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Wednesday, 31 August 2011

Superbugs; Germs as an expression of political ideology

MRSA – methicillin resistant staphylococcus aureus
VRE – Vancomycin Resistant entercooccus
The previous blog spoke to the huge initial Canadian success, followed by a near complete collapse of the efforts to contain antimicrobial resistant organisms (AROs). One remnant of the antimicrobial resistance (AMR) surveillance system in Canada that remains is the Canadian Nosocomial Infection Surveillance  Program -  or at least their reports.   MRSA in Canada 2007 , VRE in Canada 2006 .  An effort of multiple hospitals that report identification of certain microbial agents in Canada.  A second effort that focuses on antimicrobial resistant organisms is Safer Healthcare Now – Safer Healthcare Now    A great initiative, albeit focused only on institutional efforts at reducing negative patient outcomes in hospital – not about improving health.   Finally there is a collaborative known as the Canadian Antimicrobial Resistance Alliance (CARA) that was lunched in 2007 and hidden in that site are some data that are not readily recoverable. CAR-A home.  Not surprisingly, the stated audience has a huge emphasis on institutional based services. 
Perhaps you see a trend? the superb efforts focused broadly during the 1996-2006 time period have faded and been replaced by focused hospital based efforts.   Who says politics doesn’t impact health? I’m sure it was merely coincidental that the Conservative government was first elected in 2006, around the time the community based infrastructure began crumbling.  
The last public reports on admission rates for MRSA were from 2003, and rates have gone upwards since with BC reporting that almost 25% of patients admitted to a hospital show evidence of MRSA before requiring hospitalization. The bigger question is why now is it so difficult to find these rates in the public domain? Hospital based (nosocomial) infections are a failure of infection control practices to adequately protect persons needing hospital care from becoming more ill during their hospital stay.  The risk in 2007 for MRSA was just under 1% of persons admitted to hospital, and 0.1% for VRE - and the trends for both were headed upwards. Some provincial data is available, and I would welcome links to others
The only relatively current data that seems locatable at as provincial level is in BC from 2010 BC AMR 2010 report. This appears to be an excellent report and certainly needs replication nationally and within each of the provinces.   (Please send links to other recent data so that it can be shared).

Monday, 29 August 2011

Superbugs – Canadian superheroes, then a national shame

Please send messages to drphealth@gmail.com, and follow on twitter @drphealth

There are three good reasons why public health will be an enduring vocation;  Humans continue to innovate and create new technologies which have potential harmful effects; Humans are capable of choosing, and sometimes do not make the healthiest choices; and germs that can make humans sick evolve very quickly.
Things that we can’t see, hear, touch, smell or taste, and have the potential to make us very sick are very capable of instilling disabling fear.   Relatively normal people become walking phobias.  You may have had a sense of the fear during pandemic influenza fears, SARS, or some new emerging organism that you don’t know enough.   Topping the list of dreaded bugs are the aptly names superbugs. 
The job of a microorganism, just as all species,  is to survive and multiple.  The strength of their success is in shear numbers.   Their key to survival are creative ways of adapting to their environment.  When you take an antibiotic for some infection, the drugs often effectively kill off most of the invading bacteria and allow your body the chance to finish off the job.   In its efforts to survive, bacteria and viruses can adapt to the changed environment – one now designed to kill it – by some simple tricks for survival.  First is that while the process of multiplying through cell division is superb – it is not perfect.  Small errors in replication called mutations, can provide a daughter cell with differing characteristics.  Mutated cells that survive better in a hostile environment, can carry this mutation into their daughters as well – merely survival of the fittest. 
In a second common method for developing protection, bacteria that are already able to survive because of existing protection, may merge some of their protection with different bacterial species endowing them with already effective protective mechanisms. 
As such, some bacteria have developed a series of mutations or shared solutions that lead to resistance to some antibiotics – those that have adapted to almost all the weapons in the human arsenal have become dubbed “superbugs”.
While man has been creative in developing new antibiotics, the germs seem to have responded in an even faster fashion.
Canada and most countries have developed national responses to antimicrobial resistance.  Canadian integrated program for antimicrobial resistance surveillance.  One can glance through annual reports and quickly note that the focus is on the agri-food sector specifically.   The Canadian Committee on Antimicrobial Resistance which led the Canadian charge for the late 90’s and early 2000’s, was disbanded in 2009 through a lack of funding.   CCAR obituary  The Canadian Bacterial Surveillance Network is still active but seems to have  fallen off in activity CSBN however does provide antimicrobial resistance patterns through 2009.  Likewise the industry finance National Information Program on Antibiotics fell to the side in about 2004 though the website remains alive NIPA .   Just try to find recent data on antimicrobial use in Canada - please post the link if you do.  The data are owned by a private consortium and the inaccessability of drug use data at a national level is another national shame. 
In 1996, the visionary leadership of Dr. John Conly led Canada on a great success story that has gone untold.  For about 10 years, Canada successfully resisted antimicrobial resistance.  Inappropriate prescribing practices were reduced and antimicrobial stewardship became a professional standard.   Most importantly, the rates of superbug infections in Canada stayed much lower than our neighbours to the south.  While not formally analyzed, the costs savings to the Canadian health care system would be in the hundred’s of millions of dollars.  
But, as is typical in Canada, money saved through public health efforts is not counted as a success. The collective efforts of the organizations have fallen out into the shadows.  Despite assurances from the Public Health Agency of Canada that antimicrobial resistance “coordination at the federal level would be better suited to move this complex issue forward”, the issue remains without a home and without a plan.   Not surprisingly, the superbugs are marching forward relentlessly and Canadian rates have been climbing. 
And who says bugs aren’t smart?  Though perhaps it doesn’t take much brains to outsmart some governments.

