Welcome to DrPHealth

Please leave comments and stimulate dialogue. For those wanting a bit more privacy or information, email drphealth@gmail.com. Comments will be posted unless they promote specific products or services, or contain inappropriate material or wording. Twitter @drphealth.

Tuesday, 29 November 2011

Kyoto, Canada’s commitment on the chopping block - Climate change and Health

Public Health professionals who speak out on the Kyoto agreement may find themselves in a career limiting position.  That was apparent over a decade ago when a prominent Alberta Medical Health Officer took the provincial government of the day to task (and now is the leader of the liberal opposition in the province).
For its strengths and weaknesses, the key contribution of the Kyoto agreement was a near global acceptance that climate change was occurring and that we humans should be doing something to mitigate the potential consequences.  After 14 years, 191 countries have ratified the agreement, the sole and most notorious country to renege on ratification being the United States.
Canada has little to be proud about in its efforts to control greenhouse gases.   Its emissions have increased by some 50% since Kyoto was signed and clearly far off its agreed to committment. Depending on the list Canada produces about 5.5% of the global greenhouse gases 6th or 7th among nations. Emissions from China, US and India respectively combine for just short of half of all global emissions.  Collectively however, while Kyoto was designed to lead to a reduction of 5% by the end of its expiry in 2012, greenhouse gas emissions have increased about 25%.  Overall a failing effort.

Kyoto was based on the assumption that binding targets would work, without any method of enforcement.  It did not predict the growth of emerging economies that the start of the decade heralded.   Each year, countries reunite to continue the dialogue - this year it is currently being held in Durbin where discussions centre on how to save Kyoto.  
Remember, this is the world of our grandchildren we are discussing.  Most of us will just be carbon sequestered in the ground when the impacts really hit hard.

So the leaked item of the day suggests that Canada will acknowledge its failings by withdrawing from the Kyoto agreement. Timely given the current conference, so is there truth to the rumour?  Perhaps it is just a political trial balloon, gauge the reaction without doing a formal poll.  If real, the action is a typical Harperism. Rather than continue to ignore Kyoto as is the tacit government policy, fly it in the face of the those that are willing to demand change.  Canadian emission control efforts have been undermined throughout the conservative government years already.
Canada undertook a fair health vulnerability assessment published in 2009.  It remains unique in being a federal document that is not available on-line.  If you wish a copy, you can make a request by following the link at Health Canada climate change assessment.  The first link is to the Environment Canada overall assessment report which is and has always been available on-line.   Why Health Canada will not include the on-line version is a mystery for which I would welcome some intel (contact me at drphealth@gmail.com).
The lack of knowledge is the major reason for the lack of specificity – predicting the impact of climate change on Canadians is like predicting earthquakes.  While ice packs may melt, and dry regions become drier, the potential for larger areas of food producing lands exists and some industries and processes will benefit from the predicted climatic change.  
In the absence of real commitment to emission reduction globally from the major producers countries including ourselves, the action by the Canadian government to withdraw or not withdraw is no more than political posturing.  So who is the government attempting to appease?  It likely will spell the death knell for sections and departments federally that study and regulate carbon emissions, it will migrate the dialogue away from attempting to halt climate change and it may eliminate the political embarrassment of treating Kyoto as a sham.
It will not however change the dismal record of our country, the inevitable incremental changes that carbon dioxide accumulations will cause, and the need for communities to build resiliency and adapt to the change.  The change will be slow and steady with more extreme events being documented than previous. 
The major risks for global human health will be twofold: in low lying countries where flooding will reduce land availability and displace millions; and certain arid areas will reduce local food production and extend periods of localized famine.  Changes in distribution of infectious diseases, heat exposure, and extreme weather events may draw more attention than the insidious changes that will impact the greatest number. 
Many animal species have adapted to change in the past through migration and evolution, or the weakest of species have failed.    Will we survive, thrive, or dive?

PS - CBC coverage on Canada's waivering committment is commendable, worth checking out. http://www.cbc.ca/news/world/story/2011/11/28/pol-durban-conference.html 

Monday, 28 November 2011

2011/12 influenza season – news on the cusp.

Two recent public health stories worth watching.   Last week, US reported on a swine reassortment on the H3N2 strain that was crossing into humans.  Three children in one day care in Iowa.   The variant had been identified about a dozen times previously and half dozen times this influenza year.  Whether this is signal of a potential new human to human transmissible variant is perhaps too early, however influenza watchers are likely beginning to raise cautionary flags. US announcement of H3N2 reassortment
In a much less publicized scenario, a US researcher has done genetic manipulation of the currently circulating H5N1 avian influenza such that it develops transmissibility between ferrets.  Ferrets you wonder?   Turns out ferrets are reasonably good influenza model for humans. The story got more attention because of the potential efforts of Homeland Security to block the publication of the findings as a potential threat to national security than for the actual risk that the study engendered.
Beyond the national paranoia related to bioterrorism, why the legitimate concern about the study findings?  For those that have kept an eye on this disease since 2000, you would be aware that it continues to spread globally WHO avian influenza page with the most recorded activity in 2011 in Egypt.  Some caution in interpreting the statistics in that not all countries are monitoring for H5N1, and predominately only severe cases are likely being tested.  The notable characteristic of avian influenza remains its almost 60% human mortality rate amongst confirmed cases.  So if the virus developed the ability to transmit between human, it would be a potential nightmare.  
The real issues around the avian influenza scenario clouded the pH1N1 planning as pandemic planning has been working from an assumption of much higher mortality and severity of illness than was manifest in the “milder” version of pH1N1.
Overall influenza activity globally has been lower than average so far this year.  The heralding of an long term care outbreak of H3N2 in Alberta combined with the reassortment identification in the US should put everyone on alert and push for the final efforts to provide vaccine protection to as many as possible.

