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Thursday, 28 February 2013

Public health funding debate - diving deeper

One of Canada’s premier interactive health sites is supported and written through St. Mike’s in Toronto.  Healthy Debate  provides a forum for discussion of the whole range of health issues, and is to be commended for recognizing public health’s contribution to the health system.   Dr. Monika Dutt has initiated a discussion on How public health funding in Canada needs to change .  Join the conversation and support the discussion.

Those that have been through the ringer will recognize that the funding debate is complex.   What constitutes “public health” in the general sense about the organized efforts of society to prevent illness, improve health and protect wellbeing – can range broadly.  Not surprising, in the 1910’s the Canadian Public Health Association was a strong advocate for the establishment of a system of hospitals in Canada, which led to the Canadian Hospital Association and subsequently the Canadian Healthcare Association.

In the post war years and green paper documents, public health was again active in support of health service which led to Tommy Douglas’ medicare efforts based on the Swift Current health cooperative.  As we run through the decades, “public health” has fostered the birth of home care, been a strong partner and advocate for community mental health, driven efforts to improve care for seniors in residential settings.  Currently we may be seeing a divergence of maternal-child programming as it strives for independence from other public health services. 

Thus the major role of “public health” remains in initiating and stimulating change that aligns with its core definition.  

How then can the value and efforts of public health be weighed in gold?  Many efforts for preventing illness and reducing the consequences of disease on other health services are now embedded and entrenched in other pillars of the health care system.  Some administrators may legitimately argue that they are already investing more than a targeted amount in prevention efforts, while the formal “public health” sector scrounges to survive on meagre crumbs.  

Dr. Dutt admirably flags the tension that constraining resources are causing.  While health systems struggle to maintain minimum operational levels in the face of growing populations, ageing populations, inflation, utilization creep and technological developments – arguments that public health can make a difference if you invest more are falling on deaf ears. 

But, were in not for the successes of public health to date, the system would have collapsed long ago.  Hospitalization rates have been reduced to between one-quarter and one-half peak rates.   There is evidence supporting compression of morbidity and overall reductions in health care utilization due to healthier populations.  Perhaps the one failure has been an increasing cohort dependence and expectation on accessing and utilizing health care that contributes to the utilization creep – fuelled by a health care industry that needs to self-propagate.

We in public health need to remain grounded in the very efforts that Dr. Dutt has identified.  We must also be willing and able to adapt to a rapidly changing environment and not sit on our past laurels.   Conversely, for  health care readers, a new recognition and respect for public health as integral part to the solution could foster constructive efforts rather than competitive ones. Health care administrators should receive mandatory public health training and experience before feigning expertise in the topic.  

As Dr. Dutt suggests, there is a strong rationale for protecting up to 5% of the budget for public health – and labelling it as a future benefit. Many companies use fiscal targets for research and development activities which this parallels.  However, such funds must be linked with public health professionals actively responding to the challenges of today – and those are difficult and uncomfortable, unlike some past public health activities.  

Monday, 25 February 2013

Muzzling civil servants – Are Public Health professionals also subjected to censure?

The University of Victoria Environmental Law Clinic has received considerable attention for their paper on muzzling of civil servants, with particular emphasis on science based research.  The report is to be commended for identifying the concrete methods applied by bureaucracies of supporting consistent messaging and potentially controlling comments that may not be consistent with government direction.  In particular are the couched comments on differences between the Harper and Obama administrations, the expansion in openness from Bush to Obama, and the progressive containment of messaging since Harper administration came to the Prime Minister’s office.

The waxing and waning of communications within government sometimes follow political stripes, more often the leadership styles of individuals.  Bottom line none of this is new, but the current constraining crisis deserves the attention that report raises.

The criticism of the report is that it is superficial.  The report speaks to the obvious changes in communications policy that have clouded Ottawa in a veil of opacity, with particular focus on subjects that are not consistent with current government policy, such as the impacts of climate change.  

Often it is the subtler forms of muzzling that constrict the public service.   Retribution for actions or comments is rife and not necessarily within the concrete format of straight jacket policy.  Some other examples of how civil servants are kept in line.

