Chronic disease in Northern Ontario
Chronic disease in Northern Ontario is a population health problem. The population in Northern Ontario experiences worse outcomes on a number of important health indicators, including higher rates of chronic disease compared to the population in the rest of Ontario (Romanow, 2002). Population under consideration. Northern Ontario is over 800,000 square kilometers, covering nearly 90% of the area of Ontario. Its population of close to 800,000 represents only 6% of the total population for the province. This large land area and relatively small population results in a density of approximately one person per square kilometre , compared to 115 persons per square kilometre in Southern Ontario. Northern Ontario's rural population comprises more than 30% of the total Northern population. In Southern Ontario, only 11% of the population lives in rural area. Over 50% of the North's population live in the five biggest cities of Thunder Bay, Sault Ste. Marie, Timmins, Greater Sudbury, and North Bay. With mining, forestry and tourism as the major local industries, there are peaks and troughs in the economy, and unemployment rates are usually higher than in the remainder of Ontario (MNDM, 2011). The estimated area of Local Health Integration  Network (LHIN) 13 is 400,000 square kilometres or approximately 40% of Ontario, with a population of 551,691. In LHIN 13, 17% of the population is 65 years of age or older, which is significantly higher than the provincial average of 14%. LHIN 13 is diverse with 24% of the population Francophone and 10% of the population First Nations (North East LHIN, 2009). The estimated area of LHIN 14 is 470,000 square kilometers or approximately 47% of Ontario, with a population of 234,599. In LHIN 14, 14.3% of the population is 65 years of age or older. LHIN 14 is diverse  with 3.5% of the population Francophone and 19.8% First Nations (North West LHIN, 2009). Scope of the health problem. According to the World Health Organization, chronic diseases are defined as diseases of long duration which generally show slow progression (WHO, 2012a). Examples of chronic diseases are cardiovascular disease, respiratory disease, stroke, cancer, and diabetes. The main risk factors associated with chronic diseases are tobacco and alcohol use, physical inactivity and unhealthy diets (WHO, 2011). Almost 80% of Ontarians over the age of 45 have a chronic condition, and treatment for these diseases amount to 55% of Ontario's total health  costs (MOHLTC, 2007). In Northern Ontario the rates of chronic diseases are higher than the average provincial rates (MOHLTC, 2011). Current environment surrounding the problem. In rural and Northern Ontario, life expectancy is less than the provincial average; disability rates are higher in smaller communities; rates for accidents, poisoning and violence are also higher in smaller communities; and people living in remote northern communities are the least healthy and have the lowest life and disability-free life expectancies (North East LHIN, 2009; North West LHIN, 2009). On average, Northern communities have a higher infant mortality rate than Southern communities, reflecting  a lower overall health status (MOHLTC, 2011; Appendix B). The Northern Ontario population suffers from higher rates of a number of chronic diseases such as cardiovascular disease, respiratory disease, stroke, cancer and diabetes (North East LHIN, 2009; North West LHIN, 2009). There is a higher proportion of the population that are overweight or obese and a higher proportion of the population that are heavy drinkers and smokers (North East LHIN, 2009; North West LHIN, 2009). Interactions and dynamics related to the problem. Analysis of the burden of chronic disease has pointed to the importance of risk factors, such as being  overweight, smoking, alcohol, and poor diet. These are indeed potent causes of chronic disease, however considering the causes of chronic disease entails a richer understanding of the determinants of health. There is a need to examine the causes of the causes: the social conditions that give rise to high risk behaviours of chronic diseases. A social determinants lens is crucial when addressing chronic diseases in Northern Ontario (Marmot, 2005). The determinants of health (listed in Appendix A) are defined as the diverse set of factors that affect health and pertain to the conditions in which people are born, grow, live , work, and age (WHO, 2012b). The Canadian Institute for Advanced Research estimates that 75% of the health of the population is determined by factors outside of the health care system (Mackie, 2012). The determinants of health (DOH) contribute to and exacerbate the worse health outcomes in the LHIN 13 and 14 population. For example, in Northern Ontario, there are higher rates of unemployment and lower rates of education compared to the rest of Ontario (North East LHIN, 2009; North West LHIN, 2009). Low education and unemployment, which are DOH in themselves, are also obvious risk factors for poverty, which is  a very significant DOH. This exemplifies the complexity of the problem, as the DOH can interact and have synergistic effects. Furthermore, problems in access to health services in Northern Ontario quite often stem from distance and shortages of health human resources (Romanow, 2002). On average there is less than one physician per 1,000 people in rural areas, compared to two or more physicians per 1,000 people in larger urban centres (ICES, 2006). Demographic and other factors aggravate this population health problem. Northern Ontario has 106 of the 134 Aboriginal communities in Ontario (MNDM, 2011). The health status of Aboriginal people  is overall worse than other Ontarians on most measures, including life expectancy, infant mortality, cardiovascular disease prevalence, diabetes prevalence and suicides (Health Council of Canada, 2005). Aboriginal populations also lag behind in almost all DOH (Health Council of Canada, 2005). For example, social support networks are limited for many Aboriginal people due to the residential school act and its legacy. Many Aboriginal people have been unable to establish effective relationships with families and friends as a result of being taken away at an early age from their communities. The usual social bonds that occur with family members, friends and community  members were severely and permanently damaged, leaving this population particularly vulnerable (Health Council of Canada, 2005). Existing public policies and corporate strategies. There are numerous policies and strategies that have been implemented to address chronic disease prevention and management in Northern Ontario. The existing policies and strategies range from cardiovascular disease prevention programs (for example Heart Health Ontario) to diabetes education programs (for example the Northern Diabetes Health Network) (MOHLTC, 2011). Although it is good that chronic disease prevention and management is not being neglected in Northern Ontario, there is some concern about the effectiveness and efficiency of all these  different initiatives. The Centre for Rural and Northern Health Research reported that although health care organizations and relevant stakeholders were progressing towards implementing chronic disease management strategies, there was limited integration of programs at the community and regional levels. It was reported that there was a lack of communication impacting the coordination of services, to the extent that organizations were operating within separate silos, resulting in a lack of collaboration between the various organizations. There appears to be a similar situation in the North East LHIN (Minore, Hill & Perry, 2009). Assessment of options for chronic disease prevention and management. Prevention  and management of chronic disease requires a comprehensive set of initiatives. Below will outline a number of options, using the applicable determinants of health as a framework, that can help make a difference in addressing chronic disease in Northern Ontario (LHINs 13 and 14).