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Tuesday, 31 December 2013

Auld Lang Syne – Ageing as a public health issue.

For the “sake of old times”, a celebration of the passing of the year and what better time to discuss our obsession with aging.  We are all headed there, and perhaps it is the inevitable looking forward that has become an obsessions with some, and for those who are already enjoying retirement and reaping the benefits that a lifetime of hard work has deservedly earned, a pastime in improving conditions further seems a logical thing to do.

There is a propagated myth of the grey tsunami and its catastrophic impact on society and in particular the health care system.   Dire predictions of 100% growth in those over 75 and 85 seem to be equated with the suggestion that governments will crumble under the financial burden.  Yes, pension reform is needed from a strictly actuarial perspective.  As we age, we are in far better health than those when the pension plans were established.  We need to plan for not just 10 years of retirement, but those that reach age 65 can now expect to live an additional 20 years – herein lies the tsunami.  

However, while the life expectancy at age 65 has increased, the time we can expect to spend in poor health or dependent on the health care system has not doubled.   Our years in poorer health cluster prior to death, and as life expectancy increases the clustering merely starts later in life, albeit some chronic illness erode at quality of life years such as arthritis and diabetes – they are generally illnesses that have a high contribution of personal cost rather than publicly funded costs.

The following graphics break out the growth in each of the sub-components of the health care system showing that of the future expected health care costs, population aging forms only about a 15% component of the expected growth. The first two graphics are from CIHI while the third from province of BC.  The population ageing component being in light blue in the third graphic and third from the bottom.   While CIHI has a similar graphic it was no longer accessible. 

At one recent meeting even a senior’s advocate after arguing the need to increase benefits and access for seniors began to recognize that we have already eliminated children’s benefits, made it hard for families to have children, and yet sustainability of older persons benefits is dependent on population growth.  Hence the advocate’s realization if we don’t regain optimized outcomes for children and families, the ultimate losers will be the very seniors they were advocating for.  

Hence the op-ed from the Globe and Mail on Our senior Moment that starts to speak to what is our real issues associated with ageing is a fitting finale as the year closes to cries of “out with the old, in with the new”.  

Happy New Year to all, play safe and have a prosperous 2014

Monday, 30 December 2013

DrPHealth in 2013 - a review of blogging on Canadian public health

It is that time for the annual highlights.  A recap of 2013

There remains a constant question whether continuing the blog or not has value, and comments from viewers are always appreciated.

Just over 100 posts in 2013 is in keeping with a target of about two posts per week.  Just under 10,000 views within the year is again about par, and viewership continues to slip upwards as the year progressed.  Average monthly views in the last half of 2012 and into January were about 500, that has increased consistently over the last 4 months to nearly 900 per month – thank you. About two-thirds of readers are returning viewers with very clear surges when something gets forwarded and circulated within other communities.  The average viewer loads two to three pages per visit.

Several posts had over 100 specific views with the oil and vinegar of the health system  Public health and Primary Care topping the charts at 165.  Keen interest in the analysis of the New Minister of Health (who by all measures has complied with DrPHealth’s gloomy predictions) and ecigarettes which have split the public health community.  For whatever reason there has been considerable interest in the Cronut food poisoning that challenged some traditional thinking on the time and effort that we expend on food safety from commercial enterprises.  Rounding out the top five is the analysis of the throne speech.  The collective series of posts on the Oil and Gas industry has drawn over 200 views.  A synthesis with links is is the previous blog posting

Prior posts that continue to draw interest include Cost of Poverty, Hookah smoking, telehealth and fracking
While 50% of readers are located in Canada and to whom the blog is targeted, 25% are from the US where cross border comparisons are integral to business and for whom public health issues have no natural border.  Russian followers now account for 10% with an additional  smattering of followers globally amongst the remaining 15%

Twitter feeds and Google searchers account for the majority of entry points for those not accessing the blog routinely.  At over 350 Tweets, Twitter is the largest driver for visitors to the site and surges can be traced back to persons who have forwarded or mentioned the tweets to others. 

At only 88 comments, the lack of reader feedback is a question on the utility of the site.  However, conversations, emails and other feedback suggest there is value in this particular niche analysis of Canadian public health issues.  At least four additional people contributed a ‘guest’ piece during the year and a reminder that DrPHealth is a movement in transparent dialogue for which contributions are welcomed (drphealth@gmail.com)

Thanks for your continuing support and please spread the word. 

Friday, 27 December 2013

Oil and Gas - synthesizing the Public Health Impacts.

Over the past few months, this site brought together and complied information on the oil and gas sector for public health practitioners who may look at health impacts.  The story here began with an item that was getting wide circulation but did not reflect the actual public health risks from the study Oct 28, 2013 study.  It turned into an endeavor to document what is known. 

For those who are interested in going back – use the navigation on the right of the screen to link to the following dates or hyperlink from the date. Both will however take you away from this specific page and you will need to return.

Exploration, specifically fracking                                                    Dec 5, 2013 and Oct 18, 2012
Upstream issues (mining, collection and pumping)                          Oct 29, 2013
Pipeline and transport issues                                                          Oct 30, 2013
Downstream operations (refining)                                                  Nov 4 2013
End user contributions                                                                   Nov 6, 2013
Boom- bust economies of rural and remote development                Oct 9, 2013
Boom economies and the community left behind                             Dec 10, 2013

Specific other linkages of note

One new resource is the Trans Mountain  (Kinder-Morgan) application which includes in sections on human health risk assessment beginning in the 3rd Volume of Part 5c of the application – section 7.5.8 on page 7-242.   It is a prime example of health being “buried deep” in the consideration of the project as the application extends over 15,000 pages. 

