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Tuesday, 31 January 2012

Tobacco Control South of the Border - Something to learn from

The American Lung Association recently released a great report on tobacco issues in the US that is worth reviewing US lung association tobacco report card   

The short version is that after years of slow progress, tobacco control has not progressed much during 2011.  No new strengthened state laws were passed and Nevada lightened its requrirements.  No state increased taxes, New Hampshire actually reduced the tax.  Many prevention and tobacco reduction programs saw the impact of funding cuts.

The few gains that were achieved appeared within the federal government’s reach.  New warning lables, expanded cessation benefits for federal employees, and improved funding for state quit smoking activities. 
Seems like the winds of tobacco control are blowing in the opposite direction down south.  

The detailed report provides a great set of metrics by which provincial and Canadian initiatives can be measured.  But typical pan-Canadian initiatives lack the accountability that our American cousins are demonstrating in such a good report.   

Monday, 30 January 2012

Hepatitis C – A case of Inequity based on disease diagnosis.

The Krever commission report into the Canadian Blood system was a significant watershed event for public health in the country.  Link to access page for Krever commission report  .  While driven by the transmission of HIV to blood recipients, the inquiry occurred at a critical time when new developments were occurred on Hepatitis C.

 Those that have been around hospitals long enough knew well about the post transfusion problem of non-A non-B hepatitis, the existence of which was likely known as early as 1974.  It was not until the 1988 that the Hepatitis C virus was actually identified, and not until the early 1990s that appropriate virus specific testing was widely available.   (Recall that the HIV was ’discovered’ in 1982 and the virus identified in 1983 and testing was available in 1985)

Now some quarter of  Million Canadians are infected with Hepatitis C, and about 8000 new infections annually.  About 20% of those infected are unaware of their infections.  Nearly two-thirds of new infections are associated with injection drug use, but 15% with sexual activity and 10% through drug inhalation.  
While there is evidence that the incidence is decreasing, just as with HIV, data are often sparse and inadequate.  The lack of markers of duration of infection make dating of exposure difficult.   Some notable information on new infections that deserves attention  Hep C epidemiology from PHAC  .  Males have only a slightly higher rate of new infection compared to females.  The incidence is highest in the 15-35 age group.  Notably that incidence rates in females 15-24 are higher than males.   Aboriginal rates are 3-5 times that of non-Aboriginals and a cause for concern. 

75% of persons infected with the virus develop a persistent infectious state and are capable of transmitting to others.  Most of these will develop some evidence of liver disease over the duration of their lives, up to 20% will have evidence of cirrhosis, and 5% will succumb to the direct effects of the disease.   The later are probably lower estimates given our lack of understanding.  Antiviral therapy can be provided based on certain criteria, which unlike HIV drugs, are more often supplied at the patient’s cost than as a public good.   The ability to comply with the medication regime is a consistent criteria for treatment, and the use of intravenous drugs can be, and is often, taken as a reason for not prescribing them.  Genotype specific durations of therapy may increase treatment success, however successful sustained response only occurs in about ½ of patients who are provided the medication.  

There are about 4 times as many Canadians infected with Hepatitis C than HIV.  A similar ratio exists globally.  Yet, we persist in treated those infected with Hepatitis C very differently from those with HIV. 
So why the inequity based on disease?   In the early years HIV received considerable attention because of transmission not only to persons with blood dyscrasias (Haemophiliacs) but also to populations of men who have sex with men (MSM) who are well integrated into society and often in positions of authority and leadership.   Hepatitis C, which also affected the Haemophiliac population circulates more predominately in intravenous drug users and frequently associated with very high rates in prison populations.  Not the sort of population that readily influences positions of power.  Some of those with Hepatitis C infection are for a variety of reasons more challenged with personal resources and yet are frequently required to pay for their own treatment.  Even politically, the current government expanded the inequity when it moved to eliminate funding for Hepatitis C initiatives after taking power while sustaining a greater degree of support for HIV based initiatives.  Within the health care system, inconsistent support exists for dedicated Hepatitis C clinical management whereas clients with HIV have near assured access.   Training physicians in the management of Hepatitis C has been underwhelming in its success while infectious disease specialists ensure widespread management for those infected wtih HIV.

Inequity based on disease – you bet!!!  Hepatitis C is perhaps destined to be the lost illness.  The last laugh may belong to the disease, while both Hepatitis C and a HIV present technical problems in vaccine development, Hepatitis C may get there first.  

Thursday, 26 January 2012

Communicating the Health Risk of Weather – A Canadian Public Health Celebration

If you are in Calgary and don’t like the weather, wait 15 minutes

Ottawa has the perfect four season weather – every day.

I’m sure you have your own collection of favourite Canadian weather sayings.   

It should be no surprise that Canadians would be innovators in many aspects of communicating weather – we have enough of it.   We can face hurricanes in Nova Scotia, stranded in a blizzard in Inuvik, frozen to the ground in Saskatoon, or drowning in torrential rains in Haida Gwaii  – the amazing thing is can all happen in a single day.

So here are some international innovations that you probably don’t realize have Canadian roots, and were designed as ways of communicating risk to protect the public’s health.   Likely topping the list in most Canadian minds is the UV index launched by Environment Canada in 1992.  The index was adopted internationally with minor refinements in 2000 as the standard tool for communicating Ultraviolet ray exposure risk. 