In the midst of preparing for the disease season, there are always questions about the vaccine.  The question that needs to be posed, is that has the wider spread use of the vaccine already impacted the natural course of annual circulation such that we are reaping the benefits of much lower deaths and morbidity?  Perhaps an insidious form of herd immunity, and the resultant apathy towards the illness may be our greatest threat. 

Watching the false starts, the various influenza offenses and corresponding human defences manouveurs can be almost as exciting as a Grey Cup, and just as nerve-wracking.  For those active in public health, it is far from a spectator sport. 

Friday, 25 November 2011

Black Friday – Commercialism, entrepreneurialism and the public’s health

Hopefully ,  few of you arose early enough to camp out for the store openings.  Perhaps it is fortunate in Canada the November weather really is not conducive to standing outside. So this phenomenon may be predominately a US problem.   While 90% of the  blog followers are Canadian, 5% are from the US and the remaining 5%f from a wide variety of locations globally. 
The concept of Black Friday deserves scrutiny, and at least somebody asking the question what is the cost on personal and population health? 
It was not too long ago that store hours were restricted to less than a full week. Hours were limited to the daylight.  Then brilliance prevailed,  and stores became more consumer friendly in their access (health care may get there yet but is decades behind in Canada, further ahead to the south).   But, there might be a limit.  Stores are operating with special hours on the biggest shopping day in the US.  The upcoming Xmas hours take often lower paid workers away from their families, disrupt their daily routines, and teeter on the edges of labour laws.  Some stores will now even operate 24 hours a day until Christmas.
On one side of the argument is why the heck?  Is this abuse of workers and unnecessary?  The other side says it is more money into the hands of workers seeking employment, more stimulation of the economy, more purchasing of products – and a dollar spent is a dollar earned somewhere to be spent in stimulating the economy further. Hence overall a good thing, right? 
We know shift work is dangerous to one’s health.  It is classified as a probable carcinogen according to IARC IARC monograph on shift work .   So at a minimum, nighttime work hours is not a good thing for individual health.  We also know that economically vibrant communities have healthier populations and that is very positive at a population level .  If the extended hours did not result in more sales, then most businesses would not offer them – so something of an economic good must be happening.  Does the balance favour better or worse public health?
Perhaps we need to reassess the root issues our consumerism driven society.  Many economist will argue it is the efforts of small entrepreneurial business that leads to sustainable growth.  Just as an observation, I don’t see many small businesses opening at 4 am.  Big business is under the microscope, but who is looking into the lens?   With the so called one percent retaining 25% of the income, unlikely that they are representing the views of small business.  And the diversity of small businesses lend resilience to a community's health and economy.
Are we stifling our economic growth, and consequently our population health by acquiescing to consumerism?  Perhaps more importantly, is anybody concerned with the public’s health actually measuring the consequences of this trend?
I’ll do my part and will not be lined up when the doors open, perhaps I may avoid those stores that propagate an unhealthy behavior that seems to be creeping north across the border. 

Wednesday, 23 November 2011

Food security - A recent addition to the public health agenda

Today this site will have reached 3000 views.  Please continue to help this site grow by sharing the link with public health colleagues.  Follow on twitter @drphealth.  Your comments are welcomed either posted to the site, or email to drphealth at gmail.com  
Food security has emerged as a major public health policy driver over the last decade, but has its roots entrenched from the 1930s depression years.   Canada’s action plan in 1998 Canada's action plan on food security set out a path that laid out 10 priorities starting with the right to access food, the reduction of poverty, promotion of safe and nutritious foods, safe food, reemphasizing traditional foods, supporting production and sustainability, addressing fair trade, and then wandering into protecting peace as a precursor to food security and finally a mechanism to monitor food insecurity.
The definitions of food security tend to emphasize various components of this agenda.   Two that I share are “Food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life”  (Canada’s action plan).   Another commonly referred to by Hamm and Bellows  A situation in which all community residents obtain a safe, culturally acceptable, nutritionally adequate diet through a sustainable food system that maximizes self-reliance and social justice.”

The food security agenda is coming to a critical juncture.  The efforts to meet the diverse agenda have sometimes resulted in feet in two camps.  The food security agenda has migrated to the positive perspective of ensuring an abundance of food, emphasized nutritional value, addressed security through food policy and food coalitions and supported local production.  The food insecurity agenda has looked to community kitchens, good food boxes, poverty reduction, and inequity reduction.   While both are laudable, there are divergent and sometimes conflicting components.   The evidence for supporting the agenda is grounded in improvements in food consumption behaviours, numbers of programs available and numbers of policies implemented.  Less evidence exists in measuring successes in reducing hunger. 

