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Thursday, 28 July 2011

Civil Society – Crime, punishment and the betterment of the human state.

Societies, organizations, communities etc.  have developed a set of commonly understood operating framework.  These can be laid out in laws, policies, traditions or a variety of other instruments that define what actions are appropriate and which are inappropriate.  These “regulatory frameworks” define a minimum expected code of conduct.
Those that fall below the minimum standard are subjected to some form of penalization in the hope that they will subsequently maintain their conduct in a ‘more appropriate’ fashion.  Hence we have developed elaborate structures to identify societies’ negligent members and punish them for their indiscretion. It is a fascinating exploration of the effectiveness of our penal system in contributing to rehabilitation and preventing recurrence, but the short assessment it is that it is a dismal failure. 
Tough on crime,  War on drugs, Three strike policies, Mandatory minimum sentencing amongst others would not meet the minimum pass levels for programs in most social institutions.  Despite the evidence of ineffectiveness, the solution tends to be more, more, more.  
The most recent absurdity, is the conservative-led Canadian parliament’s persistent push to get tougher on crime, expand the war on drugs, build more prisons and implement mandatory sentencing – despite continuing reports that crime is on the decline.  http://www.statcan.gc.ca/daily-quotidien/100720/dq100720a-eng.htm   These are small decreases, as “crime” is down 17% over the last decade, though violent crime has only decreased about 6%.   More on crime and punishment in a future blog.
The big question should be why are things getting better?   Considerable effort has gone into supporting the social environment in which we live, learn and work so that as a society the expected norms are better than the minimum expected code of conduct.  It is the concept of a civil (or civic) society.   Wikipedia defines the civil society as the arena of “uncoerced collective action around shared interests, purposes and values”.   It is the desire of members of a society to live in the best possible conditions, and to invite neighbours and train new generations to be active participants in such a setting.   It is a force that has been continuously in effect for decades;  particularly in our education system, in modernizing religious institutions and strongly within the non-governmental voluntary sector.
It is the way to “preventing” social disturbance rather than reacting to it.  It is about good neighbourly relations, teamwork in the office setting, striving for collective improvement for the sake of improvement itself. It might be seen as society’s approach to continuous quality improvement.   The “state” may react on behalf of society by subsequently redefining social minimum standards and raising the bar.   The third leg of this stool being the impact of economic drivers which this blog has alluded to numerous times.
The Civil Society is also a fundamental component of improving our collective wellbeing and likely a more powerful influence than either policy or economy.  
So begin,  start by saying hello to your neighbour at home or in the next cubicle – and pass along some friendliness. 

Lead – another heavy metal in flux

As Health Canada moves to reduce cadmium in jewelry as noted on this blog a few days ago, right on its heals it has issued a lead science document and risk management strategy for public comment http://www.hc-sc.gc.ca/ewh-semt/pubs/contaminants/lead_sos-plomb_ecs-eng.php   Join in the public conversation and stand up to speak your voice, it is part of our role in a civil society. 

The reduction in health impacts from lead exposure is a national success.  Most past exposure has been through lead added to gasoline, a practice that was only eliminated in 1990.  Science now is identifying that while efforts to date were great, that there are more gains to be made by further reductions in exposure to lead by Canadians.  

A point to note in the science assessment is the lack of epidemiological cohort studies looking at what benefits have been accrued through the actions of the last 30 years.  The number of illnesses averted, children protected, improvement in academic performance that can be attributed to the successful public health actions in reducing lead exposures.  We are not good at celebrating success - in part because that means we must acknowledge past governments and not something current governments can take credit for.

We are good at measuring deficits and disease and the science document does this very well.
Canadians and most of the developed world continue to improve in health and wellbeing.   The detractor is that there are more important contributors to better health and disease, such as wealth distribution, than either cadmium or lead – but the latter are easier to regulate and the lower hanging fruit to be picked for a government that wants to look proactive and prefers to avoid the difficult issues.

The proposed lead risk management strategy outlines what could or would be done.  The lead strategy lacks the specifics of even of the cadmium in jewelry intention document. 

