enjoy a l e v e l of h e a l t h which ranks high amongst the n a t i o n s of the world. Health care i t s e l f i s under p r o v i n c i a l j u r i s d i c t i o n . When the B r i t i s h North America A c t forming Canada's c o n s t i t u t i o n was w r i t t e n , h o s p i t a l s and h e a l t h care were assigned e x c l u s i v e l y to p r o v i n c i a l j u r i s d i c t i o n e x c e p t i n g marine h o s p i t a l s . Over time, the p r o v i n c e s have maintained t h e i r c o n t r o l of h e a l t h care by p a s s i n g a c t s governing the p r o v i s i o n of many f a c e t s of h e a l t h care,;. e-.jg_.r--training, l i c e n s i n g , a u t h o r i t y and autonomy of h e a l t h p r o f e s s i o n a l s , p o t a b l e water standards. The f e d e r a l government maintained j u r i s d i c t i o n over s i c k mariners, m i l i t a r y and Royal Canadian Mounted P o l i c e p e r s o n n e l , immigration and n a t i v e peoples. RESPONSIBlLITY FOR HEALTH CARE, There i s an assumption i n Canada t h a t h e a l t h i s a pe r s o n a l r e s p o n s i b i l i t y . Lalonde has emphasized the need f o r i n c r e a s e d i n d i v i d u a l concern f o r one's p e r s o n a l h e a l t h . 3 . . . i n d i v i d u a l blame must be accepted by many f o r the d e l e t e r i o u s e f f e c t on h e a l t h of t h e i r r e s p e c t i v e l i f e s t y l e s . Sedentary l i v i n g , smoking, o v e r - e a t i n g , d r i v i n g while impaired by a l c o h o l , drug abuse and f a i l u r e to wear s e a t - b e l t s are among the many c o n t r i b u t o r s t o p h y s i c a l or mental i l l n e s s f o r which the i n d i v i d u a l must accept some r e s p o n s i b i l i t y and f o r which he should seek c o r r e c t i o n . 1 (p.26) S i m i l a r l y , there i s a p e r s o n a l r e s p o n s i b i l i t y f o r the i l l i n d i v i d u a l t o seek care t o r e s t o r e h i m s e l f t o a h e a l t h y s t a t e . There i s no onus on e i t h e r the s t a t e o r h e a l t h care p r o f e s s i o n a l s t o seek out the i l l or unhealthy. Health Care i s n e i t h e r r i g h t nor p r i v i l e g e , but r a t h e r a s e r v i c e t o be used when needed and f o r which the c i t i z e n may expect to pay the c o s t s . The B i l l of Rights of Canada does not mention h e a l t h . Nor do the many p r o v i n c i a l B i l l s of R i g h t s . The World Health O r g a n i z a t i o n attempted to d e f i n e c i t i z e n r i g h t s t o h e a l t h but the statement i s not p r a c t i c a b l e e i t h e r i n remote areas of wealthy n a t i o n s or i n the dev e l o p i n g c o u n t r i e s . Indeed, the H a l l Commission r e p o r t , i n i t s Health C h a r t e r f o r Canadians, l i m i t s the h e a l t h care Canadians l i v i n g i n remote and s p a r s e l y populated areas can expect to have a v a i l a b l e . . . . " U n i v e r s a l " means t h a t adequate h e a l t h s e r v i c e s s h a l l be a v a i l a b l e to a l l Canadians wherever they r e s i d e and whatever t h e i r f i n a n c i a l resources may be, w i t h i n the l i m i t a t i o n s imposed by geographic f a c t o r s . 2 (p.11) However, wh i l e h e a l t h maintenance i s regarded as a p e r s o n a l r e s p o n s i b i l i t y , there i s acceptance by Canadians o f a s o c i a l r e s p o n s i b i l i t y t h a t c o s t s i n c u r r e d i n the maintenance of and r e t u r n to h e a l t h not f i n a n c i a l l y c r i p p l e a f a m i l y . The need f o r h e a l t h care i s u n p r e d i c t a b l e . Not 4 only may the services and treatments be costly, there may also be time l o s t at work. There i s then, provision for the time l o s t from work because of i l l n e s s . As well, a system of tax-funded or contributory plans has evolved to cover payment for the treatment of the p o t e n t i a l l y and predictably most costly i l l n e s s e s and conditions and prevention of the most serious infectious diseases. PUBLIC FUNDED SERVICES Those services with universal and most consequential benefit are provided by p r o v i n c i a l health departments and funded from general taxes. Services are available (without further charge) to a l l residents and i n areas of communicable disease control such as water purity, garbage and sewage disposal, the department has l e g a l j u r i s d i c t i o n and authority over a l l residents. The services provided i n the public health service are diverse. The communicable disease control concerns mentioned above are augmented by tuberculosis screening and immunization programmes. While these are not compulsory, there i s strong s o c i a l pressure to ensure that babies and children are immunized against diseases such as smallpox, diphtheria, tetanus, typhoid fever and p o l i o m y e l i t i s . Immunization of the adult population outside the schools i s also provided free and includes protection for diseases indigenous to other c o u n t r i e s b u t * i t i s the r e s p o n s i b i l i t y of the adult population to obtain immunologic protection. Other preventive services are directed towards high r i s k groups with prenatal programmes, new baby health c l i n i c s , venereal disease control, pre-school t e s t i n g to observe and ensure 5 normal development and e a r l y d i a g n o s i s of mental, p h y s i c a l and s o c i a l development problems and d e n t a l care of c h i l d r e n . The e s t a b l i s h m e n t of Community Mental H e a l t h Centres allows e a r l y and l o c a l treatment of mental h e a l t h problems and i l l n e s s e s . Community c l i n i c s , day c e n t r e s , o v e r n i g h t h o s t e l s c o n t r i b u t e t o the e f f e c t i v e n e s s of the programmes and a s s i s t i n p r o v i s i o n o f e a r l y treatment and p r e v e n t i o n of p s y c h i a t r i c c r i s e s . NATIONAL HEALTH COVERAGE S o c i a l i z e d h e a l t h care was i n t r o d u c e d throughout Cam'!eta to cover h o s p i t a l i z a t i o n with the H o s p i t a l -Insurance and D i a g n o s t i c S e r v i c e s Act of _195 8^--..-Services covered i n c l u d e d not o n l y h o s p i t a l accommodation, n u r s i n g care and medication but a l s o l a b o r a t o r y and x-ray t e s t s . D i a g n o s t i c t e s t s f o r o u t - p a t i e n t s were i n c l u d e d i n the A c t . The e s s e n t i a l aspects of t h i s f e d e r a l programme were t h a t the coverage be f o r a l l r e s i d e n t s i n a p a r t i c i p a t i n g p r o v i n c e , t h a t i t i n c l u d e a l l of the above mentioned s e r v i c e s and have minimal or no charges l e v i e d a t the time of s e r v i c e . In B r i t i s h Columbia, ;prpvincial~"revenue was •obtained from a s a l e s tax but' is--now from g e n e r a l revenue. The M e d i c a l S e r v i c e s Act, enacted by the P a r l i a m e n t of Canada i n 1968, was a l s o based on the concept of a p r e p a i d , u n i v e r s a l and comprehensive s e r v i c e being p r o v i d e d to a l l r e s i d e n t s . There i s no charge l e v i e d at time of s e r v i c e . In B r i t i s h Columbia, a monthly fee i s p r e p a i d by the members.* The programme i s s u b s i d i z e d from g e n e r a l t a x a t i o n . M e d i c a l s p e c i a l i s t s ' s e r v i c e s are covered upon r e f e r r a l by a g e n e r a l p r a c t i t i o n e r as are those of p h y s i o t h e r a p i s t s . Coverage i n c l u d e s o p t o m e t r i s t s and p o d i a t r i s t s , but those of o c c u p a t i o n a l t h e r a p i s t s *See page 54. 6 and d i e t i c i a n s are omitted. Since 1973, the cost of drugs i s covered under a p r o v i n c i a l programme which i s neither universal nor comprehen-sive. Prescription drugs are covered for people s i x t y - f i v e and over, for the poor and those who spend more than $80. per year on prescribed medicines. Drugs c l a s s i f i e d as "over-the-counter" drugs, such as A.S.A., are not included, even when prescribed. Payment of t h i s programme i s from general revenue. SPECIAL BENEFITS There i s a growing need for dental care which can be met by the expansion of dental technology. The absence of a fee at the time of service for most other health care services has led to a demand by many for programmes to meet the costs of dental care. Many unions are negotiating dental insurance programmes i n t h e i r contracts with the premiums sometimes paid by the employer. These programmes are not comprehensive and o f f e r a variety of.coverage. As well, there may be a fee charged at the time of service. The insured person i s sometimes reimbursed by the insuring company for a l l or part of t h i s fee. Newly established p r o v i n c i a l programmes include hospital costs "cTf^extended care, 'long -term_care^^ services. Extended care hospital beds are provided for non-ambulant long-term i l l . The long term care programme which i s cost-shared by the federal government, offers a diverse range of services that enable people to remain i n independent l i v i n g arrangement - from intermediate nursing and boarding home care through to home help services. Rehabilitation hospitals provide r e h a b i l i t a t i o n 7 services for victims of stroke, i n d u s t r i a l and automobile and sporting accidents. These- are programmes based on the premise of c o l l e c t i v e r e s p o n s i b i l i t y for the d i r e c t costs of health maintenance and restoration. Indirect costs such as transpor-tation to care and income loss while receiving care are a personal r e s p o n s i b i l i t y as i s the d i r e c t cost of the Medical Services Plan premium. There are groups of people who are absolved of these r e s p o n s i b i l i t i e s . Accident victims are not charged for ambulance transportation to a primary health care centre i n an emergency. Workers injured at or because of work receive acute care treatment and r e h a b i l i t a t i o n as well as guaranteed income. People receiving s o c i a l assistance have th e i r medicare and pharmacare coverage premiums paid by government. The health care needs of Status Indians are paid for by the federal government. There may be a nurse-practitioner located i n the v i l l a g e supplemented by periodic v i s i t s of doctors, dentists, etc., or the care may be supplied by health care professionals or hospital personnel i n the nearest town. A health services system i n Canada has evolved which spreads the f i n a n c i a l r i s k of i l l n e s s over the tax-paying population, places some r e s p o n s i b i l i t y for health on the i n d i v i d u a l , guarantees the professional provider and the patient freedom to choose each other and seeks to ensure that no c i t i z e n or resident w i l l choose not to seek care because of an i n a b i l i t y to pay for the care. For the most costly medical services, 8 there i s equal coverage for a l l . MEASURES OF HEALTH SERVICES One can l i s t the health services for which the population has coverage; one can measure the f a c i l i t i e s and personnel available to provide services;one can measure the health l e v e l of the people, but such objective measures w i l l say l i t t l e about equity or inequities i n the system. F a i r -ness i s , to a degree, a subjective matter, and i t i s the obstacles to care each i n d i v i d u a l has personally had to hurdle that are his measure. He does not care how many physicians per thousand people there are. He i s concerned that when he needs a doctor, there i s one near whom he can consult. I f he must wait for an appointment, i f he must leave the area, i f he must delay seeking treatment u n t i l his summer holidays and i f he suspects or knows others who do not, he w i l l complain about inequities i n the system that conventional objective measures do not reveal. RELATIVE DEPRIVATION This comparison of one's own s i t u a t i o n with one's perception of others' situations results i n feelings of r e l a t i v e deprivation. I t occurs i n two ways. Usually, the comparison i s made upward i n s o c i a l structure i n that a person sees others with something he wants or feels he should have but does not have. It can, of course, be made downward or l a t e r a l l y as when a person who i s used to having more than someone else sees that the d i f f e r e n t i a l between the i r possessions, buying power, etc. has diminished. In both instances, and a l -though basic needs such as food, shelter and clothing are 9 adequately met, the person w i l l f e e l deprived r e l a t i v e to the person with whom he i s making the comparison. People l i v i n g i n a community which has been, since i t s inception, the largest one i n the d i s t r i c t , may f e e l deprived when d i f f e r e n -t i a l growth rates r e s u l t i n another town becoming larger and developing services that the people i n the previous leading community expect to have. Relative deprivation gives r i s e to strong feelings of inequity. An objective view of the whole s i t u a t i o n i n which each person l i v e s would frequently not show r e a l deprivation. The subjective viewpoint that leads to Relative Deprivation i s focused on a narrow range of goods and services. Because of the al i e n a t i o n that occurs when people experience inequities over long periods of time, i t i s important that people be educated to understand the special needs that some people have, s a t i s f a c t i o n of which appears to others to be p r e f e r e n t i a l . In t h i s way, r e l a t i v e deprivation and the perception of inequity can be minimized. DISTRIBUTIVE JUSTICE There are differences in the health care coverage for certain people as mentioned e a r l i e r . There are reasons for t h i s . Indians have a high morbidity rate and a lower l i f e expectancy than Non-Natives. People on s o c i a l assistance may not be able to e f f i c i e n t l y protect themselves from disease. People injured at work may need long term (and expensive) r e h a b i l i t a t i o n for i n j u r i e s sustained i n situations they would not otherwise have been i n . There i s some attempt made to compensate people for 10 sickness r e s u l t i n g from unequal conditions of b i r t h , s i t u a t i o n or extreme hardship. In respect to health, d i s t r i b u t i v e j u s t i c e would require that differences i n health care and services be based on sound, basic differences i n the popula-tions served and t h e i r needs, as well as i n the organization or the structure of the health system serving the population. Categories are established a r b i t r a r i l y and the q u a l i f i c a t i o n s necessary for c l a s s i f i c a t i o n i n the category are based on i t s d e f i n i t i o n . There may be some who q u a l i f y for the special benefits by category d e f i n i t i o n but who do not share the special problems of the group as a whole. If these people receive the benefits of the c l a s s i f i e d group, others not so c l a s s i f i e d may experience r e l a t i v e deprivation rather than seeing the others' special service as d i s t r i b u t i v e j u s t i c e . The equity that should r e s u l t from the special services w i l l have become, i n some,eyes, unfair. EQUALITY OR EQUITY? Equality i s a condition applied to two or more items which have the same measure. Applied to people, equality may mean they have the same income, status, power, or rights to vote, speak or receive education. Equality usually refers to equal ri g h t s or opportunity. The health care system (with i t s universal coverage) i s developed on the concept of equality. An equal service may not, however, be f a i r . People may have special needs or be i n special situations. A service which does not solve the s p e c i f i c problems which arise from these; which does not r e s u l t i n d i f f e r e n t services to s a t i s f y 11 d i f f e r e n t needs, w i l l lack d i s t r i b u t i v e j u s t i c e . To have equity, there must be d i s t r i b u t i v e j u s t i c e , and there must be minimal r e l a t i v e deprivation. WHAT IS FAIR? What i s f a i r w i l l depend on one's vantage point. The health planner, concerned about the apparently endless costs in s a t i s f y i n g r i s i n g health care expectations of the people, and aware of the obvious i m p o s s i b i l i t y of supplying sophisticated health care i n remote areas, may not see inequities keenly f e l t by people i n less populous regions. I t i s not the planner's, but the residents' views, which are of concern, for i t i s the residents who sense i n j u s t i c e . People i n the north want to have, a doctor or other health professional available when needed and be able to consult him with neither delay nor s o c i a l or economic costs higher than t h e i r friends and r e l a t i v e s who l i v e i n southern, less remote areas. Their concern i s with access to health care. And while access to care may have an e f f e c t on the outcome of the i l l n e s s , access and outcomes are neither i d e n t i c a l nor equal. The a v a i l a b i l i t y of manpower or f a c i l i t i e s to provide health care or services i s determined by many groups and bodies. The relationships between these groups, t h e i r various j u r i s d i c -tions and t h e i r power to obtain t h e i r varying and sometimes at variance goals are important factors i n the organization and structure of the health system. Regional inequities may arise, because of d i f f e r e n t i a l power both between regional d i s t r i c t s and 12 also between groups within a regional d i s t r i c t . I t i s the use of t h i s power that enables the people i n an area to obtain the services, manpower and f a c i l i t i e s they f e e l they.need. In any society, there are l i m i t s to the amount of funds that are available for health care. This requires society to make choices;one type of programme may be funded, another i s not. If one service receives more funds, there i s less money l e f t to be spent on another programme. A surplus of health care i s as inequitable as a deficiency because i t produces a deficiency elsewhere. It i s at lea s t equally important that the people i n an area see that t h e i r needs are being met f a i r l y ; that i s , i n respect to t h e i r s i t u a t i o n and the available resources. Lack of information about other people's situations may lead one group to view themselves as disadvantaged, when, i n r e a l i t y , they.are not. People who f e e l deprived w i l l exert pressure to obtain more services. To be f a i r , an equitable amount and kind of health services must be available i n d i f f e r e n t areas to the populations in each area without undue hardship. Differences i n the s i t u a -tions in the areas may give r i s e to differences i n the services or care available i n order to ensure the a b i l i t y to gain equivalent access to health care, i n d i f f e r e n t areas. These differences must be seen to be necessary i n order to provide equal access i f the people i n each area are to believe the system i s f a i r . REFERENCES Chapter 1 Lalonde, Marc. A New Perspective on the Health of  Canadians, A Working Document. Ottawa, Government Canada, A p r i l 19 74. Canada, Royal Commission on Health Services, Vol. 1, 1964. 14 Chapter 2 WHY THE KITIMAT-STIKINE REGIONAL DISTRICT? In the summer of 197 5 a team of graduate students from the Department of Health Care and Epidemiology, Faculty of Medicine at the University of B r i t i s h Columbia, was asked to review the e x i s t i n g health services i n the Kitimat-Stikine Regional D i s t r i c t and develop a programme for future development. I t became rapidly apparent to the team members that the people i n the regional d i s t r i c t shared strpngly-held views about how they related to the rest of the province. Northerners appeared to believe that because they l i v e i n the North, they do not receive t h e i r f a i r share of the resources i n the province. These views were shared by people i n neighbouring regional d i s t r i c t s which have s i m i l a r i t i e s i n demographic c h a r a c t e r i s t i c s . I t i s possible that the perceived inequities are i n part a r e s u l t of the geographic i s o l a t i o n of the areas from the large metropolitan centres of southern B r i t i s h Columbia. Because this raises issues with important implications for the a l l o c a t i o n and d i s t r i b u t i o n of health care resources, i t was decided a thesis should be done to objectively test the v a l i d i t y of the subjective feelings REGIONAL DISTRICT OF KITIMAT-STIKINE /.•* w< 16 that Northerners do not receive t h e i r f a i r share of health care. KITIMAT-STIKINE REGIONAL DISTRICT This i s not a pastoral land. I t i s a land of grand, towering mountains separated by vast and powerful r i v e r s . The benches of land which man can comfortably inhabit and make his domain are narrow and frequently shrouded i n mists and cloud. I t i s a majestic and mystic land; worthy of the awesome legends of the Bear and the Thunderbird which have passed to us from the Native people who have l i v e d i n the area for so long. Not here do we f i n d the peaceful meadow and meandering streams of ru r a l dairy farms. Rather, we fi n d roads scrambling alongside and sometimes across wild and rushing streams and r i v e r s ; we f i n d mudslides i n spring and f a l l , avalanches i n winter; a strong and powerful land which takes strong and independent people to s e t t l e . The land does not shape the people who l i v e there so much as i t chooses them. Only the adventuresome choose to go there and only the hardy remain. TOPOGRAPHY The Kitimat-Stikine Regional D i s t r i c t i s a very large area i n north-west B r i t i s h Columbia. Its northern boundary i s just north of Telegraph Creek and follows the 58th p a r a l l e l for 225 kilometers. Its other boundaries are ir r e g u l a r but the regional d i s t r i c t extends 585 kilometers south to Price Island near the 52nd p a r a l l e l . The western boundary follows the Alaska border, down the Portland Canal and swings eastward, south of the Naas around and excluding Prince Rupert, south of which the western boundary i s the sea. Its eastern boundary i s as i r r e g u l a r , but the d i s t r i c t i s generally about 22 5 kilometers wide. It i s an extremely mountainous area with narrow valleys along the r i v e r s between very high ranges. There are numerous ice f i e l d s as well as volcanic areas. Three riv e r s dominate the regional d i s t r i c t ; the Skeena, the Naas and the Stikine. The climate i s varied as one would expect of such a large area. The coastal areas have moderate temperatures and heavy r a i n f a l l . The normal winter-summer temperature range at the coast i s -l-l°c. to 23°C. R a i n f a l l i s 2 00 centimeters per annum, while the heavy p r e c i p i t a t i o n i n winter averages 6 metres snow at the heads of the i n l e t s and more at high elevations. In the i n t e r i o r , temperatures are more extreme and vary from -18°C. to 2 8°C. Rain and snowfalls are half that of the coast. In the north of the regional d i s t r i c t , temperatures i n the winter are colder s t i l l with snowfall being l e s s . Daylight hours vary greatly from winter to summer, depending on the l a t i t u d e . In Stewart, there are about 7 hours of daylight in winter, while i n summer, there are about f i v e hours of darkness. The length of day experienced i n the regional d i s t r i c t varies tremendously as one would expect i n a d i s t r i c t that i s nearly 600 kilometers from north to south. 18 Transportation and communication are important i n uniting people over such a vast countryside. Highway 16 and the Canadian National Railway follow the Skeena River on an east-west path. There i s road and also r a i l connection from Terrace to Kitimat. There are bridges and cable f e r r i e s which cross the Skeena between Terrace and Hazelton. The Naas i s crossed by boat at Greenville and New Aiyansh, by footbridge at Canyon City and by road bridge on:the Kitwanga access road to the Stewart-Cassiar Highway. The access road i s not highway standard; the Stewart-Cassiar Highway i s a gravel highway. R a i l and road networks depend upon the passes through the high mountain ranges. The Stewart-Cassiar Highway connects to the Alaska Highway at Watson Lake, Yukon T e r r i t o r i e s , and to the Kitwanga Access road at Meziadin Lake. Telegraph Creek i s connected by road to this highway. There i s currently r a i l l i n e construction towards the Naas and also i n the north of the Regional D i s t r i c t . The Naas Valley i s connected to Terrace and Kitwanga by a network of private logging roads. There are regular commercial a i r f l i g h t s to Terrace, to Stewart and to the north of the regional d i s t r i c t . While there are emergency landing fields throughout the regional d i s t r i c t , there are no navigational aids north of the Naas River. Thus, f l y i n g i s r e s t r i c t e d to daylight hours. There i s telephone service i n the centres along the Skeena, i n Kitimat and i n Stewart. Other areas are contacted by radio-telephone. 19 LIFESTYLE I t was s a i d e a r l i e r t h a t the North chooses the people who l i v e t h e r e . While t h i s does not apply to the Native p o p u l a t i o n , i t i s c e r t a i n l y t rue f o r the Non-Natives, p a r t i c u l a r l y those who s e t t l e away from the towns. There i s a freedom i n northern l i v i n g t h a t s outherners, with t h e i r c o n c r e t e sidewalks, highspeed freeways, c o n c e n t r a t e d p o p u l a t i o n and t r a f f i c c o n g e s t i o n , l a c k . In a l a n d where mudslides and avalanches block highways and weather c a n c e l s a i r t r a v e l with a frequency b o r d e r i n g on r e g u l a r i t y , i f not p r e d i c t a b i l i t y , people do not f r e t over delays and postponed meetings. Accepted w i t h a shrug, they are a p a r t of l i f e . The i s o l a t i o n e f f e c t e d by such breaks i n t r a v e l communication i s t o l e r a b l e o n l y to people w i t h a g r e a t d e a l of s e l f - r e l i a n c e , e s p e c i a l l y i n areas where the r a d i o -telephone i s the l i n k w i t h ' c i v i l i z a t i o n 1 . U n r e l i a b l e due to atmospheric c o n d i t i o n s , t h i s communication l i n k may be broken f o r days a t a time. Understandably, t h e r e i s a s o c i a l bond between people l i v i n g i n such a l a n d . There i s a concern f o r each other, a r e l a x e d openness amongst the people and the ready o f f e r of a needed h e l p i n g hand. A c t i v i t i e s are p r i m a r i l y the s p o r t i n g a c t i v i t i e s of outdoorsmen; hunting, f i s h i n g , h i k i n g , s k i i n g . There are a l s o indoor r e c r e a t i o n and n i g h t s c h o o l programmes i n the towns and the f a c i l i t i e s of a community c o l l e g e i n T e r r a c e . In Stewart, there are seasonal a c t i v i t i e s such as e r e c t i n g the fence i n s p r i n g 20 and taking i t down in l a t e autumn. Dances, plays and concerts i n a l l towns are l o c a l l y organized and produced.>-These are the a c t i v i t i e s of the people i n the north; for some they are recreational, for others they are necessary to survive. The Native does/not choose the North; i t i s his heritage. He hunts and fishes for food as does the Non-Native who l i v e s i n the more remote areas of the regional d i s t r i c t . Both may cut through lake ice for water i n the winter. The Non-Native has chosen t h i s l i f e s t y l e for the other freedoms i t gives. The North has been c a l l e d Canada's l a s t f r o n t i e r and most go to i t with hopes that they w i l l be able to make a l i v e l i h o o d better than they can i n the south. Many are not equipped by education or t r a i n i n g to do s k i l l e d work or to take part i n the a c t i v i t i e s of the North. The cost of l i v i n g 'and building costs are high i n the North; s k i l l e d workers are paid higher s a l a r i e s than th e i r counterparts i n southern B r i t i s h Columbia. For those people who cannot cope with northern l i v i n g , the costs of leaving may be too high. These people would not choose to remain i n the North, but there i s nowhere else they can go. These are the people who need the helping hand. As the snow f a l l s and the darkness and cold of a long winter set i n , the need for s e l f - r e l i a n c e increases. L i v i n g outside municipal boundaries because land and taxes are cheap, possessing one car at the most per household, these people experience an imprisonment by the North. T r a i l e r -21 housing, p o o r l y i n s u l a t e d and w i t h r o o f s u n s u i t e d t o high snowloads forms, f o r the poor, a v i r t u a l c e l l i n which a l l a c t i v i t i e s o f l i v i n g occur. They are unable to get out of them and r e c e i v e what s t i m u l a t i o n and a s s i s t a n c e the town's amenities p r o v i d e . L o n e l i n e s s , h e l p l e s s n e s s and d e p r e s s i o n may remove the a b i l i t y to cope. Northerners are very aware of both groups of people; those who cope i n the North and those who can n e i t h e r cope wit h nor escape from the North. The a b i l i t y to cope depends on a s t r o n g and h e a l t h y physique as much as on a s t a t e of mind. Because t h e i r l i f e s t y l e s are so v i g o r o u s , n o r t h e r n e r s worry about dangers to t h e i r h e a l t h . For an a t t a c k on a person's h e a l t h can convert someone who copes w i t h and lo v e s the North t o someone who cannot cope and must leave i t . METHODOLOGY Much of the i n f o r m a t i o n f o r t h i s t h e s i s came from the l a r g e r study which was p a r t o f the p l a n developed i n 1975. I t was d u r i n g t h i s study t h a t these problems i n v o l v e d i n h e a l t h s e r v i c e s d e l i v e r y became apparent. The data which ,were used to t e s t whether or not s e r v i c e s were equal o r f a i r o r equal and f a i r were generated i n the autumn of 1976. The data t h a t were analyzed were the a v a i l a b i l i t y and u t i l i z a t i o n of h o s p i t a l ~ f e s o u r c e s - i n the years 1973 land 1975. SUBJECTIVE DATA Interviews were conducted w i t h many p r o v i d e r s of 22 health care or health services i n the Kitimat-Stikine regional d i s t r i c t i n the summer of 1975. A l l the people interviewed had some connection with the provision of health care or services; e i t h e r at the pol i c y making l e v e l or as providers of care or services, or as active representatives of voluntary agencies which supply supportive services i n the health care system. The interviews were unstructured but planned i n advance to ensure important questions were answered. The lack of obvious structure allowed the introduction of new topics of relevance to the interviewee. Subjective information gained i n one interview was v e r i f i e d i n interviews with other people. The information was bound together and authenticated by documentary evidence. A large portion of the regional d i s t r i c t was tr a v e l l e d i n order to conduct the interviews. While the team was based i n Terrace, considerable time was spent i n Kitimat and several v i s i t s were made to Hazelton. The vi l l a g e s of New Aiyansh and Greenville along the Naas River were also v i s i t e d . In addition, a t r i p was made overland from Kitwanga to Stewart and along the highway from Stewart to Cassiar. 1 Interviews were conducted i n these centres and along the highway at Eddontenajon, and Dease Lake. The team did not v i s i t Telegraph Creek. The towns of Prince Rupert and Masset i n the Skeena-Queen Charlotte regional d i s t r i c t and Smithers i n the 1 C a s s i a r and Dease Lake a r e o u t s i d e t h e K i t i m a t - S t i k i n e R e g i o n a l D i s t r i c t , b e i n g i n S t i k i n e R e g i o n a l D i s t r i c t . 23 Bulkley-Nechako regional d i s t r i c t were also v i s i t e d . The feelings and opinions of the people l i v i n g i n the North were well a r t i c u l a t e d and form the basis of subsequent chapters. OBJECTIVE DATA The objective data were analyzed i n 19 76 from data generated from several sources. The two major aspects of the health care system examined are manpower and f a c i l i t i e s . The a v a i l a b i l i t y of these was examined for 1975 in the four study areas. In addition, the location of them i n r e l a t i o n to the population of the regional d i s t r i c t s was examined to determine the d i s t r i b u t i o n of health manpower and f a c i l i t i e s . F i n a l l y , i t was believed necessary to test whether access problems actually existed as evidenced by the use made of the resources by the population. This was done by examining the separations from hospitals and the location of the ho s p i t a l i z a t i o n around the regional d i s t r i c t by disease c l a s s i f i c a t i o n in four study regions - Kitimat-Stikine, Cowichan Valley, North Okanagan and East Kootenay Regional D i s t r i c t s . The information was generated by the hospitals within the province of B r i t i s h Columbia, c o l l a t e d by B r i t i s h Columbia Hospitals Programs and tabulated by Manpower Research & Development, University of B r i t i s h Columbia. 2 I t was expected that such a study of the Kitimat-Stikine Regional D i s t r i c t would reveal what problems 2These data will be presented in Chapter 7. 24 residents experience in gaining access to health care, what methods have evolved to control unique problems and what further innovations can reasonably be undertaken to ensure a f a i r share of health care is available to the residents. 25 Chapter 3 ACCESS Access t o h e a l t h care has been r e c o g n i z e d as an important f a c t o r i n the o b t a i n i n g of h e a l t h care f o r s e v e r a l c e n t u r i e s . I t has i n f l u e n c e d the development of p u b l i c programmes and has i t s e l f been a f f e c t e d by the o r g a n i z a t i o n of the h e a l t h s e r v i c e s . D e f i n i t i o n s of access to h e a l t h care f r e q u e n t l y r e v o l v e around b a r r i e r s t o access r a t h e r than a d e f i n i t i o n o f access i t s e l f . T h i s i s perhaps because i t i s e a s i e r to see the t h i n g s t h a t i n t e r f e r e w i t h people o b t a i n i n g h e a l t h care than i t i s to see what w i l l f a c i l i t a t e t h e i r h e a l t h . C r i c h t o n p o i n t s out t h a t " a c c e s s i b i l i t y i s more than ' a v a i l a b i l i t y ' of care.""'' Donabedian suggests i t a l s o "comprises those charac-t e r i s t i c s " of a resource t h a t f a c i l i t a t e or o b s t r u c t use by 2 p o t e n t i a l c l i e n t s . " Access can be l i k e n e d t o a pathway i n a maze which, c o r r e c t l y f o l l o w e d , leads one i n t o a c e n t r a l g o a l and beyond t h i s , out of the maze again. In t h i s case, the c e n t r a l goal i s the o b t a i n i n g of h e a l t h c a r e , the r e s t o r a t i o n of h e a l t h , an improvement i n , or a t the very l e a s t , a s t a b i l i z a t i o n of one's c o n d i t i o n . 26 PATHS AND OBSTACLES Just as there are pathways that lead one away from the goal i n a maze, there are p a r t i c u l a r situations which one must encounter and pass i n order to obtain health care. The f i r s t of these i s a perception of i l l n e s s . I t i s quite possible and i t i s ce r t a i n l y not unknown i n medical practice for people to have severe i l l n e s s e s and not know they are i l l . Consequently, they do not seek care. They are on a di f f e r e n t path than someone who perceives himself i l l . There are high costs associated with errors i n i l l n e s s perception. Disease, unrecognized i n the early stages, may r e s u l t i n suffering and intensive therapy that would have been avoided with e a r l i e r diagnosis and treatment. By contrast, people who perceive and seek treatment for non-existent i l l n e s s or disease conditions, constitute an abuse of the health service., in that resources used by them may be costly i n dol l a r s and time. Except i n the realm of infectious disease and public health, there i s no p a r t i c u l a r r e s p o n s i b i l i t y on individuals who are part of the health care system to search out people who are i l l . . . The choice .of accepting, whether or not one i s i l l i s l e f t to the i n d i v i d u a l . In a society which places a high value on a healthy state of well-being and which regards even a temporary and s e l f - l i m i t i n g i l l n e s s as unacceptable, this produces a bias towards f a l s e - p o s i t i v e self-diagnosis. A heightened awareness of health status w i l l cause some individuals i n a self-determining society to perceive i l l n e s s 27 i n themselves when, i n fact, no i l l n e s s e x i s t s . KNOWLEDGE OF DISEASE Closely related to i l l n e s s perception i s the perception that the condition can be a l l e v i a t e d . A person may recognize he has a health problem, but i f he does not believe treatment can improve his condition or produce a cure, he may not seek care. While t h i s i s affected by the available technology, i t may be affected as much by the public's knowledge of th i s technology. There has been some attempt to increase the knowledge of the public about what can be accomplished i n treating disease i n such ways as "Cancer Can be Cured" advertisements or even by such means as the income replacement support given to tuberculosis patients i n the 1930s and 1940s to encourage people to obtain diagnosis and, subsequently treatment. A r t h r i t i s and rheumatism, respiratory diseases such as emphysema, diabetes and certain heart diseases have a l l been diseases about which the public has become more knowledgeable. The increased knowledge may have resulted from conscious p u b l i c i t y by government or a charitable society or from health reporting i n the news media or magazines. Usually, media reporting emphasizes progress i n disease therapy, such as heart and renal transplants, but the success of the programme of poliomyelitis eradication was to a large degree the r e s u l t of p u b l i c i t y given to the development of Salk vaccine i n magazines and newspapers, i n t e l e v i s i o n and radio 28 programmes. Progress i n less s o c i a l l y acceptable diseases and conditions, such as epilepsy, mental retardation and schizophrenia, i s not reported as frequently nor as broadly as the diseases mentioned i n the preceding paragraph. Consequently, there i s less public awareness of new treatments or preventive measures that can be applied. Both the s o c i a l and d o l l a r costs of lack of therapy for early detection of these diseases i n individuals who do not seek therapy are very high. While an increase i n public awareness of treatment f a c i l i t i e s and methods and preventive techniques may increase the use made by the public of available health services, a dichotomy exists when concern i s expressed about the high use of health care resources for conditions that are e s s e n t i a l l y preventable. Yet, as previously mentioned, high u t i l i z a t i o n and an increase i n fals e positives (those treated for disease where none exists) are the expected r e s u l t of advertising campaigns about disease and treatment programmes. Current advertising campaigns of the federal government emphasize the importance of physical f i t n e s s and the prevention of diseases of l i f e s t y l e . i Such campaigns are d i f f i c u l t to assess. Changes i n l i f e s t y l e require behavioural changes i n what may be l i f e l o n g habits. In addition, there i s the d i f f i c u l t y of measuring the numbers of diseases or in j u r i e s that did not .-occur because of increased use of seat b e l t s , decreases i n driving under the influence of alcohol, 29 increased cardiovascular capacity from exercise programmes and decreases" i n smoking. KNOWLEDGE OF THE SYSTEM There are, of course, a number of d i f f e r e n t i l l n e s s e s from which people may suffer and for which they require attention. There i s , as well, a variety of d i f f e r e n t health care workers whose services=may be needed by a patient. Ttee organization of these workers i n the health care system i s an important factor i n access to care. The physician i s the most important gate-keeper to health care. The patient may require p r e s c r i p t i o n drugs from a pharmacist, treatment from a physiotherapist, dressings by a nurse, an i n f i n i t e variety of procedures by numerous types of personnel. A l l of these people provide t h e i r services only upon the request of the physician. Optometrists and dentists operate separately, so access to them does not require a v i s i t to a physician. The gate-keepers i n the health system perform an important role i n rationing the use made of services by a person. The gate-keeper i s expected to ensure the i l l person receives tests required to make a diagnosis and such treatment as the patient's condition warrants. He i s , at the same time, expected to use only s u f f i c i e n t resources i n diagnosis and treatment as are, i n his opinion, necessary. Hospital audits are conducted to determine i f excessive laboratory tests or s u r g i c a l procedures are being conducted. There must be knowledge among the health care workers of each others' presence and what each others' work involves. I 30 As mentioned e a r l i e r , r e f e r r a l i s an important element i n health care and i f a patient i s to be referred to a physiotherapist, the physician must be aware both of the presence of the physiotherapist and of the physiotherapist's c a p a b i l i t i e s . The presence of aA health care workersmust be known to the population i f t h e i r services are to be used when needed. Most communities are very proud when they have, or gain the services of, a physician or ho s p i t a l , and everybody within the community i s aware of the i r presence. Signs are erected so that strangers to the town w i l l also be able to fi n d the hospital i f they need i t . SERVICES The next factor that i s required i s that the needed f a c i l i t y or manpower be available. If there i s no doctor in the community, obviously the patient cannot go to a doctor. If there i s no drugstore, he cannot go to a drugstore. The a v a i l a b i l i t y of the health care workers i n a community depends to some extent on the a b i l i t y of the community to att r a c t health care workers. There i s no compulsion i n Canada for workers to work i n a given area, as there i s i n some countries. A continuing concern i s the d i s t r i b u t i o n of p a r t i c u l a r health care workers, professionals, and f a c i l i t i e s throughout the province. While the numbers of them may be adequate, they may not be located where the user wants them. Analysis 31 of d i s t r i b u t i o n i s dependent upon boundaries. Residents of the community of Smithers are i n a regional d i s t r i c t that does not have an orthopaedic surgeon, but the neighbouring regional d i s t r i c t , Kitimat-Stikine, which i s only 75 km away, does have such a s p e c i a l i s t . In 1975, the community of Terrace had an intensive care unit i n i t s h o s p i t a l , while Kitimat did not. Although the communities are i n the same regional d i s t r i c t and are only approximately 60 km apart, there was pressure to es t a b l i s h an intensive care unit i n Kitimat and th i s was subsequently done. H i s t o r i c a l l y , health care f a c i l i t i e s such as a h o s p i t a l , were supplied by communities to a t t r a c t a physician to the community. However, with the increasing costs of construction and operation of the very sophisticated buildings and equipment required i n today's hospitals, mobilization of c a p i t a l and " .>-•..