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Monday, 31 December 2012

Gun control - can we take another shot at peace in 2013?

The rhetorical question may well be if the executive director of the National Rifle Association were shot, would there be a legitimate argument that the action was in self-defense?

The second US amendment that provides for the right to bear arms was written in 1791 when  guns were limited to single shot muskets  that lacked automation, lacked multiple chambers and lacked the ability to be concealed. Each year somewhere between 10 and 15 Million guns are sold in the US.  That annual amount exceeds the total number of guns that were registered in Canada when the long gun registery was scrapped.

For this right that the NRA has steadfastly defended, one could estimate an excess of 10,000 American deaths per year.  Given the excess has existed for at least the last 50 years, it would be reasonable to assume that somewhere between half and one million excess Americans have died as a result of the broad interpretation of the second amendment.   While those numbers have actually decreased since the peak in the early 90’s, they have plateaued at about the level of the 70’s. http://en.wikipedia.org/wiki/File:Ushomicidesbyweapon.svg

No single effort in gun control will buck the US trend, or modify Canadian behaviours.   As noted, the objective analysis of the long gun registry had little impact on Canadian gun related violence http://drphealth.blogspot.ca/2011/11/gun-control-fluoridation-and-publics.html .  It is the other measures of gun control that may be effective:

                Strict limitations on assault and semi-automatic weapons
                Limitations on handguns
                Preclusion or limitation on concealed firearms
                Preclusion or limitation on gun modifications such as suppressors, reduction in barrel length
                Firearm safety training
                Development and distribution of toy facsimiles
                Limitations on ammunition including explosive or body armour piercing
                Storage and maintenance
                Restriction on movement of firearms

The challenge for countries like the US is to being developing a culture where any of these can be considered acceptable limitations.  Not all would be considered acceptable on day one, but the path to improvement is only begun by starting with the easiest of the restrictions and moving forward.   For a country where an estimated 40-50% of homes have a gun, making policy shifts will be difficult, however some surveys suggest fewer homes now own guns with ranges between 33-40%.   The Harvard review on gun control issues is a sturdy resource to work with Harvard injury portal  

Note that in Canada, estimates are that one-quarter of households own at least one firearm, most being long guns.  A full summary of Canadian firearm use is accessible at justice link on firearms in Canada  

There are an estimate 88 guns per 100 people in the US and 30 guns per 100 people in Canada.  While ownership is somewhere between one-third and one-half, firearm death rates are between one-quarter and one-third.   Ecologically comparisons are fraught with fallacies, but one might note that Japan with strict gun controls as a firearm death rate that is only 2% of Canada.  Even the UK’s rate is 15% of the Canadian rate.
The hidden question that needs to be stated in this debate, is why is the NRA so powerful? and where does it get its resources from?  Yes, it has a broad membership, but so do nursing and medical associations.  One cannot image that the names of Winchester, Reminington, Magnum, Smith & Wesson, among the over 100 US gun manufacturers,  are not key funders and supporters of the NRA given the tens of millions of firearm units sold each year.  Rarely are the industry representatives actively involved, strongly suggesting the NRA has become a business lobby group - not a protector of the US right to defend oneself.

Gun control is life protecting, and just as any other public health problem – North Americans are faced with a public health situation that could be improved through a continuous concerted effort. 

May 2013 bring peace to us all. 

Friday, 28 December 2012

Taxation, the looming Fiscal cliff and the impact on public health in North America

Just as the year comes to a close, DrPHealth will flip over 11,000 views despite very sporadic posting for the last few months.   Stay in touch by following on Twitter @drphealth where a Tweet will inform of all new posts, or you can follow or receive the blog posting by connecting at the bottom of the page. Forward the site to friends, as it is through regular use that the site will be updated.  Please leave comments or feedback – they are most welcomed.

On Dec 31, the US narrowly avoided going over the cliff by some last minute deals, however these are short lasted.  See a good analysis of the implications of the fiscal cliff on public health at Kaiser health news   

Gun control is taking second fiddle to the fiscal cliff these days.   Both will get attention by DrPHealth in the next few days.  The major question is what does the fiscal cliff mean for the health of Americans?

Canadians enjoy a standard of living which includes most health care costs being funded through the public purse.   Depending on where you live, tax burdens and marginal tax rates are slightly different, as are the cost of housing, cost of living, car insurance etc.   Picking the most affordable location to live is more complex than just looking at taxes.  If you are interested, try a tax calculator such as http://www.ey.com/CA/en/Services/Tax/Tax-Calculators-2012-Personal-Tax .  You may find that for a $30,000 per year income that the tax burden is lowest in Nunavut then BC, and highest in Manitoba.   For a $100,000 per year income, the tax burden is also lowest in Nunavut then BC, but highest in Quebec.  The marginal tax rate on that next thousand is also highest in Quebec, and lowest in Nunavut then Alberta.   At around $250,000 per year, tax levels become the highest in Nova Scotia. And around 325,000 Alberta provides the least tax burden.  At the highest income levels, marginal tax rates are between 39-50%.  For 30,000 per year income earnings the marginal tax rates are between 19 and 30%

Piecing out tax rates in the US is perhaps easier as the geographic issues are simplified.  Tax rates vary from 10% to a maximum of 35% (for those with incomes greater than 388,000), and are projected to increase when the country has gone over the cliff to 15% up to 39.6%.   So even if the jump over the cliff has occurred, the highest income earners in the US will be paying taxes comparable to Alberta.   The working poor income earners will be taxed considerably lower than in Canada.

