Sugary drinks - tough news to swallow on public health policy efforts

Two breaking Twitter feeds to lap up on sugary drinks.

BC advocates arguing for a 20% surtax on sugary drinks is stirring up some sweet debate with support right to the top of the public health leadership.  Not surprising the Fraser Institute was quick to pour water over an otherwise tasty solution.  Their rhetoric vilifies the consumer and not the producer.  The Canadian Beverage Association was quick to agree. 

Cheers to BC for stirring the cup, perhaps there may be a way to skim the cream off the top.  Business Vancouver July 23

On the East coast, disappointing but not surprising news out of New York that the Appeals Court in New York deemed the proposed ban on sale of large sized sugary drinks as unconstitutional.  Well perhaps they are right that large sized sugary drinks should never have been presented to our constitutional and hence are unconstitutional, but from a legal perspective it seems the needs of those getting fat wallets outweigh the needs of those just getting fat.  CBC news coverage

Despite the potholes, it will take an ongoing and concerted effort across the continent in a variety of government forums to begin to control this one issue.   Quebec has begun to pave the path with a preclusion on marketing of food products to children which has been in place since the 1980s and does have a positive impact on exposure to French speaking media. 

A good policy analysis on the marketing of sugary drinks to youth can be found at Childhood Obesity Foundation. 

What both go to show, is that just as in tobacco reduction, no one strategy is effective, it requires the combined collective efforts and will of communities to make something different happen.   The question we should all ask is which Canadian jurisdiction will stand up and develop and implement a comprehensive  strategy?   It usually is one that is under the radar of government and industry alike.  

The poor are in poorer health

Not surprising, but the decade from 1996-2009 saw more poor people self-reporting health as poor or fair, and far fewer as very good or excellent.

In a new short report from the Wellesley Institute in Toronto, looking mostly at Toronto residents built on previous work in the area by the Metcalf foundation on working poor and studied their health status. Self-reported health status is one of the questions in the Survey of Labour and Income Dynamics allowing for a very simple cross tabulation between those meeting various definitions of poverty and their health status. 

The data are also provided for Canada and Ontario separately, the tables broken down by non-working poor, working poor and working non-poor for comparison sake.

Neat stuff, and amazing the report can take ten pages, but kudos to the Wellesley Institute. At a time when health status reports are being generated that occupy hundreds of pages, a simple analysis of one issue using limited data, presented in clear fashion, may have more impact than the reams of paper generated to measure whole population health status.

For the pure epidemiologist out there who might cringe at how the data was used and analyzed, perhaps there is a lesson in communicating complexity of information.  Simple can be better.   

Worth a look and the question if other routinely collected survey data over at Statistics Canada could be similarly used for punctuating key health messages.  Wellesley Institute declining health of the poor

Cyclospora strikes again - the little bug that can move the bowels of a nation.

Food borne outbreaks tend to be more common in the summer months.  This one is catching a few lifting eyebrows, but since only 200 US cases confirmed perhaps just passing reference. Outbreak notification

Lets put a different spin on it. First, there are at least 8 Canadian cases between BC and Ontario that are also likely linked.  While there are vague allusions to various fresh products including berries, herbs and lettuce, there is no definitively identified food that is associated with the illnesses.  That there are recommendations to wash fresh produce is something that isn’t clearly established as being effective. 

Only a small number of organisms is sufficient to result in infection.  Up to 70% of children have asymptomatic infections.  Adult symptoms are common, start acutely, are quite discomforting  and can be protracted.  Deaths are rare.   Person to person transmission is very uncommon, almost all cases are associated with food consumption.  Washington DoH

Treatment is usually required, unlike most other causes of diarrheal infections or foodborne disease. 

Once again we have a developing situation, where the focus of attention is on fresh produce, the perceived healthy alternatives – not on the traditional food items like dairy, meat and poultry where the vast majority of our food safety resources are directed. 

The number of Cyclospora outbreaks just seems to be creeping upwards, but beyond case reports, concrete statistics don’t seem easy to come back.  Please post a link if you have access to a compendium of outbreaks. 