„ operational resources has become the role of government. Since the passing of the Hospital Insurance and Diagnostic Services Act i n 1958, hospitals have been cost-shared between the federal and p r o v i n c i a l governments. Muni c i p a l i t i e s continued to provide some funds. Hospitals are constructed according to the government's perception of what kind, what size and where they are required. This i s not to suggest that hospitals are no longer used i n order to a t t r a c t physicians to an area. Hospitals do a t t r a c t health care workers to an area, as well as providing employment for people already l i v i n g i n the community. The decision to b u i l d a h o s p i t a l , however, i s no longer s o l e l y that of the community. Plans, as well as funding, require senior government approval - the senior government being the 32 representative of a l l taxpayers. u, COSTS One of the e a r l i e s t recognized b a r r i e r s to access to health care was the cost of the fee for service. H i s t o r i c a l l y , a charity system existed i n which the poor were looked af t e r for no payment, while the rest of the population was charged whatever the physician f e l t they could pay. Because the costs of obtaining care could be very high arid_the-predictability of when one would need care was very low, and the f i n a n c i a l disruption to the family during i l l n e s s was s u f f i c i e n t l y great, many people wished some form of insurance against the costs of becoming i l l and incurring large debts. People began buying private insurance. At the same time, the most obvious needs of the poor were being met by the s o c i a l security system. Odin Anderson states, . . . Only when health services reached a certa i n l e v e l of incidence of costly episodes for middle income families (for the poor, a l l episodes were costly regardless of magnitude) was there consensus that access to health services should be "equalized" for a l l income c l a s s e s . 4 Thus there came to be s u f f i c i e n t support for equalization of costs that the federal government through i t s grant-in-aid programmes was able to esta b l i s h with the various p r o v i n c i a l governments, coverage for costs of care i n , f i r s t of a l l hospitals with the Hospital Insurance and Diagnostic Services Act and, i n 1967, with the Medical Services Act, physicians services. I t was and i s based on equalization of costs, the pooling of r i s k s . The premiums are the same for a l l . There i s no expectation that those using more service 33 w i l l pay more. Nor i s there any guarantee those who need more care w i l l receive more. The concept i s one of equality, not equity. The government contracted to pay for services, not to supply them. Anderson suggests there i s l i t t l e incentive for . . . 4 government ownership of f a c i l i t i e s and personnel. Indeed, i n Canada, for acute care, ownership of f a c i l i t i e s has remained in the private sector., usually by community or r e l i g i o u s based non-p r o f i t s o c i e t i e s . Time i s another b a r r i e r to access i n that there may be a waiting time to see a physician or to be admitted to a h o s p i t a l . Or there may simply be time required for treatment and this may be time the person does not f e e l he has or that he feels i s too cost-l y to give up. In these cases, the person may perhaps not obtain care. Both time and d o l l a r costs are factors in the e f f e c t of geographic i s o l a t i o n from care i n that the person needs transport-ation to the care. This transportation to care has always been regarded as an i n d i v i d u a l r e s p o n s i b i l i t y except i n case of an emergency. However, to people who l i v e i n towns remote from care, both these factors i n geographic i s o l a t i o n may become very import-ant. I t may require several hours' driving time or even an a i r -plane t r i p , an overnight journey; i n which case there i s , as well as high d o l l a r costs involved, s o c i a l disruption in the family as i t copes without one member of the family at home. These, then, are the pathways i n the maze that lead to health care. I f one perceives oneself i l l , i f one believes the i l l n e s s can be a l l e v i a t e d , i f one has s k i l l e d people who 34 can give the treatment and one knows they can, i f one can afford to pay for the treatment and i f one can afford the time and s o c i a l disruption involved i n obtaining treatment, then one can be said to have access to health care. AVAILABILITY Benefits by themselves do not ensure care. There must be the kind of health care worker or f a c i l i t y that i s required for the sick person to be able to take advantage of the coverage he has under any public or private insurance schemes. F a c i l i t i e s such as hospitals or. c l i n i c s are funded by senior le v e l s of government as are public health o f f i c e s . The decision as to where hospitals w i l l be and what size they w i l l be i s made for p o l i t i c a l reasons, such as job creation, increase i n employment or pressure from groups within a community, as often as i t i s based on the health needs of the population. The manpower providing health care i n the hospital or i n the community i s outside the d i r e c t control of the government. The community i s dependent upon i t s a b i l i t y to a t t r a c t these workers to l i v e i n i t s area. The h o s p i t a l i t s e l f may be used as an inducement to them. Other inducements include such things as subsidized lodging and residences for nurses, o f f i c e s for physicians i n the^hospital, subsidies for professional personnel. Governments i n d i r e c t l y a f f e c t the numbers of health care personnel available by grants to t r a i n i n g schools and 35 subsidies to students-in-training. Considerable attention i s h being "given to the a v a i l a b i l i t y of manpower i n Canada where the provinces have established health manpower research and development units to t ry to determine the future needs i n terms of the numbers of the various kinds of workers and factors within t h e i r work which w i l l a f f e c t the a v a i l a b i l i t y of manpower and the numbers of them that w i l l be required. The monthly allowance paid to students enrolled i n university nursing programmes i s an attempt to increase the number of nurses who have university degrees i n nursing. S i m i l a r l y , the establishment of t r a i n i n g programmes i n community colleges i s expected to increase the number of certain types of personnel. I t i s hoped that i f people are trained i n the areas i n which they were raised, they w i l l continue to work i n those areas and help solve some of the manpower d i s t r i b u t i o n problems that ex i s t now. Professional organizations are i n f l u e n t i a l not only i n determining the amount of manpower available by the establishment of l i c e n c i n g prerequisites, but also i n determining what work can be done only by members of a given profession. Certain procedures can be done only by a physician. Pharmacists and dentists determine what pharmacy or dental technicians can do. Registered nurses perform certain tasks and r e s t r i c t the rights of p r a c t i c a l nurses to perform them. Such r e s t r i c t i o n s are a part of the l e g i s l a t e d mandate given to the professional organizations to protect the public's health. They do, however, restrict^upward. mobility within the health care f i e l d . 36 The associations have expressed concern about the unequal d i s t r i b u t i o n of t h e i r members throughout the province. They have sought to a l t e r t h i s in various ways. In Ontario, physicians are paid to t r a v e l to northern towns to act as consultants and t r a i n the health care manpower that i s i n the towns to a higher s k i l l l e v e l . The College of Physicians arid Surgeons of B r i t i s h Columbia, i n an apparent attempt to reduce the shortage of doctors i n the north, granted provisional licences to practice medicine to immigrant physicians, only i f they would practice i n under-doctored areas. While the objective has merit, the means were found contrary to c i v i l rights and t h i s provisional l i c e n c i n g has been stopped. 5 The problems are e s s e n t i a l l y d i s t r i b u t i o n problems. There i s no lack of physicians or s p e c i a l i s t s , of pharmacists, nurses and indeed of most types of manpower. Some innovative techniques w i l l be required to ensure that t h e i r knowledge and s k i l l s are available to the people i n distant towns as well as the c i t y . PERCEPTIONS OF AVAILABILITY Citizens l i v i n g i n a community are very aware of the presence of health care personnel and t h i s i s p a r t i c u l a r l y so i n small communities. The presence of a physician or dentist, or a hospital with a l l i t s many s t a f f , i s very.vimportant. .in smaller communities.- much more important than to "individual residents of a large metropolitan area such as Vancouver. 37 The comfort one gains from having a doctor available i s not related to the use one makes of him, or the l i k e l i h o o d of i l l n e s s , but rather to the uncertain p o s s i b i l i t y , of i l l n e s s . Some of the c i t i z e n s who are most concerned about having services available i n t h e i r l o c a l communities may not actually make any use of those services. There i s great pride among members of a community i n having p a r t i c u l a r expertise available i n t h e i r town. The presence of a s p e c i a l i s t i n , for example, orthopaedics, gynaecology or paediatrics, i s something which gives every community member pride because i t increases the usefulness of his hosp i t a l . A m a t e r i a l i s t i c advantage to residents i s the increased land values a hospital maintains. Both the a l t r u i s t i c and the m a t e r i a l i s t i c advantages are re a l i z e d , i f the s p e c i a l i s t or hospital draws patients from neighbouring areas to the town. The presence of a s p e c i a l i s t i s also welcomed by members of the'medical profession and other health care professionals. The general p r a c t i t i o n e r gains an expert consultant near at hand. The other workers are able to use s k i l l s that have perhaps been dormant since they fi n i s h e d t h e i r t r a i n i n g . Both of these effects mean that patients with more complicated conditions can be treated l o c a l l y . Neuhauser and Galbraith have pointed out the importance of s k i l l and technology i n increasing prestige amongst hospital workers and members of the techno-structure. 6 38 At the same time that c i t i z e n s are aware of the importance of the presence of a professional such as a doctor or dentist, often the a v a i l a b i l i t y of a service i s seen as being associated with the presence of that person as a resident i n the community. L i t t l e thought may be given to the a v a i l a b i l i t y of services that are provided i n a unique manner to meet northern needs. Because the north has had trouble a t t r a c t i n g permanent residents i n certain f i e l d s of health care, and because some of the communities are too small to support a permanent resident, the community may subsidize a physician, dentist, etc. Service may be available for a c e r t a i n number of days per month. Some of the c i t i z e n s i n the community may f e e l they do not have that service available. An example of t h i s can be seen i n Stewart, where members of the town were very concerned about the lack of a dentist. A dentist i s available i n Stewart for one week per month when weather permits a i r transport. O f f i c e space i s supplied; he i s subsidized by the c i t y and charges the patient a fee-for-service. The usual waiting time for an appointment i s one month. At the most, i t may be two months, i f a more highly technical procedure i s needed. On the other hand, the people i n the communities of Terrace and Kitimat, each of which have several dentists, experience a long waiting time; waiting times of several months, to see a dentist. The c i t i z e n of Stewart does not relate the a v a i l a b i l i t y of dental services to the short waiting time. Rather he relates t h i s to the f a c t that a 39 d e n t i s t i s not a v a i l a b l e should he have d e n t a l problems i n the middle of the n i g h t . THE PROBLEM OF DEFINING WHEN ONE IS ILL I t was s t a t e d e a r l i e r t h a t people sometimes have s e r i o u s c o n d i t i o n s which they don't r e c o g n i z e as i l l n e s s . A cancer p a t i e n t may ignore a tumour, a c c e p t i n g i t as "only a growth". The i s s u e i s not always so c l e a r . To what category, i l l or healthy,do the long-term handicapped belong? Is the person w i t h c e r e b r a l p a l s y s i c k ? Does the p a r a p l e g i c need to l i v e i n a h o s p i t a l ? The answer to these two q u e s t i o n s i s obvious. They are not i l l . Indeed one of the problems i n the r e h a b i l i t a t i o n of p h y s i c a l l y handicapped people i s the t r a n s i t i o n away from the s i c k r o l e . Most of the f a c i l i t i e s r e q u i r e d by handicapped or d i s a b l e d people are e s t a b l i s h e d under the Human Resources F a c i l i t i e s Development A c t . These people are expected to be i n a h o s p i t a l o n l y f o r b r i e f p e r i o d s of acute c o n d i t i o n s or f o r t e s t s . There are others who do not f i t n e a t l y i n t o e s t a b l i s h e d medical d e f i n i t i o n s of i l l n e s s ; a l c o h o l i c s and some of the ment a l l y i l l . There i s c o n s i d e r a b l e c o n t r o v e r s y about whether these are d i s e a s e s or behaviour p a t t e r n s o u t s i d e a p a r t i c u l a r s o c i e t y ' s norms. C u l t u r a l p r a c t i c e s may determine whether or not a person attends a p h y s i c i a n to seek c a r e . The most obvious example .is t h a t of c h i l d b i r t h . In most c u l t u r e s , i t i s 40 considered a natural event. In 'western' cultures, i t i s surrounded with myth, awe and a profound d i s t r u s t i n the body's a b i l i t y to cope. Certainly, the neonatal f a t a l i t y rates are lower i n countries where sophisticated care i s given to pregnant women. But i n ensuring those sp e c i a l few women who require extra care obtain i t , a l l pregnant women have been converted .into,'sick' women. Et h i c a l b e l i e f s also influence people's perception of i l l n e s s . Suffering may be regarded as a part of the human condition or as punishment for sins past and present. S i m i l a r l y , some commonly prescribed treatments and disease preventive measures may be regarded as leaving the rec i p i e n t impure i n the eyes of God. People believing these doctrines w i l l neither seek help nor accept treatment for conditions that, i n medical opinion at least are e a s i l y amenable to therapy. Nor, perhaps, w i l l they accept immunization against preventable diseases. While these attitudes reduce the use that would otherwise be made of health services, they cannot be d e f i n i t e l y considered a ba r r i e r to access to health care. The removal of reduction of barrie r s to access i s predicated upon the b e l i e f that the gained objective i s desired by the person seeking access. The degree to which the suffering produced by disease i s believed God's j u s t i c e by society, may af f e c t the development of the health system. Once the health system i s developed, however, minority views may or may not be considered. 'In a p l u r a l i s t i c society .such as Canada's, where the whole 'system evolves from intense 41 bargaining, minority views may be recognized by allowing individuals to make t h e i r own choices. ISOLATION I t might perhaps be expected that i f the costs of paying for health care' were reduced and the health care manpower and f a c i l i t i e s were available i n a community, a l l the c i t i z e n s or residents of a community would have equal access to a physician or ho s p i t a l . However, t h i s has not proved to be the case. DIFFERENCES IN PERCEPTION OF SERVICES  BETWEEN PROVIDERS AND CONSUMERS The concept of Canada as a cla s s l e s s society has been exposed as a myth for some time. (Porter, Newman, 7 . . . WoqdcojEkO:"/. So c i a l class i t s e l f i s a factor i n obtaining health care or i n using health care a f t e r i t i s obtained. By and large, the members of the health care team come from the upper and middle classes of Canada. Their expectations of behaviour, t h e i r own behaviour and th e i r attitudes are shaped by the classes of society i n which they l i v e . Hospitals are maintained i n a state that makes one think that we s t i l l believe strongly that Cleanliness i s indeed nextf to Godliness Physicians' o f f i c e s frequently are furnished with the comfortable chairs, lush carpeting and pictures found commonly in the homes of the upper and middle classes. To people from a lower class, these atmospheres may be completely a l i e n and induce feelings of unease. To the person from a home with no running water where cleanliness i s d i f f i c u l t to maintain, the physician's o f f i c e with i t s stainl e s s s t e e l receptacles and arborite counters with t h e i r sparkling cleanliness, w i l l be an extremely cold and h o s t i l e environment. To the person who l i v e s i n one room, with perhaps a cot, bare f l o o r , a minimum of heat and perhaps a tattered calendar on the wall for a picture, the physician's o f f i c e can appear to be sumptuous and luxurious i n the extreme. He may not f e e l he knows how to behave i n i t or that he has a ri g h t to be s i t t i n g i n i t . To the Native, used to the relaxed l i f e s t y l e and natural beauty of the reserve, the e f f i c i e n t l y regulated a c t i v i t y and s t e r i l e atmosphere may be a l i e n . He may also experience communication problems i f he does not speak the majority language of the province. The recommendations made to patients by health care professionals may hot be possible for them to carry out, i f they l i v e i n such extreme circumstances. The person with no running water i n the home scarcely can be expected to apply s t e r i l e dressings every hour or carry out the stringent laundering of clothes that i s recommended for some conditions. To the poor person, a special diet may impose extreme hardship. Many of the sp e c i a l foods required on special diets are more expensive than the food the poor normally eat. The recommendations that health workers make may put a burden on poor people that they may not be w i l l i n g to admit to the physician or nurse. F a i l u r e to comply with the recommendations of health care workers frequently results in'the worker or professional expressing some annoyance with the patient. This type of s i t u a t i o n may be so embarrassing to the poor person that he may not seek or return for help. I t i s easier to avoid the problem than to cope with i t at the time. The loneliness and s o c i a l i s o l a t i o n experienced by the Native populations of Canada when they are hospitalized has been frequently documented. This i s not to suggest we reduce our hospital standards or furnish our physicians' o f f i c e s with bare boards and hard chairs. One action would reduce i n f e c t i o n control, the other would alienate another and very large group in Canadian society. I t i s to suggest rather that special understanding of some people's situations i s required by health care workers; understanding of why treatment has not been followed or why the patient i s loathe to admit i t or return for a second v i s i t . The need for a long journey to hospital and subsequent long h o s p i t a l i z a t i o n , possibly needed to correct dietary d e f i c i e n c i e s or because of the d i f f i c u l t y of returning home over the long distance, has been reduced by the establishment by the federal government of the community health c l i n i c s i n the Indian v i l l a g e s . These c l i n i c s are usually made of t r a i l e r units joined together and are functionally and simply equipped and furnished i n the public areas. The.nurse's quarters are often included i n one section of the unit and these are furnished a t t r a c t i v e l y to encourage nurses to l i v e i n the north i n i s o l a t i o n from t h e i r own culture. 44 The Medical Services Nurse i s assisted o f f i c i a l l y by a Community Health Representative and u n o f f i c i a l l y by the v i l l a g e matriarch. The Community Health Representative i s a v i l l a g e resident who i s given or has had some health t r a i n i n g and i s able to communicate to the v i l l a g e r s the rationale of preventive techniques and treatments suggested by the nurse. The matriarch i s usually a highly respected old woman from the v i l l a g e who knows the history of the v i l l a g e and i t s people. Because the nurse i s usually a Non-Native or, i f Native, may be from a d i f f e r e n t t r i b e and culture, the Community Health Representative and the matriarch play an important r o l e i n breaking down s o c i a l b a r r i e r s between the nurse and the v i l l a g e r s . The three, i n cooperation can often solve some problems with no ethnic intrusions or c u l t u r a l embarrassment to anyone. GEOGRAPHIC ISOLATION Equally problematic i n many areas of the province and p a r t i c u l a r l y i n the Kitimat-Stikine Regional D i s t r i c t , i s the geographic i s o l a t i o n which affects v i r t u a l l y the entire province. People i n Kitimat and Terrace look to the Greater Vancouver or V i c t o r i a Region and view themselves as very remote from them. People i n the northern part of the regional d i s t r i c t , on the other hand, look towards Terrace and Kitimat as the major trading and service centres, and in turn, f e e l themselves i s o l a t e d from them. There i s j u s t i f i c a t i o n for both views. Isolation i s 45 a r e l a t i v e experience. Chapter 2 described the distances and types of t e r r a i n i n the regional d i s t r i c t . The length of time required to f l y from Terrace to Vancouver i s about equal that required to f l y from Iskut to Terrace; the former f l i g h t s are scheduled several times a day, while i n 19 75 the l a t t e r was scheduled once a week. Similarily,' logging roads, as well as lacking smooth surfaces, do not, with t h e i r day-time closures to the public, provide the f a c i l i t y for t r a v e l that i s obtained by a highway. Geographic i s o l a t i o n creates an environment for the professional health care worker that i s both e x c i t i n g and worrisome. Working without the support of other s t a f f and with elaborate equipment, these people r e l y on i n i t i a t i v e and imagination to cope with the health problems that a r i s e . They do so with amazing success and deal with situations that might defeat more s k i l l e d workers who have only worked i n a supportive milieu. There i s , amongst health care workers of a l l kinds, a great deal of discussion about e x i s t i n g techniques, new methods and possible ideas. The ideas and information exchanged i n these often informal conversations at work are important to not only the knowledge and expertise of the worker, but also to the confidence he has i n his decisions. The nurse or physician who i s the lone supplier of health care i n a community misses the support of his colleagues and this i s an important factor i n decisions to leave the i s o l a t e d community. The professional i s torn between the obvious need 46 the community has of him and the gradual l o s s of s k i l l and e x p e r t i s e t h a t besets him i f he s t a y s . Man i s g r e g a r i o u s and too i n n o v a t i v e to remain too i s o l a t e d g e o g r a p h i c a l l y f o r long. Many d i f f e r e n t t e c h n o l o g i e s reduce the d i s t a n c e s between people i n the o u t l y i n g areas of B r i t i s h Columbia, so the d i s t a n c e s become more manageable. The telephone i s a commonly used l i n k . A i r t r a v e l i s more common i n r e l a t i o n t o c a r t r a v e l than i n the south. Radio-telephone communication e x i s t s where telephones are not a v a i l a b l e . Through t h i s network of communications, the people l i v i n g i n remote areas of the p r o v i n c e are a b l e to keep i n touch with each other and to reduce the e f f e c t of f e e l i n g t h e i r i s o l a t i o n . They use these methods i n g a i n i n g access to t h e i r h e a l t h c a r e . A i r ambulances supplement s u r f a c e ambulances, r a d i o - t e l e p h o n e c o n v e r s a t i o n s r e p l a c e v i s i t s t o the d o c t o r s as w e l l as f a c i l i t a t e nurse-doctor and d o c t o r - d o c t o r c o n s u l t a t i o n s , and when someone needs h e l p , everyone i n the area i s aware of the s i t u a t i o n and each t r i e s to do what he can to help and to o b t a i n h e a l t h care f o r an i l l person or to t r a n s p o r t the i l l person to the h e a l t h c a r e . The p a t i e n t may be flown to a h o s p i t a l on a s t r e t c h e r i n an a i r p l a n e accompanied by a nurse or he may a r r i v e at the h o s p i t a l a f t e r j o s t l i n g i n the back of a pick-up t r u c k f o r s e v e r a l hours, or he may have been c a r r i e d i n the back seat of a p r i v a t e c a r with the nurse squeezed i n and a p p l y i n g a r t i f i c i a l r e s p i r a t i o n i n what cramped space i s l e f t her as the d r i v e r d r i v e s as f a s t 47 as he dares to meet the surface ambulance. But get to health care they do. BENEFITS There are no entitlements to health care i n the l e g a l sense i n Canada. Because of the u n i v e r s a l i t y of the h o s p i t a l and medical care programmes, the p o r t a b i l i t y of these programmes and special programmes established to cover the few people exempted from these two"major programmes, vir t u a l l y ; , the entire population of Canada i s e n t i t l e d to the benefits of the health services system. The United Nations' Charter of Human Rights states, . . . The enjoyments of the highest attainable standard of health i s one of the fundamental rights of every human being without d i s t i n c t i o n of race, r e l i g i o n , p o l i t i c a l b e l i e f , economic or s o c i a l condition . . . . Governments have a r e s p o n s i b i l i t y for the health of t h e i r peoples which can be f u l f i l l e d only by the provision of adequate health and s o c i a l measures.8 The World Health Organization defines health as "a state of complete physical, mental and s o c i a l well-being and not merely the absence of disease or i n f i r m i t y . " The Hall Commission Report of Canada i n i t s Health Charter for Canadians said, . . . The achievement of the highest possible health standards for a l l our people must become a primary objective of national p o l i c y and a cohesive factor contributing to national unity, involving i n d i v i d u a l and community r e s p o n s i b i l i t i e s and actions. This objective can best be achieved through a comprehensive, universal Health Services Programme for the Canadian people, IMPLEMENTED i n accordance with Canada's evolving c o n s t i t u t i o n a l arrangements; BASED upon freedom of choice, and upon free and s e l f -governing professions and i n s t i t u t i o n s ; 48 FINANCED through prepayment arrangements; ACCOMPLISHED through the f u l l co-operation of the general public, the health professions, voluntary agencies, a l l p o l i t i c a l p a rties, and governments, federal, p r o v i n c i a l and municipal; DIRECTED towards the most e f f e c t i v e use of the nation's health resources to a t t a i n the highest possible lev e l s of physical and mental well-being.9 Implementation of these p r i n c i p l e s i s not simple. There i s considerable d i f f i c u l t y i n defining 'adequate health and s o c i a l measures'. What may be adequate i n a developing country may be unacceptable to residents of an i n d u s t r i a l society. Returning one i n d i v i d u a l to a state of complete physical, mental and s o c i a l well-being, while t e c h n i c a l l y possible, may use a l l the resources a country has. Provision of health services requires that choices be made and these choices ultimately r e s u l t i n L i f e or Death decisions for i n d i v i d u a l s . " ^ Decisions as to whether resources are better applied to a malaria eradication programme or heart transplant operations, whether a communicable disease immunization programme i s more co s t - e f f e c t i v e than i s a renal d i a l y s i s unit -such decisions, based on either hard data c o l l e c t i o n or pressure group lobbying, eventually a f f e c t i n d i v i d u a l people. The highest possible levels of physical and mental well-being referred to i n the Health Charter for Canadians may possibly be met only on a s t a t i s t i c a l basis and considering the available resources with-i n the economy. However, the chartersdo state the p r i n c i p l e underlying the development of the health services system i n Canada. Benn and Peters pointed out the importance of such statements when discussing the Universal Declaration they said, 49 Moral p r i n c i p l e s of t h i s order lay down the terms.in which discussion i s to be conducted and decisions defended; agreement on the terms i s no guarantee of agreement on p a r t i c u l a r s . (11) Costs of i l l n e s s and premature death are considered s o c i a l losses and such costs are not believed to be the sole r e s p o n s i b i l i t y of the i l l person, but are spread throughout society. Robertson expressed i t simply, "No i n d i v i d u a l should 12 be refused help because he cannot pay for i t . " The major benefit people receive for t h e i r health care i s a guarantee of payments for provision of services. For t h i s , they pay a fee to a private or public insurance programme and taxes. Under the terms of the cost-sharing formula between the federal and p r o v i n c i a l governments, the coverage of the hospital and medical care insurance must be comprehensive, universal, portable and p u b l i c l y administered. For hospital services, there must be a minimal or no fee charged at the time of service. There i s no charge made to the patient at the time of service for physician services. While i t i s easy for any health care professional to see how this concept should govern his behaviour and treatment of patients, no rights are conferred to the consumer. The kind of treatment one receives, or the receipt of treatment i s a professional judgement made usually by a physician. The consumer does not have the r i g h t to demand a p a r t i c u l a r treatment. He can only demand an examination i n an emergency. In a major c r i s i s where there are many people injured, an injured person may have to wait for treatment u n t i l patients who are i n more serious condition or whose 50 chances of recovery are more evident have been treated, PUBLIC HEALTH While there i s no l e g i s l a t e d entitlement to types of health care, there i s l e g i s l a t i o n regarding infectious disease control. Prevention i s the prime method of control of communicable diseases. The Health O f f i c e r i s responsible for ensuring healthy standards i n the environment i n addition to his r e s p o n s i b i l i t y for seeing that people with a communicable disease receive an examination and treatment. Restaurants, public swimming pools, commercial and i n d u s t r i a l premises are checked by Sanitary Inspectors and may be closed i f a sa t i s f a c t o r y l e v e l of hygiene i s "not found. The Public Health Department i s also responsible for septic tanks, water works, sewage disposal systems and campsites. Clean water i s essential to a healthy environment. It i s obviously not feasi b l e to have p a r t i c u l a r water systems or even inspectors i n a l l areas of such a large province. The service of water sampling and test i n g i s available to people i n remote areas by use of the mail system. Water p o t a b i l i t y and purity are checked and a report i s given back to the consumer with recommendations of changes that should be made to make the water safe to use. Public health services are available to the public regardless of income and cl a s s . P a r t i c u l a r programmes may be directed at s p e c i f i c age groups, but wherever these programmes are offered, they are available to a l l of the 51 population without charge, A broad range of services i s offered; prenatal and baby care counselling, childhood development testing, immunization, and v i s i o n and hearing tests of school children. However, there i s no compulsion on the Department to of f e r a l l services i n a l l areas. Nor i s there compulsion on the public to use most services that are offered. HOSPITAL SERVICES When the Hospital Insurance and Diagnostic Services Programme was introduced in B r i t i s h Columbia, a premium was charged to residents to provide funds for the programme. This c o l l e c t i o n method proved impracticable and the government changed to a system where a purchase tax i s levi e d on a l l items other than food, books and children's clothing. This sales tax, o r i g i n a l l y 3%, has been increased over the years u n t i l i n 1976, i t was raised to 7%.* I t i s used for other p r o v i n c i a l l y funded programmes i n addition to hospital costs. In the province of B r i t i s h Columbia, patients pay a charge at time of service of $4.00 per day as an in-patient and of $2.00 as an out-patient. The per diem rate covers, i n addition to food and lodging, use of the operating rooms, nursing services, diagnostic services, physiotherapy, dietary consultation and medication. Out-patient services include emergency care, minor su r g i c a l procedures, day-care surgery, out-patient cancer services, physiotherapy, diabetic day care and some psy c h i a t r i c services. Not a l l hospitals o f f e r every service. If a hospital provides a service, the cost of * In April, 1978, an agreement was made between the federal and provincial governments to reduce the sales tax to 5% temporarily. 52 provision of the service i s included i n the per diem rate charged to the government. There are no extra costs charged to the patient except for a private room that i s not required for medical reasons. In order to inform the public of the actual operating costs of the hospital rather than the patient's co-insurance payment, each acute care hospital displays i t s d a i l y operating costs on a sign i n i t s Admitting Department or main entrance. The effectiveness of t h i s information i s doubtful; many people may not notice the sign and those who do have d i f f i c u l t y i nterpreting i t s meaning. The figure i s supplied without explanation of services provided, and there i s l i t t l e appreciation of the high costs of hospital operation by the public. Costs are expressed i n d o l l a r s per patient day. Consequently, a hospital with few patients may have a higher per diem rate than a busier h o s p i t a l . The higher costs i n the small hospital may be assigned by the public to poor administration rather than the few patient-days over * which the costs are spread. Because 80% of hospital operating costs are fixed costs, such an assumption by the public i s unfair to the administration. There are quality controls i n that certain diagnostic tests can be carr i e d out only i n laboratories of a certain c l a s s i f i c a t i o n . This means that a physician i n a small hospital may not be able to have some laboratory functions performed either for or by him. Such tests must be carried out i n larger laboratories by s p e c i a l l y trained technicians, 53 the samples being shipped to them. The medical s t a f f i n each h o s p i t a l determine the drugs which w i l l be s u p p l i e d i n t h a t h o s p i t a l . Two neighbouring h o s p i t a l s may have d i f f e r e n t drug ' f o r m u l a r i e s ' . T h i s term 'formulary' has come to mean, i n B r i t i s h Columbia, a l i s t of s u p p l i e d drugs r a t h e r than i t s more g e n e r a l l y accepted d e f i n i t i o n as a volume s u p p l y i n g i n f o r m a t i o n about drugs. A p a t i e n t may, then, be charged f o r a drug i n one h o s p i t a l and not i n another, but t h i s i s e s s e n t i a l l y a medical d e c i s i o n and not an economic or p o l i t i c a l one. In theory, p a t i e n t s throughout the p r o v i n c e have i d e n t i c a l b e n e f i t s . However, the number and kinds of t e s t s or treatments t h a t can be c a r r i e d out i n a l a r g e t e a c h i n g h o s p i t a l are q u i t e d i f f e r e n t to those t h a t can be done i n s m a l l h o s p i t a l s . The amount and v a r i e t y d i f f e r s as w e l l between acute care and r e h a b i l i t a t i o n h o s p i t a l s . The l a t t e r h o s p i t a l s are l o c a t e d i n l a r g e c i t i e s and are q u i t e d i s t a n t from most communities. The p a t i e n t i n j u r e d i n a c a r a c c i d e n t or a t work i n the K i t i m a t - S t i k i n e Regional D i s t r i c t or any d i s t a n t r e g i o n a l d i s t r i c t does not have the same l e v e l of r e h a b i l i t a t i o n t h a t i s a v a i l a b l e to a person who l i v e s i n the Lower Mainland or on southern Vancouver I s l a n d . I f he i s i n j u r e d a t work, h i s expenses f o r treatment and c o s t s a s s o c i a t e d w i t h r e c e i v i n g treatment are p a i d f o r by the Workers' Compensation Board. I f there i s a long s e p a r a t i o n from h i s f a m i l y , p r o v i s i o n i s made f o r p e r i o d i c v i s i t s by h i s w i f e , or of him to h i s home. 54 However, the man or woman injured at home has no such entitlement to extensive care. The extra costs of r e h a b i l i t a t i o n ; income loss, family v i s i t s and transportation are borne by the injured person or his family. In addition, his access to care may be subject to geographic location. His l o c a l h o s p i t a l i n the remote regional d i s t r i c t s may not possess r e h a b i l i t a t i o n f a c i l i t i e s . Indeed, physiotherapists rea d i l y admit t h e i r attentions are given i n a time of c r i s i s or s t a f f shortage, to the acute care patient rather than the long-term patients. Transportation costs to the r e f e r r a l hospital must be borne by the patient, as must t r a v e l and l i v i n g costs of any family member who accompanies or v i s i t s his during convalescence. Crichton viewed th i s d i s p a r i t y of coverage as one of the areas of greatest inequality i n Canada.1 Because the health care system and i t s prepaid plans i s based on equality, d i f f e r e n t i a l coverage for s p e c i a l services required by special groups within the society have not been established. The r e s u l t i s equality without equity. MEDICAL CARE Residents of B r i t i s h Columbia have t h e i r medical care costs covered by the B r i t i s h Columbia Medical Plan. This plan which has a contributory payment of $7.50 per month for an i n d i v i d u a l , $15.00 for a couple or for a family, covers payment to general p r a c t i t i o n e r s and to physician s p e c i a l i s t s to whom the patient has been referred by a general p r a c t i t i o n e r . In addition, i t covers optometry, podiatry and physiotherapy 55 services. Except i n the case of physiotherapists, there i s no l i m i t to the amount of care that w i l l be paid for by the medical plan. The physician determines the needs of the patient and his decision i s accepted as v a l i d . Private practice physiotherapists' services are available up to a maximum of $7 5.00 per annum for those under 65 years of age and to $100.00 for those 65 years and over. There i s no l i m i t on the amount of physiotherapy treatments that can be given to an out-patient by physiotherapists working i n a h o s p i t a l . As i n the case of hospital coverage, there i s equal 'entitlement' to people wherever they l i v e i n the province. The programme i s compulsory and comprehensive. V i r t u a l l y a l l residents of the province are covered. Like the h o s p i t a l coverage, however, there are variations i n the amount and kind of services that are available i n d i f f e r e n t areas. MENTAL HEALTH This service i s established by the p r o v i n c i a l government under the Mental Health Act. Mental Health c l i n i c s e x i s t i n communities throughout the province and are staffed by psychologists, psychiatric s o c i a l workers and p s y c h i a t r i c nurses. They are able to use the services of a i v i s i t i n g p s y c h i a t r i s t , who may reside i n the community or make periodic v i s i t s to the area. The members of the unit operate as a team but the types of programme offered vary from c l i n i c to c l i n i c . The emphasis i s on care provided within the community and 56 r e f e r r a l to the Riverview Mental Hospital at Essondale i s made only when community resources have been exhausted. Hospitalization i s usually made to the community's acute care hosp i t a l , as they have increased t h e i r p s y c h i a t r i c expertise. There i s an attempt made to coordinate the Mental Health C l i n i c ' s services with those of the Public Health Unit, the hos p i t a l and sp e c i a l education and guidance counselling personnel from the schools. Like the Public Health service, there i s no charge to the c l i e n t for t h i s service. Psycho-geriatric hospitals operate under the aegis of the p r o v i n c i a l government. Some were funded and operated by the Department of Human Resources, but a l l now come under the Department of Health. Some have community input into t h e i r operation from management and a board elected from a society made up of community members. Other hospitals do not currently have community input i n a formalized manner. There are four i n the province; i n the Lower Mainland, on Vancouver Island, i n the Okanagan and i n northcentral B r i t i s h Columbia. The hospital i n Vernon i s for women; that i n Terrace i s for men. Patients may come from homes i n towns some distance from the ho s p i t a l . Just as one can be forced to have an examination and treatment for contagious disease, one can be forced to receive mental health treatment under certain circumstances. The condition i s by degree rather than diagnosis; that i s , one can be treated f o r , for example, schizophrenia i n an *The h o s p i t a l i n Terrace does accomodate a few female r e s i d e n t s . 