Not surprisingly, Canada has taken an active role in communicating the impacts of cold through the wind chill factor.   Some may recall the less than successful first attempt when Canada developed and reported wind chill as kcal/hr/m2.   Through the 70s and 80s this migrated to the more commonly used temperature equivalent and finally Canada played a coordinating and science contribution to the international standardization of the wind chill index and its temperature equivalent presentation in 2001.

More surprisingly, the humidex index was a fully Canadian innovation developed in 1965.  It does however differ from the later developed US heat index although there one might perceive similar reports given both present as equivalent temperatures. Canada is very actively involved currently in refining messaging and responses to heat Health Canada heat risks.  It is notable that different Canadian major cities use different approaches to determining when heat requires a public response.  Adaptation to heat also means that while temperatures of 40 C might only raise an eyebrow and barely start a sweat in the Okanagan, Nunavik may need to issue heat advisories at 17 C. 

The most recent contribution on the list of Canadian meterological innovations is the Air Quality Health Index (AQHI), a uniquely Canadian risk communication tool for what is likely the most important weather related public health threat.  Developed jointly by Health Canada and environment Canada, it is now available to just over 60% of Canadians. While the long term causes of air pollution are predominately anthropogenic (mad-made), the short term variation is largely driven by meteorological conditions.  Environment Canada AQHI The index is the first international index that uses public health impacts as the outcome for communicating  risk and the first to utilize the mixture of multiple pollutants using the more readily monitored measures of air quality. 

So who knew that behind the scenes of the Meterological Services of Canada, Weather Network and MétéoMédia were such marvellous Canadian innovations?  Innovations that not only make it easier for us to answer the question, “what is your weather like today? “, but also tools designed to communicate public health risk so we can make informed healthier choices as part of our daily routine.  

Tuesday, 24 January 2012

Canadian Weather that Kills – how do various extreme events stack up?

Achy joints in cold damp weather?  Headaches when the wind blows?   Sometimes it seems that popular beliefs regarding our wellbeing and the weather are better developed than rigorous medical evaluations.  If there is something that Canadians can agree upon, we have no shortage of weather to open conversations with.  It should not be surprising that the most visited website in Canada is the official weather site of the Meterological Services of Canada Weather office

We do know that heat can kill, so can cold.  Floods, lightening strikes, tornados, hurricanes and other extreme weather events are notorious for racking up mortality statistics, and presumably related morbidity.   There are other issues that are weather related like avalanches, ultraviolet light exposure and air quality that also contribute to our wellbeing. 

We spend a substantive budget on weather forecasting and reporting, for which there are some 1 ½ Million forecasts issued every year.  With that comes some 15000 severe weather warnings, in part designed as a way for individual Canadians to make healthier choices.  So the question that is seeking an answer, is which of these risks is likely the most concerning.   It appears that while some attempts have been made, none are public since the approaches used vary from counting bodies to sophisticated Poisson regression techniques with define lag times.  

Here goes an attempt, from least to most, and an invitation to readers to contribute to helping define weather attributable mortality in Canada (please either post a comment or send to drphealth@gmail.com).  

Weather condition
Estimated annual deaths
Annual rate of about 2 deaths
Natural Resources Canada reports 195 deaths over 168 flooding disasters for the 20th century
Lightening strikes
Excellent data provide an annual national incidence of 0.11 deaths per Million population
Average of 14 per year
Excellent statistics of 329 deaths over 30 years.  An extreme 1910 avalanche in Rogers Pass killed 62
Extreme episodic events – tornados, floods, etc
Average difficult to determine, likely <20.  Even the extreme events are <100.
Annual incidences vary widely.  The most tragic events in last 100 years:   Hurricane Hazel - 1954, 81 deaths, Escumina hurricane 1959 – 35 deaths; 1998 Ice storm – 28 deaths ;  Regina tornado 1912 – 28 deaths, Edmonton tornado 1987 – 27 deaths,
UV exposure
Based on all melanoma deaths and not attributing any to tanning salons
Several studies have estimated excess deaths in Toronto at ~120 per year and Vancouver ~20 per year.   Using these as an incidence provides a rough estimate nationally.
The toughest estimate to obtain but the impact is likely in the order of several times the number of deaths caused by heat.  UK estimates put the heat:cold mortality ratio near 10 times.  A gross analysis of the number of excess deaths during winter months will provide an estimate of about 5000 excess deaths for Canada annually.
Air pollution
Health Canada estimates of about 4000 while the Canadian Medical Association has issued an estimate of 20,000.  Estimates are based on times series regressions linking mortality databases with air pollution monitoring data

Were you surprised given our high attention to extreme weather events, avalanches and even heat based events?    More on air quality in a future posting.  

Monday, 23 January 2012

Waterborne outbreaks and Canada's dirty water secrets

Canadians are blessed with fresh water.  Our less than perfect drinking water infrastructure was discussed October 17, 2011 DrPHealth.   It was noted that there remain some 1800 drinking water systems on boil water advisories, with the highest proportion in BC, Saskatchewan and Newfoundland.  First Nations infrastructures are benefiting from a long term investment in improvements, a program which was renewed in 2011 with an additional $330 Million investment. The first five years of the plan saw 108 of 193 high risk systems improved. 