So in this case, it is the floating of a trial lead balloon.  Further action will only occur when Canadians speak up on these issues.  You can be assured that industry representatives will be active in their responses.

Wednesday, 27 July 2011

Obesity – a problem of what we eat or a problem of what we drink?

As an exercise, take a look at just what you drink during a day.  From the morning coffee (double double is about 115 calories) and a glass of juice( 120 calories).  A morning break latte (220 calories). A soft drink (140 calories) with lunch,  perhaps a  beer after your post-work workout ( 150 calories) and a glass of red wine with dinner (150 calories).  Finish the evening with a glass of whole milk (150 calories).  

Suddenly and without any thought, you have consumed nearly 1000 calories.  You could add in one of the top ten calorific drinks, topping the list at over 1000 calories a drink and have all those calories in a single big gulp. 

Of course you can revise the daily drink menu by having plain coffee (0 calories), water instead of juice (0 calories).  A no-fat latte (130 calories), diet soft drink (5 calories), lite beer (100 calories), white wine (90 calories), water in the evening (0 calories) for a total of 320 calories.  

Skip the alcoholic beverages and latte and the daily consumption begins to reflect what our ancestors would consume from drinks.  At first there was water and water and water.   Crushing berries and fruits that had begun to rot, resulting in a drink with intoxicating effects likely led to domestication of grapes and production of wine  9000 years ago.  Concurrently would be the domestication of animals and consumption of milk products.  Beer has its roots about 5000 years ago.  Tea is traced back about 3000 years and coffee 700 years.  Carbonated soft drinks have their origin about 300 years ago. Many of today’s calorie dense drinks like the cafĂ© latte and milk shake go back a 100 years, and the more recent sports drinks having origins in the 60’s and energy drinks in the 80’s and 90’s.   History lesson aside, the point to be made is that we as humans were not designed to maintain fluid balance and calorie balance concurrently.  Fluids have historically been calorie sparse.   Food is the normal source for caloric content. 

Perhaps it is not surprising that body building and weight gain efforts tend to focus on nutritional supplement drinks with high caloric content as a way to gain weight – an issue for a minority of the population though these supplements are often promoted as "healthy" alternatives when caloric intake required for the vitamins is substantive. 

So – the next time you are thirsty or needing a coffee break, count the number of unwanted calories that you are consuming.  Just 100 additional calories a day difference in consumption amounts to an annual total of nearly 5 kilograms.

Wouldn't most of us want to drop a few extra kilos/pounds? 

Tuesday, 26 July 2011

Cadmium - what's in a bit of heavy metal

I was going to do something on high sugar drinks, but the news of the day is Health Canada is proposing much stricter limits on cadmium in children's jewelery - only 130 parts per million.  Sounds proactive and thankfully some action is being taken.

Cadmium in jewelery is in essence a replacement for lead.  An example of a public health dilemmia, in moving to fix one public health problem, the solution also has health consequences. 

Most of us consume small amounts of cadmium in our food.  There is a "safe" consumption level established.

2010 brought attention to high doses of cadmium in certain children's toys. The highest of these levels were around 900,000 parts per million - yes that is 90% pure cadmium. 

Late in 2010, Health Canada requested voluntary cessation of importation and distribution of jewelery identified with higher cadmium content levels. 

So today, we have the political dance in action, a proposed level without clarity on how long the consultation process will take, what form it will take or when decisions will be made.

Looks like someone is floating a cadmium balloon to test the reaction.  

If you would like to join in the discussion, link to http://www.hc-sc.gc.ca/cps-spc/legislation/consultation/_2011cadmium/index-eng.php .  If you are interested in the process of risk assessment, this is a reasonable example to walk through - albeit technical.

The remaining question - when cadmium is removed, what will replace it? 

Monday, 25 July 2011

Sugar - How sweet it isn't

For those of you who don't struggle to maintain a healthy weight - enjoy.   For the rest of us, it seems like a constant battle of what to eat and what not to eat.  

Change needs the support of the environment in which we are changing.   While diabetes, obesity, hip and knee replacement,  and other weight related illnesses are epidemic and increasing at alarming rates - why have we been unsuccessful in our efforts to date?