57 acute care h o s p i t a l on a v o l u n t a r y b a s i s . However, i f one's c o n d i t i o n i s more s e r i o u s than i s amenable t o the therapy a v a i l a b l e l o c a l l y , an a p p l i c a t i o n may be made to the c o u r t s to r e q u i r e the p a t i e n t to take therapy elsewhere. I f one i s deemed by the c o u r t s to be a danger t o o n e s e l f o r t o o t h e r s , a person can be committed t o a mental h o s p i t a l . P HARMACARE The Pharmacare programme was i n s t i t u t e d by the p r o v i n c i a l government i n 1972. T h i s programme combined the payment f o r three groups of people, two of whom had p r e v i o u s l y had t h e i r p r e s c r i p t i o n s p a i d f o r by the government. The f i r s t groups comprised people r e c e i v i n g S o c i a l A s s i s t a n c e or income subsidy. The t h i r d group c o n s i s t e d of a l l the p o p u l a t i o n 65 years o f age and over, r e g a r d l e s s of means. There has been no d e t e r r e n t f ee charged the p a t i e n t . Because these groups of people have more i l l n e s s e s , and consequently h i g h e r p r e s c r i p t i o n drug needs and u s u a l l y l e s s f i n a n c i a l a b i l i t y t o procure them than the r e s t of the p o p u l a t i o n , t h i s programme appears to s a t i s f y the d e f i n i t i o n of a programme based on e q u i t y r a t h e r than e q u a l i t y . In June, 197 7, the programme was broadened to p r o v i d e u n i v e r s a l Pharmacare. P u b l i c p r e s s u r e ensured the e q u i t y o f the o r i g i n a l programme was maintained. The coverage g i v e n t o the working p o p u l a t i o n and t h e i r f a m i l i e s does not s t a r t u n t i l a person's p r e s c r i p t i o n c o s t s have reached $8 0.00 i n a year. T h i s may be of most b e n e f i t to the handicapped or those w i t h c h r o n i c c o n d i t i o n s 58 who require many drugs i n order to cope with d a i l y l i f e . DENTAL COVERAGE Unlike the previous programmes mentioned, dental coverage i s not a public programme. Most people pay th e i r dental costs at time of service rather than by a prepaid plan which spreads the r i s k to a l l pa r t i c i p a n t s . There i s coverage available by private group insurance and t h i s has been obtained frequently i n the l a s t few years as a benefit under c o l l e c t i v e bargaining agreements between unions and management. The fees paid, the services covered, and the extent of services covered, vary with each agreement. The costs of providing the dental care are equalized over everybody covered i n the plan. In areas where dental coverage i s part of union contracts, there w i l l be an increase in demand for dental care. This may increase dental supply problems i n areas where there i s already a shortage .of dentists or a u x i l i a r y dental personnel. EMERGENCY SERVICES Emergency services are of great concern to the people who l i v e i n remote areas. In a sense, t h i s i s understandable because of the f e e l i n g of i s o l a t i o n and the generally accepted b e l i e f of the public that every minute counts i n any emergency. There have been considerable changes i n the Emergency Services provided. As mentioned e a r l i e r , transportation to health care has been considered an i n d i v i d u a l r e s p o n s i b i l i t y 59 except i n an emergency. In the event of an emergency, ambulance transportation i s supplied to take the i l l person to the hospital with a deterrent fee charged to the patient. This fee has been $5.00. Ambulances are also used for transporting patients from one hospital to another one with more sophisticated services. Inter-hospital transfer charges are charged to the patients; $5.00 i f the distance i s less than 25 miles, $2.00 per mile plus $13.00 per hour i f the distance i s greater than 25 miles. In 1974, the Emergency Health Services established an A i r Ambulance to serve the northern part of the province. This programme allows the nurse or physician i n a remote part of the province to order a i r transport to a hospital for a patient i n an emergency. The diagnosis of the nurse of physician has to be reported to a central o f f i c e of the Emergency Health Services i n Vancouver for v e r i f i c a t i o n . After t h i s , the a i r c r a f t can be ordered. The service pays for a l l types of a i r c r a f t with p r i o r i t i e s given to using the l e a s t expensive rather than a more expensive a i r c r a f t . The f i r s t choice i s use of a scheduled a i r l i n e t r i p . I f t h i s i s not available, the second choice i s a chartered fixed wing airplane. I f neither of these i s available, a helicopter i s used. The helicopter service i s available on a contract with one helicopter company which i s located i n towns throughout the province. Rather than using a helicopter which i s i n the area, a helicopter from t h i s company i s sent into the area where the injured or i l l person i s , to c o l l e c t 60 him and bring him out to a h o s p i t a l . SPECIAL GROUPS Special groups of people have long been recognized as having special needs. In some instances, the needs of these people are s u f f i c i e n t l y high that i t i s f e l t by society they should receive special attention. One group of people who do are the poor; those on extremely low income and who receive Social Assistance benefits. The health coverage for these people i s extended and t h e i r fees for medical coverage are paid for by the p r o v i n c i a l government. There are p a r t i c u l a r attempts made to ensure the members of these special groups receive periodic check-ups with t h e i r physicians so they do not have health problems that are not being corrected. Their transportation costs to the physician or hospital are usually paid. There i s provision under a 1973.amendment to the Medical Grant Act (1965). for the Minister of Health to pay 90% premium for medical care of people who are i l l , disabled or experiencing f i n a n c i a l hardship for periods up to 3 months. (Medical Grant Act, November, 1973). Under the Canada Assistance Plan (1966), services outside medical and hospital plan benefits, such as dental care and eye glasses, are cost-shared by the federal government. Another group considered to have higher needs of health care are Native Indians. Their high morbidity and mortality rates and shorter length of l i f e give ample evidence 61 of t h e i r s p e c i a l problems. T h i s is a f e d e r a l government s e r v i c e of the Department of N a t i o n a l Health and Welfare and i n c l u d e s any needed h e a l t h care treatment, as w e l l as t r a n s p o r t to treatment and programmes of p r e v e n t i v e medicine. Some of the needs which w i l l s o l v e these s p e c i a l problems may not be f o r h e a l t h care but f o r water and sewage c o n t r o l , adequate housing, education and employment. Because most of the Indians l i v e i n v i l l a g e s o u t s i d e of communities wi t h a p h y s i c i a n or h o s p i t a l and many of these v i l l a g e s are ve r y remote, the f e d e r a l government has e s t a b l i s h e d c l i n i c s i n the v i l l a g e s of over 200 people. They are s t a f f e d by a nurse p r a c t i t i o n e r , with support s t a f f of a Community Health R e p r e s e n t a t i v e and p e r i o d i c v i s i t s from p h y s i c i a n s , d e n t i s t s , s p e c i a l i s t s , e t c . In a d d i t i o n t o t h i s l o c a l l y a v a i l a b l e s e r v i c e , the government may pay f o r the c o s t of eye g l a s s e s s u p p l i e d t o Ind i a n s . Because some Indians work and earn incomes, they are asked f o r a c o n t r i b u t i o n towards the c o s t s of items such as eye g l a s s e s which are not a v a i l a b l e f r e e to the r e s t of the p o p u l a t i o n . T h i s i s a group of people w i t h g r e a t e r p o t e n t i a l - b e n e f i t s t h a n - s o c i e t y " a t l a r g e . I t i s l a ^ r o u p ; thathasjara^Lil-lnejs..-.. I t i s a l s o a group which i s l a r g e l y unable to take advantage of the s e r v i c e s to which they are e n t i t l e d . They continue t o s u f f e r from c h r o n i c d i s e a s e s and r e c u r r e n t i n f e c t i o n s , to have high m o r b i d i t y and a s h o r t e r l e n g t h of l i f e than other Canadians. The other major h e a l t h supply which i s p a r t of the 62 federal government's programme i s that supplied to veterans, the Royal Canadian Mounted Poli c e , seamen on v i s i t i n g ships, foreign students, and diplomats. This service includes any immunizations needed from the public health service, v i s i t s to physicians and treatment i n h o s p i t a l , as well as prescriptions f i l l e d by pharmacists. The Workers' Compensation Board provides a comprehensive programme of accident prevention and care. Through t h e i r Accident Fund, they provide, in Vancouver, soph~i^ticated^treatment and r e h a b i l i t a t i o n for people "injured in industry and pay compensa-t i o n to_.those who are permanently infured and to the dependents or spouses of people k i l l e d while- at work. This fund i s paid for by . employer firms. There are branch o f f i c e s throughout the province. As mentioned e a r l i e r , the care available to people injured at work i s very broad. I t covers a wide f i e l d of treat-ments and concerns and attempts to treat "the whole man". There i s a conscious attempt to coordinate a l l the resources of available health care knowledge and s k i l l to r e h a b i l i t a t e him to-a new job i f possible and necessary, or i f th i s i s not possible, to restore him to the maximum l e v e l of well-being he can a t t a i n . These services are centralized i n the Vancouver area with transportation and accomodation costs of the injured person and some expenses of the spouse being included i n the benefits. The injured person must go to -the service; service may not be available l o c a l l y . The various compensations for degrees of injury, up to and including death, are stipulated i n the Workmans' Compensation 63 Act of 196 8. In 19 74, t h i s Act was amended to change i t s t i t l e to the Workers' Compensation Board, to broaden the industries covered by the Act and to increase the scope of damages. Deaf-ness became a compensable condition. The greatest compensations are for permanent injury with loss of employment with a graduated scale to cover permanent injury and p a r t i a l injury without loss of employment. A l l compensations are adjusted according to the Consumer Price Index. Pensions granted for permanent d i s a b i l i t y are paid throughout the l i f e of the pensioner. EFFECT ON UTILIZATION The services covered by prepaid plans have affected the organization of the health care system and the a v a i l a b i l i t y of services i n many ways. Medical and other health care treatments are s u f f i c i e n t l y uncomfortable or unpleasant that few pjeopl'e seek care needlessly. As Roemer pointed out twenty years ago, i t i s now accepted that more beds and more surgeons lead to more ho s p i t a l i z a t i o n and more surgery. However, there i s no evidence that people use more hos p i t a l services because of prepaid h o s p i t a l plans. In spite of t h i s , services that are not covered by any public schemes or by private insurance have tended\ricOt> to be developed to any great extent. Physicians may not order the ser-vices of an occupational therapist or diet counsellor as much as they would otherwise because the patient must pay for these services i n d i v i d u a l l y at time of service. THE DILEMMA OF ACCESS The problems associated with paying the doctor have been equalized over a l l residents. The health manpower i s 64 available i n Canada i n s u f f i c i e n t numbers; i t s d i s t r i b u t i o n i s unequal. Equal d i s t r i b u t i o n of workers raises two issues. The f i r s t i s that delineated i n the H a l l Commission Report, of the freedom of the health professional to work where he chooses. The second i s an issue of equity. Is i t f a i r to the health professionals and, ultimately t h e i r patients, to have professionals work in areas where they lack the l e v e l of support services and, possibly, the number of patients to maintain t h e i r s k i l l s ? The problems with both s o c i a l and geographic i s o l a t i o n may r e a l l y be that both impose economic hardships on people; costs that are not considered part of health care or treatment, but are a n c i l l a r y to obtaining the care. While neither of these factors are considered as part of the impact on access to health care, and so long as a n c i l l a r y costs of health care remain excluded benefits i n the health care system, people w i l l f e e l powerless to reduce t h e i r problems of i s o l a t i o n except by demanding new types of and more f a c i l i t i e s and s t a f f closer to "home". 65 REFERENCES CHAPTER 3 1. Crichton, A. 0. J., Equality as an: Organizing 1 Concept  in Health Care Policy i n Canada, Vancouver: University of B r i t i s h Columbia, Department Health Care and Epidemiology, 19 76. 2. Donabedian, A., Aspects of Medical Administration, Cambridge, Harvard University Press, 1973. 3. Lalonde, Marc, A New Perspective on the Health of  Canadians, A Working Document, Ottawa, Government of Canada, A p r i l , 19 74. 4. Anderson, Odin W., Health Care: Can There be Equity?  The United States, Sweden, and England, New York: John Wiley & Sons, 19 72. 5. Law Reform Commission of B r i t i s h Columbia. "Human Rights Commission and the College of Physicians and Surgeons of B r i t i s h Columbia", Board of Inquiry-, May 19 76.. 6 a)Neuhauser, Duncan, "The Hospital as a Matrix Organisation" in Hospital Administration, 19 72. 6 b)Galbraith, J. K., "Motivation and the Technostructure", New Industrial State, Boston, Houghton M i f f l i n Company, 1967. 7 a)Porter, John A., The V e r t i c a l Mosaic: An Analysis of Social Class and Power in Canada, Toronto, University of Toronto Press, 1965. 7 b)Newman, Peter Charles, The Canadian Establishment, Toronto, McClelland and Stewart, 19 75. 7 c)Woodcock, George, Canada and the Canadians, London, Taber, 1973. 8. World Health Organization, The F i r s t Ten Years of.the World Health Organization, Geneva, Palais des Nations, 1958. 9. H a l l , Emmet M., Chairman. Royal Commission on the Health Services, Ottawa, Government of Canada, 19 62. 10. Crossman, R. H. S., A P o l i t i c a n ' s View of Health Service Planning, 13th Maurice Black Lecture, University of Glasgow, A p r i l 19 72. 66 11. Benn, S. I . and P e t e r s , R. S., S o c i a l P r i n c i p l e s and t h e ' Democratic S t a t e , London, George A l l e n & Unwin, 1959. ' 12. Robertson, H. Rocke. ' H e a l t h Care in' Canada, A Commentary, Background Study f o r the Science C o u n c i l of Canada, August 19 73, S p e c i a l Study #29. Science C o u n c i l of Canada, Ottawa. 67 CHAPTER 4 POWER IN THE HEALTH SERVICES Reference was made at the end of Chapter 3 to the fact that i f people i n a region f e e l powerless to make needed changes i n the system or t h e i r s i t u a t i o n , they w i l l make requests for more services of a kind they can e f f e c t . I t i s time perhaps to look at what makes people regard themselves as powerless and to determine what powers people or groups of people have and how these varying powers a f f e c t the organiza-ti o n and delivery of health care i n B r i t i s h Columbia. Attempts have been made to change the health services i n the Kitimat-Stikine Regional D i s t r i c t . Mention w i l l be made of some of them. Power can be viewed as the a b i l i t y to achieve goals or objectives. Here we are concerned with the objectives of the people of the Kitimat-Stikine Regional D i s t r i c t to at t a i n the best possible health services for themselves. What do they mean by this? We discovered that i t included a number of factors. Health services personnel should be available i n good quantity and a good mix. F a c i l i t i e s should be well equipped and well placed. The people should have access to care quickly when an emergency occurs. They should have pro-per access to the r e f e r r a l system i n health care without time 68 lags, f i n a n c i a l b a r r i e r s . And t h i s r e f e r r a l system should include l o c a l primary, regional secondary and p r o v i n c i a l t e r t i a r y f a c i l i t i e s for receipt of emergent, urgent and e l e c t i v e care. F i n a l l y , they believe they should have pro-grammes available l o c a l l y for jobs and careers i n the health f i e l d . Who has the power to give them this? Where does power l i e ? Power i s d i s t r i b u t e d amongst many individuals with d i f f e r e n t i n t e r e s t and concerns and groups with cross-j u r i s d i c t i o n s . Services are obtained by bargaining within t h i s pattern; some factors are outside l o c a l control and therefore some services may be lacking or only minimally available. Because of t h i s the access to health care that people have may be determined by the power they or others well removed from them have. The d i s t r i b u t i o n of power within western democratic societ i e s has been analyzed by a number of s o c i a l s c i e n t i s t s and the organization of the health care system within these 1 2 3 so c i e t i e s by others. (Dubin , French and Raven , Schwartz , 4 5 6 I l l y c h , Navarro , Krause , etc.) This analysis w i l l concen-trate upon the l a t t e r but w i l l draw on general concepts of the former. Schwartz suggests that the p r i n c i p a l function of the p o l i t i c a l system i s the attainment of society's goals and one of i t s goals i s to promote good health. But as well as being interested i n health outcomes, so c i e t i e s are concerned with the structure and processes of d e l i v e r i n g health care, for 69 consumer and c i t i z e n s f i n d i t d i f f i c u l t to see long term out-comes and are better judges of intermediate outcomes which often seem to be the same as processes. But health and health care i s only one of society's goals. P o l i t i c a l s c i e n t i s t s have analyzed the goals of western democratic socie t i e s and the role of governments i n attaining these goals. The dominant ideology of western democracies -li b e r a l i s m - i s explained by Marchak, a Canadian s o c i o l o g i s t . I t includes the assumptions of a competitive economy, the separation of government and economic i n s t i t u t i o n s , equality of condition and opportunity, the homogeneity of the population i n terms of wealth and power^and the independence and sovereignty of nation states. Within t h i s d e f i n i t i o n of abstract p r i n c i p l e s there i s a good deal of choice. Whilst these ( l i b e r a l ) assumptions can be faulted on the evidence available, such evidence i s not common property, i s not v i s i b l e to a large section of the population, and can, i n any case be dismissed with various h i s t o r i c a l and cultural.explanations...The persistence of the l i b e r a l ideology r e f l e c t s the continuity i n the structure of Canadian society. The continuity i s a process of cumula-t i v e change and the process i s not yet at a stage where the independent growth of divergent classes and i n s t i t u -tions creates an obvious c o n f l i c t of int e r e s t s . There i s no single point at which we can say: here i s the break^ with the past: here we enter a new kind of society... The choices made are strategic says Marchak. The amount of separation between government and economic i n s t i t u -tions d i f f e r s i n the d i f f e r e n t l i b e r a l democracies, and the health care system i s i n the midst of a p o l i t i c a l arena. I t i s partly i n the market system and pa r t l y i n the government system and changes i n the balance between these two systems are the subject of continual negotiation. We can see that there are power struggles between the consumers and c i t i z e n s 70 and the providers of services but how best to work out a solution to a l l t h e i r needs and requests depends upon the context i n which the struggle i s being c a r r i e d on as well as the contenders themselves. DISTRIBUTION OF POWER Power i s widely d i s t r i b u t e d among the many components of the health services system. The i n d i v i d u a l consumer has the power to choose whether to use the system or between parts of the system and groups of consumers may try to influence the d i s t r i b u t i o n of services; health professionals have power to carry out t h e i r work within regulatory l e g i s l a t i o n and may form i n t e r e s t groups to influence regulations and resource a l l o c a t i o n as well as taking on other s o c i a l roles i n t h e i r community;- elected or appointed representatives make p o l i t i c a l decisions, but a l l have r e s t r i c t e d powers. The types and amount of power each group has, r e l a t i v e to the others' i s important to the delivery of health services. The a b i l i t y of the various groups to achieve t h e i r goals, i n comparison with t h e i r perception of others' success, determines how powerful or powerless the group believes i t s e l f to be. However, as Kerr suggests, i t may not be necessary to at t a i n goals. Regions may be content even i f t h e i r develop-ment needs are not met i f they are assured t h e i r requests g have been seriously considered. The same can be said of health care. The a b i l i t y of regional p o l i c y makers or a professional organization to make 71 contact with a cabinet minister, senior c i v i l servant or other decision-maker may be regarded as proof that the profession's or the region's views w i l l be considered. I n a b i l i t y to make such contact and express t h e i r views i s interpreted as an i n -dication of the profession's or region's powerlessness. PRESSURE GROUPS People l i v i n g and working together i n any society develop shared attitudes which are believed to be the common good. Within society, groups of people may separate themselves out and form sub-groups with other people with whom they have a shared attitude within i t about what i s needed i n any given s i t u a t i o n and i t may make demands or claims upon other groups that have formed within the society. Such groups as these can be referred to as "pressure groups". Castles distinguishes between two types of pressure groups; the attitude group and the int e r e s t group. The former has as i t s main concern the changing of values of society, the l a t t e r group i s anxious to promote the s e l f - i n t e r e s t of the group members. Writing before t h i s d i s t i n c t i o n was made, Almond i n - describing pressure groups as in t e r e s t groups, wrote Interest groups a r t i c u l a t e p o l i t i c a l demands i n the society, seek support for these demands among other groups by advocacy and bargaining, arid attempt to transform these demands into authoritative public policy by influencing the choice of p o l i t i c a l per-sonnel, and the various^process of public and po l i c y making and enforcement. The degree of success an in t e r e s t group may experience i n a f f e c t i n g p o l i c y and i n transforming i t s demand into p o l i c y w i l l depend upon several factors. One of these i s the amount 72 of agreement there i s within the organization or i n t e r e s t group. A highly.cohesive group w i l l possess more power than one which has not formulated,its demands i n a way which i s agreeable to a l l members of the group. The amount of expertise which i s available.within a group i s also an important factor; the l e v e l of knowledge within the group, the s p e c i a l i z a t i o n of the know-ledge and the d i f f e r e n t i a l between the knowledge of the group and the knowledge of the people outside the group. PROVIDERS' GROUPS - (INTEREST GROUPS) Because Canada has been loath to i n t e r f e r e with the market system more than seems necessary for ideologic reasons, the health care providers are often entrepreneurs. This posi-t i o n was legitimated i n the nineteen century by l e g i s l a t i o n giving power to the professional associations to regulate t h e i r admission to practice i n the provinces. But the professional associations have weak control over a number of aspects of practice. For example, dentists, optometrists, pharmacists and physicians, working i n private practice, are, to a large extent, self-determining about the location of t h e i r practices. A lack or small supply i n a community of the amenities that a t t r a c t professionals may r e s u l t i n accrual of considerable bargaining power to the professional. This i s e s p e c i a l l y so i f the community badly requires t h e i r services. Governments do not have the power to ensure the medical, dental and other entrepreneurial practices are opened and maintained i n a community because they recognize t h e i r dependence upon these technologists for the provision of service and they are i n a 73 world market for manpower. As well as having t h i s legitimate power, the health professions have.great technical power. The reason for t h i s i s that i n the l a s t twenty years technical development i n the health care f i e l d has been very rapid. Not only have new kinds of work role (respiratory technologist, renal technician, heart catheterization technologist, etc.) developed and already esta-blished work .roles (laboratory technologist, r a d i o l o g i c a l tech-nician) expanded t h e i r function but the s p e c i a l i s t physicians under whose supervision these people work have become "super-s p e c i a l i s t s " themselves. The d i s t r i b u t i o n of power i n the health f i e l d i s unevenly spread. Overwhelmingly, power seems to rest with the physicians. Having a knowledge of what l i v e s they can save or su f f e r i n g they can a l l e v i a t e now as compared to twenty (or even ten or five) years ago, the s p e c i a l i s t physician i s able to use his expert or technologic power to influence the provision of health.care. In addition to legitimate and expert power, physicians are high status c i t i z e n s who can bring influence to bear i n t h e i r communities. They are well educated, usually a r t i c u l a t e and admitted to c i r c l e s where informal discussions about im-portant p o l i c y decisions go..on. They are usually i n the main-stream of l i b e r a l ideology. Their influence may be exerted on p o l i t i c i a n s (provincial or regional), on hospital trustees or administrators, by the physician s p e c i a l i s t alone or sup-ported by a l o c a l community based pressure group.-: Their 74 influence on p o l i t i c a l and bureaucratic decision-making i n B r i t i s h Columbia has been very great. They form an intere s t group that has been very e f f e c t i v e i n negotiations. CONSUMER GROUPS 4PRESSURE-GR0UPS-)-Consumer groups are frequently weak pressure groups. Members of a consumer group may represent a broad array of knowledge. They may have a genuine and strongly motivated concern to achieve the goals of t h e i r group. However, because of the variety i n th e i r background knowledge and education, the various members of a consumer group may have quite d i f f e r e n t views of how the demands should be met. They may not even be sure whether they are attempting to change attitudes, look a f t e r s p e c i a l i n t e r e s t or both and, because of these confusions may riot; understand where pressures can best be brought to bear. One consumer group that can be expected to become more active i n the future i s the Native Indians. Presently, land claims are t h e i r prime i n t e r e s t , but settlement of these claims w i l l allow attention to be paid to other issues. Concern about high morbidity and premature mortality due to cer t a i n disease categories may r e s u l t i n t h i s r e l a t i v e l y homogeneous group. attempting to change the health system so that i t s a t i s f i e s t h e i r health needs while recognizing s o c i a l factors i n t h e i r cultures that d i f f e r from those of the majority Non-Native culture. Consumer groups have prepared b r i e f s for and presented them to government about t h e i r f e l t needs. In Kitwanga, a group of c i t i z e n s prepared a b r i e f about the ambulance and c l i n i c they 75 wanted available l o c a l l y because the road conditions between Kitwanga and Hazelton, the nearest hospital and ambulance, were such that a one-way t r i p was f o r t y - f i v e minutes. Conse-quently, two hours elapsed between the c a l l for an ambulance and the a r r i v a l of the patient at the h o s p i t a l . I, The Heterogeneity of most consumer groups i s a source of weakness. JOINT ACTION ON COMMON INTERESTS In Kitimat, a group consisting of doctors, community health workers, ho s p i t a l personnel and leaders i n industry and unions, have formed a study group to prepare b r i e f s and press for increases i n the health care available i n Kitimat. Concerns were expressed about the necessity of using surface ambulance for i n t e r - h o s p i t a l transfer. However, most of t h e i r attention i s directed at increasing the sophistication of f a c i l i t i e s and medical expertise i n Kitimat. There i s l i t t l e integration of t h e i r objective with those of the regional d i s t r i c t . F a c i l i t i e s and s p e c i a l i s t s are expected to be located i n Kitimat, although i t no longer serves the largest community population and i s not~~" geographically centred i n the regional d i s t r i c t . The necessity to bargain within a group to obtain cohesive and u n i f i e d ob-jectives and aims diverts energy from the achievement of the goal. This thesis i s p a r t i c u l a r l y concerned with resource a l l o c a t i o n which can be a matter of attitudes to amounts available for spending and p r i o r i t i e s i n a l l o c a t i n g these amounts of expenditure. The differences perceived from one area to another by c i t i z e n s are usually experienced as a 76 source of r e l a t i v e disadvantage or r e l a t i v e deprivation. Wealth seems to flow into the c i t i e s and i s seen by the people i n the outlying areas to give the c i t y power to obtain benefits and services which the surrounding country cannot. This town-and-country s p l i t i s evident i n the relationships between both towns and large urban centres and between v i l l a g e s and towns. In each case, the resident of the smaller community i s aware of the benefits that accrue i n the larger centre that are lack-ing i n the smaller one. However, i t i s not possible to have every service available i n kind or degree i n every hamlet, v i l l a g e , town and c i t y . Resources are scarce and have to be rationed by either market or non-market forces. The l e v e l of health care that people, consumers and professionals.;alike, would 'like to have available, could consume much more of the Gross National Pro-duct with no guarantee that the health of the population would be improved. Dollars spent on the health care sector of the economy remove d o l l a r s that might be spent on highways, housing, ai r p o r t s , radio communications and water treatment, a l l of which may influence the health care available to the people. There i s s i m i l a r rationing within the d i v i s i o n s i n the health system. The a l l o c a t i o n of resources into the com-ponent sections of the health system i s p o l i t i c a l i n the broad-est sense, influenced, by the need to accomodate the views and wishes of the most powerful groups. 77 POWERS OF GOVERNMENT Because Canada has a health care system which i s a regulated market system*, governments' powers are determined by the negotiations which have taken place and continue to take place between the entrepreneurs and the p o l i t i c i a n s and admini-st r a t o r s . These legitimate powers may be divided into regulation and resource a l l o c a t i o n and may be examined within a national context or at the regional l e v e l . POWERS OF DELEGATED BODIES I t i s not proposed to review the health system of Canada i n any detail-but s o l e l y to mention major issues. The pro v i n c i a l governments have the rig h t to be responsible for regulating health and welfare a c t i v i t i e s under the B r i t i s h North America Act. This permits them to enact l e g i s l a t i o n determining the q u a l i t y of health services. The l e g i s l a t i o n provides for delegation of authority to professional groups and health care i n s t i t u t i o n s which provide the services under certain safeguards. Federal and p r o v i n c i a l governments share the operating costs of most health services and may provide grants i n aid of voluntary organizations which provide the rest. As a re s u l t of the i r growing economic involvement, the governments have become more concerned about c o n t r o l l i n g the costs of health care provision. At one time the federal government was prepared to share c a p i t a l costs with p r o v i n c i a l and l o c a l groups *It is regulated in that entrepreneur providers of health care negotiate fee schedules for their various services with the insuring company. Health care is not subject to the economic influences of the free market. 78 but t h i s cost-sharing a c t i v i t y was terminated for hospitals i n 1969 and w i l l terminate i n 19 80 for teaching f a c i l i t i e s . The delegation of regulatory power and funding power i s made to d i f f e r e n t bodies which then become intere s t groups concerned not only with the administration of the responsibi-l i t i e s delegated to them but also with t h e i r external boundaries and t h e i r r e l a t i o n s h i p to other bodies which are empowered to undertake a c t i v i t i e s i n t h e i r sphere of i n t e r e s t . The powers of the professional associations have been mentioned above. Powers are also delegated.to hospital boards to provide patient care within t h e i r f a c i l i t i e s by t h e i r employees and to municipalities or Union Boards of Health to provide public health services. While there are l o c a l long term care and community mental health services, control over these pro-grammes i s maintained at the p r o v i n c i a l l e v e l except i n the metropolitan areas. Planning powers i n B r i t i s h Columbia are delegated by the p r o v i n c i a l government to Regional Hospital D i s t r i c t boards. These boards work i n conjunction with Regional D i s t r i c t boards which are concerned with general urban and regional planning. It i s obvious that a l l these separate systems of power delegation (or maintenance of control at the p r o v i n c i a l level) can r e s u l t i n great r i v a l r i e s and jockeying for p o s i t i o n . As well, the voluntary organizations may be granted resources to perform c e r t a i n tasks on behalf, of the community, usually after pioneering without assistance. The educational system i s i n a separate compartment from the health system i n Canada, 79 yet there are many interests held i n common. The t r a i n i n g of professionals and others who hope to enter the health care system i s ca r r i e d out by the educators who have t h e i r own p r i o r i t i e s . I t can be seen that there are a variety of l e v e l s and d i v i s i o n s within the p o l i t i c a l system of Canada and that for t h i s system to function smoothly, there must be some incor-poration of p r o v i n c i a l , regional and l o c a l interests into national goals. The various divisions, of authority must d i s -cover ways of working together i f they are to reach any of t h e i r objectives. WHAT HAS BEEN ACHIEVED? Instead of having a completely unregulated market system which would probably r e s u l t i n a poorer d i s t r i b u t i o n of services to the north than there i s at present, there i s a government-subsidized entrepreneurial system. The federal-p r o v i n c i a l cost-sharing programmes have resulted i n pushing services outwards. There were already, before the federal government became involved i n 19 49, public health services which continue, today to be provided by the Union Boards. The additions of long term care and community mental health services i n the l a s t ten years have greatly strengthened the community care that was previously available but these services are not yet well integrated with other health services. The most important federal government intervention 80 was the grant-in-aid programme for hospital construction from 1949 through 1969. Despite the condition that t h i s aid should be related to the development of a plan for hospital develop-ment drawn up at the p r o v i n c i a l l e v e l , power to establish and develop hospitals now became, divided between municipal, pro-v i n c i a l and federal bodies and bargaining for the establishment of such i n s t i t u t i o n s became much easier because of the p o s s i b i -l i t y of getting resources. People l i v i n g i n the i n t e r i o r of B r i t i s h Columbia were able to bring strong p o l i t i c a l pressure to bear because of the way i n which the e l e c t o r a l system weighted t h e i r votes and many communities got t h e i r hospitals. Then, of course, they demanded federal assistance with operating costs and a fed e r a l - p r o v i n c i a l cost-sharing system for these was enacted i n 1956. The hos p i t a l programme was t h e i r greatest success. The Medical Care Act, 19 67 provided for the payment of doctors' fees but had l i t t l e influence upon the d i s t r i b u t i o n of doctors. As the numbers of physicians increased slowly over the years, there were some increases i n the numbers of doctors who established practices i n small towns rather than i n urban areas. Hospitals acted as f o c i f o r the doctors and affected t h e i r choice of practice areas. Often h o s p i t a l boards went out of t h e i r way to provide equipment and support s t a f f for doctors. By the mid-sixties, when i t was clear that hospital construction grants would be terminated before long, B r i t i s h Columbia established Regional Hospital D i s t r i c t s i n order to 81 plan f a c i l i t y development for the future. A NEW CHANNEL FOR MAKING DEMANDS: THE REGIONAL DISTRICT The Regional Hospital D i s t r i c t s have very broad powers under the Act to control not only c a p i t a l but also operating costs of hospitals. The Regional Hospital D i s t r i c t s have not exercised the powers the l e g i s l a t i o n grants them except over c a p i t a l costs. The Kitimat-Stikine Regional D i s t r i c t went much further than some others by taking t h e i r mandate very seriously. Several studies of the health services system have been commissioned by the Kitimat-Stikine Regional D i s t r i c t . The A. V. Gray Report of 19 70 recommended f a c i l i t y construction over five y e ars. 1 0 The study;;team of which the writer was a member, i n 19 75 investigated services, programmes and manpower in the entire region and made recommendations for long-term development. 1 1 The Kitimat-Stikine Regional D i s t r i c t continued to employ health planning students to conduct studies into more s p e c i f i c areas of need, such as ambulance transportation and alcoholism. The Northwest Study Conference of 1974 was a meeting of prominent and active northerners from many regional d i s t r i c t s who discussed, amongst other items, the health pro-blems of northerners. While the a b i l i t i e s to express views of i n j u s t i c e s to which one feels subjected may reduce the feelings of de-pr i v a t i o n , some action i s expected to r e s u l t from voiced complaints. A comment frequently voiced to the study team was that the numbers of studies carried out in the Kitimat-Stikine 82 Regional D i s t r i c t had resulted i n l i t t l e or no change i n the sit u a t i o n . Complicating the evaluation of such studies i s the fact that some r e s u l t s may be introduced over or a f t e r a long period of time; months or years a f t e r the study i s completed. Expectations of short term results may be u n r e a l i s t i c . The Regional D i s t r i c t Boards have legitimate authority to e f f e c t changes. They can procure funds for new hospitals, more hospital beds or health c l i n i c s . They can also generate technical power. Studies can be commissioned by the regional h o s p i t a l d i s t r i c t to assess the s i t u a t i o n i n the regional d i s t r i c t and a s s i s t the board i n determining the needs of the area and the long and short range goals and objectives that w i l l meet them, whether they be f o r more hospital beds, sewage treatment plants, more professionals, s p e c i a l i s t s , for l o c a l education of health care workers or programmes to reduce the incidence of certa i n diseases. They can also exert influence on the senior l e v e l s of government for services that meet t h e i r special needs, such as for a i r ambulance services, c l i n i c s i n remote v i l l a g e s and v i s i t i n g s p e c i a l i s t s i n mental health, dental disease and n u t r i t i o n . And, within the regional d i s t r i c t , the regional hospital d i s t r i c t board can a f f e c t the programmes offered by pressing agencies to establish new programmes to meet s p e c i f i c needs and to integrate related services which a f f e c t or treat the same people. However, i t s authority i s limited and i t can work only within these l i m i t a t i o n s . 83 As far as t h i s thesis i s concerned, the most important development i n reducing the b a r r i e r s to access to health services was the hospital construction programme which enabled northern and outlying communities to obtain f a c i l i t y resources. Nor-therners expressed the b e l i e f -often and strongly to the team that factors outside the existence of the hospital f a c i l i t y i n t e r f e red with the use they were able to make of that resource. In the l i g h t of t h i s , i t was decided to examine the numbers of hospital separations of residents of the Kitimat-Stikine Re-gional D i s t r i c t to determine whether, i n fact, u t i l i z a t i o n indicated that they were unable to use the community hospitals within the regional d i s t r i c t and the r e f e r r a l hospitals outside i t to t h e i r best advantage. 84 REFERENCES CHAPTER 4 Dubin, Robert, The World o f Work: I n d u s t r i a l S o c i e t y and  Human R e l a t i o n s , Englewood C l i f f s , N. J . , P r e n t i c e - H a l l , 1958. French, J . R. D. and Raven, B. "The B a s i s o f S o c i a l Power" i n C a r t w r i g h t , D. (ed.), S t u d i e s i n S o c i a l Power, Research Center f o r Group Dynamics, U n i v e r s i t y o f Michigan, 1959. Schwartz, M i l d r e d A., P o l i t i c s and T e r r i t o r y : The  So c i o l o g y o f Regional P e r s i s t e n c e i n Canada^ M c G i l l Queen's U n i v e r s i t y P r e s s , Montreal, 19 74. I l l i c h , Ivan, M e d i c a l Nemesis, The E x p r o p r i a t i o n o f H e a l t h , Toronto, M c C l e l l a n d and Stewart, 1975. Navanro/ V i c e n t e , Medicine under C a p i t a l i s m , New York, P r o d i s t , 1976. Krause, E l l i o t t A., Power and I l l n e s s : The P o l i t i c a l  S o c i o l o g y of Health and Med i c a l Care, New York, E l s e v i e r , 1977. Marchak, Maureen P a t r i c i a , I d e o l o g i c a l P e r s p e c t i v e s i n  Canada, Toronto, New York, McGraw-Hill Ryerson, 1975. Ker r , Donald P., " M e t r o p o l i t a n Dominance i n Canada: i n John Warkentin, (ed.), Canada, A Geog r a p h i c a l I n t e r p r e t a t i o n , Methuen P r e s s , Toronto, 1968. Almond, G a b r i e l A., " I n t e r e s t Groups and the P o l i t i c a l P rocess, quoted i n Engelmann, F r e d e r i c k C. and Schwartz, M i l d r e d A., P o l i t i c a l P a r t i e s and the Canadian S o c i a l  S t r u c t u r e , Scarborough, P r e n t i c e - H a l l of Canada, 1967. Bauder, E. M. and Gray, A. v., Economic Development o f the Regional D i s t r i c t o f K i t i m a t - S t i k i n e , B r i t i s h Columbia, Vancouver: AVG Management Science L i m i t e d , 19 71. C r i c h t o n , Anne (ed.), H e a l t h Seen i n Northwest B.C., A Review o f E x i s t i n g Programmes i n the K i t i m a t - S t i k i n e Regional D i s t r i c t , Summer 19 75, Unpublished, U n i v e r s i t y of B r i t i s h - Columbia, Department of He a l t h Care and Epidemiology, 19 75. CHAPTER 5 DESCRIPTION OF HEALTH SERVICES IN KITIMAT-STIKINE REGIONAL DISTRICT A discussion has been presented about factors that enhance access to health services and the power that exists in the health service system. This thesis i s about the health services i n the Kitimat-Stikine Regional D i s t r i c t , so i t i s important to know what health services existed in that area. The health care benefits covered by plans are the same for northerners as for southerners; hospital and medical care insurance coverage and benefits are the same for various groups of residents of B r i t i s h Columbia regardless of the regional d i s t r i c t i n which they reside. While prepaid programmes may reduce the cost of access to care at the time of service, they do not guarantee provision of the service. The l a t t e r r esults from programmes that are established by health service personnel i n various kinds of f a c i l i t i e s ; some i n private practice and others sa l a r i e d , some employed i n p u b l i c l y funded programmes and f a c i l i t i e s and others operating under market forces. This chapter w i l l describe what f a c i l i t i e s and manpower resources were available and what programmes were offered i n the Kitimat-Stikine regional d i s t r i c t they were located i n and what was not available or offered i n the area in 1973 and 1975. FACILITIES It may appear l o g i c a l to discuss the several types of health f a c i l i t i e s by t h e i r location and c e r t a i n l y , the greatest use of any f a c i l i t y i s made by l o c a l residents. However, the establishment of Regional Hospital D i s t r i c t s as a decision-making body for the a l l o c a t i o n and d i s t r i b u t i o n of hospital resources implies that f a c i l i t i e s w i l l be usable by a l l residents of the regional d i s t r i c t . In t h i s way, i t i s expected that unnecessary duplication of costly f a c i l i t i e s can be avoided. In this respect, a more l o g i c a l discussion may r e s u l t from one based on the type of f a c i l i t y , rather than by lo c a t i o n . Hospitals There were four acute care general hospitals and one psycho-geriatric hospital i n the regional d i s t r i c t . Through-out the period of the study, 19 73 and 1975, the acute care bed capacity of the hospitals i n the regional d i s t r i c t did not change, though there were plans for development which were beir implemented. The M i l l s Memorial Hospital i n Terrace had eighty-seven beds and cots, while Kitimat General Hospital had 113, Wrinch Memorial Hospital i n Hazelton had 50 and Stewart General Hospital had 10 beds and cots. These acute care hospitals contained some common f a c i l i t i e s , but because of manpower differences i n the communities, there were some 8 differences i n the f a c i l i t i e s provided, and consequently i n the services they offered within the hospitals. Use of the s p e c i a l services offered i n one h o s p i t a l was available to a l l the people i n the regional d i s t r i c t . This was enabled by the granting of physician's p r i v i l e g e s by a hospital to a medical s p e c i a l i s t who l i v e d i n a neighbouring community. S p e c i a l i s t s who required highly s k i l l e d support personnel and bulky, expensive equipment for e f f e c t i v e treatment of t h e i r patients, practised only i n one h o s p i t a l , or directed s p e c i f i c aspects of t h e i r work to that ho s p i t a l . In t h i s way, a more e f f i c i e n t use of the a v a i l a b l resources was made. The access problems of patients from remote areas of the regional d i s t r i c t were necessarily i n c o n f l i c t with and balanced against the physician's determination of the requirements basic to the provision of good patient care. TABLE I NUMBER OF HOSPITAL BEDS AVAILABLE IN KITIMAT-STIKINE REGIONAL DISTRICT, 1975. BY LOCATION Number of adult & c h i l d beds av a i l a b l e Type of F a c i l i t y Terrace Kitimat Hazelton Stewart Other Acute Care 87 a 113 50* 10 Extended Care — 35 __b __d Psycho-Geriatric 75 6 — — __ a. This does not include 10 p s y c h i a t r i c beds that were opened i n M i l l s Memorial Hospital, Terrace i n l a t e 1975. b. Plans were being drawn f o r a new h o s p i t a l with 45 acute care and seven extended care beds. c. Indian v i l l a g e s of over 200 population were served by a c l i n i c containing one or two beds. d. The h o s p i t a l in Stewart did have some long-term patients although the beds were not c l a s s i f i e d as extended care beds. e. These beds were f o r male patients, but plans were being made to admit some female patients i n the future. 