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Monday, 31 December 2012

Gun control - can we take another shot at peace in 2013?

The rhetorical question may well be if the executive director of the National Rifle Association were shot, would there be a legitimate argument that the action was in self-defense?

The second US amendment that provides for the right to bear arms was written in 1791 when  guns were limited to single shot muskets  that lacked automation, lacked multiple chambers and lacked the ability to be concealed. Each year somewhere between 10 and 15 Million guns are sold in the US.  That annual amount exceeds the total number of guns that were registered in Canada when the long gun registery was scrapped.

For this right that the NRA has steadfastly defended, one could estimate an excess of 10,000 American deaths per year.  Given the excess has existed for at least the last 50 years, it would be reasonable to assume that somewhere between half and one million excess Americans have died as a result of the broad interpretation of the second amendment.   While those numbers have actually decreased since the peak in the early 90’s, they have plateaued at about the level of the 70’s. http://en.wikipedia.org/wiki/File:Ushomicidesbyweapon.svg

No single effort in gun control will buck the US trend, or modify Canadian behaviours.   As noted, the objective analysis of the long gun registry had little impact on Canadian gun related violence http://drphealth.blogspot.ca/2011/11/gun-control-fluoridation-and-publics.html .  It is the other measures of gun control that may be effective:

                Strict limitations on assault and semi-automatic weapons
                Limitations on handguns
                Preclusion or limitation on concealed firearms
                Preclusion or limitation on gun modifications such as suppressors, reduction in barrel length
                Firearm safety training
                Development and distribution of toy facsimiles
                Limitations on ammunition including explosive or body armour piercing
                Storage and maintenance
                Restriction on movement of firearms

The challenge for countries like the US is to being developing a culture where any of these can be considered acceptable limitations.  Not all would be considered acceptable on day one, but the path to improvement is only begun by starting with the easiest of the restrictions and moving forward.   For a country where an estimated 40-50% of homes have a gun, making policy shifts will be difficult, however some surveys suggest fewer homes now own guns with ranges between 33-40%.   The Harvard review on gun control issues is a sturdy resource to work with Harvard injury portal  

Note that in Canada, estimates are that one-quarter of households own at least one firearm, most being long guns.  A full summary of Canadian firearm use is accessible at justice link on firearms in Canada  

There are an estimate 88 guns per 100 people in the US and 30 guns per 100 people in Canada.  While ownership is somewhere between one-third and one-half, firearm death rates are between one-quarter and one-third.   Ecologically comparisons are fraught with fallacies, but one might note that Japan with strict gun controls as a firearm death rate that is only 2% of Canada.  Even the UK’s rate is 15% of the Canadian rate.
The hidden question that needs to be stated in this debate, is why is the NRA so powerful? and where does it get its resources from?  Yes, it has a broad membership, but so do nursing and medical associations.  One cannot image that the names of Winchester, Reminington, Magnum, Smith & Wesson, among the over 100 US gun manufacturers,  are not key funders and supporters of the NRA given the tens of millions of firearm units sold each year.  Rarely are the industry representatives actively involved, strongly suggesting the NRA has become a business lobby group - not a protector of the US right to defend oneself.

Gun control is life protecting, and just as any other public health problem – North Americans are faced with a public health situation that could be improved through a continuous concerted effort. 

May 2013 bring peace to us all. 

Friday, 28 December 2012

Taxation, the looming Fiscal cliff and the impact on public health in North America

Just as the year comes to a close, DrPHealth will flip over 11,000 views despite very sporadic posting for the last few months.   Stay in touch by following on Twitter @drphealth where a Tweet will inform of all new posts, or you can follow or receive the blog posting by connecting at the bottom of the page. Forward the site to friends, as it is through regular use that the site will be updated.  Please leave comments or feedback – they are most welcomed.

On Dec 31, the US narrowly avoided going over the cliff by some last minute deals, however these are short lasted.  See a good analysis of the implications of the fiscal cliff on public health at Kaiser health news   

Gun control is taking second fiddle to the fiscal cliff these days.   Both will get attention by DrPHealth in the next few days.  The major question is what does the fiscal cliff mean for the health of Americans?