To maintain current weights, most of us require about 2000 calories if a woman, and 2400 calories if a man.  The actual needs depend on activity levels and weights.

The last few years have seen an uncovering of the big sugar companies and there ability to manipulate dietary habits and appalling approaches to third world working conditions.   The fruits of their labours are the additions to many prepacked foods and drinks that we consume.   As is common in major food production industry, close links will be found between primary food processors (taking sugar cane or sugar beets and converting to refined sugar) and secondary food processors (using refined sugar as a component of beverages, snacks, canned foods), and even to the food distribution networks (where we buy our food).   It should not be surprising that objections to simple things like food labelling were often backed by food producers.

It is not easy to remove sugar from our processed food chain.  I've not heard anyone calling for banning chocolate bars, or placing them on hidden racks behind counters.   There are no discussions on limiting the maximum concentration in certain drinks.  The idea of taking the sugar container off the table or prescribing limits on sugar as an additive to coffee and tea would result in a psychiatric assessment.

On the other hand, where is the dialogue on how can we systematically reduce caloric (and salt as per the previous blog) intake through changes in how we prepare foods.   For our society that is expanding at the waistline, tough choices will need to be made on how to revert to sustainable and healthy diets.  Leaving it to  consumers to "choose" the healthy option is abandoning our neighbours - something a civic society would not consider acceptable. 

The first start is to make the healthy options easier and cheaper. 

Perhaps its time to talk about a sugar tax.

Sunday, 24 July 2011

Salt - Its enought to put your blood pressure up.

There is a newswire article on how a major soup company has been unsuccessful in marketing salt reduced soups south of the border. 

Canada released salt consumption guidelines in December 2009 http://hc-sc.gc.ca/hl-vs/iyh-vsv/food-aliment/sodium-eng.php.  I won't reiterate them; but basically cut back on salt and you will have less chance of high blood pressure, stroke, heart disease and kidney disease.   Makes sense.  Should be easy,  right?

There are some significant problems in remembering to comply with this advise, think about them the next time you grab the salt shaker.  
1.    We have become accustomed to salt in food, it is a flavour enhancer and eliminating it means replacing it with flavour that one may not be accustomed to.
2.    Salt is the original food preservative.  For those concerned about those chemicals added to food to keep it safer, it will need to be replaced with something, or revert to using fresh foods (not a bad idea)
3.    Food companies are concerned about the competition created by fresh foods that do not need preservation - hence stand a very good chance to lose market share and profit if consumption of salt is reduced
4.    Salt increases thirst.  A good thing if you are trying to market drinks along with foods.  Salt content in many fast foods is specifically increased with this in mind.

Prepared foods are convenient, fast and easy to use.   The cost to our health is mounting, and similar to that of tobacco, we need to innovate as a society to reduce the impact.  Popping pills is not the answer. 

The barrier is quickly becoming "Big Salt", working closely with "Big Sugar" - a topic for another blog.  Major food companies that depend on the consumer appetite for quick and convenient food options.

Cut down, take the salt shaker off the table, reduce convenience foods, eat at home more often - simple advise for fast times.

Thursday, 21 July 2011

Economics and health - not health economics

Communities that are healthy, are economically vibrant.  Conversely those communities that are deemed economically successful tend to have residents who are healthy.

Which is the chicken? and which is the egg?

Do communities blessed with characteristics that have led to their flourishing, attract people who are healthy and have money?  The costs of living are higher.  The higher economic status of the average members means the communities can spend more on social services, plan for development that encourages healthy lifestyles, and attract more money. 

Or, can a community control the health destiny of its members by nourturring economic success?   To some extent the answer appears yes.  The caveat is that at least at a national level, it is less about economic success than it is about the relative equitable distribution of wealth.  So communities and countries that implement policies that support equity of all its members are the most successful, and tend to be overall the wealthiest.

Money begets money.  Likewise health begets health.  

Anyone who has worked in small rural areas (say less than 5000 population) will know the tenious relationship between the local economy and many factors.  Single industry communities where the industry closes result in more health problems (the most resilient communities see the opportunity and can thrive through economic diversity).   The hospital is not necessarily a protector of health, but can be the main economic driver within a community and employs often the highest paid residents.   Hospitals may well contribute to a greater inequity in the distribution of wealth in a community and that is a bad thing.

