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Thursday, 31 May 2012

Census 2011 - Demographic planning for public health


The voluntary census of 2011 is beginning to trickle out its results.   Bookmark the home page for direct access to information as it is being released Census 2011 data

This weeks  released on age and sex contains two bits of information for future planning.  First and to noone’s surprise, the proportion of persons over the age of 65 is continuing to grow, having reached 14.8% of the population. Good news for geriatric specialities, but perhaps not as notable as it is being made to sound.  Consider the large countries with a seniors ratio that exceeds 20%, including Japan, Germany and Italy.  Sweden, Greece, Bulgaria, Austria, Portugal, Belgium, Finland, Spain – in fact most of Europe have proportions in the upper teens.   14.8% actually puts Canada 42nd of 230 countries globally. While some of the European countries may be economically challenged, and a portion of that caused by social programming – economic prosperity is not well related to the age structure of the population.  Enlightened countries look to the ageing population as an asset, not a liability. 

Subtly in the release of the data was the other hidden gem.  The baby boomerang generation (babies of the Baby boomers) are themselves having babies.  In fact the population aged 0-4 has gone up 11% in the past 5 years. What the census doesn’t capture is that the annual birth cohort after slowly decreasing for a couple of decades has continued to expand for the past 6-7 years.   Schools continue to see decreasing student populations and will do so for about the next 7 years, but school planners should be ramping up kindergarten opportunities and elementary schools in anticipation of the surge.  Not a tsunami of kids, but certainly growth can be anticipated. (of interest will be whether the recent recession has slowed family choices on having children or the number of children per family)

From a health system perspective, it is the perfect storm converging.  The seniors population in need of services continues to grow and will do so as the Baby boomers who are now just reaching retirement years begin to expect and need increased health services, and demand is placed on the two other groups that frequently utilize health services, the expanding child population and their new mothers.  

Baby boomers have come to know and expect ready access to health services, and an analysis by cohort demonstrate that a significant proportion of growth on health service utilization is based on expectation and not on need.

Of course, in our myopic health system planners may well review this from an absolute increase requirement of the things we are already doing.  Better clarity on defining expectations, training on health service utilization, self management, and diversification of providers can mitigate the absolute numbers needed,  but are rarely incorporated into planning models and sacred cows not to be touched politically.  Megalomaniac administrators and politicians may well look at the growth opportunities that absolute demand places on the system.  So,  regrettably, expect more of the same.   

Tuesday, 29 May 2012

Health indicators – who is the best?


The CIHI report https://secure.cihi.ca/free_products/health_indicators_2012_en.pdf  introduced in the previous blog provides the richness of information that can be a guidance for health improvement.  Of course, improvement to what is a good question since currently immortality is a fantasy.  So here are the best of the health regions, best province and how much better could the worst of the provinces and regions do if they were to get to the best practices in Canada.  Except for the one rate to celebrate, the territories were omitted from the analysis and oftentimes have poorer health indicators than the worst health region.  PEI is treated as a single health region as well as a province.

Indicator
Best region and rate
Best province and rate
Improvement if worst province could align with the best
Improvement if the worst region could align with the best
Age standardized mortality (per 100,000 population)
Richmond BC (155)
BC  (244)
a reduction of 66 or 21% of the current rate)
a reduction of 211 or 58% of the current rate
Potential years of life lost
Richmond BC 2707
Ontario 4182
A reduction of 1849 or of 31%
A reduction of 5017 or of 65% of the current rate
Cancer incidence

Alberta 399.8
186.6 or 32%

Youth body mass index (25 or greater)

BC 16.4
Reduction of 15.8 or 52% of the current level

High blood pressure

Yukon, NWT and Nunavut with ranges of 9-11.6
Current highest level is 24.6% of population

Injury hospitalization per 100,000 population
Central ON 306
Ontario 407
302 or 48% reduction to be achieved
A reduction of 790 or 71% of the current rate
Acute myocardial infarction hospitalization
South Vancouver Island BC 118
BC 163
157 or a 48% reduction
260 or a reduction of 69%
Smoking

BC 17.4
5.8 or a 25% reduction

5+ fruits or vegetables per day

Quebec 50.4%
21.8% or a 76% increase required

Potentially avoidable mortality
Richmond BC 113
BC 172
46 or a 20% reduction
159 or a 58% reduction
Avoidable mortality from preventative causes
Richmond BC 70
Ontario 110
33 or a 23% reduction
114 or a 61% reduction

The point here is consistently the better to do provinces are 25% better than those that are not so well off, and the better health region are a whopping 3 times worse off than those that are well off.  To which the reminder must be issued that the rates for the territories are often worse that the poorest of the health regions on many indicators.

