Public Health quickies - Tuberculosis, Oxycodone restrictions, Crime and mental health, CIDA

Many Canadian families are on school break, preparing for or enjoying Easter, Passover or just a long weekend ahead.  Stay safe and healthy, and enjoy the opportunity to be connected with friends and families – it is an investment in your own personal health.

March 24^th was World Tuberculosis Day.   A remembrance of a disease that too often is forgotten, but affects over 12 Million persons currently.  Disconcerting is the 5% of these individuals with a multiple drug resistant strain of the disease.

This week has seen several articles on the implications of the near nation-wide cold turkey cessation of Oxycodone (OxyContin).  What have we seen, heroin use appears to be up.   Anecdotally, overdoses concurrently seem to increasing although the numbers are not available yet.  Almost a year later, several of the key addictions agencies in the country are proposing a plan entitled “First Do No Harm” which presumably once released will be posted to Canadian Centre on Substance Abuse . 

These are NGOs perspectives, and the Harper government just tightening the mandatory sentencing screws to persons convicted of crimes despite mental illness.  Contrast this with the excellent CBC Calgary expose on Mental Health and Crime CBC Calgary on mental health   

And, buried in the budget is the loss of the Canadian International Development Agency (CIDA).   While a colourful history, CIDA was a cornerstone of Canadian international policy – a further sign of current government retraction from issues other than what benefit themselves Life and death of CIDA  

Public Health Ethics - a must read release for public health professionals

It is not very often a book comes along that has the potential for significant in how we practice public health.  Much has been hinted to in respect of public health ethics, but relatively little definitive documented. 

Population and Public Health Ethics:  Cases from research, policy and practice is a treasure chest of real examples combined with some excellent analyses which lay out the foundations for ethical public health practice.   Solid introductory discussions of frameworks should make this book required reading for all public health trainees, and innumerable lessons for those already in practice may help refine their current practices. 

While the basis within the book is that of utilitarianism, acknowledgement of the influence of other frameworks of ethical practice is enlightening. Specific discussion of cases by various different ethicists demonstrate subtle differences in approach, although cases are widely disparate.  Research, policy and practice ethical issues are explored through real practice problems submitted by practitioners in Canada.

A common thematic that seems to shine through is that some public health practitioners interpret scenarios with a different ethical perspective.   The conflicting interpretations are not well discussed within the book and provide ample room for stimulating discussion. 

At issue, is that while most public health practitioners will utilize a utilitarian approach, oftentimes the clients we serve may make their decisions bound from different ethical frameworks.  Clear examples exist from groups with entrenched religious beliefs such as polygamy and refusal of blood products or vaccines.  More common and couched in shades of grey are when public health professionals run into persons entrenched in libertarian beliefs where the state has no role in individual or family decisions, or even capitalism where individuals believe the greatest benefit to society is in amassing wealth and distribution through benevolence rather that state facilitated equity.

Another ethical dilemma unaddressed in the book comes from where professional disciplines have conflicting codes of ethics.  Clearly this underlies some of the case scenarios, but is unexplored where issues such as a nursing focus on the provider-patient relationship is not balanced with a duty to population wellbeing as explicitly stated in the medical discipline.  Many other health professionals codes of ethics have no mention of a duty to society where nursing and medicine do. 

Despite some gaps, this is a book that should be read, and likely reread to assimilate the subtleties.  It will go a long way to helping resolve many of those situations where one member of the team refuses stating that such actions are “unethical”, and this is a welcomed reference for such situations.

Download the CIHR sponsored book for free from Joint centre for Bioethics Public Health Ethics . 

Thanks to Ted Schrenker for announcing the book on the CHNET blog even though he discloses as being both an author and analyst.  

War on drugs and cancer - more losers than winners?

War has few winners and many losers.  

You were probably assuming that referenced the tragedies of global conflict which are documented and reported here in November 2012 global peace day.   

Three reports from the past week on the failure of “wars” against health problems.   The War on Drugs has had numerous reports in the last few years such as psychoactive-drug-tidbits  with increasingly high profile individuals questioning the costs of the current approach.  The UN commission on Narcotic Drugs met in Vienna and received a scathing editorial from the New York times March 10.   The UN development chief subsequently spoke out on the negative consequences Reuters March 15 and openly challenged the 40 year old US led war that has cost 70,000 lives in Mexico along in the last 5 years alone.  