Enter the health care insurance costs. For the 60% of Americans who are insured through self-pay or employment insurance, the added financial burden now becomes an absolute number – significantly impacting lower income earners, and dramatically impacting those without work benefits.   Health care insurance costs for a family earning that $30,000 are the same as the $100,000, and can double the “tax” burden at about $4500 per year.   Higher income earners are more likely to be have employment associated health care benefits.  All of sudden, what might look like a good deal, becomes significantly more challenging for marginal income earners, and a major inequitable benefit for higher income earners. To which we have been reminded that BC retains health premiums as essentially a flat tax for households, Ontario has a scale of premiums based on taxable income.  Neither of these is considered in calculations of provincial "tax" rates - but just as when comparing US rates, should be factored as tax burdens  

As the fiscal cliff looms, most Americans appear to be expecting and accepting of tax increases. The tax burden increases are being spread across all income earners in a somewhat gradient fashion.  The downside to the fiscal cliff is the compromise that is being seen in public health related programming as major funding cuts continue to whittle away while resources are being shifted into health service delivery.   Be sure to review the actuarial analysis of what this means to actually increasing health care costs More health care does not mean better health September 2012 

There is a major step yet to be made in both countries to more equitable wealth distribution.   Moreover, any calculation of tax burden or wealth must now health care out of pocket expenses, otherwise there is no comparability between two vastly different systems.   Finally, as the fiscal cliff looms, the impact on health becomes burdened by the increased tax load, the reduced spending on government programs that keep Americans healthy, and lastly, the health costs that another recession may bring. 

Thursday, 20 December 2012

Who ever said that vaccinating was not dangerous?

No,  this is not about the allegations of dangers of vaccines.  This is about the dangers of being the vaccinator.

Most public health professionals have been subjected to harassment as fervent supporters of protecting children and others from preventable communicable diseases.  It is inherent to the job and employers would move to defend staff abused for supporting immunization.

The disconcerting development is the targeted murder of eight Pakistani community vaccinators employed in the final push for global polio eradication.  National Post article.   Potential retaliation by radicals who believe that a false vaccinator was used to collect information vital to the raid on Bin-Laden.  

Ongoing discourse continues to be directed that other vaccinators are acting as spies.  Misinformation in vaccine resistant areas has included accusations that vaccines are a ploy to make children sterile.  Heavy religious overtones are inserted into the discourse by some community leaders. Opponents in the terrorist war in Pakistan have used the polio eradication efforts as a negotiating ploy to stop drone flights and attacks.

Both parties in this debate should carry the guilt of death and disability from any future polio cases.   That a ruse of providing health care was used to collect military information speaks to the inability of our systems to keep public good separate from political (and religious) debate.   That innocent women, providing an invaluable global public health service, have been murdered in a coordinated, directed attack for being public health workers is beyond deplorable.  

It should make the irrelevant musings of North American anti-immunization groups merely an annoyance. 

Tuesday, 18 December 2012

Mass homicides - making sense and learning from tragedy

The Newton massacre is weighing heavily on all of North America.   It is a tragedy of immense proportion and no words will ever do justice to the impact on the families and children involved.  

The parallel conversations are notable.  First is the valid conversation on the effectiveness and utility of gun control.   Only in the US is this a constitutional right to bear arms, but the spin-off into Canada has killed many Canadians.  The US sees in excess of 11,000 firearms homicides annually, Canada at 10% of the population has 1.5% the number of firearms homicides.  Places like Japan with strict gun control an order or two fewer firearms homicides. 

The second parallel conversation is just on the social ramification of firearms in society which was well reviewed by the US National Research Council in 2004 NRC meta analysis .  The report is exceptionally conservative in its interpretation of the state of knowledge at the time.   The absence of wide ranging reviews since 2004 is a notable gap in the literature.   There are multiple reviews prior to the NRC documentation. (eg Harvard portal on injury control

The third substantive conversation links to the discussion on media reporting such that is parallels suicide reporting Dr P Health copycat suicides.  The Globe’s self criticism is a good starting point in the discussion Globe and Mail self critique.  The criticism does not speak to the public health impact in any fashion, just about misinformation in publication.   Two weeks post the Columbine tragedy, the Taber High School shooting was a demonstrable instance of copycat behaviour related to attention seeking behaviour.

The fourth of the substantive discussion relates to mass shootings.   Tragic events, where multiple deaths have occurred and asking the question why.  The US only listing can be accessed at Mass shooting timelines and a reminder of the major incidents such as Virginia Tech in 2007 with 56 deaths. At last half of the incidents ended in suicide of the perpetrator.   Canada has had its share including the Ecole Polytechnique de Montreal shooting in 1989 that resulted in 15 deaths and a defining point in Canadian gun control.

The motivation of the perpetrators becomes the fifth discussion topic.  Inherently assumed to be associated with mental illness and potentially the shortcomings of our community mental health system, there is very little literature on the subject.  One relatively inaccessible article sounds interesting and would be great to provide a link to – but alas, welcome to the shortcomings of academic journals.  (Mass Murders: implications for mental health professionals Int J Psychiatry Med. 2008;38(3):261-9


No doubt there will be the calls for action, and sets of recommendations – but will sustainable constructive change be achieved.  Other than legislative controls, community based responses have rarely been sustained beyond the initial required reaction, and the lack of any rationale sense or communications in Newton will not likely lead to sustainable societal change despite the evidence.      

Friday, 7 December 2012

Suicide and the media - is there a copycat effect? Do the reporting guidelines save lives?