In Canada, inequity is alive.  The CIHI report begins to at least unmask some of the disparities that are in place at home.  

Monday, 28 May 2012

CIHI 2012 Health Indicators report released


There is an annual tradition for which we owe a debt of gratitude to MacLean’s magazine.  It is the release of the comparison indicators between health regions in Canada by the Canadian Institute of Health information. health indicators report 2012  or if the link does not work, access through the CIHI site and download for free at CIHI store 

The document does what the provinces have long feared, makes some direct comparisons combeined with celebrating the cumulative accomplishments of health improvement in the country.   Considerable focus is on the impact of the health care system on wellbeing, a calling deaths as avoidable and preventable – then listing where the system is not working. 

The actual document which compares health regions is embedded starting at page 45 – perhaps another message of how the document has impacted perceptions.  Most notably though is while there are reams of statistics, the presentation is standard geographic format and you will need to study the information before drawing any conclusions.  So much so that while regions may be marked as statistically different, you may find yourself asking if the finding is higher or lower than the national rate, and statistically testing does not appear to have been applied to provincial data – leaving the impression that perhaps there is no statistical difference when clearly there is.

And when will the health system learn that it has a huge impact on the determinants of health and that these are inappropriately called the “non-medical” determinants of health?  The document defines these as factors outside of the health system that affect health.   And yet, right up front in the document the health system is defined as "by the World Health Organization in 2000, includes “all activities whose primary purpose is to promote, restore or maintain health.” Therefore, in addition to the provision of care, the health system also includes public health activities of health promotion and disease prevention and other policy initiatives such as road and environmental safety  improvement, access to clean water, support for good nutrition and housing.”

Such inconsistencies are reflective of biases and prejudices of some of the members of the CIHI board who might be obvious when reviewing the names, but will not be shamed publically here. Thankfully the more rationale heads of the likes of Brian Postl, Vivek Goal, Corey Neudorf, and Luc Boileau who bring strong public health thinking to the table have influenced the remainder of the document. Thanks to these broad thinking directors of CIHI we have such a worthwhile document. 

The data are a major contribution to determining how well health regions and provinces are performing.  DrPHealth would welcome your interpretations of any particular section – if you don’t analyze it, don’t expect that the report will have made what is inherently obvious to you, something that others would recognize (write your piece and send to drphealth@gmail.com)   

Thursday, 24 May 2012

Prostate screening recommendations - First, do no harm


The main topic of the week on the wires is the US preventative task for recommendation (USPTF) against PSA screening for prostate cancer.   Timely given this sites discussion on overscreening a week previous overscreening - a new public health risk.  DPHealth takes no credit for the wisdom of the  USPTF. prostate screening recommendations .  The Canadian task force came under similar scrutiny for its enlightened view of breast cancer screening CTF breast cancer screening ,  CTF has yet to comment on prostate cancer screening. 
The USPTF short version – PSA screening may benefit the reduction in death from prostate cancer by 0-1 men per 1000 screened. 

80% of PSA positive tests are false positive - that is they do not reflect cancer, but they will likely result in at least a discomforting biopsy. 

Screening leads to an upwards 50% increase in detection of what otherwise would have been clinically non-relevant cancers (ie asymptomatic and would not contribute to the individual’s subsequent health)

1/3rd of men who have prostate surgery develop significant post surgical discomfort, 5 in 1000 die post surgery, and 10-70 will have significant complications.

On the balance sheet the harms are roughly the same, or slightly more than the benefit.  

As Hippocrates wrote into the oath taken by physicians – "first, do no harm".  One of the four pillars of modern medical ethics is this principle of non-maleficence. Kudos to the USPTF for staying true to the Hippocratic oath.  

To celebrate the Canadian contribution, the Canadian Task Force on the periodic health examination was founded in 1976 and formed the model for the USPTF that followed in 1984.  The CTF developed the methodology that has been emulated numerous times in assessing quality of evidence review and the synthesis into grading of recommendations.   Both bodies as well as other national bodies modelled after the CTF are designed to look carefully at the evidence for applying population level interventions.  The current iteration of the task force was revived in 2010 after a 5 year disbanding and one only hopes survives the scythe which is swinging in Ottawa these days.  