This site would like to stimulate further reports on public health impacts and concerns relative to the energy sector in general and specifically the booming oil and gas sector.  Please comment or forward resources that others may utilize.  Those wishing to remain anonymous can communicate in confidence to drphealth@gmail.com  

Monday, 23 December 2013

Sex trade work in Canada will become safer. Supreme Court of Canada supports public health principles

Happy holidays to all.   

Sex trade workers in Canada are celebrating a gift issued by the Supreme Court. By striking down the existing Canadian laws on prostitution is the Supreme Court signaling that messages on public health are making it into the judicial system?  In the decision of December 20  the court  ruled specifically that three sections of the Criminal Code are an infringement of rights under s 7 of the  Canadian Charter of Rights and Freedoms  and the court was explicit in stating that the code infringes on their personal safety. 

Moreover the court speaks to changing legal principles over the past 20 years that allow for a revisiting of previous legal decisions, a marker for seeing the law as a reflection of a changing society.

At the heart of the decision is the danger and risk that prostitutes are placed in and their efforts to mitigate these risks as being defined in criminal code as illegal.  The court stipulated that Parliament does have the right to limit where and how prostitution can be conducted as long as it does not impinge upon the constitutional rights of prostitutes.  Given the recognized balance required, the government was provided with one year to correct the current situation.

Prostitution has not been illegal in Canada, where an exchange of money is made between consenting adults for the purposes of sex.  It is the provisions associated with prostitution that the criminal code imposed that have come under challenge.  Given that prostitution was legal, those engaged in the profession were being placed in danger by the Criminal Code.

In the unanimous decision written by Chief Justice Beverly McLachlin, the court reviews how each of the three sections precludes prostitutes from reducing their risk and enhance making their work unsafe.  The decision does not speak to the risk, nor even include demonstration that real risk existed.  The decision speaks from the perspective that safety was potentially compromised and includes fundamentals as negotiation of condom use as a safety issue.  In this, the court follows its previous recent decisions that acknowledge safety and health as an inherent good to be protected.

Perhaps there is hope that further legal actions will take aim at political stances which have inherently put individuals at risk, including by not limited to inequitable incarceration of subpopulations, personal use of drugs and policies that benefit those with resources and compromise those without such as pharmacy reimbursement plans for employees.  

Kudos to the Supreme Court, and legal watchers should read the fine detail of the decision as it lays down the foundation for future direction. 

Thursday, 19 December 2013

Pill Popping as Primary Prevention - The common practice finally comes under fire

If we could redirect nearly $3 Billion in Canada and nearly $30 Billion in the US in wasted health care costs to something useful would that not be logical?  Basically that is the conclusion of several publications and editorials released this week on the impact of purchasing vitamin products that have no proven value.

Duel winning Nobel prize winner Linus Pauling popularized the concept of pill popping Vitamin C, multivitamins and other dietary supplements starting in the mid – 1960’s.  The supplement industry has evaded drug regulatory approval and oversight, actively resisted attempts at Canadian regulation even with provisions for grandfathering, and self-promoted to the point that the majority of North Americans consume at least one supplement, with the industry still enjoying healthy business growth.

So the release of the studies is met with fanfare and reasonably expected skepticism from those addicted to what are mostly glorified placebos. Over half of the adult population regularly takes one of the products that the studies have demonstrated as ineffective.  

Pauling was sometimes referred to as the father of quackery.  Charlatan approaches to extracting money from those suffering where time was the essential curative agent.  As time allows body healing, some therapies become perceived as the reason and then easily promoted.  Vitamin C being touted as the cure for a common cold which will run its natural course in a few days.  And, as most vitamins and dietary supplements have minimal effects -  there are few side effects that warrant hesitancy. 

Dietary supplements are not going to disappear quickly, but perhaps now health professionals can make informed and appropriate guidance on the limited value, leaving recommendations where proven efficacy has been demonstrated such as during pregnancy. Many colleagues have recommended vitamins and other supplements knowing that the value was not dissimilar to that of a placebo but wanting to appear that they are "doing something good" for their patient/client/consumer. 

The whole industry of non-traditional health services including naturopathy, homeopathy and a host of others will most likely continue to promote and advocate for expanded use of such therapies in the wake of the same “science” that has not demonstrated their value and attracts a clientele wishing to rebel against what has become known as traditional medicine.

Popping pills was first a way of treating illness and then a lifetime investment in preventing existing illness from getting worse.  These studies challenge the thought that pill popping is a way of preventing disease.  CTV coverage is enhanced if you take the time to read the comments, many of which speak to individuals justifying that they are special or different and hence rationalize continuation of current practice despite the mounting evidence.  

There are better things like taking a walk in the park.  

Tuesday, 17 December 2013

Antibiotic soaps are getting a cleansing. Are they a victim? or the cause?

Those working in the field of antibiotic resistance have often aimed, and perhaps misdirected, their control efforts at use of antibiotics in the livestock industry and in handwashing.  The issues of general antimicrobial and superbugs have been touched on previously  Superbugs and Canadian response, Political expression of superbugs  plus mentioned many other times, and antimicrobial use in livestock industry at     AMR and livestock,  

Thus the Food and Drug Administration focus on antimicrobials in customer products is a refreshing look at an old problem.  As typical in health, the previous concerns have related to the negative impacts of such products.  The FDA focus introduces the question of whether such claims on protecting health are valid.
A nice FDA overview document not only lays out the evidence, regulatory action and recommendations, but links to key science analysis of the main product, triclosan which was undertaken by the EPA.  Such cross government collaborations are uncommon and speak to better regulatory practices in the US as well.   It is notable that the triclosan review was undertaken in 2008 and the FDA review was promised for the winter of 2012, so only five years in the making for a policy direction. 

Triclosan is unrelated to other human antibiotics, hence its role in facilitating antimicrobial resistant organisms in general has been challenging to extract.  The novel FDA asks the more fundamental question, is there evidence that triclosan containing products can care any health claim on preventing illness?   Handwashing is predominately a mechanical scrubbing process for cleansing.  Disinfectants like iodine, chloride and alcohol used in clean settings like operating rooms have proven beneficial in reducing contamination.  Hence the use of antibiotics in handwashing soaps was an extension of infection control practices.