Thursday, 25 August 2011

Organic foods - Consumer choice and caveat emptor.

The latest and greatest food fad is organic production.   I call it a fad only in that it has its great proponents and zealous followers.  Organicity has certain value in attempting to reduce chemical use  - which should be a good thing.  It is a movement that has agriculturists rethinking some long standing less than sustainable practices - which is a great thing.  
It is not a practice without some risks or costs.   The E. Coli outbreak in Germany that killed at least 44 and caused illness in nearly 4000 was associated with organic farming. Not that most organic farming is associated with such terrible outcomes.   While costs for pesticides and antibiotics may be reduced, there may be a higher cost for labour,  and more animal losses during production, all of which lead to increases in per unit production costs.  The cost to the consumer is increased, sometimes partially attributed to reduced costs through subsidization of regular food production. 
There is little evidence either way whether the quality, taste or nutrient value of organic foods is superior or not to non-organically produced foods.  Nor is there definitive evidence that organic foods reduce other health related risks. I am sure that stating the facts may disappoint some people.  I’m also sure there are many in the industry that would like to tout such claims.  
So,  we have less than definitive evidence that either organic or non-organic is safer, healthier, tastier or more nutritious.  We do know they cost more, and the environmental footprint required to produce equivalent amounts of food is more. Seems the consumer is left to make the choice, and the public health role is to ensure that they can make an informed choice. 
Organic food practices are overseen in Canada by the Canadian Food Inspection Agency (CFIA) and through national regulations CFIA Organic Products information .  The value in this is knowing that false claims cannot be made -  something claiming to organic needs to be able to demonstrate that it is organic (there are further graduations of “organicity” that are not enshrined in regulation and are voluntary in nature so claims can be stretched).
On this issue, it is the buyer’s call.  Decisions may be based on values other than health and safety.  Just be an informed consumer as the added cost will come from your wallet.

Wednesday, 24 August 2011

Food irradiation - is it a nuclear debate or a missed opportunity?

Potentially dangerous things that we can’t see, smell or sense fuel fears. Seems that nothing fuels these fears more than the words "nuclear" or "radiation".  A little knowledge can ease the mind - slightly. 
Probably more sensitive that GMO foods is the issue of using irradiation on foods foods.  We seem to know that exposure to radiation may cause cancer, so it doesn’t take much of a leap to conclude that exposure to irradiated foods would also cause cancer.  That is not the case, but in the absence of good education and communication, lingering fear will dominate. 
Irradiation can be a good technology for certain food processes, and in some situations may be the best technology. It potentially has value and purpose.  The controversy exists because organized groups have mounted aggressive campaigns opposing the use of irradiation that have affected political processes - particularly south of the border and in Europe. Political decisions are often made on the basis of lobbying and not based on scientific rigour. Policy need not exclusively consider science, but should at least acknowledge its contribution to the debate and not offhandedly dismiss the evidence.
Lost in the irradiation debate is the value of potential reductions in toxic chemical use, physical processes that can affect food products, and sometimes the lack of alternatives.  The result can be decisions to not import/export certain foods and indefensible trade barriers.  Fruits in particular,  can have shelf lives extended through irradiation making longer distance transport and providing greater healthy food options.
Unlike with GMOs,  there are few strong proponents for the use of irradiated foods as alternate options do exist.   Food distributors can recognize the added value and potential cost savings, however the costs and risks of approval and conditions for use are a deterrent to the needed initial investments.  Radiation is not subject to patent protection,  and processes can be readily modified for unique commercial application thus avoiding patent infridgements.  As such, there is no big money behind supporting irradiated foods.  In the absence of big money there is limited research undertaken to truly test food irradiation safety and dangers.  
There may be legitimate safety issues. Following rigorous scientific methodology will answer such questions.  As with other non-patent protected solutions to health problems, there is an inherent bias against exploration as there is limited public or private money for developmental research.   In the end, we may just be missing a simple and cost-effective way of solving many food production problems for unwarranted fears.  If there are dangers, they can be documented rather than merely speculated.
As with GMO foods, in Canada foods that are irradiated undergo regulatory review, something that should make Canadians feel safer  CFIA irradiation fact sheet  .  On top of this is that foods with more than 10% irradiated components require labelling (unlike GMO foods where industry has successfully argued against labelling).   That the regulatory environment does not treat the issues in a parallel fashion is perhaps the good indicator of what money can buy.