88 TABLE II SERVICES OFFERED IN ACUTE CARE HOSPITALS IN KITIMAT-STIKINE REGIONAL DISTRICT, 197 5. BY LOCATION Available Department/Procedure Community Location of Hospital Terrace Kitimat Hazelton Stewart Medical/Surgical beds * * * * O b s t e t r i c a l beds * * * Paediatric beds * * * * P s y c h i a t r i c beds * Anaesthetics * * * Emergency * * * * Intensive Care * a Laboratory * * Operating Room * * * Ophthalmology * Pharmacy * Physiotherapy * * Radiology * * a. The laboratory i n Kitimat General Hospital contained equipment f o r s p e c i a l i z e d functions that were not a v a i l a b l e i n M i l l s Memorial Hospital, Terrace. In addition, use was made of the Regional Labora-tory services of the Royal Columbian Hos p i t a l , New Westminster. The acute care hospitals i n Terrace, Kitimat and Stewart were owned by municipal socie t i e s and operated by a board made up of members of the communities i n which they were located. Wrinch Memorial Hospital i n Hazelton was owned and operated by the United Church of Canada. The extended care 89 beds i n Kitimat were i n Kitimat General Hospital and consequently, municipally owned. The psycho-geriatric hospi t a l , Skeenaview i n Terrace, was owned by the p r o v i n c i a l government. Its health care function was the r e s p o n s i b i l i t y of the Department of Human Resources and there was a board of community members who managed i t . Maintenance of the buildings and grounds of t h i s hospital were the r e s p o n s i b i l i t y of a government department, Public Works, responsible to a d i f f e r e n t Ministry of the government. Because of•the i s o l a t i o n of the town of Stewart, Stewart General Hospital's existence was reassuring to the townspeople and the research team found a high l e v e l of community support for the h o s p i t a l , despite the l i m i t a t i o n s of i t s services. I t offered only medical care and emergency treatment. Because there was only one physician, any procedures requiring general anaesthesia could not be done and patients requiring these procedures were transferred to another h o s p i t a l . Most transfers from Stewart were to the hospital i n Prince Rupert, outside the regional d i s t r i c t . Simple X-Rays could be taken, but were sent to Prince Rupert to be read. Only simple urinalyses could be carried out i n the hospital because there was no laboratory. A l l of the hospitals supplied some accommodation for s t a f f . This was used as an a t t r a c t i o n i n s t a f f recruitment. 9 0-MAP 2 LOCATION OF HEALTH FACILITIES IN KITIMAT STIKINE REGIONAL DISTRICT T e l e g r a p h C r e e k I s k u t E d d o n t e n a j o n U . S . A . K i n c o l i t h S t e w a r t G r e e n v i l l e New A i y a n s h S k e e n a - \ Queen C h a r l o t t e " R e g i o n a l K i t k a t l a H a r t l e y Bay H a z e l t o n T e r r a c e K i t i m a t KEY: +• - Hospital - Pharmacy O - Mental Health Centre X - Medical Services C l i n i c D - Public Health Unit - Doctor's O f f i c e - 91 C l i n i c s , Offices and Businesses As was mentioned e a r l i e r , i l l n e s s e s with the greatest s o c i a l costs and disruption are the object of preventive programmes which attempt to reduce the incidence or ameliorate the effects of them. Such programmes as Public Health and Mental Health are housed i n o f f i c e s established by the p r o v i n c i a l government. Medical Services o f f i c e s and c l i n i c s were supplied by the federal government. The most s i g n i f i c a n t gate-keepers i n the health care system, however, operate as entrepreneurs and provide t h e i r own o f f i c e s or businesses. In an attempt to ensure the gate-keeper providing access to hospital care i s available, some hospitals b u i l d physician's o f f i c e s into t h e i r f a c i l i t y . The physician i s charged rent for these premises.. At the time of the study, most c l i n i c s , o f f i c e s and businesses were housed separately. The Public Health Unit was housed in the same building as the Medical Services nurse i n Hazelton and there were plans for the construction of a new f a c i l i t y i n Terrace which would house the Mental Health Centre, the Public Health Unit and several non-health service agencies whose caseloads overlap with these health agencies. It was hoped that in t h i s way, these agencies would develop close communications, an example of which existed between the Public Health nurse and the Medical Services nurse i n Hazelton. In Kitimat, Stewart and Hazelton, physicians' o f f i c e s were located i n the h o s p i t a l , which i n each case was 92. c e n t r a l l y located. Equipment and o f f i c e s were available i n Kitimat General Hospital for v i s i t i n g s p e c i a l i s t s . In Terrace, the physicians had o f f i c e s d i s t r i b u t e d i n buildings throughout the business section, while the hospital was located across the railway yard i n a newly developing area of the community. Dentists' o f f i c e s i n Terrace and Kitimat were located throughout the business sections of these communities, while being located i n the hospitals i n Stewart and Hazelton. S i m i l a r l y , the hospital i n Stewart provided an o f f i c e and equipment for optometrists who v i s i t e d r e g u l arly. The optometrists i n Terrace and Kitimat provided t h e i r own o f f i c e s . There were four community pharmacies i n both Terrace and Kitimat and one i n Stewart. There was no drug store in Hazelton. The outlying v i l l a g e s were served by Medical Services c l i n i c s . Most c l i n i c s had two beds for patients, oxygen equipment and a supply of commonly used medications, while that i n Telegraph Creek contained, i n addition, a dental chair and X-Ray equipment. The c l i n i c s were located i n New Aiyansh, Greenville, Hartley Bay, Hazelton, Iskut, K i n c o l i t h , K i t k a t l a and Telegraph Creek. •'9*3-TABLE III NON-HOSPITAL FACILITIES IN KITIMAT-STIKINE REGIONAL DISTRICT, 1975 BY LOCATION AND TYPE Type of F a c i l i t y Terrace Kitimat Hazelton Stewart Other Medical Services Mental Health Centre Community Pharmacy Public Health Unit 1 1 1 0 7 a 1 o 0 0 0 0 4 4 0 1 0 1 - 1 1 1 0 a. These 7 c l i n i c s were located i n New Aiyansh, Gr e e n v i l l e , Hartley Bay, Iskut, K i n c o l i t h , Telegraph Creek and K i t k a t l a . MANPOWER Health services personnel were located i n the communities which housed the f a c i l i t i e s i n which they practiced. Consequently, there was a concentration of them i n the towns; Terrace, Kitimat, Hazelton and Stewart. While some communities, and i n some instances, the regional d i s t r i c t , lacked s p e c i f i c resident health care workers, the services of these dentists, optometrists or medical s p e c i a l i s t s were available to the people during periodic v i s i t s of the health care professionals to the communities. The numbers and location of the health services personnel can be seen i n Table i v . For each group of manpower, the table also indicates the percentage of the t o t a l p r o v i n c i a l supply of workers that the quantitative number TABLE IV HEALTH SERVICES PERSONNEL IN THE KITIMAT-STIKINE REGIONAL DISTRICT, 1975 BY LOCATION AND TYPE Type of P r a c t i t i o n e r Regional''' D i s t r i c t * # % Terrace Number Kitimat Number Hazelton Number Stewart Number Dentists 9 0.70 5 4 - v i s i t 2 D i e t i c i a n s 3 0.82 - - _ _ Food Service Supervisors 1 1.30 1 - - _ Licenced P r a c t i c a l Nurses 88 1.53 No area breakdown was obtained. Registered Nurses 161 1.30 No area breakdown was obtained. Registered No area breakdown was obtained but Psy c h i a t r i c Nurses 43 2.61 most were i n Terrace. Occupational Therapists 1 0.66 1 - _ _ Optometrists 2 1.20 2 v i s i t s - • • .u 2 v i s i t s Pharmacists 14 0.84 7 6 _ 1 Physicians 43 1.22 Anaesthesiology 2 1.12 1 1 2 - -Dermatology 0 — v i s i t - -General Practice 32 1.51 22 5 4 1 Family Practice 2 1.51 No area breakdown was obtained. Internal Medicine 1 0.38 1 , v i s i t s . v i s i t s , _ Medical Health O f f i c e r 0 — • • 4 v i s i t s • • J. 4 v i s i t s • • *_ 4 v i s i t s , _ Obstetrics - Gynecology 1 0.80 1 2 - • • ^ 4 v i s i t s -Ophthamology 0 — v i s i t s v i s i t s - -Orthopaedics 1 1.22 - 1 4 - _ Otolaryngology 0 — - v i s i t s - -Paediatrics 1 0.80 1 4 v i s i t s v i s i t s Pathology 1 1.30 v i s i t s ^ 1 2 - -Psychiatry 0 — v i s i t s v i s i t s - _ Radiology 1 0.61 v i s i t s 4 1 4 - -Rheumatology 0 — v i s i t s v i s i t s _ _ Surgery 3 1.19 2 1 • • X. 4 v i s i t s _ Physiotherapists 5 0.69 2 3 - -These numbers were obtained and percentages of t o t a l p r o v i n c i a l manpower were ca l c u l a t e d with data from D i v i s i o n of Health Services Research and Development, R o l l c a l l 75: A Status Report Of Health Personnel In The Province Of B r i t i s h  Columbia, Report R: 1, Health Sciences Center, University of B r i t i s h Columbia, 1976. V i s i t from p r a c t i t i o n e r i n southern B r i t i s h Columbia. None were i n p r a c t i c e . V i s i t from p r a c t i t i o n e r within Kitimat-Stikine Regional D i s t r i c t or from Prince George or Prince Rupert. represents. The Kitimat-Stikine Regional D i s t r i c t contained 1.7% of the population of B r i t i s h Columbia i n 1975. Dentists, pharmacists and physiotherapists appear from th i s s t a t i s t i c to be i n comparatively short supply and d i e t i c i a n s not available at a l l , but such i s not e n t i r e l y true. While dentists and physiotherapists did complain of a heavy workload, and the pharmacists said the a v a i l a b i l i t y of more pharmacists would improve the problem of obtaining r e l i e f s t a f f during i l l n e s s and holidays, i t i s doubtful the population could support more pharmacists and physiotherapists The support of community pharmacists, s a l a r i e d or entrepreneurial, i s dependent on market forces. Physiotherapists are usually employed by hospitals and dependent upon the a l l o c a t i o n of resources to and within the h o s p i t a l . There were four d i e t i c i a n s residing i n the regional d i s t r i c t , none of whom were employed i n d i e t e t i c s . The apparently high proportion of registered p s y c h i a t r i c nurses in the regional d i s t r i c t was due to the Terrace location of Skeenaview, one of four psycho-geriatric hospitals i n the province. The concern expressed by the physiotherapists about th e i r workload r e f l e c t e d on the d i r e c t i o n given to the delivery of health services by the a l l o c a t i o n of resources. There has been an emphasis on the provision of care to patients i n acute phases of disease or injury. The services the physiotherapists provided were dictated by the exigencies of the a c u t e l y . i l l patients, both pre and post-operatively. Time available after these patients' needs were met was available to the r e h a b i l i t a t i o n of the long-term patient. The workload on the dentists was described as extremely heavy. The demand for dental services had increased with the development of plans to cover the costs of dental care as part of c o l l e c t i v e bargaining agreements. Waiting time for a dental appointment i n Kitimat and Terrace was said to be from six to eight months. The dentist i n Hazelton said he was correcting dental decay diagnosed by him i n patients a year e a r l i e r when he f i r s t opened his practice. The s i t u a t i o n was even worse i n the v i l l a g e s , where the v i s i t of a Medical Services dentist occurred once a year to provide dental therapy to school children. Prophylactic services i n the v i l l a g e s was provided to school children by the nurses i n the c l i n i c s . The pressure of the workload was f e l t by the dentists as well.as .their c l i e n t s . Dentists i n Kitimat and Terrace indicated the heavy workload was i n f l u e n t i a l i n decisions of dentists to leave the area a f t e r only one or two years' practice. Such a decision might appear to be the only way a conscientious dentist could preserve his privacy and family l i f e . Most health care professionals complained of the d i f f i c u l t y i n obtaining r e l i e f s t a f f which would enable the provision of service during t h e i r absence at continuing education courses or on holidays. There were pools of Registered Nurses and Registered Psychiatric Nurses who provided r e l i e f s t a f f for the hospitals. However, people had to be brought i n to the area to replace a physician, pharmacist or dentist. The Medical Services Nurses i n the v i l l a g e s bore the r e s p o n s i b i l i t y of being the only trained health care worker available to the residents. When she l e f t the v i l l a g e for a day to shop for groceries i n Terrace, the people had no person with health care t r a i n i n g available. The t o t a l commitment to work which t h i s placed on the nurses was possibly a large factor i n the turnover of Medical Services Nurses. It can be seen i n Table IV .that many communities i n the regional d i s t r i c t were served by v i s i t i n g health care p r a c t i t i o n e r s . V i s i t s by professionals within the regional d i s t r i c t were on a regular weekly or bi-weekly basis; those by professionals from outside the regional d i s t r i c t were less frequent. The t r a v e l l i n g p r a c t i t i o n e r s enabled people to Obtain specialized care l o c a l l y without the family disruption and f i n a n c i a l hardship of travelling.- themselves to the metropolitan areas of the province. The fact of a s p e c i a l i s t ' s v i s i t did not resolve a l l access problems. Most of the t r a v e l l i n g professionals were in private practice and paid on a fee-for-service basis. While there .were a few complaints of the waiting time to consult with them, the professional usually worked long hours while i n the community to accommodate a l l c l i e n t s or patients, thus reducing queue length to the period between v i s i t s . By contrast, the p s y c h i a t r i s t was unable to see a l l patients referred to him. At that time, the p s y c h i a t r i s t was a v i s i t i n g , s a l a r i e d consultant. The supply of s a l a r i e d services does not adjust to changes i n the demand for them as quickly as the supply of entrepreneurial services does. The former i s dependent on the a l l o c a t i o n of public funds. In t h i s s i t u a t i o n , large numbers of patients or c l i e n t s may r e s u l t i n long queues rather than increased supply of service. This forces the medical pr a c t i t i o n e r to be s e l e c t i v e i n the patients he sees. Not shown i n the chart are s o c i a l workers or p s y c h i a t r i c s o c i a l workers i n the regional d i s t r i c t . There were two employed i n the P r o v i n c i a l Mental Health o f f i c e i n Terrace. The p s y c h i a t r i s t ' s monthly v i s i t s were adjunctive to t h e i r work and they served as gatekeepers to the p s y c h i a t r i s t , a s s i s t i n g i n patient s e l e c t i o n . The workload on the unit was described as extremely heavy. At the time of the study, the personnel i n the Mental Health C l i n i c had asked the general p r a c t i t i o n e r s , public health nurses and other sources of r e f e r r a l to l i m i t t h e i r r e f e r r a l s of patients to the Mental Health services. Since then, a s a l a r i e d p s y c h i a t r i s t -has become resident in Terrace. Missing Workers: There were a number of types of health care workers who were not i n practice i n the Kitimat-Stikine Regional D i s t r i c t . The lack of some of these workers was f e l t by the population i n the area and mention was made to the study team of p a r t i c u l a r ones that people would l i k e to have had available. The health care workers who were missing comprised biomedical engineers, chiropractors, d i e t i t i a n s , osteopaths, p o d i a t r i s t s and psychologists. "" 99 •' The physicians f e l t the lack of a d i e t i c i a n and mentioned t h i s p a r t i c u l a r l y i n reference to ongoing care and r e h a b i l i a t i o n of the patient i n which di e t can influence the return to good health. The older people i n the community f e l t the lack of a p o d i a t r i s t . However, there were so few people over the age of 65 i n the regional d i s t r i c t , p o d i a t r i s t services could not economically be provided. The various health workers i n the Kitimat-Stikine Regional D i s t r i c t had s p e c i f i c t r a i n i n g and p a r t i c u l a r work roles which they carried out with p a r t i c u l a r s k i l l s . The integration- of each with the others made up the composite whole of the health services available i n the regional d i s t r i c t . Through ind i v i d u a l e f f o r t s and departmental p o l i c i e s , s p e c i f i c programmes were able to be offered i n the f i e l d s where workers s k i l l e d i n those types of programmes were available. Where workers were not available, these s p e c i f i c programmes became somewhat more d i f f i c u l t to esta b l i s h . PROGRAMMES The presence of p a r t i c u l a r f a c i l i t i e s or manpower enables p a r t i c u l a r programmes to be carried out. In ce r t a i n situations, the establishment of a programme i n an area draws into the community,,., workers with p a r t i c u l a r expertise. In others, the presence of health care professiona]s results i n the development of programmes to meet both the health care needs of the community and the professional needs of the 100 worker. Communities that lack c e r t a i n s p e c i a l i z e d health care workers may develop innovative programmes to meet t h e i r needs, using the more lim i t e d medical s k i l l s of available residents. The l a t t e r type of programme has been delineated very c l e a r l y in the Celdic Report, which expressed the b e l i e f that, in the f i e l d of mental retardation, untrained, caring people are frequently more successful i n a s s i s t i n g people to overcome t h e i r problems than are speci a l i z e d professionals."*" This study found that the perception of highly s k i l l e d professionals was directed to p a r t i c u l a r and narrow aspects of the person's health problems and was unable to observe aspects outside t h e i r specialized f i e l d s of t r a i n i n g . Because half the population in the Kitimat-Stikine Regional D i s t r i c t l i v e d outside municipal boundaries, and because p a r t i c u l a r health care workers were not abundant, a number of volunteer groups existed to define the health care needs of t h e i r communities and the best use of t h e i r resources that would a s s i s t i n t h e i r solution. These groups supplemented the programmes established or provided by health care professionals i n the regional d i s t r i c t . ACUTE CARE Acute medical care was available to people throughout the regional d i s t r i c t i n physicians' o f f i c e s , hospitals and Medical Services c l i n i c s . The acute care provided i n Stewart was limited to medical treatments and procedures not requiring an inhalation anaesthetic. Medication necessary for treatment 101 was available i n Terrace, Kitimat and Stewart through- community pharmacies. In Hazelton, drugs were issued from the h o s p i t a l , while i n the v i l l a g e s , they were issued by the Medical Services nurse. Acute dental care was available in Kitimat, Terrace, Hazelton and Stewart on a regular basis, but emergency dental care was not available i n Stewart. ALCOHOLISM TREATMENT It i s widely asserted that the prevalence of alcoholism i s higher i n the north than i n the south. Concern about the prevalence of this condition and the s o c i a l ramifications of i t had given r i s e to the establishment of programmes as well known as Alcoholics Anonymous, Al-Anon and Al-A-Teen to the less well understood Church Army. While Alcoholics Anonymous attempts to break the drinking habits of the a l c o h o l i c , Al-Anon provides the support needed by spouses of alcoholics to cope with the existence of alcoholism i n the home. Al-A-Teen provides s i m i l a r support to children of alcoholics. These programmes were available i n Terrace and Kitimat. At the time of the study, the Salvation Army provided assistance to alcoholics i n Terrace and was planning to es t a b l i s h i t s work i n Hazelton. In the v i l l a g e s , Alcoholics Anonymous did not e x i s t . One band counsellor t o l d the writer that many of the Natives f e l t that A.A., to be successful, must be started by a Native and not by a Non-Native. In addition, there was the widely held view that non-alcoholics could not a s s i s t alcoholics 102 because of t h e i r supposed i n a b i l i t y t o understand t h e i r d r i n k i n g problems. The band c o u n s e l l o r was p a r t i c u l a r l y f r u s t r a t e d by both of these a t t i t u d e s because the combination of the two a t t i t u d e s r e s u l t e d i n a l a c k of any programme i n t h a t p a r t i c u l a r v i l l a g e to cope w i t h a l c o h o l i s m . T h i s problem, suggested the band c o u n s e l l o r , accounted f o r about 75% of the poor h e a l t h amongst the N a t i v e p o p u l a t i o n . In many of the Indian v i l l a g e s , however, there was an o r g a n i z a t i o n which had formed i n the v i l l a g e and which was r e f e r r e d t o as the Church Army. While the team encountered constant r e f e r e n c e to the Church Army and were t o l d r e p e a t e d l y by M e d i c a l S e r v i c e s personnel of the e f f e c t i v e n e s s of the Church Army's programme a g a i n s t a l c o h o l i s m , we were unable to a s c e r t a i n e x a c t l y what t h a t programme was and how the Church Army was o r g a n i z e d . In some v i l l a g e s , i t appeared to have some r e l a t i o n s h i p to the l o c a l church; i n other v i l l a g e s i t d i d not. However, there was repeated mention of the e f f e c t i v e n e s s of the o r g a n i z a t i o n . The team was i n one v i l l a g e a t the time of a meeting of the Church Army. However, they were discouraged from a t t e n d i n g the meeting by the h e a l t h personnel i n the v i l l a g e . AMBULANCE SERVICE Surface ambulances were l o c a t e d i n T e r r a c e , K i t i m a t and Hazelton. In an emergency, use was made a f t e r work hours of the ambulances maintained and operated by the l o g g i n g companies throughout the r e g i o n a l , d i s t r i c t . I n t e r - h o s p i t a l t r a n s f e r of p a t i e n t s was covered under the then newly 10 3 established Emergency Health Services/ i f the transfer was by surface ambulance. The combination of extreme topography, vast distances and a poor highway system within the regional d i s t r i c t , , made i t necessary to use a i r ambulance for the delivery of acutely i l l or injured patients to a h o s p i t a l . The Emergency Health Services covered the cost of emergency delivery of such patients to the primary care available i n a h o s p i t a l . However, i n t e r - h o s p i t a l transfer was not covered by a i r ambulance.* The costs of these transfers were borne by the patient. HOME CARE Home care, programmes are used most frequently i n c i t y hospitals where there i s a shortage of hospital beds s u f f i c i e n t to meet the demand for them. The Kitimat-Stikine Regional D i s t r i c t had a r e l a t i v e abundance of hospital beds to serve i t s population, and consequently the physicians had no problems i n obtaining a bed for a patient they believed required admittance to a h o s p i t a l , nor was there any pressure on the physician to discharge the patient before the patient was ready to return home. Consequently, there was no home care programme developed i n the Kitimat-Stikine Regional D i s t r i c t . MENTAL HEALTH It has previously been stated that a shortage of manpower existed to provide the services of a community Mental Health o f f i c e for a l l the patients who required t h e i r services. At the time of the study, there were no f a c i l i t i e s i n the hospitals to provide p s y c h i a t r i c services to the general population. Skeenaview Hospital provided r e s i d e n t i a l and r e h a b i l i t a t i v e services for psycho-geriatric patients referred from communities i n northern B r i t i s h Columbia. Innovative programmes, such as "Hope to Cope" in Terrace, were designed to a l l e v i a t e the problems of housewives that might exacerbate or induce mental health problems. The programme emphasized development of homemaking s k i l l s ; c onstitution of a health-giving d i e t , balancing of a limited food budget and provision of recipes for int e r e s t i n g and economic meal planning. In addition, the programme attempted to deal with the d i f f i c u l t i e s and loneliness i n northern communities by holding meetings i n neighbourhood suburban areas, thereby enabling women who lacked transportion, to attend. Separation of mothers and children into separate rooms provided freedom for both and an opportunity to s o c i a l i z e with t h e i r peers. PLANNING The Kitimat-Stikine Regional Hospital D i s t r i c t was very involved i n planning of f a c i l i t i e s , i n a t t r a c t i n g personnel to the area, and i n the encouragement of and establishment of programmes that comprised the health services system i n the regional d i s t r i c t . They sponsored studies to determine the health service needs of the people i n the area. 105 In addition to the legitimized planning role of the Regional Hospital D i s t r i c t , there was needs determination i n each of the towns i n the regional d i s t r i c t . The Kitimat-Stikine Regional D i s t r i c t was fortunate i n having many extremely capable, concerned people who took a strong leadership role i n the health programmes developed in the community. The physicians were very strong leaders i n t h e i r communities. The hospital administrators were frequently involved i n many committees and organizations. The Directors of Nursing were also involved i n the communities i n many ways. Organizations and socie t i e s i n the community which were formed to look after p a r t i c u l a r health needs made very good use of the health care workers i n the community who belonged to the organization or society. In addition, there were groups formed by the health care workers i n some of the communities which attempted to assess the needs of t h e i r own p a r t i c u l a r community and to determine the best method to f i l l those needs. These groups themselves might be expected to act as very strong pressure groups to obtain services which they f e l t were important i n the i r community. PRENATAL PROGRAMMES Prenatal and infant care information was provided by the Public Health Units i n Terrace, Kitimat, Hazelton and Stewart and by the Medical Services nurses i n Hazelton, Greenville, New Aiyansh, Kitamaat, K i n c o l i t h , K i t k a t l a , Tskut, Hartley Bay and Telegraph Creek. Although programmes were available i n the towns, people who moved outside the .. 10 6 towns and were without transportation found, i t d i f f i c u l t to make use of the programmes; i n e f f e c t the service was not available to them. PREVENTIVE MEDICINE Immunization programmes are, l i k e the prenatal and c h i l d care programmes, carried out by Public Health Units and Medical Services personnel. School age children are e a s i l y i d e n t i f i e d and immunization of t h i s group can be expected to be high. The same can not be said of pre-school children and adults, whose immunization i s the r e s p o n s i b i l i t y of the adult or parental population. S i m i l a r l y , the screening programme for four year olds conducted by the Public Health Units to allow early detection of development problems may t e s t only a portion of the four year old population i n the area. The transiency Of northern families and lack of compulsory r e g i s t r a t i o n u n t i l school age of six years precludes accurate i d e n t i f i c a t i o n of the population and contact with i t about the programme. Water p o t a b i l i t y and sewage treatment are prime concerns of the Public Health Units. Sanitary inspection existed i n Terrace and Kitimat. The population l i v i n g outside municipal boundaries and some distance away from these centres were able to have t h e i r well.water tested for pathogens by mailing a sample of the water to the P r o v i n c i a l Public Health Department. 107 REHABILITATION- AND ACTIVITIES OF DAILY LIVING While there were no formal r e h a b i l i t a t i o n programmes i n the regional d i s t r i c t , workers were covered by Workers' Compensation Board. F a c i l i t i e s and personnel for r e h a b i l i t a t i o n were located i n Greater Vancouver, and the expenses of using t h i s service were paid by the Workers' Compensation Board for e n t i t l e d employees. The coverage included the cost of periodic v i s i t s by the worker's spouse during long term r e h a b i l i t a t i o n . There were no such benefits available for people injured away from work, and the transportation costs involved i n long-term care were borne by these i n d i v i d u a l s . People suffering from a r t h r i t i s often had need of extensive physical therapy and occupational therapy to enable them to cope with a c t i v i t i e s of d a i l y l i v i n g . Physiotherapy services were available to out-patients i n Kitimat and Terrace, but the programme was not extensive. Occupational therapy services which emphasize functional a b i l i t y i n the home, were not available i n the regional d i s t r i c t , except for an annual v i s i t by the Occupational Therapist of the Canadian A r t h r i t i s and Rheumatism Society. There was no r e h a b i l i t a t i o n service available outside Terrace and Kitimat. CONCLUSION The map of the regional d i s t r i c t e a r l i e r i n t h i s chapter indicates the location of f a c i l i t i e s and programmes in the regional d i s t r i c t . The dispersion of the population 108 outside municipal boundaries resulted in differential degrees of access due to time and transportation costs of a large proportion of the population. The location of hospitals and clinics in the towns and villages appears to be such as to ensure rapid access to acute care in an emergency. Some innovative programmes existed throughout the regional d i s t r i c t to assist in the planning of services or to deliver social services affecting health. Preventive medicine was effective in the towns, but clean water supply and sewage treatment were more problematic outside municipal boundaries. Treatment of long-term illnesses and injuries was not available in the regional d i s t r i c t . 109 Chapter 6 TWO VIEWS OF SERVICES: PEOPLE'S EXPECTATIONS • ''/'_." AND PLANNERS' EXPECTATIONS" There has been discussion of the factors involved i n e f f e c t i v e l y gaining access to health care, of the power d i s t r i b u t i o n amongst the various groups concerned with the provision or receipt of health care and of the health f a c i l i t i e s and manpower available i n the Kitimat-Stikine Regional D i s t r i c t . From these factors, c e r t a i n expectations arise about the u t i l i z a t i o n that w i l l be made by residents of existing health services, pressures that w i l l be brought for expanded services and the areas that the pressures w i l l be most e f f e c t i v e i n procuring health services. PEOPLE'S EXPECTATIONS The expectations of the Canadian people for health care and services are a r e f l e c t i o n of technologic achievements in the country i n the past century. Only seventy years ago, B r i t i s h Columbians going to the fort s and outposts scattered throughout the province were aware there were no doctors or nurses i n those areas and that t h e i r a b i l i t y to survive depended on t h e i r own physical state, avoidance of i l l n e s s and t h e i r knowledge of home treatments. Today's population i s much less s e l f - s u f f i c i e n t i n the provision of health care. The diseases that plague Canadians are no longer the infectious diseases that eradicated whole v i l l a g e s f i f t y to one hundred years ago, but rather are diseases of genetic, environmental or l i f e s t y l e o r i g i n . 1 The a b i l i t y to sustain l i f e i n an acutely i l l person has increased with the improved equipment, knowledge and s k i l l s , but while many of these diseases have acute phases, t h e i r e f f e c t on the person's health state may be a long-term one. The health care system concentrates on those tasks i t can accomplish. The drama surrounding a patient with a Myocardial Infarction i s high and the short-term re s u l t s r e l a t i v e l y immediate, but the recovery of the patient to a stable l i f e state i n which he or she i s able to take part i n a l l a c t i v i t i e s i n his or her previous (pre-i l l n e s s ) l i f e s t y l e i s a very long one. The acute phase i s more manageable due to the advances i n medical technology, than i s the r e h a b i l i t a t i v e phase. Immunization and water p u r i f i c a t i o n programmes are conducted by health care workers under l e g i s l a t i v e authority. Much more d i f f i c u l t to enact are changes i n the l i f e s t y l e of an i n d i v i d u a l , for these are dependent on the individual's behaviour every day. Consequently, there i s an emphasis on acute care and preventive medicine that i s c a r r i e d out by health care personnel, rather than on s e l f improvement health programmes. There i s no apparent d i s p a r i t y between the established I l l objectives of the health care system.and the health care expectations of the population. Despite t h e i r removal from the c i t i e s to the small towns, hamlets and country i n order to lead a more simple l i f e , Non-Native people have.taken with them to the North, expectations based on t h e i r perception of what was available to them i n the South. They expect a sophisticated l e v e l of acute care to be available close at hand and the health care system i s w i l l i n g to p r o v i d e . i t . Elaborate f a c i l i t i e s i n themselves are not s u f f i c i e n t to ensure good quality care. Rather, s k i l l e d manpower i s the key factor i n the provision of health care that meets the standard of excellence Canadians expect i n the l a t t e r quarter of the twentieth century. The s k i l l - r e q u i r e d to sustain l i f e and render improvement i n the health state of individuals suffering from the complex i n j u r i e s and medical conditions of an i n d u s t r i a l society i s made available at great cost. Measurable educational costs for health manpower workers are high, but many costs associated with the development of treatment s k i l l s are not measurable.in terms of d o l l a r cost. The cost of operating a t r a i n i n g school can be applied against the number of graduates the school produces, but the e f f o r t s expended by the students i n the academic and experiential learning process are not included in those costs. Nor are the mental manipulations of the experienced health professionals as current and past observations are analyzed for future solutions. These costs are r e a l and very necessary i f health workers are to have accurate judgement and 112 confidence i n that accuracy i n t h e i r day-to-day decision-making. Such s k i l l s are not obtained by the observation and treatment of one case; a large number of cases and .the accumulated knowledge of a large number of cases i s a r e q u i s i t e to s k i l l development. S i m i l a r l y , the maintenance of developed s k i l l s i s dependent upon the frequency as well as the quality of the observation. The urban hospital with i t s large population provides the large pools of p a r t i c u l a r diagnostic or treatment problems that are required to develop and maintain such s k i l l s . The hospitals i n small towns do not do so, and indeed, Herdman- found that surgeons i n some small communities do not practice s u f f i c i e n t surgery to confidently maintain t h e i r l e v e l of expertise. 2 However, i t i s important that such s k i l l l evels be maintained and that new s k i l l s be developed as health technology changes. Diagnostic medical equipment i s highly elaborate and requires s k i l l e d s t a f f to operate i t and to interpret the r e s u l t s . Drugs are known to be less s p e c i f i c i n s i t e of action than they were thought to be a decade ago. There are constant gains i n knowledge of the effects of drugs on metabolism of the c e l l and of the patient as well as on the metabolism and s i t e s of action of other drugs. The use of complex equipment or drugs by persons not knowledgeable of t h e i r use and potential problems constitutes a dangerous practice. Iatrogenic disease, or i l l n e s s caused by treatment, i s a major concern of a l l health professionals and workers; -11.3 physicians, nurses, pharmacists, radiologic technicians, etc. From th i s there would appear to be an inherent c o n f l i c t between the objective for l o c a l treatment of people i n small towns and the a b i l i t y of the health care system to meet that objective. While i t i s necessary to have health care available l o c a l l y , i t may be feasible..to-provide highly^ s k i l l e d care only at a somewhat distant r e f e r r a l centre. The technology to meet the physiologic needs may be at variance with the psychologic and s o c i a l needs of the patient for l o c a l treatment. Those people who expect complex s u r g i c a l and medical procedures to be performed i n small community hospitals would appear to have l i t t l e understanding of the complexity of the medical treatment system and of the s k i l l s possessed by the many types of personnel comprising the treatment team. Nor has much of the d i f f i c u l t research been done to measure the influence of the psychologic and emotional needs of a patient on his recovery. PROVIDERS' EXPECTATIONS Not a l l the population i n the area i s c l a s s i f i a b l e at a l l times as consumers. Many are suppliers or providers of health care and health services. The health care provider, upon graduation from his program, i s proud of his knowledge, and enthusiastic about applying i t for the well-being of his patients. Most expect to maintain t h e i r knowledge at the same l e v e l ; current and expert. The professional expects to have available to him the academic and experiential learning 114 situations, the new equipment and support personnel .that are required for provision of the continually changing techniques of high standards of health care. Many of the professional organizations provide the continuing education courses and have established assessment mechanisms of previously licenced members. The Registered Nurses Association of B r i t i s h Columbia o f f e r s courses for members wishing to return to the work force af t e r an absence of some years. Some urban hospitals require the completion of these courses by nurses who have not worked i n recent years as a condition of employment. The College of Physicians and Surgeons conducts seminars for i t s members. The College of Pharmacists sponsors a mobile education program which enables some seminars to be taken to the outlying areas of the province. Numerous seminars are held for i t s members, and i n November of 1977, a self-assessment examination was given to a l l p r a c t i c i n g pharmacists. This examination was designed to determine professional areas of weakness of the member, and to a s s i s t the pr a c t i c i n g pharmacist i n his best personal choice of course. While continuing education courses for physicians, nurses, pharmacists and the other health workers are currently voluntary, there are indications that t h i s s i t u a t i o n may change. Assessment of areas of weakness provides a basis for mandatory completion of a course that i s designed to strengthen s p e c i f i c weaknesses. Many of the health professionals i n the Kitimat-Stikine Regional D i s t r i c t did not f e e l that there was s u f f i c i e n t 115 opportunity for them to attend the courses provided. Courses held i n Vancouver, V i c t o r i a or out-of-province, required the professional worker to obtain a replacement to do a locum during h i s absence. Because of the d i f f i c u l t y i n obtaining one, the physicians had attempted to es t a b l i s h such a locum tenens as a recognized part of the residency or internship programmes offered i n the urban hospitals. However, they had not been successful. Pharmacists experienced s i m i l a r problems, but to a lesser degree. Membership of a drugstore i n a "chain" provided a pool of manpower as personnel were s h i f t e d from one community to another, thus enabling some pharmacists to attend the courses. There was a pool of r e l i e f s t a f f for nurses available i n the towns, and h o s p i t a l nurses did not experience this problem i n attending courses. The Medical Services nurses, however, were not able to leave t h e i r v i l l a g e s to attend courses and seminars. The Public Health Service has a period of time worked into i t s schedule for Medical O f f i c e r s of Health, Public Health Nurses and Sanitary Inspectors to attend courses. Health care professionals may be more i n f l u e n t i a l i n the planning process i n the areas i n which they practice than they are amongst t h e i r colleagues i n t h e i r professional associations. Amongst the most highly educated members of the community, they are a r t i c u l a t e and devote considerable time and thought to t h e i r work; how best to conduct i t and what changes could be effected i n i t . Physicians expect the community to provide the f a c i l i t i e s and equipment they need 116 to give the best care of which they are capable and also to attrac t the support personnel whose work i s adjunctive to th e i r successful treatment of the patient. F a i l u r e of the community to supply the f a c i l i t i e s believed required may r e s u l t i n the physician leaving the community to es t a b l i s h practice elsewhere. Administrators and planners, faced with the problem of att r a c t i n g and retaining s k i l l e d health workers i n an area, w i l l use the resources available i n the community or area to do so. The resource may be a l l i e d personnel, c o l l e a g i a l support, housing, f i n a n c i a l incentives, construction of f a c i l i t i e s and . purchase of equipment, or be p o l i t i c a l . A l l of the hospitals in the Kitimat-Stikine Regional D i s t r i c t offered accommodation to hospital s t a f f . Radiologic equipment, s u r g i c a l implements and supporting physiotherapy s t a f f were available for the orthopaedic surgeon i n Kitimat. Administrators and planners expect the senior government to provide funds for the f a c i l i t i e s and equipment they require to a t t r a c t and retain.... the personnel they believe are necessary for the provision of the desired health services i n t h e i r region. This i s the major method of a t t r a c t i n g health care workers to an area. Neither the government nor the professional association have powers to require mandatory residence i n p a r t i c u l a r communities in B r i t i s h Columbia. Because of t h i s , the regions w i l l exert pressure to obtain f a c i l i t i e s and equipment. --.117 INVESTIGATOR'S' EXPECTATIONS It has been pointed out that i n the Kitimat-Stikine Regional D i s t r i c t , the number of f a c i l i t i e s i n terms of hospital beds per one thousand population i s higher than the pr o v i n c i a l average. The r e l a t i v e l y large proportion of hospital beds i n the regional d i s t r i c t would lead one to expect the u t i l i z a t i o n of the beds to be high. The number of separations from the hospitals i s expected to be greater than one would expect based on the size.