Canadians enjoy a standard of living which includes most health care costs being funded through the public purse.   Depending on where you live, tax burdens and marginal tax rates are slightly different, as are the cost of housing, cost of living, car insurance etc.   Picking the most affordable location to live is more complex than just looking at taxes.  If you are interested, try a tax calculator such as http://www.ey.com/CA/en/Services/Tax/Tax-Calculators-2012-Personal-Tax .  You may find that for a $30,000 per year income that the tax burden is lowest in Nunavut then BC, and highest in Manitoba.   For a $100,000 per year income, the tax burden is also lowest in Nunavut then BC, but highest in Quebec.  The marginal tax rate on that next thousand is also highest in Quebec, and lowest in Nunavut then Alberta.   At around $250,000 per year, tax levels become the highest in Nova Scotia. And around 325,000 Alberta provides the least tax burden.  At the highest income levels, marginal tax rates are between 39-50%.  For 30,000 per year income earnings the marginal tax rates are between 19 and 30%

Piecing out tax rates in the US is perhaps easier as the geographic issues are simplified.  Tax rates vary from 10% to a maximum of 35% (for those with incomes greater than 388,000), and are projected to increase when the country has gone over the cliff to 15% up to 39.6%.   So even if the jump over the cliff has occurred, the highest income earners in the US will be paying taxes comparable to Alberta.   The working poor income earners will be taxed considerably lower than in Canada.

Enter the health care insurance costs. For the 60% of Americans who are insured through self-pay or employment insurance, the added financial burden now becomes an absolute number – significantly impacting lower income earners, and dramatically impacting those without work benefits.   Health care insurance costs for a family earning that $30,000 are the same as the $100,000, and can double the “tax” burden at about $4500 per year.   Higher income earners are more likely to be have employment associated health care benefits.  All of sudden, what might look like a good deal, becomes significantly more challenging for marginal income earners, and a major inequitable benefit for higher income earners. To which we have been reminded that BC retains health premiums as essentially a flat tax for households, Ontario has a scale of premiums based on taxable income.  Neither of these is considered in calculations of provincial "tax" rates - but just as when comparing US rates, should be factored as tax burdens  

As the fiscal cliff looms, most Americans appear to be expecting and accepting of tax increases. The tax burden increases are being spread across all income earners in a somewhat gradient fashion.  The downside to the fiscal cliff is the compromise that is being seen in public health related programming as major funding cuts continue to whittle away while resources are being shifted into health service delivery.   Be sure to review the actuarial analysis of what this means to actually increasing health care costs More health care does not mean better health September 2012 

There is a major step yet to be made in both countries to more equitable wealth distribution.   Moreover, any calculation of tax burden or wealth must now health care out of pocket expenses, otherwise there is no comparability between two vastly different systems.   Finally, as the fiscal cliff looms, the impact on health becomes burdened by the increased tax load, the reduced spending on government programs that keep Americans healthy, and lastly, the health costs that another recession may bring. 

Thursday, 20 December 2012

Who ever said that vaccinating was not dangerous?

No,  this is not about the allegations of dangers of vaccines.  This is about the dangers of being the vaccinator.

Most public health professionals have been subjected to harassment as fervent supporters of protecting children and others from preventable communicable diseases.  It is inherent to the job and employers would move to defend staff abused for supporting immunization.

The disconcerting development is the targeted murder of eight Pakistani community vaccinators employed in the final push for global polio eradication.  National Post article.   Potential retaliation by radicals who believe that a false vaccinator was used to collect information vital to the raid on Bin-Laden.  

Ongoing discourse continues to be directed that other vaccinators are acting as spies.  Misinformation in vaccine resistant areas has included accusations that vaccines are a ploy to make children sterile.  Heavy religious overtones are inserted into the discourse by some community leaders. Opponents in the terrorist war in Pakistan have used the polio eradication efforts as a negotiating ploy to stop drone flights and attacks.

Both parties in this debate should carry the guilt of death and disability from any future polio cases.   That a ruse of providing health care was used to collect military information speaks to the inability of our systems to keep public good separate from political (and religious) debate.   That innocent women, providing an invaluable global public health service, have been murdered in a coordinated, directed attack for being public health workers is beyond deplorable.  

It should make the irrelevant musings of North American anti-immunization groups merely an annoyance. 

Tuesday, 18 December 2012

Mass homicides - making sense and learning from tragedy

The Newton massacre is weighing heavily on all of North America.   It is a tragedy of immense proportion and no words will ever do justice to the impact on the families and children involved.  