I'd be interested in your thoughts - which would you prefer GMO foods, irradiated foods - or do you sit in the organic food camp that will be discussed next?   Leave a comment for all to ready, or contact me at drphealth@gmail.com   

Monday, 22 August 2011

GMO foods - a reality show with a really bad plot

Private comments or suggestions for topics - you can reach me at drphealth@gmail.com

There are several food related debates that increase passion and confusion:  Genetically Modified (organisms[GMO]) Foods, radiation sterilization of foods, and organic production make for a nice controversial week of possible blogs.  The news front for public health has been relatively quite.   The premature and sad death of Jack Layton is a blow to health advocates across the country -  that however is a digression.
You might think the GMO debate would make a tremendous movie.  It pits those struggling to address global hunger through improving food production,  against the unknown threats of genetic manipulation, with right wing pundits looking at patent production, left wingers claiming money grabs, and just to spice up the plot - a really bad guy in the form of a well known corporation (that produces pesticides and seed products).   Okay, perhaps the audience wouldn’t be so enthralled, but then who would ever have thought that a movie about big tobacco would be produced?  
Our monoculture approach to food production is rife with the vulnerability of crops to specific threats from pests.  GMO approaches attempt to bolster crop defences through several means, and just like many interventions, those means may have very different impacts and threats.  There are some 70 or so GMO foods that are routinely utilized, and when  you sit down at your dinner table, you will likely find one of them being served without your explicit knowledge. 
One of the most notable defences to the use of some GMO foods, is that after literally millions of person years of consumption, that no adverse effects have been noted.  The caution, is that while the initial GMO modifications focused on insect, virus, drought and herbicide resistance, more recent modification looks to enhance the food quality, and certainly the most controversial, is modification for the purposes of patent protection (affecting plant sterility).
Prior to direct genetic manipulation, man has selectively been genetically modifying plant and animal species through breeding programs including interspecies breeding efforts. Hence the more recent debates about GMO perhaps are a bit exaggerated.
Of course the debate about GMO would likely be restricted to science if approaches to patent protection and intellectual property rights did not shroud the evaluation process in secrecy, adding to the mystique and perceived danger.   The “bad guy” tactics of big agri-farming giants further fuel the scepticism. 
Canada does maintain a regulatory approach to GMO Health Canada fact sheet on GMO which is worth becoming familiar with.  Those that support GMO innovation will likely be impressed with the rigour, those that oppose may choose to stop eating any foods.  
In the meantime, consider donating to the Somalian drought situation.   We may currently have enough food globally to support everyone, regrettably however the food is not distributed equitably and an estimated 925 Million people are undernourished, (roughly 15% of the global population).  Our Somalian brothers and sisters are amongst the worst affected right now.

Friday, 19 August 2011

Maternal-infant care - a great public health success story.

Public health has its roots in communicable disease control (actually in ‘biological’ warfare in biblical times).  Then it wandered into occupational health issues in the mid 1800’s.  The turn of the 1900’s saw a growing interest in maternal and child health.  At that time about 1 in 200 births resulted in the death of the mother and one in ten the death of the infant before their first birthday.  Today, those numbers are 1 in 11,000 mothers and 5.1 infant deaths per 1000 live births.
Incredible improvements - due mostly to the simple public health interventions of improved nutrition and better hygiene.
Today there rightly remain concerns for the thriving growth of the infant.  Death is not the only health outcome of concern and issues like attachment in the first hours to year of life are receiving more attention as they relate to our health as adults. 
There is also a “quality of birth experience” that has driven change to the birthing experience for some mothers and at times can be at a odds with increasing risks to the baby.  On the other hand, formal health care services are not yet always aligned with ensuring a good quality of experience while maximizing the reduction in risk.   
There is a good recent Canadian set of surveys and studies on the maternity experience at http://www.phac-aspc.gc.ca/rhs-ssg/survey-eng.php  
Notably, Caesarean section rates continue to increase and often exceed 1/3rd of births.  This was considered acceptable until 2009 when new guidelines now stress that C-sections should only be provided when there is a threat to infant or mother http://www.sogc.org/guidelines/documents/gui221PS0812.pdfRates have yet to  not come down yet, nor has promotion of the new guidelines received much attention.     
Good news - breastfeeding initiation rates are in the 90% range.  Continuation through 6 months is much lower than needed to promote the health of infants. More good news is the routine circumcision is decreasing and now about 1/3rd of male infants.   Two more public health success stories.
Midwifery is reinvigorating the health system approach to normalizing the birth process,  this is a great thing.  Many physicians have shied away from continuing obstetrical practice.  While specialization in managing only one component of our health care has some value, it undermines the primary health care relationship that should form the foundation of personal health care.  Collaboration between health care providers is essential, and with this the sharing of information referenced in the previous blog on electronic health records. 
Lacking in many parts of the country is a dedicated focus to maternal child health based on public health principles.  Replacing this are specific approaches driven by philosophy and often in competition.  The undermining of the public health approach to maternal-child health is perhaps something only to be mourned now - and hopefully without the need to mourn mothers or children who suffer because of the change.