Tuesday, 22 May 2012

Flu report card launched by the Lung Association fails grade.


A few weeks ago the lung associations from BC and Quebec released a report card on influenza in Canada BC Lung association link.  Last Friday the American Public Health Association picked up on the report card and gave Canada an overall failing grade.  APHA link.

On the surface, it made for good media coverage and much mileage CBC report on report card.  Probably made the folks in BC feel good, and provided fodder for Quebecers to tighten up their influenza vaccination program.

Here’s where the critical public health mind needs to go to work and read the fine print.  You can find on the original release that the study was based on a 3 day telephone blitz of 1019 residents for Canada.  It provides some level of stability on a national level, but start breaking that down into provincial data, and your confidence intervals are such that even the difference between BC and Quebec likely becomes not-significant. And then to draw a conclusion about recall on influenza like illness to suggest that certain provincial policies are better than others is a bit of a stretch.

Of course, look to the Canada community health survey for more accurate data – buried in reams of paper and not user friendly.  From 2007/08 (please let us know if there is comparable data for 2010 yet available anywhere).  Turns out that total population coverage rates has Canada at 30.5%, Nova Scotia doing the best at 38.9% and Newfoundland and Labrador in the basement at 23% (BC at 29.3% and Quebec at 25.2%). 



Ok, the years aren’t comparable and we did have a little H1N1 in between the surveys, but the rigour of the CCHS survey and the overall differences between this and the Lung Association must be noted. Likely no harm done other than the APHA headline that suggests Canada has a failing grade collectively and it would be interesting to see some international comparisons.   

Of course, kudos to the lung association for doing what PHAC and Health Canada seem so reticent to do - actually compare jurisdictional data.  McLeans magazine started the trend and over the years the McLean’s rankings carry more credence than most government reports, but isn’t this something that our major health oversight folks should be doing so that we can make decisions made on solid science?  

Monday, 21 May 2012

Cosmetic pestcide ban falls in BC - how to release politically unwanted news before the long weekend


If you are interested in how to release politically unwanted information, watch the media on the Friday before a long weekend. 

A year ago, BC’s premier indicated that she would move to regulate cosmetic use of pesticides and join the forward thinking provinces of Qu├ębec, Ontario, New Brunswick, Prince Edward Island, Alberta, Nova Scotia, and Newfoundland and Labrador in precluding the use of cosmetic pesticides.   (and in Saskatchewan and Manitoba pesticides companies are so much of the economy they might be excused).  But in tree hugging BC, known for its environmental extremism and oftentimes very insightful policies, the shocker was released on a Friday afternoon before the first major outdoor camping weekend – one can just imagine the back-to-naturists having departed their telecommuting offices for the relative wilds - when the earthquake was released.  BC cosmetic pesticide committee's collective wisdom flew in the face of the 40 existing communities and 60% of the BC population that already have voted no to cosmetic pesticides.

No wonder the report was released before the long weekend. By Tuesday, all that will be left are some echos in the blogosphere like this.  

Read the decision.  Pesticide ban committee report May 18 2012  it actually seems to make sense of many of the aspects of the rationale.  What should disturb our BC colleagues thought is that little is made to suggest that there are not health effects currently.  The decision seems more based on everything is currently hunky-dory, and that further restrictions would hurt certain industrial processes, with the kicker being on page 25 where media reports were used to demonstrate that pesticide limitations were problematic as it led to weed overrun playing turf. So while popular reporting received considerable attention by the committee, the health consequences were skimmed at best and almost accepted as trivial fact. 

Thus the committee knowingly decided not to act in the face of a potential health hazard.  Perhaps another blow for Premier Clark in controller her government.  Clearly a win for the minority industry supporters that responded in the process, and likely a win for some ultra conservative cabinet ministers who wear liberal red clothing.  

While BC’s public health community seems to have had some differences of opinion leading up to the committee deliberations, the final decision will be seen as another blow to public health in BC.   The strong advocacy efforts of the Canadian Cancer Society with many NGO partners clearly overwhelmed the committee input with supportive comments that have been ignored.  

And BC gets to stand alone – renowned for its green stances, but willing to poison its land. 

