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Friday, 30 September 2011

INsite ruled legal - Supreme Court unanimous decision

The surpreme court has unanimously affirmed the BC court of appeals decision that INsite is a health facilty and directed that the Minister of Health grant an exemption to drug laws. http://scc.lexum.org/en/2011/2011scc44/2011scc44.html 

Some key quotes from the decision:
"The Minister’s decision, but for the trial judge’s interim order, would have prevented injection drug users from accessing the health services offered by Insite, threatening their health and indeed their lives."
"during its eight years of operation, Insite has been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada.  The effect of denying the services of Insite to the population it serves and the correlative increase in the risk of death and disease to injection drug users is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics.
"On future applications, the Minister must exercise that discretion within the constraints imposed by the law and the Charter, aiming to strike the appropriate balance between achieving public health and public safety.  In accordance with the Charter, the Minister must consider whether denying an exemption would cause deprivations of life and security of the person that are not in accordance with the principles of fundamental justice.  Where, as here, a supervised injection site will decrease the risk of death and disease, and there is little or no evidence that it will have a negative impact on public safety, the Minister should generally grant an exemption."

Great news for INsite and hopeful news for other Canadian cities that have come to value the benefit that Vancouver has achieved through the presence and utilization of the safe injection site.

The question of the day, will the current government willingly recognize and permit the utilization of other facilties?   A smart government wanting to win the war on drugs, will acknowledge that successful drug policy includes harm reduction and treatment - something that supervised injection provides, or at least provides the avenue to rehabilitation. 

Now, is the current government smart enough to see this?

Thursday, 29 September 2011

Breastfeeding and brain development - A public health success to savour

Please send messages to drphealth@gmail.com, and follow on twitter @drphealth

Children are our greatest resource. It still amazes me how often governments can treat children as an afterthought since they hold minimal political value.   That will only change when every person, including children are given a vote. (Speaking of which, kudos to Saudi Arabia for granting women the right to vote and run for office – and reminding us in Canada how privileged we currently are)
 One of the key determinants of health is early childhood development.  We know that from conception,  affects on the mother can positively or negatively impact growth of the fetus.  Brain development occurs mostly in the first 2 years of life, slowing down as we prepare our children to start school. 
If you miss the irony of this statement -  go back to birth.

In this simplified view of the multiple aspects of brain development, note that the central line is at age 1, and after that point all higher brain functions decrease their rate of growth.  
It should not be surprising that schools that score well on geographic comparisons of test results tend to be located in areas of relative socioeconomic prosperity.  Children with enriched infancy where parents can focus on nourishment through good feeding, stimulating play, social interaction and emotional warmth stand a far better chance of success in later years.   Those children who are prepared for school, not surprisingly, are the children who do well at school.   The inequities in school success are engrained before the formal education “system” greets the child as they walk into those hallowed hallways for their first time.  
Can we shift our focus to attention around the first year of life, and not just ensure immunizations are completed?  There are other successes as well.
National Breastfeeding Week is October 1- 7.  There are many benefits to breastfeeding beginning with both physical and emotional nourishment.  Initiation rates (Figure 1 in the link) in Canada are nearly 90% and have gradually moved upwards over the past decade.  Breastfeeding rates in Canada 2001-2009 .  The best news that we need to reflect upon, is at its lowest point in the early 1960’s, breastfeeding initiation was only about 25% with rates in Quebec as low as 10%.  Here is a huge public health success that has been lost in the debates of year to year recent history and a culture of support for breastfeeding that needs to create an urgency to remain active. Over the past 50 years, or just two generations, a full reversal of culture has occurred.  This exceeds any other public health success that comes to mind. 

The more recent and appropriate gains have been made in sustaining breastfeeding through the full first six months of life (Figure 2 in the above link).  Rates are currently only 25% of the current recommendation – and needs to be the focus of breastfeeding programs designed to support women through the full first 6 months. The best practices are in BC at33%.  Nova Scotia needs to redouble its efforts with current rates of only 13% at 6 months.
 Public health workers should take note that the medicalization of clinics designed to support a small percentage of women with breastfeeding pathology may be a barrier to efforts to achieving where the greatest benefit lies – in encouraging and supporting all families to breastfeed for the minimum of six months, and to do so without alienating and imposing guilt upon those that have not yet appreciated the shifting cultural tide.  

Tuesday, 27 September 2011

Drphealth turns 1000 pages. INsite court decision soon. Its election time?