Tuesday, 16 August 2011

Electronic health records - information is power AND possibly lifesaving

Private comments or suggestions for topics - you can reach me at drphealth@gmail.com

We are all individuals.  Our genetic make-up varies.  What we eat and drink forms part of what we are.   What we are exposed to can affect our bodies.   It should not be surprising that when a battery of “tests” are done, that unlike machines that operate in a specific fashion, that each of us ‘operates’ differently.  Thank goodness for physicians and others that interpret these differences, determine when we are operating incorrectly and recommending ways to function better.
All that takes information.  What is happening today is important. What has changed is often the most critical information when something goes wrong.   The Star Trek tricorder concept of a quick scan misses that the story is usually about the change.  How can a physician who doesn’t know you, figure out what you need if they don’t know your information?  
Health system users expect that their information is readily available to anyone working in the health system.   A small minority are concerned that their “privacy” is compromised.  In our often libertarian driven policy environment, the privacy concerns have won out.  This perception is likely fuelled by health care workers that recognize that information is power,  and to not share information, means keeping control.
Unlike Facebook where nearly half of Canadians are willing to post intimate details of their personal life,  your medical information is usually so tightly wrapped up that hospitals do not have information from your family doctor. Even you would be challenged to amass all the health information into a single location if you tried. You have the right to access your medical records, but you are not the owner of the record.  It is this problem that contributed to the demise to Google Health. How can you populate your record, if there are barriers to you collecting the information (physicians may charge for copies, hospitals may require written requests and can charge to review the record for sensitive information before you can look at it, and can charge for anything that is copied)  
While there are attempts being made to integrate health information together, the inadequacy of the efforts should scare us all.  Our bodies and mind tell an important story.  Time to share it with those that are involved in helping us care for it.   This won’t happen until the public demands it – and that is more often something critical in an emergency, not when we are well.   In the meantime, propagating the information inefficiency requires more workers, and at risk is your wellbeing.

Monday, 15 August 2011

Public health news of the day – hot topics. Asbestos, MS, war, electronic health records and what's missing

Asbestos – can you believe the audacity of the Canadian government to chastize the widow of a worker killed by mesothelioma for expressing her views on Canadian asbestos policy.   One has to wonder how dependant the governing party of Canada is on industry supported money.  They put enough in to support the industry, it is a great way to have money back in their party coffers.
MS treatment by venous angioplasty (CCSVI) – a preliminary report that shows some benefit in symptom reduction and duration of remission – only 15 patients though.   Keep your fingers crossed, but it is still too early to spend personal money on unproven treatments.
If you read the blog on Leukemia and MS and are amazed at coincidence, check out the CTV blog by Dr. Lorne Brandes http://healthblog.ctv.ca/post/Immunity-leukemia-and-multiple-sclerosis-A-tale-of-two-studies-and-their-politics.aspx .  Uncanny parallel.   
War and Peace – gang related violence hits peaceful Kelowna.  3 shot in garage in Winnipeg.  Both headlines seem related to gangs.  Talk about bringing the issue of war close to home. Iraqi bombs kill 56.  Syria enters third day of “major assault” (at least 188 deaths this month). 
Google Health has announced its imminent demise.  The effort to allow individuals to make their personal health records available.  A topic for later this week. http://googleblog.blogspot.com/2011/06/update-on-google-health-and-google.html
Now for the interesting stuff – what’s not in the news.  
·         What ever happened to C. difficile in Ontario, after a documented 26th death in late July, no reporting.
·         When was the last time you heard the Public Health Agency in Canada (PHAC) in the news.   These are the defenders of our wellbeing.
·         For that matter – have you heard anything from the Ministry of Health where you live?  Health expends close to 50% of provincial budgets, you might think that it should generate some news daily.  Only in Quebec does the media dedicate effort to tracking health stories, and only through Andrew Picard at the Globe and Mail are public health issues even occasionally reported nationally. 

Private comments or suggestions for topics - you can reach me at drphealth@gmail.com

Thursday, 11 August 2011

Leukemia, MS and promises of miraculous treatments - who gets hurt?

Two headline stories overnight speak to a key issues in health services.

A 2nd Canadian dies after vein surgery for multiple sclerosis. 

Gene therapy for leukemia treatment successful. 

Multiple sclerosis is a devasting disease on individuals and their families.   Despite years of research, minimal progress has been made on effectively altering the course of the disease.

Leukemia strikes fear into most of our hearts.   Someone we have known has likely suffered from the disease and we are all too familiar with the tragic consequences for some.   Unlike multiple sclerosis tremendous gains have been made in treatment options and survival rates over the past 4-5 decades.   While incidence of childhood leukemia stable, 90% survival rates and improvements in mortality over the past 30 years from 50% mortality.  However one needs to read the fine print of the article, the treatment is only for persons with chronic lymphocytic leukemia (CLL). 

There are four major classes of leukemia, CLL is almost exclusive an illness afflicting aging person and rarely seen before age 40.   It had a 75% 5-year survival rate, with as many afflicting succumbing to other disease of age as to the disease itself.  It afflicts about 1800 Canadians a year.  About 50% more common in males than females, it has been slightly increasing over the past couple of decades with rates up about 50%. Unlike most leukemias – there are the majority of suffers have genetic anomalies.  

The treatment being utilized is exciting from a technical perspective and no doubt likely something of considerable expense.  Its application to other forms of leukemia or cancers will be limited, although the technology perhaps will form the basis for treatment of other genetic anomaly disorders.   The cost of developing the techniques will be millions of dollars to help a very small subset of sufferers. The good news, is that the procedure is following the accepted process for scientific scrutiny.  The researchers do not attempt to overstate the value, it is the media spin that may elevate some people’s hopes.