Any other May 18th, Friday before the long weekend stories to share?   Feel free to write a piece and submit to Drphealth@gmail.com   

Thursday, 17 May 2012

Pertussis – back in the news big time, but where is it in formal surveillance systems?


Several months ago this site spoke to the issue of pertussis DRPHealth a need for adult pertussis vaccine  in the face of some small outbreaks within the country.

Today’s news includes a report on nearly 1500 cases of pertussis from the state of Washington Washington department of health pertussis statistics .  Of note is a New York Times piece that specifically blames the large number of cases on state funding cuts to public health NYTimes editorial on pertussis   even though Governor Gregoire released a whopping $90,000 in additional resources to fight the outbreak.  

Undoubtably related in some fashion to Canadian exportation of pertussis from BC’s outbreak that began last fall Vancouver sun article referencing 224 BC cases since outbreak start .

There would apparently be clusters of pertussis throughout the US  - but one would not capture this by looking to CDC statistics CDC reporting on pertussis , try Twitter @pertussis for notes about Washington, Illinois, New Mexico, Wisconsin. Google adds at least Iowa and Montana.   Of course weekly US stats are published in the MMWR  MMWR morbidity stats May 11.

While Canada posts weekly influenza statistics, try finding anything more recent than 2004 on national pertussis statistics, and certainly nothing yet this year in Canada Communicable Disease Report   CCDR home page
Have Twitter and Google become the de facto communicable disease surveillance tools of 2012?  Try other search strategies and see how successful you are in getting an update on Canadian pertussis activity in the year, if you are lucky you will find reports of a 100 or so cases in New Brunswick, a cluster in Elgin St. Thomas health unit in Ontario, a distinct rise in cases in Quebec so far this year, and now Southern Alberta in the past week.   

The disconnect between transparent disease reporting in Canada and the US, and the use of newer means of surveillance are becoming increasingly apparent and perhaps foreboding, or perhaps a new opportunity to do things differently.  In any case pertussis remains a dangerous disease and there is a gap in public communication regarding the risk.  

Wednesday, 16 May 2012

Opposition mounting to Bill C-31 and cuts to Refugee health funding.


A variety of health care organizations and groups have been mounting pressure on the government to reverse its decision on reducing the Interim Federal Health Fund (IFHF) and declaring certain new refugees ineligible for health care benefits if it does not put the public at risk (see DrPHealth Bill C-31 proposed treatment of refugees)

The impacts of the cuts can be found at  http://www.cic.gc.ca/english/refugees/outside/summary-ifhp.asp   

Notably are the following on the wires, additional links will be added as received.

Canadian Association of Community Health Centres CACHC news release  with some on-line petitions to sign.
Canadian Doctors for Medicare Docs for medicare letter 
Coverage of physicians protesting in the MLA office Star coverage of physician occupation  CBC coverage  (nice to see Phil Berger’s name surfacing – he was instrumental in forcing more ethical interactions with the pharmaceutical industry )  
Globe and Mail editorial of why cuts will cost money let along are unhumanitarian  Globe and Mail
Healthy Debate blog from St. Michaels Cuts to IFHP 
Tweeters – check out @RefugeeHealth for more and join the conversation. 

The rage is mounting.  Regrettably Bill C-31 is through committee stage and was presented to the house on May 14th and will likely slip into 3rd reading imminently despite the growing outrage.   Consider expressing your opinion.  Notably, the cuts to the IFHF, while linked to the refugee reform process are not inherent in legislation and may be open to reversal through public demand even if C-31 passes 3rd reading.

Please be sure to communicate any further updates or interpretations to drphealth@gmail.com


Tuesday, 15 May 2012

Public health on the wires: Cancer statistics, Breastfeeding, MS and Garlic.


Periodically a list of items stacks up that reflect small bits of information relevant to public health workers.  Based on viewing numbers, such reviews are well received – so here is another one in celebration of topping 7000 views. 

Cancer statistics Annually, the Canadian Cancer Society has released the Canadian Cancer Statistics.  Top of the incidence list for females and males respectively is breast and prostate cancer.  Second and third for both is lung and colorectal cancer.  Lung cancer remains the top killer both genders with breast second for females, colorectal third for females and second for males, and prostate the third leading male killer.  Pancreatic cancers are fourth leading cause of death for both genders.