The converse of the lagging infrastructure is the history of outbreaks that have plagued Canadians.  First to reader’s minds will be Walkerton, and the likely North Battleford.  The known list however is  much longer.  Hence several studies that have looked at drinking water outbreaks are of interest.  From the PHAC enterics group located in Guelph came in 2005 article on  CJPH Waterborne outbreaks .  Just prior to the CJPH article was the work by Hrudey and Hrudey on Safe Drinking Water: Lessons from recent outbreaks in affluent nations .

A consultant’s report commissioned by PHAC and the National Collaborating Centre on Environmental Health (NCCEH) looked at outbreaks and retrospective data up to 2008 using different methodologies.   Finally NCCEH undertook a review of outbreaks in small water systems Small water system outbreaks 

There are consistent features that should be a reminder to all:
·         Lack of treatment or inadequate water treatment
·         Lack of source water protection
·         Problems in the water distribution system

And often associated with:
·         Precipitation event, spring thaw or change in demonstrable change in source water quality
·         Human mistakes in system operation.

To the above needs to be added several factors that should be addressed.
·         Disjointed or inconsistent regulatory oversight at a provincial level
·         Lack of recognition by government s and the public of the “public good” provided in drinking water (ie as a utility)
·         Lack of consistent national surveillance and reportability

There are several bright lights. Look to Quebec for both expertise and as an example. The responses of both Saskatchewan and Ontario in the wake of the two disasters are building solid systems - and perhaps shining examples of the legal liability that governments carry for failing in their public duty.  The National Collaborating Centres are collectively looking at issues related to small water systems.  Hopefully the collective work of these centres of excellence will contribute to reducing public vulnerability NCCPH small water system project.  

Core to Canada's drinking water problem is the misguided belief that we have a pristine resource in ample abundance that doesn't require the same level of rigorous pan-Canadian concern that we afford food, health care or the economy.  

Wednesday, 18 January 2012

Income inequity and debt – a major driver of health inequalities.

The Canadian Centre for Policy Alternatives has started an innovative display of what the Occupy movement was trying so hard to convey:  Wealth is getting increasingly sequestered in the top few percent of the population.    The full piece and the income clock are at http://www.policyalternatives.ca/ceo .   In short, by the start of the first workday on January 3rd, the top 100 executives in Canada had already made more than the average income for all Canadians  – their average annual wage is $8.4M.  Put in perspective, given the average public health workers now makes around $70K per year, that is four times more money that the entire earnings of a 30 year average public health employee. 

This site has written many  times about income inequity including the graphic on the widening income disparity that drove the Occupy movement . Living in tents the Occupy movement more than symbolically demonstrated the financial plight of unaffordable housing.  Yet "we" as a society,  removed their tents and forced them back to live in more expensive housing.  The very actions of a supposed civil society exacerbating the income disparity.   

The Conference board of Canada has provided great graphic representation of the growing Canadian inequality Canadian income inequality.   

If you did not previously see the Sir Richard Wilkinson lecture on income inequality, take the 15 minutes now and  have a gander – it condenses the income inequality discussion.  Wilkinson lecture .     

It has been 20 years since the landmark Rio conference that laid the foundation for many pan-global collaborative efforts, some more successful than others.  The 2011 Rio conference on social determinants left with some great rhetoric and we now need to demand further action.   There are many gems from the conference discussions related to the impact of inequities.   Rio SDOH conference site 

Now as a reminder, we in public health are well endowed. Although we may whine about our relative plight compared to our professional colleagues.  The public health physicians amongst us, likely some of the more poorly paid physicians, still are in the top 1-2% of income earners nationally.  Before exhibiting professional envy, please remember most public health workers earn well above the median national income and are in the top quintile of wage earners.  This applies to those that are single income households, so for those in dual income situations, you are in even more fortunate circumstances.  Collectively we have a role to play in advocating for income equality.  Yet, there is the converse side that we are in part the earners that should be looking to contribute to this equality. 

As you review your bank statements and outstanding financial obligations, likely sharing with most Canadians in expanding debt, take a moment to consider how fortunate we actually are compared to the “average” Canadian.   The average Canadian household debt has reached a record 153% of annual income.   Irrespective of our incomes, we rise to a level of financial obligation which stretches our ability to repay, bolstered no doubt by lending institutions more than willing to establish a long term relationship.   Current university graduates and first home buyers are entering a market driven by the expectation of easy access to “credit” and long term debt repayment structuring.  It is the same fundamental flaws that lead to the subprime mortgage meltdown in the US which started the plunge into recession.

Yet, someone is making money on banks who continue to lend indiscriminately. It is the flow of dollars from those in debt to those that have resources.  From the 99% to the 1%.     From the south to the north. 
And social expectations drive students to post-secondary institutions and young families to suburban single family homes.   There are some fundamental cultural norms that will require readjustment to truly achieve sustainability while readjusting the income disparities that continue to expand.