Hence the proposed FDA rule does not negate addition of triclosan like products, but does limit health claims about using the word “antibiotic” in labelling as the public perceive such labels as being more protective.     A variety of other products have used antibiotic claims including toilet seats, however the proposed rule only addressing body applied products such as soaps and washes. There are numerous other agents other then triclosan which will be subject to scrutiny concurrently, but the public focus has and will be on the triclosan-like products.   The rule is now out for a 180 day comment period.

For those intrigued, a careful read of the proposed rule will raise a few eyebrows.  Well written from a regulatory perspective, its conclusions are based on shaky evidence and dismissal of the bulk of existing research as methodologically unsound.  Such comments should raise concerns from an industry that might just be interested in protecting its current practices, and who may be justifiable concerns at the potential implications of the ruling.  Given most mild illnesses are viral in nature, antibiotics are of no value compared with certain disinfectants.  Scientific studies where the outcome of interest is a only small contributor to the general outcomes of interest are methodologically very difficult. 

Given the limited value, it is likely a good thing to eliminate an unnecessary chemical exposure. However society works on a different principle, that of generally safe, it means demonstrating true harm is being caused by products rather than proving value.  The FDA is taking a bold step to question the generally safe current status. 

Two closing comments
1.        It requires at least twice as much evidence to take something out of common practice in comparison to what we accept before putting something into practice.

2.       Antimicrobial resistance (AMR) is driven predominately by prescribing of antibiotics for human illnesses.  Addressing minor issues like triclosan containing products or growth promotion use will do very little to alleviate AMR problems and more likely as this case shows, focuses attention away from the prime concern. 

Tuesday, 10 December 2013

Oil and Gas - the untold story of community left behind

To conclude the series on oil and gas, we asked a dedicated social media enthusiast colleague to reflect on the consequences of the boom and bust cycles on communities that have given up their healthy predominately males to support the boom. Follow her on Twitter with her over 1500 other followers at @Monika_Dutt

As a Medical Officer of Health (MOH), I work to approach issues surrounding resource development from an evidence-based perspective, weighing risks and benefits, and adding my voice to discussions as warranted. This may mean a range of activities including participation through the Environmental Assessment process, responding to concerned citizens, attending community meetings, or discussions and planning with local councilors and other partners.

As someone who is now, and has been in the past, an MOH in post-industrial communities, I’m also acutely aware of the toll industry can take on communities. As a Deputy MOH in northern Saskatchewan, I walked through the eerie setting of Uranium City, the town that once housed about five thousand people who were centred on uranium mining. When the mines closed in 1982, the town collapsed economically, and most residents left. Now what are left are crumbling houses, many with appliances still visible, the Candu High School with writing on its chalkboards, and a desolate skating rink. About two hundred people still live in the community.

I came to Cape Breton in 2012, where I witnessed the end of another environmental health saga. The waste that was contained in the Sydney Tar Ponds from coke ovens was globally infamous. In September 2013, a stunning park opened on the site, marking the culmination of years of controversy, work, and financial investment.

The closing of the steel factory on that site, as well as the closing of coal mines across Cape Breton Island, has left both a strong sense of history, as well as wide social and economic gaps that the residents of the island are struggling to rebuild from. Many have felt compelled to leave the island to participate in another boom economy, that of the oil sands in Alberta. Strident efforts are being made to reinvent the local economy, but that process takes time.

Although anecdotally most Cape Bretoners can name friends and relatives working out west, there is little sense of the number of migrant workers or the health impacts this phenomenon is having on the island. One researcher at Cape Breton University, Dr. Doug Lionais, has completed qualitative studies assessing the health impacts on the workers, usually men, and their partners, usually women. Many partners described a sense of hopelessness, as having no other alternatives for income, and as connecting emotional and physical ailments with their situations. Many workers described liking their jobs, but resenting the living conditions, and described having to shut parts of themselves down when going to work.

Further research is underway to gain a better sense of individual and community health impacts of having workers in Alberta while having a partner and/or family in Cape Breton. It seems the impacts are significant, and it is difficult to determine whether the benefits outweigh the costs.

Greater understanding of the health impacts of boom economies, both in the immediate area of the resource development, as well as more distant areas they might impact, are necessary in order to truly make decisions about whether to proceed with resource development. In line with this imperative, Dr. Eilish Cleary, the Chief Medical Officer of Health of New Brunswick, completed a health impact assessment in September 2012 on shale gas development in that province. In it she provided recommendations in these areas:

  1. Protection of Health and Community Wellbeing Related to Changes in the Social Environment
  2. Protection of Health Related to Changes in Both the Social and Physical Environments
  3. Protection of Health Related to Changes in the Physical Environment
  4. Protection of Future Generations
  5. Implementation and Oversight

This type of assessment is essential, in particular with significant resource development projects. The implications of the projects can be great in the present and the future and need to be factored into risk/benefit. The benefits that resource development brought to Cape Breton, and the downfall that its ending created, are a lesson, the ramifications of which are still being explored and experienced. The lessons connected to resource development continue here, given the presence of the Alberta oil sands and the understandable lure for Atlantic Canadians seeking work.

Monday, 9 December 2013

The cost of eating healthy.

It is a story that has gotten considerable traction.   Eating healthy costs a whole bunch more than unhealthy.  Perhaps it is just conclusion that most of us already knew that attracts attention. That the media have picked up on the story is a strong reflection of social conscious and attention to items that determine health.   The most blatant finding is that somebody went and proved the obvious.  

Or did they?

The stories ranged from lowers costs ranging from $550-$2000 per year.   When discrepancies occur, and perhaps an underlying theme of this blog site, dive for the original article – in this case accessible at BMJ Open.