Unethical research - Can we learn today from what went wrong in yesteryears?

It reads like the Nazi cold water exposure experiments on prisoners in the second World War.  Canadian Aboriginal Children subjected to nutritional experimentation because of their state of malnourishment.   A propagation of wrongs against Aboriginal peoples that is unacceptable and should never have happened.  But it did, and it has taken 70 years for such work to be uncovered.   There will be more to this story, just as we have learned from those peoples that are finally being given voice to discuss the horrors of residential schools and Indian hospitals.  Toronto Star article

Wearing the lenses of historical knowledge puts real context to ethical decisions making regarding research.   In this case the subjects were already undernourished as a result of archaic and embarrassing Canadian policy towards First Nations peoples.  The outcomes were an understanding of nutritional diseases that today may in some part form the basis of nutritional policy.   Science works in unusual and sometimes unacceptable ways.

Canadian research has only gone through a renaissance in reviewing its ethical requirements with the establishment of the Tricouncil Policy on Ethical Conduct for Research Involving Humans, the second edition of which was released in 2010, the first edition was only released in 1998.  The history and products of the Canadian panel is well worth reading and should be mandatory requirements for researchers and new graduates – this has happened in some universities already where documentation of successful completion of the tutorial is a requirement.  http://www.ethics.gc.ca/eng/index/ 

Fast forward into the future and imagine yourself fifty years from now looking back.  Can you begin to see where current research efforts might just be perceived as unacceptably unethical?   Corporate sponsored research into promoting unhealthy lifestyles.  Government censorship of researchers findings.  Directed research funding that ignores more important health issues.   Funding of drugs and devices that might subsequently be found to be health compromising (eg thalidomide).

There is no excuse for the distasteful experimentation that was undertaken in northern Manitoba and likely in other areas of Canada.   No amount of apology will suffice.  But as we look around at current unacceptable practices towards refugees in Canada, towards racial tensions in the US, towards religious conflicts that defy any religious doctrine, etc.   one can only imagine how we will be judged by our great grandchildren for the atrocities that perhaps we are performing today.

The Men Who Made Us Fat: The food industry impact on the obesity epidemic. Essential public health viewing

The BBC has produced a 3 part series called “The Men Who Made Us Fat”.  The nearly three hour series can be found on Youtube and probably the best way to access if you don’t borrow the DVDs from your library (eg  12 part play list ).  It is essential public health reading from several perspectives, not the least is a need to reframe our current thinking in respect to healthy eating.   Are we propagating incorrect advice?

The second perspective is how public health professionals may have been complacent in allowing this misdirection and an excessive focusing of attention on fat reduction. 

Third, and less surprising is the impact big business has on political decisions, to the extent of being able to modify national level advice and recommendations from scientific panels.

The investigative documentary explores several issues about why globally we are seeing an increase in obesity.  At the sake of being accused of missing something important, here are some of the key messages:

1.       A fundamental shift in the 80’s to the use of fructose from plant products, namely corn, to replace other sugar and even some fat products

2.       The insistent exclusion of reducing sugar from national recommendations in favour of the “reduce fat” message

3.       The use of sweeters in foods to increase consumption

4.       The expansion of serving sizes

5.       The bundling of meals by rapid service establishments.

6.       The promotion of “snacking” as a healthy lifestyle, particularly for children.

7.       The use of product labelling as healthier, such as “organic” or “low-fat”  to appeal to health conscious consumers.

8.       The power of the food industry

a.       In resisting any form of regulation or labelling that modifies consumer choices

b.      In places blame on parents and consumers

c.       In lobbying decision makers to prevent and modify science based recommendations.

To put the situation in perspective a nice piece in the  Globe and Mail on current global obesity rates by nation.

The expose will be essential viewing for public health professionals during a time of transition when the food industry looks at how to both improve food consumption habits while maintaining or increasing profits, and continuing to adamantly resist restrictions such as eliminating food advertising to children, product labelling that impacts decisions, limitations on product size and other interventions already known to be effective in the fight against obesity. 