I sat through many discussions where health administrators have argued that it is not their job to stimulate economies, often resulting in closure of less efficient hospital resources and subsequent whithering of the community.   Those very decisions contributed to health reductions - not through the loss of services, but through the loss of an economic driver.   Hospitals and long term care facilities however do appear to be contributors to economic growth, more like economic stabilizers.

Saskatchewan in the late 80's closed a large slew of hospitals to the cries of disaster from those communities. The criteria for closure was an average daily census of less than 8 (or 6?) patients.   A decade or so later, and evaluation actually demonstrated that the health of residents in those communities had improved.  Partially attributed to the improved quality of care.  The communities were generally provided some buffer to the economic reduction which likely lessened the negative impact.

I recall the evaluator's presentation, that when faced with the data the communities response was "that is all well and good, but when do we get our hospital back?"

Successful communities will look to economic diversification, policy that is socially responsible and encourages socialability, planning based on the needs of the next generation, and a solid sustainable infrasture.  To do this may mean saying no to the developer after a quick buck, and possibly taking their money and running to the next town. Hard choices for politicians who need to think to the next election, not the next generation.   Look to some successful communities and see how often a visionary leader has steered the community to the future. They have the health and pocketbooks of their residents at heart.

Tuesday, 19 July 2011

Children - a liability or an asset?

Parents are only too familiar with the costs of raising a child.   Few would ever consider giving up the joy that child-raising brings.

While attributed to many people including an old African saying and  a president's wife:  "It takes a whole community to raise a child."   So why in Canada do we view children as a liability?

Communities which are child friendly;  are preparing for their future, developing a legacy, and economically more successful.   It is rare that I run into a community that does not see economic vitality and prosperity as a civic goal.  However, these same communities seem to be challenged to incorporate child-friendliness into their short and long term planning.  

Planning for healthier communities makes long term economic sense.  The trade-off is that sometimes short term cash benefits conflict with sustainable planning.   Yet, if you review the literature on Healthy Communities, you will find children rarely considered.  When they are, they are treated as a vulnerable population - in essence a community liability.   Sure, planning will include schools and a few parks and recreational areas - but being child-friendly means so much more.   And, being child-friendly means community planning is investing in both economic vitality and the economy. 

When you have a double win and are still faced with obstacles, start asking why?   Development in communities is driven by developers who measure success by the bottom line.   Investing in frivolous components that add value over time is perceived as cutting into the bottom line - so children are treated as a liability.

Canada scores poorly on international comparisons of our social approach to children.  Our neighbours to the south are similarly ranked.  The systemic exclusion of children and children's issues from social decision making deters progress on investing in our own future. 

Take any issue in today's paper that decision makers are grappling with, and ask yourself the question - how would this decision change if each child were each given a vote. 

Monday, 18 July 2011

Evidence - putting numbers into action

Don't be shy, your comments are welcomed.

There is a small collection of individuals who are coming back to the site, I thank you.  Pass the word along. Email the address to a friend and ask them to read. 

The issue today is applying evidence.  If there was no evidence of activity on this blog, I'd be foolish to continue it. 

The gold standard for evidence has rapidly become the double blinded randomized control trial.  Neither the observer or the recipient are aware of who is getting the intervention and the results are only analyzed when the study is completed.  It is the closest thing to laboratory based research that we can get with humans.

The problem, is that not every intervention can be neatly wrapped up in a pill.  When you start intervening at the level of communities or populations, the techniques to amass and measure "evidence" of the effectiveness become increasingly challenging.  Those that review such evidence (check out Health Evidence Canada http://health-evidence.ca/  (within Canada)  or the Cochrance databases http://www.cochrane.org/ ) often dismiss such studies are methodologically flaws or weak design. 

When we look at the things that have improved the population's health, the quality of evidence is not good.   Who would question that reducing tobacco use rates had not been instrumental in saving millions, that water chlorination doesn't work, that safer vehicle and road design is not worth it?  

However, if you were to take these issues and do a science review, the conclusion may well be that there is insufficient evidence to demonstrate effectiveness. 