Today is also a big day for the blog – some lucky reader will be the 1000th hit to the site.  Sorry no prizes for the lucky person and tracking won't be able to say who that person is.  The relative success of sharing Canadian public health stories speaks to a need. 
In keeping with good public health practice and evaluating the efforts, some interesting facts from what I can gleam and happy to share with you. 
10% of the visitors in the past month have been good neighbours to the south.  Welcome to the cloistered life of the Canadian public health worker. 
The most popular page is on the issue of health equity south of the border and Gini Coefficient. 
Visitors have come from 10 countries, with France and Russia running a distant 3rd to the US. Canadian visitors who are the main target appropriately constitute 90% of the following.   
Only a handful of people have signed up for Tweets (@drphealth) and no one has used the following feed feature (at the lower left corner).   The retweets through the Linked-IN professional network are the largest single social media source driving people to the website.  As most people seem to access the site directly, I am thankful to those that are following.
As with many blogs, there may be lots of readers but only a very small number willing to actually put their words to a comment.   I have received more emails than posted comments (drphealth@gmail.com), but still just a handful. Rest assured I will maintain your confidiality as well. Join the dialogue, it is the way the public health community will thrive. Your feedback on the blog, on any issue, and suggestions for topics are all welcomed. 

INsite decision soon.
The rumour mill is starting to buzz.  The Supreme Court decision on INsite may come out in the next week.  Jump back to August 3 blog Insights into Insite   to review the background.  It is a substantive issue for the public health community that pits public health against the government of the day and no one looks good. No doubt the fight has caused negative repercussions throughout the public health community.  It is interesting timing as the government continues to promote its 'get tough on crime' and 'lock up the drug users’' agendas.   It might signal a loss for the government and need to regroup, or it may retrench their blinders. My bet is for the later and more troubled waters ahead.  Stay tuned.

Provincial elections
Advocacy begins with you.  
PEI and NWT go the polls October 3rd
Manitoba October 4th
Ontario October 6th
Newfoundland and Labrador and the Yukon October 11th
Saskatchewan Nov 7th
Quebec, Nunavut and Alberta  probably in 2012. 
I think our friends in BC are starting a guessing lottery and could slip in the queue sometime.
Can anyone make public health an issue on the political agenda?    What questions can you find to ask candidates? A good resource is the CPHA policy website at http://www.cpha.ca/en/programs.aspx .  CPHA also put out a guide for candidates questions for the spring national election, I could not locate it and seems so relevant now. 

Monday, 26 September 2011

Public Health News Headlines. Jail, antibiotics, sex, tobacco and air

Monday’s always seem full of public health news headlines
1.      Groups opposing mandatory minimum sentencing
2.      Canada has some of the cleanest air in the global – but still affects thousands of Canadians
3.      Alternatives to antibiotics sought for farm animals
4.      More persons having unsafe sex
       And in the email box, a notice on the national consultation process for the Federal Tobacco Control

The previous blog article spoke to the insistent perversion of the current government to impose mandatory minimum sentencing when health advocated, judicial experts and rehabilitation specialists speak openly against the utility of such legislative strategies.  Mandatory Minimum sentencing a waste of wallet.
A WHO report on air quality ranked Canada and Australia tied for 3rd amongst 80 countries for the quality of air.   A subject that this blog will have to come back to.  Canada has some marvelous air quality scientists and was the first country to use a multipollutant approach to assessing air quality as it negatively affects health.
CBC is running a piece following an “announcement” on Marketplace that the federal government will invest $4 Million in looking to address antibiotic use in farm animals.   The good news is the government responded to the actions of  the media in forcing transparency.  The bad news is neither the government nor the CBC read the blog AMR and livestock Kicking the cat or for that matter the government has only minimally taken the advise by their own expert advisory panel report from almost 10 years ago now.  
 A pharmaceutical company sponsored study for today as World Contraception Day shows that increasingly sex with new partners is without any form of contraception in the developed world.  Press release Clueless or Clued up.  Some developing countries appear to be doing better with sex education.  Regrettably Canada was not part of the survey.   It does go to show that sometimes Big Pharma can be involved in some good work.
Finally, the federal government is calling for input on a one year federal tobacco control plan.   Tobacco Control Strategy consultation  What caught my eye most, was the initiative led by Health Canada, includes partnering with Public Safety, RCMP, Revenue Canada, Border Services and Public Prosecutions.  Of course Canada should be proud of its accomplishments to date in reducing smoking in this country.  Peak levels in the high 30% range have decreased to 17% and Canada has outperformed many developed countries in reducing tobacco use.  The emphasis of the strategy is on enforcement through penalizing those that sell to minors,  cracking down on smuggling, cracking down on counterfeiting, restricting advertising and at least making tobacco less attractive.  Missing of course are efforts to support a smoke free lifestyle, educational activities, cessation support and targeted efforts at two overrepresented groups, those with mental illness and our First Nation communities.  I suspect more fodder for the blog. 
Do your part, and submit something to the government supporting a positive approach to tobacco-free environments, supporting cessation, and developing directed strategies to work with First Nations and those afflicting by chronic mental illness.  

