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Friday, 30 December 2011

Resolutions for Public Health workers - what can I do in 2012?

The list of public health workers resolutions for 2012 are about adopting higher professional standards in the things we do constantly.   Here are some measurable and targeted specific resolutions of things that you as an individual can (and perhaps should) accomplish

1.       Support clients, friends and family in adopting a healthier behaviour through constant applicable of brief motivational interventions.
2.       Volunteer for a partner organization to assist in addressing health inequalities
3.       Argue vocally in a non-work setting for ensuring that the rights of the child and their future global inheritance are protected.
4.       Have at least one challenging conversation about inappropriate prejudicial behaviour by someone you know.
5.       Personally adopt
a.       One healthier lifestyle habit (eg.  less alcohol, less food, more exercise....)
b.      A new environmental sustainability action (eg. Finally start taking public transit, sell that second or third family vehicle, start composting)
6.       Speak to at least one local politician on an issue that potentially could negatively affect the population’s health that you serve.
7.       Write one letter to provincial politicians requesting adoption of a healthier policy
8.       Write a media piece (letter to editor, editorial, on-line posting etc.) that is intended to stimulate discussion on a health issue in your community.
9.       In the workplace
a.       support a colleague who is suffering a health or family challenge
b.      advocate for adoption of a policy to reduce cultural barriers
c.       eliminate physical and psychological barriers to accessing services that are constructed by gender, age or ethnical background.
d.      ensure that harm reduction services are available in your setting
e.      place one prevention item on the agenda of groups that normally aren’t concerned with public health issues
10.   Each month, ask the question, “what more can I do as a public health worker to improve the health of the population I serve”?
11.   Quarterly, review your commitment to staying current professionally, engaging in lifelong learning, continually questioning the status quo, and striving for quality improvement in your work setting.
12.   Start the year by reflecting on your accomplishments and celebrating how much of a difference you have already made to the lives of those you have touched as a public health professional.  Continue the year by supporting colleagues, friends and family in commending them for their positive public health contributions.  

As for DrPHealth the resolution objective is to reach 10,000 views by the end of 2012.  Assist by sending the link to colleagues and friends and checking in frequently.  

Happy and a safe New Year to all

Thursday, 29 December 2011

Resolutions for Public Health workers. How can we personally make Canada healthier in 2012?

In the actions and encounters we on a daily basis, the question that we should continually ask, is how can I make the world that I can touch a healthier place today and into the future?   DrPHealth would like to propose two sets of resolutions, the first as resolutions for us as individual public health workers in Canada, the second for the next posting, as resolutions for my personal contributions.

The strength of the Canadian public health system is the people who see what we do as a vocation.  Collectively we have accomplished so much to improving the health of Canadians.  Daily we see how much more we can do.   The following are perhaps just reminders as to what might be the dozen most important things to do in 2012.  
  1. Advocate for policies that specifically reduce income disparities as it is the major modifiable driving force for poorer health.
  2. Ask frequently the question, how will this service/policy/action improve the health of our children and future generation?
  3. View the world that our grandchildren will inherit and the threats caused by Climate Change, Contamination, Consumption of non-renewable resources and Consumerism. 
  4. Be a constant reminder of the prosperity we enjoy and the challenge so many others of our global neighbours face in accessing the minimum prerequisites for health of peace, shelter, education, food, income, stable eco-system, sustainable resources, social justice and equity.
  5. Support the adoption of healthier lifestyles in at least the major risk behaviours of tobacco use, alcohol consumption, poorer nutrition and sedentary lifestyle.
  6. Recognize the value of our current health care system, and constantly ask what is the added value to the health of the population of the resources we are about to expend.
  7. Encourage frequently that the solution to sustainability of our health system, is to prevent the need to utilize the health care services in the first place.
  8. Put safety and injury reduction on the agendas of those that can make safer choices
  9. Argue for incorporation of culturally appropriate approaches to improve health and reduce the existing disparity.
  10. Ensure sexism, ageism, racism, or other non-modifiable characteristics are exorcised from the places we live, work and play.   
  11. Promote tolerance of the diversity of individuals in our society including those with addictions, mental health disorders, disabilities and living street oriented lifestyles and others  
  12. Support the adoption of services that reduce harm for those who engage in unhealthy practices.  
Of course, we would welcome suggesting for additions and modifications.   Please post a comment or contact us at drphealth@gmail.com 

be sure to share these resolutions with colleagues, perhaps a creed for public health workers to adopt for the New Year. 