-and age/sex composition of" the population. In addition, the average length of stay w i l l probably be longer than i s the p r o v i n c i a l average. Under these circumstances, one would expect not to f i n d an established home care service, and i t has been shown such was the case i n the Kitimat-Stikine Regional D i s t r i c t . If the physician-population r a t i o were extremely, low, some e f f e c t could be expected on hospital admissions due to the absence of the gatekeeper to hospital care. However, the physician-population r a t i o i n the Kitimat-Stikine ^Regional D i s t r i c t i s not that low, and the areas of the regional d i s t r i c t not served by a physician have access to hospital care through the Medical Services Nurse ' s physician contact. The physician-population r a t i o of the Kitimat-Stikine Regional D i s t r i c t i s lower than the p r o v i n c i a l average and much lower than that of the urban communities of B r i t i s h Columbia. Because of t h i s , the numbers of patients treated outside the regional d i s t r i c t would be expected to be higher than i n areas with larger physician l e v e l s . The low number of s p e c i a l i s t s 118 in the Kitimat-Stikine Regional D i s t r i c t should also r e s u l t i n r e f e r r a l s to specialized treatment services outside the regional d i s t r i c t . The low r a t i o of dentists to population and the existence of dental plans i n union contracts should r e s u l t i n heavy use of dental services by union members and th e i r families and long waiting time for appointments. These long queues and the centralized locations of the dentists w i l l r e s u l t i n l i t t l e use of the dentists by the Native population, although they may have many dental problems. Certain medical conditions or i l l n e s s e s may be higher than that expected, due only to age, sex and size of the population. The lack'of water and sewage treatment services and municipal water supply for the half of the population l i v i n g outside municipal boundaries would lead one to expect a high incidence of water-borne and sewage-related infectious diseases. Alcoholism and mental i l l n e s s may be higher due i n part to the i s o l a t i o n experienced by some people, l i v i n g i n the region. The lack of mental health workers may r e s u l t i n r e f e r r a l out of the region:of those people requiring care. The absence of an alcohol treatment f a c i l i t y i n the region may possibly be r e f l e c t e d i n a higher number of patients treated i n the acute care hospital than would otherwise be done, although i t must be recognized that hospital s t a t i s t i c s related to alcoholism are inaccurate and tend to present a picture of lower admissions than the actual s i t u a t i o n . 119 The d i s t a n c e of much, of the p o p u l a t i o n £rom p h y s i c i a n s and h o s p i t a l s r e s u l t e d i n the e x p r e s s i o n of much need f o r a i r ambulance s e r v i c e s and h i g h u t i l i z a t i o n of i t . Because i t i s a v i s i b l e h e a l t h care programme f o r the people i n i s o l a t e d areas and i t d i f f e r s from what these people b e l i e v e urban d w e l l e r s have, one can expect a l o t of d i s s a t i s f a c t i o n with the s e r v i c e . The d i s s a t i s f a c t i o n i s u n r e l a t e d to the q u a l i t y of the s e r v i c e and q u a n t i t y used, but i s more a f f e c t e d by the f e e l i n g s of r e l a t i v e d e p r i v a t i o n experienced by people unable to partake i n the u s u a l type of s e r v i c e and f o r whom unique and i n n o v a t i v e programmes have been d e v i s e d . While the people i n the K i t i m a t - S t i k i n e Regional D i s t r i c t may expect to have a s o p h i s t i c a t e d l e v e l of care a v a i l a b l e l o c a l l y and the p h y s i c i a n , nurses, d e n t i s t s and other h e a l t h care workers are w i l l i n g t o p r o v i d e such c a r e , the h e a l t h care system may not be able to meet t h i s o b j e c t i v e and,:indeed, may p r o v i d e more e x c e l l e n t care at some d i s t a n c e from the homes of r e s i d e n t s . The numbers of f a c i l i t i e s and manpower i n the r e g i o n a l d i s t r i c t would l e a d one to expect t h a t the u t i l i z a t i o n of h e a l t h care s e r v i c e s by the o v e r a l l p o p u l a t i o n of the K i t i m a t - S t i k i n e Regional D i s t r i c t w i l l not be low, although the use may not be p r o p o r t i o n a t e l y d i s t r i b u t e d between a l l groups i n the community. In a d d i t i o n to high u t i l i z a t i o n , t h e r e may be h i g h i n c i d e n c e and prevalence of some d i s e a s e s , such as i n f e c t i o u s d i s e a s e s , a l c o h o l i s m and mental i l l n e s s . There may be a requirement f o r expanded P u b l i c Health or s o c i a l problems to cope with them. Because -120 the objective of locally available health care.of a l l types can not be met by the health, care system, innovative programmes designed to meet the special access needs of the people, while being used extensively, w i l l be subjects of dissatisfaction and because the emotional and social needs of the sick have not been examined to determine their effect on recovery to physical well-being, health planners and administrators w i l l have di f f i c u l t y in reducing this dissatisfaction. For these same reasons, they w i l l have d i f f i c u l t y in determining what programmes and f a c i l i t i e s are to be available and to what groups, and in explaining why some services are available locally while others are remote and why some groups receive special benefits from which others are excluded. 1-21 REFERENCES Lalonde, Marc, A New Perspective on the Health of Canadians,  A Working Document, Government of Canada, Ottawa, 1974. Herdman, John, Patterns of Practice of General Surgeons,  Non-metropolitan B r i t i s h Columbia, M.Sc Thesis, Department of Health Care and Epidemiology, University of B r i t i s h Columbia, 1975. 122 Chapter 7 METHODOLOGY FOR OBJECTIVE DATA ANALYSIS From Chapter 6, a number o f c h o i c e s of data a r i s e t h a t can be analyzed to determine the o b j e c t i v e v a l i d i t y o f Northern-e r s ' concerns about u n f a i r n e s s . A complete a n a l y s i s of a l l the f a c t o r s i n v o l v e d would r e q u i r e a major study of s e v e r a l y e a r s , examining a v a i l a b l e resources and u t i l i z a t i o n p a t t e r n s as w e l l as determination o f the needs o f the people f o r h e a l t h c a r e . The l a t t e r i s , however, a s u b j e c t i v e d e c i s i o n , dependent almost t o t a l l y upon the p o s i t i o n o f the viewer. No s a t i s f a c t o r y data on h e a l t h care needs c u r r e n t l y e x i s t . I t i s p o s s i b l e to examine data about a v a i l a b l e r e s o u r c e s and the u t i l i z a t i o n o f some o f those r e s o u r c e s . The f a c i l i t y and manpower resources a v a i l a b l e i n the K i t i m a t - S t i k i n e Regional D i s t r i c t were d e s c r i b e d i n Chapter 5 as were many of the pro-grammes t h a t they o f f e r e d . H o s p i t a l bed data as a measure o f f a c i l i t y a v a i l a b i l i t y i n a l l r e g i o n a l d i s t r i c t s e x i s t i n pub-l i s h e d r e p o r t s of the p r o v i n c i a l government. He a l t h care man-power data are p u b l i s h e d by the H e a l t h Manpower Research U n i t . These data c o n s i s t of numbers of h e a l t h personnel who be-long to either.mandatory, l i c e n c i n g bodies o r to v o l u n t a r y o r g a n i z a t i o n s of co-workers. H o s p i t a l workers who do.not r e q u i r e licericTng"arid 123 who do not j o i n a v o l u n t a r y c a r e e r - o r i e n t e d o r g a n i z a t i o n such as a d m i n i s t r a t o r s , o r d e r l i e s , a i d e s and housecleaning s t a f f are not i n c l u d e d i n these data. The data are most accurate f o r p r o f e s -s i o n a l s who r e q u i r e a l i c e n c e t o p r a c t i c e but d i s c r e p a n c i e s do a r i s e because some p r o f e s s i o n a l s who have l e f t the work f o r c e maintain l i c e n s u r e as a c t i v e l y p r a c t i c i n g p r o f e s s i o n a l s . In a d d i t i o n , workers employed by the f e d e r a l government may be l i c e n c e d i n a p r o v i n c e o t h e r than t h a t i n which they work. However, these data w i l l be analyzed i n chapter 8. U t i l i z a t i o n data e x i s t f o r a number o f s e r v i c e s but are not always c o l l e c t e d i n a way which i s usable f o r the t e s t b e i n g conducted. Because d e n t a l insurance i s now a b e n e f i t i n many c o l l e c t i v e agreements, u t i l i z a t i o n of d e n t i s t s by the workers covered i s a v a i l a b l e . However, these data are c o l l a t e d , not by r e g i o n but by union membership. S i m i l a r l y , Pharmacare data are t a b u l a t e d i n r e l a t i o n to the pharmacy to which payment i s made f o r the p r e s c r i p t i o n s dispensed. For the use of u t i l i z a t i o n data v a l i d l y to determine d i f f e r e n t i a l access to h e a l t h care by r e g i o n s , i t i s important t h a t the r e g i o n of r e s i d e n c e of the consumer of the s e r v i c e s examined be i d e n t i f i a b l e and t h a t a l l use o f the s e r v i c e measured be i n c l u d e d . Some u t i l i z a t i o n data e x i s t e d t h a t , c o l l e c t e d i n t o a s u i t a b l e form c o u l d be analyzed to determine whether geographic i s o l a t i o n i s a b a r r i e r t o access to h e a l t h care by N o r t h e r n e r s . These secondary data are the numbers of h o s p i t a l s e p a r a t i o n s o f r e s i d e n t s o f the r e g i o n a l d i s t r i c t from h o s p i t a l s , payment t o which i s by B r i t i s h Columbia H o s p i t a l s Programme. I t was decided to use these data f o r t h i s t h e s i s . 124 The data on hospital separations that were obtained were for residents of the regional d i s t r i c t s from hospitals both within and outside the regional d i s t r i c t s . The numbers of separations were provided by disease grouping and included the average length of the h o s p i t a l i z a t i o n s i n each disease category. I t was expected that an area that had fewer ho s p i t a l beds and/or health care personnel i n proportion to i t s population would have fewer ho s p i t a l separations i n r e l a t i o n to those expect-ed than would an area with larger proportions of beds and manpower. I t was also expected that a larger proportion of hospital separa-tions would be from hospitals outside the regional d i s t r i c t i n any regional d i s t r i c t that had fewer beds and manpower within i t . The use of h o s p i t a l separations by disease category data requires certain assumptions and these assumptions affected the choice of comparison areas. The f i r s t assumption i s that the predisposition of the residents to seek care for health problems i s the same in a l l the comparison areas. The second assumption i s that the prevalence and incidence of each disease do not d i f f e r i n the comparison areas. I t i s also assumed that the styles of medical practice are s i m i l a r and physicians use beds i n the same way. While prevalence and incidence of certain diseases w i l l a f f e c t the amount of use made of the hospitals, h o s p i t a l i z a t i o n data are not data about the incidence or the prevalence of d i s -eases. One person may be separated from a h o s p i t a l two or more times in a year for the same disease. The disease for which a patient i s separated may be one which he has had for a number of years. I t i s possible that the incidence of a p a r t i c u l a r 125 disease may d i f f e r i n one of the regional d i s t r i c t s . A high or low number of separations for a p a r t i c u l a r disease may, i n fact be a r e f l e c t i o n of the incidence or prevalence of the disease rather than unfairness of the system to meet the needs of the people. Mortality data supplied by the Division of V i t a l S t a t i s t i c s provides a cross check for. some diseases. COMPARISON AREAS, GEOGRAPHIC ISOLATION A dramatic topography and adventurous l i f e s t y l e are not r e s t r i c t e d to the Kitimat-Stikine Regional D i s t r i c t . The entire province of B r i t i s h Columbia consists of mountain ranges dividing the land and being divided themselves by r i v e r systems and lakes. Many regional d i s t r i c t boundaries follow >these natural divides. The Okanagan and C h i l c o t i n and Cariboo ex-perience cold winters; the Kootenays, Rogers and A l l i s o n Passes have high snowfalls. The area from Squamish to L i l l o e t , as well as Vancouver Island, has much of i t s area served by a net-work of private logging roads. If one says that one group of people receive less than t h e i r f a i r share from the health delivery system, there are by inference, others who receive more. The Kitimat-Stikine Regional t D i s t r i c t can be compared to the Province as a whole. However, the figures i n the p r o v i n c i a l averages include other areas similar to the Kitimat-Stikine Regional D i s t r i c t ; i s o l a t e d and with widespread population i n small settlements. I t was decided to compare Kitimat-Stikine Regional D i s t r i c t with some other regional d i s t r i c t s as well as with the Province of B r i t i s h Columbia. No other regional d i s t r i c t s are exactly comparable 126 to the Kitimat-Stikine Regional D i s t r i c t . However, three were' .-" found that have certain s i m i l a r i t i e s to and differences from —-Kitimat-Stikine which are s i g n i f i c a n t to t h i s thesis. These regional d i s t r i c t s are Cowichan Valley, North Okanagan and East Kootenay regional d i s t r i c t s . Each of the four regional d i s t r i c t s had, i n 1971, a population ranging from around 35,000 to 40,000 and was expected to grow, by 19 75, to 40,000 to 45,000.1 Two of the areas have large populations of native Indians; Kitimat-Stikine with 6,220 2 and Cowichan Valley with 2,405 Indians i n 19 71. These Native populations, which are the largest i n the -Province, represent 16.7% of the Kitimat-Stikine and 6.16% of Cowichan Valley regional d i s t r i c t s ' populations, respectively. The other two " regional d i s t r i c t s have proportions of Native populations smaller than the p r o v i n c i a l average of 2.4%.* The i n d u s t r i a l base of an area i s important i n determining comparison areas. The resource industries of logging and mining are the prime industries i n the Kitimat-Stikine Regional D i s t r i c t , supplemented by aluminum smelting i n Kitimat. There i s l i t t l e agriculture i n the Kitimat-Stikine. The vast majority of the working population are employees working for firms whose s t a b i l i t y depends on international demand for resource materials; wood or mineral. Changes i n the economy"" have profound and rapid e f f e c t s on such companies, and the work force i n the area has no control over the job market. When a recession occurs i n such an area, there are few alternative *These figures r e f e r to Status Indians and do not include the Non^Status Indians resident i n the areas. 127 jobs to do, and the worker who i s l a i d o f f due to reduced pro-duction, must move to another area to f i n d a job. Logging i s common to a l l four regional d i s t r i c t s and i s the primary industry i n a l l but the North Okanagan, where i t i s second to agriculture. Mining i s important in the East Kootenay Regional D i s t r i c t , as well as i n the Kitimat-Stikine. In a l l of the areas except the Kitimat-Stikine Regional D i s t r i c t , agriculture i s an important industry. In each of the regional d i s t r i c t s , there were pockets of people l i v i n g i n i s o l a t e d camps or v i l l a g e s away from the s e t t l e d homelife of the towns or the farms. One e f f e c t of t h i s was p a r t i c u l a r l y evident i n the East Kootenay and Kitimat-Stikine regional d i s t r i c t s . Males comprised 52.6% of the population i n East Kootenay and 5 3.5% of the population i n the Kitimat-Stikine Regional D i s t r i c t , as compared to 50.3% of the population of the Province of B r i t i s h Columbia. Many men l i v e d i n camps, access to and egress from which was by private logging road. There were also camps that had married quarters; so families as well as single men l i v e d i n these i s o l a t e d areas. Some of the areas were .more than one hour overland t r a v e l from the amenities of the town; polic e , h o s p i t a l , high school, stores, and so f o r t h . They could accurately be c a l l e d remote. A large proportion of the population l i v e d in suburbs or v i l l a g e s clustered outside the towns, but within an hour's drive of the town and could be considered r u r a l . None of the towns were large enough to be considered urban or metropolitan. I t i s worth noting that urban d e f i n i t i o n s vary widely. S t a t i s t i c s Canada includes v i l l a g e s of 1,000 population i n i t s 128 d e f i n i t i o n of urban. - 3 V i l l a g e s of 1,000 do not provide the services one expects i n a c i t y or urban area. Unfortunately, the term " c i t y " is., not a useful d e f i n i t i o n , as there are many towns that have larger populations than some c i t i e s . Enderby, with a population i n 19 76 of 1,410, i s a c i t y ; Terrace; 19 76 population 10,09 3, i s not. Lucas suggested urbanism implies a special mode of existence, a way of l i f e found only i n a c i t y - the freedom 4 . . to choose. Wirth described the d i s t i n c t q u a l i t i e s of c i t y l i f e including . . . a complex d i v i s i o n of labour with a d i v e r s i f i e d occupational structure, s o c i a l s t r a t i f i c a t i o n , high t e r r i t o r i a l and s o c i a l mobility, marked functional dependence of the population, substantial personal anonymity i n interpersonal contacts and segmentation of s o c i a l roles and role interactions, reliance on i n -d i r e c t moves of s o c i a l control, and normative deviance. Lucas states that the ranges of choice are severely limited i n communities of 1,000 people or even of much larger communities. This i s c e r t a i n l y true; there are l i m i t s on the number of f i r s t - c l a s s restaurants, churches, physicians, furniture stores, hospitals, theatres or t r a n s i t methods these communities can support. According to Lucas' d e f i n i t i o n , there was no urban population in the Kitimat-Stikine Regional D i s t r i c t , nor i n the comparison regional d i s t r i c t s . Only Vernon, in the North Okanagan, approached i t and i t could s a t i s f y the d e f i n i t i o n only i f the three Okanagan regional d i s t r i c t s were regarded as a whole unit. Such an approach would recognize the a b i l i t y of many Vernon residents to t r a v e l to Kelowna. However, urban d e f i n i t i o n s must include some li m i t a t i o n s on topography. Although the choices may be 129 available i n a neighbouring town or d i s t r i c t , only very mobile residents may take advantage of them. Because of t h i s , none of the areas under study was considered urban. From the point of view of analyzing health care, two important factors i n the populations studied are age and sex. I t i s extremely d i f f i c u l t to f i n d a southern area of the province with a s i m i l a r age structure to the Kitimat-Stikine Regional D i s t r i c t , where only 14.4% of the population i s aged 45 or over. However, u t i l i z a t i o n for p a r t i c u l a r diseases can be adjusted for both sex and age, so these two factors were disregarded when choosing comparison areas. The remoteness of the regional d i s t r i c t as a whole from the metropolitan areas of B r i t i s h Columbia, Greater Vancouver and V i c t o r i a , i s of great importance to people l i v i n g in the province. These two c i t i e s provide the sophisticated choices people expect to f i n d i n a metropolis. The image, r i g h t l y or wrongly, i s of people dining elegantly, attending the theatre, symphony, many d i f f e r e n t movies, of bus systems, subways and freeways, of a vast choice of recreational a c t i v i t i e s , l i f e i n chic apartment blocks, and work i n high o f f i c e towers with splendid views. Even people who have chosen the simpler l i f e i n small towns enjoy a holiday or v i s i t i n such a large c i t y , so that they can have a choice of shops and goods, and where they f e e l they can obtain a choice of health care. Medical s p e c i a l i s t s tend to congregate i n the large c i t i e s , and there appears to be more choice for the patient. In r e a l i t y , the patient rarely chooses 13.Q,_ MAP 3 MAP OF BRITISH COLUMBIA SHOWING LOCATION OF 4 REGIONAL DISTRICTS Kitimat-Stikine Regional Distribt 131 h i s s p e c i a l i s t ; t h i s i s u s u a l l y done by the p h y s i c i a n i n gen e r a l p r a c t i c e who makes the r e f e r r a l . The main t r a d i n g c e n t r e i n the K i t i m a t - S t i k i n e R e g i o n a l D i s t r i c t i s T e r r a c e , which i s 1,285 k i l o m e t e r s from Vancouver. In Ea s t Kootenay Regional D i s t r i c t , the l a r g e s t c i t y i s Cranbrook, 819 k i l o m e t e r s e a s t o f Vancouver. Vernon, the l a r g e s t c i t y i n the North Okanagan, i s 488 k i l o m e t e r s from Vancouver, w h i l e Duncan i n the Cowichan V a l l e y , i s 54 k i l o m e t e r s north o f V i c t o r i a , and 78 k i l o m e t e r s from Vancouver; the l a t t e r d i s t a n c e i n v o l v i n g 16 n a u t i c a l m i l e s . The Cowichan V a l l e y i s not i s o l a t e d i n any way. I t was a n t i c i p a t e d t h a t , i f access t o care was hampered by geographic i s o l a t i o n , t here would be fewer s e p a r a t i o n s from h o s p i t a l s o f r e s i d e n t s o f the K i t i m a t -S t i k i n e and Ea s t Kootenay r e g i o n a l d i s t r i c t s than o f the Cowichan V a l l e y Regional D i s t r i c t . The North Okanagan, moderately i s o l a t e d but wit h c l o s e a c c e s s ' t o Kelowna, Kamloops and P e n t i c t o n i n neighbouring r e g i o n a l d i s t r i c t s was expected to have a u t i l i z a t i o n p a t t e r n between the two. METHODOLOGY The methodology i n v o l v e d the choice o f data, sources o f c o l l e c t i o n , c h o i c e o f s t a t i s t i c a l a n a l y t i c methods and computations to ensure v a l i d c o m p a r a b i l i t y o f the data from the f o u r r e g i o n a l d i s t r i c t s . DATA The d e c i s i o n t o use data on h o s p i t a l s e p a r a t i o n s was mentioned e a r l i e r i n t h i s chapter. While i t i s r e c o g n i z e d 132 t h a t some problems e x i s t i n the use of u t i l i z a t i o n s t a t i s t i c s as a measure of access, these are the o n l y data t h a t p r o v i d e an i n d i c a t i o n o f whether or not Northerners are r e c e i v i n g h o s p i t a l s e r v i c e s , the most s o p h i s t i c a t e d p h y s i c a l care p r o v i d e d i n our h e a l t h system. These data w i l l not t e l l us who w i t h i n a r e g i o n a l d i s t r i c t i s u s i n g the s e r v i c e s . There i s no way o f knowing i f the u t i l i z a t i o n r e f l e c t s the socio-economic or the r a c i a l mix of the r e s i d e n t s o f the area. Nor i s i t p o s s i b l e t o determine i f r e s i d e n t s of c e r t a i n geographic areas w i t h i n the region, are not making use o f the h o s p i t a l s . F i n a l l y , there i s no way of r e l a t i n g these data to the needs of the people f o r h o s p i t a l i z a t i o n , needs t h a t remain undetermined. The Northerners we met b e l i e v e d t h a t they experienced delays i n o b t a i n i n g h e a l t h c a r e . I f such delays were of major importance f o r the h e a l t h s t a t u s o f the i n d i v i d u a l , the average l e n g t h o f h o s p i t a l i z a t i o n might be expected to be longer than i t otherwise would have been. I t must be be borne i n mind however, t h a t average l e n g t h o f stay i s a l s o a f f e c t e d by the a v a i l a b i l i t y o f h o s p i t a l beds and the demand f o r those beds. Urban areas which have experienced queues f o r t h e i r beds have s t r i v e n t o reduce the average l e n g t h of stay by e s t a b l i s h m e n t o f home care programs f o r p a t i e n t s d i s c h a r g e d e a r l i e r than the norm. F a c i l i t y and manpower a v a i l a b i l i t y have been mention-ed as necessary c o n s t i t u e n t s o f an a c c e s s i b l e h e a l t h system H o s p i t a l bed data were e x t r a c t e d from p u b l i s h e d data o f the 1 3 3 p r o v i n c i a l government w h i l e manpower data were o b t a i n e d from r e p o r t s p u b l i s h e d by H e a l t h Manpower Research U n i t . H o s p i t a l bed data were broken down i n t o numbers o f acute c a r e , extended care and p s y c h o g e r i a t r i c beds. In a d d i t i o n , the numbers of beds a v a i l a b l e i n M e d i c a l S e r v i c e s c l i n i c s were ob t a i n e d from M e d i c a l S e r v i c e s branch o f the Department o f N a t i o n a l H e a l t h and W e l f a r e . S i m i l a r l y , the manpower data were broken down i n t o types o f workers and the M e d i c a l S e r v i c e s nurses were i n c l u d e d i n the data. The h o s p i t a l s e p a r a t i o n data were c o l l e c t e d f o r the f o u r r e g i o n a l d i s t r i c t s and the p r o v i n c e o f B r i t i s h Columbia, by d i s e a s e grouping, u s i n g the I n t e r n a t i o n a l C l a s s i f i c a t i o n o f Diseases as the source of the c a t e g o r i e s . The data o b t a i n e d from the B r i t i s h Columbia H o s p i t a l s Program p r o v i d e d the numbers of s e p a r a t i o n s , the l o c a t i o n s o f the s e p a r a t i o n s , the percentage of the p r o v i n c i a l s e p a r a t i o n s these r e p r e s e n t e d and the average l e n g t h o f stay f o r each o f one hundred n i n e t y d i a g n o s t i c c a t e g o r i e s used i n B r i t i s h Columbia h o s p i t a l s . These 190 c a t e g o r i e s r e p r e s e n t an aggregation o f the thousands of d i s e a s e s f o r which people are t r e a t e d . The a d m i t t i n g diagnoses o f h o s p i t a l i z e d p a t i e n t s are coded and aggregated i n t o the 190 c a t e g o r i e s by the government. Only 186 of the d i s e a s e c a t e g o r i e s were used i n the a n a l y s i s ; d i s e a s e s #187 through #190 were not observed i n B r i t i s h Columbia h o s p i t a l s i n the study p e r i o d and, more important, no data allowed a c a l c u l a t i o n o f an expected f i g u r e f o r these f o u r d i s e a s e s . 134 In determining the access to care of r e s i d e n t s o f the area by the use o f h o s p i t a l s e p a r a t i o n s , i t was necessary to e l i m i n a t e s e p a r a t i o n s from h o s p i t a l s o f no n - r e s i d e n t s i n each area. I t was a l s o important t o i d e n t i f y h o s p i t a l i z a t i o n s o f r e s i d e n t s t h a t o c c u r r e d i n h o s p i t a l s o u t s i d e the r e g i o n a l d i s t r i c t . To o b v i a t e a c c i d e n t a l choice o f an a t y p i c a l year, two years were chosen; 1973 and 1975. They were b e l i e v e d s u f f i c i e n t l y c l o s e to-gether not to be a f f e c t e d by changes i n h e a l t h care technology. METHODS OF ANALYSIS There are a number o f methods o f s t T a t i s t i c a l a n a l y s i s t h a t were c o n s i d e r e d . I t was determined t h a t m u l t i p l e r e g r e s s i o n would show the r e l a t i o n s h i p between the numbers o f s e p a r a t i o n s and l e v e l s o f manpower and h o s p i t a l beds. A Frequency D i s t r i b u -t i o n and t - s t a t i s t i c would show i f any areas were e x p e r i e n c i n g s i g n i f i c a n t l y more or l e s s h o s p i t a l s e p a r a t i o n s than o t h e r areas. I t was necessary t o compute an expected number o f s e p a r a t i o n s f o r each d i s e a s e i n each r e g i o n i n order to have a base f o r v a l i d comparison. Throughout the study the l e v e l of s i g n i f i c a n c e i s p = .05. I t was decided to re g r e s s the observed o r a c t u a l s e p a r a t i o n s w i t h the expected o r c a l c u l a t e d s e p a r a t i o n s , the numbers o f h o s p i t a l beds per thousand pop-u l a t i o n , the numbers of p h y s i c i a n s per thousand p o p u l a t i o n , the numbers of s p e c i a l i s t p h y s i c i a n s per thousand p o p u l a t i o n , and the t o t a l numbers o f h e a l t h care workers per thousand popula-135 t i o n on a l l four r e g i o n a l d i s t r i c t s u s i n g the 186 d i s e a s e s . T h i s was done s i n g l y and with them a l l i n the Regression formula. C e r t a i n d i s e a s e s are c o n s i d e r e d to have more urgent or important need of h o s p i t a l i z a t i o n from the p o i n t o f view o f recovery o r r e h a b i l i t a t i o n o f the p a t i e n t . Some o f the 186 diseas e s were grouped i n t o s m a l l e r c a t e g o r i e s t o determine i f d i f f e r e n c e s e x i s t e d i n the h o s p i t a l i z a t i o n s o f people o f the four r e g i o n a l d i s t r i c t s f o r these groups of d i s e a s e s . Frequency D i s t r i b u t i o n s were o b t a i n e d o f the r a t i o o f the observed to the expected numbers o f s e p a r a t i o n s i n each area and the r e s u l t s o f these d i s t r i b u t i o n s were compared by a students t - t e s t . CALCULATION OF EXPECTED SEPARATIONS Because the p o p u l a t i o n s o f the f o u r r e g i o n a l d i s t r i c t s d i f f e r e d i n s i z e and age and sex composition, d i f f e r e n c e s i n the numbers o f s e p a r a t i o n s due to any p a r t i c u l a r d i s e a s e c o u l d be expected. I t was decided to c a l c u l a t e the expected number o f s e p a r a t i o n s f o r the r e s i d e n t s o f each r e g i o n a l d i s t r i c t con-s i d e r i n g these f a c t o r s . Data, p u b l i s h e d by S t a t i s t i c s Canada p r o v i d e d numbers o f s e p a r a t i o n s per 100,000 p o p u l a t i o n by age and sex f o r the whole o f Canada f o r 186 di s e a s e c a t e g o r i e s . No such breakdown was a v a i l a b l e f o r the p r o v i n c e o f B r i t i s h Columbia. The expected values f o r the s e p a r a t i o n s due to each disease category i n each o f the fo u r r e g i o n a l d i s t r i c t s and f o r the p r o v i n c e were c a l c u l a t e d u s i n g Canadian s t a t i s t i c s o f 136 s e p a r a t i o n r a t e s . The use of the Canadian s e p a r a t i o n r a t e s was to pr o v i d e a b a s e l i n e f o r comparison of the f o u r d i s t r i c t s , which would not otherwise be p o s s i b l e . Only the n a t i o n a l s t a t i s t i c s p r o v i d -ed an age and sex breakdown o f s e p a r a t i o n s and s e p a r a t i o n r a t e s . I t was assumed t h a t there were no f a c t o r s i n the f o u r r e g i o n a l d i s t r i c t s t h a t would i n c r e a s e the i n c i d e n c e and/or prevalence o f the di s e a s e s other than age and sex. The numbers o f expected s e p a r a t i o n s were c a l c u l a t e d by m u l t i p l y i n g the numbers of people i n each age grouping and sex i n each r e g i o n by the Canadian s e p a r a t i o n r a t e f o r t h a t age and sex group. The numbers of s e p a r a t i o n s expected f o r each age and sex group were then summed to determine the number o f s e p a r a t i o n s expected f o r each d i s e a s e . These c a l c u l a t i o n s were done f o r each r e g i o n a l d i s t r i c t and f o r the p r o v i n c e o f B r i t i s h Columbia. The s e p a r a t i o n c a l c u l a t i o n s were o r i g i n a l l y based on the p o p u l a t i o n p r o j e c t i o n s f o r 1975 of B r i t i s h Columbia Research and the age-sex d i s t r i b u t i o n o f each r e g i o n t h a t e x i s t e d a t the time o f the 19 71 census. A reverse p r o j e c t i o n was used to estimate the p o p u l a t i o n s i n 19 73. I t was expected t h a t no l a r g e change i n the age and sex d i s t r i b u t i o n would occur i n such a s h o r t p e r i o d o f time. P r e l i m i n a r y r e l e a s e o f the 19 76 census f i g u r e s and o t h e r data i n d i c a t e d t h a t both t h i s assump-t i o n and the p r o j e c t e d s i z e o f the p o p u l a t i o n s by B.C. Research were i n c o r r e c t . T h e . s i z e o f the p o p u l a t i o n s and the numbers of s e p a r a t i o n s were r e c a l c u l a t e d i n three o f the four r e g i o n a l 137 d i s t r i c t s . I t was s t a t e d e a r l i e r t h a t the f o u r r e g i o n a l d i s t r i c t s were expected to grow to p o p u l a t i o n s o f 40,000 to 45,000 by 1976. The i n i t i a l s t a t i s t i c s compiled and r e l e a s e d by S t a t i s t i c s Canada i n d i c a t e d growth r a t e s c o n s i d e r a b l y a t v a r i a n c e with p r o j e c t e d growth i n three o f the areas 1^  The K i t i m a t - S t i k i n e Regional D i s t r i c t e xperienced growth of 2% and had a p o p u l a t i o n i n mid-1976 of 38,098 r a t h e r than the expected 47,762. The Cowichan V a l l e y doubled i t s expected growth and had a p o p u l a t i o n of 45,138 i n mid-1976 r a t h e r than 42,407. The North Okanagan experienced a 35% growth r a t e and had 45,794 people i n 19 76. The E a s t Kootenay Regional D i s t r i c t , alone of the study areas, e x p e r i e n c e d an a c t u a l growth (15.2%) s i m i l a r to i t s p r o j e c t e d growth (16.3%). Data a v a i l a b l e about s c h o o l enrolment and people e n t i t l e d to Pharmacare i n d i c a t e d there had been a change i n the age s t r u c t u r e o f the p o p u l a t i o n s o f the North Okanagan and Cowichan V a l l e y r e g i o n a l d i s t r i c t s . Subsequently, an a d j u s t -ment was made to the p o p u l a t i o n f i g u r e s f o r these two r e g i o n a l d i s t r i c t s from those t h a t had been p r o j e c t e d .for"1973 and 1975. Because the growth r a t e s and s c h o o l enrolment i n c r e a s e s were d i f f e r e n t i n the areas, each area was a d j u s t e d a c c o r d i n g to a d i f f e r e n t formula. The growth r a t e i n the K i t i m a t - S t i k i n e Regional D i s t r i c t over f i v e years from 19 71 to 19 76 appeared to be 2.1% r a t h e r than 2 8% as had been p r o j e c t e d by B r i t i s h Columbia Research. I t was necessary to determine whether the growth 138 rate had been uniform over the f i v e years, or whether the population had increased as projected for some of that period and then had decreased. The l a t t e r i s l i k e l y the more accurate description of what occurred, and population figures were calculated on the assumption that the projected growth rate had been r e a l i z e d u n t i l the end of 1973. There was an economic recession i n the Kitimat-Stikine Regional D i s t r i c t which started i n 1974, with a s t r i k e i n the forest industry and a reduction i n the need for chips because of the establishment of a plant i n Burns Lake* by 7' ' Babine Forest Products. Later, B r i t i s h Columbia Molybdenum shut i t s operation at A l i c e Arm. In 19 75, Granduc Mines at Stewart reduced i t s output i n response to i n t e r n a t i o n a l changes i n the copper market. The regional d i s t r i c t estimated 2,500 7 jobs were l o s t due to these factors. I f an average family size of 3 i s assumed, this would account for a population loss of 7,500, as the families moved out. The population above the age of 65 years would not be affected, but t h e i r numbers i n the Kitimat-Stikine Regional D i s t r i c t are so small that they would not a f f e c t the c a l c u l a t i o n of the proportion of the population. Accordingly, i t was assumed the population was affected equally i n a l l age and sex groupings. Population calculations i n 1975 for each group i n the Kitimat-Stikine Regional D i s t r i c t were adjusted downward by a uniform percent-age from those calculated on the basis of the B r i t i s h Columbia Research data. Normal population growth i s said to have occurred i n the regional d i s t r i c t u n t i l a f t e r 19 73. No B u r n s L a k e i s i n t h e P r i n c e .George R e g i o n a l D i s t r i c t . 139 adjustment was made f o r 1973 p o p u l a t i o n o f the K i t i m a t - S t i k i n e Regional D i s t r i c t on the B r i t i s h Columbia Research p o p u l a t i o n p r o j e c t i o n s . The s i t u a t i o n was more complex i n the North Okanagan and Cowichan V a l l e y Regional D i s t r i c t s which had experien c e d h i g h growth r a t e s . In areas w i t h l a r g e numbers o f people over the age of 65 ye a r s , i t was b e l i e v e d these l a r g e growth r a t e s would not have a f f e c t e d a l l age groupings e q u a l l y . Pharmacare records are not kept by r e g i o n a l d i s t r i c t , but the i n c r e a s e i n the p o p u l a t i o n over 65, by t h a t agency, was e s t i m a t e d t o be 6% from 1974 to 1976. The o v e r a l l p r o v i n c i a l p o p u l a t i o n over 65 was 11% i n 1976. In the North Okanagan, sc h o o l enrolment grew a t a r a t e o f 30.4%, l e s s than the t o t a l p o p u l a t i o n growth. From these data, the p o p u l a t i o n s were ad j u s t e d i n d i v i d u a l l y f o r each age grouping. The growth i n the r e g i o n a l d i s t r i c t was assumed evenly spread over the f i v e y e a r s , and a s t r a i g h t l i n e p r o j e c t i o n was made from 19 71 to 19 76 to c a l c u l a t e 19 73 and 1975 p o p u l a t i o n . The sex d i s t r i b u t i o n p o p u l a t i o n was assumed unchanged. I t i s r e c o g n i z e d t h a t s t r a i g h t l i n e p r o j e c t i o n s are not normally used to estimate p o p u l a t i o n changes. However, over a p e r i o d o f f i v e y e a r s , i t was decided t h a t such a l i n e would not be s u b j e c t t o too much e r r o r and would be a c c e p t a b l e . The s c h o o l enrolment i n the Cowichan V a l l e y had i n c r e a s e d f a s t e r than the t o t a l p o p u l a t i o n , d e s p i t e a r e d u c t i o n i n the s i z e o f the s c h o o l d i s t r i c t . Consequently, the formula used f o r the Cowichan V a l l e y adjustment d i f f e r e d from t h a t 140 used f o r the North Okanagan. The adjustments were made i n -d i v i d u a l l y f o r each age grouping. The p o p u l a t i o n estimates used to c a l c u l a t e the expected numbers of separations are i n Appendix A. Using the r e s u l t s of these complex computations, the expected numbers of separations f o r each disease were c a l c u l a t e d f o r each r e g i o n a l d i s t r i c t and f o r the province i n 1973 and 1975. While i t would have been e a s i e r and provided a neater study had the p o p u l a t i o n growths followed t h e i r p r e d i c t e d trends, the diverse growth t h a t d i d occur c e r t a i n l y i l l u s t r a t e s the dependence on world economic market forces of r e g i o n a l d i s t r i c t s such as K i t i m a t - S t i k i n e . The r e s u l t s of the analyses of h o s p i t a l beds, manpower and h o s p i t a l separation data are pres-ented i n Chapters 8 and 9. 141 REFERENCES CHAPTER 7 1. B. C. Research, B r i t i s h Columbia Population Projections, Vancouver, 19 75. 2. Canada, S t a t i s t i c s Canada, 19 71 Census-, of Canada, Catalogue 92-723, Vol. I, Part 3, October, 19 73./ 3. Canada, S t a t i s t i c s Canada, 19 71 Census of Canada, Vol. 1, Part 3, October, 19 73. 4. Lucas, Rex A., Minetown, Milltown, Railtown: L i f e i n  Canadian Communities of Single Industry, Toronto, University of Toronto Press, 19 71. 5. Wirth, Reiss, Albert J., (ed.), Louis Wirth on C i t i e s and  Social L i f e , Selected Papers, Chicago, University of Chicago Press, 1964. 6. S t a t i s t i c s Canada, Vancouver Of f i c e , Personal Communication. 7. Pousette, John, Personal Communication. 