Saturday, 24 September 2011

War on drugs - Canadian government once again pushing mandatory sentences

Bill C-10 was introduced into government on September 20th.  It follows the typical government approach of using omnibus legislation to change numerous acts, and preclude substantive discussion on individual issues.
Not surprising, the concept of mandatory minimum sentences for certain drug offences has been reintroduced, and with a majority government, expect this to sail through government without barriers this time.   Bill C-10 section 41
This blog has raised the issue previously War on drugs - your wallet is the loser  and certainly groups like the Urban Health Research Initiative have actively led the opposition to previous legislative efforts UHRI home page  .
The supposed intent of the legislation is to enhance the war on drugs, in particular as relates to distribution of drugs.  The effect has been demonstrated in the US and other countries as having no benefit, overcrowding jails, increasing costs for correction services  and not reducing drug utilization.  
Note that anyone caught with five plants of cannabis, has the potential to be incarcerated for a minimum of 6 months if the courts can be convinced that the plants were to be used for distribution and not personal consumption.  That there is an onus to demonstrate intent to traffic is an improvement over the previous iterations of the legislation – but get real. 
It is the fourth time these sections have been introduced in legislation and always with significant opposition.  When will this government listen to evidence and to justice and health professionals instead of remaining stoically entrenched in archaic ideology.

It is time to annoy your MP on this one and raise the bar of opposition.  

Friday, 23 September 2011

Social support - the forgotten determinant of health

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How many of you have a friend that you can confide in? Someone who’s advice you can trust? Someone that you can depend upon if in a crisis?  Chances are if you are reading this blog that the rate is almost 100%.   Have you considered how your personal lifestyle protects your health and how privileged you are relative to the determinants of health?
 Up to 20% of the population are not able to respond affirmatively to the questions of who they can look to when in need.   Such social support networks were clearly identified in the 1994 Determinants of Health document, and the cross fertilization of social scientists and epidemiologists led to much better definition of what social support entailed. With this came a migration of language noticable in the  "social" determinants of health to 'social inclusion and exclusion' and 'contribution of the social economy'.  These items were detailed in two resource papers that are worth reading Social inclusion PHAC backgrounder and social policy PHAC backgrounder
Social inclusion/exclusion denotes the health impacts associated with recent immigrants, discrimination, linguistic exclusion and addressing issues related to institutional, workplace, and community ways of limiting these exclusionary barriers.  The backgrounder however does not speak to the “wellbeing” afforded by increasing communality, friendship, and collaboration.  These constructs have been interwoven into how the education system engages students and will likely redefine community, business and social relationships in the future (hopefully in a healthy fashion).
The social economy component comes from a well entrenched Quebec rhetoric and might better be translated as the “non-government (NGO) sector”.   Other terms include “voluntary” sector, the “third” sector, “non-profit” (amongst other terms).  It is the huge contribution that the social economy provides to enhancing wellbeing in the population.  While components are formalized, must of the social economy is through informal networks. 

Regrettably, Governments have looked past the contribution of this sector and over the past decade have substantively reduced funding to the NGO sector. The long term implication of such undermining of the social economy has not yet been seen, and unlikely being evaluated. Nor is there a vibrant discourse on the implications or resilience of the social economy to respond to this brutal attack.  
A challenge to any reader to try to find government statistics on total funding to any NGO sector, but most specifically to the health NGO community and how this has changed since 1990 or 2000.   Please let me know at drphealth@gmail.com   Such massive reductions desire being unmasked and the consequences of policy shifts made transparent.
The flaw in the migration to the newer "social" determinants has actually been that the population level interpretation has diluted the individual level measures.  The original determinants spoke of the protective health effects being correlated with the number of friends, with marital status, personal assistance in dealing with adversity, problem solving and mastery and control of life circumstances.  These individual level attributes have been lost and yet remain central to the discourse on determining what keeps us healthy. The background papers likely led to the inclusion of the "social environment" as one of the added determinants after 1994, but the dialogue on social support networks has disappeared.
The divergence of interpretations has added to the richness of our understanding of one of the lesser appreciated and understood of the determinants.   It begs the question of how newer technology in texting, tweeting and blogging will compromise or potentially enhance social support networks – those technologies weren’t even imagined in 1994 and emailing was still a relatively limited commodity. There is a topic for a future blog. 