A great Canadian commentary blog resource comes from Ted Schrenker who blogs at Health as if everybody counted.  Many of the postings relate to discussions on inequity in both a Canadian and international  context, and perhaps a more rigorous and academic analysis than DrPHealth will offer.  As an aside, noting his recent blogs and the continued dedicated  following for this site- there appears to be a role for  “professional commentary” on changing public health climates.  (Thanks Dr. Schrenker  for the endorsement of this site as well)

Tuesday, 17 January 2012

Qualitative research reaching new pinnacles

Thanks everyone.  This site continues to attract a consistent Canadian public health following.  Please help it grow by sharing the link with public health colleagues. 

Follow on Twitter @drphealth,  by  signing up for emails at the lower left, or click on the "following" on the lower right.

Please leave comments,  or email to drphealth at gmail.com  

Are you tired of the phrase “there is not enough evidence...”?   Especially when we “know” something is good and the research just hasn’t been formulated into a randomized double blinded controlled trial?   Great examples exist such as prenatal education, post natal visiting and supports, early childhood education and on and on... When the outcomes relate to full populations and not to sterile laboratory conditions the application of the rigour of evidence becomes diluted, and the conclusion is the “evidence is weak at best”.  

One could say that the Cochrane initiative has done a disservice to public health for failing to develop tools to synthesize “evidence” that is not readily subjected to the rigorous controlled trial methodologies.  Hence a 2012 tweet (about a 2008) paper caught our attention, about developing methodologies for systematically reviewing qualitative research Thematic synthesis of qualitative research .     

Qualitative methods, amongst other benefits,  tend to provide a more comprehensive identification of the issues that might be explored when reviewing a particular question.   By the very nature of the expectation, quantitative methods tend to focus on only one specific variable to determine its impact on the outcome.  For the purest in either research field the sense is sometimes that one should never let the other near as it is so different.   The reality is that we need to embrace both approaches and seek to use all the available information, so please get on the QualyQuanty boat.  In the simplest form, use the qualitative methods to identify the issues and questions that should be posed, and then take a comprehensive approach to reviewing each question as it relates to the quantitative evidence that is available – but where insufficient evidence exists an explicit statement on what is known and what is not known is required.  

The fields of systematic reviews and evidence based medicine need to step to the plate and provide such leadership in undertaking comprehensive knowledge synthesis that defines parameters that should be evaluated, not just look at what was researched.

And may the phrase “there is not enough evidence...” be banned from use in policy documents and research alike.  Its use is akin to a form of population health malpractice. Too often it has been interpreted as ‘what evidence exists does not support' a particular action, and that is a whole different conclusion.  Too many programs and interventions have withered to the phrase and with it, the health benefit such activities seem to have been providing.  

Monday, 16 January 2012

Suicide action in Canada, and linked to a performance review for Minister Aglukkaq

Let us begin with congratulations to Leona Aglukkaq on reaching the pinnacle of her third anniversary in October 2011 as Minister of Health.  There have only been four previous to meet this mark in the past 40- years.  The Honourable Minister joins the elite club with the likes of Mark Lalonde,  Monique Begin,  Jake Epp and Alan Rock, impressive company to stand with. 

She was last week in the roaring metropolis of Happy Valley/Goose Bay announcing funding for the gathering of best evidence on suicide prevention.  Granted it is only a total of $300K. 

The other question might be given a resource in the Centre for Suicide Prevention  why this existing infrastructure was not bolstered to continue its past work in the field ? (previously SIEC the Suicide Information and Education Centre which lost federal funding after rise of the federal conservatives to power,  and remains as an Alberta provincial resource Centre for Suicide Prevention  and a hidden treasure of national scope.

 Efforts to prevent and contain suicide have seen funding come and go quickly.  Sustained and continuous efforts have not yielded wide swings in reducing mortality from suicide, though no doubt have had a positive impact on mental health manifestations and responding to suicidal behaviour.  The proposed literature reviews should provide a valuable update to the very active works that previously existed.  

The graphic actually demonstrates the long term trend, although there are some notable problems with the data.   PHAC and Health Canada are now 6 years delayed in posting mortality data for public use.   Quebec has for many years not reported suicide rates to the federal mortality system.    The good news is that suicide rates in both genders have trended downwards over the past few decades.  If the data was extended back we would see climbs after WWII to the 70’s followed by a flattening before the slow and steady decrease.    More was discussed DrPHealth suicide and the stock market crash

There is a good news story here in the suicide rate reduction and good news in some renewed funding for research/knowledge synthesis in suicide prevention.  The unspoken questions that might be asked are:  

·         Why a mere $300K for what has been consistently a top 10 killer in Canada and there isn’t much other research or programming going on?
·         What will be done with the best evidence knowledge synthesis papers?
·         Is there a longer term pan-Canadian commitment to finally invest adequately in programming and research to substantively affect suicide rates?
·         What exactly has the Minister done during her leadership role? 

Perhaps the last question is a bit unfair, but take a scan of Ministry press releases for the past year News releases from Ministry of Health.  A couple of subjective observations:
Most of the releases relate to non-controversial or niche issues
Few related to substantive investments in efforts to improve the health of the population. 

Perhaps the secret to preventing political suicide is to avoid negative publicity, in this respect Minister Aglukkaq may be a master and key to her longevity.  Does she deserve to stand amid the elite club that she recently joined?  What do you think?  Time for some pointed comments to be posted on this blog.