Wednesday, 28 December 2011

The cost of US medical costs - Financial stress has a health cost itself

Throughout the holiday season, the public health machine continues to grind away.  If ever there was something to be grateful for in Canada, perhaps it is appropriate to sing platitudes to the Canadian health system.   We can easily find shortcomings in anything so complex, but let us look at one of the major reasons why the system exists – to provide universality and comprehensive care to everyone irrespective of their personal circumstances.  This becomes ever so obvious by comparing to others southern relatives. 

Out of the Robert Wood Johnson Foundation http://www.rwjf.org/  which funds the Centre for Studying Health System Change Centre for US study of health system  are reports on the challenging state of US personal costs borne for health services.  The sobering statistics contained in  medical bill problems for US families:

  • ·         The number of uninsured Americans has increased nearly 25% from pre-recession and now stands at 51.7 Million
  • ·         One in five American families are having problems paying medical bills, up one-third. 
  • ·         Utilization is being reduced with fewer visits to doctors, which some people might suggest could explain an increase in the health of some families too.
  • ·        Persons with medical debt have much higher unmet health needs than those without, presumably through decisions to not seek care when needed.

There is a good analysis of the potential beneficial impact of the first steps in expanding US medical insurance beginning in 2013 by demonstrating the added value provided to persons in the working poor income range. 
The good news for those living south of the border is the major impact on health care utilization was in the first half of the last decade.  Through the recession years there has been a relative flattening of some of the indicators. 

This blog touched on the issue of health care spending in Canada Canadian health spending November 8, 2011. One of the issues not discussed was that only about 70% of health care expenditures are covered by government programs in Canada, fortunately the ones that are most likely to be major financial burdens – however many costs are borne by Canadians.  This proportion of “insured” benefits is slowly being whittled.  The best example is the failure to insure needed prescription medications, and the active choice of some marginalized families to not fill prescriptions.  The work by the Canada Health Council referenced in the comment posted by Nonstop GO speaks to specific financial barriers in the subpopulation of those with chronic illness, worth the read and a focus of a future blog. 

As the US implements repairs to a crumbling foundation, Canada needs to consider a few renovations to protect the benefits that we currently enjoy.  

Friday, 23 December 2011

DrPHealth blog - Year end summary, is it worth it?

It has been just short of 6 months since this project began.  My thanks to the faithful followers and to those that just pop in for a special topic - clearly there are both.   Here are some points for amusement:

  • 94 posts since July 3
  • 3799 separate views
    • 88% are from Canada which is the target audience
    • 191 visits from the US
    • 95 from Russia
    • 29 from Germany
  • The most visited postings - Admittedly it was sometime in December that I more correctly linked specific posts to the Twitter account and that has driven up specific page views considerably for the month
    • Social Injustice - December 5
    • Fluoridation - November 1
  • 13 comments, with the infamous Anonymous leading the list.  Only one commentator has used a real name, several have provided personal information in different settings.  
  • While there is one follower, there are no statistics on the number who have linked for routine downloading of the pages and these are not counted in the statistics 
  • On the Twitter account, there are 79 Tweets but still only 15 Followers 
The gmail account has received a handful of additional private communications. 

The main questions for 2012:
  • Is there continued value in the project?   
  • Are there specific topics you would like to see posted and discussed? 
  • How can we grow the site to double the current utilization of about 1000 hits per month?  
So, for your New Year's resolution, please:
  1. Post at least one comment or send an email to drphealth@gmail.com
  2. Forward the site linkage to at least half a dozen colleagues and encourage them to follow
  3. Sign up on Twitter - and the follow @drphealth
  4. Consider submitting a guest piece on your favourite topic  - contact drphealth at the gmail address. 
Happy holidays and the best for 2012, no doubt that public health will be in the spotlight and lots will continue to happen. 

Dr. P.  