A meta-analysis of over two dozen studies covering ten countries.  Most of the studies were market value studies looking at shopping list comparisons.   In essence it was a comparison of what additional costs were required to meet a specific “healthy” diet.  Items compared included chicken that was de-skinned versus skin-on.  Healthier snack options such as whole grain or unsaturated fat choices.  Hence the question was not whether one could eat healthy or not, but to choose a healthier option between two items tended to cost more.   

There were broader studies that compared two types of diets such the Mediterranean diet compared to “typical” Western diet.  The study strength was specifically self identified as comparing costs per food group rather than diet patterns in total.

There were marked differences when looking at cost per service, cost per calorie or when looking at specific nutrient components such as fat content. The authors also acknowledge that there is considerable variability amongst the studies. Notable is that if the issue is obtaining calories, cost for a less “nutritious” meal is lower per calorie. 

The study is to be commended for tackling the question of cost of eating well. For someone who is challenged with obtaining sufficient calories, the study likely confirms that they are making the right choice in less nutritious options in favour of calorie-dense foods.   For those with sufficient resources to making choices, there is a cost. 

The average Canadian currently spends about $215 per person per month on food eaten in the home (and yes at $275 each, teenage boys outeat the rest of us – no surprise there) .  Budget experts flag that currently we spend almost an equivalent amount per person per month on eating out.   Suggesting that there may be an easier way for those wanting to choose a healthier diet.

Kudos to the Harvard group for addressing the issue of the cost of food.  The details on linking purchasing behaviour with diet would appear to be far more complex.  

Friday, 6 December 2013

Pesticides for cosmetic purposes – do bans make things better or not?

For some of Canada a ban on cosmetic pesticides has been integral to normal operations for over two decades since the town of Hudson Quebec passed its bylaw in 1991.  The by-law has been subjected to Supreme court decision in 2001 affirming that there is both the authority and value in such action.  

Despite adoption of pesticide bans in both provinces of Ontario and Quebec (Nova Scotia and New Brunswick have bans on a single pesticide product), and over 150 other municipalities in the country, the value of such actions remains hotly debated within the public health community. 

Hence a review by the National Collaborating Centre on Environmental Health of the public health value of cosmetic bans is a welcomed contribution.  The review appears to have been requested by the Chief Medical Health Officer in BC, a province with a recent history of local community fights and what appears to be split opinions amongst public health practitioners. 

The detail of the potential benefits of harms and the extent of the review make the material seminal in terms of currency and well worth a read for any community with a current ban or exploring any restrictions. 

While acknowledging the challenge in quantifying the benefit, the statement expresses appreciation for some of the value in an environment of some uncertainty.  

        The impact on population health of exposure to pesticides used specifically for cosmetic purposes is difficult to quantify.
·         There is poor quality of evidence pertaining to the direct health impacts associated with exposure of residents to pesticides used for cosmetic purposes.
·         Acute and long-term toxicity has been demonstrated for many of the common pesticides used for cosmetic purposes, acutely in documented poisonings, and long-term, typically in studies of experimental animals, applicators or farm families exposed at levels well above those associated with cosmetic applications.
·         Relative exposure to the active ingredients of cosmetic pesticides used in lawns and gardens compared to exposure to the same agents used indoors, in agriculture and commercially, is not well characterized, but likely is small.
·         Possible harms resulting from a provincial ban of cosmetic pesticides may be the illegal use of toxic pesticides and musculoskeletal injuries among householders using manual methods to
remove weeds.
        With regard to provincial public health actions, children are particularly vulnerable to exposure
and effects of toxins at all stages of development and would most likely benefit from measures to reduce exposures to pesticides from any source.

Credit to the NCCEH for having restraint in not issuing an opinion on the need for or against such limitations.  The full document can be accessed at the NCCEH website or directly at Cosmetic Pesticides

Thursday, 5 December 2013

Fracking and public health risk

It seems the best work on public health impacts of fracking is being done in those areas where the fracking is not already occurring. First from New Brunswick and discussed at the most visited DrPHealth posting at  Fracking an obscene word . Now out of the UK comes an excellent review of the potential public health impacts and a solid contribution to our understanding.

Notable in its conclusions are that well managed and executed fracking is unlikely any risk to public health.  The threat is in the management of materials on the surface and the integrity of the well casing.  

Contamination of ground waters where it has happened appears secondary to poorly sealed wells or surface spills, putting the emphasis back to the development and operation of the fracking as the concern if any. 

What the document does well is break out in a health risk assessment approach to the relative potential threats, reviews existing evidence in areas such as air pollution, radon and other radioactive materials, water, wastewater, and chemical contamination.

Most public concerns seem to centre around water contamination.  The report details a review of 43 documented incidents of water contamination.  It also emphasizes that natural gas fracturing occurs at typically 1 km or more, whereas even the deepest ground water supplies do not approach this depth.    

The report provides excellent recommendations on further research needs.

Check it out at Fracking HP England

Monday, 2 December 2013

Preventing food allergies in Children: How little we know about an emerging public health crisis

Sorry for the gap in posting.   It is now December and perhaps the world will begin to turn more slowly.  Thanks for your patience.

Perhaps it is a sign of the times, but food allergies were rarely diagnosed in the past and while now likely overdiagnosed, the number of student with peanut, egg  and ‘milk’ allergies in school has become a challenge for schools grappling with having emergency procedures in place to manage anaphylaxis and classroom food policies.

In this changing milieu, a statement from the Canadian Pediatric Society is worth reviewing for its excellent review of the topic. 

Despite the increased interest in food allergies in children, and in anaphylaxis issues in students, the article provides no definitive conclusions beyond stating that delayed introduction has no benefit. Newer thinking is exploring whether early introduction can actually be preventive.  Even the value of breastfeeding is based on weak evidence and becomes questionable which will lead to horrific rebuttals from some biased professionals.  