Tuesday, 20 September 2011

Homelessness - who is benefiting from programming?

About 1 in 200 people in North America are without a home.  Depending on how one wants to define homelessness, these numbers are more likely two to three times higher.
In the extreme incidence of homelessness, individuals may not be able to receive subsidy checks, open bank accounts, get health care because of lack of a free insurance number, or obtain any form of identification because of a lack of address.  Not only are they homeless, but they become almost invisible to a system that is dependent upon identity to function. The gradient extends across the UNs criteria for housing which include; the shelter must protect the occupants from the elements, provide safe water and sanitation, provide for personal safety, and the criteria extend to being located near employment, education and health care, and be affordable.
Those that have permanent housing that erodes a significant portion of monthly income (>30% but realistically some are over 80% of costs going to housing) are considered at-risk for homelessness. Considerably more individuals live a “street oriented” lifestyle, which frequents public locations for social benefit and may extend to activities that supplement incomes (including sexual services), or as coping mechanisms for certain addictions. About 70% of street oriented youth have attempted to escape situations of physical or sexual abuse in their homes. 
Roughly ½ of homeless persons have a chronic mental illness.   Half have challenges with substance addictions (a proportion struggle with both).   “Homeless persons” are at risk for being victims of violence, higher rates of infectious disease, higher rates of certain chronic illnesses.  They often require hospitalization more frequently and are at a significantly increased risk of death from a variety of causes, including extremes of temperature. 
Between 1999 and 2007, Canada had a National Homeless Initiative designed to provide for the fundamental need of shelter.  This changed under current government to a Homelessness Partnering Strategy which supposedly provides funding for community initiatives through to 2014 Homelessness partnering strategy .  It is an interesting exploration to try to find more information and determine what successes are being achieved.  While there are anecdotal stories of contributions to local initiatives, one has to wonder where the dollars are going and who is benefiting?   Seems like an excellent program for the Auditor General to try review to determine what and how well dedicated funds are actually benefiting persons on the street. The full program is supposed to provide an additional $1.5B – that amounts to about $8500 per homeless person in the country, presumably it should be make a huge difference, but somebody please tell me where the transparency is in how the money is being spent and what value is to be accrued. There is political currency is being seen as generous to the homeless population, but lets hold the political bodies accountable to deliver.
In the meantime local communities have often responded, not driven necessarily by altruistic motives to help the least fortunate of our communities, but often driven by economic concerns of addressing deteriorating urban core areas where businesses are struggling and perceive homeless persons as a impediment to attracting buying consumers to their shops. 
Homelessness is a real problem, something that requires dedicated and concerted effort to address and accountability for measuring success.   Ask your local, provincial and federal leaders what has been done and how has the money been spent?

Monday, 19 September 2011

Klebsiella superbug - a real life Contagion.

Even in Public Health, the urgent can bump the more important longer term preventative measures.   With the hit "Contagion" in the theatres, what better than a real life terror story of bugs running rampant.
Homelessness will be later this week and will have killed more people in the meantime. 
Superbugs hit the headlines again, this time it is KPC -  Klebsiella pneumonia Carbapenemases .  Not your everyday  bug, but for hospital Klebsiella is a well known problem causing sepsis and not infrequently contributing to death amongst persons struggling with other disease challenges. The Carbapenemases are a sub class of antibiotics of beta lactamase antibiotics (typified by penicillin and cephalsporins)  which were designed to work against resistant organisms.    The organism which can be resistant to all known antibiotics was first identified in 1996 in North Carolina, and found in Canada in 2008.   This weekend the Jewish General Hospital in Montreal reported on an outbreak that has lasted for about one year.   Supposedly the second “outbreak” in Canada with upwards of 80 known cases having been identified. 
The challenge with the superbugs is that they become colonized in hospitals and readily spread from patient to patient, usually through less than ideal infection control practices amongst very caring individuals.  The volunteer who distributes books, the pastoral community who visit multiple patients, the health care workers who we know are less than ideally diligent in the use of handwashing techniques.  Combine this with older physical structures that include multiple bed rooms, sharing of washrooms, lack of handwashing facilities, and difficult areas to houseclean. 
Those that work in hospitals recognize the balance between the need for constant care and the risks that the hospital environment entails.  These days the risks are starting to exceed the benefits.   While home care is a viable option, in the efforts to maintain the bastions of political generosity to communities, home care programs have been compromised and certainly do not provide the level of service that could be used to replace hospital care (and still be at a lower cost).  
Hospital utilization rates have decreased over 50% in the past 25 years, in some places they are down to almost 1/3rd their previous rates of utilization (bed days per 1000 population).   They remain the flagships of our overweight   health care system and continue to be fuelled by public desire, vested interests and political aspirations rather than strictly driven by contributions to the overall health of a community.   We remain fortunate in Canada that other than individual health care workers, there is limited influence by corporations that include financial profit within their “balanced scorecard”. 
If you need to go to a hospital, remember to wash your hands going in and out of rooms, only visit one person, and limit what you touch.  Not just for your own protection, but you can easily become the vector that transmits organisms from one person to another without your knowledge or any symptoms.