Wednesday, 21 December 2011

Presents under the Tree - Holiday time public health in the news

Perhaps it is being cynical, but why would so many major public health issues be released the week before Christmas, when media coverage is lowest, few people are in the office, and the material could easily dissipate before it receives adequate attention. 
Do the entire public health community a favour and forward some of the following.  The posting on Diabetes in Canada DrPHealth post on Diabetes report  . 
December 19th posting of the government's response to the investigation into Listeria and food safety system.  CFIA page linking to food safety report (which supports the posting on Santa’s list DrPHealth on political decisions  in order to not loose votes  because of poor  food safety).  The federal government is spending close to a half billion dollars to respond to shortcomings in the system – now if only that was directed to something more constructive but less well measured.
The launch of the European Portal for action on Health Inequalities.  In fairness the launch looks like it was in November, but the Canadian dissemination hit the inbox just hit the inbox  European zone portal on health inequalities. A reminder too to check in with Ted Schrecter's posting on health inequities CHNET blog site.  A deep thinker and great writer also looking at Canadian public health issues.  
Health Evidence posted a nifty review on compressed work weeks and their added value to work-life balance without significant adverse effects.  Compressed work weeks    Perhaps wishing thinking on this writer’s part. Makes for a great exam question
Another gift for the season was the Brazilian announcement on going smoke free for the country Tobacco free Brazil.   Now, if only Canada could move 10 provinces, 3 Territories and 630 First Nations governments to a harmonized confederation approach to tobacco control.  Oops, perhaps the reason why we struggle is more obvious when stated that way.  Related to this is a slightly older Health Evidence review on the effectiveness on smoking control policies, irrespective the date a resource worth linking to. Second hand smoke control policies. 
The cynic wonders if it is just that the communications folks have a breather from the urgent issues and can focus on releasing  the “C” drawer material, or is it carefully timed so that the potentially embarrassing plight of public health issues receives the least attention possible.

Finally, a reminder to check in with Ted Schrecter's posting on health inequities as well.

Tuesday, 20 December 2011

Diabetes in Canada - a Christmas present

Were it not for a Tweet the report might have gone unnoticed.  No press releases, no announcements, no email chatter.  Only a little birdie let the cat out of the bag.
Once again a phenomenal resource arises from PHAC that has minimal to no public attention.   Worse, a report on food safety in Canada received more attention from the communications folks and is posted on the PHAC website than the definitive resource on diabetes in Canada.   Can someone please provide some charitable public relations support to our lead public health agency? 
Ranting aside, what a Holiday bonus!  This tome on diabetes in Canada is worth reading every page.   From basic epidemiology through health service utilization, to the impacts on tertiary dialysis and physiatrist services, it covers everything but how to treat the disease.  As such, it is a tremendously valuable resources for one of the few disease conditions that has an increasing incidence.
Some tantilizing teasers to draw you to the website; 
Did you know (because we didn’t)
·         Diabetes now affects 6.8% of the Canadian population.
·         One-third of end-stage renal disease is secondary to diabetes
·         Type 1 diabetes has doubled in incidence in the last decade
·         Inuit rates of diabetes are comparable to non-Aboriginal rates
·         10% of Canadian deaths could be prevented by eliminating diabetes
Put aside a half hour at least before you click to the website  - Diabetes in Canada 2011

Santa’s list - on being good or bad: the need for political success

There are at least three kinds of public service functions.  
1                     Those things that are associated with the perception that good is being done by government and carry political currency as vote getters.
2                     Those things that if government does bad will cost votes in the next election.
3                     The rest of the stuff that is morally the right thing to do and traditionally what civil governments did.
Santa Claus would likely easily get elected to government.  He swoops in once a year and gives out lots of goodies, does a phenomenal public relations job, and then disappears without having to accountable for his actions or inactions. 
Politicians would love to be Santa. They are however held accountable to the public every 3-4 years for the totality of their work.  So how to you decide who you vote for? 
·         Are you a staunch supporter of a single political party because of their ideological beliefs?
·         Do you vote out the incumbent because you didn’t like the way they handled a particular issue?
·         Do you retain the incumbent because they did something really good, or more likely you can’t recall a major blunder while they were in office?
·         Do you weigh the characters lined up in a public forum as if you were speed dating?
Churchill said it well when he stated that democracy is the worst form of government except for all the others that have been tried.  
So what has this got to do with public health?   How often have you bemoaned the lack of resources for public health?  Questioned why a needed program was sliced and diced?  Wondered why program X got funded when program Y would make a bigger difference? 
We are in an age where populous opinions run governments.  Near real time polling can provide quick feedback on decisions and the overall stature of the government.  What hurts governments the most are decisions that lose votes.   Doing nothing is next worst.  Doing the “morally” right thing for the public’s health is hardly on the page.  
New hospitals buy votes.  A long wait in the emergency lose votes.  Cutting prenatal education or family supports hardly goes noticed as most of those affected haven’t enjoyed the service in the past.   Shifting funds to new programs is seen as "doing” something and therefore politically correct. In a time where impoverishment and homelessness carry political currency as a form of collective charity, these become areas for investment.  It alleviates personal guilt when I know 'my government' is 'taking care of those in need'.
Moreover success breeds success.   We’ve gotten much better at replacing hips and knees and reducing the wait times, so of course it is politically valuable to seen as supporting such joints through more resources.    No doubt you can see the value in funding more cataract surgeries.   That we have progressed to a point where some of the value of the surgeries is being questioned by experts, has yet to deter the public who if told by “their” expert that they need the surgery will be dismayed if informed that they don’t qualify. And politicians can stand up and say, we have done so much to ensure that surgery is available, emergency rooms accessible, hospital and long term care beds are there we you need one.  Lately the push is to ensure that every Canadian has a family doctor, do you see a pattern developing in how to shift health care resources?
I’ve yet to hear a politician brag that there is a shelter bed available for you should you ever need one, or that there will be a nurse available to support you through your pregnancy and first years of being a new mother.  Or that you are expected to live  10 years longer and healthier than your parents, and three-quarters of that gain was due to public health efforts.   
So the holiday question, is how to make public health issues political currency so Santa will come and visit?  