New Minister of Health announced - implications for public health?

Not surprising, and as predicted here not even  two weeks ago DrPHealth July 2 2013 , Minister Aglukkaq’s third longest running term as Minister of Health has come to an end and she will be replaced by Rona Ambrose.  It is not necessarily the best reason to celebrate the sites 300th posting.  

What are we in for under Minister Ambrose?  A gifted lady with experience inside government as a policy analyst, in her 9 years as a member of parliament she has continuously held Ministerial portfolios since the conservatives took power, covering six different portfolios. 

Most notable from her past positions is her lack of notability.  In this respect, she brings some predictable characteristics to the role of Minister of Health:

A core party girl, not in the celebratory sense, but can be relied on to carry the Harper government line on any issue.  

Has been successful to date in staying out of trouble and sticking to the reiterating Harper government policy

She has kept a relatively low profile

(although she has been known for taking a stance supporting reviewing the point at which a fetus becomes a human being, stating that Canada had no chance of meeting the Kyoto targets, and referring to Liberal child care policy as “old white guys telling us what to do”.  For nine years in office, that is a pretty short list of credits).

While she has bounced around between Ministries, notable for her lack of leadership and vision in any of them. 

Not from the inner cabinet circle where important decisions are made.

As such, she makes an ideal Minister of Health for Stephen Harper, someone who will obey orders, avoid the limelight, not convey any particular vision, not stir the pot and has minimal real influence on government policy.   In many respects a clone of Minister Aglukkaq.

Is this what we really want from our Minister of Health? 

Planes, trains, buses and boats. Public transportation disasters and the public health perspective

It has been a difficult week.  Canadian hearts reach out to Lac-Mégantic and the expected fifty deaths and toll on the community.  The tragedy highlighted by the challenge in even finding human remains will be remembered as one of the largest death tolls, but more devastatingly for its impact on one community in terms of residents and infrastructure.

Within the week we have also heard of six deaths and dozens injured in a derailment in France, their worst in 25 years.

The crash of a 777 on approach to San Francisco only left 3 deaths, while a crash following take off in Anchorage killed all ten on board.

Eighteen deaths following a bus crash in Moscow, nine dead in Spain when a bus ran off the road.

While the seas have been more friendly recently, the fate of the bridge crew in the fatal sinking of a BC ferries ship was determined, no doubt forcing the remaining passengers into reliving the harrowing experience.

July 30 - the past week has seen a speeding passenger train derail killing at least 79 in Spain, two Swiss trains colliding with dozens injured and death toll small but not totalled,  an Italian bus plunging into a ravine with at least 38 dead, and a school bus crash in India killing at least 9 students. 

Behind all this terrible news, must be the question “Is our public transportation systems becoming riskier or safer?”

Interprovincial, marine and international transportation falls to the Canadian Transportation Safety Board which deserves commendation for well presented statistical information at http://www.tsb.gc.ca/eng/stats/index.asp 

Rail fatalities are dominated by persons on tracks, and followed by collisions with vehicles at crossings. Trends are slightly downward in many of the outcomes followed, and are absolute numbers providing added assurance. 

Aviation also demonstrates a slight downward trend in incidents, but consistent mortality statistics.

Marine incidents are on a steeper downward trend, with fatalities trending slightly downward.

Bus related incidents are not as easily accessible.  Overall motor vehicle indicents and fatalaties are accessible at the less user friendly Transport Canada and have been consistently trending downward over the past few decades.  Bus related date are not segregated

The overall trend towards safer public transportation in Canada may be general cause for celebration, but for the deaths that do occur, including the community of Lac-Mégantic, no reassurance will be convincing sufficient.  

It is the fate of public health that good news will be hidden by the shroud of the failures. 

Respect for Communities Act - Total disrespect of the public's health

In September 2011, the Supreme Court of Canada issued a unanimous ruling regarding the Vancouver Supervised Injection Site, Insite. The Court found that the Conservative government had violated the Charter rights of Insite’s clients when it refused to extend its exemption from the Controlled Drugs. The ruling was widely praised by the public health community and the Globe and Mail declared it “open doors to drug injection clinics across Canada "

The reaction to the Harper government’s recent Bill C-65, tabled June 2013, has been the polar opposite.