The second story is an example of a therapy that has not received scientific scrutiny and yet public expectation have been raised.  As with any new therapy, there is hope that the final result will demonstrate a significant benefit and judgement on its effectiveness should be reserved until it has undergone the level of rigorous testing required to ensure it works, and ensure it is safe.  That an increasing number of private facilities offer the service on a user pay basis reflects the challenge of living with MS.  There are about 85000 Canadians living with MS.  Canada is well known for its high incidence of MS – one of the highest in the world.  As such, the potential for a dramatic breakthrough in treatment would be very welcomed. 

The big BUT, the vein cleaning surgery for chronic cerebro-spinal venous insufficiency (CCSVI) has not undergone the types of testing that medical procedures would normally be subjected to.  Its origins in an Italian clinic in 2008 that has not undertaken formal research on the procedure has incited controversy across the world.  Governments are pouring dollars into researching the procedure and to date the findings are not nearly as promising as the hype.  In the meantime,  hundreds of Canadians have traveled out of country for the procedure and disease specific societies have advocated for inclusion of the procedure as funded as well as research into its value.  Objectivity in the debate is easily lost. Millions upon millions of dollars will be spent to ultimately determine the value of the procedure. As a rule of thumb it costs twice as much to prove something doesn’t work as it does to prove it does.  The onus has now been placed on the public to fund this work. 

True “breakthrough” therapies in medicine are rare.   Breakthroughs are large improvements in outcomes over existing therapy.  Most improvements occur through incremental improvements over existing therapy.  Research is expensive, and the “system” is unlikely to fund research into unproven therapies that might lead to breakthroughs – most likely because they are so rare and uncommon. However, there are innumerable vulnerable populations ripe to respond to overzealous claims of benefit, and ready to dig deep into their personal pockets to buy hope. 

The damage done by excessively raising public expectations, by siphoning research dollars away from activities that will benefit larger numbers or persons, and the personal toll taken by individual pocketbooks or through lives of those that are unwittingly being subjected to unproven therapies is discouraging in the least. My sympathies to those caught in the middle between the need for hope and the desire for something that works.

If it sounds too good to be true – it probably isn’t. 

Wednesday, 10 August 2011

War and Peace - as a public health issue

Rioting in the streets in England,  protestors killed in Syria, the Libyan crisis, Afghanistan conflicts -  all current conflicts with the potential for significant numbers of deaths or injured. Global conflict is a public health problem.
It is difficult to get good statistics where governments are engaged in conflicts.  Numbers of deaths and injured are conveniently underestimated by one side, and overestimated by the other.   Discrepancies of the order of an order of magnitude are not uncommon. Injury statistics are even more difficult to obtain in areas of active conflict.
In England, there are at least 4 related deaths (including the initial event) and 125 injuries in the past 5 days.  Reports of up to 2000 dead in Syria;  6,000-30,000 in Libya; about 10,000 in Afghanistan; and estimates from Iraq vary from 100,000 to 1 Million Iraqi body count in a nice Wikipedia item on how statistics on the same subject can be so different.
There is an Oslo peace institute that tries to track the impact of global conflict.  The most recent article estimates about 10 Million battle related deaths since WW2 Global conflict related deaths 1940's-2005 .  More importantly though are the estimates of increased mortality due to conflict that are not directly attributed to battle with some conflicts having only a few percent of all deaths related to the battlefield.   Check the home institutes website and explore the data set at http://www.prio.no/CSCW/ 
About 55 Million people die each year, and while it is tough to get a really good fix on the number of conflict related deaths, it is likely in the 300,000 range for just battle related deaths and not unreasonably 10 times this for non-battle related deaths due to conflicts.  The categorization is not enough to make the world’s top ten list of causes of death Top 10 causes of death by income grouping of countries , however it should be enough to receive more concerted attention at the root causes of global conflict.
Most conflicts result from the inequitable distribution of resources.  Peace depends on a civil society in its most basic form.

Private comments or suggestions for topics - you can reach me at drphealth@gmail.com

Tuesday, 9 August 2011

Suicide and the crash of stock market.