Friday, 13 January 2012

Sodium reduction messages for Canada - and an inherent process problem in their development

Sodium reduction was touched on this blog DrPHealth july 24, 2011.  In early December, Health Canada began to release some resources to support sodium reduction nationally Health Canada sodium in Canada .  Included in this resource are key messages; the link is provided as it is somewhat buried on the website Proposed sodium reduction messages.  All this is good.  The messages are worth reading although there might be some question about the sustainability and dynamic need for change of the messages that have not been addressed. 

The downside is in a separate communication that isn’t posted that speaks to the process used to develop the messages.  Let us consider it a case study in how not to do consultation within public health.  A contract was let to a national professional discipline specific organization who set up an advisory committee - only listed as from Health Canada, one provincial Ministry of Health and their own organization. They appointed a project manager from the within themselves.  Criteria for an ‘expert” validation panel based were developed and requests for participation were distributed only to BC and Central/South Ontario region members.  The criteria being

·         Member of the professional organization carrying the contract.
·         > one year in practice
·         In a community setting such that it would exclude academic, industrial, hospital and long term care personnel
·         Between ages of 25-55
·         Were from greater Vancouver, greater Toronto or Kitchener

The messages were translated into multiple languages and then focus tested using the same markets served by the validation panel - with the addition of Ottawa for the French speaking component. 

After development they were then distributed for further validation to a limited number of hand picked discipline specific professionals in the same BC and Ontario regions. 

Hence the ranting blog.  The process smacks of professional incestuous behaviour.  There are other Canadian experts in client communication, knowledgeable other professionals in aspects of nutrition or health, and most critically experts in the users of the information that is being generated when working with patients/clients. The absence of at least Quebec/New Brunswick francophone professionals and any Aboriginal populations are notable from this process. There would be an interesting debate on the representativeness of Kitchener for rural lifestyle from at least the north, prairies and Atlantic.  It is not surprising that there is supposed “regional consistency” from the focus testing. 

One of the great strengths of the public health community has been its historic commitment to a multidisciplinary team approach.   Such approaches can be readily eroded by professional elitism and protectionist approaches that we all must guard against and unmask when identified. The added concern of conflict of interest is raised by several of the criteria and the decisions undertaken further undermine the product.  

One also wonders why this material was so quickly posted to the Health Canada website, when many other contracted and more important works remain buried in bureaucracy. 

The messages may or may not stand the test of time.   However, can we learn from the errors inherent in the process? 

Thursday, 12 January 2012

The Cost of Poverty in Canada - a potential way to reduce health costs

The posting Determinants of Health January 9 2012 had a quick reaction, something that is very welcomed.   The comment that evoked the response was 20-25% of health care costs are directly attributable to income disparities.   Where did this come from?  Is it time this information came to the finance table?  Great questions and thank you.

There are several analyses of health care costs associated with poverty that have been undertaken.   The absolute simplest is recognizing a linear relationship between income and poorer health outcome, whereby those in the lowest income bracket have a relative risk of about 2 which (might be interpreted as the proportional increased costs as well), gives a simple graphic as follows:

For the mathematicians in the audience, the total area under covered by the bars is 7.5 units.  The area covered in excess of a relative risk of 1 is 2.5 units.  Hence to eliminate all inequality by shifting to the status enjoyed by the highest income quintile would result in a 1/3rd reduction.    If you think a relative risk of 2 is too high -  note that at relative risk 1.5 the potential reduction is still 20% - a relatively conservative estimate for total costs. 

Of course reality isn’t quite so simple,  there are many other aspects that affect the equation.  At a simple level there is not only increased rate of disease, but also differences in cost for ameliorating the effects of a problem, and those in the highest income quintile tend to respond better to treatment as well (the determinants of health should also be seen as the determinants of recovery).   Most analyses of income impacts are limited to studying one of these components, not the combined effect of the three.

Having said this, there are numerous attempts to try to define the “cost of poverty”.  Canada’s tome on the issue is a consultant’s report that is posted to their website, but not identifiable on the sites of the agencies that contacted the work, namely PHAC, Nova Scotia, and BC.  The findings of the 421 page document support the 20-25% number.   The report provides a fairly definitive review on the known consequences of poverty and also critically appraises four reasonably done studies looking at health care costs – however it is notable that the report does not render its own conclusion.  Health costs of poverty in Canada GPIAtlantic      

The report also acknowledges that the costs of poverty extend well beyond the health sector and include at least justice, education, and social services.

So the three deep questions that DrP would ask and welcome comments (or send to drphealth@gmail.com)

1.       Why is the only place this document is posted is that of the consultant and not of the three government agencies that contracted the work?
2.       Since we are relatively good at describing poverty consequences, can we apply this intellect to determining what have been the effective interventions?
3.       Why is the message that poverty is expensive so difficult for some health decision makers to swallow?   

Tuesday, 10 January 2012

Knowledge Dissemination - some Canadian gems worth mining

Over the years, Canada has been a leader in technology development for knowledge synthesis and utilization.  Some of these have become integral to the functioning of knowledge dissemination globally, others were designed for Canadian audiences. if you have not mined them for what they are worth, put on your headlamp and hard hat and go digging.  

