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Monday, 29 April 2013

Public Health Blogging in Canada

DrPHealth was established to provide a blogging voice to public health in the country. The audience is for those in public health as a resource and commentary on public health activities of relevance.  For those that look back at the early day postings from July 2011, it began as a learning experiment that has been sustainable.  The hope is that others would contribute is still foundational to keeping authorship somewhat anonymous. 

Other blogs have come along with different perspectives.  Most notable was the work of Ted Schrenker with the support of CHNET  (who have a large share of the public heath webinar market nationally). 

Ted reminisces in his latest and final blog A change of scene, and a farewell as he moves across the Atlantic, another victim Canadian tsunami of government cuts.   Thank you Dr. Schrenker for your series of the last year.   The posting view rate being several times greater than what this site has achieved. 

Healthydebate.ca runs the gamut of health news, and includes the occasional public health posting averaging about one public health posting a month.

Dr. Monika Dutt has started a blog to match her prolific and well worth following on Twitter @Monika_Dutt . 
We would love to hear about other Canadian focused public health blogs.  Send information to drphealth@gmail.com 

The average posting on this site eventually receives about 50 hits, and on a daily basis 20-30 visits. The blog is also sent directly to a handful of individuals.  

This site is committed to being unfunded, unsponsored and not influenced externally.  Only through your following and promoting its value, does the work remain sustainable.

H7N9 influenza update.  115 cases, 23 cases, 9 provinces in China and first case amongst a person returning from China.  

Thursday, 25 April 2013

Autism - a public health issue that deserves more than a societal autistic reaction.

CIHR recently reviewed many aspects of autism, a condition with more questions than answers, more puzzles than solutions. Why isn’t autism on the public health radar?  Why as a society do we show a lack of interest, avoid conversation and lack empathy?  - typical autistic symptoms. 

Despite 70 years of interest, it remains unclear whether the perceived increase in autism is related to actual increases in the disorder, or better diagnosis.  Certainly the condition has been the focus of growing public and scientific scrutiny, and the focus of many bogus claims.   Most notably the MMR allegations on which innumerable money has been spent and time wasted debunking. As measles ravages the UK where the antivaccination scam may have had one of its greatest impacts, innocent children are suffering consequences unrelated to the issue of autism  There have been allegations of association with increased radiofrequency exposure and with multiple chemical exposures.  More time has been spent on what it isn’t caused by than getting a better determination of what are the root causes (genetics is one). 

As such, the synthesis material available at Understanding autism CIHR  is a welcomed update on what deserves attention from public health professionals. 

While the site focuses on CIHR funded researches, the link to Cochrane reviews on group therapy, music therapy, extensive behavioural intervention and newer pharmacological approaches is reviewed.

Put in context, the US estimate of adequately caring for a child with autism is pegged at about $70,000.  Various provinces have funding allocations for children, some provinces the funding is more easily identified  such as BC (22K), Manitoba (20K), PEI (20 hrs/wk @13.18/hr ~ 14K).  The remaining provinces have much more complex funding models and rules.  An older parliamentary review from 2006 is still available for all provinces/territories at Parlimentary review

The match between funding and needs is subject to an Ontario audit currently Ontario audit  with no expected date of completion other than inclusion in the 2013 Auditor General’s report for the province.
At the heart of autism treatment controversy is the use of EIBI (Early Intensive Behaviour Intervention).  Referenced on the CIHR site is a Cochrane review, worth evaluating if you can access the paper Cochrane EIBI review  .  Only one randomized trial and four clinical trials were included in the review.  The RCT being one of a total of 28 children, each of the four clinical trials similarly with 41-44 children.  While few of the clinical studies demonstrated significant effects independently, combined in an additive metaanalysis there were reported benefits.  However, the metaanalysis excluded the RCT which had consistently demonstrated lower effect values in most measures. The Cochrane review does not justify its rationale for excluding the gold standard methodology and must be the only time Cochrane essentially excluded an RCT in favour of weaker methodologies.  (Cochrane notoriously dismissing methodologies other than RCT in its clinical reviews).

Now remember, this study forms the foundation on which we are spending hundreds of millions of dollars in Canada each year.