There are valid reasons in this political environment for placing less emphasis on the insecurity and hunger agenda.  There is a dissertation thesis focused on food security agenda development that flagged barriers for emphasizing the hunger component; lack of successfully evaluated initiatives,  volume of NGO activity in addressing insecurity issues, the politics of “poverty”, the tension between universal (aka food security) and targeted (aka food insecurity) approaches, that hunger dilutes the food security agenda, and the poor understanding of the logic connection between food insecurity and food security.  

There are tensions between the food security and food safety components of public health that have not been resolved and result in internal discord.

There are also disciplinary tensions around food security.  The public health nutrition community has led the movement forward.  The institutionalization of the food security agenda means that other public health and non-public health professionals need to be active and own the deliverables. Concurrently public health nutritionists must do what public health has been so successful in accomplishing over the century, that is having allowed for health improvement agendas to move to the mainstream and be integral to business operations in health and other sectors, nutritionists need to step back from owning the issue.  As a broader multidisciplinary team addressing food security, we all need to be thankful for the leadership that has been demonstrated by nutritionists, and we need to utilize the expertise and skills that this group of professionals have brought to the table without discounting their contributions

Food security is here to stay. We are faced with divergent paths that can be followed at this juncture.   Strong and respectful leadership can take the agenda to a new level.   Persistent inconsistencies and disagreements can impede progress.  What will your role be?

Tuesday, 22 November 2011

Breast Cancer Screening Recommendations - when science and passion collide

Please help this site grow by sharing the link with public health colleagues.  Follow on twitter @drphealth.  Your comments are welcomed either posted to the site, or email to drphealth at gmail.com  

Many of us scratch our heads at our neighbours who refuse immunization despite "expert interpretation" of the scientific evidence, continue to smoke in the face of illness or indulge in unhealthy foods while still knowing the consequences.   No doubt you could provide many examples of attitudes and behaviours that defy the public health practitioners logic.
Along come new recommendations on breast cancer screening based on evidence Breast Cancer screening recommendations . These recommendaations are from the Canadian Task Force on Preventative Health Care.  This is a reincarnated group that all health practitioners should look to for guidance on preventative activities http://www.canadiantaskforce.ca/index.html. The efforts of the task force are an extension of activities that have been undertaken in Canada since the 70’s. 
The current iteration of the task force reaffirms the recommendation to not do mammography screening on low risk women age 40-49 and are now reversing recommendations on clinical and self examination of the breast such that these are no longer recommended to be advised or routinely performed.  There are recommendations on when mammography is highly recommended for women 50-74.
I have faith in the scientific review process that has prompted this high powered group in reviewing the literature to conclude as they have, even if they are light on the population epidemiology skill set.   The challenge that will arise is the outcry of passionate health devotees that perceive that they are being deprived of access to what they value as a needed health intervention.  This is the diametrically opposed end of the spectrum of those disbelievers that challenge the evidence to avoid engaging in health improving activities – this equally robust group of individuals will dismiss the proposed recommendations, claim that they are being denied access to medical services, and undermine the credibility of the task force’s actions.  Similar, but perhaps less strident responses occurred to the US counterpart’s recommendation against prostate cancer screening released last month http://www.uspreventiveservicestaskforce.org/uspstf12/prostate/prostateart.htm .
The challenge here, is that the committee was disbanded for 4 years and this is their first set of recommendations.  Coming forth with recommendations that may be science based, but lack the public (and some professional) alignment undermines their potential great efforts.  Perhaps there are some suggestions on the need for public consultation, transparent peer review processes and generally building support for modifying those sorts of recommendations that are likely to result in condemnation by public opinion leading groups.  The process is a great one and very valuable to the health community.  It needs to be remembered that science is only one aspect of public policy development.

Monday, 21 November 2011

Meningococcal disease – the frightening aspect of public health, and a germinating success.

It is not common that I hear fear in people’s voices, but it happened a few times in the past week.  That sense of emergency and dread that fear causes.   The cause was a couple of unrelated cases of meningococcal disease.  Sure, the expected rate is 1 per 100,000 population per year (or roughly 1 in 5 Million in any given week) and we all need to be prepared to respond and manage the situations. Something most public health professionals will be involved with at least some point in their career – and it appropriately is handled as an emergency. Many in Canadian public health will have be engrossed in at least one Meningococcal C outbreak, the most recent that I recall being over the Western provinces in 1999-2001.  Fortunately all Canadian jurisdictions now provide childhood meningococcal programs, although variations exist in the primary, catch-up and reinforcement scheduling which confuses the best of professionals. Canada’s lack of a unified immunization approach unmasked once again.
Detailed statistics and vaccine recommendations can be found at NACI meningococcal disease update 2009.   
The mainstay for decades for preventing secondary transmission of meningococcal disease has been short term antibiotics.   Rates in the immediate period after a case amongst household contacts are nearly 1000 times higher than in the general population – sounds like a huge increase.  This converts to less than 1 in 100 household contacts.  For those further distant like health care providers involved in care, the rate may be 25 times the general population, or about one in 200,000 workers exposed to a case of disease. Public health should be treating the situation as urgent, but perhaps it is worth remembering what the risks actually are.  There are tangible and measurable risks for the antibiotics in use as well.  
The flip side of this coin is that up to 10% of invasive meningococcal cases result in a fatality, the highest rate being amongst meningococcal C serotypes which has twice the fatality rate as other serotypes.  The dread is often that meningococcal disease strikes healthy adolescents or young adults at the prime of their life.  As one person said to me, is this the “really really really bad meningitis”?  
There is evidence from the UK and Quebec that post vaccination programs result in the reduction in meningococcal illness.  The major gap in our defense has been the lack of an effective meningococcal B vaccine, and that may be just around the corner.  It is less likely that we will bid farewell to meningococcal illnesses in a similar fashion to Hemophilus influenza, but dramatic reductions could reduce the fear and anxiety that outbreaks and tragic deaths have fueled.