The second war that was recently panned was the War on Cancer as the National Post March 13 questions the return on billions in research investment.  Sure there have been the successes through interventions like stem cell transplants, radiotherapy and the HPV vaccine.  The mainstay of therapy in chemotherapy where most research dollars gets channelled in clinical trials has rarely resulted in breakthrough drugs that substantially improve the number of quality life years.

Concerted efforts have been successful in addressing smallpox, and substantively effective in North American in addressing tobacco.   Hence identifying some characteristics of where the return on investment would likely result in benefit might shift current expenditures to viable long term successes.  One of the keys is that prevention is needed long before the war on the problem is undertaken

Here are a couple of “wars” that have the potential to result in wins.

1.       Sexual predators – kudos to W5, Toronto Star and Miami Herald on their expose on Canadian exportation of sexual predatation Toronto Star article.   Slower but some progress is being made in countries like India where recent high profile incidents are causing considerable attention

2.       Polio and Dracanulosis – two diseases that once eradicated should never threaten humans again.

3.       Addictions -  alcohol, drugs, gambling – where prevention is key and early intervention is effective.

We invite nominations for other illnesses where directed and concerted efforts have the potential to lead to real winners. Leave a comment, or send your suggestion to drphealth@gmail.com 

Alcohol – addressing the Public health problem

Alcohol consumption remains consistent theme as public health professionals grapple with how to tackle the two headed beast.  Its cardiovascular benefits touted while its overuse continues to challenge health and social communities.  

A new study from the Centre for Addictions and Mental Health (CAMH) sheds more light on the global problem,  but published in a non-accessible on-line early release in the journal Addictions Addictions abstract Mar 4 2013.    The key points are accessible through the CAMH press release at CAMH study on global alcohol exposure.  Despite all the secrecy in supposed intellectual property rights, the data relate back to 2005 and relevance can be questioned.

An unrelated article reflected upon the recent trend of alcohol distributors to target women in advertising as the largest growing sector of the population engaging in imbibing.  CBC news item March 8

Concurrently, the CAMH released a report on alcohol policies in Canada by province.  Strategies to Reduce Alcohol Related Harms and Costs in Canada  This comprehensive look at alcohol control policies is worth the read and a study in the approach.   Fundamentally a  report card that puts Ontario, BC and Nova Scotia at the top of the provincial list of alcohol responsible provinces, and Quebec, PEI and Newfoundland and Labrador in need of some improvements.   The overall provincial average being just less than 50% of a perfect score, and the range only from 35-55 showing greater congruence between provinces than divergence in addressing alcohol problems.

The ten policy dimensions of healthier alcohol policy are a great starting point for any comprehensive review of alcohol control strategies.  Details are provided on what constitutes best practice in each of these dimensions – and for this reason along the document is recommended to anyone addressing alcohol issues.  The report adds further by providing anecdotes of best practices.

The document then details a provincial comparison on each policy issue for each of the dimensions.  There are some intriguing geographic variances and some fairly easy starting points for all provinces to look at more intensely.  That the territories have been excluded from the analysis is a major oversight

It would be very useful to apply the same scoring to some of our neighbours to the south, where alcohol accessibility seems to have broadened quickly in the past years and prices are decreasing.  

Alcohol related mortality may be trending in a worsening direction over the past decade, but to find the evidence is a worthy publication.   Annual stats for the US, Health Canada reports .     Better statistics exist on alcohol consumption as inserted below from the Centre for Addictions Research  .   Some evidence from the graph suggests that after strict drinking and driving laws were implemented in BC, substantive alcohol consumption reductions were achieved.   The benefits on mortality trends may take years to see the reverses as well. 

So for public health workers addressing alcohol issues, there is lots to celebrate this week, but please do so with sobriety.  

New York large sized soda ban put on ice.

Big Sugar took a win at the eleventh hour.

New York has been the continental leader in addressed foodborne chronic diseases. The elimination of trans-fats, reduction in sodium intake, and the announced elimination of large sized soda servings.   Their efforts have already likely saved hoards of people across the continent as many major food producers moved to comply with local ordinance in New York by system wide changes.

The ban on large soda containers was to go into effect March 11th at midnight.  Years in the making, but less than 12 hours from execution the public health initiative has suffered a "stay of implementation". Issued by a New York Supreme Court Judge, as a bit of surprise, the American Beverage Association which represents the big soda companies, clearly the ringleader in the fight in opposition.

Read the Atlantic story at Atlantic wire  and the reaction by Mayor Bloomberg at Mayor's response.