Friday, 16 September 2011

Determinants of Health: Original versus Social - both have value. Where is the debate?

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1994 brought the landmark document from the Council of Ministers of Health on Strategies for Population Health Investing in the Health of Canadians as prepared by the Advisory Committee on Population Health.   http://www.phac-aspc.gc.ca/ph-sp/pdf/strateg-eng.pdf .   It laid the foundation for the eventual 12 standard determinants of health (the original document referenced only 9 determinants and has since added gender, culture and social environments and modified wording)

Income and Social Status
Social Support Networks
Education and Literacy
Employment/Working Conditions
Social Environments
Physical Environments
Personal Health Practices and Coping Skills
Healthy Child Development
Biology and Genetic Endowment
Health Services

The rhetoric has stood the test of time, and many of these are now integral to the discourse and approaches used in the field born by the terms of Population Health.  The genesis of the document can be found in a 1991 document by Fraser Mustard and John Frank named “The Determinants of Health” (I have a republication in a 1994 Western Geographical Series Vol 29 on The Determinants of Population Health, but no link if anybody has a link, please send it to me).  
There has been a migration to using the term “Social Determinants of Health”.  While the discourse is similar, the social determinants are a different list and vary depending on where they are accessed.  The concept was founded in 1999 by Sir Michael Marmot who has since led the WHO review on the Social Determinants and Health that was released in 2009.  It has been championed in Canada by Ron Labonte
*  income inequality
*  social inclusion and exclusion
*  employment and job security
*  working conditions
*  contribution of the social economy
*  early childhood education and care
*  food security
*  housing
*  education

Both lists have overlapping issue. The main difference is that several of the determinants items are “non-modifiable” such as gender, genetics and age, and the influence of the physical environment is lacking.   Both lists stress that health is more than disease and certainly more than the health systems ability to reduce the impact of dis-ease.  The determinants list includes health services for which most estimates will say contribute to about ¼ of our wellbeing at most. The original statement about Health Services in the report is worth repeating “particularly those designed to maintain and promote health, and prevent disease.” The melding of the two determinant lists has led to much of the current focus on reducing inequities.   When the discussion uses the term “social determinants of health”, check and see which list as actually being referenced.  The intent may be similar, but the basics and language are actually dissimilar. 

Wednesday, 14 September 2011

Health Equity headed south. The Gini coefficient in action

One has to question the motivation behind a system that propagates failure and causes grief.  This blog has just discussed health equity and progress in Canada when the US Census Bureau announces 2010 information on poverty and health insurance US Census Bureau statistics 2010.   While the focus of this blog is on Canadian public health, such activity lives in the shadow and influence of our great neighbours and partners to the south.  
What is wrong with the picture of 50 Million Americans who do not have health insurance?   Or the 15% who live in poverty?   While achieving balance in the US political system requires incredible intellect and tact, what system allows so many individuals to suffer at as a result of the social structures that it supports? 
Using the US as a comparison provides the opportunity to discuss what has been found to be an even better predictor of health than the absolute distribution of wealth, but the equitable distribution of health.  Countries where the rich carry more wealth, tend to have significantly poorer measures of wellbeing.  Countries with more equitable distribution of wealth tend to have better measures of health (and various other civil society measures).  One measure of equitable distribution of wealth is the Gini coefficient of income.    

The global picture in 2009 looks as follows and can be found in that excellent resource of general knowledge called Wikipedia (link below).  The findings suggest excellent income distribution in nordic and mid European countries.  Canada fairing reasonably well.  Very poor performance from some South American and African countries and moderately poor from the major entities of the US, Mexico and China.
Just as interesting is what has happened to income equality over the past 60 years and this is also found in the Wikipedia article. Long term trends are a good measure of the general cultural direction and influence within a nation.    Countries like France, Mexico, Norway are leading the charge in the “right” direction.   China, US, and UK are perhaps headed in the wrong direction.  
Canada’s performance is neither commendable nor embarrassing.  In 2009 the coefficient has slipped back up to about the same point it was at in 1952.   The US’s consistent trending upwards has continued.
I’m reminded of the saying by Baron Acton “Power tends to corrupt, and absolute power corrupts absolutely.”    