Friday, 18 November 2011

Antibiotic Awareness Week - are you using your antibiotics wisely?

It is National Antimicrobial Awareness Week.  Somewhat aligning with the start of the cold and influenza season where inappropriate antibiotic prescribing hits its peak.   This site has addressed the issue of superbugs and antimicrobial use on multiple occasions July 8, 12, August 29, 31, Sept 1, 2, 19 and 26.  But really, who is counting?   Its just one of those public health issues that needs a home, needs champions and needs to be addressed.  
Antibiotic stewardship is integral to reducing dissemination of antibiotic resistant organisms (ARO), prolonging the effective life expectancy of newer antibiotics, and most importantly reserving antibiotics for treating severe illness and saving lives.  There are not many new antibiotic opportunities coming down the pipeline to maintain protection from infectious disease. 
The Canadian Antimicrobial Resistance Alliance CAR-A has become the default organization for providing leadership in the country.  Notable about CAR-A is the focus on institutions and specialists, and the lack of public health involvement.  There are some good statistics, but minimal trending information on the antimicrobial surveillance tab.   The ability to compare geographic areas exists, although the format is not user friendly to identify where substantive variance in practices is in place, or variance in policies like formulary restrictions.
The Canadian track record is passable and better than some countries, but certainly not in the same league as Denmark or other Scandinavian countries where policy limitations are designed to prolong the use of antibiotics.
And where is PHAC, at least they have started to take a leadership role, but what are the objectives and the deliverables?  The focus of work is based on the group that has historically looked at animal based antimicrobial use, and while an issue it is not the main ARO problem.  Humans prescribing and using antibiotics are the primary problem and we know less about that than we do about animal husbandry management with antibiotics.
Add to this are efforts by other health care professionals to increase access to prescribing antibiotics, rather than reducing access by existing health care professionals to this vital service only when needed.   
Next time your health care professional offers you an antibiotic, at least ask if there is another alternative to be considered first. 

Wednesday, 16 November 2011

Vaccine Policy in Canada - progress on a province to province basis

Vaccines are now the backbone of public health.  Rightly or wrongly, communicable disease control has become the prime indicator of public health programming.  Outbreaks are seen by professionals, public and media as a failure of the public health system and the one time public health is held accountable.  We have responded by increasingly directing scare public health resources to supporting immunization programs and the concomitant individual services, the opportunity costs for other health improvements that have not been implemented are enormous. 
BC has become one of the first provinces out of the starting gate in announcing rotavirus vaccine coverage and second dose varicella BC vaccince announcement Nov 2011 . The announcement also includes Hepatitis A vaccine for Aboriginal populations where an ongoing outbreak remains unchecked.  Kudos to them, the announcement includes $3.1M in funding for purchase and avoids any discussion of the costs for delivery.  If typical of many provincial vaccine funding announcements, it may be seen as occurring within the “routine immunization program”.
What does that mean? for public health provided services, no extra money and a further dilution of stretched programs.  For physician delivered vaccine services, incremental vaccine payments on a fee for service basis which are just as mysteriously disbursed without comment. 
The vaccine programs are warranted.  Several other good vaccines are in the pipeline and will need to be funded in the next few years.   However the infrastructure to support their delivery is taxed and crumbling.  Health care professionals are challenged to remain current with new schedules, adjust to new vaccines, update vaccine safety programs and modernize documentation.
Why do we still not have a national immunization registry and common electronic platform? – was this not a deliverable of Health Infoway?  or has decades of information neglect in public health resulted in such disarray that common IT systems are not even possible?  Have we in public health become our own worst enemy in resisting implementing modern information systems which are conversable with electronic health records and accessible at the multiple points of contact (and de facto immunization delivery points)?  Why is scanning technology which is mainstay of pharmaceutical delivery, beyond the reach of the front line public health practitioner? 
There is political currency in announcing vaccine programs, so expect to continue to see such program expansion.  Will it take a disaster or breakthrough outbreak to acknowledge the system vulnerabilities?  Will expert opinion go the way of SARS recommendations? 
Canada has a great vaccine infrastructure with Health Canada approving vaccine licensure, NACI leading on recommending vaccine use, Canada immunization committee sometimes recommending standardization of programming – however too often this step is undermined. Shared purchasing and large scale public contracts substantially reduce the cost of vaccines, and corporate profits are minimized while public dollars wisely spent. 

Residents like to hear they are the first to receive a benefit, not the last – hence the political currency of early announcements.  Vaccine programs should be evidence based, standardized, portable and consistent.  On a national basis, most of these criteria are lacking – and that is an indefensible public health flaw.  