Thursday, 15 December 2011

Housing as a novel solution for homelessness - Happy holidays

Tis the holiday season, and for most of us that means family, friends and fun.  Time to be thankful for the pleasures we enjoy.   As we enjoy our festivities in warm company, we will hardly think twice about the roof over our heads or the cold outside. 
It is the time where countless generous volunteers for brief times will provide service and aid to those not able to enjoy basic comforts. For some the warmth of generosity of placing some coins into a basket at a mall is calming charity.  It is the time of the season that the impact of homelessness strikes home the hardest for those without shelter or those living in vulnerable housing situations where a choice between warmth in turning up the heat is balanced with food on the table. 
This blog has touched previously on housing Sept 20 2011.   This week, Health Evidence released a review on the health benefits of housing that is well worth reading.  Housing summary statement Health evidence.ca .   The relative dearth of information on benefits and harms, long term impacts, directed shelter benefits for women and children speaks to the ongoing need for directed and channelled research in this area.
The review mentions the estimated 17,000 shelter beds and the nearly 10,000 persons in Canada who nightly are still considered homeless. It weighs the evidence on what efforts should be undertaken to address their basic needs and perhaps reduce the health burden that they carry, and the burden on the health care system.  
Hospital administrations should take note before expanding far more expensive services.   Emergency departments should be pleased that the report suggests a reduction in emergency room utilization.  A reduction in psychiatric inpatient days was also noted.  The impact on other hospital resources appeared mixed, and possibly because of the 20% increase in mortality amongst homeless with HIV who likely avoided in-patient care – a poor excuse for describing the impact on hospital utilization as mixed.  Nonetheless the significant impacts on health care resources provides ample justification for health jurisdictions to be actively involved in advocating for housing as a health intervention.
Commendably as well, the review sneaks in that upwards of 400,000 Canadians live in vulnerable housing situations and notes that the health profile of this group is similarly poor to those that are homeless.
The review places considerable emphasis on the issues of abstinence versus non-abstinent housing options.  It would be well worth a careful methodological review to segregate the biases inherent in resolving such a question, and what outcomes are being sought.   The review suggests outcomes only in the 1-2 month time frame while persons arguing in favour of non-abstinent housing interventions will suggest that addictions are often secondary issues that can only be addressed after primary issues are managed and longer term benefits are achievable.
There are as many questions as answers, and applying “evidence” can take us down inappropriate paths when the real life questions are not answered.  Those real life questions also tend to be messy to answer using rigorous research methodologies that stand up to the expectations of the Cochrane panels.   There is currently a large scale study in Canada looking at randomization of housing options for the homeless to measure health impacts which will be exciting to view the final reports.
The Ottawa Charter on Health Promotion clearly identified shelter as a pre-requisite for health.  Yet 25 years later, we continue to debate the science about whether it truly is.  This Health Evidence review at least suggests some value in seeing housing as a solution for homelessness. 
DrPHealth will take a brief vacation from routine postings.  This reflects a large reduction from an average 50 visits to 15 during this week, and no doubt reflects the opportunity of followers to enjoy the holiday season.  So from the tips of our fingers, through this posting, we wish you the best of the holiday season, safe and healthy times, and shall look forward to a joyous 2012. 

Tuesday, 13 December 2011

Kyoto, Bali, Cancun, now Durban – Are environmental leaders taking a vacation from delivering on real action?