No doubt friends in Toronto would like a Mayor that stands behind his convictions and behind the health of the population they serve.

Daily Savings Time - is it really a health risk?

Most of us are waking up today a bit more weary-headed than usual.   It is amazing what a single lost hour to our biologic rhythms can do.  We do have an innate internal clock that just got reset. 

Of course jet-setters, or anybody travelling cross country learns quickly about jet lag at one end, and waking up at four in the morning going the other direction. 

Of course there are the advantages.   After a long dark winter, most of us gain an hour of added sunshine later in the day.  That opportunity to replete some Vitamin D.  For those that summer from seasonal affective disorders (SAD), the apparent brightening at one end of the day may be a welcome sign for coming relief aided by the longer days as summer approaches. 

There are the downsides that seem to attract attention.  Potential Increased rates of heart attacks and suicides have been reported.  A reported 8% increase in traffic collisions during the Monday morning commute combined with a nearly 6% higher risk for workplace injuries during the Monday.  While not earthshattering, the purported rate of myocardial infarct increase is 10% - mitigated by an equivalent decrease when the clocks are set back in the fall. 

For most of us it is just that foggy-headed feeling with reduced performance matched and a decreased productivity on the first day back to work. 

So, don’t expect too much of yourself or others on the Monday after the start of daylight savings time.   Your circadian clock will reset itself within a few days for most of us.  You could benefit from making some changes to your daily routine, including being sure to have a solid breakfast, get outside when that sun does rise and do a bit of more exercise in the morning.

Of course, an extra dose of caffeine might just help clear the cobwebs. 

Sparkling public health gems: Using maps and spatially analyzed data.

A picture tells a thousand words.   Geographic Information Systems have matured over the decades and are not only a good tool for epidemiological and analytic purposes, but wonderful displays of how disparities exist in society.   The following are a collection of gems from the past few months worth gazing upon.

Adult obesity rates in Canada, updated for the past decade.  The full article in the Canadian Journal of Public Health for members only at this time, the charts are accessible at UBC press released on CJPH article  in the lower right corner. 

A wonderful but long slide show on global inequity when it comes to health outcomes and health services.   Views of the world.   The website provides access to other data presented through illustration with an emphasis on UK and European issues.

The disturbing distribution of uninsured Americans in the US Uninsured Americans .  Imagine the public health challenges faced in Miami, Houston, Dallas,  Las Vegas and Los Angeles areas where between one-fifth and one-quarter of the population have no health insurance.  The US improvement to only 15% without insurance is a remarkable positive step, but reflects the hurdles ahead to ensure access.

Not presented as maps, but using geographic boundaries for analysis, five key datasets presented on global economic health at Davos economic summit   .  Kudos to the World Economic Forum for included the GINI coefficient of equity as an economic health measure

And a point of trivia.  Despite great strides in reducing tobacco in Canada, each month, Canadians smoke about 2 billion cigarettes.   Statistics Canada follows monthly production and sales Stats Can daily  

Shorter Lives, Poorer Health - US Health under an international microscope

As we have debated some of the challenges of practising public health in Canada, a pre-release document from the US undertaken by the National Research Council and Institutes of Medicine provides solace for those that feel vilified north of the border.  Prepublication access site 

The US has 2565 local public health departments that operate in highly disparate situations and circumstances.   While this and other sites are debating public health funding in Canada, estimates from the US lack precision with 3-9% of its health budget (and most health services are not within publicly funded health budgets).   Canada has about 100 distinct geographic public health entities which receive about 3% of the Canadian publicly expended health resources. Regionalization compounds the ability to count distinct entities where provinces like Alberta might count as one or nine depending on definition.

A notable conclusion of this expert group is that there is insufficient data to compare public health services between countries, whereas the information on health care systems is more robust.  Further evidence that what gets measured, gets the attention.  

The international comparisons in the document are well worth the scan.  A nice summary of the reaction by Dr. Ted Schreker at Health as if everyone matters 

While the document in part defends portions of the health system, its irrefutable conclusion that whatever the US is doing, is not resulting in good health status compared to peer countries that invest considerably less per capita in health services.  Its conclusions and recommendations come up very short with a focus on services and personal choice, and a dearth of recommendations on population level interventions for which there is acknowledgement of significant differences in approach in other countries, but for which they claim minimal evidence. 

Mandatory reading for anyone in public health as it provides for great international comparisons and some good Canadian information embedded throughout the document.  Be forwarded, the text runs to 300 pages.