Tuesday, 15 November 2011

Child Poverty - Canada's failing performance and some embarassing provincial feebleneess

It was dated November 10th, reported in the Edmonton Journal and then in only Alberta fashion, no record that the announcement of the poverty reduction strategy was proceeding.  I do have a copy of the media release, but it is not listed as a government endorsed media release to which I can provide a link.
Many provinces have moved forward on addresses health inequities by developing as a first step poverty reduction strategies.  Details on progress can be found at provincial poverty reduction activities.  Even the website alludes to the Alberta announcement – but it seems to have disappeared.  Let us only hope that the 8th province to move forward on formalizing a poverty reduction strategy, and historically the more right wing, is true to the leaked information.
While Saskatchewan and BC have undertaken activities to reduce poverty, neither has to my knowledge formally developed or committed to a poverty reduction strategy.  Given BCs notorious reputation for the highest child poverty rates in the country, one wonders where the rationale persists and where the efforts have been directed. Campaign 2000 monitors Canada’s commitment to end child poverty by the year 2000, clearly a goal that has been missed, but disappointing is the lack of progress over the nearly 2 decades since announced http://www.campaign2000.ca/

Globally Canada's track record is as an underperformer. Even the Conference Board of Canada just gives it a passing grade and ranks it 13th of 17th http://www.conferenceboard.ca/hcp/Details/society/child-poverty.aspx.  More socially oriented groups might consider this is a generous ranking so it is perhaps the 'best' case assessment
Kudos likely go to Manitoba and Newfoundland, and an honourable mention to Ontario in their collective efforts to address child poverty.   Quebec’s stronger social programming needs commendation as well.  Federal leadership on the issues on income inequity deserves nothing above a failing grade and is highly unlikely under the current government. The right leaning governments of BC and Saskatchewan likely contribute to their blinded view of the health consequences caused by poverty. 
Hence Alberta’s announcement was a pleasant surprise and perhaps the tipping point for the left side of the country, that tends to lean more to the right. The mystery is what happened to the announcement, perhaps merely a short term oversight – or is it symptomatic of premiership that does not have the following of the party as is occurring in a few other provinces as well.
No matter the number of children living in poverty is unacceptable.  Confusion persists on measures like LICO before or after tax, market basket measure, Gini coefficient, Human Poverty index, Social deprivation index etc. Such confusion can be used as political fodder.   At the end of the day, let us remember, no child is merely a statistic, and none should be left wanting in any respect.  
As the Occupy movement is being slowly dismantled, let us continue to remember the fundamental message of their efforts – economic disparity is widening and social policy needs to be reinvented so that fewer of our brothers and sisters suffer. 

Monday, 14 November 2011

Health equity blog, a great new Canadian contribution to be followed

The explosive growth of the Internet Web 2.0 technologies has resulted in an abundance, probably an overwhelming abundance, of real time information designed to inform and stimulate the mind.  Knowledge synthesis, interpretation and dissemination is becoming a speciality itself.  There are many niche’s to be filled to meet the knowledge needs of specialized professionals, and every so often there will be a new and potentially useful niche that gets filled.
Along comes “Health as if everyone counted” blog, written by a Canadian deeply engrained in the international equity discussions. Linked with the U of Ottawa continuing public health education series CHNet-Works (which if you aren’t aware, also worth following or subscribing CHNet home page .  You can reach the blog from the home page as well.  Ted Schrecker is with the Population Health Improvement Research Network with the University of Ottawa and was an active member of the WHO Commission on Social Determinants, so who better to speak about social inequities?
Read his first few postings, and as with any new blog, there is lots of information crammed together that will fill minds with the answers to the very questions that we would like to see.  
Well done Ted. 

Friday, 11 November 2011

Remember Peace as a public health prerequiste

Canada remembers its fallen today.   The gallant efforts of Canadian forces to maintain peace and protect those values that we cherish.  In its most recent mission in Afghanistan, Canada has lost 158 military and 4 non-military brothers and sisters, whose lives deserve rememberance and celebration.
International efforts to maintain peace have often been successful.  This year saw up to 30,000 people die in Libya.  Other hotspots include Afghanistan where in the first 6 months civilian deaths were up nearly 30% over 2010 when at least 2500 persons died. 
The Iraq conflict has claimed over 100,000 lives in total with some estimates over ½ Million.   Mexican drug wars killed about 15,000 in 2010.
Counting the number of wars is not easy, but there are some 40 current conflicts globally.  Ten of these result in more than 1000 deaths per year,.  About half the conflicts are intranational (civil conflicts).  Notably is that collectively in these wars, up to 70% of the deaths are amongst civilians rather than military personnel.
The Ottawa Charter on Health Promotion defined peace as one of the pre-requisites for health.   On this day of rememberance, scan your eyes to both our Canadian military heroes, and also to the global community that continues to strive for global peace and to our fallen civilian neighbours. 