We should be grateful that the world leaders have come to an agreement on climate change.  Or did they?   Be sure to weave your way through the conference website. http://unfccc.int/2860.php 

The key point is in the fourth clause of the Conference of the Parties (17) President’s proposal for the establishment of an Ad Hoc working group, which supplements the work of the Ad Hoc working group on Long Term Cooperation that was established at COP 13 in Bali, that the Bali working group was to have completed its work this year and reporting out in 2011 but requires that its work be extended by at least one year.
4.  Decides that the Ad Hoc Working Group on the Durban Platform for Enhanced Action shall complete its work as early as possible but no later than 2015 in order to adopt this protocol, legal instrument or agreed outcome with legal force at the twenty-first session of the Conference of the Parties and for it to come into effect and be implemented from 2020
Now, if that is not a bunch of bureaucratize – what is? It is the only saving of face that the conference can say it achieved.  An agreement to discuss the possibility of setting up a structure that could be considered in advance of proposing some controls which might commence in a decade from now. 
Canada’s performance at the conference can be described as anywhere from deplorable to despicable.  One wonders if the current Minister of the Environment will be cheered by his caucus colleagues for his rogue capitalism, or sent packing into a new portfolio as the embarrassment that does not reflect majority public opinion.   Even China has criticized the Minister's actions. 
Regrettably it is not a time to be a proud Canadian.   Canada’s dubious position of being 6th or 7th among the greenhouse gas emitting countries while ranking 35th in terms of population. Canada was one of the poorest performers of the Kyoto protocol signatories, and is the country that has openly abandoned continuation of the Kyoto targets. 
Apparently even India, China and the US hinted that would try to achieve some targets although proof of such statements seems scarce. 
Canada is a privileged country, relatively well off and certainly a magnet for opportunity.  However just as individual inequity has continued to grow and contributes to the poorer health outcomes amongst Canadians, the inequitable distribution of wealth between countries expands and national impoverishment is becoming epidemic (we need only look to the debates within the European Union block on the consequences). The global health consequences will be borne by our children and grandchildren who are already the leaders in the Occupy movement and standing tall as protectors of the environment. 
Canada was renowned for its generosity, commitment to peace, and international collaborative efforts.   Where are we headed now?  As fortress North America further builds its security walls,  it is expanding its disposal of waste into the air where those “downwind” of the slipstream will need to grapple most with the consequences, and setting fiscal direction that is hurtful within the fortress and dragging down the health of countries throughout the planet we share.  

Sunday, 11 December 2011

Immunization – who does it better? Public Health Nurses or Physicains?

It is the question that remains unanswered and one that brings out the biases amongst public health professionals.  is it not clear that Public Health Nurses provide a better childhood vaccine delivery system than through private physician’s offices?
Of course what is “better”.   Higher coverage rates?  Fewer vaccine errors?  Less vaccine wastage? Better documentation?  Less expensive?  Fewer delayed immunizations? 
If the answer was apparent then we have enough experience to be able to distinguish which is better and we would not have the mixed system that exists.   Newfoundland, PEI, Saskatchewan, Alberta, the territories - childhood vaccines are predominately delivered by PHNs.  BC and Quebec have mixed systems, with BC split geographically and Quebec intermixed.  Manitoba, Ontario, Nova Scotia and New Brunswick are predominately delivered by physicians.   Should this not be enough to demonstrate variance and a clear best practice?  apparently not. Or at least if someone has the data comparing the different systems, they have not released it.  
A few things that probably need confirmation, but likely could be substantiated.  PHNs are more likely to have a structured approach to timely immunization, physicians more opportunistic. As such, it would make sense that there may be less delayed infants with a public health system right?   Well some work suggests otherwise as accessing public health for a clinic appointment can be more of a problem than a physician office visit.  Vaccine wastage is likely lower in Public health systems.  Vaccine safety reporting is definitely higher in public health systems. Documentation is not great anywhere, but better where public registries exist - although Manitoba has an excellent system based on physician delivered vaccines demonstrating that it can work as well.  Clearly, no clear winner based on what we currently know.
As for vaccine coverage, it should be simple to compare something like 2 year old immunization rates, right?   Well, try to find two provinces that actually use the same measure let alone publish any data.   2 year old MMR versus just measles, or all age appropriate vaccines by 2 years of age, or even every antigen specific rate.
The best data that was located in reviewing the question was for the four Western provinces.   Manitoba suggesting rates from 2003 in the 72% range for all 2 year old age appropriate vaccines, Saskatchewan claiming near 80% for each antigen in 2008/09, Alberta holding bragging rates to 84% for Penta, and 89% for MMR in 2008, and BC suggesting 66% for all age appropriate vaccines in 2010 (however this excludes one of the largest geographic areas where physicians provide vaccine).   Again, no clear winner based on very crude assessment.  I’d welcome some data from the other provinces if it is available and this site will be updated. (drphealth at gmail.com).
The point of this exercise is that we spend hundreds of millions of dollars each year on vaccination programs in Canada, yet we have not yet defined which model of care is the best at delivery.  Parallel systems have redundancies and inefficiencies.  Resolving these may lead to  better outcomes at a lower cost – so is exploration of the question justified?
There are other factors at play.  It seems that there is a high correlation with immunization rates by the density of physicians.  A definite but lower correlation also exists by density of PHNs.  This makes inherent sense.  Where there is a physician oversupply, ensuring routine preventative care is undertaken is integral to staying in business.   PHN distribution is more equitable within provinces and should not be a major accessibility issue, and hence a better distribution system for rural and smaller communities in the country.
So, the simple question remains unanswered, but may be a key question for public health to determine.  Policy forces may push vaccination out of the public health realm and into primary health care settings if the evidence is not amassed and communicated. 