There was an interesting Twitter debate this week between Andre Picard and Nova Scotia’s provincial health officer.  At issue is whether media reporting of suicide is associated with copycat activity that leads to further suicides.  The conversation was led by an article in the Vancouver Sun talking about suicide .  Mr. Picard’s position being clearly that  “Not potential. Not speculation. Evidence. My position is there is none.Twitter feed December 5, search on @RobertStrang   

Then, in a twisted ironic tragic event, the frenzy surrounding the media prank pulled on the Duchess of Cambridge which duped a nurse into sharing confidential information, appears to have contributed to the nurse’s  decision to complete suicide. Telegraph report.

As with many interventions in public health, we often forget why we do things.  The debate having resurfaced is probably reflective that there is a journalism ethic and sometimes formally written rules in limiting reporting on suicide. 

Turn back the clock, and somewhere around 3% of suicides were considered as part of clusters or associated with copycat activity.  The more explicit the information shared on the suicide, the higher the number of copycat based activity.  

The suicide literature is replete with case studies looking at clusters, time series evidence that media policy change on reporting resulted in a drop in copycat activity. 

A fairly comprehensive literature review is accessible at J Epi and Comm Health  which is a cornerstone peer reviewed publication for public health professionals.   Of course, that was nearly a decade ago, and many countries and media have implemented suicide reporting guidelines so that the issue today is likely so dilute as to be barely measureable and unlikely to approach the 3% level.

Measuring a 3% expected difference in suicides, with an expected rate of 15 per 100,000 population – would actually be statistically challenging.   So while Mr. Picard’s assertions may have some basis, over the years many lives have been saved by following suicide reporting guidelines. Let us not be foolish enough to go backwards and have to relearn the lessons again.

Dec 10 - the debate rages on, the Globe and Mail editorial piece (no doubt with M. Picard's influence - unbalanced commentary) http://m.theglobeandmail.com/commentary/editorials/teen-suicide-contagion-and-the-news-media/article6116592/?service=mobile   

Thursday, 29 November 2012

HIV success stories for World AIDS Day - and a bit of statistical slight of hand

Plenty of news on HIV these days.   That World AIDS day is December 1st might be just coincidental.

Leading the headlines is the report out of BC on the success of HAART in reducing population transmission Picard story on HIV fight. This is great news.   Perhaps a bit self-serving for the 'treatment as prevention' folks that are taking credit for the reduction.  The STOP HIV program, which inherently makes a lot of sense, was only implemented in 2008 and the data on which the research they are claiming success reflects the time period of 1995-2008 (up to start of STOP HIV).  The BC reduction in incidence began in about 2003 and has been consistent over most of the last 9 years.  

They also fail to acknowledge that Canada has started trending downwards since 2008. 

Read the full article at PLOS One Burden of HIV in Canada.   The conclusion is based on data from only three provinces who had innumerable other differences in their approach to addressing HIV and not just in access to HAART.  There are other correlations that might also explain the differences noted, including political stripes of the leadership.  So while non-treatment public health efforts across the country have likely been the major initiators of the downward trend, the use of treatment will be advantageous to sustaining the decrease.   One can see a very similar trend with tuberculosis rates prior to and following the discovery off streptomycin as one of the first effective anti-TB drugs.

A more balanced discussion of the Stop HIV approach can be found in a CMAJ editorial at CMAJ on HIV seek and treat 

In honour of World AIDS day, Health Evidence has produced a list of high quality evidence reviews of practices associated with control of HIV http://health-evidence.ca/saved_searches/run_search/1134  although some are very dated. 

Also in recognition of World AIDS day is the release of an international report The beginning of the end.  Notable as well on page 11 is the incidence of HIV globally has been decreasing since 2003 – the reasons internationally are different from the Canadian experience.  

US rates are more difficult to obtain, and perhaps reflective of less positive news as well.   A detailed analysis was published at US HIV statistics 2008-2011.  A real positive is the addition to the USPTF of universal screening for HIV USTPF draft HIV screening recommendation as a Grade A recommendation.

Tuesday, 27 November 2012

Hot public health topics: Gambling X 2, intimidation, privatization, HPV and influenza vaccine

While headline stories capture our attention, the follow-up of such stories often has a very different course and outcome.   Here are a few story updates.  

Gambling remains an emerging public health issue. DrPHealth October 2012 reviewed some of the more recent trends. Two stories of note that are worth updating.  First, that the Toronto Board of Health, on recommendation from Dr. David McKeown recommended against the expansion of gambling in the city.  Read the excellent background information at Board of health materials.  These resources will be beneficial for all public health workers going into the future and mandatory reading for students of public health.    

Regrettably the federal government House of Commons moved in the opposite direction by approving a bill that will open single sport betting in Canada.  That the sports industry and health professionals alike may object has raised the possibility that the bill will be defeated in the senate CTV coverage of sports betting issue.   There is no doubt that this form of gambling that is uniquely not permitted in Canada, is fuelled by illegal gaming operations.  

Just weeks after his inflaming comments about the Toronto Medical Officer of Health political intimidation of public health workers , Mayor Ford has become the centre of one of Canada’s largest political fiascos.  He has had the judiciary rule him in conflict and requiring him to vacate the mayorality seat.  Follow the story at CBC on Mayor Ford 

Toronto’s Shouldice Clinic was on the verge of sale to the private sector Shouldice clinic and privatization of health care.  The offer for purchase expired without approval or denial from the Minister of Health – effectively killing the transaction in a no context situation Shouldice clinic sale abandoned.