·         Reorganizing or disbanding departments inconsistent with government policy
·         Internal review and editing of publications – “spin doctoring”
·         Removal of responsibilities, often those that are considered incentives for certain positions
·         Behaviour modification through the performance management systems – some of which can be linked to income incentives.
·         Having work subjected to formal review
·         Curtailing or constraining project funding to effectively castrate scientific freedom and transparency
·         Elimination or threat of elimination of positions and jobs
·      The current governments pervasive use of confidentiality contracts/agreements that preclude freedom of expression prior to becoming aware of results. The consequences of non-compliance can be significant.   

Professionals that are aggrieved and frustrated by the subtler approaches to restricting their professional freedom,  move to other positions within and without of government.   The system by its very nature promotes mediocrity and alignment with political direction.   Not that all governments are inherently bad, in fact they are representative of the majority vote of the populous – so if there is a grievance on policy direction, it will only be resolved at the polls.  

Those in public health may well recognize these subtler forms of censure.  Public health professionals are frequently engaged in social topics that are uncomfortable to political leaders, and while we would like to remain autonomous, the reality is that most of us have suffered some or all of the listed forms of censure.If you have other methods that you have been subjected to, please send your experience to drphealth@gmail.com  and lets lift the veil of silence.  One of the key reasons this site continues to protect anonymity, are the experiences in censure that have been far too commonplace. 

Kudos to the University of Victoria Environmental Law Clinic for holding government accountable.   The full report is appended to a letter to the Chief Information and Privacy Officer UVic Env Law Clinic letter

February 27th update:   Ric Mercer wandered into this discussion as only such a comedian could, Rick Mercer UTube.  

Thursday, 21 February 2013

Emerging Coronavirus threat - how should local public health professionals respond.

A new coronavirus has received considerable attention in the past week.   The virus has only been identified in less than 20 people so far, but of the first dozen in Saudi Arabia, half died and the remainder had significant morbidity.  Now a report from the UK highlights relative ease of infection upon exposure UK coronavirus study.

Whether it is the fun or the fear that emerging pathogens represent, they are one of the reasons why public health professionals have an assured degree of employment.  Germs survive by adapting to their environment.   Selective propagation favours those germs that can readily move to new environments and hosts, can thrive and multiply on their hosts, and are less likely to cause the host to die.

Highly mobile hosts facilitate dissemination and spread of such germs.   Humans have modified the natural ecology by condensing global travel times to hours from days and weeks – hence broad dissemination of novel and emerging pathogens becomes a real risk of our technological advances.   (the second of the main reasons why public health has an assured future – new technology).

The major point of this discussion is what are the appropriate actions in preparation?   We have multiple jurisdictions who are redundantly closely observing this and other emerging pathogens.   Their perceptions tend to be comparable, but occasionally interpretations differ and one jurisdictions/organization/society acts autonomously leading to a “spiralling” of responses.   Trimming some of the duplicity might lead to greater efficiency, more focused response and better coordination (contrast the Canadian and American responses to pH1N1 for a study in efficiency, and no, Canada’s performance was not the more stellar)

The augmenting “spiral” response is rather than retaining logical sense based on evidence, global recommendations for something like surgical masks as respiratory protection, become N35 respirators in some centres, and then specific professions adopt even higher protection like self contained breathing apparatus.  Professional demands for equity drive responses to the highest common denominator, not the most efficient.

The lack of evidence often drives up the precautionary response, compounded by the inevitable changing understanding of the science which conveys a message of distrust and fuels public and professional hysteria. 

Let us hope that this coronavirus quietly disperses faster than its cousin that prompted the SARS scare.   Conversely, we need to be prepared to grapple with a range of moderate to severe pathogen outcomes and current public health infrastructure in North America has probably slipped below the needed surge response capacity, in part in an effort to reduce duplicity because we have this tendency to want to do things within jurisdictions and not trust our national or international leadership

Tuesday, 19 February 2013

Electronic ecigarettes - an emerging smouldering public health issue

August 20, 2013 - please leave a comment.  There continues to be a steady stream of visitors to this site, we would love to hear why you have come to this particular posting.  DrPHealth

eCigarettes or electronic cigarettes are burning up the continent.  Perhaps smouldering north of the border, but a raging fire south of the 49th.   The concept reached market level production following North American patents in 2009 and 2011, as such it represents an emerging public health issue  ecigarettes have been marketed in China since 2006 as a smoking cessation aid.