While all cancer age standardized incidence rates have remained relatively stable, the numbers diagnosed each year increase as the population grows and ages.  Mortality rates have been decreasing substantially - but even so the numbers of persons dying from cancer continues to increase for the same reasons.  The monograph does a good job of explaining this anomaly.

So the cautionary notes:  The incidence of non-Hodgkin’s Lymphoma, Kidney, Liver and thyroid cancers are going up.  With thyroid in females being the most rapidly increasing.  Lymphomas can be secondary to immunosuppression including treatment for other illnesses or primary due to environmental exposures.  Liver cancers are likely secondary to carriage rates of Hep B and C.

Overall the annual publication is a good read and well worth staying in tune with the changing face of cancer in the country.  This year’s iteration is found at Cancer stats 2012

Breastfeeding:   As Time magazine stimulates the breastfeeding dialogue with discussion of the socially acceptable upper age to feed Star editorial on Time magazine , it was noteworthy to see a good quality review of the value of exclusive breastfeeding to 6 months of age.   Science playing catch up to society.  Breastfeeding literature review.

MS and CCVI treatment:  Suffers of multiple sclerosis and their families have no doubt followed the chronic cerebrovascular insufficiency (CCVI) debate closely.  DrPHealth spoke to this in August 2011 if its too good to be true, it probably isn't.   Last week the FDA issued a warning about the risks of CCVI  alluding that the risks exceed the benefits.  While some trials are still in progress, expect more bad news for MS suffers that have been placed on the roller coaster of hope.   FDA alert on CCVI

Garlic and the common cold:  Finally, a fun tidbit for garlic fans, and who isn’t a fan of the aromatic bulb?   The popular home remedy has been touted as a cure for many ailments.   Its a quirk language that “ail” in English means to become ill, in French it is garlic itself.  The Cochrane collaborative reviewed the evidence of garlic’s healing powers over the common cold.  Perhaps speaking more to the bias against complimentary medicine, only one rigorous scientific study was found, and results allude to a benefit – but the typically conservative Cochrane conclusion being insufficient evidence to make a definitive statement.  Kudos for to the Cochrane for looking at traditional remedies, and perhaps a call for better and more rigorous controlled studies of something “we all know”.  Garlic keeps others away further away, so is a great preventive measure for the common cold.   Garlic and the common cold

Monday, 14 May 2012

Overscreening - a potential new public health problem


This site is dependent upon you as readers for its success. Early this week the site will exceed 7000 visits over the past 10 months and does not include those the receive the posts as an email.   Please follow the site (click on lower right for following or lower left to have blog emailed to you) and forward the links to colleagues.  Just as importantly, contribute issues of interest by contacting drphealth@gmail.com.   Or follow on Twitter @drphealth.   


Screening for disease prior to the development of overt manifestation of illness , also referred to as secondary prevention, has been a mainstay of public health practice.   Few would question the value of screening for cervical dysplasia/cancer, hypertension, newborn hypothyroidism and enzyme deficiencies,  or hypercholesterolemia.   Disease that once showing overt symptoms are often already past points of symptomatic intervention.  

Of course once diagnosed, there is an intervention that is required.  For cervical dysplasia that has been reduced to essentially a one-time cure.   The other illnesses noted above often require lifelong intervention and incur significant costs.  

Screening programs only work if they reach a high proportion of the population at risk for developing the disease – hence the cost can be significant.   Compound this where there are individuals or groups of individuals who stand to benefit from the screening program who are separate from where the cost benefits of early intervention are accrued and a fertile ground for abuse develops. That ground can extend to biased research and poorly founded recommendations.  

So in come the two major gender specific debates, screening for breast and prostate cancers. Both are still the leading cancer type for each of the sexes.   The outcomes of both illnesses are dreaded and frequently result in death, adding dramatization to the debate.   The cost of a mammogram is about $100, that of a prostate specific antigen (PSA) around is about half that.  Spread over millions of folks, that begins to look like a lot of money.   Add to the cost of screening is both have fairly high false positive rates that mean intervention in the absence of disease that would likely have progressed.  

So it is notable that within a short space of time there are finally some review articles and lay literature beginning to push back based on the negative consequences of overscreening.  Health Evidence has recently published two reviews, international mammography comparison  and meta-analysis of prostate screening raising concerns about current programs.  The former questioning the value of population based screening and not even delving into the debates of age-specific recommendations, the later further fuelling the evidence that PSA screening is not recommended.  