The Calgary dioceses has been the central point for controversy over the HPV vaccine for many years, refusing to permit vaccination of girls in their schools.  While Bishop Henry has not changed his position, the school board is reconsidering its position HPV vaccine and Calgary Board of Health.  There was a recent study released showing HPV transmission occurring amongst girls prior to sexual intercourse.
November 29th - apparently just last evening, the school board reversed its 4 year old decision and will permit HPV vaccination - story at Calgary Herald Story

As the influenza season rapidly approaches, and the first outbreaks are being reported from H3N2, another story out of Ontario that pharmacists will be given the scope of practice to immunize against influenza and prescribe tobacco reduction aids amongst other preventive measures.  Based on experience in a few other provinces, this is a positive move.  Ontario pharmacists gain right to immunize. 

Monday, 26 November 2012

Nut allergies and Nutty Reactions

Someone should start collecting stories of the reaction that parents have when their young child develops a rash after eating peanut butter, and the next thing they are advised they must carry an epinephrine autoinjector and that the condition is life-threatening.  It would be enough to freak out the best of parents.

A recent story related to the mother who wanted oak trees removed from the school yard because her child had developed a “nut allergy”.   Stories that we’ve heard include parents who insist on the right to inspect other students lunches, or on staying with the child in the classroom, appeals for children to have education assistants with them as health challenged students with severe disabilities do. And the topper is the Texas company that trains “nut sniffing” dogs, with parents appealing that the animal is required to protect their child’s wellbeing and therefore required to stay with the child in the classroom.

Some might consider the above a bit of an overreaction.   Were it our children though, we would likely be just as concerned.  The question is what is a reasonable level of concern?  and from a public health perspective, what should we support parents and schools in ensuring a risk reduced environment?

1-1½ % of students at school start will have a positive skin test to peanut extract.  Only half of these will display any clinical symptoms.  Moreover almost all peanut allergic reactions require an adequate volume of consumption, often at least a full kernel, before any manifestations are expected.   That most peanut allergies are treated as if any antigen exposure in the air will elicit a reaction is inappropriate.

The existence of a peanut allergy also does not mean allergies to other tree nuts (and peanuts are not even be classified as a nut by biologists but more a legume as they grow underground).  Even having skin test reactions to certain tree nuts does not mean an allergy or any reaction to all tree nuts.   So, to have a peanut reaction and associate this with acorn associated reactions is a huge misinformed leap.  Another common misperception is that milk allergies are manifest in a similar fashion, and rarely do milk products result in anaphylaxis, nor is there a need to modify the classroom environment to become “milk-aware” in an effort to reduce exposures. 

Schools have become much more “nut-aware”, resulting in overall school based exposure reductions by some 90%.  However even in classrooms with known interventions to eliminate peanut exposures, careful examination will usually reveal some peanut containing materials – and this has not resulted in life-threatening situations. 

As a great resource, Anaphylaxis Canada has developed a common sense and reasoned approach to food allergies of a variety of natures.  Anaphylaxis Canada .   In the end, it is about education, the environment, and emergency response.   Education of the parents, child and classmates, reducing exposure through making the environment nut aware, and lastly parents and the school being prepared for managing the very uncommon emergency situation.  

Wednesday, 21 November 2012

Oxycodone generic approval - a political mess with public health consequences

For those that follow the debate, back in the beginning of this year numerous provinces delisted oxycodone and severely decrease its access.   The debate at the time was the consequence of poorly prepared drug policy shifts on the large number of prescription drug addicted persons.  Oxycodone loosing public funding DrPHealth Feb 22, 2012.  Many of the predictions have materialized.    

In the subsequent months numerous stories ran that followed the impacts including the rise in heroin use  Calgary Sun article and the substantive costs associated with single oxycodone doses for persons wishing to maintain their addictions.   Limited value in managing the addiction has been documented but is a potential positive outcome. 

Now, in the weirdest of ironic moves.  The very government that started the domino of confusion and angst, has its left hand approving the generic form of oxycodone. 

Remember that one of the key switches that occurred was the maker of OxyCotin restructured the formulation in a harm reduction effort by utilizing slow release drug delivery mechanisms. 

So the basic dilemma  we have a drug that has been demonstrated as unsafe but has not been delicensed totally by Health Canada. Because it is not delisted, and the patent is expiring, Health Canada apparently does not have the power to preclude the licensing of the generic formulations.

It is not bureaucracy run amok – but a symptom of a system that was designed to preclude bureaucratic obstacles in the drug approval process.   That  Minister Aglukkaq would stand up and say that politicians can’t stop the process is an oxymoron – it is the politicians that set the process up so it would not be stoppable. 

As Andre Picard flags in his Globe and Mail piece, the oxycodone situation is unique and requires political leadership Andre Picard on oxycodone.  Regrettably, this federal government has consistently failed to show leadership on health issues – and this is another example of its causing a problem that the provinces will be expected to solve, and have to foot the bill for the associated costs.

Monday, 19 November 2012

International Day of the Child - is it a time to celebrate or one to grieve?

November 20th is the International Day of the Child.  It celebrates the 1989 signing of the UN Convention of  Rights of the Child Convention document.   The landmark document is an update of a 1959 which updated a 1924 declaration.  It is reassuring to note that children are high on the international list of priorities, but one has to ask how successful we are globally?  And how successful we are within Canada?