Insufficient evidence should not be interpreted as the evidence supports the contrary.  It is better stated that the research undertaken on the topic does not have the gold standard type of research that is used when making individual level decisions.  Ultimately, there is a bias against population level health interventions even when they can be more efficient, less costly and more effective.

In the meantime, we are channelling limited health resource away from population level activity because of "insufficient evidence".   We all suffer.  

Friday, 15 July 2011

When rights conflict

There is a BC member of the legislative assembly making noise about wanting to give emergency services workers (ESW) the ability to require persons from whom they were exposed to blood to have testing for HIV, Hepatitis B and Hepatitis C.

On one side is the desire of the ESW to prevent infection (justice and non-malfiesence or do no harm).  On the other side is the autonomy of the individual who'se blood caused the exposure.  Disclosure of such information can have a devastating impact on an individual, their relationships, their employment and insurance.   Testing is preferably associated with appropriate counselling

The risk of transmitting infection from a person who is known to be positive for one the diseases from a needle that went into their body, and then into someone else, is roughly 30% for Hepatitis B, 3% for Hepatitis C and 0.3% for HIV.   How common on the diseases?  Numbers are almost estimates  but about   0.3% of the Canadian population are carries of hepatitis B, 0.8% carry hepatitis C, and 0.2% have HIV.   Some relatively simple math means that in an everyday scenario, the likelihood that an ESW is infected by a needlestick exposure would mean about 1 in 1000 patients for Hepatitis B (for which an effective vaccine will prevent disease in the ESW in the first place, about 1 in 2500 patients for Hepatitis C, and about 1 in 6000 patients for HIV. 

Admittedly there are some populations for whom the likelihood of infection is higher, but as proposed, the autonomy of thousands in individuals will be compromised for little value. The results of the testing would be available to several individuals and no effort has been made to ensuring their privacy is protected

ESW do however need protection.  Requiring vaccination makes sense.   Using best practices is engrained into their activities.  For HIV exposures, persons can be offered medication to prevent the infection.  for Hepatitis C, there is no current way of preventing infection.  So, to complicate the matter more, we actually can prevent one of the diseases that is most likely to occur, cannot prevent the second most likely disease, and would only provide intervention for the least likely illness. 

Is there a need for compromising the privacy of all those people?  Is there a better way of doing risk assessments, protecting confidentiality through limited access to information, having specialized services that protect the rights of both parties - probably.  There is a balance of need here. Kudos to the member for raising the issue. Shame for assuming that patients can be treated like mere objects.

Which side of the dabate do you stand on?  Is there a middle ground that can adequately protect both?

Wednesday, 13 July 2011

Public health ethics - an overlooked perspective

The field on  biomedical ethics has blossomed over the past decade - and thankfully so.  Care to individual patients has been improved through a standard set of principles, which have their basis in the Hippocratic Oath and basically try to ensure that actions are beneficial, are not harmful, are applied with fairness to all, and respect for the individual.

The field of public health ethics has received much less attention.  With a recogntion that the general benefit of the population at times conflicts with the principle of respect for the individual.

Perhaps it seems not relevant in day to day practice. When looking at the allocation of scarce resources and investment in those actions that will benefit the greatest number - it should be considered. However, faced with the patient in dire need of care, respect for the individual and the desire to do good will naturally predominate.  When we are in crisis and in need of the emergency department this is a reassuring thought

Contrasting however, is that the ability to provide emergency care for future generations may well be compromised by our inability to direct existing resources.   We need only look south of the border to where 20% of the population could shy away from an emergency department for fear of the costs - the result being a population that despite its economic vitality, has some of the poorest indicators of health of the developed world.

Have you considered the difficult question of when should limitations be placed on individual care for the sake of protecting the public's health?  it is a question that does not carry political currency - and as such our response is to hide our heads in the sand hoping that each year the health system allocation of resources can continue to grow at twice the growth in the economy.   Even worse, is the compromise of services that might actually protect the public's health for the sake of squeezing a few drops more money to provide care services. 

Where are the ethicists challenging our shortsighted approaches to health allocation?