From the days of Durkheim in 1897, there has been a fascination in exploring what prompts individuals to tragically take their own life.  Scores of publications have explored descriptions of risk factors from several types of mental illness, alcohol dependency, history of abuse, family history, certain major physical illnesses, job or financial loss, relationship loss, lack of social support, amongst other.  Studies have described protective factors such as religious and cultural beliefs, female gender, good formal and informal support networks, reduced access to lethal methods (gun control), improved skills in conflict resolution and problem solving. 
With such great information, how well are we doing?   Canadian Suicide rates 1980-2005  shows a significant but subtle reduction of about 15% over the 25 year period of time in both males and  females.  Improvements in fatal health outcomes  for many other issues have improved substantively more, posing the question why have we not been as successful in preventing suicide?
Males complete suicide 4-5 times more often than females.   While male suicide rates are similar across all adult age groups in Canada, female rates tend to peak in the 35-65 age range.  In the US, male suicide rates increase dramatically over the age of 75 – one has to wonder about the impact of a less universal medicare structure. In Canada,  Aboriginal populations have historically had suicide rates 3-5 times the non-Aboriginal population.
Suicide attempts are about 4-5 times more common in females, and at a younger age range.  Hospitalization for suicide attempts is about 5 times more common than completed suicide. Only about 1 in 3 attempters is actually admitted to hospital.  The discouraging statistics is that in some studies less than half of attempters are referred for any follow-up despite their pleas for help.
60% of suicides occur amongst unmarried persons.  60% of suicides occur within the home. Among high school students, one in 5 has considered suicide in the previous year, 8% have taken some action on a plan, only 2-3% come to the attention of the formal support systems. 
As I said, we are great at describing suicide.  But how good are we at preventing it? There are innumerable programs that have been implemented in the name of preventing suicide ranging from school intervention programs through to assisting doctors in identifying depression in the elderly.  There are emergency room crisis teams and standardized follow-up protocols, case management of chronic mentally ill persons and bereavement crisis teams.  Most sound good on paper but have not been adequately evaluated for their impact on suicide rates.  There are only a couple of interventions that have shown benefit.  Suicide prevention training has been effective in military settings and long term follow-up (over one month) of attempters from the emergency room.
With all the good efforts and diversity of programs, you might think that only seeing a reduction in suicide rates of 15% during a time of economic prosperity seems inadequate.  Most other illnesses have improved dramatically more. The proof may be in seeing how the repression starting in 2009 has impacted suicide rates.  Yesterdays tumultuous freefall of the stock markets in the wake of the downgrading of US debt, will place more indivdiuals in financial trouble than the impact on financing the debt.  
Of course, there is very little glamour and glory to addressing a topic that has religious and cultural taboos associated with it. And in times of economic desperation, somehow watching out for the average citizens hit hardest by fiscal policies is not high on the agenda.  Seems the only time money flows for improved programming, is when suicide touches the families of a politician.  That in itself is a tragedy.

Monday, 8 August 2011

Motor Vehicles Collisions – A risk we live with.

Motor Vehicles Collisions – A risk we live with.
The death rate from Motor vehicle collisions (MVCs) has declined about 50% since 1980 Canadian motor vehicle deaths 1980-2005 by gender .  A success of  numerous activities from better road and vehicle construction, improved driving performance, and higher gas prices resulting in lower vehicle use. 
Looking at hospital admissions over a shorter space of time of only 10 years, the reduction is about 35% MVC hospital admissions 1995-2005 .  
The improvement in young male drivers is even more pronounced MVC deaths 15-24 year olds by gender 1980-2005.   The PHAC injury surveillance site can be used to explore more.  These graphs represent rates and not absolute numbers.   The good news is that absolute numbers of deaths have decreased about 40% from 1990-2009, hospitalizations by 56%, and any injury by 34%.     If we looked at Transport Canada collision statistics there is some information on numbers of collisions to compare the trends in injuries and fatalities.  Between 1988 and 1997, the number of collisions decreased 22%. Roughly ¾ of collisions are property damage only, ¼ involve injuries and only 1 in 200 result in a fatality.
There may be a debate as to why. The success of interventions directed at engineering solutions and at driving performance should be celebrated for the large reduction in both deaths and hospitalizations Driving performance related improvements in Canada include a downward trending in the proportion of  MVCs deaths that are alcohol related, graduated licensing that restricts and protects new drivers,  and possibly driver education. Seat belts, air bags and engineered passenger spaces (reinforced sections of vehicle) are major contributors to reduction in severity of injury when a collision occurs. Road design though better intersection design, turning lanes, divided highways, and rumble strips are further engineering successes.
There are another three groups that likely would claim a share in the reductions; Emergency responsers, trauma management specialists and, enforcement agencies.   Had better care and emergency service contributed to the reduction in deaths, one would have expected less of a reduction  in hospital admissions as injured persons would still require hospitalization.  So the major improvements are in reductions in the numbers of persons being injured, particularly with more severe injuries. On the enforcement end, it is on the continuum of education activities that ultimately contribute to better prevention, but only a small fraction of persons committing a traffic offense will be caught and penalized.
In the end, half of the reduction is achieved through a reduction in collisions, most of the remainder of the reduction is in the severity of injury at the time of a collision.  That is,  injuries are less likely to be severe when a collision occurred. 
Kudos to Transport Canada who have issued a good comprehensive overview of motor vehicle safety for the Canada Year of Road Safety Road Safety in Canada 2011 as part of the UN Decade of Action on Road Safety
There is a long way to go to making motor vehicles less risky and safer.  But, where are the public health, transportation advocates and design engineers in celebrating the huge successes which they have achieved?  Some days I get the impression that the reduction is due to emergency air transport systems, trauma teams and high tech emergency intervention.  The data just don’t support it, but our pocket books do. 

Private comments or suggestions for topics - you can reach me at drphealth@gmail.com

Friday, 5 August 2011

Community Mental Health – Turning a blind eye until it is too late.