Link this with a newspaper article that actually looked at the value of whole body screening – the concept of doing CT or MRI scanning routinely of the whole body just to see if there are anomalies that should be acted upon.  A whole 86% of asymptomatic persons had an anomaly that if found in isolation would have resulted in further investigation.   The article further bemoans overdiagnosis of prostate and breast cancer  - it is a great read for lay persons and health professionals alike Oversceening Vancouver Sun.   


Notable in the 2012 Cancer statistics just released, there is multiple references to the value of screening for cervical, breast, prostate, and colorectal cancers without mention of the potential negative consequences. Screening and secondary prevention have a very clear role in public health,but also  in public health objectivity remains a core value, even in passionate debates over life and death.  Worse still is the confusion caused by supposed 'expert' advice that is conflicting.   Groups like the Canadian Task Force on Preventive Health Care were and are designed to wade through this myriad and develop defensable recommendations that all health care workers should follow http://www.canadiantaskforce.ca/

Thursday, 10 May 2012

Mental Health in Canada - a celebration week and Canada's first national strategy


This is Mental Health week in Canada.  

The past decades have seen incredible changes in our approach to persons with mental illness, the recognition that mental illnesses are one of the most prevalent illnesses in society, and discussions that are leading to the normalization and destigmatization of mental illness similar to physical illnesses.  

There is a long way to go.

In recognition of the week, the Mental Health Commission of Canada has released its first national mental health strategy.   Perhaps you are cringing with the thought of another mental health plan, think of how many have been released already, the innumerable recommendations, and the slow dis-coordinated responses to previous local, regional or provincial plans.   So what possibly could a national mental health strategy bring to the table that has not been previously recommended?

Begin by looking at the Mental Health Commission of Canada website http://strategy.mentalhealthcommission.ca/  ,  A plethora of valuable information condensed to one location.  Right up from the recognition that 20% of Canadians suffer a mental illness at an annual cost of $50Billion (Canada’s total health care bill runs about $200 Billion annually).  Thirty per cent of disability work claims relate to mental illness, in the federal public service this is nearly fifty per cent.  The site is rich in its provision of facts supporting the efforts of bringing mental health to the forefront. 

The strategy summary is supposedly easier to read at only 34 pages Summary document   The full strategy only runs 113 pages Full report.  Typical however of mental health strategies are the 109 recommendations.  Also not surprisingly is the recommendations do not define who is responsible, in particular lack any direction to the federal government who would be the ones to whom a national commission should be explicitly directing their recommendations.  In an environment where the government is reluctant at best to receive advocacy, and at its worst eliminates funding for bodies who attempt to provide constructive suggestions on the role of the federal government – it is perhaps the best that might be expected. 

In contrast, the standing committee on social affairs, science and technology in releasing the Out of the Shadows at Last report in 2006 Out of the Shadows at Last  (closer to 500 pages and still with 116 recommendations), specifically developed recommendations for federal government and agencies to move the mental health agenda forward.  An update and report card on actions of this committee would seem to be warranted at this time. 

The strategy lacks in anything new.  With a stretch,  it does provide a better emphasis on rural and Aboriginal issues than most previous reports.  All in all, you may have been right to cringe at the thought of another mental health report and another bunch of diluted recommendations that will go onto the shelf. 

In the meantime, real credit goes to workers at the front line and consumers who have resulted in moving the mental health agenda along.  So to all Mental Health workers who continue to provide great service and fight for even better service, thanks.   May National Mental Health week be a celebration of how far you have brought our country.  

Monday, 7 May 2012

Bill C-31: Refugees to be treated worse than prisoners


In August 2010, a refugee ship landed on the West Coast with just under 500 persons claiming refugee status, a mere fraction of the 20,000 or so claims each year in Canada.  That ship has started a series of events that has resulted in unmasking an embarrassing face of Canada to the world.  Bill C-31 will treat some refugees with less value than any criminal and apparently less than international conventions for human rights let alone what Canadians have defined in the Charter of Rights and Freedoms as minimum expectations. 

Even more disappointing, is that policy compromises achieved under the previous minority government have been thrown out by the new majority government in total disrespect of previous decisions and over the objections of innumerable public policy organizations.   Legal experts have declared that Bill C-31 violates international human rights obligations, the United Nations Convention on the Rights of the Child and the Canadian Charter of Rights and Freedoms.