Tuesday, 12 July 2011

Superbugs, drinking and driving

Many physicians start their morning by doing rounds in a hospital to see to the health of their patients.  I start mine by scanning headlines for emerging public health issues.

This morning's newspaper had two stories that reminded me of why public health will never be short of work.  I at least theorize that I spend equal amounts of time addressing three main issues. 
  • First is that germs evolve very quickly,
  • Secondly is that as humans we have two unique characterisistics -
    • we apply intelligence to manipulate our environment and develop new technologies, and
    • we have the capacity to make choices, and often enough those choices are not the healthiest of choices. 
The stories were about a new form of superbug - a gonnorhea (sexually transmitted illness) that is resistant to 'all' current antibiotics.   A topic for a future blog, but superbugs are partly due to the desire of bacteria to survive, hence mutate when threatened by something that might kill them.  The overuse and abuse of antibiotics contributes to the rapidity of development of antibiotic resistence.  

The second story was about British Columbia's aggressive approach to reducing deaths and injuries due to mixing alcohol and driving.   Motorized vehicles are the product of human technology.  Using alcohol is a potentially unhealthy choice.  Mixing the two we all know is a deadly combination.  BC has taken a very hard stance with signficant penalities above .05% blood alcohol levels in addition to the Canadian criminal code penalities above .08%.  It seems the changes are resulting in protecting the public's health and will continue, despite the desperate cries of the hospitality industry that have noted reductions in alcohol sales and overall sales in restaurants and bars.  

We know that sometimes the benefits achieved by public health interventions exceed that which was predicted because of other effects.  Targetted programs to reduce drinking and driving - perhaps reduced drinking, perhaps reductions in obesity from reduced driving.

Conversely there are examples where the intended impact of a public health intervention was less than and occassional worse overall than prior to the intervention.   Evaluating programming when impacting the populations health is critical.

Monday, 11 July 2011

Supportive community is what keeps public health apart

As I began this journey a week ago, it was an experiment in communication related to public health.  Seems there is some appetite out there and I only hope I can get better.  I do welcome comments and suggestions, or questions that you would like to be addressed.

Today was an announcement of an impending career change.  This blog is related to that change.   It was notable the number of folks that needed to be communicated with, and the large number of notes of thanks and appreciation.  They are appreciated and speak to the closeness of the public health community.  It is the respect for multiple disciplines and the lack of hierarchial approaches that have been hallmarks of public health as a sturctural entity.  These values are unique and should be something that public health workers strive for.

A favourite note of mine is that public health is more than a job, it is a vocation - a lifetime commitment to improving the public's health in all aspects of what we do.  

As I migrate to a new location and new challenges, I may reference such changes in the blog, but this is an extension of that vocation.  Perhaps this will be as personal a note as I will leave.

To my colleagues and friends that I will be leaving, my heartfelt thanks for your warmth, dedication and passion.   To the new challenges and open doors ahead -  let the fun begin!!

Saturday, 9 July 2011

Public expectations and inspections - when they are not met

The Peel Health Unit settled out of court on its failure to deliver on the public's expectation on inspecting a personal services establishment (tattoo parlour) http://www.mississauga.com/news/news/article/999812 .   The cost potentially $800K.  The acknolwedgement in this settlement is that there is an expectation by the public that a miminum level of health protection is being provided, and when it is not, there is an obligation to compensate. 

For public health managers it is a dilemmia.   There are not sufficient funds available to perform the level of inspection which is considered health protective.  Food establishments should be inspected 1-3 times a year depending on the sorts of food they serve.  Ask your local health unit what their compliance with this expectation is. I have seen as low as 50%, and I've seen high risk establishments go uninspected for years.  Now, as a manager when the information becomes available there is a duty to remediate it and things are better - but try to find the performance of public health entities anyway on this expectation.

Other areas that the public expect are healthy and depend on the work of enviornmental health officers include ensuring the water is safe at the tap, restaurant food won't make you really sick, when you swim in pools or at beaches that you aren't going to contract an illness, that housing is safe, our children aren't exposed to nasty things in schools like radon, that the disposal of human waste doesn't lead to sickness, or in the hospital setting where sterilization processes ensure germs don't spread from one person to the next on whom those instruments are used.   Or at least we have come to expect that these things are safe.   History has shown repeatedly that when routine inspections are whittled to lesser infrequency - disasterous situations occur.  These aren't the situations where one or two people become ill, but as in the Mississauga tattoo parlour, some 3000 persons were potentially exposed are recommended to be tested.