Several provinces have children’s advocates.  Arms length individual charged with watching out for the wellbeing of children.   A report from the BC representative for children and youth was just released that touches on a subject in the wake of the Amanda Todd tragic suicide.  Trauma, Turmoil and Tragedy is a report on youth suicide and self-harm. 

Notable were the consistent themes of risk for youth with tragic outcomes.
                      Lack of stable living arrangements – most notably, children in care being subject to multiple moves .
                      Domestic violence – a significant feature in the lives of more than half the youth.
                      Mental health issues – identified in nearly 70 per cent of the youth and compounded by a lack of clarity of services to address these issues .
                      Substance abuse – by family members as well as the youth themselves.
                      Learning disabilities and lack of attachment to school.
                      Significant romantic conflict in the 24-hour period leading to these incidents.

The report further flags the overrepresentation by Aboriginal persons and those that have been involved with social services.

Many youth suicide prevention programs have been based on preparing caregivers such as teachers to grapple with individuals displaying self-harm behaviours.  Assist (Living Works home page) is one of a number of programs available in Canada dependent upon training providers to work with youth at risk of self-harm.  Other programs attempt to build resilience in individuals to reduce thoughts of self-harm or improve confidence to seek help.  Regrettably after all these years and innumerable programs, there remain few evidence based programs that demonstrate a reduction in the outcome of self harm or suicide amongst youth.

The contribution of the BC representative helps flag why current programming is likely not as effective as hoped.  Many of the characteristics are individuals are pre-existing risks that are identifiable and deserve intervention long before the youth become distraught.  Active intervention for those with risk may be a rationale new approach to consider.  The list of possible risks is similar to what one finds for truancy, school drop-out, criminal behaviour, unplanned pregnancy and a host of other socially unacceptable behaviours that can be interpreted as cries for help.

So while we celebrate the International Day of the Child, let us reflect on the innumerable instances where we as a society are failing to provide for the future of our youth. 

Thursday, 15 November 2012

Rare events – a Public health case history of US fungal meningitis outbreak

When rare organisms cause disease, finding the problem should not be a challenge.

How many of those working in communicable disease have ever seen a case of Exserophilum rostratum meningitis (and meningitis of all causes is notifiable in most jurisdictions)?  In fact the Mayo Clinic reported only one case over 40 years of a skin infection in an immunocompromised person. So when a cluster happens, alarms will sound and the system jumps into overdrive. 

The public health question is why have there been 32 deaths and over 400 illnesses from such an oddity? 

The first case was reported September 21 out of Tennessee where the bulk of initial cases were noticed.  By October 1, eleven cases from a single pain management clinic had been identified.  It only took just over a week to focus attention on the implicated methylprednisolone product, and that most of the deaths occurred in persons who received epidural injections.  The product was recalled by October 3rd.  By October 5th, active trace back was encouraged for persons receiving the product and many of the cases are related to the active trace back despite cessation of infections.

So far, Michigan has had 50% more cases than Tennessee and therefore should have been able to identify a problem sooner.  Based on the state's reaction, a delay in obtaining notices and initiating trace back occurred. Perhaps a reflection of the lack of depth of the state public health service.  

Not that any more rigorous process would have prevented infections or saved lives.   No doubt, there will be the occasional case that could argue they were injected after the lots were recalled, but most cases did not develop symptoms until 1-4 weeks after injection. The retrospectoscope will likely find flaws in the notification system, in the surveillance system, in the recall and trace back processes and likely in microbiological laboratories.  The ultimate critical question being how did contaminated injectable drug product enter into consumer circulation? and what drug preparation processes were lacking before lot release?

We are fortunate the product was not distributed in Canada – or maybe just lucky on this one.  Pharmaceutical quality control requirements are similar between countries and product can readily cross the international border. 

It will make for a fascinating series of monographs and publications.  For those interested in following the outbreak, check out the CDC outbreak website .   A notable omission in the public information are the epi-curves relating date of injection and onset of symptoms.  With such an extensive trace back, one has to wonder when did the first cases occur? And who missed the first rare bird that might have protected others?    

Rare birds incite curiosity, provide an opportunity to test the system, are unlikely to recur in an identical fashion, and may or may not contribute to improving the system required for the common, mundane and potentially larger outbreak scenarios.

Tuesday, 13 November 2012

Peace as a prerequisite of Health

Each November we remember those fallen in wars. The date set in memory of the Armistice that laid down arms on just the Western Front in Europe during World War II.   With recent costly military missions in Afghanistan and Iraq, attention has rekindled back to celebrating the sacrifices of our military personnel.

What we often forget, is that over 70% of the victims of war are civilians – caught between the power struggles and philosophical debates over which they have no control and often no opinion.

2011 saw an increase to 37 armed conflicts, of which 6 had more than 1000 deaths and are classified as “wars”.  This represented an increase of six armed conflicts over 2010. Formal statistics are tracked by a Norwegian centre following wars http://www.prio.no/CSCW/ .  Wikipedia lists a dozen wars, five of which have stated since 2011 Wikipedia listing of global conflict 

The war in Afghanistan topping the list of 2011 fatalities.  Some 1.4 Million deaths have been directly attributed to the war since 2001.  An additional 4.2 Million deaths attributed to the impact of sanctions against the country in efforts to stop the civil strife. 

The Syrian uprising that has garnished the most media attention, has amassed some 50,000 deaths, approximately half of whom were civilians up to 2011.  An estimated 20,000 people have died so far in 2012 and likely will be the war with the greatest number of fatalities this year.   Some 1.5 Million people have been displaced, and another 30,000 have ‘disappeared’.  Consequences of war that are easily overlooked.