Tuesday, 13 September 2011

Equity in Health: Progress or a Pipe Dream?

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At the end of August, Minister Aglukkaq announced funding for research on health equity in Canada http://www.cihr-irsc.gc.ca/e/44157.html .  This is an extension of the Canadian institute of population and Public Health strategic plan http://www.cihr-irsc.gc.ca/e/40593.html  which identified health equity of one of 4 research priorities.  As noted in the previous posting, equity is a pre-requisite for health.  While much literature links the determinants of health and equity, equity itself is not one of the determinants of health, it is the inequities that exists within the determinants that are the focus of reducing inequities.  Hence, of the pre-requisites for health in the Ottawa Charter, equity is the one that has received the greatest attention.
Margaret Whitehead spoke of Health Equity in 1992 (Int J Health Services 22:429-445) in a foundation article.  The WHO report chaired by Michael Marmot on Closing the Gap in health inequities through action on social determinants is a landmark international document worth a read WHO report on social determinants . 
It was fitting that the first report of the Chief Public Health Officer of Canada, Dr. David Butler-Jones, was on addressing health inequalities  2008 Addressing Health inequalities report .  Despite the intense political scrutiny that the position must endure, it is a publication that clearly lays out the disparities that exist within Canada.  That the report was released without any announcements and quietly posted to the PHAC website speaks volumes to the political acceptability of the current government in addressing this agenda, so kudos for Minister Aglukkaq for now recognizing that this is a matter of health and not ideological stripes.
Not surprisingly, the report draws heavily on work by Russell Wilkens, a person whose contributions to research on health inequities spans several decades and perhaps one of the most underrated public health heroes in the field within Canada Stats Can report on neighbourhood inequities  .  Hidden in this technical report is much in the way of good news for Canada.  First is that inequities have not been increasing as they have in some supposedly developed countries, second is that in some instances the gap has been reduced.   Also hidden is the estimate that about 25% of disease burden can be directed attributed to excess caused by inequitable distribution of income alone.
If your fall schedule isn’t too busy, don’t miss the World Conference on social determinants of health in Rio de Janeiro in October where the “Rio Declaration on Social Determinants of Health” will be finalized.

Sunday, 11 September 2011

Pre-requisites for Health: 25 years after the Ottawa Charter. Are they being overlooked?

Much is made of the current discussion on the determinants of health, this blog will get there too.  The Lalonde report of 1974 introduced the concept of two aspects of health, the first being that of carrying for those with deficiencies in their health.  The second begin about prevention health problems and promotion of good health – hence the field of health promotion had its naissance. 
The second major contribution was that of “health fields” which recognized that the health care organizations was one of the things that contributed to health, and identified human biology, environment and lifestyle as other aspects.
Fast forward to 1986 with the Ottawa Charter on Health Promotion.  Thank goodness the WHO still posts the document for a Google search.  Good luck finding it on formal Canadian government websites (it is hidden on the PHAC website Ottawa Charter on Health Promotion ) .
The fancy logo and catching phrases speak to strengthening community action, developing personal skills, creating supportive environments, reorienting health services and building healthy public policy through enabling, mediating and advocating. The basic principles have endured the years with perhaps building partnerships and collaborating as informal add-ons.  In my opinion, the most important contribution is hidden after the definition of health promotion and before explaining the key words.   It speaks to the fundamental conditions and resources for health, or the “pre-requisites”.   Peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity.
 As we celebrate the 25th anniversary of the Charter,  the Canadian Journal of Public Health has a special anniversary edition that is worth reading including a discussion of the impact of the document – you will not find a discussion of progress on the pre-requisites of health. ( CJPH July/August 2011  for the contents and abstracts).
For peace to exist, the violent crime rate should have disappeared.   The rate peaked in about 1990 in many locations, and violent crime is down about 20%.  Some places like New York city have documented up to 80% reductions.  All of which is good, but none of which demonstrate that we yet leave in a peaceful society.
Up to 700,000 Canadians (about 2%) are at risk for homelessness.  The true number which are without shelter is not known. 
13% of the Canadian working population have not completed high school, this rate is down from 29% in 1989.  Only 25% of the Canadian population graduated from University.
In March 2010,  870,000 Canadians were assisted by a food bank, up nearly 20% over the previous decade.  
The unemployment rate took a huge increase during the 09 recession, and has gradually fallen again to about 7.2%.   While not necessarily a measure of income, it is one of the surrogate measures.  
A stable ecosystem is a terminology that I have not fully understood.  In the midst of climate change predictions and documented impacts of human affects, it is hard to believe that the eco-system is stable.
Sustainable resources.   Remember the Club of Rome’s  Limits to Growth? The book that predicted dire consequences for humanity if growth remained unchecked.  An Australia has done a 30 year follow-up on those rapidly dismissed predictions and demonstrated how accurate the original work actually was.  It has not received the acknowledgement that perhaps it should and is worth the read http://www.csiro.au/files/files/plje.pdf   
Social justice is another term that I have difficulty understanding.   Moreso in the context of distingushing the constructs from that of equity that follows.  There may well be issues more fundamental in measuring discrimination and intolerance.  Aboriginal issues, racial issues, religious differences , language differences still fill the newspapers – what is unclear is how these issues have improved or changed since 1986 and I would welcome thoughts and comments. 
Equity has perhaps had the greatest attention of any of the pre-requisites.   While Canada fares better than some countries in the equitable distribution of health, it is losing ground.  A topic of its own for the future.
Much has been made about the determinants of health.  So little has been said about the failure to address the pre-requisites that we all need to even have a chance at health.   While this piece  focuses on the shortcomings in Canada, the issues of North-South gradients, developing countries and continental variation make the subtle variances in Canada seem trivial.  