 Two current studies in the United Kingdom LEAP and EAT (obviously somewhere somebody has a full time job developing catching acronyms for research studies) hope to provide further information on appropriate interventions.   

If there is a consistent message on food allergy prevention, it is “we really don’t know, but perhaps we will know more in the future”.   Read the full statement at CPS position on food allergy prevention

Regardless of the lack of evidence, the CPS in conjunction with Canadian Society of Allergy and Clinical Immunology produced a set of recommendations.  Note that the only recommendation which has better than Grade 2B evidence is on selection of formula where breastfeeding is not indicated.  2B is considered weak evidence generally of low quality methodologies.

·         Do not restrict maternal diet during pregnancy or lactation. There is no evidence that avoiding milk, egg, peanut or other potential allergens during pregnancy helps to prevent allergy, while the risks of maternal undernutrition and potential harm to the infant may be significant. (Evidence II-2B)
·         Breastfeed exclusively for the first six months of life. Whether breastfeeding prevents allergy as well as providing optimal infant nutrition and other manifest benefits is not known. The total duration of breastfeeding (at least six months) may be more protective than exclusive breastfeeding for six months. (Evidence II-2B)
·         Choose a hydrolyzed cow’s milk-based formula, if necessary. For mothers who cannot or choose not to breastfeed, there is limited evidence that hydrolyzed cow’s milk formula has a preventive effect against atopic dermatitis compared with intact cow’s milk formula. Extensively hydrolyzed casein formula is likely to be more effective than partially hydrolyzed whey formula in preventing atopic dermatitis. Amino acid-based formula has not been studied for allergy prevention, and there is no role for soy formula in allergy prevention. It is unclear whether any infant formula has a protective effect for allergic conditions other than atopic dermatitis. (Evidence IB)
·         Do not delay the introduction of any specific solid food beyond six months of age. Later introduction of peanut, fish or egg does not prevent, and may even increase, the risk of developing food allergy. (Evidence II-2B)
·         More research is needed on the early introduction of specific foods to prevent allergy. Inducing tolerance by introducing solid foods at four to six months of age is currently under investigation and cannot be recommended at this time. The benefits of this approach need to be confirmed in a rigorous prospective trial. (Evidence II-2B)
·         Current research on immunological responses appears to suggest that the regular ingestion of newly introduced foods (eg, several times per week and with a soft mashed consistency to prevent choking) is important to maintain tolerance. However, routine skin or specific IgE blood testing before a first ingestion is discouraged due to the high risk of potentially confusing false-positive results. (Evidence II-2B)


Wednesday, 20 November 2013

New York City does it again - the role of the city-state in improving the public's health

In passing an ordinance that prohibits the sale of tobacco to those under age 21, and setting minimum prices for a pack of cigarettes at just over 10, New York City continues to demonstrate innovation in respect to addressing health issues for its residents. New York ban on tobacco sales under 21

Okay, New York has roughly the same population as the province of Quebec and with size comes capacity and resource.
The point is that the city is taking control over its own public health issues.  It is not depending on, or demanding that the state take action. It has acknowledged the need to address its own health concerns and find its own solutions.   New York’s attack on the fundamental problems of community violence have expanded over the years in its attempts to address obesity and now tobacco. With evidence of success    NYC dept of health and mental hygiene. It helps to have a mayor that is brave and caring enough to address such issues (something both Toronto and Montreal have lacked in recent years).
The re-emergence of the city-state should not be dismissed.  While some local governments mock the radical efforts and legal barriers that New York has experienced, their efforts are turning heads in the municipal ranks.
Vancouver’s mayor declaring a public health crisis over the issues over mental illness,  Toronto’s work on housing and more recently on racialization and health inequalities, Montreal’s work on Transportation and health are all examples of local city-state efforts to address community health issues without allowing the federal-provincial divide to become an impediment.
The obstacle is Canada has about 3700 local/municipal governments, each one needs to be addressed in person and uniquely.  As such, it is not surprising that the focus of policy efforts is aimed at the 13 provincial/territorial governments, or when possible the single federal body.  It seems increasingly though that the decision power is moving from pan-Canadian to provincial/territorial and now to local government/First Nations communities.

Public health professionals have long been associated with local governments and their efforts. Paraphrasing a quote that isn’t readily at hand ‘The greatest gains in the health of the people has been made, not through the efforts of doctors and hospitals, but through the efforts of local government’.  A statement that was made over fifty years ago and remains just as true today.

Kudos to New York City and those local governments that take “governance for the good of the people” to heart and apply a broad interpretation. 

Thursday, 14 November 2013

Homelessness in Canada - the efforts of Housing First to find a cure.

There are 150,000 to 300,000 homeless people in Canada.  It seems obvious that homelessness is detrimental to health, yet we do seem to limit our efforts to making homelessness more comfortable through food programs and transient sheltering.

Housing First is an intervention that began in New York City and Toronto that provides people with immediate access to permanent and independent housing, without conditions that an individual be “housing ready” (e.g. requiring one be sober).  Studies of the Housing First initiative have been promising.  It was found to increase housing stability, reduce costs in healthcare and justice system use, and improve quality of life.  Could this work across Canada?

In 2008, the Mental Health Commission of Canada funded the “At Home/Chez Soi” study, implementing the Housing First intervention in 5 cities: Vancouver, Winnipeg, Montreal, Toronto, and Moncton.  It was a randomized controlled trial in which participants living with mental disorders were randomized to receive housing and community support versus treatment as usual.