There are three solutions. First lets begin by ensuring that inspection rates are transparent and compared across regions, second is to ensure programs are adeqately funded to perform the duties. The third choice is to lower public expectations and depend on the old adage of buyer beware.  In the absence of this, politiicans and public health managers play a game of chance with people's lives.   Most of the time there won't be a problem, and when a problem occurs perhaps we will apologize and compensate somewhat for the damages. 

Tainted blood scandal, Walkerton, Listeriosis outbreak, "Hamburger" disease outbreaks in large fast food chains, E. Coli in sprouts from Germany, and many more that I could list.   My sympathies to any who personally, or through a family member or friend, were impacted by similar situations. We have been good at learning from these situations, but implementation of the solutions has almost inevitably fallen far short as the memories faded and burried.

Look around and ask the question what do you depend upon that your health and safety have been protected by an inspection process - and what would it mean if you know that the job was undertaken in a "half" hearted fashion.

Friday, 8 July 2011

C. difficile outbreak - whatyou want to know and perhaps don't want to know

 Clostridium difficile is a bacteria that can cause a nasty diarrheal illness.  It is almost always associated with the use of antibiotics and almost always associated with hospitalization.

There have been numerous outbreaks in Canada and globally.  The Quebec health system was brought to its knees in 2003-04, at least 3 dozen people died from the infection however there are numbers that state this may have been closer to 100.   Related cases appeared globally in the subsequent few years.   Ontario in the Niagara area is now admitting ongoing outbreaks that have included deaths.  Check out the formal response at http://www.health.gov.on.ca/en/news/release/2011/jul/nr_20110707_1.aspx  

C. difficile tends to affect the most vulnerable in our society, usually those with illnesses already and often have complicated courses of care in hospital when the infection occurs.  It is a tragic consequence in situations that are often already tragic.  

But C. difficile is not a reportable infection.  Statistics are not collected in a consistent fashion, outbreaks, while they should legally be reported to local health units are often not reported by hospitals who have knowledge and expertise in managing the outbreaks.  At least until the outbreaks become the subject of public outcry and as one searches for reports, it is the public media reporting that tends to proceed the formal health systems reporting. 

Add to this is a subtle controversy in the background about the use of fecal transplantation as a mode of therapy for the disease. I don't have an opinion on the benefit or risk of the procedure, but certainly the suggestion invokes a gut reaction that perhaps has made the scientific investigation of the procedure less than rigorous.  

In the end we have a convergence of issues
1.   a bad infection that is associated with bad news
2.   less than transparency occuring for the public
3.   Science that debates the best way to prevent, manage and treat
4.   Controversial non-medical therapies that have a distinct following of knowledgeable medical professionals as well as their detractors.

it is a dirty little subject being treated as a dirty little secret.

Dr. P.

Wednesday, 6 July 2011

The dilemmia of rurality, misplaced priorities and public perception

The day approaches when I will tell friends, family and colleagues of the impending switch.  It does weight on my mind as any change has major implications, and the current setting is very unstable and less than productive.

I was struck by two public health issues today, one planned one inadvertant.

In the first is the challenge faced in providing a basic service like clean safe water.   We all assume when we turn on the tap that it comes with some sense of a guarantee.  For over a 1000 communities/systems in Canada that is not the case, these communities/systems openly state the water is not good enough so use another form of safety.   Often referred to as a boil water advisory, few users boil the water, most buy bottle water or get their own personal treatment system.   More fundamentally is the question why would a local government or health agency allow for a system to be built that doesn't meet safety expectations?   For that matter why do we continue to make decisions at a local government level, that knowingly have financial consequences to "fix" later, but perhaps provide an immediate benefit through growth.   The cost of the fix to all concerned is much higher than the cost of doing it right the first time.   This was in rural Canada, and one local councilperson noted that we lack a rural growth strategy - our focus is on sustaining the ever increasing bulky urban structures.   The domination of urban issues has overridden the need to have concerted discussion on how to diversify our population.  On the other hand, the small p politics of rural areas has a pettiness that precludes the rich level of discussion needed.