Six  national collaborating centres in public health practice; Environmental health, Healthy public policy, Aboriginal health, Infectious diseases, Methods and tools, and Determinants of Health  - they can be accessed through a joint project website http://nccph.ca/en/home.aspx  by clicking on the centres on the map at the upper left which is not intuitively obvious.

So what about chronic diseases and surveillance?   These are the areas that PHAC has invested in internally more than the scopes of the collaborating centres. Many good resources and publications are found buried in the PHAC site.   One of which is an evidence access point on best practices in chronic disease prevention and health promotion.   Canada best practices portal - chronic diseases .  Not dissimilar from many other PHAC resources, it is a excellent resource and not sufficiently well known.

It is integrally linked to HealthEvidence.ca and provides a different search engine to extract evidence, resources and tools that can aid public health practitioners in their work.  The added value of a portal is that it is merely an access point to the primary resources which are often not easily identified. 
Go surfing on your favourite topics, the site isn’t comprehensive, but is foundational in what resources are available for access.  

As for the surveillance component, PHAC has innumerable on-line resources if you can figure out how to access and use them.   PHAC surveillance.  Link this with the public health skills development program   Skills Enhancement for Public Health which is a well subscribed and hugely successful initiative Skills enhancement page . Those interested in actually trying to find the training modules, click on the About Skllls online on the right menu (modules are about 40 hours over a 6 weeks time period).  Navigation on the page is not the easiest suggesting a great way to administratively filter by technological comfort in order to even register for the on-line training (but well worth doing). 

One last one in development is the new CPHA knowledge centre CPHA knowledge centre which just opened and may be a good source for current and developing knowledge resources.  

Good luck with your prospecting efforts.   There is gold to be found in many of these resources. 

Monday, 9 January 2012

The Determinants of Health - moving description into solutions

The Determinants of Health were covered in drphealth Sept 16 DofH. The nagging question that all of public health should ask, is so what?   We are familiar with the relationship between income, education etc. but not that knowledgeable with the technologies on how to modify or mitigate the impacts caused by disparities in the determinants.  Ontario brings to the table an intriguing review of practices amongst health units Ontario action on determinants of health . Jointly produced by OPHA and ALPHA , mostly notable not a government based initiative, the survey of the 36 Ontario health units is informative for the country. 

Ontario’s relatively unique structure autonomous health unit governance bodies, aligned to some extent with local government, reflects the more traditional delivery structure for public health.  Perhaps ironically, it is the structure that now allows for greater freedom to innovative that the remaining provinces where health regions now dominate. 

The gist of the report comes down to the health units being partners, stimulating change through information (surveillance, evaluation, research, dissemination), targeting services to reduce inequities within the public health scope, advocating for policy change, and supporting planning.  The barriers were found in workforce skills, knowledge gaps, leadership, and lack of planning.  The supporting needs were mostly in information (best practices, evidence reviews, network).   While the report is entitled Activities to Address the Social Determinants, it speaks to the broader Determinants of health in its analysis. OPHA/alPHA survey report

In 2008 the WHO  completed and released its report on the social determinants of health http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf , which more than previous works speaks to potential actions to address and mitigate the impacts of the social determinants (noting that WHO does acknowledge the difference between the determinants and social determinants in its publications).   The committee was chaired by Sir Michael Marmot, who was the CPHA 2008 keynote speaker and spoke to the effectiveness of interventions in a presentation that regrettable is still not posted to the CPHA archives.  The main components of his thesis, but not the details, were published in Lancet 372 (9650) 1661-1669, Marmot Health inequities action 2008 Lancet and talks to closing the gap in a generation.  The detailed analysis looked at policy difference by country and the impact on reducing inequities.   A similar analysis looked at states in the US (and including Canadian provinces) and can demonstrate not just the inequities, but the ability to use macro level policy intervention to modify their impact.

Now, for the health leaders in the country who say that poverty and other determinants have an impact on health, but it is not the health sectors responsibility to address those factors, given that 20-25% of health care costs in Canada are directly attributable to the disparity caused by income inequalities – perhaps its finally time to come to the finance table and not only put cash on the table, but require public health and other health sector groups to integrate determinants work in what they do routinely.

Thank you to the OPHA/alPHa for demonstrating that even in the absence of a requirement, that public health bodies are willing to do what is the right thing to do.  Subtly hidden in the report is that the lack of leadership is one of the key obstacles in moving forward, and these organizations are showing some leadership that is desperately needed. 

Friday, 6 January 2012

Chronic Disease Management: An Ounce of Prevention is Worth the Pound of Care.

Guest blog by NONstop GO

This posting is a special guest article from a reader who wanted to share a valuable resource.  If you are interesting in submitting a guest posting, please contact drphealth@gmail.com  

People coping with chronic diseases don’t always feel “sick” or use a lot of health care services.  However, those that rated their health as poor or fair, as outlined in the recent  report from the Health Council of Canada (HCC), have concerns regarding the management of their chronic conditions and the health system overall.  

The survey respondents that rated their health as fair to poor were; older age, lower education, lower income and more likely to live in a rural area.   On the brighter side, these people were likely to; have access to a regular physician,  able to access same or next-day appointments and,  use less emergency room visits in place of seeing their regular physician.  