The final report of the study is slated to be released later this year.  Interim results (Mental Health Commission of Canada) have found that participants who received housing spent a greater proportion of time in stable housing over the year.  The initiative may also offer savings to the public purse through reduction of costs for other shelters, health, and justice services.  But it is the personal stories of people recruited to the study that describes the most important results. (National Film Board at home)

It is a minor tribute to the current government that Housing First was acknowledged in the October 16th throne speech as one of the few health areas that this government purports to promote through this sitting of the house.  Will they deliver on the benefit? or maintain a mere rhetoric of feeble support?

It is odd that we need a study to show that stable housing improves lives.  After all it is acknowledged internationally as a fundamental need and a prerequisite of health.  It is nice to know that it can also save money.  But, is that the reason we act?  

Wednesday, 13 November 2013

Fat Taxes and Mexico's quest to address growing obesity problem

DrPHealth welcomes guest postings such as the following.  Contact us at drphealth@gmail.com 

Mexico has just announced an 8% tax on junk foods to address the growing obesity concern in their country.  (Guardian Nov 1 According to the UN, 32.8% of Mexican adults are overweight or obese, exceeding the proportion in USA.

Taxation of unhealthy foods, often referred to as a “fat tax” have been a frequently considered strategy to combat the growing problem of obesity by influencing consumption patterns, particularly given the success of tobacco taxes on reducing initiation of smoking and increase in smoking cessation.  However, fat taxes are much more difficult to implement than tobacco taxes. 

Firstly, one must determine what is considered to be an “unhealthy food.”  These may be based on nutritional value (e.g. saturated fats, sodium, or sugar), caloric content, or categories of food (e.g. soft drinks, snack foods).  Each have their own limitations.  For example, taxation on fats may result in an increase in price for whole milk, despite it being a recommended food for young children. 

In addition, there are concerns that fat taxes may contravene international trade agreements, such as the WTO.  However, other taxes, such as alcohol and tobacco taxes, have not been contested and fat taxes may be viewed similarly as a “sin tax.”[i]

Importantly, fat taxes must be non-trivial to influence behaviour.  As a result, fat taxes have been criticized for its regressive nature.  Taxes on goods place a greater burden on the poor who will have to spend a larger proportion of their income on food.  Thus, poor people will be most sensitive to price changes.  However, this same group also has the highest risks of obesity and thus, the health benefits of a “fat tax” may be progressive but the effects on material well-being are likely to be regressive.[ii]  Tobacco taxes raise similar equity arguments.[iii]

One mechanism to mitigate the regressive nature of a fat tax is to use the revenue to subsidize healthy foods (i.e. a “thin subsidy”).  However, mathematical modelling has shown that even with a revenue-neutral fat tax/thin subsidy, people in the lowest income quintile would experience a 0.86% loss of income.   But, because the burden of disease is largest in this quintile, the same individuals would likely benefit the most from such a policy.[iv]

In 2009, Denmark introduced a similar “fat tax” strategy that taxed all foods containing more than 2.3% saturated fats.  It has been criticized for raising the prices of foods that may not be “unhealthy,” such as whole milk.  But, more importantly, the taxation led to a dramatic increase in cross-border shopping to neighbouring Sweden and Germany.  After 6 months, the tax was repealed due its high administrative costs and the increase in cross-border shopping.  Nevertheless, the “fat tax” may have had an effect on food consumption.  Early research from Denmark showed that there was a 10-20% reduction in fat consumption in the first three months after the tax went into effect.  It is difficult to identify the exact reason for this, but it does suggest that these taxation strategies may encourage healthier behaviours. 

Would Canada implement a similar “fat tax”?  One aspect of Canadian culture that could be challenging is classifying the diversity of ethnic foods as healthy or unhealthy. 

Mexico has taken a bold step to try and address the issue of obesity.  Mexico’s experience with this “fat tax” will be an important case study to evaluate the benefits and consequences of such a policy.   

[i] Leicaster A, Windmeijer F. The “fat tax”: economic incentives to reduce obesity. Institute for Fiscal Studies, Briefing Note No. 49, 2004. Available online at: http://www.ifs.org.uk/publications/1797.  Accessed November 30, 2009.
[ii] Marshall T. Exploring a fiscal food policy: the case of diet and ischaemic heart disease. BMJ 320:301-5, 2000.
[iii] Townsend J, Roderick P, Cooper J. Cigarette smoking by socioeconomic group, sex, and age: effects of price, income, and health publicity. BMJ 309:923-7, 1994.
[iv] Nnoaham KE, Sacks G, Rayner M, Mytton O, Gray A. Modelling income group differences in the health and economic impacts of targeted food taxes and subsidies. International Journal of Epidemiology 38:1324-1333, 2009.

Monday, 11 November 2013

Remembering peace as a public health prerequisite

November 11 reminds us of those that have given of themselves in the name of peace and a time to reflect on progress towards global peace.

In 2012 there were 32 armed conflicts documented by the Uppsala department of peace and conflict Prio Uppsala , 41 are listed by Wikipedia. Wikipedia.  The largest of these being the Syrian civil war which took over 40,000 lives, the Mexican drug wars at 18,000 and the war in Afghanistan at over 8000.  In total the armed conflicts taking some 100,000 lives

Two new conflicts were noted in 2012, Mali and the Central African republic, with the civil unrest in Egypt making the list for 2013\

Canadians suffered less through 2012, the first year in a decade with no deaths in Afghanistan and only 24 injured, all in not battle situations.  Canada listed as still being active in fourteen armed forces missions, with some 1300 members on active service overseas at the current time. Canadian forces missions To those that continue to serve our countries in the efforts of maintaining peace, our gratitude – it is perhaps the very efforts that have led to a perception that such services are less necessary.

Within the country, we have lost four peace officers in 2013 and five in 2012.  A tribute site for all domestic peace officer deaths Officer Down provides a fitting tribute to those who lost their lives in the line of domestic peace service

Given the de-escalation in many of the current international conflicts, perhaps 2012-2013 might become known as a time of relative peace, or is it merely the calm before the storm?  Peace is an international movement that has advocates everywhere, irrespective of the rationale and desires of those in power and seeking power.