Wednesday, 9 November 2011

Influenza immunization - the unspoken public health questions

Yes,  I recommend influenza vaccination and something that even healthy people should consider getting.   There are experts,  and back up experts, and other experts,  that have reviewed and combed the evidence  and keep coming up with the same conclusions.  So I shan’t bore you with the reasons.   You can have more fun looking at the anti-influenza immunization propaganda anyway. 
However, we have influenza issues in public health that need resolution.   First, time to stop overstating the problem and celebrating the success.  Without vaccine, some 4000 Canadians would die annually in an average year from influenza.  There is no doubt hundreds to low thousands may die each year, but the widespread use of vaccine, nearly one in 3 Canadians,  makes a huge difference to the hospitalization and mortality stats.  So the message should be influenza vaccine now saves thousands of lives in Canada in each and thousands more hospitalizations.  Where is the data that shows what good we are doing, not the bad that might happen if we don’t do it? Please stop saying that influenza kills thousands in the country annually, that is just not a factual statement anymore.
Supposedly,  H1N1 only killed 428 Canadians.   How do you reconcile the numbers to the public when we immunized 40% of the population and we say that influenza kills thousands in a normal year?  Of course we immunized so many and didn’t communicate the number of lives that were saved – Where are those numbers?  The public will likely never hear how the program was of benefit. 
There are legitimate science question about the vaccine and disease control that the experts will pose and seek answers, and the details of who, how, what and when may get refined over time.  The petty debates that are played out in the public eye contribute to distrust in the vaccine and the system. 
We have 2 and maybe 3 provinces doing universal immunization (Ontario, Alberta  - and Saskatachewan if the resident wants it).  How come we don’t have consensus on the value of the program after nearly a decade in Ontario? Will the politicians decide before the professionals do? Inconsistency is perhaps our greatest enemy. 
The system for delivery is so varied from public health to private practitioners.  Western provinces are moving to pharmacist delivery and where is that taking us?  Public health is great at building things and passing them along, is it time to put influenza vaccine almost solely into the hands of other providers? Are we hanging on to a dinosaur in wanting to retain mass public clinics? 
There are 8 different influenza vaccines now available and it is great that we now have multiple home grown providers.  Where is the proliferation of vaccine types taking us?  Does privatization of production have a cost along with its value?
Influenza vaccine needs to be provided to those who work with the highest risk individuals, yet we continue to play roulette with their lives when we allow non-immunized staff or others to set a foot into high risk facilities.  The vaccine is not great in those that need it the most, so we should use the old public health approach and build the circle of protection.
The Weather Channel, Google and others have developed more effective surveillance systems for public communication while public health practitioners have utilize the old stand-bys that are not as sensitive.  
The vaccine is changing the natural progression of the disease, and this is probably a good thing.   We in public health need to change with the times too.  Influenza will be with us no matter what. The major vaccination fights have been won and it is time to move on to other important public health issues and leave the operational delivery to others to maintain.     

Tuesday, 8 November 2011

Health care spending in Canada - Lets face the real facts.

“Health care spending cannot continue to rise faster than the rate of growth”. 
“We need to reverse the upward trend of health care spending”. 
“Time to turn down the curve”
“Health care spending cannot be let rise above 30% of the provincial budget”
“Health care spending cannot be let rise above 40% of the provincial budget”
“Health care spending is almost at 50% and we can’t let it eat up more of the provincial budget”

I’ve heard enough quotes by senior system administrators over the years to fill a book.  If they had been successful we would not be consistently facing crisis mode for the past multiple decades, during which it has never gone away. They also would not have announced the plethora of CT scanners, then MRI scanners, then new hospitals, expanded in-patient units, dialysis units, ICUs, CCUs, NICUs  etc.  The flagships that buy the public votes.
CIHI released its annual spending report to the sounds of $200 Billion chinking through the till for 2011. CIHI health care spending report .  Good luck finding the information, but it is there.  We now spend nearly $3800 public dollars per person on health care annually in the country, with the territories being hit with expenditures that are over twice this level.  Add in private payments and that number increases to $5800, a gap that continues to widen as a higher proportion of health costs are being borne by consumers.
To surpise many, hospital spending has proportionately decreased over the past 35 years from 55% to 37% of the dollars.  Physician costs have remains proportionately at 18-20% with minor fluctuations. Drugs have over quadrupled to almost 9%.  Public health has supposedly doubled from 4.4 to 8.9% - though one has to wonder if that includes all community based services, or truly public health/preventative services, and is down from a peak of 9.4% in 2007.  Administrative costs have declined to a 35 year low of 1.8%.  

More questions are burried in the detailed provincial data.  The health status of Canadians does not vary to the same extent as public expenditures.  Ranging from a low of 3400 in Quebec, to a high of 5300 in Newfoundland, expenditures don't correlate well with health status.  Public health investments vary from a low in Newfoundland of 3.1%, to a high in Saskatchwan of 9.2% - again raising questions on definitions, however a 300% variance across the country undermines the value of the data and the universality of our current Canada Health system.
There is much to the report, including placing Canada middle to bottom of the OECD pack for many public expenditures, and debunking many of the political propaganda on the dire and imminent demise of the health care system.  The facts by CIHI is perhaps the one document worth reading unless you enjoy pouring over the detailed data tables accessible on the site.   
Kudos to CIHI, but given the future rests in home care, community based services and public health in the pure sense of prevention, perhaps these could be detailed out in the future.  Phooey on those that continue to engender a sense of imminent failure and collapse, fear is not a good motivator for change.

Monday, 7 November 2011

Occupy movement – what are you fighting for? The Inequity Rebellion

 “1-2-3-4 what are we fighting for” was the rage at Woodstock in 1969, sung by Country Joe McDonald.  It was an anti-Vietnam protest song that reflected a generation that was rebelling. Fast forward now some 42 years –almost two generations and the new generation “Y”ers are starting to speak out.  The 2011 Occupy movement is the current rage globally and founded in Canadian roots Adbusters.   
The focus of the revolt is the 99% speaking out against the 1% who now constitutes almost 25% of the income in the US.  