Respondents were significantly less likely to rate the care that they receive as excellent or very good.  They do not think the system works well. They identified that test results and medical records were frequently not available when attending specialist appointments. They felt their regular doctor’s office did not help in coordinating their care, did not spend enough time with them, and did not explain things in an easily understandable way.

Concerning, (as per the drphealth blog on medical costs in the US )   these respondents would skip medications, tests, appointments, and treatments because of concern over cost.  So the oldest, poorest, least educated sector of our population, dealing with multiple chronic medical conditions, are least able to afford the care they need to manage their illness.  We must advocate for comprehensive health care to include essential treatments to manage chronic medical conditions -  before these same treatments, prescriptions and tests,  are delivered to these same people in hospitals.

The excessive burden to the health care system for care of chronic diseases was demonstrated in a CHSPR report on chronic diseases .   This report amongst others,  has explored the relationship between chronic diseases and multiple co-morbidities, and found that those clients suffering from multiple chronic conditions used much more health services than those clients with less co-morbidities.  The conclusion was that care that focuses on only one condition does not serve the client well.   A case-management system to provide comprehensive, continuous and person-centred care to clients with chronic medical conditions is recommended.    Several case studies demonstrating the utility and success of chronic disease case management by collaborative, team-based care are outlined in a 2009 HCC report, Getting it Right!  Through effective leadership, clear roles and responsibilities, common values and philosophy, easily accessible electronic medical records, and patient-centred programs and supports, including self-management tools, these teams have managed to significantly decrease the health care utilization of these clients – and improve their health. Although these developments have shown success, they have been slow to gain traction in many jurisdictions.

Stepping it Up!, the report issued in December 2010 by the HCC, reiterated the importance of an all-of-government approach to address the underlying determinants of health. In the meantime, we all should advocate for more comprehensive management of chronic diseases in the face of budgetary restraints and shrinking federal funding support.   

I am anxious to see some action on these three Health Council of Canada reports which should inform government policy and anxious to see an engaged government that is interested in improving the health of Canadians. As a public health professional it is part of my job to educate them what it is going to take to accomplish this goal.  That is my New Year’s Resolution.

Wednesday, 4 January 2012

Food safety in 2011 – Did your favourite bug make the least wanted list?

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On December 21st, one of the public health holiday “presents” was the release of Canada’s food safety report CFIA food safety page with links.  Later on that very day, the US food safety report was also released and is accessible at US food safety report .  Coincidence?  The probability of two annual reports being released on the same day is roughly 0.002.  The probability that two independent national level reports on the same subject are released on the same day within the year that they were actually supposed to be released is even closer to zero.  We should be reassured that our governments continue to have close relations and work collaboratively on many joint public health issues. 
The major difference between the two reports, is the US report is in relatively plain language and easier to read.  The Canadian report talks about what has been done since the Listeria outbreak of 2008.  The US report speaks to what has been accomplished since adoption of the Food Safety Modernization Act early in 2011 and clearly states the steps going forward. Both are worth reading and provide a crash course in the food safety issues and a real impetus to drive down disease rates further like some Scandinavian countries have already accomplished through aggressive methods of ensuring food reaching the kitchen is not contaminated.
According to CFIA 1 in 3 Canadians is expected to suffer a bout of foodborne illness every year, that converts to some 11 Million episodes each year in Canada.  Using the US estimates would suggest the rate of illness is about half south of the border.   Actually it is unlikely that the rates are substantially different but the methods to calculate them are.   What’s a few Million illnesses between neighbours anyway.  Conservatively about 12000 will require hospitalization and there will be some 300 deaths that are likely attributable to foodborne illness.
The good news, is most enteric infection rates continue to trend downward.  See the embedded graph of Campylobacter (red), Salmonella (green) and Verotoxic E. Coli. (blue) rates in Canada from 89-04   

The bad news and the constant reminder of why renewed vigilence is required is on the front pages of newspapers.   In a continuing education module (which is not openly accessible) was a review of a few of the top foodborne outbreaks for 2011. They are a sobering reminder of the burden. 
·         In June the deadliest modern history foodborne outbreak killed at least 46, caused haemolytic uremic syndrome in 782 and infected nearly 4000 people associated with fenugreek sprouts – the contaminated seeds of two epicentres of the outbreak were traced back to Egypt. The causative agent was a Shiga-toxin producing E. Coli 0104:H4.
·         In August, 106 infections for Salmonella Agona associated with papayas from Mexico
·         On the tails of the 23 Canadians who died in 2008, a cantaloupe associated Listeria outbreak killed 30 Americans through the fall.
·         In November, some 136 infections and one death were associated with multidrug resistant S. Heidelberg in ground turkey resulting in 16 Million kilos being recalled.
If you haven’t noticed, an increasing proportion of foodborne outbreaks appear to be associated with fresh fruits and vegetables.   Ground meats (including processed meat slices) remain a major cause and are usually associated with cross contamination in the meat processing plant. 
A nice quick review of the top 10 bugs can be found on the CFIA website Top 10 foodborne illness bugs
A few quick tips for personal protection:
·         Clean your fresh fruits and vegetables
·         Keep cold foods cold, and hot foods hot – probably applies to fresh fruits now too.
·         Don’t cross contaminate surfaces in the kitchen.  
·         Use a food thermometer to makes sure foods are cooked
Did you know that during pregnancy, for persons over 60, and those with weakened immune systems should avoid processed meats and unpasteurized mild products (eg. Some soft cheeses)?   While the warning is posted in many places, it is not advise that is getting to those at risk.  