The burning question – is it an emerging benefit or threat to public health?

Essentially it is a delivery mechanism for often the same inhalant matrix used to deliver asthma medication.   In some instances nicotine can be delivered, but many ecigarettes are designed to replicate the tactual sensations of smoking without the need for a nicotine rush. The cost of a "pack" being comparaable to that of the tobacco based cigarette product

At the individual level they appear safe.  The evidence currently is weak at best for efficacy in smoking cessation, however it carries construct validity.  Certainly switching from tobacco based smoking products has a high probability of having individual health benefits and as such would be, and has been, strongly supported by organizations focused on individual patient care. With 4.9 Million Canadian smokers who could benefit, there is a substantive market to reach. 

Public health proponents have argued for decades the importance of modeling smoke-free behavior as an aid to population level reduction in smoking activity, hence effective bans on indoor smoking are now extending to public outdoor venues.   Tobacco reduction coalitions have been quietly vocal to date on raising objections and concerns to regulatory agencies that the tremendous efforts of the past decades could falter under this new threat.

One US television advertisement brings the ecigarette right back into a crowded elevator as a safe alternative for users and those in the immediate vicinity.

As such the battlelines are slowly being drawn.   Individualist proponents arguing for their implementation, population health folks resisting their dissemination.  The legal environment being diffuse enough in many jurisdictions to be unclear – and posing challenges for enforcers of cigarette bans that will now need to prove not only smoking in a public place, but that the smoked product contained tobacco or other “weed” and not just an electronic simulation.

Regrettably the evidence either way is sparse. Hence a brewing war of words with both sides lacking concrete evidence.

Health Canada issued a precautionary warning in 2009 Health Protection branch warning, and recently have reiterated in a communication to a non-smoking advocates group that a nicotine is a drug, where ecigarettes are used for delivery of nicotine, they must undergo Canadian approval processes.  That leaves a huge gap for those entrepreneurs that target the market of those habituated more to the tactile and oral stimulation than to the nicotine high through marketing non-nicotine ecigarettes.

The regulatory void is unlikely to be filled quickly.  Research on such products lacks industry funding and the current government environment is not likely to quickly reallocate funds to answer the smoking questions on cessation efficacy  and population effects.  Behaviourist will be interested in whether an ecigarette utilize can mix safe and unsafe smoking behaviours, more readily overcome the habituation, and what is the influence or youth or others who are already barraged with smoking images.

Rumour has it that at least one of the major tobacco companies has invested significantly in ecigarettes, if anyone can substantiate this, please advise drphealth@gmail.com and the information will be updated. 
In the meantime, public health professionals need to become better informed, recognize the conflicting messaging and be prepared to act appropriately for the sake of the population, not just based on speculation.  

Monday, 11 February 2013

Clyde Hertzman - a fallen Canadian Public health hero

Canada has prematurely lost a public health hero.

Clyde Hertzman has been an inspiration, leader, and mentor for public health professionals in Canada and globally.  His mild mannered approach to public health tutored many over the years.  The past years have been devoted to a shared passion – the betterment of opportunity for children in Canada. Perhaps fitting that seven of Canada's provinces have inserted a February holiday to acknowledge the value and importance of family time in the development of children.  

Clyde’s legacy will always be found in the Human Early Learning Partnership and the work done on measuring the preparation of children for kindergarten and the school years.   For those not familiar, the fruits of his vocation are documented at http://earlylearning.ubc.ca/ .  He modelled excellence by putting his beliefs openly on the table, following a rigorous approach to public health methodology, and building a great team -  something all of us should aspire to.  

His contributions to the wellbeing of children were formally recognized just a few weeks ago  in being named to the Order of Canada, an award that regrettably he will not collect in person. 

Sadly, Clyde passed unexpectedly February 8th at the far too young an age of 59. He will be dearly missed by the public health community in Canada and internationally.

Thank you Clyde for inspiring a generation of public health professionals.  We all wish that you will continue to inspire and will continue to watch over the successful implementation of your vision.