Most notably is how this share of the income has grown disproportionately over the decades since the peak of the anti-Vietnam protests. The challenge in the Occupy movement, is that while the streets have been filled and the tent cities have been erected, the knowledge and passion on the lines reflects the lack of focus of a generation squeezed by outdated economic policies, challenged to break into job markets and pushed out of decision making.   The internal rage looking for an outlet, and the Occupy movement has provided the same.   It is a subtle form of revolution that can be criticized for its lack of specificity, but should not be overlooked as future social leaders begin to encroach on traditional government structures.
While the Conservatives effectively won a majority nationally, there was a second message arising from portions of the country that were quietly revolting. The insertion of significant youth into the opposition and the rise of the New Democratic Party are reflections of a discontented generation, further isolated by a financial crisis that they have carried the burden, but clearly own only a fraction of the reason. 
On the surface, public health professionals might distance themselves from what is a revolt against financial policies and rampant consumerism – but lets remember the real reason.  This is a movement against inequities, and a key driver of poor health is the inequitable distribution of wealth.  If you did not view the Wilkinson lecture that was posted a week ago, take the 15 minutes today to look at it  Wilkinson lecture .  Here is the synchronicity with the public health agenda manifest for all to see. 
The death of a 20 year old at the Occupy Vancouver site can either be a martyrdom of the cause, or the start of the slow demise of the “inequity rebellion”.   The least we in public health can do, is support their noble efforts.

Friday, 4 November 2011

Gun Control, Fluoridation and the Public's Health

Please contribute comments or email to drphealth at gmail.com  
With a blog title like this, no doubt the hits to this site will be up.   The posting on fluoridation from November 1 resulted in 3 times more page views than any previous posting.   Two options, first is that the posting was widely circulated within the dental public health community.  More likely, that search engines are constantly roving the web for triggering terms – and fluoridation invokes a passionate response in those that are not supportive. It is great to know that such fervency persists in our society. 
The key issue for the day is the Harper government’s unwavering obsession to kill the long gun registry in Canada.   I expect another passionate response shall ensue. I will concede that I actually had no preset opinion and tried to ask the questions that I would like answered to help me decide what to think.  Follow through the logic and see if you concur with the opinion. 
First question – what has happened to homicide rates in Canada since the introduction (and prior) of gun registry? Homicide rates have been consistently declining in Canada for nearly 4 decades.   No there was not a large step reduction post registry implementation Globe and mail report on Stats Can release on homicide rates  

Second question – what happened to homicide rates in our neighbours to the south over the same time period?  Homicide rates peaked in the US in 1980s and have been steadily decreasing at a rate that is proportionately comparable if not better than reductions in Canada. 
Third question:  what proportion of homicides are caused by long guns? Firearms only contribute to roughly 1/3rd of Canadian homicides Violent crime in Canada - statistics Canada .   Of all firearms homicides, long guns are implicated in 23%, this is down from 36% prior to the 1991 commencement of more rigorous gun control.   (the registry was introduced in 1996).
Fourth question:  What is the rate of homicide per long gun?  There were some 7.8 Million registered firearms, of which about 90% are long guns.   Long guns were responsible for about 40 homicides in 2010, or a rate of 5.5 homicides per Million long guns.  Any attempt to measure the rate of registered long gun, or where all legal aspects were complied with would take this low rate even lower.   
Fifth question:  How much money will be saved?   There’s a question for the politicians to play with, but looking at their claims the registry cost $2 Billion. Unlikely, and that number is more likely inclusive of a broad range of interventions some of which related to gun control, and some of which will continue irrespective of proposed changes.  The current annual cost the government claims is supposedly $22M, however with the elimination, there will be no job losses, so please tell me how any money will be saved?   The RCMP report the savings will more likely be in the order of $1-4 Million per year and I will concede I’m more likely to believe their estimate.
Sixth question:  What actually will be lost and what stays under the legislation?  While the long gun registry is being executed, owners still require a license and completion of the training and licensing process. Rules for securing firearms will not change.  Immediate accessibility to firearms will not necessarily be increased if people comply with existing legislation. Those 10% of guns considered restricted or prohibited which are inclusive of handguns and automated guns still require certification and will be registered and there will continue to be a gun registry infrastructure to be maintained.   7.1 Million bits of information on the current location and ownership of long guns will be lost.  
Perhaps the Harper obsession may be justified. Nonetheless, the failure to come clean on; What the savings actually are?  What is being retained and lost? and What the risks are? contribute to the distrust surrounding the change.   It is being positioned more as a political coup and populist action designed to appeal to conservative roots (and as with the ship building contracts, likely to penalize Quebec for its lack of political support) than as a potentially rationale and logical action based on facts.   Not surprising from a government that tends to ignore facts and science in their decision processes already.
At the end of the day, we should recall that the presence of a firearm in a household substantially increases the risk for a suicide (and probably a homicide) within that household.  The long gun registry debate has detracted from discussing the risks of long gun ownership, something that professionals may wish to focus attention on. It is time to move on, since at this point this government isn’t likely to listen to passionate or rationale arguments anyway. 

Thursday, 3 November 2011

WHO conference on social determinants of health – Where does Canada stand now?