Closer to home, the US war on drugs has just over 1000 causalities a year.  The Mexican drug wars resulting in an estimated 19000 deaths in 2011 with some optimism this is reducing going through 2012. 
While we remember those that have fallen in service, let us also remember those that have been the innocent victims deprived of their choices to live.  

Thursday, 8 November 2012

Economists' view of improving the Canadian Health Care system - reflective of a public health agenda

Economists and accountants are not the solution to the health care system, but what they have to say is worth listening to.  Not the beancounting bureaucratic accountants justifying current programming, but the broad thinkers that look at the industry from above the minutiae of professional protection, labour benefits and crisis management.   So when the Conference Board of Canada’s economists come out with a five point plan to fix the system, it is at least worth reading, and probably worth listening to.  

Five priorities for fixing the Canada health care system  is the result of a summit held late October in Toronto that sets out a logical and well thought through plan that focuses on doable and rationale approaches to health care reform. It is not new material or widely divergent from many other studies of the health care system, just this is coming from people who care about how our money is spent.

The plan, simply put:

1.       Build the “gateway” into the health system, primary health care
2.       Invest in information technology
3.       Link professional compensation to outcomes
4.       Manage elderly in the community
5.       Improve Canadian wellbeing

What is missing is the long list of where our major health care cash flows. No mention of high tech medical interventions, drug development, improved facility infrastructure, more surgeries, reduced waiting times, or more health care workers.  The focus is on what helps the patient not the professional.

Granted the details are missing on how to get there and what investments are most logical, but at least it is a vision that is solidly founded and perhaps might shape health system development going forward.  And in a country where investment and economy are currently the key decision drivers of the political machines, such statements from the Conference Board of Canada should be referred to and referenced as health policy is being shaped. That the statements for the most part reflect many of the ideals of public health for the last few decades is a refreshing vote of confidence.  

Monday, 5 November 2012

The US election - what happened to the health care debate?

'tis the day before the great decision.
Romney or Obama are furiously skittering
Rounding up votes with hopes of four years of bliss.
Tallying the states and crunching their numbers.

Jobs are the issue, with stimulating the economy close behind
Training, education, and energy still on the plate.
Sandy is history and left her mark on millions.  
But where, oh where, has the health debate gone?

In a race for the finish line, what was to be one of the biggest election issues, seems to have silently fallen off the political banter.   The election that had such clear political lines at the start; Romney campaigning to eliminate Obama's tentative efforts at health care reform; Obama attacking hard to defend the cautious progress that has been achieved.

There are some groups that have tried to speak out and make the issues public.  With little doubt, the Republican machine is bolstered by some of the 17% administrative costs and profits that the US health care industry generates and are somewhat at risk.  Women's groups, public health, environmentalists and others have shouted into the fog about the implications of not supporting the Democratic caravan and Obamacare reforms, but voices are few, far between and rarely associated with the actual political parties.

The Canadian "universal health care system",  around which can be found a national culture, when tinkered with,  can be the cause of loosing voter confidence and loosing subsequent elections.  Rarely can a political party run a campaign based on even the slightest of adjustments save a promise of a new hospital or expansion of existing services. More of the same will bring the voters out. Reforming the system occurs quietly out of the eyes of the public.  

Has the health care curse hit below the border?   Have the two political machines discovered that discussing health care change means only one thing - loosing voters to the other guy?  In a race that on the day before the election is too close to call by even the sophisticated pollsters and number crunchers, any comments that might shift voters away could crash the train just before it comes into the station - too big a risk to take.

Thursday, 1 November 2012

Sandy - a disaster in evolution

As the fury of the storm named Sandy dissipates moving through Quebec towards the Atlantic, its toll is being tallied.  Two Canadian deaths have so far been attributed to the storm, some 70 in both the US and another 70 from its initial assault in the Caribbean.   It is a tragedy of immense proportions.  Many will be grieving loss of the life, homes, possessions and finances. 

Notable is that on the 4th day after it rammed into the Eastern seaboard are the stories that emergency supplies having been used up, hospitals evacuating as generators fail, some communities still cut off from contact, and millions of homes without power. Gas stations  are closing because fuel supplies are exhausted from running generators. Communications lost as cell phone infrastructure has not been restored.   It will take days yet to restore some of those services – highlighting that emergency preparedness should reinforce the need for at least one week of supplies before expecting sustained assistance and not just the 72 hours that is often quoted.

As is expected in disasters, the consequences have been broader than damage caused by the predicted winds and rain.  Notable is the extensive loss of homes from gas related fires and hazardous spills associated with rupture of containment vessels.  In the days ahead will come the stories of personal impact – both heartening, and those of devastation. 

In a disturbing way, two stories that are circulating reflect somewhat misplaced priorities.  Out of Atlantic City is the income lost from casinos that closed.  The second is that even as the New York city attempts to recover from the storm, and many of their transportation subways are flooded, that the scheduled marathon this weekend will proceed – in part because of the number of participants who are registered from other countries and parts of the US who are to travel into the city even through transportation systems are crippled. 

Emergency planners will speak about continuity and recovery phases and planning.  Perhaps the least well developed and yet most important phases of managing a disaster.  How to maintain essential services, and how to rebuild from the rubble.  Let us hope that the next few days demonstrate strong leadership by emergency management crews that keep people as the central focus of the recovery efforts. 