Thursday, 8 September 2011

Celebrate: Canada’s international contribution to public health

Canada has long been seen as an international leader in public health innovation.  While some achievements are quietly celebrated, many are not celebrated for their immense global contributions.
A reminder of some of the great achievements
late 40's through the early 60’s:  University hospital care and medicare - topics for another discussion.   Carried through in the cultural attachment to and defense of the Canada Health Act by Monique begin in 1984.
The 1974 Lalonde Report that introduced the concept that health was more than the absence of disease.  It can be traced to a CMAJ article the year before by a person named Lafromboise.
The 1986 Ottawa Charter on Health Promotion, which mirrored to a significant extent the 1985 government publication known as the “Epp Framework”.
The 1994 efforts issued by the Adviosry committee on population health to the Council of Ministers of Health on the Determinants of Health which built upon years of work on relating health with issues like employment, income, education occurring in Canada and throughout the world, but coalesced the material under the new discipline of population health.
With such an esteemed track record of success, combined with the gains made in the public’s health that have been flagged in earlier blogs – one might wonder why the public health community feels under siege and underappreciated?

Tuesday, 6 September 2011

Politics and the Scientific Process: An unheralded bias.

Last weeks blogs spoke to how political ideation can affect emerging science issues.

I would like to call on your assistance.  Please post comments or email to drphealth@gmail.com .  I am looking for examples where politics has resulted in a bias to the scientific process. 

Politics can affect interpretation of science, such as the debates of evolution and creationism.  Media biases can also bias the interpretation of a situation through "balanced" reporting. 

There is an inherent political bias to support existing science structures rather than explore new branches.  When looking at funding for research, some major issues like mental health and injury prevention are overlooked in favour of the more traditional fields of heart, stroke and cancer - all of which remain very important and burdisome illnesses, but for which research funding remains disproportionately skewed.

There are instances where politics have interferred with the progression of science.   Most of the examples that come to mind, have their genesis south of the border.  The stem cell research limitations in the US are a prime example.  The US biased against certain air pollutants under the Bush administration by refusing to fund research for selected pollutants (eg ozone). 

I recall the impact of one guberneral election in Minnesota that brought the famour WWF wrestler Jessie Ventura to the governors position.  Up until that time Minnesota was an international leader in research related to the health impacts of intensive hog farming. Some of the best resources were only to be found on the state health department website.  Within a few years, the key researchers and administrators were no longer in their health and hog related position, and research material had been removed from the state website and essentially inaccessible.

While we readily acknowledge the challenges in science of controlling for biases in methodology, and appreciate the impact of biases related to non-publication of negative findings. There is little written or appreciated about the affect of political bias on science.

Please post a comment with examples that you are aware of.  Or for the shy amongst the readers, send an email to drphealth@gmail.com so we can begin to amass evidence of the impact.

Friday, 2 September 2011

AMR and livestock – When you won’t take the blame yourself, just kick the cat.