Health experts have stated that the bill will cause psychological harm and suffering to highly vulnerable people who have already experienced repeated trauma.

The key points to ponder. 
1.    Refugee claimants arriving as a group can, on designation by the Minister, be incarcerated in high-security prisons for one year without review. Children aged 16 or more will be imprisoned as if they were adults.
2.    Children under 16 will either be separated from their parents and handed over to child protection agencies, or unofficially detained with their parents.
3.    There will be no access to early release, even for the most vulnerable individuals, such as pregnant women, torture survivors, or people who are mentally or physically ill.
4.    Designated claimants who are recognized as refugees will be barred from obtaining permanent residency for 5 years, and will therefore not be allowed to reunite with their families.
5.    Many refugee claimants will be deprived of the right to appeal decisions rejecting their claim for refugee status.
6.    The government will have the power to strip refugees of their status and deport them from Canada, even after they have lived here for years and become permanent residents, simply because conditions have improved in their home country so that they are no longer at risk of persecution.
7.    The Minister will have the authority to designate certain countries as ‘safe’ and not take into account that marginalized groups may be subject to violence without meaningful access to state protection even in countries that are safe for most of their citizens.
8.   Certain refugees will be denied access to health care, for even the basic of needs unless it puts the public at risk http://www.thestar.com/news/canada/politics/article/1168118--ottawa-to-cut-health-care-for-some-refugees  

In particular, child detention awaiting refugee status has already been shown in Australia and England to be associated with sleep disturbances, separation anxiety, post traumatic stress disorder, suicidal ideation, self-harm and various development delays.  These might be expected in war related refugees marshalled into camps, but not in developed civilized countries. A general systematic review of mental health impacts on adult and children detained as refugees is available at http://bjp.rcpsych.org/content/194/4/306.full.pdf+html 

Canadians who are dismayed with such regressive, totalitarian and damaging approaches to welcoming potential New Canadians have only a few days to express their displeasure to Immigration Minister Kinney and the Public Safety Minister Toews.  Bill C-31 was through second reading on April 23 and currently referred to committee.  Follow the bill at http://www.parl.gc.ca/LegisInfo/BillDetails.aspx?billId=5383493&Mode=1&View=7&Language=E  

Jason Kenney, Minister of Immigration jason.kenney@parl.gc.ca<mailto:jason.kenney@parl.gc.ca

Vic Toews, Minister of Public Safety vic.toews@parl.gc.ca<mailto:vic.toews@parl.gc.ca

Healthy Built Environment Part 4 – Mental Health and wellbeing


It could be speculated that second to obesity reduction, improvements in mental health and wellbeing are the most sensitive to built environment manipulation. 

From a mental wellbeing perspective, integration and blurring of socioeconomic gradients arms future adults with social skills, competence, relations that will contribute to their success and reduce the likelihood of maladaptive behaviours like truancy, delinquency, education incompletion, addictions, teen pregnancy amongst a whole range of less healthy choices that can put individuals are risk.  Mental health promotion starts in infancy and should be focused on younger school age settings. 

Community design can support a sense of collegiality through encouraging the likelihood of inclusion and reducing the possibility of social isolation.   Precluding drive through services may sound like a good way to improve air quality, but likely also has the potential to increase socialization.  It is not sufficient, but is an enabling mechanism.

Planning for the 1-3% of persons with major psychotic disorders who are challenged to be integrated requires strategically placing group home settings where positive socialization will occur.  We will all be surprised about how housing that supports the socially disabled aggregates in areas poverty, addiction and crime – only to wonder why current approaches are not successful.

Conversely negative psychological stressor, particularly those that are repetitive have the potential to exacerbate some mental illnesses.  Crowding, noise, smells, and excessive nighttime light are known to be stressors, although their long term impacts on 12% of Canadians with mental anxiety disorders are not well determined.  Neighbourhoods challenged by these physical stressors tend to be perceived as less desirable and hence more convenient for locating subsidized housing including group homes. Graduates from group home settings tend to  remain in reasonable proximity during their transition times.   Thus a confounded relationship between location and mental illness would be expected.  

Depressive symptomatology may be exacerbated by physical surroundings, however it is apparently not documented whether such surroundings contribute to the development of clinical depression which affects up to 8% of the population. .  