8. T i d b a l l , Pat, Personal Communication. Chapter 8 IS THERE ACCESS? The data t h a t were c o l l e c t e d were analyzed and s e l e c t e d data w i t l be .presented i n t h i s .chapter to determine and demonstrate whether access to care can be shown to have been l e s s i n the K i t i m a t - S t i k i n e and E a s t Kootenay Regional D i s t r i c t s than i n the Cowichan V a l l e y and whether t h a t o f the North Okanagan was between these. The data have a l s o been examined to determine what e f f e c t was manifested on h o s p i t a l u t i l i z a t i o n by manpower and f a c i l i t i e s f a c t o r s i n h e a l t h s e r v i c e s . In a d d i t i o n , the data were analyzed to determine i f there was r e l a t i v e d e p r i v a -t i o n i n terms o f i n c r e a s e d s o c i a l and d o l l a r c o s t s to the r e s i d e n t s o f the K i t i m a t - S t i k i n e Regional D i s t r i c t compared to r e s i d e n t s of the comparison areas. The q u e s t i o n to be answered i n t h i s chapter i s whether or not i n e q u i t i e s e x i s t i n the use made o f h o s p i t a l s by r e s i d e n t s of the r e g i o n a l d i s t r i c t s , i n p a r t i c u l a r , the K i t i m a t - S t i k i n e . AVAILABLE RESOURCES HOSPITAL BED FACILITIES While the number o f beds and cots f o r acute care i n c r e a s e d from 1973 to 1975 i n the Cowichan V a l l e y , the North Okanagan and the E a s t Kootenay Regional D i s t r i c t s , the i n c r e a s e 143 i n those beds d i d not keep pace wi t h the p o p u l a t i o n growth i n the Cowichan V a l l e y and the E a s t Kootenay r e g i o n a l d i s t r i c t s . There was an i n c r e a s e i n the r a t i o o f acute care beds and c o t s to p o p u l a t i o n i n the K i t i m a t - S t i k i n e Regional D i s t r i c t which was due t o a d e c l i n e i n the p o p u l a t i o n ; the number o f beds and c o t s r e m a i n i n g t h e same. The numbers o f h o s p i t a l beds as w e l l as the p r o p o r t i o n -ate numbers o f them f o r the f o u r r e g i o n a l d i s t r i c t s can be seen i n Table V. The p r o p o r t i o n i s u s u a l l y expressed as the number per 10,000 p o p u l a t i o n , but f o r extended care beds i t i s express-ed as the number per 1,000 p o p u l a t i o n aged 65 o r over. The numbers per p o p u l a t i o n were c a l c u l a t e d u s i n g the p o p u l a t i o n estimates i n Appendix A. While extended care beds are not e x c l u s i v e l y f o r g e r i a t r i c p a t i e n t s , the m a j o r i t y o f extended care p a t i e n t s are over 65 years o f age. Computation o f the extended-care bed-population r a t e on the b a s i s o f the numbers o f p o p u l a t i o n aged 65 and over reduced the d i s p a r i t y o f the r a t e s between the r e g i o n a l d i s t r i c t s f o r 19 75. There were i n c r e a s e s i n the number o f extended care beds i n the K i t i m a t - S t i k i n e , the Cowichan V a l l e y and the E a s t Kootenay r e g i o n a l d i s t r i c t s from 1973 to 1975. While the r a t e o f extended care beds per t o t a l p o p u l a t i o n i s much h i g h e r i n the Cowichan V a l l e y and the North Okanagan r e g i o n a l d i s t r i c t s i n 19 75, by comparison to the p o p u l a t i o n most l i k e l y t o use those beds, the K i t i m a t - S t i k i n e Regional D i s t r i c t would appear to be o v e r - s u p p l i e d . The K i t i m a t - S t i k i n e Regional D i s t r i c t had a compara-t i v e abundance o f acute care as w e l l as extended care beds i n 144 TABLE V COMPARISON OF AVAILABLE BEDS AND COTS FOR ACUTE AND EXTENDED CARE IN FOUR REGIONAL DISTRICTS OF BRITISH COLUMBIA, 19 73 AND 1975. Kitimat-S t i k i n e Cowichan Valley North Okanagan East Kootenay 1973 ACUTE CARE Number Beds & Cots 260. 213. 156. 221. Number Beds 10,000 poj?. & Cots 62.90 51.43 40.35 52.40 EXTENDED CARE Number Beds & Cots 0. 78. 60. SO-Number Beds 10,000 pop S Cots - 18.83 15.52 l l . 86 Number Beds 1,000 pop + & Cots 65 - 25.78 14.14 19.48 1975 ACUTE CARE Number Beds & Cots 260. 223. 194. 244. Number Beds 10,000 pop* & Cots 66.37 50.80 44.68 53.31 EXTENDED CARE Number Beds & Cots 35. 100. 101. 50. Number Beds 10,000 pop & Cots 8.93 22.78 23.26 11.22 Number Beds 1,000 pop + & Cots 65 40.37 35.52 21.89 18.04 145 r e l a t i o n to the size and age d i s t r i b u t i o n of i t s population. Although not the most populous of the regional d i s t r i c t s , i t had the most acute care beds i n i t s h o s p i t a l s . Neither the p s y c h i a t r i c beds opened i n the h o s p i t a l i n Terrace i n November 1975 nor the beds i n the Medical Services c l i n i c s are included i n these figures. Inclusion of them would r e s u l t i n even greater d i s p a r i t y between the regions. MANPOWER Three of the regional d i s t r i c t s had t o t a l health worker levels below the p r o v i n c i a l average; Kitimat-Stikine, Cowichan Valley and East Kootenay. The numbers of personnel can be seen i n Table VI. Both the number and the r a t i o of t o t a l health workers i n the North Okanagan were considerably higher than those of the other regional d i s t r i c t s . The Kitimat Stikine and East Kootenay regional d i s t r i c t s had s i m i l a r levels of health personnel. However, not a l l types of workers were i n short supply. Registered p s y c h i a t r i c nurses were high i n both the Kitimat-Stikine and the Cowichan Valley regional d i s t r i c t s and r a d i o l o g i c technicians were comparatively high i n the North Okanagan and East Kootenay regional d i s t r i c t s . By con-t r a s t , the l e v e l of laboratory technologists was comparatively lower than the p r o v i n c i a l l e v e l i n Kitimat-Stikine, Cowichan Valley and East Kootenay regional d i s t r i c t s . Presumably, the hospitals i n these areas make use of the regional laboratories which are licenced to perform more complex tests than small 14 TABLE VI NUMBER1 AND NUMBER PER 10,000 POPULATION2 HEALTH SERVICES MANPOWER AVAILABLE AND PRACTICING IN FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA, 1975 BY CATEGORY Regional D i s t r i c t Kitimat- Cowichan North East B r i t i s h rype of P r a c t i t i o n e r S t i k i n e V a l l e y Okanagan Kootenay Columbia Biomedical Engineers # Rate # Rate # Rate # Rate # Rate 0 - 0 - 1 0 23 1 0. 22 96 0 40 Chiropractors 0 - 3 0 68 5 1 15 3 0. 67 208 0 86 C e r t i f i e d Dental Assistants 8 2 04 20 4 56 13 2 99 1 0. 22 634 2 63 Dental Hygeinists 2 0 51 3 0 68 4 0 92 0 _ 263 1 09 Dental Laboratory Technicians 1 0 26 2 0 46 2 0 46 0 _ 237 0 98 Dental Mechanics 1 0 22 3 0 68 3 0. 69 2 0. 45 134 0 56 Dentists - Non S p e c i a l i s t s 9 2 30 16 3 64 21 4. 84 14 3. 14 1208 5. 01 - S p e c i a l i s t s 0 - 0 - 1 0. 23 1 0. 22 79 0. 33 Dieticians^ 0 - 1 0 23 2 0. 46 2 0. 45 153 0. 63 ?ood Supervisors 1 0 26 4 0 91 1 0. 23 1 0. 22 76 0. 32 ie a l t h Record Personnel 1 0 26 3 0 68 3 0. 69 5 1. 10 162 0. 67 Laboratory Technologists 16 4 08 16 3 64 24 5. 53 14 3. 14 1185 4. 92 Medical O f f i c e Assistants 4 1 02 3 0 68 0 - 0 - 389 1. 61 Licenced P r a c t i c a l Nurses 88 22 46 177 40 32 146 33. 63 129 28. 30 5739 23. 82 Registered P s y c h i a t r i c Nurses 43 10 98 0 - 46 10. 59 4 88 1647 6. 84 Registered Nurses 161 41. 10 207 47 15 213 49. 06 202 45. 31 12347 51. 24 Dccupational Therapists'* 1 0. 26 0 - 0 - 0 - 269 1. 12 Dptometrists 2 0. 51 1 0 23 2 0. 46 5 1. 10 166 0. 69 Dsteopaths 0 - 0 - 0 - 0 - 8 0. 03 Pharmacists 14 3. 57 19 4 33 26 5. 99 27 6. 06 1658 6. 88 Physiotherapists 5 4 1. 02 3 0. 68 6 1. 38 6 1. 32 559 2. 32 Physicians - General Practice 32 8. 17 32 7. 29 29 6. 68 38 8. 52 2122 8. 81 - S p e c i a l i s t s 13 3. 32 12 2. 73 30 8. 10 15 3. 28 1409 5. 85 Podiatrists 0 - 0 - 0 - 0 _ 35 0. 15 Psychologists 0 - 3 0. 68 1 0. 23 0 • - 242 1. 00 Public Health Inspectors 2 0. 51 2 0. 46 3 0. 69 3 0. 67 181 0. 75 Radiologic Technicians 6 1. 53 9 2. 05 12 2. 76 14 3. 14 477 1. 98 TOTAL REGISTERED PERSONNEL 409 104. 40 539 122. 78 694 159. 85 487 106. 39 31683 131. 49 "ledical Services Nurses 6 9 2. 30 2 0. 46 0 - 0 _ - _ TOTAL PERSONNEL 418 106. 70 541 123. 24 694 159. 85 487 106. 39 - -Province of Number of a l l personnel except Medical Services are from R o l l c a l l 75; a Status Report  of Health Personnel i n the Province of B r i t i s h Columbia, D i v i s i o n of Health Services Research and Development, Health Sciences Centre, U.B.C, 1976. Number of personnel per 10,000 population i s calculated on the basis of populations of 39,177 i n Kitimat-Stikine, 43,898 i n Cowichan Valley, 43,417 i n North Okanagan, 44,580 i n East Kootenay Regional D i s t r i c t s and 2,409,514 i n B r i t i s h Columbia. In addition, there were d i e t i c i a n s who were not employed as d i e t i c i a n s . The numbers of them were 3 i n Kitimat-Stikine, 2 i n Cowichan Valley, 0 in North Okanagan, 1 i n East Kootenay and 209 i n B r i t i s h Columbia. In addition, there were Occupational Therapists who were not employed i n occupational therapy. The numbers of them were 2 i n Kitimat-Stikine, 2 i n Cowichan Valley, 2 i n North Okanagan, 0 i n East Kootenay and 118 i n B r i t i s h Columbia. In addition, there were Physiotherapists who were not employed i n physiotherapy. The numbers of them were 1 i n Kitimat-Stikine, 1 i n Cowichan V a l l e y , 4 i n North Okanagan, 3 i n East Kootenay and 215 i n B r i t i s h Columbia. Nurses i n Medical Service employment may be registered i n provinces other than B r i t i s h Columbia. They are not included i n s t a t i s t i c s for Registered Nurses. 147 laboratories. D i e t i c i a n s , registered nurses, occupational therapists and psychologists were low i n a l l areas. The l e v e l of t o t a l physician manpower was lower i n a l l of the regional d i s t r i c t s than the p r o v i n c i a l l e v e l . The Kitimat-Stikine and East Kootenay regional d i s t r i c t s had higher levels of general practice physicians than the Cowichan Valley and North Okanagan but the North Okanagan had more s p e c i a l i s t s per 10,000 than the others and than the province as a whole. Much of the p r o v i n c i a l t o t a l comprises s p e c i a l i s t s . I f general p r a c t i t i o n e r s , family p r a c t i t i o n e r s , i n t e r n i s t s , paediatricians and general surgeons are grouped the di s p a r i t y between the regions i s reduced sharply. Highly technical medical s p e c i a l -t i e s such as neurology, neuropsychiatry, neurosurgery, physical medicine, p l a s t i c surgery and thoracic surgery were not a v a i l -able i n any of the comparison areas. The numbers of these s p e c i a l i s t s i n the province are low and there i s no reason to expect these s p e c i a l i s t s to e s t a b l i s h practices i n non-metropolitan areas. In fact, i t would be a waste of manpower and s k i l l were they to do so. The numbers of physicians can be seen i n Table VII. Table VIII provides some explanation for the complaints of the residents of the Kitimat-Stikine Regional D i s t r i c t about the a v a i l a b i l i t y of dental services. While the t o t a l number of dental personnel per 10,000 i s higher than that of East Kootenay Regional D i s t r i c t , both are much lowef than the pr o v i n c i a l average. The shortage i s spread throughout a l l types of dental health manpower. I t must be r e a l i z e d that 148 TABLE VII NUMBER1 AND NUMBER PER TEN THOUSAND POPULATION2 OF PHYSICIANS IN FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA BY SPECIALTY, 197 5 AND TOTAL PHYSICIAN MANPOWER, 19 73 Type of P r a c t i t i o n e r Regional D i s t r i c t K itimat-S t i k i n e Cowichan V a l l e y North Okanagan East Kootenay Province of B r i t i s h Columbia # Rate # Rate # R a t e •# R a t e # Rate General Practice Family Practice Anaesthesia Dermatology Eye, Ear, Nose and Throat General Surgery Internal Medicine Neurology Neuropsychiatry Neurosurgery p b s t e t r i c s - Gynecology Ophthalmology Orthopaedic Surgery Otolaryngology Paediatrics Pathology & Bacteriology Physical Medicine P l a s t i c Surgery Psychiatry Public Health Radiology Thoracic Surgery |Urology TOTAL 1975 TOTAL 1973 32 2 2 0 0 2 1 0 0 0 1 0 1 0 1 1 0 0 0 0 1 0 45 37 8.17 0.51 0.51 0.77 0.26 0.26 0.26 0.26 0.26 0.26 11.49 8.95 32 1 1 0 0 2 1 0 0 0 1 1 1 0 0 0 0 0 3 0 1 0 0 7.29 0.23 0.23 0.46 0.23 0.23 0.23 0.23 44 39 0.68 0.23 10.02 9.42 29 5 1 1 0 7 3 0 0 0 1 3 0 1 1 1 0 0 1 1 3 0 1 59 48 6.68 1.15 0.23 0.23 1.61 0.69 0.23 0.69 0.23 0.23 0.23 0.23 0.23 0.69 0.23 13.59 12.41 38 3 0 0 0 7 1 0 0 0 0 1 0 0 1 0 0 0 0 0 2 0 0 8.52 0.66 ,53 ,22 0.22 0.22 0.44 53 11.58 49 11.62 2122 132 178 39 2 252 260 25 4 22 125 118 82 53 125 77 13 25 201 32 163 13 53 8.81 0.55 0.74 0.16 0.01 1.05 1.08 0.10 0.02 0.09 0.52 0.49 0.34 0.22 0.52 0.32 0.05 0.10 0.83 0.13 0.68 0.05 0.22 4116 17.08 General P r a c t i t i o n e r / Substitutes 1975 38 9.97 36 8.21 45 10.36 50 11.13 2891 12.01 Numbers of Personnel are from: D i v i s i o n of Health Services Research and Development: R o l l c a l l 75, a Status Report  of Health Personnel i n the Province of B r i t i s h Columbia, Health Sciences Centre, University of B r i t i s h Columbia, Vancouver, 1976. Numbers of personnel per 10,000 population, 1975, are c a l c u l a t e d on the basi s of populations of 39,177 i n K i t i m a t - S t i k i n e , 43,898 i n Cowichan V a l l e y , 43,417 i n North Okanagan, 44,580 i n East Kootenay Regional D i s t r i c t s and 2,409,514 i n B r i t i s h Columbia. Number of Physicians per 10,000 1973 are c a l c u l a t e d on the b a s i s of populations of 41,334 i n K i t i m a t - S t i k i n e , 41,417 i n Cowichan V a l l e y , 38,663 i n North Okanagan, 42,173 i n East Kootenay Regional D i s t r i c t s and 2,295,823 i n B r i t i s h Columbia. Physicians i n c l u d e d i n t h i s category are those i n General P r a c t i c e , Family Practice, General Suregery, I n t e r n a l Medicine and P a e d i a t r i c s . TABLE V I I I NUMBER1 AND NUMBER PER 10,000 POPULATION2 OF DENTAL CARE MANPOWER AVAILABLE IN FOUR REGIONAL DISTRICTS TN BRITISH COLUMBIA BY CATEGORY, 1975 : Type of P r a c t i t i o n e r C e r t i f i e d Dental A s s i s t a n t s Dental Hygienists Dental Laboratory Technicians Dental Mechanics TOTAL SUPPORT PERSONNEL Dentists - Non-Specialists - S p e c i a l i s t s TOTAL DENTISTS TOTAL DENTAL PERSONNEL Kitimat-S t i k i n e 8 2.04 2 0.51 1 0.26 0.26 1 12 9 0 9 21 3.06 2.30 2.30 5.36 Regional D i s t r i c t Cowichan North Va l l e y Okanagan 20 4.56 3 0.68 2 0.46 3 30 16 0 0.68 6.83 3.64 16 3.64 46 10.48 13 2.99 4 0.92 2 0.46 3 0.69 21 4.84 21 4.84 1 0.23 22 5.07 43 9.90 East Kootenay 1 0 0 2 0.22 Province of B r i t i s h Columbia 0.45 14 1 15 18 0.67 3.14 0.22 3.36 4.04 634 263 237 134 1068 1208 79 1287 2355 2.63 1.09 0.98 0.56 4.43 5.01 0.33 5.34 9.77 Numbers of Personnel are from: D i v i s i o n of Health Services Research and Development: R o l l c a l l 75, a Status Report  of Health Personnel i n the Province of B r i t i s h Columbia, Health Sciences Centre, U n i v e r s i t y of B r i t i s h Columbia, Vancouver, 1976. Numbers of personnel per 10,000 population, 1975, are calculated on the basis o f populations of 39,177 i n Kiti m a t - S t i k i n e , 43,898 i n Cowichan Va l l e y , 43,417 i n ^ -North Okanagan, 44,580 i n East Kootenay Regional D i s t r i c t s and 2,409,514 i n B r i t i s h Columbia. 7".'- ~ ~~ ' ^  150 TABLE IX NUMBER1 AND NUMBER PER 10,000 POPULATION2 OF REGISTERED NURSES AVAILABLE AND EMPLOYED IN FOUR REGIONAL DISTRICT IN BRITISH COLUMBIA BY TYPE OF WORK, 19 75  Regional D i s t r i c t Province of Kitimat- Cowichan North East B r i t i s h Type of P r a c t i t i o n e r Stikine V a l l e y Okanagan Kootenay Columbia General Hospital- 131 33 44 150 34 17 153 35.24 161 36 11 8668 35.97 Rehab i l i t a t i o n Hospital 0 - 3 0. 68 0 - 0 - 103 0.43 Extended Care Hospital 0 - 6 1. 37 0 - 0 - 226 0.94 P s y c h i a t r i c Hospital 1 0 26 0 - 5 1.15 0 - 297 1.23 Other Hospital 2 0 51 3 0.68 0 - 1 0 22 250 1.04 Nursing Home 2 0 51 0 - 0 - 2 0 45 89 0.37 Public Health 11 2 81 15 3. 42 8 1.84 16 3 59 699 2.90 Occupational Health 0 - 0 - 1 0.23 0 - 99 0.41 Home Care 0 - 7 1. 59 16 3.69 0 - 276 1.15 Community Health 4 1 02 1 0. 23 4 0.92 2 0 45 114 0.47 Physician's O f f i c e 3 0 77 7 1. 59 7 1.61 7 1 57 239 0.99 Educational I n s t i t u t i o n 0 - 4 0. 91 3 0.69 1 0 22 259 1.07 Other 7 1 79 11 2. 51 16 3.69 12 2 69 1028 4.27 TOTAL EMPLOYED R.N.S (B.C.) 161 41 10 207 47. 15 213 49.06 202 45 31 12347 51.24 Medical Services Nurses 9 2 30 2 0. 46 0 - 0 _ TOTAL NURSING PERSONNEL 170 43 39 209 47.61 213 49.06 202 45. 31 I Numbers of Personnel are from: D i v i s i o n of Health Services Research and Development: R o l l c a l l 75, a Status Report  of Health Personnel i n the Province of B r i t i s h Columbia, Health Sciences Centre, University of B r i t i s h Columbia, Vancouver, 1976. Numbers of personnel per 10,000 population, 1975, are calculated on the basis of populations of 39,177 i n Kitimat-Stikine, 43,898 i n Cowichan Valley, 43,417 i n North Okanagan, 44,580 i n East Kootenay Regional D i s t r i c t s and 2,409,514 i n B r i t i s h Columbia. 151 den t a l s e r v i c e s are not a p u b l i c l y i n s u r e d s e r v i c e . While many unions i n the north have dental plans i n c l u d e d i n c o l l e c -t i v e b a r g a i n i n g agreements, the costs of dental s e r v i c e s are not spread across the whole population as are medical and h o s p i t a l c o s t s . Consequently, w h i l e they may complain about long waits f o r dental appointments, there can be no suggestion by Northerners t h a t they are paying f o r d e n t a l s e r v i c e s they cannot themselves o b t a i n . A l l of the comparison areas had fewer r e g i s t e r e d nurses per 10,000 than the p r o v i n c i a l average w i t h the K i t i m a t -S t i k i n e Regional D i s t r i c t having the lowest l e v e l . As would be expected because of the numbers of h o s p i t a l beds, the l e v e l of r e g i s t e r e d nurses working i n general h o s p i t a l s approximated the p r o v i n c i a l average and shortages i n a l l the r e g i o n a l d i s t r i c t s appeared to be i n s p e c i a l i z e d f i e l d s . I t i s impos-s i b l e to know i f there i s a need f o r s p e c i a l i z e d nurses i n these areas. The numbers of nurses can be seen i n Table IX. The l e v e l o f p u b l i c h e a l t h personnel was lowest i n the North Okanagan i n 1975, the g r e a t e s t shortage being of P u b l i c Health nurses. The Medical Health O f f i c e r s f o r the K i t i m a t - S t i k i n e and Cowichan V a l l e y r e g i o n a l d i s t r i c t s were l o c a t e d i n P r i n c e Rupert (135 km distance) and Nanaimo (54 km distance) r e s p e c t i v e l y . The l e v e l s of p u b l i c h e a l t h personnel would appear to be adequate. However, as over h a l f of the population i n the K i t i m a t - S t i k i n e Regional D i s t r i c t l i v e s outside municipal boundaries, there may be need of higher s t a f f i n g l e v e l s i n order to ensure water p u r i t y and sewage TABLE X NUMBER1 AND NUMBER PER 10,000 POPULATION2 PUBLIC HEALTH, PERSONNEL IN FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA, 19/75 i Regional D i s t r i c t Province of Kitimat- Cowichan North East B r i t i s h Type of P r a c t i t i o n e r S t i k i n e V a l l e y Okanagan Kootenay Columbia Public Health Nurses 11 2. 81 15 3.42 8 1.84 16 3.59 699 2.90 Public Health Inspectors 2 0. 51 2 0.46 3 0.69 3 0.67 181 0.75 Medical O f f i c e r s of Health 0 0 1 0.23 0 - 32 0.13 TOTAL 13 3. 32 17 3.87 12 2.76 19 4.26 912 3.78 I Numbers of Personnel are from: D i v i s i o n of Health Services Research & Development: R o l l c a l l 75, a Status Report  of Health Personnel i n the Province of B r i t i s h Columbia, Health Sciences Centre, University of B r i t i s h Columbia, Vancouver, 1976. 2 Number of personnel per 10,000 population i s c a l c u l a t e d on the basi s of population of 39,177 i n Kitimat-Stikine, 43,898 i n Cowichan V a l l e y , 43,417 i n North Okanagan, 44,580 i n East Kootenay Regional D i s t r i c t s and 2,409,514 i n B r i t i s h Columbia. 153 disposal standards are met and that a s a t i s f a c t o r y immunization l e v e l i s maintained amongst the population of a region as vast and with as scattered a population as Kitimat-Stikine. The numbers of public health personnel are presented i n Table X. HOSPITAL UTILIZATION Our examination of hospital and manpower resources in the four regional d i s t r i c t s revealed that the lowest number of hospital beds was i n the North Okanagan while the highest number was i n the Kitimat-Stikine Regional D i s t r i c t . By contrast, the North Okanagan had the most physicians with Cowichan Valley having the least . From the point of view of types of physicians who are prime gatekeepers to hospitals (general p r a c t i t i o n e r s , family p r a c t i t i o n e r s , paediatricians, i n t e r n i s t s , and general surgeons) the East Kootenay and the North Okanagan had the largest numbers of manpower. As the East Kootenay Regional D i s t r i c t also had a large number of hosp i t a l beds, one might expect the use made of hospitals i n that region to be higher than i n the other areas. However, that was not the case. Heavy use was made of hospitals by residents of a l l four regional d i s t r i c t s . I t i s e a s i l y seen from Table XI that i n 19 73 a l l four regional d i s t r i c t s had more separations than expected while i n 19 75 the observed numbers of separations considerably exceeded those expected i n the Kitimat-Stikine, Cowichan Valley and East Kootenay regional d i s t r i c t s . Indeed, i n 19 73, while there were 706 more separations than expected 154 i n B r i t i s h Columbia, there were w i t h i n these four r e g i o n a l d i s t r i c t s 6,869 more separations than expected. In 19 75 the numbers of separations observed f o r both the province and the North Okanagan Regional D i s t r i c t were l e s s than a n t i c i p a t e d w h i l e the other three r e g i o n a l d i s t r i c t s experienced between them s i x thousand e i g h t hundred s i x t y more spearations than expected. I t can a l s o be observed that the 5.2% d e c l i n e i n population from 1973 to 1975 i n the K i t i m a t - S t i k i n e Regional D i s t r i c t produced a p a r a l l e l decrease i n numbers of separations of 6.1% but w i t h the numbers of separations observed s t i l l f a r higher than expected, i n f a c t exceeding them by 2,2 85 i n 19 75. The same can be s a i d f o r the East Kootenay Regional D i s t r i c t . While the t o t a l number of separations d e c l i n e d , they remained higher than expected. With numbers of t h i s magnitude, s t a t i s t i c a l t e s t s are almost redundant. However, t e s t s were c a r r i e d out and s u b s t a n t i a t e these o b s e r v a t i o n s . The numbers of separations data are presented i n Table XI f o r both 19 73 and 19 75. The s t a t i s t i c a l analyses are presented i n Tables XII and X I I I f o r 19 73 and 1975 r e s p e c t i v e l y . Frequency d i s t r i b u t i o n s were obtained of the r a t i o s of the observed to the expected separations i n the four r e g i o n a l d i s t r i c t s . A t - t e s t a p p l i e d t o only the four regions i n d i c a t e s t h a t the Cowichan V a l l e y had s i g n i f i c a n t l y higher numbers of separations w h i l e the North Okanagan had s i g n i f i c a n t l y lower numbers than the other r e g i o n a l d i s t r i c t s i n 1973. By c o n t r a s t , a t - t e s t based on the p r o v i n c i a l mean i n d i c a t e s each 155 TABLE XI NUMBER OF SEPARATIONS FROM BRITISH COLUMBIA HOSPITALS OF RESIDENTS AND NUMBER OF EXPECTED SEPARATIONS, CONSIDERING AGE AND SEX COMPOSITION OF POPULATIONS FOR FOUR REGIONAL DISTRICTS AND BRITISH COLUMBIA FOR DISEASES #1 TO #186 AND BY YEAR  Regional D i s t r i c t s Province of B r i t i s h Columbia Observed Expected Kitimat-Stikine Observed Expected Cowichan Valley Observed Expected North Okanagan Observed Expected East Kootenay Observed Expected 1973 1975 8795 6213 8258 5973 9495 6651 9816 6913 6739 6473 7226 7350 8920 6775 8845 7173 400005 399299 405437 435974 area had s i g n i f i c a n t l y higher r a t i o s of a c t u a l to expected numbers of separations than the r e s t of the province i n 19 73. In 19 75 a s i m i l a r s i t u a t i o n e x i s t e d w i t h the North Okanagan and East Kootenay r e g i o n a l d i s t r i c t s s i g n i f i c a n t l y lower than the group mean and the K i t i m a t - S t i k i n e and Cowichan V a l l e y s i g n i f i c a n t l y higher. L i k e 19 73, i n 19 75 each of the four r e g i o n a l d i s t r i c t s had s i g n i f i c a n t l y higher numbers of ^separations than the province as a whole. In the t a b l e s i t can be seen that i n both years the North Okanagan had a median o f 1 although i t s mean was, i n 1973 1.259 and i n 1975 1.166. This would i n d i c a t e t h a t the s i g n i f i c a n t l y high numbers of separations i n the North Okanagan i n 1973 were due to the s i z e of the d i f f e r e n c e s between the observed and the expected separations r a t h e r than to the TABLE XII RATIO OF OBSERVED/CALCULATED SEPARATIONS IN 1973 FOR 186 DISEASES (ICDA-8) IN 4 REGIONAL DISTRICTS OF BRITISH COLUMBIA S t a t i s t i c Four Regional Kitimat- Cowichan North East D i s t r i c t s Stikine Valley Okanagan Kootenay V a l i d Cases 687 170 174 172 171 Missing Cases 57 16 12 14 15 Minimum 0.079 0.125 0.190 0.095 0.079 Maximum 10.000 6.000 10.000 9.000 4.308 Median 1.250 1.333 1.429 1.001 1.270 Per Cent Greater Than 1 64 64 76 50 66 Per Cent Less Than 1 31 31 22 42 31 Per Cent Greater Than 2 17 24 21 12 14 Mean 1.468 1.596 1.645 1.259 1.371 Std. Deviation 1.007 1.113 1.114 0.961 0.756 B.C. Mean 1.022 tRD 1.489 2.084* -2.866* -1.695 t 6.645* 7.377* 3.234* 6.037* B.C. a Diseases with a zero value of eit h e r expected or observed separations were excluded. * a t = 1.960 s i g n i f i c a n t a.05 TABLE XIII RATIO OBSERVED/EXPECTED SEPARATIONS IN 1975 FOR 186 DISEASES (ICDA-8) IN 4 REGIONAL DISTRICTS OF BRITISH COLUMBIA S t a t i s t i c Four Kitimat- Cowichan North East Regional Stikine Valley Okanagan Kootenay D i s t r i c t s V a l i d Cases 692.000 169.000 174.000 174.000 175.000 Missing Cases 52.000 17.000 12.000 12.000 12.000 Minimum Value 0.071 0.071 0.333 0.096 0.184 Maximum Value 12.000 12.000 12.000 4.000 5.000 Median 1.269 1.369 1.500 1.000 1.235 Per Cent Greater Than 1 63 70 78 48 56 Per Cent Less Than 1 31 21 18 45 40 Per Cent Greater Than 2 17 23 21 11 15 Mean 1.457 1.674 1.676 1.166 1.320 Std Deviation 1.010 1.265 1.128 0.643 0.798 tRD 2.230* 2.561* -5.970* -2.271* Mean BC.-1.013 6.793* 7.753* 3.139* 5.089* * s i g n i f i c a n t ™ = 1.960 157 numbers of diseases i n which observed separations outnumbered expected. In the three other r e g i o n a l d i s t r i c t s f i f t y per cent of the diseases had separations considerably more than expected i n both years. The s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s we're due to not only high r a t i o s of observed to expected separations but a l s o to l a r g e numbers of diseases i n which observed exceed-ed expected s e p a r a t i o n s . Examination of the r e s u l t s shows th a t i n the K i t i m a t - S t i k i n e , Cowichan V a l l e y and the East Kootenays most of the diseases had observed separations i n excess of what was expected. In the K i t i m a t - S t i k i n e Regional D i s t r i c t one out of f o u r diseases had more than twice the separations expected w h i l e i n the Cowichan V a l l e y the same can be s a i d f o r one out of f i v e diseases i n both years. Even fewer diseases had lower numbers of separations than expected i n the K i t i m a t - S t i k i n e and Cowichan V a l l e y r e g i o n a l d i s t r i c t s i n 19 75 than i n 19 73. I t had been expected t h a t these diseases would have been the major concern o f t h i s a n a l y s i s but they assume l e s s importance i n view of the high r a t i o s of so many other diseases. I t can be noted i n Table X I I I that the Cowichan V a l l e y has the fewest diseases f o r which the expected separations outnumbered those observed but the K i t i m a t - S t i k i n e ' s decrease of 10% from 19 73 to 19 75 i n d i c a t e s t h a t i f there were access problems a c t i n g on the 31% of diseases i n t h a t r e g i o n a l d i s t r i c t i n 19 73 t h a t had fewer separations than expected, many of them were overcome by 1975. Without more d e t a i l e d data than we have, one can only speculate on the r o l e played i n t h i s r e d u c t i o n by the 158 a i r ambulance s e r v i c e , a s e r v i c e designed t o meet the needs o f the remote r e s i d e n t s o f r e g i o n a l d i s t r i c t s and one t h a t i s h e a v i l y used i n the K i t i m a t - S t i k i n e Regional D i s t r i c t . There i s no evidence t h a t b a r r i e r s to access to h o s p i t a l care t h a t e x i s t i n e i t h e r the K i t i m a t - S t i k i n e o r the E a s t Kootenay r e g i o n a l d i s t r i c t s reduced the amount of h o s p i t a l care o b t a i n e d by the p o p u l a t i o n . The use o f h o s p i t a l s was h i g h e r than t h a t by the p r o v i n c e as a whole i n the fo u r r e g i o n a l d i s t r i c t s i n 1973 and i n the K i t i m a t - S t i k i n e , the Cowichan V a l l e y and the E a s t Kootenay r e g i o n a l d i s t r i c t s i n 19 75. RELATIONSHIP OF FACTORS T e s t i n g o f the r e l a t i o n s h i p between the observed s e p a r a t i o n s and the expected s e p a r a t i o n s , the numbers o f h o s p i t a l beds, p h y s i c i a n s and s p e c i a l i s t s showed t h a t there was high c o r r e l a t i o n between the numbers o f observed and the expected s e p a r a t i o n s i n a l l four r e g i o n a l d i s t r i c t s i n 19 73. Not s u r p r i s i n g l y there was a l s o h i g h c o r r e l a t i o n between the numbers o f s p e c i a l i s t s and p h y s i c i a n s i n an a r e a . The importance o f c o l l e a g i a l support i n a t t r a c t i n g s k i l l e d person-n e l has been commented on e a r l i e r . The s u r p r i s i n g l y n e gative and weaker c o r r e l a t i o n s between h o s p i t a l beds and manpower l e v e l s i n d i c a t e s t h a t a t t r a c t i o n s other than f a c i l i t i e s draw personnel to the North Okanagan. There was no c o r r e l a t i o n between the observed numbers of s e p a r a t i o n s and the a v a i l a b l e l e v e l s o f h o s p i t a l beds and manpower r e s o u r c e s . The c o r r e l a t i o n -c o e f f i c i e n t s o f the v a r i a b l e s can be seen i n Tables XIV and XV. The r e s u l t s o f the r e g r e s s i o n o f the independent v a r i a b l e s TABLE XIV CORRELATION CO-EFFICIENTS OF VARIABLES, OBSERVED AND EXPECTED SEPARATIONS, PHYSICIANS, SPECIALISTS AND HOSPITAL BEDS IN 4 REGIONAL DISTRICTS OF BRITISH COLUMBIA IN 19 73 Observed Separations Expected Separations Hospital Physicians S p e c i a l i s t s Observed Separations 1.00000 0.89883 0.05666 -0.06191 -0.07964 Expected Separations 1.00000 -0.00918 0.00972 -0.00441 Hospital Beds 1.00000 -0.82202 -0.76340 Physicians 1.00000 0.66954 S p e c i a l i s t s 1.00000 TABLE XV CORRELATION CO-EFFICIENTS OF VARIABLES; OBSERVED AND EXPECTED SEPARATIONS, TOTAL HEALTH WORKERS, PHYSICIANS, SPECIALISTS AND HOSPITAL BEDS IN 4 REGIONAL DISTRICTS OF B.C., 1975 Observed Separations Expected Separations Hospital Physicians S p e c i a l i s t s Total Health Workers Observed Separations 1.00000 0.88673 0.01007 -0.07262 -0.06588 -0.04294 Expected Separations 1.00000 -0.05010 0.01873 0.02531 0.03072 Hospital Beds 1.00000 -0.36142 -0.57498 -0.77328 Physicians 1.00000 0.93971 0.67025 S p e c i a l i s t s 1.00000 0.88338 Total Health Care Workers 1.00000 160 with the dependent variable, singley and together can be seen i n Tables XVI and XVII. The lack of e f f e c t on the observed separations of available l e v e l s of hospital bed and manpower resources can be ..; seen further i n the two tables, XVI and XVII. Looking f i r s t at Table XVI, i n equation 2>.the addition of hospital bed level s to the regression formula of the observed separations with the expected resulted i n a dr a s t i c change i n the constant away from zero. The slope of the hospital beds i s subject to comparative-l y high error which indicates the hospital bed level s i n these four areas have only weak influence on the numbers of separations observed i n them. The e f f e c t on the c o e f f i c i e n t of co r r e l a t i o n (adjusted R ) can be seen to be minxmal. The addition of physician le v e l s to expected separations as independent variables produced an even more marked change i n the constant. The slope of physicians l i k e the slopes of hospital beds and s p e c i a l i s t s (the l a t t e r i n Equation 4) i s subject to comparatively large error. The l a s t equation i n Table XVI i s the multivariate regression of a l l the independent variables for 19 73. The constant diverges from zero more i n this t e s t than i n the previous ones and the slopes of the various resource components of the formula are subject to comparatively large error. The F s t a t i s t i c s for thi s regression l i n e indicate that only the expected separations are s i g n i f i c a n t i n the predic t i o n of the observed separations. By contrast, the slope of the expected separations TABLE XVI REGRESSIONS OF OBSERVED SEPARATIONS WITH INDEPENDENT VARIABLES: EXPECTED SEPARATIONS, NUMBERS OF HOSPITAL BEDS, PHYSICIANS, SPECIALISTS PER 10,000 POPULATION IN FOUR REGIONAL DISTRICTS OF BRITISH COLUMBIA IN 1973 Test Constant Slope (Error of Slope): Expected Separations J Hospital Beds Physicians/10,000 | Specialists/10,000 2 Adjusted R Equation 1 • 4.15066 1.18679(.02) - - - 0.80789 Equation 2 -25.50198 1.18754(.02132) 0.57245(.14236) - - 0.81159 Equation 3 40.13106 1.18766(.02127) - -3.40549(0.77656) - 0.81237 Equation 4 18.58519 1.18632(.02123) - - -4.54131(.96486) 0.81310 Equation 5 43.30696 1.18680(.02122) -0.15002(0.28800) -2.20746(1.36890) -3.48050(1.50270) 0.81338 F 3128.83* 0.27 2.60 5 .36 * S i g n i f i c a n t .001 162' i s c l o s e to . and s u b j e c t t o smal l e r r o r i n each t e s t . The r e g r e s s i o n l i n e o f b e s t f i t would appear i n Table XVI to be the simple r e g r e s s i o n i n Equation 1: Number of Number of Observed Separations = 4.15066 + 1.18676 (Expected Separations) The changes i n the c o e f f i c i e n t of c o r r e l a t i o n by the a d d i t i o n o f the other v a r i a b l e s i s observable o n l y a t the t h i r d decimal p l a c e . The v a r i a b l e s i n the 19 75 t e s t , shown i n Table XVII i n c l u d e d the l e v e l o f t o t a l h e a l t h workers i n the areas as w e l l as the expected s e p a r a t i o n s and the resource l e v e l s o f h o s p i t a l beds, p h y s i c i a n s and s p e c i a l i s t s t h a t were t e s t e d i n 1973. In Equation 2, the i n c l u s i o n o f h o s p i t a l beds had the same e f f e c t as i n 1973; the constant became h i g h l y n e g a t i v e , the slope o f the h o s p i t a l beds i s about the same and s u b j e c t to s i m i l a r e r r o r . I n c l u s i o n o f the p h y s i c i a n l e v e l s , i n Equation 3 of Table XVII r e s u l t e d i n a more pronounced e f f e c t on the t e s t i n the same d i r e c t i o n as i n the t e s t i n 19 73; the con s t a n t i s f a r from zero and the negative slope i s s u b j e c t t o comparatively h i g h e r r o r . The same can be s a i d when s p e c i a l i s t l e v e l s were s u b s t i t u t e d f o r p h y s i c i a n l e v e l s i n the formula i n Equation 4. The r e -s u l t s o f the i n c l u s i o n of t o t a l h e a l t h workers i n the r e -g r e s s i o n o f observed s e p a r a t i o n with expected s e p a r a t i o n s can be seen i n equation 5 of Table XVII. The con s t a n t of 34 i s f a r from zero and the negative slope of the t o t a l h e a l t h workers i s s u b j e c t t o comparatively h i g h e r r o r . TABLE XVII REGRESSION OF OBSERVED SEPARATIONS WITH INDEPENDENT VARIABLES: EXPECTED SEPARATIONS, NUMBERS OF HOSPITAL BEDS, PHYSICIANS, SPECIALISTS, TOTAL HEALTH WORKERS PER 10,000 POPULATION IN FOUR REGIONAL DISTRICTS OF BRITISH COLUMBIA 1975 Test Constant Slope (Error of Slope) : Expected Separations 1 Hospital Beds 1 Physicians/10,000 | Specialists/10,000 Total Health Workers/10,000 2 Adjusted R Equation 1 6.81837 1.05952(.02) - - - - 0 .78630 Equation 2 -18.60850 1.06279(.02044) 0.47017(.14721) - - - 0 78869 Equation 3 62.34609 1.06153(.02017) - -4.76369(.90085) - - 0 79369 Equation 4 23.04374 1.06220(.02018) - - -4.16052(.79531) - 0 79353 Equation 5 34.05469 1.06210(.02033) - - - -.22043(.05339) 0 79065 Equation 6 -7.65115 1.06300(.02021) 0.32199(11484.22* -0.77205(17435 3UD2) -5.42917(2465808.64) 0.22038(76694.95* 0 79346 F 2766.49** 0.0 0.0 0.0 0.0 * Suspected computational errors have produced these large errors of the slope ** Significant .001 164 In the f i n a l t est, Equation 6 of Table 1XVII, the inclu s i o n of a l l the variables together resulted i n slopes of the resource components that were subject to gross error. The resource components had no influence on the prediction of observed separations as indicated by the F s t a t i s t i c . As in the regression of the 1973 data, the e f f e c t s on the co-e f f i c i e n t of correlation i n the 1975 tests can be observed only at the t h i r d decimal place. From the 1975 test, the regression l i n e of best f i t would appear to be the simple regression i n Equation 1 of Table XVII Number of Number of Observed Separations = 6.81837 + 1.05952 (Expected Separations) There has been a s l i g h t increase i n the size of the constant in 19 75 over 19 73 but the two formulae are very close and w i l l account for 79 - 80% of the observed separations. The use of the calculated separations based on s i z e , age and sex of the populations would appear from these re s u l t s to have been v a l i d . The lack of e f f e c t of the hospital and manpower resources on the observed numbers of separations i s i n t e r e s t i n g because i t was unexpected. Regressions within Regional Districts": -Because the f a c i l i t y and manpower level s were constants in-any^one region, no re-gressions including a l l the variables were done for i n d i v i d u a l regional d i s t r i c t s . Tables XVIIT and XIX show "The results of simple regressions for each regional d i s t r i c t *of, the numbers of TABLE XVIII SIMPLE REGRESSION OF OBSERVED WITH EXPECTED SEPARATIONS FROM HOSPITALS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA FOR 186 DISEASE CATEGORIES (ICDA-8) IN 1973 CATE R e g i o n a l D i s t r i c t C o n s t a n t S l o p e E x p e c t e d S e p a r a t i o n s R 2 K i t i m a t - S t i k i n e 7.16256 1.20618 .76235 Cowichan V a l l e y 3 .21641 1.35838 .88064 N o r t h Okanagan 5.59046 0.88475 .79723 E a s t K o o t e n a y 2 .49722 1.24018 .86337 TABLE XIX SIMPLE REGRESSION OF OBSERVED WITH EXPECTED SEPARATIONS FROM HOSPITALS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA FOR 186 DISEASE CATEGORIES (ICDA-8) IN 1975 R e g i o n a l D i s t r i c t C o n s t a n t S l o p e E x p e c t e d S e p a r a t i o n s ( e r r o r o f s l o p e ) R 2 K i t i m a t - S t i k i n e 8 .55050 1.12085 ( .03848) .82498 Cowichan V a l l e y 6 .20056 1.25354 ( .04074) .84097 N o r t h Okanagan 7.83504 0 .78910 ( .03473) .74248 E a s t K o o t e n a y 4 .79394 1.09394 ( .03965) .81009 166 observed with the expected separations. In a l l four regional d i s t r i c t s i n both years the constant i s above zero i n d i c a t i n g a hospital u t i l i z a t i o n l e v e l that exists independent of the indepen-dent variable used i n the formula. I t has already been shown that the factors contributing to t h i s are not h o s p i t a l bed and manpower a v a i l a b i l i t y . There may be differences i n the pre-di s p o s i t i o n to seek care or i n the health status of the popula-tions i n these regions or there may be factors i n the health services that w i l l explain these u t i l i z a t i o n l e v e l constants but they are unknown at t h i s time. The trends of the constants of the various regional d i s t r i c t s i s upward over the two years. The Kitimat-Stikine has the highest constant i n both years, the East Kootenay has the lowest of the four and the Cowichan Valley and North Okanagan maintain the same rank position between them. In both years a l l of the slopes are p o s i t i v e i n d i c a t -ing that an increase i n the number of expected separations resulted i n an increase i n the observed separations. There i s considerable v a r i a t i o n between the slopes of the regions. The North Okanagan experienced an increase i n the observed separa-tions that was quantitatively less than the increase i n the expected separations. Although i t s regression l i n e starts from a higher constant than either, the East Kootenay or Cowichan Valley, the higher slopes of these l a t t e r two d i s t r i c t s indicate that for diseases of any but a very few numbers of expected separations, the h o s p i t a l u t i l i z a t i o n of the East Cowichan Valley Regional D i s t r i c t s w i l l be higher than that 167 of the North, Okanagan. The higher slope of the Cowichan Valley i n comparison to the Kitimat-Stikine Regional D i s t r i c t indicates that t h e i r regression l i n e s — a r e c o n v e r g i n g and w i l l -cross for diseases with large numbers of expected separations. The expected separations accounted for from 74% to 2 88% of the actual separations as can be seen from the R . There was an increase i n the predictive a b i l i t y of the regres-sion formula for the Kitimat-Stikine Regional D i s t r i c t i n 1975 over 1973 while there was a decrease i n the amount of the observed separations that were explained by the expected separations i n the three other regional d i s t r i c t s . RELATIVE DEPRIVATION A frequently voiced complaint i n the Kitimat-Stikine Regional D i s t r i c t was the cost of obtaining care outside the regional d i s t r i c t and the frequent need of r e f e r r a l to t r e a t -ment centres i n Greater Vancouver or V i c t o r i a . The complaints referred to both d o l l a r and s o c i a l costs r e l a t i n g to family inconvenience. I t was believed that people i n the South had fewer r e f e r r a l s to hospitals outside t h e i r regional d i s t r i c t and therefore fewer costs. However, costs are not necessarily related to the outside r e f e r r a l s so much as to the distance of the outside r e f e r r a l s . The breakdown of the separations by location of h o s p i t a l i z a t i o n can be seen i n Table XX. I t should be noted that i n three of the regional d i s t r i c t s , Kitimat-Stikine, Cowichan Valley and East Kootenay the numbers of separations 168 from hospitals within the regional d i s t r i c t alone exceeded the t o t a l numbers of separations expected for these regional d i s t r i c t s as shown in Table XX. TABLEJ XX TOTAL NUMBERS OF HOSPITAL SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS OF BRITISH COLUMBIA FOR 186 DISEASE CATEGORIES (ICDA-8) ~-FOR 1973 & 1975 BY LOCATION Year Location Kitimat-S t i k i n e Cowichan' Va l l e y North-Okanagan East.. Kootenay 1973 Within RD Outside RD Ratio within RD/ outside RD 7,662 1,133 6.763 7,118 2,377 2.995 5,785 954 6.064 8,381 547 5.322 1975 Within RD Outside RD Ratio within RD/ outside RD 6,928 1,330 5.209 7,200 2>616 ' 2.752 6,282 944 6.655 8,283 562 14.738 The East Kootenay Regional D i s t r i c t appears to have fewer separations from hospitals outside the regional d i s t r i c t than the other regional d i s t r i c t s . Many of the outside reg-ional d i s t r i c t separations people i n the East Kootenay Reg-t i o n a l D i s t r i c t do experience are from hospitals outside the province, in Alberta. The residents of the Cowichan Valley make the most use of hospitals outside t h e i r regional d i s t r i c t and t h i s may be related to the lower numbers of physicians i n the 169 Cowichan V a l l e y as w e l l as to the pr o x i m i t y of V i c t o r i a which has large numbers of p h y s i c i a n s , both general p r a c t i t i o n e r s and s p e c i a l i s t s and two t r a i n i n g h o s p i t a l s . There i s no doubt t h a t the cost of these r e s i d e n t s i n o b t a i n i n g approxi-mately 2500 separations a year outside t h e i r r e g i o n a l d i s t r i c t i s l e s s than t h a t i n c u r r e d by the r e s i d e n t s of the K i t i m a t -S t i k i n e Regional D i s t r i c t i n o b t a i n i n g about 1200 a year. I t may even be l e s s than t h a t of the 550 separations a year t h a t are used by the r e s i d e n t s of the East Kootenay Regional D i s t r i c t but i t must be assumed t h a t a high q u a l i t y of s o p h i s t i c a t e d care was r e q u i r e d f o r a larg e p r o p o r t i o n of these ouside r e f e r r a l s or they would have been t r e a t e d i n t h e i r l o c a l h o s p i t a l s . I t i s not p r a c t i c a b l e t o l o c a t e h i g h l y s o p h i s t i c a -ted s e r v i c e s i n regions t h a t do not make f u l l - t i m e use of them. I t may i n the end be l e s s c o s t l y i n human l i f e and s u f f e r i n g t o have an outside r e f e r r a l f o r care t h a t r e q u i r e s a high degree of technology. Average Length o f Stay: I f people are exp e r i e n c i n g e f f e c t i v e b a r r i e r s to access to care, one would expect delays i n o b t a i n -i n g care. These delays might r e s u l t i n a more se r i o u s con-d i t i o n of the p a t i e n t a t the time of h o s p i t a l i z a t i o n which would r e q u i r e a longer treatment p e r i o d than otherwise. However, the average length of stay may be a f f e c t e d by the r e l a t i v e shortage or surplus of h o s p i t a l beds and p h y s i c i a n s and by the age and sex composition of the p o p u l a t i o n . The i s o l a t i o n of the i n f l u e n c e exerted by comparative a v a i l a b i l i t y of beds and ph y s i c i a n s from the degree of i l l n e s s i s d i f f i c u l t 170 and beyond the scope of t h i s t h e s i s . Age-sex a d j u s t e d values o f average l e n g t h of s t a y have not been determined f o r each r e g i o n a l d i s t r i c t . Consequently, a s t a t i s t i c a l a n a l y s i s o f the data was not performed. The t o t a l average l e n g t h o f stay f o r the 186 d i s e a s e s of r e s i d e n t s o f the f o u r r e g i o n a l d i s t r i c t s are shown i n Table XXI. TABLE XXXI AVERAGE LENGTH OF STAY FOR TOTAL DISEASES IN FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA BY LOCATION AND YEAR Year Location BC Kitimat- Cowichan North East S t i k i n e V a l l e y Okanagan Kootenay 1973 Within RD 6.7 8.4 10.4 8.7 Outside RD 11.6 15.2 12.1 13.3 O v e r a l l * 10.5 7.33 10.1 10.6 8.98 1975 Within RD 6.7 10.7 10.0 9.4 Outside RD 14.4 12.9 13.7 15.0 O v e r a l l LOS 11.6 7.9 11.3 10.5 9.8 * calculated.as Average - l e n g t h - o f :'Stay-within -©'r- 'outside . . R e g i o n a l D i s t r i c t . (within RD x # separations In RD) - + '. (outside: RD x separations outside RD) t o t a l separations RD= Regional D i s t r i c t 171 The o v e r a l l Average Length of Stay of the residents of the North Okanagan Regional D i s t r i c t was equal to the p r o v i n c i a l Average Length of Stay i n 1973. I t was le s s than the p r o v i n c i a l average i n the remaining three regional d i s t r i c t s i n 1973. The Average Length of Stay i n the four regional d i s t r i c t s was lower than the p r o v i n c i a l average i n 19 75. The thesis that more s e r i o u s l y i l l patients have longer lengths of stay i s supported by the figures which show the Average Length of Stay of residents h o s p i t a l i z e d out-side t h e i r regional d i s t r i c t was greater than that of r e s i d -ents treated within t h e i r regional d i s t r i c t . The number of patient-days of h o s p i t a l i z a t i o n , being the product of the Average Length of.Stay and the number of separations, was calculated for the four regional d i s t r i c t s . However, i n t e r p r e t a t i o n of the data would be subject to the v a l i d i t y problems of age-sex adjustments. Without age-sex adjustments, comparison of patient-days would not be v a l i d for the determination of equity between the regions. Nor would i t be a measure of access to care. In summary, i t can be s a i d that there i s no evidence of r e l a t i v e deprivation i n obtaining h o s p i t a l services i n the regions studied. They obtain h o s p i t a l i z a t i o n i n sur-p r i s i n g l y large q u a n t i t i e s . The average length of stay does not indicate that an undue wait for treatment has i n - ' creased the s everity of the i l l n e s s e s . At the same time, the average length of stay does indicate that r e f e r r a l s to hospitals outside the regional d i s t r i c t of residence are made for those who are more seriously i l l than those treated w i t h i n the r e g i o n a l d i s t r i c t . Such l a r g e numbers of s e p a r a t i o n s do, however, r a i s e f u r t h e r q u e s t i o n s . For what d i s e a s e s are these people b e i n g h o s p i t a l i z e d and are there c a u s a t i v e f a c t o r s i n those s e p a r a t i o n s t h a t can be c o n t r o l l e d ? Reduction o f these numbers o f s e p a r a t i o n s would seem d e s i r a b l e not o n l y from the p o i n t o f i n c r e a s i n g the w e l l - b e i n g and h e a l t h o f the people i n these areas but a l s o from the economic view t h a t Northerners r a i s e d to t h i s w r i t e r i n 1975. H o s p i t a l s e r v i c e s are an i n s u r e d programme wit h the c o s t s spread over a l l taxpayers r e s i d e n t i n B r i t i s h Columbia. I t would appear t h a t the excess u t i l i z a t i o n i n these four areas of B r i t i s h Columbia has been p a i d f o r by the p o p u l a t i o n i n a l l o f the p r o v i n c e , h e a v i l y s u b s i d i z e d by r e s i d e n t s of o t h e r r e g i o n a l d i s t r i c t s . The f a c t o f the excess u t i l i z a t i o n does not by i t s e l f o f f e r any s o l u t i o n s t o h e a l t h p l a n n e r s . Consequently, analyses o f these s e p a r a t i o n s by grouping of the 186 d i s e a s e s i n t o s m a l l e r , more uniform d i s e a s e groups was done and these data w i l l be p r e s e n t e d i n the next chapter. I t was a n t i c i p a -t e d t h a t these analyses would i n d i c a t e a c t i o n s the r e g i o n a l d i s t r i c t s c o u l d take to reduce the amount o f h o s p i t a l i z a t i o n s i n these a r e a s . 