Friday, 9 December 2011

Emergency Contraception: When politics, values and science collide

Plan B ® is better known as the morning after pill.  Not the best or the most effective method of birth control, but an essential part of a program of reproductive wellbeing.  What caught DrPHealth’s attention is the US decision from the FDA on an application by the manufacturer for eliminating the US requirement for prescription for women 17 years or younger.  FDA decision on Plan B.  After careful scientific review the FDA was prepared to grant the request, only to have the Secretary of Health and Human Services directed the FDA to not approve the request.  
So the reaction might be, only south of the border – right?   Of course while the Canadian approval for drugs is undertaken by Health Canada, the decision of the conditions under which drugs are distributed is a provincial function.   So barriers for access can be erected and local conditions may not recognize that such disparity exists within the country.  
Here is where the Canadian fabric unravels.   Plan B is available over the counter in most provinces and territories without prescription – but there are exceptions.   Plan B is only available under prescription for all women in Quebec.   Access may be facilitated by CLSCs where physicians or nurses can dispense the medication.   In Saskatchewan, pharmacists can dispense without a prescription, but must be involved in the assessment (selling under the counter).  
Go further, and begin to ask the question if it is available without barriers to the roughly $40.00 cost that can be a challenge for young adults.   Depends on the community let alone the province.  In some instances a form of emergency contraception (ECP) may be available in some physician offices, emergency departments, or health units – but not in others.  
The science on unplanned pregnancies is very strong.   Expected pregnancies should be encouraged for the health of baby and mother.  Measuring unplanned, unwanted or unexpected is not something that has been consistently undertaken – the usual surrogate being the assumption that all pregnancies under 20 are unplanned (which is also not a correct assumption).   Teenage pregnancies have  been decreasing steadily in Canada.  There is lots of evidence that the strong family education programs in schools are being successful as sexual activity and age at first intercourse, and use of protection during last intercourse have ‘improved’.  Statistics Canada teen reproductive health behaviours  Therapeutic abortion rates increased steadily to the start of the century and more recent reports are suggested this trend is flattening which again is a positive trend. 
Forward thinking minds are envisioning a time when access to effective contraceptives are considered a preventive measure without any barriers (including cost).   Changes are occurring despite bureaucratic barriers that can impose the values of the minority on those that are directly affected by the circumstances.   Public Health has been on the forefront of supporting sexually active youth in their decisions, it is time to become proactive again. Can we not collectively demand that ECP access be equitable across provincial lines, and that ECP is readily available without a financial barrier from all emergency departments, public health units and preferably also pharmacies.
As for our colleagues south of the border, the approval of Plan B was significantly delayed many years in comparison to most other countries, patience and diligence in pushing is still required.  The US teenage birth rate is the highest of developing countries.   More staggering however is that the pregnancy rate is also the highest.   There are some fundamental public health interventions that are probably more important than whether Plan B is available to women under 17 without a prescription.  Some of this discussion means challenging some very difficult and engrained value systems by unmasking the extreme status of the US as an outlier internationally in this area.

Wednesday, 7 December 2011

Alcohol - lower risk consumption guidelines released

Before the main item, an acknowledgement to the National Day of Remembrance and Action Against Violence against Women in recognition of the 22nd anniversary of the l'École Polytechnique de Montréal  tragedy.

In a recurring theme, addictions and psychoactive substances once again make the blogosphere headlines.  This time it is that substance that over 80% of us use regularly, alcohol.  The document is an attempt at converging a variety of differing recommendations on harm reduction approaches to the use of alcohol as a legal, addictive, psychoactive substance for which national per capita use is increasing about 1% per year. 

It is also the one substance for which positive population health attributes are noted (tobacco, cannabis and other substances have much less, if any,  evidence of a population or net individual level benefit).