Friday, 8 November 2013

Chief Public Health Officer’s 2013 report on Infectious Diseases - or “How to safely say anything about public health in Canada these days”

Canada’s Chief Public Health Officer has released his 2013 report. This is his sixth report, most buried without any fanfare and with no public face to the release.  This year there was one notice sent by CPHA, but the report was again released with no media notice and this year not even a mention on the PHAC home site.  Once again the CPHO role relegated to some back corner and not standing tall for the protection of the health of Canadians.   While this should be the last report for Dr. David Butler-Jones as he has indicated a need to step down due to health reasons, it should also have been a time to celebrate his remarkable contributions to Canadian public health and courage in wandering into the unknown waters of the CPHO role.

The report focuses on the state of communicable disease control.  Truly a “safe” topic for public health, a theme carried throughout the report. 

The report opens with the “safe” topic of vaccines in preventing disease.  It touches on the touchy subject of health care associated infections and while it hints at the growing problems of C. Difficile and MRSA, it quickly moves to the safer issues of hand hygiene and infection prevention.  The document then meanders into antimicrobial stewardship and celebrates some of Canada’s success.

Buried deep in the chapter on tuberculosis is a hint of the persistent problem in Aboriginal populations, but the urgent problem of TB in Inuit populations is carefully skirted. Unless you note the axis break on the graph, you may be left with the impression Inuit populations have rates twice that of Aboriginal reserve dwellers instead of ten times that rate, and forty times the general Canadian population rate.  Sections such as this speak to the sanitizing of the report by spin doctors and not public health professionals.

Not surprisingly the section on foodborne and waterborne illness is well written and is recommended reading on Canada’s solid approach in both these fields. 

As one nears the end of the report, the bad news on increasing rates of sexually transmitted illnesses is alluded to. The subheading on “individual responsibility” reflecting the predominant current government’s approach to the problem, although with credit there are other approaches mentioned and the brevity of the individual responsibility section might just be a nicely concealed barb from the CPHO.

Share the reports, they are a reflection of what is happening in Canada, albeit the topic and the presentation are as “safe” as one can achieve in the current government’s clutches. Access the on-line version at 2013 CPHO report.    

Wednesday, 6 November 2013

Oil and Gas - the contribution of the end user

The unspoken issue in reviewing the oil and gas industry, is what is the impact of consumer demand on the pipeline.  Were consumer requirements for gas and other petroleum products decreasing, the need for increased production would be moot.

If car mileage utilization were dropping, if more public transit trips were being made, if active transportation were becoming the norm, then one would be expect to see oil production decreasing.

And we as the consumer are the driver of the this pipeline. 

Canadian net gasoline sales have increased an average of 0.6% annually over the past five years.  While diesel sales dropped with the recession in 2009, since then have increased by 7%.   Stats Canada detail gasoline and diesel consumption annually at Stats Can gasoline consumption reports  .  The US has fared slightly better with flattened utilization over the past few years and overall reduction of 6% since 2007. US consumption of gasoline

Most countries will do not have the positive experience of the US.  Japan, UK and other European countries have marginal improvements as well.  Globally, typical projections of global demand suggest a 2% annual overall demand in petroleum products driven by growth in Asia and other emerging economies.  Check out your country or region at international petroleum consumption 

As long as demand increases, the need for exploration and tapping existing supplies will continue. Just as importantly, many traditional supply sources such as US based fields, North Sea and even Canadian non-tar sand supplies have decreasing productivity requiring shifting to newer sources such as tar sands. 

Despite the marginal improvement in US and other countries, dramatic reductions in demand would be the only scenario where consumer demand would decrease sufficiently to warrant limiting industry growth.  Sadly, sustained decreasing trends are not likely given best efforts in European centres have plateaued at marginally lower demand.

In the meantime, keep walking, biking, using public transport, and encourage friends and family to do the same. Aiming words at producers can only be backed by substantive behavioural change at the end of the pipeline.

Monday, 4 November 2013

Oil and gas - downstream operations provide the greatest public health concern

Recapping this site has looked at the impacts of oil and gas industry, where angst is expressed on issues like pipelines and fracking, but less attention is given to the boom-bust cycle on communities and their health.

Surprisingly little attention is drawn to the downstream processing industry.  Refineries are perhaps accepted as a necessary evil, or perhaps just not understood.  Albertans in the regions where processing occur are more familiar with the concerns, but vehement objections are more likely to be raised to coal fired electrical generation stations than to new refineries.

Yet the list of disastrous refinery incidents should raise questions of most people on the siting and location of these downstream processing operations.  Massive explosions have occurred in Texas in 2005 killing 15, Venezula in spring of 2012 killing 42 and Mexico just under one year ago killing another 30. Catastrophic events are just one of the threats

Beyond the risk of explosion, persons living in the vicinity of processing operations may be subjected to a variety of chemical exposures. 

Vagrant emissions are caused by leaks in conveyance systems and are not uncommon in collection piping (upstream operations prior to distance transport) and in processing facilities.  Processing may result in release of certain compounds through stack release (planned), and while under regulation, cumulative impacts of multiple facilities will not receive the same level of scrutiny.

The article that prompted this series was focused on exposure information of persons living in proximity of downstream operations in conjunction with upstream collection for fields located adjacent to downstream processing.  Processing may occur at any point in the transport, with well known refinery zones that receive minimally pre-processed petroleum products.

Numerous reviews have alluded to the risks of living in proximity to any oil refinery.  Most notable are proximity is associated with socioeconomically challenged conditions which are the greatest risk to personal health. Many live with the perception and stress that the refinery is negatively impacting their wellbeing despite regulatory control.   While objectively the studies are mixed in their findings, the preponderance of lay literature would lead to a conclusion numerous health impacts including increased leukemia rates.  The typical solution for most downstream operations is to build at a distance from populations, but populations are also encroaching closer to long standing facilities.  (A challenge to readers to find a good objective review article for reference, there is so much biased material to taint perceptions)

Further downstream production includes secondary processing into consumer products.  Proximity of secondary processing to refining augments local industrial emissions.