173 CHAPTER 9 DISEASE SPECIFIC HOSPITALIZATIONS The analyses of hospital utilizations to this point have been of the total separations for 186 diseases of the ICDA-8. The diseases have individual cjTaracteristics_that -justify grouping of selected diseases into smaller units, each member of which has particular common characteristics pertain-ing to the delivery of health care. Such factors as degree of c r i s i s and pre-onset warning symptoms, prognosis of the patient based on historical pattern of the disease and the effect of the disease on the person's social health affect the importance ascribed to access to hospital or medical care. The acute onset of mycoardial infarction, the low survival rate of the patients with this condition who do not obtain medical attention and hospital care and the disruption to the family i f the person dies result in a need for hospital care that is more urgent than that of the person with, for example, a deflected nasal septum. While the latter condition involves surgery, the patient may wait without harm for a hospital bed. Some diseases with environmental and li f e s t y l e factors in their aetiology may present with acute and sudden onset requiring urgent medical attention although the condition may have been preventable. 174 In the o r i g i n a l design of t h i s study i t was anticipated that some areas would have been shown to be obtaining less access to hospitals by an amount that could be said to be 'unfair'. I t was deemed important to determine i f the b a r r i e r s to access applied to groups of diseases for which h o s p i t a l i z a t i o n i s generally accepted to be an important contributing factor i n the prognosis of the patient. Certain diseases were grouped together on the basis of treatment, recovery and prevention factors. The disease groups separated out were Infectious Diseases, Malignant Neoplasms, Psych i a t r i c Conditions, Diseases of the Ear, Acute Respiratory Infections, Diseases of the Heart, Cardiovascular Diseases, Cerebrovascular Diseases, Diseases of Pregnancy, Diseases of Delivery, Discretion-are Suxgeffes, Diseases of the Joints and Traumatic Inj u r i e s . I t had been decided to analyze the r a t i o s of the observed to the expected separations within each of these disease groups and t h i s was done by obtaining Frequency Distributions for them. We have seen, however, that the tested hypotheses were disproved and we have also seen evidence of u t i l i z a t i o n i n a l l four study regions s i g n i f i c a n t l y higher than that of the province. While one cannot exclude the p o s s i b i l i t y that people seeking treatment for some of these smaller disease groups may experience access problems, the numbers of un-expected separations i n the regions were s u f f i c i e n t l y large to have made i t u n l i k e l y . Rather than looking for disease groups with access problems we were now looking at these disease groups to see i f they were the ones responsible for 175 the increased u t i l i z a t i o n i n the four areas and, i f they were, to explore the implications of that to the health planner. OVERALL UTILIZATION BY DISEASE GROUPS While there were thirteen disease groups for which Frequency Distributions were obtained, there are 14 disease groups presented i n the tables of numbers of separations. Malignancies other than neoplasms are included i n the table or Malignant Diseases but the s t a t i s t i c a l analysis was of Malignant Neoplasms only. These disease groups i n the separation tables are composed of 90 of the 186 disease c l a s s i f i c a t i o n s for which the data were obtained. Only 86 of these 90 diseases were included i n the s t a t i s t i c a l testing. I t was mentioned i n Chapter 8 that i n 1975 the Kitimat-Stikine Regional D i s t r i c t had 2 2 85 more separations than expected. These ninety diseases i n t h e i r 14 groups, account for 1958 of those unexpected separations. S i m i l a r l y , these disease groups account for 2563 of the 290 3 unexpected separations that occurred i n the Cowichan Valley and 1607 of 19 72 unexpected separations i n the East Kootenay regional d i s t r i c t s i n 1975. There were 636 more separations than expected due to these ninety diseases i n the North Okanagan Regional D i s t r i c t i n 19 75. However, the North Okanagan had a t o t a l of 124 fewer separations than expected for a l l diseases i n 1975 even although that u t i l i z a t i o n was s i g n i f i -cantly higher than the province's t o t a l u t i l i z a t i o n * ' These diseases can be said to have accounted for 86% of the Kitimat-176 Stikine, 88% of the Cowichan Valley and 96% of the East Kootenay regional d i s t r i c t ' s extra u t i l i z a t i o n and for an undetermined amount of the North Okanagan Regional D i s t r i c t ' s . They also accounted for 70% of the t o t a l hospital separations i n the Kitimat-Stikine, .64% in the Cowichan Valley, 63% i n the North Okanagan, 60% i n the East Kootenay regional d i s t r i c t s and 58% of the province's t o t a l hospital separations. Not only does there appear to be good access to hospitals i n these four regions but the h o s p i t a l i z a t i o n s have been for diseases for which provision of hospital care may be considered important. SELECTED DISEASE GROUP UTILIZATION In the remainder of t h i s chapter the data regarding the disease groups are presented. Tables are provided that give the numbers of observed hospital separations and the numbers of expected separations for each disease i n these groups in both 1973 and 1975. S t a t i s t i c a l tables are provided for the thirteen disease groups comprising 86 diseases i n 19 75 that were subjected to Frequency Dis t r i b u t i o n . These tables show the r e s u l t s of the Frequency Distribution and of the student's t - t e s t that was applied to the 1975 d i s t r i b u t i o n i n order to determine i f any of the regional d i s t r i c t s was s i g n i f i c a n t l y d i f f e r e n t from the Province. INFECTIOUS DISEASES The l e v e l of infectious diseases i n an area i s a TABLE XXII INFECTIOUS DISEASES NUMBER OF SEPARATIONS FROM BRITISH COLUMBIA HOSPITALS AND "nZZL°F S E P A R A T I 0 N S EXPECTED CONSIDERING AGE AND SEX COMPOSITION OF POPULATION FOR FOUR REGIONAL DISTRICTS AND BRITISH COLUMBIA BY DISEASE CATEGORY jWTC YEAR Disease Name Etrentococcal Sore Throat Bcarlet Fever, P _ , . , „ _ , l ' erysipelas 1973 UVcute Poliomyelitis fairal Encephalitis palmonella Infections 1973 1975 |Other Intestinal Infections 1973 1975 fruberculosis 1973 1975 1975 1973 1975 1973 1975 jlnfectious Hepatitis 1973 1975 Other Virus Diseases Venereal Diseases 1973 1975 1973 1975 Other Infectious and Parasitic Diseases 1973 1975 Total Separations for Infectious Diseases 1973 1975 Kitimat-Stikine Regional D i s tr i c t Act. Exp. Cowichan Valley 239 200 7 17 48 82 5 7 27 26 150 162 46 45 5 4 20 22 386 346 243 253 Act. Exp. 261 185 54 9 51 60 3 12 38 34 131 141 39 43 4 4 20 27 420 312 213 237 North Okanagan Act. Exp. 140 118 18 6 10 0 26 51 5 3 16 17 225 200 112 123 36 39 3 4 15 19 181 203 East Kootenay Act. Exp. 248 243 12 11 68 57 9 5 13 21 139 146 40 43 5 5 18 20 Province of Bri t i sh Columbia Act. Exp. 96 93 6782 6288 388 392 234 201 91 82 739 362 1907 2143 288 318 911 935 128 135 6 7 8 6 7255 561 629 205 213 399 417 2088 2207 274 299 956 1027 259 348 225 239 11441 11452 10814 12243 TABLE XXIII STATISTICS FROM FREQUENCY DISTRIBUTION AND t - T E S T S OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 1975 WITH ADMITTING DIAGNOSES OF INFECTIOUS DISEASES (Valid Cases [Missing Cases Minimum iMaximum Mean Standard Deviation Kitimat-Stikine 7 3 0.675 2.429 1.566 0.515 Regional D i s tr i c t Cowichan Valley 8 2 0.500 3.000 1.344 0.775 North Okanagan 6 4 0.500 2.000 1.069 0.528 East Kootenay I 8 2 0.250 1.664 1.090 0.483 •significant 178 measure of the need for public health measures and of the effectiveness and adequacy of ex i s t i n g public health measures or services i n the area. Screening programmes should detect Tuberculosis. Immunization programmes should eradicate Po l i o m y e l i t i s . I f sanitary conditions are adequate i n an area, Salmonella and other i n t e s t i n a l infections should not be unusually high, nor should Infectious Hepatitis, V i r a l Encephalitis and other virus diseases. Environmental sanitary conditions w i l l also have a bearing on the incidence of p a r a s i t i c diseases. An e f f e c t i v e public health system may ensure that cases of venereal disease are detected, reported and treated as such. For the purposes of t h i s study, the infectious d i s -eases comprise diseases numbers 1 through 10; Salmonella infections (ICDA #1), other i n t e s t i n a l infections (ICDA #2), Tuberculosis (ICDA #3), Streptococcal Sore Throat/Scarlet Fever/Erysipelas (ICDA #4), Acute Poli o m y e l i t i s (ICDA #5), V i r a l Encephalitis (ICDA #6), Acute Poli o m y e l i t i s (ICDA #5), V i r a l Encephalitis (ICDA #6), Infectious Hepatitis (ICDA #7), other virus diseases (ICDA #8), Venereal Diseases (ICDA #9), and other infectious and p a r a s i t i c diseases (ICDA #10). Table XXII contains the number of observed and expected separations of residents of the four regional d i s t r i c t s and the Province for these diseases i n 19 73 and 19 75. Except for V i r a l Encephalitis, the numbers of observed separations for these diseases were lower than the expected separations for the Province of B r i t i s h Columbia. Because these diseases, with one exception, are reportable and hospital 179 treatment based, the number of separations should provide a reasonably accurate picture of the incidence and/or prevalence of these diseases. However, while venereal diseases are re-portable, the majority of people are treated for these d i s -eases without being hos p i t a l i z e d and i t i s well known that many cases are not reported. On the basis of t o t a l separations for infectious diseases one could conclude that o v e r a l l i n B r i t i s h Columbia public health measures appear to be adequate. The same cannot be deduced from these data for the regional d i s t r i c t s i n the study. While the province had fewer separations than expected, three of the four regional d i s t r i c t s had higher separations than expected for Infectious Diseases i n 19 75. The separations i n only the North Okanagan approximated the expectations. The differences can most dramatically be seen i n Disease #2, I n t e s t i n a l Infections other than Salmonella. While there were decreases^ in •the-"'" numbers of separations for t h i s disease from 1973 to 1975 in the four regions studied, i n three of the regions the observed numbers far exceeded those expected. A l l three of these areas have large numbers of people l i v i n g outside municipal boundaries and without municipally provided water and sewage services. The comparatively large number of separations of residents of the Kitimat-Stikine Regional D i s t r i c t for tuberculosis may mean any of three things; people are hos p i t a l i z e d several times during treatment, detection i s better than i n the other regions or the prevalence i s higher 180 than i n the other regions. There was a r e l a t i v e l y large increase i n the numbers of separations for other virus diseases (ICDA #8) i n 1975 from 1973 i n the Kitimat-Stikine and North Okanagan regional d i s t r i c t s . In the Cowichan Valley there was a large decrease i n numbers of separations due to Infectious Hepatitis from 1973 to 19 75. The results of the frequency d i s t r i b u t i o n of the i n d i v i d u a l diseases and the t - s t a t i s t i c s indicated that while the t o t a l numbers are large, they were not s i g n i f i c a n t l y so in the Cowichan Valley, North Okanagan and East Kootenay regional d i s t r i c t s . Because i n eight of these ten diseases the Kitimat-Stikine Regional D i s t r i c t had consistently higher numbers than expected, the numbers of separations due to Infectious Diseases were s i g n i f i c a n t l y higher i n the Kitimat-Stikine Regional D i s t r i c t than the Province i n 19 75. For the planner t h i s might indicate a need to strengthen public health services or measures i n the Kitimat-Stikine Regional D i s t r i c t . While the s t a t i s t i c a l t esting did not show s i g n i f i c a n t differences i n the Cowichan Valley and East Kootenay regional d i s t r i c t s , the numbers are s u f f i c i e n t l y larger than expected to suggest to a planner a need to i n v e s t i -gate the reason for those high numbers. MALIGNANCIES Malignant Neoplasms are a serious class of diseases. I n a b i l i t y to gain access to care has grave implications for such patients. Diseases i n t h i s category included Diseases TABLE XXIV MALIGNANCIES NUMBER OF SEPARATIONS FROM BRITISH COLUMBIA HOSPITALS OF RESIDENTS AND NUMBER OF SEPARATIONS EXPECTED CONSIDERING AGE AND SEX COMPOSITION OF POPULATIONS FOR FOUR REGIONAL DISTRICTS AND BRITISH COLUMBIA BY DISEASE CATEGORY AND YEAR Disease Name Kitimat Stikine Regiona Cowichan Valley 1 D i s t r i c t North Okanagan East Kootenay Province c British Columbi; Act. Exp. Act Exp. Act. Exp. Act. Exp. Act Ex; 11 Malignant Neoplasm, Buccal Cavity and Pharynx 1973 1975 1 3 3 3 5 4 6 6 5 7 7 7 11 3 5 5 308 399 3 6 : 44C 12 Malignant Neoplasm, Stomach 1973 1975 0 18 4 4 21 19 9 8 13 11 10 11 15 4 7 8 591 623 571 641 13 Malignant Neoplasm, Intestine, fexcept rectum) 1973 1975 10 11 7 6 16 33 17 16 41 47 21 22 23 11 15 15 1207 1363 1164 1285 14 Malignant Neoplasm, Rectum and Rectosigmoid Junction 1973 1975 6 4 3 3 14 16 9 9 15 15 12 12 14 15 7 8 659 693 606 692 15 Malignant Neoplasm, Other Digestive Organs 1973 1975 4 4 5 4 16 18 11 10 15 18 13 13 11 25 9 11 803 827 686 776 16 Malignant Neoplasm, Trachea, Bronchus and Lung 1973 1975 11 13 14 14 24 44 27 26 46 35 31 34 12 24 25 26 1856 2181 1686 1950 L7 Malignant, Neoplasm, other respiratory organs 1973 1975 9 0 2 2 3 5 4 3 4 5 4 4 1 9 3 4 237 248 273 320 L8 Malignant Neoplasm, Bone 1973 1975 0 1 0 0 2 4 0 0 1 3 0 1 0 0 0 0 97 164 120 130 L9 Malignant Neoplasm, Skin 1973 1975 1 3 1 3 7 5 5 5 6 18 7 7 7 3 5 5 455 532 447 501 10 Malignant Neoplasm, Breast 1973 1975 13 16 12 12 35 57 25 25 28 36 28 33 35 28 32 24 1915 2170 1631 1725: ?1 Malignant Neoplasm, qervix uteri 1973 1975 5 4 5 4 6 13 8 8 27 25 9 10 7 5 8 8 591 567 551 579 22 Malignant Neoplasm, Uterus 1973 1975 4 4 2 3 IS 18 6 6 9 9 7 8 8 9 6 6 579 614 457 479 pisease Name [23 Malignant Neoplasm Ovary 1973 1975 {24 Malignant Neoplasm Other female genital organs 1973 1975 {25 Malignant Neoplasm, Prostate 1973 1975 £6 Malignant Neoplasm, Bladder 1973 1975 £7 Malignant Neoplasm, Other genito-urinary organs 1973 1975 ^8 Malignant Neoplasm, Brain 1973 1975 £9 Other Primary fi Secondary Malignant Neoplasms, 1973 1975 B0 Leukemia 1973 1975 pi Other Neoplasms of Lymphatic and Hematopoiatic Tissue 1973 1975 Regional D i s t r i c t Kitimat-Stikine Act. Exp. Total Malignant Neoplasms 1973 1975 Total Malignancies 1973 1975 5 10 2 12 7 12 3 14 90 126 101 141 13 12 15 13 Cowichan Valley 87 95 110 117 13 9 30 30 20 25 5 12 5 17 15 23 Exp, 17 16 13 13 21 21 11 11 21 18 North Okanagan Act. Exp. 242 327 262 367 190 184 222 213 23 6 15 28 12 32 7 15 15 8 16 11 15 31 17 19 East Kootenay 24 26 10 13 21 24 295 321 326 363 226 345 257 382 Act. Exp 4 10 27 15 189 201 217 224 1 Province oj British I Columbia! 11 16 25 17 IS 22 11 12 8 19 10 20 1 11 8 13 17 19 187 179 215 211 450 493 Expl 326] 344 1 71 110 1 102 116 1287 1107 | 1566 1230 1167 881 I 1320 995 , 409 542 228 326 345 390 160 179 646 1359 790 4679 654 729 789 794 1239 1508 1267 1411 13556 12867 15520 17451 15444 I 4 8 6 3 17817 19656 00 182 #11 through, @29, c l a s s s i f i e d as malignant Neoplasms, as w e l l as Disease #30, Leukemia and Disease #31, other Neoplasms/ Lymphatic Haematopoieatic t i s s u e . Frequency and t - t e s t were a p p l i e d to the group c l a s s i f i e d as malignant Neoplasms i n 19 75. While the numbers o f separations shown i n Table XXIV appear very la r g e i n the Cowichan V a l l e y , the s t a t i s t i c s i n Table XXV do not i n d i c a t e the d i f f e r e n c e s were s i g n i f i c a n t . There was a very la r g e increase i n numbers of separations f o r malignant Neoplasms i n the Cowichan V a l l e y i n 1975 over 19 73. TABLE XS&i STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 19 75 WITH ADMITTING DIAGNOSES OF MALIGNANT NEOPLASMS Number of Diseases - 19 Mean of Province 1.107 Regional D i s t r i c t Kitimat- Cowichan North East S t a t i s t i c S t i k i n e V a l l e y Okanagan Kootenay V a l i d Cases 16 17 19 18 Missing Cases 3 2 0 1 Minimum 0.071 0.333* 0.308 0.500 Maximum 12.000 12.000 3.000 5 .000 - - , 2 . 6 6 ' 2.6?2 '. T r Mean 2.448 2.372 1.510 1.441 f ' a n d a — -/• . • . " " 0 .1 7 0 Standard Deviation 2.970 2.561 0.741 1.124 \ L i r j L a n c t - . 6 5 5 ? i . .£ Or -0.54 c i : '' t 1.749 1.976 2.307* 1.225 BC 19 * s i g n i f i c a n t t ^ = 2.101 OC 183 It was thought that new treatment measures may have been acting on the Cowichan Valley which could have resulted i n these high numbers of separations with perhaps a shorter length of stay. Many cancer patients are treated with i n t r a -venous chemotherapy on an out-patient basis without being admitted for an overnight stay i n h o s p i t a l . Such patients do not of course show up i n these h o s p i t a l separations but i t was wondered i f the Cowichan Valley might have been treat-ing more patients for shorter periods as in-patients than were being treated i n the other regions. However, the average of the lengths of stay of residents treated both within and outside the regional d i s t r i c t for malignant Neoplasms i n the Cowichan Valley i n 1975 was considerably larger than those of the other three regional d i s t r i c t s . The average of the lengths of stay for malignant Neoplasms in the Kitimat-Stikine and North Okanagan regional d i s t r i c t s was 14.7 days each; i n the East Kootenay Regional D i s t r i c t i t was 12.6 days and i n the Cowichan Valley Regional D i s t r i c t i t was 21 days. Not only were more hos p i t a l separations observed i n the Cowichan Valley but those separations were for longer periods of treatment. Because of the large numbers of diseases i n t h i s " category i n the North Okanagan that had r a t i o s of observed to expected separations higher than 1, the Standard Deviation i s small. Consequently and although the numbers t o t a l no higher than those of the Cowichan Valley Regional D i s t r i c t , the number of separations for Malignant Neoplasms was 184 s i g n i f i c a n t l y higher than the Province i n the North Okanagan Regional D i s t r i c t i n 19 75. What t h i s means i s d i f f i c u l t to determine. I t may mean that each cancer patient receives a l o t of hospital care. Many malignancies develop over long periods of time. Because the North Okanagan i s a retirement centre, people may move into i t with the malignancy i n some stage of develop-ment or i t may mean that there i s either a greater incidence or prevalence of these diseases in the area. MENTAL DISEASES The group l a b e l l e d as Mental Diseases i s a mixture of psychotic and neurotic conditions as well as conditions d i f f i c u l t to define i n medical terms as disease, such as Alcoholism and drup dependence. The diseases are Disease #52, Alcoholic Psychosis; Disease #53, Schizophrenia; Disease #5'4, A f f e c t i v e Psychoses; Disease #55, other Psychoses; Disease #56, Neuroses; Disease #57, Alcoholism; Disease #58, drug dependence; and Disease #59, other non-psychotic mental disorders. Mental health problems, as well as alcohol abuse and addiction were frequently mentioned as being of concern to health care and community workers i n the Kitimat-Stikine Regional D i s t r i c t and, indeed, the numbers were high i n that region i n both 19 7 3 and 19 75. At the time of the study there were few health workers trained to cope with these conditions in the Kitimat-Stikine Regional D i s t r i c t . These manpower shortages did not r e s u l t i n reduced access to care and 185 TABLE XXVI MENTAL DISEASES NUMBER OF SEPARATIONS FROM BRITISH COLUMBIA HOSPTTATc; aun N U M B E ™ ^ A R A T I 0 N S EXPECTED CONSIDERING AGE^^D SEX COMPOSITION OF POPULATIONS FOR FOUR REGIONAL DISTRICTS AND BRITISH COLUMBIA - BY DISEASE CATEGORY AND YEAR Disease Name and Number Kitimat-Stikine Region Cowichan Valley al District North Okanagan East Kootenay Province of British Columbia Act. Exp. Act Exp. Act. Exp. Act. Exp. Act. Exp. 52 Alcoholic Psychosis 1973 1975 24 9 5 4 11 22 7 6 10 12 6 6 11 17 5 7 1058 374 935 437 53 Schizophrenia 1973 1975 57 34 23 23 38 56 24 25 46 40 22 25 84 71 26 28 2597 1450 2798 1588 54 Affective Psychosis 1973 1975 41 37 20 22 65 106 27 28 31 29 27 30 70 53 26 29 2047 1583 2103 1767 55 other Psychosis 1973 1975 9 9 10 9 76 IS 13 13 15 15 15 16 26 20 14 15 882 914 1040 1001 56 Neuroses 1973 1975 139 167 89 85 151 157 98 102 136 174 94 107 184 199 100 95 6598 5823 6505 6370 57 Alcoholism 1973 1975 68 94 46 45 26 59 49 52 21 50 51 57 24 122 53 56 1715 3107 2678 3640 58 Drug Dependence 1973 1975 6 10 3 3 7 6 2 4 10 8 2 2 12 10 3 3 494 256 407 287 59 other Non-psychotic Mental Disorders 1973 1975 45 43 33 33 45 46 35 37 34 65 35 38 47 58 37 39 3221 2063 3307 2243 Total 1973 1975 389 403 229 224 419 470 255 267 303 393 252 281 458 550 264 272 18612 1557C 19773 1733; TABLE XXVTI STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 1975 WITH ADMITTING DIAGNOSES OF MENTAL DISEASES 8 DISEASES (ICDA »52 - 59) Mean of Province 1.348 ^alid Cases hissing Cases minimum Maximum •lean Standard Deviation Kitijnat-Stikine 0 1.000 3.333 1.888 0.718 Regional District Cowichan , North Valley 8 0 1.135 3.786 2.062 1.079 Okanagan 8 0 0.877 4.000 1.715 1.013 East Kootenay 0 1.333 3.333 2 .152 0.637 3.339* •significant 186 u t i l i z a t i o n of hospital services; so presumably people other than t r a d i t i o n a l health workers were also assuming the role of gatekeeper. The numbers of observed separations seen i n Table XXVI are higher than the expected separations i n a l l areas i n -cluding the Province. Only Alcoholism separations,were lower than expected on a province-wide basis. I t i s in t e r e s t i n g that the drop i n population from 1973 to 19 75 i n the Kitimat-Stikine Regional D i s t r i c t was r e f l e c t e d i n a drop i n the numbers of separations due to Alcoholism, Neuroses and Drug-Dependence increased i n that period. •' One can only wonder about ".-,the ef-fects-ofj the^'economic recession that__sjtarted in 19 74 on ^these l a t t e r separations"."- ^ ~ The number of separations for psy c h i a t r i c conditions was s i g n i f i c a n t l y higher than the Province i n the East Kootenay Regional D i s t r i c t i n 19 75. EAR INFECTIONS Ear infections were another problem mentioned frequently. Health care providers spoke of the recurrent ear in f e c t i o n s , p a r t i c u l a r l y among the Indian population, and of p a r t i a l deafness r e s u l t i n g from such chronic conditions. Hearing impairment interferes with a child ' s learning i n school and has broad s c o i a l implications beyond the c h i l d i n the educational system to the adult he becomes, seeking employment and s o c i a l i n t e r a c t i o n s . I t i s important that i f such infections are prevalent, access to care be 187 TABLE XXVTII DISEASES OF THE EAR ^ D ^ M ^ OF RESIDENTS COMPOSITION OF POPULATIONS ^ I T o l ^ o X l ^ J T S ^ A N ^ I I ^ C O L U M B I A BY DISEASE CATEGORY AND YEAR BRITISH COLUMBIA Disease Number and Name 73 Otitis Media without mention of mastoiditis 1973 1975 [74 Mastoiditis with or without Otitus Media 1973 1975 |75 Other Diseases of ear and mastoid process 1973 1975 Total separations due to ear diseases 1973 1975 Kitimat-Stikine Act. Exp. 151 101 42 42 194 144 74 70 25 23 Regional D i s t r i c t Cowichan Valley Act. Exp. North Okanagan Act. Exp. 106 88 101 96 31 32 145 133 58 62 29 29 89 93 51 35 22 18 73 56 51 57 East Kootenay Province of British Columbia Act. Exp 27 30 82 90 38 34 11 23 49 58 93 98 Act. 2966 2391 19 3 179 1255 1576 Exp . 2914 3057 272 206 1548 1697 4414 4146 4734 4960 TABLE XXIX ^i\TlST1CS F R 0 M FBEQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 1975 WITH ADMITTING DIAGNOSES OF EAR INFECTIONS  Number of Diseases - 3 Mean of Province 0.8599 Statistic Kitimat-Stikine Regional D Cowichan Valley i s t r i c t North Okanagan East Kootenay l/alid Cases hissing Cases 3 0 3 0 3 3 •iinimum •laximum 0.333 1.826 1.103 6.500 0 1 0 600 000 0 0 0 .250 793 lean 1.201 3.008 0 738 0 522 Standard deviation 0.775 3.029 0 227 0 272 0.622 1.003 -0. 759 -1 757 188 gained. The etiology of the ear infections i n the Native population i s not f u l l y understood and i s beyond the scope of t h i s thesis. However, i t can be t r u t h f u l l y stated that prevention of these infec t i o n s would be preferable to care and cure of them. It can be seen i n Table XXVIII that the t o t a l numbers of separations for diagnoses of ICDA #73 to #75 were much higher than expected i n the Kitimat-Stikine and the Cowichan Valley Regional D i s t r i c t s i n 19 73 and 1975 and most of these extra h o s p i t a l i z a t i o n s were due to O t i t i s Media, ICDA #73. There was a large decrease i n the number of separations for th i s disease in the Kitimat-Stikine Regional D i s t r i c t from 19 73 to 19 75 and a somewhat smaller decrease i n the Cowichan Valley Regional D i s t r i c t . Neither of these i s explainable from data available to t h i s investigator. Despite these decreases, the numbers of separations for O t i t i s Media-re-mained higher than expected. In both the North Okanagan and East Kootenay Regional D i s t r i c t s the observed separations were lower than expected as were those for the Province of B r i t i s h Columbia. None of the differences between the observed and expected separations i n any of the four regional d i s t r i c t s was s i g n i f i c a n t l y d i f f e r e n t from the Province i n 1975. For the planner, the numbers involved may be of concern. While there i s no way of knowing the ethnic breakdown of these separations nor whether the same people who suffered ear infections also suffered upper respiratory t r a c t i n f e c t i o n s , i t i s worth remembering 1 that both the Kitimat-Stikine and Cowichan Valley regional d i s t r i c t s have Targe Native populations, most of whom l i v e i n housing that Non-Natives would judge inadequately heated and insulated. The concerns about ear diseases were f i r s t raised to us by the nurses l i v i n g and working i n Indian v i l l a g e s i n the Kitimat-Stikine Regional D i s t r i c t . HEART DISEASES Heart diseases are one of the primary causes of pre-mature mortality i n Canada. The gaining of care i n the less acute phases of these diseases or for less acute episodes, i s important to the reduction of t h i s mortality. The speed of obtaining medical care i s c r u c i a l to the outcome of acute conditions such as myocardial i n f a r c t i o n . I f geographic ba r r i e r s reduce the access to care gained for these conditions the prognoses of patients who suffer from them may be affected I t can be seen from Tables XXX and XXXI that i n both 19 73 and 19 75, the Cowichan Valley had considerably more separations than expected and that t h i s s i t u a t i o n applied to both i t and the Kitimat-Stikine Regional D i s t r i c t i n 1975. By contrast, the North Okanagan and the Province as a whole has fewer separations than expected due to heart diseases i n 1973 and 1975. None of the regional d i s t r i c t s has s i g n i f i c a n t r a t i o s of observed to expected separations. I t would not appear that residents of any of these regional d i s t r i c t s have d i f f i c u l t y i n obtaining hospital care for heart diseases. TABLE XXX DISEASES OF THE HEART NUMBER OF SEPARATIONS FROM BRITISH COLUMBIA HOSPITALS OF RESIDENTS AND NUMBER OF SEPARATIONS EXPECTED CONSIDERING AGE AND SEX COMPOSITION OF POPULATIONS FOR FOUR REGIONAL DISTRICTS AND BRITISH COLUMBIA BY DISEASE CATEGORY AND YEAR Regional Dis t r i c t Province of Kitimat- Cowichan North East British disease Number and Name Stikine Valley Okanagan Kootenay Columbia Act. Exp. Act Exp. Act Exp. Act. Exp. Act. Exp. 78 Hypertensive Disease 1973 57 25 64 41 30 48 33 38 1851 2718 1975 78 23 95 38 43 53 57 36 1963 3019 79 Acute Myocardial Infarction 1973 39 46 113 81 75 95 78 76 4670 5126 1975 34 41 93 77 109 105 75 80 5076 5924 SO Other ischaemic Heart Disease 1973 101 82 340 158 193 192 233 145 12879 10356 1975 113 74 419 149 296 211 246 152 14312 11741 31 Other Forms of Heart Disease 1973 32 49 61 87 28 108 23 92 1702 5746 1975 35 44 51 86 30 118 32 87 1784) 6377 Total Separations due to heart disease 1973 229 202 578 367 326 443 367 351 21102 23946 1975 260 182 658 350 478 487 410 355 23135 27061 TABLE XXXI STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 1 9 7 5 WITH ADMITTING DIAGNOSES OF HEART DISEASES  Number of Diseases - 4 Mean o f Province 0.809 Regional District Kitimat- Cowichan North East Statistic Stikine Valley Okanagan Kootenay Valid Cases 4 4 4 4 Missing Cases 0 0 0 0 Minimum 0.795 0.593 0.254 0.368 Maximum 3.391 2.812 1.403 1.618 Mean 1.636 1.778 0.877 1.127 Standard Deviation 1.218 1.052 0.481 0.595 0.679 1.595 0.245 0.926 {.OS' 3 - 1 8 2 191 There are i n s u f f i c i e n t data to provide clear planning implications.< The t r a v e l time between the hospital and home of these residents, the number of separations each resident had and the prevalence of these diseases i n these areas need to be studied. Diseases of the Heart have considerable l i f e -s tyle influences i n t h e i r incidence and they are c e r t a i n l y diseases that are better prevented than treated. However, i t i s perhaps better to err on the side of caution and r e l y on too much h o s p i t a l i z a t i o n than too l i t t l e f or these d i s -eases . CEREBROVASCULAR AND CIRCULATORY CONDITIONS People suffering from both these groups of diseases have need of rapid access to hospital i n the acute phases. Cerebrovascular diseases present as acute conditions, often of sudden onset whereas Circulatory diseases may present during t h e i r development stages with acute episodes following l a t e r . Cerebrovascular Diseases: These include Cerebral Haemorrhage (ICDA #82), Cerebral Embolism and Thrombosis CICDA #83) and other cerebrovascular conditions (ICDA #84). Following the often sudden onset, recovery may..require long-term r e h a b i l i t a -t i v e therapy. However, the success of the therapy i s affected by the speed with which access to care i s gained. I f access i s slow, the patient may gain back less of his former health status than he otherwise would have done. In both 19 73 and 19 75 a l l four of the regional d i s t r i c t s 192 TABLE XXXII CEREBROVASCULAR AND CIRCULATORY DISEASES NUMBER OF SEPARATIONS FROM BRITISH COLUMBIA HOSPITALS OF RESIDENTS AND NUMBER OF SEPARATIONS EXPECTED CONSIDERING AGE AND SEX COMPOSITION OF POPULATIONS FOR FOUR REGIONAL DISTRICTS AND BRITISH COLUMBIA BY DISEASE CATEGORY AND YEAR Disease Number and Name Kitimat-Sti k i n e Region Cowichan Valley a l D i s t r i c t North Okanagan East Kootenay Province o f B r i t i s h Columbia B2 Cerebral Haemorrhage 1973 1975 B3 Cerebral Embolism and Thrombosis 1973 1975 B4 Other Cerebrovascular Disease 1973 1975 T o t a l Separations f o r Cerebrovascular Disease 1973 1975 Act. Exp 2 2 0 2 6 8 13 7 37 29 51 27 Act. Exp. 19 4 6 4 45 18 22 17 120 66 167 63 Act. Exp. 7 6 10 6 16 23 25 26 87 86 133 93 Act. Exp. 1 4 2 4 16 16 12 16 101 58 118 62 118 78 132 82 Act. Exp. 315 329 308 367 1345 1272 1257 1425 4790 4600 5813 5073 45 39 64 36 184 88 195 84 110 115 168 125 6450 6201 7378 6865 B5 A r t e r i o s c l e r o s i s 1973 1975 B6 Other Diseases of A r t e r i e s , A r t e r i o l e s an C a p i l l a r i e s 1973 1975 87 Pulmonary Embolism and In f a r c t i o n 1973 1975 88 P h l e b i t i s , Thrombophleb Venous Embolism, Thrombosis 1973 1975 89 Varicose Veins of Lower Extremities 1973 1975 T o t a l Separations (ICDA for C i r c u l a t o r y Diseases 1973 1975 4 6 5 5 3 9 18 14 16 0 5 5 5 21 15 32 13 40 33 37 33 #85-89) 74 77 130 109 39 14 32 13 37 29 63 29 6 6 3 6 21 20 20 19 53 43 55 44 156 112 237 158 20 18 18 18 23 36 30 39 11 7 9 8 19 21 22 23 40 45 51 51 113 127 183 189 4 13 12 13 35 30 24 30 16 7 12 7 50 18 51 19 55 42 53 45 160 110 197 164 1020 941 1144 1050 1632 2006 1898 2292 325 454 472 508 1149 1225 1360 1356 2972 2666 2828 2907 7098 7292 10455 11373 92 Haemorrhoids 1973 1975 93 Other Diseases of the Cir c u l a t o r y System 1973 1975 32 34 32 30 5 7 5 7 39 38 56 39 3 8 8 8 35 40 49 41 9 7 4 9 51 39 34 41 18 9 11 9 2354 2352 2234 2642 377 553 519 61 t Total Separations f o r Cerebrovascular and Cir c u l a t o r y Diseases 1973 1975 156 157 231 182 382 246 496 289 267 289 404 364 347 236 374 296 16279 16396 20586 21493 / TABLE XXXIII STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 1975 WITH ADMITTING DIAGNOSES OF CEREBROVASCULAR DISEASES  Number of Diseases - 3 Mean o f Province 0.956 Statistic Kitimat-Stikine Regional I Cowichan Valley district North Okanagan East Kootenay Valid Cases 2 3 3 3 Missing Cases Minimum Maximum 1 1.857 1.889 0 1.294 2.651 0 0.962 1.667 0 0.500 1.903 Mean 1.873 1.815 1.353 1.051 Standard Deviation 0.022 0.731 0.359 0.748 He 58.95 • 2.035 1.915 0.220 2 * *.05 = 1 2 ' 7 1 TABLE XXXIV STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 1975 WITH ADMITTING DIAGNOSES OF CARDIOVASCULAR DISEASES Number of Diseases - 5 ICDA #85 - 89 Regional District Kitimat Cowichan North East Statistic Stikine Valley Okanagan Kootenay Valid Cases 5 5 5 5 Missing Cases 0 0 0 0 Hinimum 0 875 0 .500 0 769 0.800 Maximum 2 462 2 462 1 125 2.684 He an 1 292 1 .487 0 970 1.460 Standard Deviation 0 660 0 .812 0 129 0.769 Sc 1 108 1 437 0 087 1.439 l.05 " 2 - 7 7 6 194 had larger numbers of separations for cerebrovascular diseases than expected while the Province had a n e g l i g i b l e amount more than were expected. The s t a t i s t i c a l analysis indicated that the Kitimat-Stikine Regional D i s t r i c t had s i g n i f i c a n t l y more separations than the Province. Like the Heart diseases, more information i s needed to indicate i f any actions by a planner are needed. Cardiovascular And Circulatory Conditions: Cardiovascular conditions require early treatment to control the progress of the diseases and prompt action for successful treatment of the acute phases. Access barr i e r s have serious implications for people developing or suffering from these conditions. Diseases i n t h i s group include A r t e r i o s c l e r o s i s (ICDA #85), other artery diseases (ICDA #86), Pulmonary Embolism (ICDA #87), P h l e b i t i s , Thrombophlebitis, Venous Embolism and Thrombosis (ICDA #88) and Varicose Veins (ICDA #89). Circulatory condi-tions that were not included i n the s t a t i s t i c a l analysis but the numbers of which appear i n the separations table are Haemorrhoids (ICDA #90) and other Diseases of the Circulatory System (ICDA #91). In 1975 the t o t a l numbers of separations for Cardiovascular diseases were higher than expected i n the Kitimat-Stikine, Cowichan Valley and East Kootenay regional d i s t r i c t s and lower than expected i n the North Okanagan Regional D i s t r i c t and i n B r i t i s h Columbia. There were large increases from 19 73 to 1975 i n both the Kitimat-Stikine and the Cowichan Valley regional d i s t r i c t s . In none of the regions was the number of separations s i g n i f i c a n t l y d i f f e r e n t 195 from the Province. ACUTE RESPIRATORY INFECTIONS Respiratory infections are, i n Canada the diagnostic categories that account for more separations from hospital than any other category except hypertrophy of the t o n s i l s and adenoids, o b s t e t r i c a l d e l i v e r i e s and s e n i l i t y . While r e s p i r a -tory infections are short-term i l l n e s s e s with less residual damage than the heart and vascular diseases, they are an ilidaJcation of, the ease of access to hosp i t a l s . Because of modern drug therapy.-using a n t i b i o t i c s and other drugs, these diseases may i n many cases be treated at home. In hospitals experiencing pressure on t h e i r beds by the existence of long queues, two results may be found: only those patients who are i n an acute condition may be admitted or the length of stay may be shortened by the encouragement of early discharge by the use of home care programmes. Diseases grouped i n th i s category include acute upper respiratory i n f e c t i o n (ICDA #92), Influenza (ICDA #93), Pneumonia (ICDA #94) and Bronchitis (ICDA #95). I t can be seen that the t o t a l numbers of separations were much larger than expected i n the Kitimat-Stikine, Cowichan Valley and East Kootenay regional d i s t r i c t s i n both 1973 and 1975. While the p r o v i n c i a l t o t a l separations was s l i g h t l y lower than expected, there was a large reduction i n the t o t a l number of separations i n the Kitimat-Stikine Regional D i s t r i c t i n 1975 from 1973. TABLE XXXV ACUTE RESPIRATORY INFECTIONS Disease Number and Name Kitimat-Stikine Region Cowichan Valley al District North Okanagan East Kootenay Province o British Columbia El 32 Acute upper Respiratory Infection, except Influenza 1973 1975 J3 Influenza 1973 1975 >4 Pneumonia 1973 1975 >5 Bronchitis and 1 Emphysema 1973 1975 Total Separations for Respiratory Infections 1973 1975 Act. Exp. 516 251 341 249 38 27 53 25 342 159 263 156 179 94 135 91 1075 531 792 521 Act. Exp. 308 190 356 207 53 29 51 30 274 153 303 163 163 97 147 100 798 469 857 500 Act. Exp. 123 159 188 179 37 29 40 30 167 148 143 165 98 97 98 110 425 433 469 484 Act. Exp 334 206 414 216 50 29 87 29 164 159 133 166 167 99 129 104 715 493 763 515 Act. Exp 9503 9798 9398 10183 1576 1614 1613 1829 8169 8590 7979 9270 4461 5598 3984 6489 23709 25600 22974 27771 TABLE XXXVI STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 19 7 5 WITH ADMITTING DIAGNOSES OF ACUTE RESPIRATORY INFECTIONS Number of Diseases - 4 Mean of Province 0.8199 Regional District Kitimat- Cowichan North East Statistic Stikine Valley Okanagan Kootenay Valid Cases 4 4 4 4 Missing Cases 0 0 0 00 Minimum 1 369 1 470 0 B67 0.801 Maximum 2 120 1 859 1 333 3.000 Mean 1 665 1 687 1 035 1.740 Standard Deviation 0 331 0 161 0 215 0.957 5 106* 10 .771* 2 .001 1.923 t _ 0 5 - 3.182 197 Examination of the figures for acute upper respiratory i n f e c t i o n except Influenza indicates that l i t t l e change i n the numbers was expected i n any of the areas from 19 73 to 19 75. The Cowichan Valley, North Okanagan and East Kootenay regional d i s t r i c t s had large increases i n the numbers of separations for t h i s disease while the Kitimat-Stikine had a large decrease. In spite of t h i s decrease the number of separations i n the Kitimat-Stikine Regional D i s t r i c t for t h i s disease was high in 1975. Pneumonia (ICDA #9 4) also showed a large decrease i n numbers of separations from 19 73 to 19 75 i n the Kitimat-Stikine Regional D i s t r i c t and also had a much higher number of separations than expected despite the decrease. The number of separations f o r Pneumonia was much higher than expected i n the Cowichan Valley Regional D i s t r i c t i n both 19 73 and 19 75. The s t a t i s t i c a l test applied to t h i s group of diseases indicated that the numbers of separations for acute respiratory infections were s i g n i f i c a n t l y higher than those of the Province i n both the Kitimat-Stikine and the Cowichan Valley regional d i s t r i c t s . No d e f i n i t i v e causal statements can be made on the basis of these data. However, the numbers are s u f f i c i e n t l y large to suggest the need to determine causative factors for these high numbers of separations. The incidences of acute respiratory infections are related to adequacy of clothing and housing as well as to s o c i a l contact. I t would seem advisable to determine i f the incidence of these diseases i s higher i n these regional d i s t r i c t s than elsewhere i n the Province. 