Wednesday, 6 February 2013

Canada's Social Performance - detailed analysis by the Conference Board

While the Harper government repeatedly ignores pleas for addressing social  issues when the source is from left leaning groups like public health, it surely will pay some attention to right leaning groups like the Conference Board of Canada.   In a well written and nicely laid out document, the Conference Board gives Canada an overall “B” grading, putting it 7th of 17 members of the similarly structured countries (The US ranked last and Norway had no ratings below a "B")

The methodology and rigour are worth the read in of itself, although the methods support certain justice based components – and the rankings should incite debate and cries of overinflation.  Ultimately, that Canada is in the middle of the pack should not be considerable acceptable except to a government that promotes mediocrity.

Notably poor performances were ranked in working age poor, child poverty, income equality, gender and income gap.  If this should not have raised alarms country-wide, it is a national disaster.   Equity seems to have been achieved better for disabled persons and the elderly.

That measures of government performance also ranked poorly (confidence in parliament and voter turnout) might beg some questions about the political fabric that loosely binds Canada.

Read the high level report at Conference Board report.  The report does delve deeper into the poverty relationships and the impact of the recession.  While numerically a ranking is given for Canada, grade wise, only Italy, UK, Japan and the US were graded as “C” or “D”, with the five Nordic countries all receiving “A” ratings.

Further, link into the areas of your interest such as child poverty for a detailed analysis or income inequality for detailed analyses which helps put time trended performance into perspective.  (an excellent annual Canadian graph of GINI coefficients is a hidden gem).

This resource is well worth the read and wide dispersion.  Kudos to the conference board for such an excellent document.   

Monday, 4 February 2013

Private health care facility goes bankrupt - what does it mean for public health care system?

The public private debate in Canada hit another hurdle this past week, when one of the flagship private hospitals in Calgary went belly-up, leaving Alberta tax payers with the debt, costs, and embarrassment.   Bankruptcy notice

Not that private health care can’t work in Canada, there are examples of successes across the country and standard option for operations such as home care and long term care.  Just that private health care is not going to thrive as a source of profit.  Firstly, the public payer has such purchasing power that margins will be razor thin as the community care sector demonstrates, secondly, that  while some members of the public might be willing to pay for hotel services, it is just not part of the equitable social fabric we try to weave, thirdly, the Canada Health Act requirements for universality and public accountability limit diversification options in the private sector, and finally, the public health care sector administrative margins have been driven so thin that private operators must try to shave profit margins within administrative costs while most operational costs and expectations are comparable.

In some jurisdictions that run parallel private and public systems (eg New Zealand, Australia and to some extent the US), a major criticism is that the private system pays better wages and hence attracts better staff.  The cost of providing care is greater.  Given that in Canada, the funding is still provided from the public purse, the quality gains to be made for elite staffing are not affordable within the established allocations.  Hence, while the hospital may have been private, it was still bound by public funding and the reason why private facilities will unlikely flourish within Canada. 

Perhaps a nicer way to say it, in the US, the costs for profit and administration total over  17% of health care spending.  In Canada, the public cries unfair at comparable administrative costs that are below 4%.

Of course, one could argue the economic stimulation benefits of that additional 13% spending would place Canada on much sturdier financial territory as an integral part of public spending. There’s a hypothesis to intrigue economists who were more concerned with ensuring the financial sector remained afloat during the ’09 recession. 

Friday, 1 February 2013

Brain damage - rehabilitation services as an integral part of health continuum

The previous posting spoke to the impact of strokes in Canada when counting numbers.   Two recent events have brought brain health back into the public eye.   

Canada’s Chief Public Health Officer suffered a stroke just over a year ago.  Recently he spoke to the Globe and Mail about his experience and current rehabilitation Globe and Mail January 17, 2013.   His risk factors combined with lifestyle were contributors to his event, and his recovery remains at less than 100%.  One can hope the machinations of the PHAC entity continue to grind, but since they appeared to be near a standstill, it is hard to notice a difference.

South of the border, Hiliary Rodham Clinton’s “concussions” (but sounds a lot like a subdural hematoma) and noticeable neurological deficit have the media attention.  

In one case the individual remains in his job, in the other, a replacement is pending.

Both however speak to the personal impacts of brain damage, something that some 1% of the population carry with them daily.

Rehabilitation services are often scanty and difficult to access.   It is the other end of the health spectrum, truly contributing to functional recovery and adaptation, but generally tolerated only in so much as it is a convenient service to channel stroke or hip fracture patients who are blocking badly needed acute care beds.

When will we learn balance in health care requires consideration of all aspects of continuum of health services?