I’ve heard eloquent physicians over the years state that the problem with antimicrobial resistance (AMR) is the tons of antimicrobials used in the agri-food sector where resistance breeds.  The US National Academy of Sciences once estimated that the agri-food sector only contributed about 8% to the AMR problem, I suspect that is a good estimate.   In Canada, that proportion is likely even less. Canadian cautiousness actually protected against AMR trasnmissable to humans from animals through at least three significant and appropriate decisions. 
1.  Not approving enrofloxacin use in poultry sector as a routine therapy as occurred in the US resulting in resistance to fluoroquinolone resistance in humans. 
2.  Avoparcin was never approved in Canada but achieved widespread use in Europe before it was noted to be associated with VRE (vancomycin resistant enterococcus) development.  
3.  Virginiamycin was not approved in Canada, an antibiotic which led to aminoglycoside resistance, predominately south of the border.
This is not to say that the veterinary industry is not without an ability to improve its practice.  There efforts are something that perhaps human medicine and dentistry should took a lesson from. Veterinary schools collaborated in Canada on a unified antimicrobial stewardship curriculum as an expectation of new graduates - driven by the concerns of AMR 
Another approach has been the policy restriction on use of antibiotics in the livestock industry as led by Denmark - with successful reduced utilization and antibiotic resistance.  Other Scandinavian countries have followed suit.
While the Canadian regulatory environment remains rather lax and predominately supportive of the livestock industry, the veterinary community has responded in a constructive fashion to the challenge.   It is not surprising that the little antimicrobial resistance work in humans to be found currently, still rests with CFIA colleagues in Guelph who have championed the general issues about antibiotic resistant organisms.
Yes there are a few recorded cases of antimicrobial resistance directly linked between companion animals (pets, horses…) and humans, but for every case reported nationally, there is likely a similar human to human transmission that occurred in your local hospital sometime in the last few weeks.
AMR is a human problem.  Rather than blame the livestock industry, perhaps there are some things that the industry has successful accomplished without regulation from which human health professionals can learn.

Thursday, 1 September 2011

The difficult case of C. difficile.

Please send messages to drphealth@gmail.com, and follow on twitter @drphealth

An earlier blog (July 8 2011) touched on the spread of C. Difficile through Quebec and Ontario.  In both jurisdictions once the issue received widespread media attention, reporting and progress of the outbreak has become very quiet.   Two factors may have caused this, one is the application of better infection control practices and antimicrobial stewardship may have reduced the actual incidence, second is that politically it is enough of a hot potatoe that keeping it off the front pages has been a priority for public relations folks since early July in Ontario when the last reports were public.

The bottom line is the number of outbreaks of C. difficile would appear to be increasing, which means the number of people infected is likely increasing – finding that data seems impossible. Please send links.
The Canadian Nosocomial Infection Surveillance Program  (CNISP) Clostridium difficile in Canada     has some data up to 2007 and then an abyss. PHAC has a recently updated fact sheet where they even acknowledge/claim that they lead CNISP  PHAC information on C. Difficile .  Leadership also provides control over information release, and their last posted information is from 2005. 
C. difficile requires two conditions to be present for infection to manifest itself.  First is transmission of the organism which readily moves from person to person but does not cause illness.   The second is usually the use of a strong antibiotic.  “Strong” being a simple description for an antibiotic that kills not only bacteria that are causes a specific illness, but also kill a high proportion of healthy and normal bacteria.   It is the death of the healthy bacteria that provides the necessary environment for C. difficile to flourish and cause its toxic effects.
C. difficile is the most problematic of the superbugs currently in that affected persons suffer illness, usually result in more days in hospital where most cases are occurring, and occasional results in death.  
There are three ways to avoid the infection; 1. stay very healthy   2.  Avoid hospitals  3. Avoid antibiotics.    Sounds simple, but for many persons, particularly suffering illness associated with aging, hospitalization is health protection and antibiotics an be a necessity.   The final way to avoid infection is to prevent the transmission of the organism within the hospital setting – and we know how to do this through handwashing and other immaculate hygiene and infection control practices.  Even the best of health care professionals rarely wash their hands more than 50% of the time that they should.   Infection control practices have improved in the wake of SARS and H1N1 outbreaks, but remain far short of what we might hope is being practiced if we were hospitalized patients.  
Be a knowledgeable consumer, and if you go to hospital, check that staff have washed their hands entering and leaving the room.   Ask if they have had their influenza immunization.  Be sure that “equipment” for your comfort is dedicated for your use only and not shared.   Just don’t assume that it is being taken care of on your behalf. 
Amidst the threat of C. difficile is buried a controversy on fecal transplantation as a treatment.  If one of the problems is the loss of normal healthy bacteria, there might seem to be rationale in taking those bacteria from others and reestablishing the normal balance.   Not to take sides in the debate, the purpose is to acknowledge that there is proposed solution. In what might seem a pattern, such radical thinking is not being subjected to the process of scientific evaluation, but is receiving considerable policy debate because of the negative perceptions of the practice and in some instances the radical stance taken by some practitioners without persuing rigorous evaluation.  
For the moment, I’ll try to stay healthy, avoid hospitals and reserve antibiotics for those very rare really really bad infections.