In follow up to Canada’s embarrassing political absence from the WHO social determinants of health conference drphealth October 18 2011, the collective global wisdom passed the Rio declaration which should be widely read and distributed WHO Rio declaration on social determinants.
Canada was supposedly represented by the Chief Public Health Officer (CPHO) Dr. David Butler-Jones as the senior Canadian official.   A contingent of an additional 6 senior representatives were involved, one of who was on the conference advisory committee. A solid Canadian government administrative representation.   A smattering of additional Canadian participants were also registered attendees to the conference. Regrettably drphealth was not invited to enjoy the sunshine. 
The declaration speaks to the inequities that exist, and that addressing the inequities is a shared responsibility of all sectors of government, society and the international community.  It affirms that inequities are unacceptable.   It speaks to the previous WHO leadership work which rightly deserves recognition. 
Section 7 almost appears to be a rewrite of the Canada Health Act.  Well not quite, but include 3 of the 5 Canadian principles (omits portability and public administration which are uniquely Canadian issues and includes equitable, effective and responsive).   Section 10 and the remainder of the document lay out a clear plan for addressing inequities through: (i) to adopt better governance for health and development; (ii) promote participation in policy-making and implementation; (iii) to further reorient the health sector towards reducing health inequities; (iv) to strengthen global governance and collaboration; and (v) to monitor progress and increase accountability. 

The declaration ends with a call for the endorsement by the 65th World Health Assembly (WHA) which will be held in Geneva May 21-26, 2012.  The declaration also calls upon member states to affirm actions under the 62nd WHA in resolution 62.14 – (which is also worth reading  62nd WHA resolutions and requires scrolling to the 14th resolution on page 21) .  It would be worthwhile to ask the CPHO for an accounting of Canada’s performance in implementing the actions requested of the member states. 
The questions for the moment are will the Canadian government endorse the declaration itself? And will the Canada vote in favour of supporting the endorsement of the declaration at the WHA meeting next May?
I’d welcome anyone with additional information on Canada’s political response to share your comments in case there is a need to escalate this as a public issue. 

Tuesday, 1 November 2011

Fluoridation: A huge cavity developing in protecting oral health

Thanks everyone.  Yesterday this site received over the highest single day visit of 95 visitors. Please help it grow by sharing the link with public health colleagues.  Please leave comments or email to drphealth at gmail.com  
Fluoridation has been touted as one of the great public health interventions of the past century.  The past few years have seen the anti-fluoridationists slowly winning and succeeding in reversing past decisions.   This combined with ambiguously changing “professional” guidelines that went from 1.0 mg/L to 1.2 and now reduced to 0.7, must make members of the public suspicious of what the real story behind fluoride is.  Do we need it or do we not?   I’ve certainly had dental professionals advising that water fluoridation is not the panacea that it once was because of the innumerable alternate ways to receive fluoride combined with better oral hygiene.   This advice usually precedes a discussion as to what intensity of effort should be undertaken in the next community plebiscite to drop fluoridation.
The list of communities that have reversed fluoridation seems to be growing faster than new additions. About 45% of Canadians now benefit from water fluoridation and while that increased from 2002-2009, I would be shocked to learn that it has not decreased given the demise of fluoridation in some large Canadian jursidications recently.  Without changes to public policy this can expect to drop further. Provinces such as Alberta, Manitoba, Ontario, Nova Scotia and NWT provide fluoride to a majority of their residents. BC, Yukon, Nunavut, Newfoundland and Quebec leave over 90% of their populations unprotected.   Few provincial or federal political parties want to own the issue of pushing fluoridation.  
Like vaccine preventable diseases, many middle class parents are forgetting the horrors of poor oral hygiene and at times oral health professionals have become more concerned with the quality smile than the quality of health. The debate has become over the cosmetic problems associated with mild fluorosis (staining secondary to fluoride exposure) rather than the impacts of restorative treatment (which can now nearly mimic normal teeth).  Even the Health Canada information on fluoride is more about mitigating concerns than promoting the benefits Health Canada and you Fluoride  .  
Oral health is getting better Chief Dental Health Officer statistical report but is far from being acceptable.  Most children still have at least one experience with caries in their lives, with an average of 2.5 restorations, down from over 10 a few decades back.  The situation in Inuit communities is much bleaker Inuit oral health survey  with decay scores of 7 and numerous other poorer measures.   Other First Nations are likely similar and not yet as well documented.  Few First Nations communities have ever benefited from fluoridation. 
There is evidence that there is a correlation between poor oral health and some chronic diseases and poor school performance.  While the causal link may need to be better proven, chronic inflammatory processes may well contribute to exacerbating atherosclerosis;  pain and under nutrition to poorer school performance.
Aging infrastructure that needs costly replacing provides incentives for communities to reverse public decisions on fluoridation. Dental public health programs have been undermined across the country and are shifting to high needs populations for restorative care and abandoning the efforts at universal protection.  The lack of leadership may be the slow death bell for water fluoridation – or perhaps some enlightened Canadians could look to California that is a bastion for public health policy.  State law requires communities of greater than 10,000 to fluoridate. Now that seems to make a lot more sense that the perverse approach to requiring plebiscites for adopting fluoridation, and in the Calgary situation merely a Council vote to stop.  Clearly there is something wrong with this singular approach to protecting the public’s health.