Nor have physical factors in the environment been manipulated to determine the ability to intervene on any of the mental illnesses.  Given the plethora of seniors housing communities that have developed, it would seem that some cohort analysis of the geriatric psychiatric impacts of different seniors housing options would be one of the easiest studies to undertake, if you are aware of such a study, please let DrpHealth know  (drphealth@gmail.com)

A literature search on the topic of mental health and the built environment will not result in anything more than a similar superficial scan of the potential impacts.   It seems to be an area where real investment is justified given the over 20% of Canadians that will experience a significant mental illness. 

Thursday, 3 May 2012

Healthy Build Environment Part 3: Health and social services, food stores and fast food outlets


Have you looked around your community?  Where are the shopping centres?  Where are the fast food outlets?  Where are the doctors and dentists located?   Where are social agencies located? Where is the local income housing located?

Perhaps not surprising the body of literature supports that food depots and those with fresh foods tend to aggregate to large shopping centres, which tend to be located in suburban, middle income areas.   Some urban area studies have clearly demonstrated that socioeconomically challenges neighbourhoods actually have less access to food and in particular fresh food supplies. In contrast, fast food outlets are often located on the margins of lower income areas – at times precluded from becoming established in middle and upper income neighbourhoods. 

In large centres the hospitals used to be on the community fringes when they were built, many are now integral to the downtown areas.   In smaller centres the hospital is often located in a prime community location away from the stresses of the downtown environments.  Doctors may aggregate near the hospital, but certainly tend to become established in mid to upper income neighbourhoods.  Lower income neighbourhoods can at times be without any medical services.  Likewise with dentists.  Of course these private health care profession businesses are going to where income can be maximized and risks minimized.  Not necessarily through any malice, just a function of making solid business decisions.

In contrast, look where social agencies are ghettoed, often expected to provide service to the most needy and aggregating where the need is.  An appropriate choice, just one that further ghettoizes the area and precludes social integration.  

Lower income housing is relegated to the least healthy locations.  Close to major roads, industrial areas, existing low income neighbourhoods.   Community living housing, halfway houses, group homes and homeless shelters can find getting established in such neighbourhoods is without the hassle and public outcry that locating in middle income settings may entail.  

It is just a description of what happens.  Perhaps the simple description is sufficient to suggest that where such blatant and obvious geographic correlations exist – healthful planning and purposeful development could overcome such problems.  


Public Policy interventions to affect built environment were reviewed in a national working sessions in 2011 NCC on Healthy Public policy workshop proceedings   and fact sheets on some of these topics and others like impact on safety are accessible through the national collaborating centre on environmental health  NCC on environmental health fact sheets     

The built environment defines our wellbeing.   As we discuss the built environment, lets be sure we understand the multiple diverse impacts that currently exist and then test and modify to ensure that better outcomes can be achieved.  Lets not wait 50 years to figure out that the process isn’t working for everyone.  

Tuesday, 1 May 2012

Healthy Built Environment Part 2: Green spaces, climate change, social inclusion and social support


The green movement and healthy communities have their roots urban planning, and we should be indebted to the work of Dr. Trevor Hancock back in the 70s and 80’s in founding the healthy community movement.  It was an initial step on the healthy built environment.  Urban planners ran with the concept of making parks, green spaces, planting trees and revitalizing urban areas.   Some of the solutions have caused problems, but no doubt prevented many more. 

Now we are challenged with how to build our communities to be sustainable. 

Climate change is upon us and the impacts will be felt by our children and grandchildren.  While perhaps not all impacts are reversible, the least we can do is develop communities that can adapt to the change and minimizes their contribution to worsening of greenhouse gas emissions.   Kudos to those provinces that require government agencies to be carbon neutral – it is perhaps not sufficient, but it is a significant step in the right direction. 

Social isolation can be partially overcome by designed mechanisms to increase neighbourly contact.  Porches on the street side and not the backyard.  Pooling personal yard space into small parks on each block.  Community gardens, community centres, even community kitchens can lead to social connectedness and building social support networks.

Planning for inclusion of children, seniors, those with physical, mental and development disabilities, those with reintegration into society,  leads to very different neighbourhood plans than would typically occur for two parent single family housing.   The challenge is to make such planning integral to urban design.  Eliminate the not in my backyard (NIMBY) mentality and build from the value and strengths of all communities members.

How we plan for and build our communities can have not only a personal health benefit, but a benefit for the health of all community members.  Planning must be founded in the needs of all residents, not just those that stand to profit.