The parallel conversations are notable.  First is the valid conversation on the effectiveness and utility of gun control.   Only in the US is this a constitutional right to bear arms, but the spin-off into Canada has killed many Canadians.  The US sees in excess of 11,000 firearms homicides annually, Canada at 10% of the population has 1.5% the number of firearms homicides.  Places like Japan with strict gun control an order or two fewer firearms homicides. 

The second parallel conversation is just on the social ramification of firearms in society which was well reviewed by the US National Research Council in 2004 NRC meta analysis .  The report is exceptionally conservative in its interpretation of the state of knowledge at the time.   The absence of wide ranging reviews since 2004 is a notable gap in the literature.   There are multiple reviews prior to the NRC documentation. (eg Harvard portal on injury control

The third substantive conversation links to the discussion on media reporting such that is parallels suicide reporting Dr P Health copycat suicides.  The Globe’s self criticism is a good starting point in the discussion Globe and Mail self critique.  The criticism does not speak to the public health impact in any fashion, just about misinformation in publication.   Two weeks post the Columbine tragedy, the Taber High School shooting was a demonstrable instance of copycat behaviour related to attention seeking behaviour.

The fourth of the substantive discussion relates to mass shootings.   Tragic events, where multiple deaths have occurred and asking the question why.  The US only listing can be accessed at Mass shooting timelines and a reminder of the major incidents such as Virginia Tech in 2007 with 56 deaths. At last half of the incidents ended in suicide of the perpetrator.   Canada has had its share including the Ecole Polytechnique de Montreal shooting in 1989 that resulted in 15 deaths and a defining point in Canadian gun control.

The motivation of the perpetrators becomes the fifth discussion topic.  Inherently assumed to be associated with mental illness and potentially the shortcomings of our community mental health system, there is very little literature on the subject.  One relatively inaccessible article sounds interesting and would be great to provide a link to – but alas, welcome to the shortcomings of academic journals.  (Mass Murders: implications for mental health professionals Int J Psychiatry Med. 2008;38(3):261-9


No doubt there will be the calls for action, and sets of recommendations – but will sustainable constructive change be achieved.  Other than legislative controls, community based responses have rarely been sustained beyond the initial required reaction, and the lack of any rationale sense or communications in Newton will not likely lead to sustainable societal change despite the evidence.      

Friday, 7 December 2012

Suicide and the media - is there a copycat effect? Do the reporting guidelines save lives?

There was an interesting Twitter debate this week between Andre Picard and Nova Scotia’s provincial health officer.  At issue is whether media reporting of suicide is associated with copycat activity that leads to further suicides.  The conversation was led by an article in the Vancouver Sun talking about suicide .  Mr. Picard’s position being clearly that  “Not potential. Not speculation. Evidence. My position is there is none.Twitter feed December 5, search on @RobertStrang   

Then, in a twisted ironic tragic event, the frenzy surrounding the media prank pulled on the Duchess of Cambridge which duped a nurse into sharing confidential information, appears to have contributed to the nurse’s  decision to complete suicide. Telegraph report.

As with many interventions in public health, we often forget why we do things.  The debate having resurfaced is probably reflective that there is a journalism ethic and sometimes formally written rules in limiting reporting on suicide. 

Turn back the clock, and somewhere around 3% of suicides were considered as part of clusters or associated with copycat activity.  The more explicit the information shared on the suicide, the higher the number of copycat based activity.  

The suicide literature is replete with case studies looking at clusters, time series evidence that media policy change on reporting resulted in a drop in copycat activity. 

A fairly comprehensive literature review is accessible at J Epi and Comm Health  which is a cornerstone peer reviewed publication for public health professionals.   Of course, that was nearly a decade ago, and many countries and media have implemented suicide reporting guidelines so that the issue today is likely so dilute as to be barely measureable and unlikely to approach the 3% level.

Measuring a 3% expected difference in suicides, with an expected rate of 15 per 100,000 population – would actually be statistically challenging.   So while Mr. Picard’s assertions may have some basis, over the years many lives have been saved by following suicide reporting guidelines. Let us not be foolish enough to go backwards and have to relearn the lessons again.

Dec 10 - the debate rages on, the Globe and Mail editorial piece (no doubt with M. Picard's influence - unbalanced commentary) http://m.theglobeandmail.com/commentary/editorials/teen-suicide-contagion-and-the-news-media/article6116592/?service=mobile