Regulation is limited to environmental management requirements, generally only supplemented by general zoning limitations into industrial zones where refining may be one of the permitted uses already approved.  Hence environmental or health impact assessments for processing builds or expansions subject to minimal public consultation, input or surveillance.

In Canada the number of refineries has decreased from 40  in the 1970’s to 19 currently.  The US reports 143 operating refineries. 

Wednesday, 30 October 2013

Oil and Gas - Pipelines and other transport technologies and their impact on public health

Keystone XL:  Alberta to Texas
Northern Gateway:  Alberta to BC port of Kitimat
Enbridge’s Line 9 reversion :  Alberta to Montreal
TransCanada Corp West to East line – Alberta to Quebec or New Brusnwick ports
Kinder Morgan twining: Alberta to Vancouver port

If approved, daily movement of oil from Alberta outwards would approach 3.7 Million barrels per day or roughly what is predicted as production for 2020. Details about the pipeline proposals were written up in Globe and Mail Feb 2013.

Each of the projects has a story of consultation and conflict; Politics and ploys; Fundamentally about how to get oil from Alberta oil sands (and other production well fields) to market to make a profit. 

While only 4% of Canadian crude makes its way across country in trains, two very high profile and disasterous scenarios have underlined why train movement has its limitations.  The Lac M├ęgantic   tragedy killed 42-47 persons while the Gainford incident was the latest and just month previous a train derailed near Calgary.

The National Transportation Safety Board maintains statistics on pipelineaccidents and incidents (as well as trains).  TSB pipeline data .  The term accident inappropriately reserved for situations where damage to person or property has occurred, incident where no damage has occurred but a near miss was identified.  Some of these definitions don’t seem to match that an incident could cause environmental damage in four instances in the last decade.

The vast majority of incidents and accidents are associated with releases of <1 cubic metre of petroleum material.  Only 18-20% of both defined outcomes were actually associated with transmission pipelines, most instances appear related to start or end of the transmission, or with compressor or pump stations with a handful of others that deserve better definition.

The key statistic from a public health perspective are the health outcomes.  The data tend to merge injury sufficient to require hospitalization with death – and report on a total of 4 such instances in the past decade with the last fatal pipeline related death in 1988.

Contrast this with the full rail industry where an average of 80 or so deaths occur annually, most with persons on the tracks or at intersection collisions.

For those concerned with environmental damage, pipelines also have a good (but not great record), and certainly compared to the high profile train derailments, the environmental damage is more constrained.
So, if one had to choose, which would be the best option – trains carrying petroleum, or a pipeline?  

Both of which may end up at a port, where the product is loaded onto ocean liners for distance transport.  

Tuesday, 29 October 2013

Oil and gas - upstream public health impacts. Do the benefits outweigh the costs, and who gets to decide?

This series on oil and gas industry and public health impacts stated with a the previous blog looking at the tar sands and impacts DrPHealth October 28 2013, only to discover misrepresentation of a scientific study that wasn’t about the tar sands at all.

Previously, and still the most referenced blog posting,  is an article on fracking from just over a year ago DrPHealth fracking October 2012. Related to the boom and bust cycles of rural and remote industry is a post DrPHealth rural, remore and northern development October 9 2013.

The oil and gas industry is a complex multitude of processes and health threats. Routine operational aspects such as flaring, fracking, and refining are common day terms with a multitude of implications.  “Upstream” resource extraction activities tend to be associated with more rural locations, transient workers, boom and bust economies with associated health challenges.  Some 120,000 people in Alberta are employed in the upstream activities.  The annual “investment” in oil sands activity being in the range of $20B.  The royality benefit to Alberta in the range of $4.5B annually.  One of the best measures of personal and community health is economic vibrancy, so supporting a dynamic economic environment has value, while monitoring and mitigating the potential negative impacts. 

Itinerant worker camps over double the population of the area, and while many are concerned about the health impacts of such camps, the proportion of emergency visits to local hospitals in oil and gas country which are industrial driven or even camp related is a small percentage (reportedly ~5% in NE BC).   Not surprising given very healthy workers and rigorous occupational safety requirements. 

Add to the requirement for good health prior to employment, many camps are moving towards strict drug and alcohol restrictions for workers in camp.  Camps are becoming managed mobile communities – not specific to any one employer, but cautiously managed to ensure a supply of able bodied persons. 

The major concern in these developing communities is less about health care system demands, and more about the social disruption to communities, the threat of recession and loss of income for local businesses (itinerant workers merely travel somewhere else).  

There are few local protests to the environmental damage, and while concerns are expressed about personal health and wellbeing and the potential negative impacts, they do not dominant discussion.  Some excellent work has been done in flagging the real and potential concerns on health (and other consequences) and should guide public health’s approach to upstream energy sector impacts.

The excellent Royal Society report is augmented by a few other key public health documents

A fundamental question to be asked is whether industrial development of this nature should have a new positive benefit (utilitarian ethic of the greatest good for the greatest number), or that there should be no negative consequence for any person/community (liberal ethic that there is some good for all)?  Depending on your view, the tolerance for negative consequences may be different, and respecting differences of opinion a key to conflict resolution that can be a significant issue. 

As environmentalists across the globe project their concerns about the impacts of oil and gas growth in Alberta (and concurrent growth in BC and Saskatchewan areas benefiting from natural resource fields), the issues facing residents, workers and local communities are at a disconnect from what critics located in urban settings and at distance from the “coal face” purport as the problems. 

To come, distribution and pipelines, downstream refining and processing, and product utilization