A gruesome assault in Penticton BC mirrors the notorious Manitoba Greyhound bus attack that killed a young man in July 2008. A father in Merritt BC killed his 3 children several years ago.  Outside Canada there are questions about the tragic massacre in Norway, the Fort Hood shooting spree, the Virginia Tech massacre and even further back to the Montreal Polytechnical Institute massacre of 1989.   While the four massacre examples may have a different basis, they likely share a common theme of persons with mental illness in the community. 
The victims of all these tragic situations were innocent.  Families and loved ones are left suffering. Their grief and pain is something we all need to understand, feel and empathize with.  Their losses are irreplaceable and form the fears that many hope they never experience.
Details on the Penticton situation have not been released, but there is enough media testaments to suggest the perpetrator suffered from a chronic mental illness and was inadequately treated.  Hence the parallel to the Manitoba situation on which more scanty information has been released.
Mental illnesses are a diversity of diseases and do not have the same causes.  In any society, there are about 3% of the population who suffer or have suffered from illnesses that cause a break from reality (psychosis).   1% are diagnosed with schizophrenia, about half as many with either bipolar (manic-depressive) illness or major depressive illnesses.  There are only enough psychiatric beds for about 1 in 60 of these individuals at any one time.  The other 59 live in the community, most requiring long term medication.  Many of these have insufficient case management to support their needs to remain functional.
When a person with a chronic mental illness fails to show for an appointment with their caregiver/case manager, there may be some limited attempts to reach them and reconnect.  After several failed attempts, the individual may be dropped from the caseload. One of the most common reasons for someone with a chronic mental illness to not follow through on an appointment is deteriorating mental illness.
Fortunately most persons with chronic mental illness are unlikely to put others at risk but may put themselves at risk.  The most unusual behaviours may be displayed on street corners, they may find themselves friendless and homeless as a result of their illness, or they may cope with the unpleasantness of their illness through using alcohol or drugs. Then we can victimize the individual rather than blaming the system that has failed them.
Occasionally, mental illness decompensation may be associated with disturbed thought processes that put others at risk.  In the case of the Greyhound  and likely other attacks mentioned. This results in public outrage and horror.  The solution is to find criminal fault with the person undertaking the attacks even when the proverbial “psychiatric assessment” has found mental illness as a major contributor to the event.  
Mental illness can be treatable and controlled by a system of services designed to manage individuals and support them within the community. Persons with mental illnesses are often constructive contributing members of society when well.  We do not criminalize people who have heart attacks or strokes.  Not only that,  we insist on having the best medical care available when such events happen and build bastions of health care for their needs.  Prisons have become the psychiatric institutions of this century, thankfully some recognize their role in providing humane care.  
Why in a supposed civil society do we continue to treat some people with mental illness as outcasts and deny them the best possible medical care?  Why when floridly ill and their actions hurt others, do we place them in prisons instead of putting the system that failed them on trial?

Thursday, 4 August 2011

Asbestos – when public policy kills, who is responsible?

Canada’s actions on asbestos for decades is embarassing and should be considered criminal.   In the face of international scrutiny, national pressure from most major Canadian health organizations, and public opinion opposing asbestos, not only does Canada continue to manipulate the international acceptance of chrysotile asbestos, it invests and supports in the expansion of domestic mining of the sole purpose of exportation to countries where health consequences will occur.
Almost all forms and uses of asbestos are prohibited in Canada for health and safety reasons (and mostly banned from US, Europe and developed countries).  Yet Canada continues to mine, export and promote the safety of one of the six forms of asbestos. 
The Rotterdam convention www.pic.int/ sets a framework for international trade in hazardous substances, it does not preclude international trade just lays out the conditions for movement of hazardous substances. The other five forms of asbestos are covered by the convention.  Chrysotile asbestos was recommended in 2005 for addition.  Canada has been observed to have taken an active role in 2006 and 2008 meetings encouraging countries that receive its products to successfully oppose its inclusion.  The Canadian delegation was supposedly conveniently absent from the vote in 2008.  At the June 2011 meeting, it was debated again whether to add chrysotile asbestos.   (http://www.pic.int/TheConvention/ConferenceOftheParties/Meetingsanddocuments/COP5/tabid/1400/language/en-US/Default.aspx  agenda item 5.11 which also provides good background information on which decisions are to based).   Canada openly opposed inclusion right up to the week of the meeting and lead the efforts to prevent its addition.  http://www.thestar.com/news/canada/article/1013166--canada-blocks-asbestos-from-hazardous-chemicals-list-at-un-summit   
Asbestos is associated with a variety of disease outcomes.  Most notably the rare form of lung cancer known as mesothelioma.  Even small amounts of asbestos exposure is associated with a variety of other cancers and interactions within Canada are tightly regulated. Canada has exported chrysotile asbestos to developing countries with less rigorous occupational health and safety regulatory frameworks, expectations and oversight.  In doing so, it has condemned some workers in those countries to a painful death. 
Such action if it occurred within Canada would constitute wilful negligence resulting in death and would be considered a criminal offence.  For a government who purport getting tough on criminals it is a major inconsistency. Standing in the background and no doubt supporting the efforts of the Canadian contingent  are; a powerful lobby group - the Chrysotile Institute; the Government of Quebec; and economic development activities for struggling economic areas of Quebec. 
All asbestos in Canada is mined in Quebec, and hence there is a special role for Quebec provincial policy in directing national action. The Government of Quebec has censored and rebuked scientists and my public health colleagues for speaking out and against the issue of health impacts and asbestos,  in favour of industry led statements on scientific uncertainty. So much for the freedom of expression of scientific evidence in the supposed democratic society of Canada. 
This past year, Canada has participated in publically funded loan guarantees for the refitting of the Jeffery asbestos mine near Asbestos PQ.   Thus, your and mine tax dollars are going to efforts that will result in people dying in other countries. 
How does it make you feel to live in a country that uses our dollars to kill our global neighbours?