Lest we forget, Sandy’s impact is however only a fraction of the over 1800 deaths from Hurricane Katrina in 2005.  

Tuesday, 30 October 2012

CPHO 2012 report released on Sex and Gender: A silent release.

David where are you?    

On Friday October 26th, the Chief Public Health Officers 2012 report was released.  No press release, no media attention, no public communication.   We know you better than that.  While your health has been assaulted this year, we know you have been active in many areas.  But, this is not the first year either.   Once again, your major document outlining the dominating health issues in Canada is silently posted to your website, with no effort to publicize its existence.

Are you so quashed by federal communications folks as to truly be painted as suffering the very intimidation that this site spoke to at Intimidation, politicians and public health professionals?  You are admired and respected across the country, and have left legacies of benefit from across the country.  DrPHealth has followed your rise from Barrie, through your home roots in Saskatchewan and back to the hallowed halls of Ottawa.  Your tenure as president of CPHA was one of the most fruitful and impactful.  You are a master of the public health professions.

Have the federal bureaucrats handcuffed you to the point of impotency?   And while awaiting translation has a measurable impact on public release of federal documents, the material is available in both official languages from time of release. 

Ranting aside, it takes bravado to release a report on sex and gender in the environment that you are working. The fundamental perspective being that of recognizes sex and gender as a determinant of health, and discussion of its known contribution.  The burden carried by males and females in society. 

The report opens with a general discussion of the state of public health in Canada.  Mixing the good and the bad, and highlighting the impact of the recession, the widening gap between rich and poor and updating knowledge on risk taking behaviours. 

The provocative discussion that follows in part 2 recognizes the impacts of sex and gender, discusses sexual health  in a frank and dispassionate fashion, and speaks to the diversity of sexual practices.  Notable is the lack of visual aids such as charts and graphs.  The differences are buried in the text and require careful reading.  Is it politically unacceptable to flag the plight of single mothers? Gay men? Transgendered individuals? Stigmitized persons with mental illness?

The full report is found at 2012 CPHO report on Sex and Gender.  Previous reports are found at CPHO annual reports.  

While the efforts to speak on behalf of the health of Canadians of Dr. Butler-Jones should be commended,  there is a need for a significant reprimand for the inability to speak out on these very issues.   Somehow it is not surprising given the current government, the comparable lack of communication from Minister Aglukkaq, and the prevailing communications trend from government that the best news is not to be in the news, but it is not an excuse for not doing your job.  

Monday, 29 October 2012

Influenza vaccine suspension: Special posting: Politics trumping Public Health

Those on the inside of the vaccine distribution system and following the Novartis Fluad® and Agrflu®  product “suspension” are shaking their heads.   Why?  

At a time when influenza vaccine has become the lightening rod for anti-immunization rhetoric, it is fuel on the fire.  

The Canadian logic appears to be that since the Italians noted some minor aggregates and recalled the vaccine, then the French followed suit – that we in Canada need to look like we are doing something as well.   Even if the vaccine is okay, we need to look like we were being prudent in protecting the public’s health and reacting to a potential threat.  We will need to look like we have taken an appropriate time to evaluate the problem, consider safety and risks, determine options and make decisions.   All for the sake of appearing to do the right thing.  Another case of politics trumping science. 

The vaccine has been through quality controls.  The minor issue is not different or problematic.  Every expectation is that existing product will still be released, the only question is what length of delay will be believable for the public. 

The damage is done.  There will be the usual nay-sayers rhetoric and “I told you so” from the immunizer detractors.   The calls are already coming in from those concerned their health has been assaulted having all ready received the vaccine.   Those seeking vaccine will want the “other vaccines” as they are perceived as safer.  Some who received the vaccine will not believe it worked and will return for a second dose of another brand. There may be a shift away from getting any vaccine as distrust builds against vaccine manufacturers and public health, or there could be run on vaccine if the perception is that there now will not be enough.  

Through it, the decision makers will not be standing on the front line fielding the tirades and inquiries.

Normally there would be a media feeding frenzy, but Hurricane Sandy will take precedence.   If we at DrPHealth were making the public relations decision -  wait until the storm passes and influenza vaccine starts creeping back towards the front page, and then re-release the vaccine for general use.   We could be wrong and perhaps some magical scientific finding will appropriately justify the caution and a full recall -  but heck, why not unmask the predictability of the current shallow politicos who are more worried about public perception than public health.

October 31 update:  As predicted, Health Canada released the influenza vaccine, although as the storm was still drenching and blowing major centres – its impact on Canada certainly nowhere as devastating as our southern cousins and therefore not in the forefront of the news. The release of the vaccine quietly occurring with minimal media attention and without some greatly needed questions answered as to why any action was taken. 

Disaster preparedness – are you ready?

The west coast was rocked by a 7.7 magnitude earthquake. Tsunami warnings were followed by swells that were mostly less than 1 metre.  Damage was minimal.  Essentially a training exercise for the predicted “Big One”

Comparatively speaking the east coast is about to be pummelled by Sandy as she makes landfall near New Jersey, will collide its warm humid air with a cold front, and then get pushed north and finally east  with the storm centre expected to pass on a track over Kingston and Montreal before heading across New Brunswick, PEI and Cape Breton.   Our thoughts in advance to those that will still feel its slightly buffered down furry.

For those in the expected path, perhaps a bit of time to scramble to prepare.  Check out some quick reliable sites like the Red Cross or the Canadian government. The only added advise, is be prepared for up to 7 days before aide becomes available.   The typical 72 hour notice is based upon Californian expectations of the time to initial contact – not the time to receive aid.