The guidelines build on previous national work that called for a national strategy on harm reduction for alcohol, a subject this blog addressed previously (October 7, 2011 alcohol national strategy need.) 

The document is as much a science review of the current knowledge of risk and benefit associated with alcohol, and as such is recommended reading for public health practitioners to stay current (and trainees preparing for exams) in a relatively rapidly changing environment.   Amazingly, and to the credit of the authors, they have summarized the data into three readable tables on pages 28-30 of the report.  It is as much out of respect for the quality of the work that they aren’t replicated here and the reader is urged to follow the link below to the full report.

This national effort is done despite at least 4 different existing low risk guidelines currently in place in Canada. It will result in an increase for consumption above existing Ontario and Quebec weekly guidelines, and align more closely with those in place in the provinces on the two coasts. 

There are two downsides to be noted that reflect the policy environment in Canada. While this is a superb reference and report and its authors are recognized academic leaders in the country, it carries no weight of government support or willingness to adopt, and secondly, while the report is published it has not undergone the level of public scrutiny to date that such guidelines might best be subjected. As a first step, the “keepers” of the existing guidelines should link to this material and if they are unwilling to migrate to the single set of recommendations, then justify why five different Canadian guidelines should be propagated. As a second step, Health Canada and PHAC should transparently review and consider incorporation of the guidelines as a step in the development of a national alcohol strategy rather than continuing the current approach to outsourincing quasi-national policy to an arm's length organization, in this case the Canadian Centre on Substance Abuse (http://www.ccsa.ca/) .

Despite the policy development gaffs, quality efforts such as this may meet the ultimate tests, that of professional acceptability and of time.   Kudos to the National Alcohol Strategy Advisory Committee who have released the document and continue to push for a national alcohol control strategy.  Low risk alcohol consumption guidelines 

Tuesday, 6 December 2011

Tweeting the public's health. Social media as a knowledge adjuvant

Please help the site grow and send a link to a colleague, or retweet from @drphealth
Twitter provides a rapid mechanism for the dissemination of headlines.  In a world overwhelmed with information, knowledge management becomes a skill in need of honing.   If you do not yet have a Twitter account, sign up for one (
World AIDS Day -  December  1. Please forgive this site for failing to celebrate the day on time.    Health Canada announcing $17Million HIV research and vaccine development HIV vaccine announcement.    Can we ascribe some political currency to be seen involved in HIV research as relates to African countries?  The relative shortage of funding in other fields doesn’t get this level of attention.  Of course it was linked to World AIDS day on December 1, World AIDS day which provides a strong reminder there are some 34 Million infected persons, of which about 5% die each year. There were multiple tweets from south of the border as well celebrating the day .  HealthEvidence.ca published a list of comprehensive systemic reviews in celebration which is notable Health Evidence list of reviews on HIV and a commendable way to celebrate.   
From the APHA - Measles in Europe  A strong report from MMWR on the increase in measles across Europe MMWR and European Measles.   26,000 cases so far this year.  Concomitantly there have been numerous reports of measles importation into the Americas with a total of about 1000 recorded cases.   
From PHAC – a safe reissuing of travel advisory for sub-Saharan Africa and the meningococcal disease increases that have existed for longer than most of us have worked in public health. PHAC meningococcal advisory.  Nothing new and makes one wonder who is writing the PHAC tweets – some twit?
The 17% increase in utilization of school meal programs since prior to the recession in the US should have gotten much more attention School meal program increase.  Perhaps it is finally time to make school meals a standard part of the education programming at schools.  Healthy students learn better, and successful learners are healthier – we do need to appreciate the interrelationship.    
  Finally, a fun little piece on using social marketing  to target distracted driving amongst teenagers from the US Department of transport Social marketing strategy on distracted driving
Just a quick tour of a week of tweets from selected public health related websites focused on Canada and North America.  Sign up, and then learn to retweet the drphealth tweets to your colleagues!!!
Twitter home page) and at a minimum follow this site’s twitter companion  as the titles are “Tweeted” after posting  by @drphealth.   Just one more skill to add to your public health repetoire, and a relatively easy one to develop competence, and eventually master.

Two updates - yesterday the federal Minister of the Environment announced, as predicted, that Canada will not maintain its committment to the Kyoto protocol after it expires in the upcoming year.

Today,  the federal omnibus "get tough on crime" legislation will pass parliament despite opposition from a wide range of corners of the country, in fact, other than the sitting government, there does not seem to have been public support for the legislation - odd.  