On to the second issue.  It was a 2 hour drive to the water system.  I was delayed in arriving by the second major public health issue.  Two vehicles had collided.   In rural Canada that may mean that there is no detour around the block.  The highway was closed for several hours, and I was fortunate to arrive as the carnage was being cleaned.   Perhaps I will learn that the occupants of these vehicles survived, their vehicles are not salvagable based on my cursary and uninformed observation.   Put simply, there was a lot of damage to both vehicles.   The tragedy is that we continue to lose so many of our neighbours to motor vehicle collisions each year, and for rural residents the risk is double or more where "depopulation" is already a crisis.   The most effective prevention strategy has been the continuously escalating price of gasoline (and I do remember gas at 16 cents a litre).  

Both events reminded me of how far we have to go to protect ourselves, our families and our communities.  

The headlines were about infants (and dogs) left unattended in vehicles when temperatures soar.   Another tragedy that is simply prevented.   No doubt we tragically loose a handful of infants each year to heat exposure in cars.   We lost close to 3000 to motor vehicle collisions and that is nearly half of what it was 2 decades ago.   There are an estimated 90000 illnesses and 90 deaths each year in Canada from waterborne disease. 

There is irony in the dilemmia of what causes public outcry, where we are spending massive amounts of dollars, and what is killing us.  

Dr P

Tuesday, 5 July 2011

Deception and the public's health

I''ll concede, I've not always provided to the public all the information about a situation or that concerns are softened. Decisions are based on risks and benefits, not just to the public but impacts on decisions makers, politicians, and professionals.   The rationale can be justified in still protecting the "public's health" through the greater benefit. 

How would you feel to know that despite assurances that informaton was being shared, that perhaps it was not? 

There was a time when Canada was transparent about Mad Cow disease, when some nations very close would have unlikely ever identified a case.   One premier had said that in the public's interest the best thing to do was to bury animals and not have them tested.  The economic consequences were significant and economic vitality is probably the best predictor of future health - so why would something that is not a substantive human risk be shared such that there is a negative economic impact?   The tragedy of SARS was not just in the direct  number of deaths and hospitalizations, but in the compromsie of the economy that likely resulted in real health impacts to others as well.

On the other hand, take H1N1 for example, transparency was the dominant feature and skeptics question whether too much was done, or it wasn't necessary.   I ask audiences which was more of a public health threat, H1N1 or SARS.   The majority lean towards saying SARS was worse.   Lest we forget, H1N1 killed at least 10 times more Canadians than SARS and resulted in much higher hospitlization and debilitating illness.  

It is a no win situation - but begin by asking yourself - would you prefer to know all the facts and be allowed to make an informed choice?  or have some of the information 'modified' to make it appear less concerning?   Both answers are correct, hence it becomes a no-win situation.   If you have an suggestion, it would be welcomed.

Monday, 4 July 2011

Day 2

It may seem like very little, but the challenge for the day was to get back here and put up a second posting.  I've learned a few other things along the way.  

Maybe its a functoins of the job,  but I drove some 700 km today, a full 16 hour day as there were meetings and activities to do.  Grappled with bureaucratic mess up that is the culination of decades of overlooking a problem, and likely associated with a conflict of interest.   It is the balance between starting anew and taking the momentum or lack of momentum and turning it into a positive outcome.   Not a day to make friends.

Tonight the waning moon is setting on a lightly reddish tinged sky.  Ironic. 

Sunday, 3 July 2011

Day 1

Day 1 - as much as anything, this is a trial to develop a new skill set. It is the start of a new career and the passage from an older one. There will be moments and learnings ahead, for the moment the learning is how to blog.

My business is the public's health. Since 1987 through multiple locations and positions, with a focus on creating an integrated environment that brings the health system into the realm of prevention, promotion and protection. Success is variable - sharing thoughts and processes will be a new experience, and perhaps create new opportunities.

Dr. P