Sandy has already killed over 60 people in the Caribbean, and likely that number will substantially increase.   Deaths from falling material, wave surges amongst gawkers who feel indestructible, exposure, and add to this the exacerbation of cardiac and other chronic diseases caused by acute stresses that can lead to sudden death or disease exacerbation.   With the predicted levels of snowfall in some areas, motor vehicle deaths may increase.  A review of the Canadian weather that kills provides a reminder that annually about 20 people are killed by weather, but extreme events can increase that to 100. 

In the aftermath, there is a predicted $80 Billion clean up expected as this Frankenstorm hits some of the most populated US areas and will pass along a portion of Canada’s most populous area.   Canadians, while priding themselves in being intimately familiar with extreme weather events, may still not be adequately prepared for the consequences and conduct of this hurricane/tropical storm.  Let us hope that the predictions are exaggerations. 

When preparing for a potentially disastrous situation, pray for the best, but plan for the worst.  For those not affected, your thoughts are welcomed, and  take this opportunity to plan for your disaster, there is not a part of the country that is immune from extreme natural events. 

Friday, 26 October 2012

Intimidation: Politicians and public health professionals.

The Ford brothers in Toronto have openly done what many, perhaps smarter, politicians routinely engage in – Intimidation and harassment of those invested with non-partisan responsibilities for in the public good.  Central to this debate are comments about the Medical Officer of Health (MOH) for Toronto, David McKeown.  The epitomy of a style of public health worker who is humble, thoughtful and a considerate gentleman. Globe and mail reporting of radio broadcast and   Wellsley Institute commentary 

Perhaps there are thanks to be directed to the Fords, for openly stating in a public forum, what often occurs behind closed doors.

Where kind-hearted and truly invested individuals migrate towards public health, successful politicians must by necessity invoke multiple personalities.  One of those personalities is hard nosed, ruthless and dispassionate.   Hence we have a butting of heads that could occur.  For the Toronto case, perhaps the lack of credibility of the Fords can make the situation laughable.

The more challenging situations are the backroom discussions that place MOHs in conflict with governance people, where expectations are linked to performance and resourcing, a form of insidious blackmail and clearly personally intimidating.  Some MOHs can ride the situation easily, in particular those that have stability in a community that has longevity that exceeds the current political regime. 

One has to assume that the relatively inability to speak out of our Chief Public Health Officer Dr. David Butler-Jones is linked to implicit expectations on towing the government’s line as much as possible, and speaking rarely where public policy may compromise the public’s health. The CPHO situation is also echoed by stories that slip out of the chief provincial health officers. 

In fairness, butting heads constantly leads to resource reductions making doing the job more challenging. While a skirmish may be won, the battle can easily be lost.  Strategic posturing is essential and rarely is a fight worthwhile that leads to succumbing and lost of a job worthwhile. We have seen many a CPHO and MOH fall to the side as they have fought their way on the mountain.    Sometimes groveling or dancing to the political piper can be rewarded with the tools to make a difference in another area. 

While the current issues seem to relate to censoring the mayor and his brother, the reality is the issue is much broader than a public spat.

The job of the Medical  Officer of Health or other senior leader in Public Health is not a job for the faint of heart or fragile egos.  It is also not a job for those that are stubborn or overinflated egos.  In the end, our better public health leaders are rarely accumulators of friends, or of enemies. They are also infrequent recipients of expressions of gratitude or offers of personal support.

So thanks to Dr. McKeown for his leadership and foresight, and our expressions of condolences for his current challenge of having to work with such disrespectful politicians.  

Tuesday, 23 October 2012

Blogging with DrPHealth - Viewers Choice

Sometime next week, DrPHealth will turn over 10,000 views.  There will have been about 230 posting over the 17 months of contributions, suggesting an average of about 50 views per posting.  Blogspot has gotten better over the year of tracking individual posting views, but the number of tracked views is probably only about half of the views. 

A massive one day surge about fracking, which led to a historic high number of single day views prompted this posting about what do you as the readers say are the most important issues.  

There are some clear favourites amongst readers.  Not only do they have high numbers of views, but intermittently there are surges in activity around a particular posting.  Most continue to have views months after the posting. Except from the fracking post, the most frequently visited posts tend to be over several months old. 

Viewers who subscribe to an emailed version are not counted as there is no listing of the number of persons who receive the blog on a regular basis through email. 

So, here for everyone’s pleasure, are your favourite postings, in reverse order by volume of views. 

Public Health hot topics
Canada`s 2012 Budget - Public health implications
The cost of US medical costs - Financial stress has a health cost itself
The Determinants of Health - moving description into solutions
Tweeting the public's health. Social media as a knowledge adjuvant
HIV progress in Canada – A great public health success story to start the New Year
Eggceptional news: Its no yolk. The myth has been laid
Healthy Build Environment Part 3: Health and social services, food stores and fast food outlets
Social injustice - Attawapiskat, Aboriginal Health and Janus
Hot public health topics worth reviewing: Provincial budgets, low sodium diets, smoking cessation and perinatal indicators

Electronic Health Records - so much spent and so far from achieving the goal
Smart meters –The role of public health in scientific controversy


Hookah pipes – a new generation of smoking hazard

Telehealth: A real public health contribution - or at least a major convenience 

Fracking - Is it an obscene public health word 
The Cost of Poverty in Canada - a potential way to reduce health costs

Thanks to everyone that makes DrPHealth worth continuing to post.