Monday, 5 December 2011

Social injustice - Attawapiskat, Aboriginal Health and Janus

It is a tough job being a politician at any level of government. We likely don’t admire and respect those that donate their lives in the public's service enough. In one way it is kind of like parenting. A tough job - oddly we don’t train parents either. If we want the best politicians, we need to properly train them, adequately compensate them, and certainly respect them.   It really makes you wonder why anyone would run for and sit in public office.
So two stories caught the public interest this week. The first being the outrageous and unacceptable living conditions on the Attawapiskat First Nation.   What started as a desperate plea for chronic wronging the community and letting infrastructure deteriorate to third world conditions, became a political ploy suggesting that the very Chief and Council that extended the plea were incompetent and their administrative powers relieved by the federal government.  Talk about blaming the victim. Are we regressing to the days of the Indian Agent? The government official who managed reserve affairs and was even responsible for issuing passes to allow Aboriginal peoples to temporarily leave their reserve?  
There are several studies that have demonstrated the improvements in health to be achieved amongst Aboriginal peoples in Canada are being catalyzing and accelerated by empowering the very same communities.  It is integral to the 1979 Declaration of Alma Ata on primary health care, central to the 1986 Ottawa Charter on health promotion, and even woven as a misinterpretation of conservative ideals in shifting responsibility to the individual.  It seemed we were headed in a constructive direction.
Many Canadian First nations are in dire straights.  Basic infrastructure such as drinking water, sewerage, access to food and housing are compromised from decades of neglect that preceeding efforts at administrative transfer and self-government.  The problems will not resolve overnight.  There are many First Nations that hugely successful financially, engaging in large business operations and with community members that are thriving – so painting a brush that even hints that First Nations political structures need to be held more accountable is paternalistic at best, and more likely just insulting.  Just as with municipal and federal governments, there is a bell curve of success.  With cities like Detroit, and countries like Greece on the verge of finanical collapse, an acknowledgement of the diversity of successes is needed and a plan to support communities that are struggling.
Double the Attawapiskat insult with the indiscretion of a senior cabinet minister who for the sake of an additional 90 minutes of fishing, utilized a military helicopter to be extracted from a resort location.  Or the senior military official who last year used a government jet to attend to 'business' in the West Indies.   The icing on this cake is the Prime Minister publically defending the actions of his cabinet Minister
Perhaps we need to accept the rationale for what looks on the surface as a “perk”.  It might even be encouraged that those that are willing to stand for office be rewarded rather than penalized for their contributions.   We have independent government officers whose job it is to oversee and rule on inappropriateness in government and that process can be invoked as needed. 
What is not understandable is how Harper can apply a double standard, suggesting most First Nations governments are corrupt, and then excusing his own Cabinet Minister for possible misuse of public funds. So why might we be having such a tough time respecting his leadership?  Janus was known as the two-faced god.
The Ottawa Charter identified social justice as a prerequisite for health. Should we be surprised at the continuing health disparity amongst First Nations when social injustice persists?

Thursday, 1 December 2011

Psychoactive drug policy from a logical public health perspective. What a novel idea

Finally some logic being applied to the issues of psychoactive and other addictive substances.   The illogic of having differing historical approaches to tobacco, alcohol, cannabis and other non-prescriptive substances is not an approach that can or should be sustained.   This blog has addressed the issues of drug policy and the negative health impacts of the policy on several occasions.  We are all tacitly aware of the health impacts of substances such as tobacco and alcohol, and on a daily basis utilize harm reduction activities in addressing the risks associated with those substances.
So the BC public health community has issued a call for a national dialogue and reform to take a logic approach to all substances.  Link from the website at Public Health Perspective for regulating Psychoactive substances .  The message is a simple one, apply a public health approach to all substances with the intent of minimizing harm from all aspects – recognizing there is harm in the substances and harm in the consequences of criminalization, then look for the sweet spot that minimizes the total effects.
Brilliant!  And kudos to the BC Health Officers Council on openly advocating for another forward thinking approach that addresses public health problems.  
The documentation posted on the website also provides for a request for feedback, endorsement and comment from the public health community – that is us!! It has my support already.  While the document will supposedly be submitted to governments, if it is arising in BC – it may make it to that province and to the federal government as a sole provincial voice.   The challenge to all provincial public health communities  is to view and endorse the document, and then stimulate the discussion locally, provincially and nationally so that the collective efforts of the pan-Canadian community can be heard.
This, just before the final House of Commons vote on Bill C-10 which will implement mandatory sentencing and take this country further up the steep curve of personal and societal harms induced by our penal system. 

Tuesday, 29 November 2011

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

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

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

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

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

Monday, 28 November 2011

2011/12 influenza season – news on the cusp.

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

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

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