198 DISCRETIONARY- SURGERIES Another gauge of pressure on hospital beds and physicians i s the number of discretionary surgeries. Grouped in t h i s category are Hypertrophy of the Adenoids and Tonsils (Disease #9 7), Appendicitis (Disease #110), Hernia without mention of obstruction (Disease #111), and C h o l e l i t h i a s i s (Disease #118). Each of these f i v e diseases was responsible for fewer separations i n 19 75 than i n 19 73 i n the Kitimat-Stikine Regional D i s t r i c t and the number of separations for each disease was less than expected. Like the Kitimat-Stikine, the North Okanagan had fewer separations than ex-pected for each disease i n both years. S i m i l a r l y the Province showed a decline ifi.vr.9 75.. from--19.73 i n the t o t a l number of separations and had fewer separations for the i n d i v i d u a l diseases than expected i n both years. The t o t a l number of separations for discretionary surgeries i n the East Kootenay— Regional D i s t r i c t declined from 1973 to 1975 and, i n 1975 was considerably less than expected. One might be tempted to conclude that here i s an example of inequity with discretionary surgeries being low because of pressure to provide other care, thus reducing the opportunity to perform these surgeries. That cannot be said however, because the o v e r a l l trend i n B r i t i s h Columbia indicates that the numbers of discretionary surgeries pa r t i c u -l a r l y Tonsillectomy and Adenoidectomy (for ICDA #97) are fewer than i n the rest of Canada. The r a t i o of observed to expected 199 TABLE XXXVTI DISCRETIONARY SURGERY NUMBER OF SEPARATIONS FROM BRITISH COLUMBIA HOSPITALS OF RESIDENTS AND NUMBER OF SEPARATIONS EXPECTED CONSIDERING AGE AND SEX COMPOSITION OF POPULATIONS FOR FOUR REGIONAL DISTRICTS AND BRITISH COLUMBIA BY DISEASE CATEGORY AND YEAR Regional District Province of Kitimat- Cowichan North East British Disease Number and Name Stikine Valley Okanagan Kootenay Columbia Act. Exp. Act Exp. Act. Exp. Act. Exp. Act. Exp. 97 Hypertrophy of Tonsils and Adenoids 1973 303 322 344 275 181 233 288 276 12274 13267 1975 241 305 349 300 187 369 188 289 10548 13618 99 Deflected Nasal Septum 1973 26 39 26 36 19 33 3 38 1737 2074 1975 22 37 33 39 30 36 9 42 1976 2289 110 Appendicitis 1973 82 88 110 86 65 75 101 85 4300 4401 1975 77 80 88 92 56 85 113 90 4170 4646 111 Hernia without mention of Obstruction 1973 126 127 127 142 125 141 173 141 7241 8116 1975 116 119 146 143 147 153 127 150 756 9198 118 Cholelithiasis 1973 138 128 191 159 159 161 184 157 8620 9737 1975 105 121 164 162 153 185 136 168 7292 10652 Total Separations for Discretionary Surgery 1973 675 704 798 698 549 643 749 697 34172 37595 1975 561 662 780 736 573 833 573 739 31549 40403 TABLE XXXVIII STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 1975 WITH ADMITTING DIAGNOSES OF DISCRETIONARY SURGERIES  Number of Diseases - 4 Mean o f Province 0.795 Regional District Kitimat- Cowichan North East Statistic Stikine Valley Okanagan Kootenay Valid Cases 4 4 4 4 Hissing Cases 0 0 0 0 Minimum 0.790 0.957 0.507 0.651 Maximum 0.975 1.163 0.930 1.256 Mean 0.899 1.038 0.731 0.891 Standard Deviation 0.087 0.088 0.187 0.258 2.391 5.523* -0.684 0.744 * J_05 - 3.182 200 separations was lower only i n the North Okanagan Co.69) than i n the Province '(0.77). i n 1975 and that difference was not appreciable. The East Kootenay Regional D i s t r i c t had the same r a t i o as the Province while Kitimat-Stikine had a r a t i o of 0.85 and Cowichan Valley, one of 1.06. While the Cowichan Valley had the highest r a t i o of actual to expected separations, the other areas did not show lower rat i o s than the Province. By contrast, the Cowichan Valley had more t o t a l separations i n both years than were expected and showed a n e g l i g i b l e decline from 1973 to 1975. Indeed, the numbers of separations for discretionary surgeries was s i g n i f i c a n t l y higher i n the Cowichan Valley than those of the Province i n 19 75. This cannot be explained on the basis of ho s p i t a l beds or physician manpower resident i n the regional d i s t r i c t as previously enumerated i n this study. The Cowichan Valley residents are also able to make use of physicians and ho s p i t a l beds i n the Capital Regional D i s t r i c t and indeed;106 of the 780 separations for discretionary surgeries of residents i n the Cowichan Valley i n 19 75 were from hospitals outside the Cowichan Valley Regional D i s t r i c t . During the same period 50 of the 561 separations of residents of the Kitimat-Stikine Regional D i s t r i c t were from hospitals outside t h e i r regional d i s t r i c t . COMPLICATIONS OF PREGNANCY AND DELIVERY Neonatal mortality i s higher i n Canada than i n countries 201 of s i m i l a r i n d u s t r i a l and economic development. Complications of pregnancy and of delivery are considered factors i n this mortality. Attempts have been made by Public Health prenatal programmes to improve the health of the pregnant woman and to ensure that she seeks medical attention throughout her pregnancy. Yarie, studying attendance and non-attendance at prenatal classes, questioned the effectiveness of t h i s programme i n e f f e c t i n g changes i n the prospective mother's behaviour that would a f f e c t the baby's h e a l t h . 1 Yarie was concentrating on smoking and breastfeeding while much of the Public Health programme i s directed at exercises and body control to f a c i l i t a t e d elivery. Two of the regional d i s t r i c t s contain high proportions of Native Indians who may not take advantage of or f i n d i t easy to gain access to prenatal care. The question arises, i f access to care for conditions of pregnancy i s f a c i l i t a t e d , are complications of delivery reduced? TABLE XXXIX STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 19 7 5 WITH ADMITTING DIAGNOSES OF DELIVERY WITHOUT COMPLICATIONS Disease Number and Name Kitimat-Stikine Regiona Cowichan Valley 1 D i s t r i c t North Okanagan East Kootenay Province of B r i t i s h Columbia 141 Delivery without mention of complications 1973 1975 Act. Exp. 520 513 505 502 Act. Exp. 517 425 546 465 Act. Exp. 279 362 314 413 Act. Exp. 607 490 571 534 Act. Exp. 23841 26296 24073 28828 TABLE XL COMPLICATIONS OF PREGNANCY Disease Number and Name Kitimat-Stikine Regional Cowichan Valley District North Okanagan East Kootenay province o British Columbia 1 tort. Exp. Act. Exp. Act. Exp. Act. Exp. Act. Exp. 136 Infections of GenitD -urinary tract during pregnancy and Puerperium 1973 1975 20 9 7 6 11 16 5 6 8 13 5 6 9 9 7 7 400 464 366 398 137 Haemorrhage of pregnancy 1973 1975 75 77 30 29 59 47 25 27 33 31 22 24 74 56 29 31 2114 2060 1549 1682 L38 Toxemias of pregnancy and Puerperium 1973 1975 36 61 18 18 25 35 15 18 23 14 14 15 41 35 18 19 1153 1268 945 1029 L39 Other Complications of pregnancy 1973 1975 88 110 89 86 101 115 75 81 87 89 63 73 108 108 84 93 4316 4659 4555 4977 Total Separations for Complications of Pregnancy 1973 1975 219 257 144 139 196 213 120 132 151 147 104 118 232 208 138 150 7983 8451 7415 8086 TABLE XLI STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 1975 WITH • ADMITTING DIAGNOSES OF DISEASES OF PREGNANCY Number of Diseases - 4 Mean of Province 1.140 i/alid Cases Missing Cases Minimum Maximum Mean Standard Deviation Kitimat-Stikine 4 0 1.279 3.389 2.206 0.993 Regional District Cowichan I North Valley | Okanagan 4 0 1.420 2.667 1.943 0.529 3.036 4 0 0.933 2.167 1.403 0.532 East Kootenay 4 0 1.161 1.842 1.524 0.351 2.168 |.05 = 3 - 1 8 2 203 The numbers of separations for diseases of pregnancy and delivery must be related to the t o t a l numbers of un-complicated d e l i v e r i e s as well as to the calculated numbers for each condition. The numbers of uncomplicated d e l i v e r i e s (ICDA #141) can be seen to have been about what was expected i n both the Kitimat-Stikine and east Kootenay regional d i s t r i c t s , higher than expected i n the Cowichan Valley and less than ex-pected i n both the North Okanagan and the Province. Complications Of Pregnancy; The diseases i n the grouping, Complications Of Pregnancy are Infections during Pregnancy (ICDA #136), Haemorrhage during Pregnancy (ICDA #137), Toxaemia of Pregnancy (ICDA #138) and Complications of Pregnancy (ICDA #139). F a i r l y consistently, the numbers of observed separations exceeded those expected i n a l l areas. In only one disease each in the North Okanagan and the Province were the numbers approximately what was expected. The high numbers of separa-tions compared to what was expected i n the Kitimat-Stikine Regional D i s t r i c t for Toxaemias'- of Pregnancy and P,uerperium (ICDA #138) may be an i n d i c a t i o n that the physicians are being very c a r e f u l . This i s another disease where a physician may decide too much treatment i s preferable to too l i t t l e . None of the regions had s t a t i s t i c a l l y s i g n i f i c a n t differences i n numbers of separations for complications of pregnancy. Complications Of Delivery; Conditions grouped into Complications of Delivery include d e l i v e r i e s complicated by abnormality of . the p e l v i s or other prolonged labour (ICDA #143), and d e l i v e r i e s TABLE XLII COMPLICATIONS OF DELIVERY NUMBER OF SEPARATIONS FROM BRITISH COLUMBIA HOSPITALS OF RESIDENTS A N5„S? f f l E R 0 F SEPARATIONS EXPECTED CONSIDERING AGE AND SEX COMPOSITION OF POPULATIONS FOR FOUR REGIONAL DISTRICTS AND BRITISH COLUMBIA BY DISEASE CATEGORY AND YEAR 1 Regional District Disease Number and Name Kitimat- Cowichan North East Stikine Valley Okanagan Kootenay Act. Exp. Act Exp. Act. Exp. Act. Exp. L42 Delivery Complicated by Antepartum or Postpartum Haemorrhage 1973 46 18 24 15 26 13 31 17 1975 51 18 27 15 30 14 32 18 L43 Delivery Complicated by Abnormality of Pelvis or Other Prolonged Labour 1973 70 56 57 46 90 39 54 44 1975 77 55 79 51 93 45 84 59 L44 Delivery with other complications, Anaesthetic Death, in uncomplicated delivery 1973 172 115 45 83 171 72 89 97 1975 229 99 53 91 199 81 78 107 L45 Complications of the Puerperium 1973 15 11 7 9 5 7 19 10 1975 10 10 17 9 10 9 3 11 Total Separations -Complications of Deliver r 1973 303 200 109 153 292 131 193 168 1975 367 182 176 166 332 149 197 195 Total Separations for Complications of Pregnan •y and Delivery 1973 522 344 305 273 443 235 425 306 1975 624 321 389 298 479 267 405 345 Province of| British Columbia | Act. E: 1409 922 1437 1011 3869 2885 4327 3162 5084 6282 636 567 10998 9575 12613 10508 18981 16990 21604 18594 TABLE XLIII STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 1975 WITH ADMITTING DIAGNOSES OF COMPLICATIONS OF DELIVERY  Number of Diseases - 4 Mean of Province 1.295 Regional District Statistic Kitimat Cowichan North East Stikine Valley Okanagan Kootenay Valid Cases 4 4 4 4 Missing Cases 0 0 0 0 Minimum 1.000 0.582 1.111 0.273 Maximum 2.833 1.889 2.457 1.778 Mean 1.887 1.455 1.944 1.051 Standard Deviation 0.837 0.599 0.581 0.677 S c 1.415 0.534 2.234 -0.721 * .05 - 3 - 1 8 2 205 with other Complications, A n a e s t h e t i c Death i n Uncomplicated D e l i v e r i e s (ICDA #144). In a l l areas i n c l u d i n g the Pr o v i n c e and except the Cowichan V a l l e y Regional D i s t r i c t , the numbers of s e p a r a t i o n s f o r t h i s group of d i s e a s e s exceeded those expected i n 1973. In 19 75 both the Cowichan V a l l e y and E a s t Kootenay r e g i o n a l d i s t r i c t s e x p e r i e n c e d numbers of s e p a r a t i o n s t h a t were c l o s e to what was expected although the number of s e p a r a t i o n s i n the Cowichan V a l l e y was a l a r g e i n c r e a s e from 19 73. T h i s w r i t e r can r e c a l l the p r i d e i n t h e i r work taken by the maternity s t a f f o f one of the h o s p i t a l s i n the Cowichan V a l l e y Regional D i s t r i c t where she worked a number of years ago. However, s t a t i s t i c a l l y there were no s i g n i f i c a n t d i f f e r e n c e s between the numbers of s e p a r a t i o n s f o r c o m p l i c a t i o n s o f d e l i v e r y o f any of the regions from the P r o v i n c e . There does not appear t o be any i n d i c a t i o n t h a t i n c r e a s e d numbers of se p a r a t i o n s due to c o m p l i c a t i o n s o f pregnancy r e s u l t i n r e -duced numbers of s e p a r a t i o n s due to c o m p l i c a t i o n s o f d e l i v e r y . DISEASES OF THE JOINTS Mention was made of the shortage o f phys i o and o c c u p a t i o n a l t h e r a p i s t s i n the K i t i m a t - S t i k i n e Regional D i s t r i c t and the problems t h a t t h i s shortage c r e a t e d i n r e h a b i l i t a t i o n of people w i t h long-term d i s e a s e s l i k e A r t h r i t i s . A l l o f the r e g i o n a l d i s t r i c t s b e i n g s t u d i e d had lower p h y s i o t h e r a p i s t l e v e l s tharf the. p r o v i n c i a l l e v e l . Because few s e r v i c e s were a v a i l a b l e i n ambulatory and home TABLE XLTV DISEASES OF THE JOINTS NUMBER OF S E P A R A T I O N S FROM B R I T I S H COLUMBIA H O S P I T A L S OF R E S I D E N T S AND NUMBER OF SEPARATIONS EXPECTED CONSIDERING AGE AND S E X COMPOSITION OF POPULATIONS FOR FOUR REGIONAL D I S T R I C T S AND B R I T I S H COLUMBIA B Y D I S E A S E CATEGORY AND Y E A R Disease Number and Name K i t i m a t -S t i k i n e Regions Cowichan V a l l e y 1 D i s t r i c t North Okanagan Eas t Kootenay P r o v i n c e o i B r i t i s h Columbia A c t . Exp. A c t Exp . A c t . Exp . A c t . Exp . A c t . Exp, 149 Rheumatoid A r t h r i t i s and A l l i e d Cond i t ions 1973 1975 17 20 11 12 41 51 19 19 17 19 21 25 31 54 17 19 1321 1546 1399 1423 150 O s t e o a r t h r i t i s and A l l i e d Cond i t ions 1973 1975 56 27 17 15 62 63 30 28 54 73 36 39 42 60 27 28 2160 2548 2022 2257 151 Other A r t h r i t i s and Rheumatism 1973 1975 36 40 17 18 55 39 23 26 48 36 25 29 45 43 23 24 1358 1338 1493 1644 152 O s t e o m y e l i t i s and o ther Diseases o f the Bone 1973 1975 19 26 19 19 35 30 21 23 18 18 20 25 22 20 20 21 1352 1280 1225 1323 153 Displacement o f i n t e r v e r t e b r a l d i s c . 1973 1975 186 161 53 51 131 109 60 62 57 55 59 68 82 83 62 67 4252 4059 3676 4149 156 Other Diseases o f J o i n t 1973 1975 82 67 61 55 91 113 57 63 34 46 58 61 86 118 61 66 3080 3526 3466 3850 T o t a l Separa t ions fo r Diseases o f the J o i n t 1973 1975 396 341 178 170 415 675 210 221 228 247 219 247 308 378 210 225 13523 14297 13281 14646 S T A T I S T I C S FROM FREQUENCY D I S T R I B U T I O N AND t - T E S T S OF R A T I O OF OBSERVED TO EXPECTED SEPARATIONS OF R E S I D E N T S OF FOUR REGIONAL D I S T R I C T S I N B R I T I S H COLUMBIA I N 1975 WITH A D M I T T I N G DIAGNOSES OF D I S E A S E S OF THE J O I N T S  Number o f D i s e a s e s - 6 Mean o f P r o v i n c e 0 . 9 82 Regiona l D i s t r i c t K i t i m a t - Cowichan Nor th Eas t S t a t i s t i c S t i k i n e V a l l e y Okanagan Kootenay V a l i d Cases 6 6 6 6 h i s s i n g Cases 0 0 0 0 l4inimum 1 218 1 .304 0 720 0.952 Maximum 3 157 2 .684 1 .872 2.842 Mean 1 905 1 .882 1 026 1.793 Standard D e v i a t i o n 0 706 0 .506 0 458 0.669 3 202* 4 .358* 0 235 2.969* I .05 " 207 care programmes, one might expect these people to be admitted to hospitals to obtain treatment i n the acute care f a c i l i t y . There was an orthopaedic surgeon i n both the Kitimat-Stikine and Cowichan Valley regional d i s t r i c t s , and the a v a i l a b i l i t y of these s p e c i a l i s t s i n these areas would i n -crease the access to care of the people i n those areas with bone and j o i n t diseases. The numbers of observed and expected separations from hospitals of residents of the four regional d i s t r i c t s and the Province are detailed i n Table XLIV, while s t a t i s t i c s on the frequencies of the observed to the expected separations are presented i n Table XLV. The numbers of separations were higher than expected i n the Kitimat-Stikine, the Cowichan Valley and the East Kootenay regional d i s t r i c t s i n both 19 73 and 19 75 while those of the North Okanagan and the Province were about what was expected. The numbers of separations decreased i n the Kitimat-Stikine Regional D i s t r i c t from 19 73 to 19 75 while those i n the Cowichan Valley and East Kootenay regional d i s t r i c t s increased. The numbers of separations for diseases of the j o i n t s were s i g n i f i c a n t l y higher than those of the Province i n 19 75 i n the Kitimat-Stikine, Cowichan Valley and the East Kootenay regional d i s t r i c t s . FRACTURES AND TRAUMATIC INJURIES Traumatic conditions r e s u l t i n g from automobile accidents, i n d u s t r i a l accidents and accidents i n the home are preventable by control of l i f e s t y l e and environmental 208 factors. Some conditions have longer average length of stay than generally other diseases do. Bad road conditions, common use of logging roads with unusual roadbeds and bridge construction and high alcohol consumption were factors the health care workers frequently expressed concern about. There are eleven diseases i n this group; fractures of the s k u l l (Disease #171), fracture of the spine and trunk (Disease #172), fractures of the upper limbs (Disease #173), fractures of the femur (Disease #174), other fractures of the lower limbs (Disease #175), d i s l o c a t i o n without fracture, sprains, strains of j o i n t and adjacent muscles (Disease #176), in t e r n a l injury of the chest, abdomen and pe l v i s (Disease #177), laceration, s u p e r f i c i a l injury, contusion and crushing (Disease #178), e f f e c t s of foreign body entering through an o r i f i c e (Disease #179), burns (Disease #180), and injury to nerves and spinal cord (Disease #181). I t can be assumed that however transportation to care i s effected, people with conditions of a traumatic nature w i l l be taken to a care f a c i l i t y and w i l l receive treatment. However, i f the incidence of these i n j u r i e s i s high i n an area where the average distance of residents from hospitals i s long, there may be high costs of transportation. These costs may be f e l t i n suffering, i n increased treatment time and i n high d o l l a r costs. They may give r i s e to feelings of r e l a t i v e deprivation. The separations for fractures and traumatic i n j u r i e s were higher than expected i n a l l four regional d i s t r i c t s and TABLE XLVI FRACTURES AND TRAUMATIC INJURIES NUMBER OF SEPARATIONS FROM BRITISH COLUMBIA HOSPITALS OF RESIDENTS AND NUMBER OF SEPARATIONS EXPECTED CONSIDERING AGE AND SEX COMPOSITION OF POPULATIONS FOR FOUR REGIONAL DISTRICTS AND BRITISH COLUMBIA BY DISEASE CATEGORY AND YEAR Disease Number and Name Kitimat-Stikine Regional Cowichan Valley District North Okanagan East Kootenay Province of British Columbia Act. Exp. Act Exp. Act. Exp. Act. Exp. Act. Exp. 171 Fracture of the Skull and Intracranial Injury 1973 1975 200 185 117 113 215 200 112 120 120 121 99 112 198 197 117 121 7959 8534 5945 6376 172 Fracture of Spine and Trunk 1973 1975 55 58 27 26 66 68 35 37 53 56 36 42 51 66 35 37 2947 3345 2129 2361 173 Fracture of Upper Limb 1973 1975 97 103 59 58 102 99 67 69 87 82 63 70 149 110 64 67 5021 5264 3590 3820 174 Fractures of Femur 1973 1975 34 40 22 20 58 56 41 39 55 66 49 54 39 47 34 38 3110 3346 2693 2903 175 Other Fractures of Lower Limbs 1973 1975 127 103 54 53 77 113 58 60 96 107 56 63 155 138 58 63 5028 5107 3331 3645 176 Dislocation without Fracture, Sprains, Strains of Joint and Adjacent Muscles 1973 1975 231 195 47 46 182 185 48 52 93 151 45 51 224 205 52 54 6925 8193 2869 3179 L77 Internal Injuries of Chest, Abdomen and Pelvis 1973 1975 45 25 11 11 32 17 13 14 27 15 11 12 30 22 13 15 1323 1122 726 799 L78 Laceration, Superficial Injury, Contusion and Crushing 1973 1975 406 284 112 107 221 216 112 118 178 155 101 113 281 229 114 119 9536 8923 11917 6656 L79 Effects of Foreign Body Entering through Orifice 1973 1975 8 18 8 8 9 19 6 6 11 13 6 8 14 12 8 9 481 511 448 495 L80 Burns 1973 1975 71 72 21 22 19 33 20 24 15 25 17 21 52 37 24 25 1555 1493 1174 1271 L81 Injury to Nerves and Spinal Cord 1973 1975 8 15 4 3 4 6 5 5 2 3 5 5 3 3 5 5 247 316 335 303 Total Separations for Fractures and Traumatic Injuries 1973 1975 1282 1098 482 467 985 1012 517 544 J 737 794 488 S51 1196 1066 524 553 44132 46154 35157 31806 TABLE XLVTI STATISTICS FROM FREQUENCY DISTRIBUTION AND t-TESTS OF RATIO OF OBSERVED TO EXPECTED SEPARATIONS OF RESIDENTS OF FOUR REGIONAL DISTRICTS IN BRITISH COLUMBIA IN 1975 WITH ADMITTING DIAGNOSES OF TRAUMATIC INJURIES Number of Diseases - 11 Mean of Province 1.387 Regional District Kitimat- Cowichan North East Statistic Stikine Valley Okanagan Kootenay i/alid Cases 11 11 11 11 4issing Cases 0 0 0 0 ni mum 1.637 1.200 0.600 0.299 4A* imnm 5.000 3.558 2.961 3.796 lean 2.661 1.873 1.409 1.613 standard Deviation 1.078 0.779 0.589 0.908 Sc 3.737* 1.973 0.118 0.787 11 t n s = 2.23 1 -1 210 i n the Province.in both 1973 and 1975. Those i n the Kitimat-Stikine Regional D i s t r i c t were two and a h a l f times that expected i n both years with those of the Cowichan Valley and East Kootenay regional d i s t r i c t s being about twice the ex-pected numbers. The increase i n the number of separations i n the Cowichan Valley Regional D i s t r i c t from 19 73 to 19 75 was about that expected but the numbers of separations i n 1973 established a high s t a r t i n g base. There was a s l i g h t reduction in the numbers of separations i n the East Kootenay Regional D i s t r i c t from 1973 to 1975. The r a t i o of observed to expected separations for fractures and traumatic i n j u r i e s was s i g n i -f i c a n t l y higher i n the Kitimat-Stikine Regional D i s t r i c t than the Province i n 19 75. The question of why such i n j u r i e s were high i s beyond the scope of t h i s t h e s i s . Because such i n j u r i e s are prevent-able, further study of the environmental and l i f e s t y l e factors involved i n each accident might indicate measures that could reduce the numbers of them. Comparison of these data with data generated i n 19 78 would be i n t e r e s t i n g to determine the possible e f f e c t s of mandatory seat b e l t l e g i s l a t i o n on the number of separations for these i n j u r i e s . CONCLUSION I t was said e a r l i e r that h o s p i t a l separations are not a measure of either incidence or prevalence of a disease. While th i s i s true, h o s p i t a l separations are the r e s u l t of diagnosed disease and such high numbers would suggest that 211 the incidences and/or prevalences of some of these diseases should be the subject of some review i n these regions, f i r s t to determine i f they are higher there than i n the rest of the Province and, i f they are higher, to determine what i s needed to reduce the incidence and/or prevalence of these diseases. This investigation w i l l require investigation of factors outside the s t r i c t d e f i n i t i o n of health services, into socio-economic l e v e l (housing conditions), r a c i a l factors, sewage disposal, water supply, road conditions, drinking patterns and so for t h . Even for those disease groups where the significance was not established such as ear inf e c t i o n s , the large numbers of separations would indicate a need to improve the health status of the population. In the Kitimat-Stikine Regional S D x s t r i c t the numbers of separations due to Infectiour Dis-eases, Cerebrovascular Diseases, Acute Respiratory Infections, Diseases of the Joints and to Traumatic Injuries were s i g n i -f i c a n t l y higher than those of the Province. With the exception of Diseases of the Joints, there are environmental and l i f e -s t yle factors involved i n these diseases. Cerebrovascular diseases have a genetic factor i n t h e i r incidence but they also are subject to l i f e s t y l e influences. In the Cowichan Valley, there were curiously high numbers of separations for Discretionary Surgeries and for Malignant Neoplasms. Like the Kitimat-Stikine Regional D i s t r i c t the Cowichan Valley experienced s i g n i f i c a n t l y high numbers of separations for Diseases of the Joints and Acute 212 Respiratory Infections. One wonders whether the l a t t e r i s influenced by the large Native population i n these two areas and, i f so, what can be done to reduce t h e i r need of h o s p i t a l i z a t i o n . The high numbers of separations due to Malignant Neoplasms i n the North Okanagan i s a complex problem. Many malignancies develop over long periods of time. The a t t r a c t i v e climate of the North Okanagan res u l t s i n i n -migration of large numbers of people as was shown in the growth of the population from 19 71 to 19 76. This migration was of an older group than that to the Cowichan Valley and some of them could have developed the disease before moving to the area. However, the regional d i s t r i c t might f i n d i t worthwhile to investigate these high separations. The large numbers of separations compared to expected separations due to Mental Illnesses i n the East Kootenays are consistent throughout a l l the p s y c h i a t r i c conditions l i s t e d . While some psy c h i a t r i c diseases, l i k e Diseases of the Joints (also high i n t h i s region) are not amenable to actions by health planners, the large numbers of separations suggest a need to ensure that community services are available that are suitable for people suffering from these conditions. There was no evidence from examination of t o t a l h o spital separation data that b a r r i e r s to access to care reduce the access to care of the residents of the Kitimat-Stikine Regional D i s t r i c t . Nor has the breakdown into disease categories indicated any types of conditions i n 213 which, access to care i s hindered i n the Kitimat-Stikine Regional D i s t r i c t . The disease group breakdown did account for a large percentage of the unexpected h o s p i t a l i z a t i o n i n the regions and there i s i n d i c a t i o n of the need for further study into causative factors of the high separations due to certain diseases. -2-14 REFERENCES 1. Sarah Fulton Yarie, A Study.of Factors Influencing U t i l i z a t i o n  of Prenatal Educational Services, M.Sc Thesis, Department of Health Care and Epidemiology, University of B r i t i s h Columbia, 1977. 215 Chapter 10 POLICY AND PLANNING IMPLICATIONS In previous chapters, we have conducted a study of access and power i n the health services system, examined i n d e t a i l the health services available i n the Kitimat-Stikine Regional D i s t r i c t and analyzed acute care hospital u t i l i z a t i o n of that and three other regional d i s t r i c t s . The results have implications for planning directions and policy decisions. REGIONAL DISTRICTS The Kitimat-Stikine Regional Hospital D i s t r i c t has made e f f e c t i v e use of p o l i t i c a l power to obtain health f a c i l i t i e s i n i t s area. While i t i s to be expected the regional d i s t r i c t w i l l continue to exert influence v i a the p o l i t i c a l process to improve the s i t u a t i o n within the d i s t r i c t , there i s a need to divert more of the regional d i s t r i c t ' s objectives away from f a c i l i t y construction to programme and manpower needs. There are b a s i c a l l y two situations which inter f e r e with such a t r a n s i t i o n . The establishment of Regional Hospital D i s t r i c t s i n 1967, by name focusses the attention of regional planners on hospitals rather than on community-based programmes and - 216' f a c i l i t i e s . In addition, the decision of most regional h o s p i t a l boards to concentrate on c a p i t a l funding of hospitals not only i n i s o l a t i o n from operating costs, but also with no control over the operating costs of those hospitals,. has directed the attention of the boards towards equipment and a r c h i t e c t u r a l spaces rather than programmes as resources of the h o s p i t a l . Their charter allows them to exercise control over operating costs and such an expansion of control would ensure that decisions on c a p i t a l expenditures included the long term effects on operating costs and were not based s o l e l y on the short term outlay of c a p i t a l funds. One d i f f i c u l t y that would be encountered i s the possible lack of health and hospital care knowledge and expertise of elected board members. There would need to be a commitment by them to obtain the knowledge necessary for r a t i o n a l decision-making. I t i s much more d i f f i c u l t to change the l e g i s l a t e d name from Regional Hospital D i s t r i c t to Regional Health D i s t r i c t . Indeed, such a change may not be regarded by a l l sections of the province's health industry as desirable. Much can be accomplished to integrate community-based health services i n a regional d i s t r i c t by charismatic leadership i f the administrators of the various programmes can meet t h e i r objectives more s a t i s f a c t o r i l y by coordinating some aspects of t h e i r programmes. Because hidden goals are sometimes more instrumental than are public goals, t h i s marrying of the goals of a variety of administrators requires a co-ordinator with 217 s k i l l . There was co-operation between administrators and health care professionals i n the Kitimat-Stikine Regional D i s t r i c t and r e a l attempts were being made to co-ordinate programmes and to more e f f i c i e n t l y use available manpower. To continue to concentrate attention on cure and hospital care rather than prevention and home care would re s u l t i n even higher use of very expensive h o s p i t a l services. While the l a t t e r meet physical needs, they do not meet the spe c i a l s o c i a l and emotional needs of the i l l or injured. Hospital u t i l i z a t i o n i s high i n the four regional d i s t r i c t s examined i n t h i s study. Construction of more acute care f a c i l i t i e s w i l l increase hospital u t i l i z a t i o n with no appreciable e f f e c t on the health of the residents. Attention should be directed towards investigation of causative factors i n diseases with higher than expected hospital u t i l i z a t i o n . In the four regional d i s t r i c t s studied, high numbers of acute h o s p i t a l separations were frequently observed for diseases that have aetiologies which include l i f e s t y l e or environmental factors. There may be a need to educate the residents about t h e i r personal r e s p o n s i b i l i t y for t h e i r health status and the need for them to a l t e r l i f e s t y l e s that are known to be hazardous to health. Environmental factors may be a personal r e s p o n s i b i l i t y or, as i s frequently the case, a corporate one. The dual role of members of Regional Hospital D i s t r i c t boards, being also members of Regional D i s t r i c t boards, would appear to provide a mechanism to control , 218 i n d u s t r i a l p o l l u t i o n of a pathologic nature. Restrictions could be applied to discharge of wastes or to production i f the i n d u s t r i a l e f f l u e n t was a causative factor of increased incidence or prevalence of s p e c i f i c diseases. In addition, the regional d i s t r i c t can;; regulate.' water supply and sewage treatment and disposal as well as influencing road construction and highway standards. MANPOWER The problems of a t t r a c t i n g s u f f i c i e n t manpower to service the size of the population coupled with the problems of serving a scattered population indicate a need for innovative manpower u t i l i z a t i o n . Education of l o c a l l y available lay personnel to work inpprofessional roles while having consulting input by a professional could be useful and would possibly allow services to be provided to the r u r a l population. Health care t r a i n i n g available l o c a l l y at the regional college would enable northerners to enter work roles that might be denied them had they to l i v e away from home and t r a i n i n the south. The writer understands some funding has been obtained to investigate t h i s p o s s i b i l i t y . 1 In addition, innovative practices such as the h i r i n g of several s p e c i a l i s t s with special leave p r i v i l e g e s may be being considered. 2 The l a t t e r would provide each professional with the colleagual support which i s so necessary to the development and growth of t h e i r work. ,219 PROVISION OF AN EQUITABLE SERVICE There are very r e a l needs that Northerners have for health services that are either less important to or already provided for Southerners. Programmes established to meet these needs must be c a r e f u l l y planned around conditions of the North. Decentralization of policy formulation and l o c a l autonomy i n decision-making are necessary or Northerners w i l l experience frustrations with the service that overwhelm t h e i r appreciation of i t . Without l o c a l autonomy and input, perception w i l l be s e l e c t i v e l y directed towards the fault s and problems and away from the benefits. The granting of l o c a l autonomy imposes a r e s p o n s i b i l i t y on the health practioner to be an e f f e c t i v e gate-keeper, rationing services to people who meet the c r i t e r i a established for the use of the service and who have a genuine need of i t . Programmes provided only i n selected areas of the province to meet unique needs of large portions of the population would seem to be f a i r while not being equal. There i s a need to educate the public about the purpose, costs and advantages of various programmes as well as the reasons s p e c i f i c groups of people receive d i f f e r e n t i a l benefits. There i s need for an expanded a i r ambulance service and for increased access to r e h a b i l i t a t i o n services for the handicapped who are not e l i g i b l e for Workers' Compensation Board benefits. There i s , i n addition, a need to educate the public about the complexity of the health care provided to them, the s k i l l s of those who provide that care and the reasons why i t i s better to transfer seriously i l l or injured patients to a r e f e r r a l ,2 2 0 hospital rather than treat them by less s k i l l e d s t a f f i n the l o c a l h o s p i t a l . D i s t r i b u t i v e Justice requires that people with special needs be given special services. Relative Deprivation w i l l r e s u l t i f the public or a section of i t i s unaware of the special needs of the d i f f e r e n t i a t e d group. In a society where the a l l o c a t i o n of health funding i s determined largely by n e g o t i a t i o n , l i t i s important to ensure the health services i n an area provide everybody a ' f a i r share'. That i s , the special needs of people must iae acknowledged, known to a broad public and met. I f the health services offered s a t i s f y these requirements, Relative Deprivation w i l l be minimized while D i s t r i b u t i v e Justice i s seen to be provided. While services based on equality give r i s e to feelings of unfairness or deprivation, a health service based on equity w i l l provide a service that i s accepted as ' f a i r ' to a l l . REFERENCES CHAPTER 10 Romanycia, Paul, personal communication, A p r i l 1978-Key, Ch-apin, address to Health Services Planning Alumnae, University of B r i t i s h Columbia, March, 1978. - 222 APPENDICES APPEND!X A TOTAL POPULATION CHANGES IN 4 REGIONAL DISTRICTS IN BRITISH COLUMBIA, 1971, 1973, 1975 POPULATIONS KSRD CVRD NORD EKRD B.C.-. 1971 census 37,325: 38,990 34,035 39,715 2,184,625 1973 ca l c u l a t e d 41,334 41,417 38,663 42,173 2,295,823 1975 c a l c u l a t e d 39,177 43,898 43,417 45,774 2,409,514 1976 census 38,089 45,138 45,794 45,752 Key: ,KSRD i s Kitimat S t i k i n e Regional D i s t r i c t CVRD i s Cowichan V a l l e y Regional D i s t r i c t NORD i s North Okanagan Regional D i s t r i c t EKRD i s East Kootenay Regional D i s t r i c t t o t o c o A P P E N D I X B C A L C U L A T E D P O P U L A T I O N S O F 4 R E G I O N A L D I S T R I C T S I N B R I T I S H C O L U M B I A F O R 1 9 7 3 B Y A G E A N D S E X Age and Sex Grouping Kitimat-Stikine REGIONAL Cowichan Valley DISTRICT North Okanagan East Kootenay Province of B r i t i s h Columbia 0- 4 years Male 2,884 1,900 1,498 2,166 94,591 Female 2,765 1,862 1,338 2,012 90,342 Tot a l 5,649 3,762 2,836 4,178 184,933 5-14 years Male 5,029 4,866 4,180 4,588 218,069 Female 4,834 4,678 4,180 4,278 209,594 Tot a l 9,863 9,544 8, 360 8,866 427,663 15-19 years Male 2,078 2,283 1,980 2,199 109,847 Female 1,856 2,134 1,923 1,965 105,136 Tot a l 3,934 4,417 3,903 4,164 214,983 20-24 years Male 2,073 1,769 1,397 1,919 101,442 Female 1,971 1,596 1,237 1,767 100,179 Total 4,044 3,365 2,634 3,686 201,621 25-34 years Male 3,749 2,533 2,179 3,433 170,563 Female 3,279 2,436 2,156 3,157 162,592 Tot a l 7,028 4,969 4,335 6,590 333,155 35-44 years Male 2,909 2,409 2,182 2,632 138,407 Female 2,184 2,273 2,118 2,215 125,843 Total 5,093 4,682 4,300 4,847 264,250 45-64 years Male 2,682 3,748 3,858 3,836 221,068 Female 2,057 3,904 4,194 3,439 228,599 Tot a l 4,739 7,652 8,052 7,275 449,667 65 years + Male 656 1,528 2,132 1,426 102,397 Female 328 1,498 2,111 1,141 117,154 Tot a l 984 3,026 4,243 2,567 219,551 Tot a l Male Population 22,060 Female Population 19,274 Tot a l Population 41,334 21,036 20,381 41,417 19,406 19,257 38,663 22,199 19,974 42,173 1 1 2 ,156,384 ,139,439 ,295,823 APPENDIX c CALCULATED POPULATIONS OF 4 REGIONAL DISTRICTS IN BRITISH COLUMBIA FOR 1975 BY AGE AND SEX Age and Sex Groupings Kitimat-Stikine REGIONAL Cowichan Valley DISTRICT North Okanagan East Kootenay Province of British Columbia 0 -4 years Male 2,926 2,075 1,696 2,292 100,417 Female 2,810 2,034 1,514 2,129 95,912 Total 5,736 4,109 3,210 4,421 196,329 5-14 years Male 4,431 5,314 4,732 4,693 213,610 Female 4,265 5,109 4,731 4,378 205,329 Total 8,696 10,423 9,463 9,071 418,939 15-19 years Male 2,016 2,494 2,242 2,279 116,203 Female 1,803 2,330 2,176 2,034 111,227 Total 3,819 4,824 4,418 4,313 227,430 20-24 years Male 2,065 1,933 1,581 1,999 109,358 Female 1,965 1,742 1,400 1,838 108,003 Total 4,030 3,675 2,981 3,837 217,361 25-34 years Male 3,635 2,767 2,429 3,946 192,119 Female 3,182 2,661 2,478 3,626 183,180 Total 6,817 5,428 4,907 7,572 375,299 35-44 years Male 2,716 2,631 2,470 2,802 144,051 Female 2,045 2,482 2,398 2,357 130,965 Total 4,761 5,113 4,868 5,159 275,016 45-64 years Male 2,517 3,679 4,291 3,917 295,977 Female 1,934 3,832 4,664 3,518 235,570 Total 4,451 7,511 8,955 7,435 531,547 65 years + Male 578 1,421 2,319 1,538 110,013 Female 289 1,394 2,296 1,234 125,760 Total 867 2,815 4,615 2,772 235,773 Total Male Populati Female Populati Total Population on 20,884 on 18,293 39,177 22,314 21,584 43,898 21,760 21,657 43,417 23,466 21,114 44,580 1,213,649 1,195,865 2,409,514 226 APPENDIX D TABLE 55—DEATHS, BY CAUSE (INTERMEDIATE LIST), SEX, AND REGIONAL DISTRICT, BRITISH COLUMBIA, 1973—Continued Cause of Death Malignant neoplasms . Malignant neoplasm of pharynx _M buccal cavity and M F Malignant neoplasm of oesophagus i_.M F Malignant neoplasm of stomach . F Malignant neoplasm of Intestine, except rec-tum M Malignant neoplasm of rectum and rectosig-moid junction M F Malignant neoplasm of larynx M F Malignant neoplasm of trachea, bronchus, and lung M F Malignant neoplasm of bone M V Malignant neoplasm of skin M F Malignant neoplasm of breast . Malignant neoplasm of cervix uteri F Other matlgnant neoplasm of uterus F Malignant neoplasm of prostate M Malignant neoplasm of other and unspecified sites M F Digestive organs and peritoneum (155-159) M F Respiratory organs (160, 163) „ M F I Connective and other soft tissue (171)... M F Ovary, Fallopian tube, and broad ligament (183) F Other and unspecified female genital or-gans (184) . -. _F r Other male genital organs (186, 187)-Bladder (188) Other and unspecified urinary organs (189) M F Brain and nervous system (191, 192) .. Other Leukemia F M F Other neoplasms of lymphatic and hasmo-topoletic tissue , , M F Hodgkuvs disease (201) M F Other _ M F Benign neoplasms and neoplasms of unspeci-fied nature _ — M F III. Endocrine, nutritional, and metabolic T M F Thyrotoxicosis, with or without goitre . Diabetes mellitus Avitominoses and other nutritional deflclencv - M F Other endocrine and metabolic diseases.. M F IV. Diseases of blood and blood-forming organs T M F Aiuemias M F Other dtseases of blood and blood-forming organs „ M V. Mental disorders . Psychoses . 2008; 1570, 17 173 82. " 5 ! 216| 115 65 22 4 597 143 9 1 291 16: 322 5.1 501 1951 397: 432 164 155 6 5 5 8 313 163 iso| 11 1391 127 2 6 22 16 227 APPENDIX E TABLE 54—DEATHS, BY CAUSE (INTERMEDIATE LIST), SEX, AND REGIONAL DISTRICT, BRITISH COLUMBIA, 197]4—Continued Cause of Death Malignant neoplasms . M F Malignant neoplasm of buccal cavity and pharynx , — M F - M F _ M F Malignant neoplasm of intestine, except rec-tum M F Malignant neoplasm of oesophagus . Malignant neoplasm of stomach Rectum and rectosigmoid junction — Malignant neoplasm of larynx Malignant neoplasm of trachea, bronchus, and lung • M MnH|!nnn( neoplasm of bone —. M Malignant neoplasm of skin M Malignant neoplasm of breast — M Malignant neoplasm of cervix uteri F Other malignant neoplasm of uterus , F Malignant neoplasm of prostate M Malignant neoplasm of other and unspecified siics M F Digestive organs and peritoneum (155-159) M F Respiratory organs (160, 163) M F Connective and other toft tissue ( 1 7 1 ) _ M F Ovary, Fallopian lube, and broad ligament (183) F 2075 1641 SI 36! 164 91 202 208 83 61 23 2. 591 161 »l * 22 22. >i 33H 43 34| 2261 472| 461 162j 21 146i 3 » 3 «l 43 i H 3 i — r i 21 31 37 r " 1061 8581 1SI 10' 28 8! 38 99 114 41 3 2 , 12 2 ( 1 ) Other and unspecified female genital or-gans (184) - F Other male genital organs (186, 1 8 7 ) — M Bladder (188) M Other and u n s p e c i f i e d urinary organs (189) M Brain and nt-vous system (191, 1 9 2 ) — M Other M Leukzmia F - M F Other neoplasms of lymphatic and tunmo-topoietic tissue M Hodgkln's disease (201) M Other M Benign neoplasms and neoplasms of unspeci-fied nature M III. Endocrine, nutritional, diseases . metabolic _._ T M F 81 «l-62 1 23 j 1 54 33 601 34 107] 96' 871 65 76 18 <• 97 70 283, 154 129 Thyrotoxicosis, with or without goitre.. Diabetes mellitus . M F _M F A65 I Avitomlnosis and other nutritional deficiency " F ] Other endocrine and metabolic diseases M I V . Diseases of blood and blood-formtaj organs ^ F A67 A68 Other diseases of btood and blood-forming organs . ™ V . Mental disorders . 129 107 l\ 17 13 I Ml 88! 42 7 57 2 1 61 "~7 — ~~49 1 ~ I 50 3 7 5 " i — 4 2 2 6 2 9 4 2 15 2 2 2 4 — 2 2 5 64 2 4 39 1 75 1 4! 2 l) (l> ') (i)| l) (') 2 1 i Not availuble. 228 BIBLIOGRAPHY Adams, J. Stacy, "Inequity i n S o c i a l Exchange", i n Henry L. Tosi, W. Clay Hammer, Organizational Behavior.and Management,  A Contingency Approach. Chicago: St. C l a i r Press, 1974. Anderson, Odin W., Health Care: Can There be Equity? The United States, Sweden, and England. New York: John Wiley & Sons, 1972. Bauder, E. M. and Gray, A. 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