Named the “Respect for Communities Act,” it incorporates an extensive list of information and demonstration of support required for future applications for exemptions. Both Insite and any future supervised injection sites (SIS) would need to provide this information in order to obtain the exemption necessary to begin or continue operations.  On the list are groups that are basically given a veto over improving the public's health.

According to Minister Aglukkaq’s press conference comments, one of the Bill’s goals is to bring “bring much needed clarity to the way future applications are made.” However, the Bill outlines only the information an application must include, not the means by which it will be evaluated or who has independent authority to issue the decision. Greater clarity on how the Conservative party will use this information is given by the literal “Not in my Backyard  ” campaign it launched in conjunction with the bill.

The Bill’s goal of ensuring thorough community consultation and input is consistent with the standard public health programming practices and reflected in the 2011 Supreme Court ruling. However, it is telling, whose voices the Conservative government values by who is listed in the Bill and who is excluded – those whose voice would be enshrined in law, and who is left at the whim of the Minister.  Police and physicians have been given standing. The Supreme Court called on the Minister to “balance public health and public safety” and to consider “whether denying an exemption would cause deprivations of life and security of the person that are not in accordance with the principles of fundamental justice,”, to this end it is notable that potential SIS clients and their families are excluded from consultation in C-65.

This Bill exemplifies the Harper government’s antagonistic attitude towards harm reduction treatments.  The barriers facing new SIS facilities currently exist as demonstrated by the no new SIS sites in the twenty months between the ruling and the tabling of the C-65.

The Toronto Board of Health openly supporting the need for a supervised drug consumption site in Toronto will be the battlefield, not surprising given the predominant red colours flying over Toronto. If only Mayor Ford would publicly support such a need.

Bill C-65 is a setback, but even if it is defeated or dies on the order paper, significant challenges remain to moving supervised injection from the current two Vancouver sites to being a standard of best practice in care. Clarity is needed and fear will abound as it did with the first needle exchanges.  Since the public consultation leading up to the tabling of C-65 was non-existent, perhaps Prime Minister Harper might inject some of his own medicine and ensure that C-65 gets "open and balanced consultation".

Based on the myriad of health organizations that have already publicly filed objections, one can only imagine that someone unwilling to respond to the public health concerns might be utilizing their own substances. Harper has shown patience and persistence with the mandatory sentences for drug possession taking three sessions before it was stickhandled through the parliamentary arena.  Watch for a similar game being played to prolong the agony, district the opposition and ultimately block Canadians from accessing health services.

Is Canadian health care policy killing rural Canada?

The first warning was when the Google search on Canadian rural hospitals produced 1992 papers.   Perhaps the issue is intuitively more obvious and we need to test some hypotheses.

Regionalization closed a large number of small, supposedly inefficient rural hospitals.  The best studied were the Saskatchewan closures of 54 rural facilities back also in 1992. Not surprisingly, health status supposedly increased in the short term.  Also not surprisingly, many rural communities said that’s interesting, now can we please reopen our hospital?   Why – because hospitals drive a huge component of the economic activity of rural communities where they are located.  While individual health may have had certain measures of improvement, communities quickly recognized that their community health was suffering.

Did anybody care? Not really, quality and health outcomes improved in the short term, and overall dollars were saved in eliminating supposedly inefficiencies. 

For decades, the proportion of physicians practising in rural areas has been only a third to a half of that expected when compared with urban Canada.   Staffing rural facilities is often a constant effort of training, recruitment and then departure for bigger cities.

As one bureaucrat once said, the best economic policy is to let rural Canada die.  Efficiency is gained through economies of scale only achieved in urban settings.  Scary given their ability to affect political policy in the country.  The consequence is the migrant movement of youth and young families into larger urban settings, curtailing the community future.  It should not be surprising that areas of Canada with proportions of seniors exceeding 20% aggregate around rural areas. 