Tuesday, 3 January 2012

HIV progress in Canada – A great public health success story to start the New Year

What better issue to celebrate the New Year with than what is the number one new public health story of the last few decades and a celebration of Canadian public health.

Far too many of those active in public health can remember the initial postings of the unusual new immunodeficiency syndrome that was first identified in San Francisco in 1981 with viral identification in 1983.  The disease has killed over 25 Million people, and still kills about 2 Million per year.  There are currently an estimated 35 Million infected persons living with HIV worldwide, about 2/3rds of these in Africa.  The secondary impact is the loss of a significant proportion of young adults and the development of a generation of 14 Million African youth who have been orphaned by the disease. 
This posting is less about the tragedy of the disease which is not to be understated; it is not about the epidemiology and transmission as a sexually transmitted, blood borne or perinatal infection; nor about the disease process, social impact or treatment; – you can be readily directed to thousands of resources including Wikipedia.  This posting is about celebrating the accomplishments of a generation of public health contributors from Canada.
From an unknown clinical syndrome that was quickly identified as mostly fatal over about 10 years, to within 30 years to being a disease where the life expectancy in Canada under treatment is potentially similar to non-infected persons is nothing short of remarkable.
There are an estimated 65,000 infected Canadians, with an estimated incidence of about 3,000 cases annually.  Roughly half are men who have sex with men (MSM), and 20% amongst intravenous drug users (IDU).   Somewhere around one-third are attributable to heterosexual transmission, roughly equally divided between persons from countries with high HIV prevalence and those where transmission likely occurred within Canada amongst second or more generation populations. 
The embedded figure speaks to incidence over time by risk categorization, for which several notable observations need to be made.   The initial rapid decrease in incidence in MSM began to rebound in the early 2000’s.  The incidence in IDU has decreased in parallel with other indicators of overall IDU use suggesting protection as much by changing drug use habits (eg. shift to cocaine inhalation from heroine injection) as to the focus on safer injection practices.  The final notable observation is the steady increase in persons acquiring infection through heterosexual transmission. The hidden statistic is that Aboriginal populations are currently carrying twice the burden of illness incidence as non-Aboriginal Canadians.  The full story is available at HIV epidemiology in Canada

The main focus of the celebration is the consistent success that Canada has contributed to fighting HIV.  Likely there more and perhaps some of you would like to add to the list so we can edit it in celebration of great national accomplishments.
1.       Identification and synthesis of one of the first antiviral medication 3TC by Bernard Belleau of McGill who then went on to established BioChem Pharm
2.       Dr. Mark Wainberg of McGill numerous contributions including:
a.       the mechanism of effect of 3TC
b.      postulating and proving resistance development of HIV to antivirals and
c.       co-leader on HAART triple therapy
d.      President of the International AIDS Society
3.       Dr. Rafik-Sekaly and the team of the Université de Montreal who furthered considerably the knowledge about the immune response to HIV infection.
4.       Dr. Julio Montaner’s now at UBC and the BC Centre for Excellence in HIV, momentous contributions including:
a.       collaborating on the triple therapy HAART approach,  
b.      innumerable trials on improving the effectiveness on antiviral therapy delivery in hard to reach populations
c.       past president of the International AIDS Society
d.      recent contributions on the public health benefit of reducing viral loads to undetectable levels as a method of prevention of transmission (“STOP HIV/AIDS” “Treatment as Prevention” project). The combined efforts of this group are demonstrating that HIV incidence can be reduced and can currently claim multiple year reductions since 2003/04 a remarkable 40% reduction BC 2010 STi and HIV statistics  and for all provinces see Table 6B HIV incident cases by province to 2009 
5.       Dr. Frank Plummer at PHAC and the National Microbiology Laboratory and his innumerable contributions that extend back to the early-80’s.
6.       Many researchers who have looked at the question of reducing transmission in communities, or increasing effectiveness of reaching therapy into hard-to reach populations.
7.       The notable contributions of Steven Lewis as UNAIDS ambassador and advocate for AIDS reduction in Africa.
8.       Dr. Kate Hankin’s work at the epidemic onset within Canada and then with UNESCO. 
9.       Numerous Canadian teams that have been involved in addressing specific questions of a global health nature, predominately but not exclusively in Africa.
10.   The recent announcement by Dr. Chil-Yong Kang at University of Western Ontario of a new HIV vaccine candidate for human trials is hopefully the next step on the ladder of great Canadian contributions.   

Every list suffers from the risk of incompleteness and your contributions are nominations are welcomed (drphealth@gmail.com).  

Canada is the 35th most populous country, with only 1/2 % of the global population, yet Canada’s contributions to research, control and treatment of HIV/AIDS is consistently in the top 4-6 countries on an absolute level and rivalling any country on a per capita basis.  Now isn’t that a Canadian public health success to celebrate?  

Check out some of the disparate sources that list a few of the innumerable Canadian contributions. 

Centre of Excellence on HIV/AIDS Centre of Excellence BC