Wednesday, 3 August 2011

Insights into INsite – Canadian drug policy decided by the courts

Canada has two supervised drug injection site.  Both are in Vancouver.
The second  site receives the notoriety and is the focus of this discussion – namely INsite. Opened in 2000.  Its primary purpose was to reduce drug related deaths in Vancouver, concurrently to undertake extensive scientific research on the impacts of such services.  It required an exemption from illicit drug laws to allow for the presence of controlled substances so that users could feel unthreatened from police action while in the site.  
The research is now relatively clear, some 30 odd studies, most showing  benefit or at least no harm.  One poorly done study suggests increased private security requirements.  The latter study is broadly cited as reasons for not supporting the ongoing operation of the centre.  Read the full advisory committee review from 2008 at http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#ex   There are additional supportive studies that have been released since 2008.
The site has been mired in legal issues since 2008 when the conservative government ended the exemption and INsite challenged the decision.  The interpretation being that if the exemption to laws on possession of drugs was not continued the site would close.  Various courts have ruled on the matter as it has worked its way through to the Caandian supreme court.  The BC Appeals court has upheld lower court decisions that take aim at two issues.  The first is the criminalization of possession of drugs.  The second being the apparent ability under the Canadian constitution for provinces to determine what constitutes health care – and in this case the decision allows the province to designate any facility as a health care facility, something that causes grief for the federal government relative to the potential application to other non-hospital health care settings.
The supreme court heard the case in mid-May 2011 and a decision is still pending.  
There are at two issues relevant to Canadians:
1.    The continued resistance of the conservative government to policies that can be perceived politically as supportive of drug use, even though their actions are in reducing drug use and in preserving health.  Combined with the failure of the government to acknowledge the massive weight of evidence demonstrating benefit from INsite.
2.    The ongoing legal circumstances surrounding INsite have effectively barred other large North American cities from establishing supervised drug consumption sites.  Montreal, Toronto, and Ottawa (perhaps under a different mayor) at a minimum are Canadian locations that would move forward once the legal battles are concluded.  In the meantime, hundreds to thousands of users have been denied access to health improving and drug reduction services
You will recall that there are two supervised injection sites in Vancouver, the older one has operated quietly, outside public scrutiny, without fanfare and without legal battles.  The only limitiation is that its clients do not have the benefit of recognition of it being a “legal” safe injection site, however they have not once been hassled by police.
The legal battles of INsite have overshadowed how effective local community action can be in protecting health, and working as a community to address an urgent need. 

Tuesday, 2 August 2011

The War on Drugs – your wallet is the loser.

Drugs are a controversial topic at the best of time  – your opinion is welcomed so that the diversity can be expressed.
True or False:
1.     Psychoactive drug use is rising?  - False – while drugs specific information can vary, most drug use prevalence data has continued down  over the past few decades.   Some drugs like Cocaine peaked later in the 90’s. http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/stat/_2009/summary-sommaire-eng.php#tbls
2.      The War on Drugs is working?  – that depends on what is considered working.  At best the situation is a stalemate based on drug seizures.  Drug offenses have decreased and overall use is decreasing, unlikely a consequence of enforcement activities. Illicitly derived drug related money remains the major driver for organized crime activities in Canada.  http://www.rcmp-grc.gc.ca/drugs-drogues/2009/index-eng.htm
3.    Locking up drug offenders will reduce drug use?  - False -    The past three sittings of the Canadian government have entertained legislation which would see the introduction of mandatory minimum sentencing for drug crimes – the “get tough on drugs” agenda.  This included a minimum of 6 months for possession of 6 cannabis plants.   The debate and background research can be following through the Urban Health Research Initiative at http://org2.democracyinaction.org/o/6452/p/dia/action/public/?action_KEY=4894   The good news is that the legislation has died on the order paper so far, but with a new majority government in place, expect this to become a reality despite the evidence against its effectiveness.
 While the evidence suggests longer term reductions in drug use are occurring, this is not attributable to “war on drug” policies.  Prevention and early intervention underlies the effective social change behaviours related to long term substance use.   These efforts are the most cost-effective and efficient in reducing demand.  
Having read this brief introduction, and armed with information from Health Canada, the RCMP and Canada’s foremost researchers in this field -  be amused by reading the government’s perception and ease with which it has dismissed Canadian generated data by questioning the methods http://www.parl.gc.ca/Content/SEN/Committee/371/ille/library/DrugTrends-e.htm .
There is a common saying about how politicians and others dismiss information that is not in keeping with their beliefs
First Question the data
Them, Question the methods
If necessary,   Shoot the messenger
The current right leaning Canadian government has routinely questioned the data and methods, and in the case of the supervised injection sites in BC, shot messengers that carried supportive messages.   The price will be more jail terms, more prisons, more enforcement – and  too often reductions in programming that support prevention and early intervention.  The cost is borne by Canadians everywhere, duped into thinking that money is being wisely spent.
Is it too much to hope that national policy that affects health is driven by informed decision making?