So, DrPHealth is looking for examples of newly opened rural hospitals?  Or even rebuilt facilities on the order of what many health regions have accomplished with their flagship hospitals.   Where have health regions actively planned to encourage rural growth by implementing expanded health care facilities. (email to drphealth@gmail.com)  

Experience,  without supporting data,  would suggest that where even the slightest gains are made, they are in semi-urban settings (10-50K populations),  only after massive public and political leveraging, and without growth in the form of intervention services like in-patients, obstetrics and surgery.  Perhaps this is "good" clinical practice, and there is ample evidence that outcomes in rural settings have perhaps not been as good as urban.

There is also ample evidence that rural populations have reduced access to health care, seek treatment later in illness, tend to have poorer outcomes and a whole list of measures suggestive of an inequity that deserves more attention. Rather than treating rural health as an question of inefficiency, it is time to view it from the lens of equity. 

And, what about the slow death knell placed on rural communities through loss of their autonomous health structures?  Perhaps a gain in short term efficiency as rural Canada is only about 20% of the population.  

Yet birth rates are much higher than urban settings, family sizes tend to be larger, and rural life provides opportunities for future growth and development that would be logical investments to support the whole of the Canadian economy rather than the constrained and razor thin margins that large urban settings now offer.  

Perhaps regionalization has padded the wallets of the majority who live in the big cities, but it may well be cutting off our future by not planning to build a sustainable Canadian infrastructure  through maximizing the potential of our country. 

Its time that more than just a few lone voices like the Society for Rural Physicians of Canada  http://www.srpc.ca/  speak out for supporting rural health care.  This is an issue that is about Canada’s future and the health of our country. 

Canada's Chief Public Health Officer is resigning - what does a changing of the guard hold in store for public health?

Thank you David.

After 9 years as the first Chief Public Health Officer and key architect of the Public Health Agency of Canada, David has bowed to the impacts of less than ideal health. 

A dominating figure in any room, with a booming voice and ability to mesmerize through his speeches, Dr. Butler-Jones has lead public health in Canada in many different settings as well as his current role.   He will best be known as the voice and face of the H1N1 response. 

While the agency he led was a product of a Liberal government reeling from the SARS catastrophe, his tenure in the position was under an ideologically opposite government that cares little for disease prevention and can perceive public health as a left wing plot.    

His major success,  for which we should be grateful was to have survived and maintained an independent and politically neutral public health agency throughout these years.   His legacy is the very agency that we have come to know as PHAC (pronounced P-hack by some, Fack by others).  Like all government activities, PHAC has taken its share of downsizing, but to the credit of its leadership – it has only taken its share and not more.  That he could hold his own amongst the political power brokers in Ottawa at the Deputy Minister level is likely a story that cannot be told but is part of his legacy.  That PHAC remains an autonomous agency is itself a credit to his leadership. 

His critics will comment on the lack of public profile, that even the annual reports lacked any government recognition or commitment, that he did not turn PHAC into the pan-Canadian public health enterprise that might supersede certain pockets of provincial power, and that on an international basis, Canada’s public health profile has diminished.  Were it not for the comments of critics, there would be no targets for his successor to address as they place their stamp on the role.  

While the easy questions about who fills his large shoes will form speculation across the country, the bigger question should be in how the Harper government will react to this ‘opportunity’ in the form of change?  The change in leadership provides a weakness in the public health structure that might well be manipulated - in a similar fashion to other changes under the current government.  And, don’t be surprised to see Minister Aglukkaq wandering the corridors of a new government department with a new Minister of Health charged with marching orders to limit the effectiveness of Canada’s Public Health Agency.  (DrPHealth does not mind being wrong,  and on this one, we can only hope that such a prediction is wrong).   Minister Aglukkaq has now walked the halls of the Ministry for 56 months, the third longest tenure for any Minister of Health since WWII (only topped by Jay Monteith at 66 months and Paul Martin Sr. at 126 months)

David, may good health find you.   Thank you for your decades of contribution to Canadian public health, and for all your future contributions.