For such a profound and deeply distressing condition for families, our rudimentary knowledge and need for quality information should attract high quality epidemiological research and review.  

Monday, 22 April 2013

Life expectancy may be decreasing for certain population groups - the negative implications of current government economic contractions

BC Health Officers Council seem to have pulled another hat out of the bag. A study on life expectancy across the province which has implications for all of Canada.  

Most importantly the health difference between the riches areas and poorest is growing.  Life Expectancy is spread across 10 years in the province.  The study however ecologically links imputed socioeconomic  variables of deprivation and education with life expectancy and demonstrates what many suspected.

Those with resource are getting healthier faster.   A full 14 month increase in life expectancy over consecutive five year periods.   Those with the least resources gained only 1 month total life expectancy.  

The disturbing part was those in the 4th of the five quintiles, sometimes referred to at an individual level as the “working poor” saw life expectancy decrease by 3 months. 

Not to be over interpreted, we are looking at populations ranging from a few thousand to hundreds of thousands, and contraction in life expectancy refers to reduction at the population level and not amongst those individuals living in socioeconomic quintiles – but it does beg a lot of questions.  Read the report at HOC website 

National variation was noted in the CIHI health indicators 2012 report available at CIHI health indicators 2012 where age standardized mortality varied from 155 per 100,000 in Richmond (also the highest life expectancy in the above report) to almost a doubling of 365 in Prairie North of Saskatchewan.  Data by necessity is needed to drive change, and report cards can elicit some interest.  Data however do not appear to be sufficient to drive change of themselves.  Who is best .  

There are still people out there that don’t believe health and wealth are related, who deny climate change is happen, and even a few that still believe the world is flat and the sun circles the earth.   We need to focus on those that are willing to look to the future and not worry so much about changing the opinions of those that perhaps are fixed in their beliefs.   

Thursday, 18 April 2013

The Generation Squeezed - young adults are being smothered in debt and burdened by underemployment

Remember when you graduated from your “last” degree?   What level of debt did you incur?   How did this impact your life decisions subsequently?

Today’s graduates are faced with unprecedented debt loads to complete their degrees? Are being expected to assume mortgages that greatly exceed income ratios of their parents?  Are deferring partnering, reducing family size or even not opting for parenting. 

Full time jobs for entrance level graduates are becoming scarce. Many are expected to work part time, shiftwork or at considerable distance from their home base to become established in the workforce.  Yes their predecessors were faced with similar issues, but not to the extent that this year’s graduating class will  Globe and mail April 10 video on youth employment  .  Federal support for youth employment has been eroded to a minimum.  As youth who have not achieved full time employment do not contribute to unemployment statistics, they are not measured.  While reported unemployment is unacceptable, its inverse is an underestimate of the reciprocal measure of youth employment. Nor is underemployment factored into unemployment statistics. 

Statistically a wonderful way to hide the extent of the problem. Moreover limited resources are being channelled to retraining adults and even older employees who contribute to the classical unemployment measures, further undermining youth employment support programs.

A lone voice has emerged and is bringing attention to the problem. The efforts of Paul Kershaw, with the Human Early Learning Partnership at UBC deserve far more attention than they have mustered to date.

Follow Generation Squeeze at http://gensqueeze.ca/ .  Be sure to sign up and support the efforts to remobilizing our youth, before not only are the jobs outsourced, but the youth emigrate to where the outsourced jobs are ending up. 

Wednesday, 17 April 2013

Health Council of Canada has been given its termination notice

The Health Council of Canada has been given its final rites. iPolitics report April 16

Not the most auspicious group, however they did do some excellent work.  If you have not read their reports, they are very worthwhile. Most notable in the last couple of years on chronic disease and primary care issues http://www.healthcouncilcanada.ca/  .  In total their production of a few dozen publications since 2003 are a legacy that likely will only be found on dusty Ottawa shelves. 

With the expiry of the accord on health funding in the country, the federal government has pounded its autocratic fist and advised the council that they will have no funding after the accord expiry next year.   Given that the federal government unilaterally axed the accords, there is no blaming outside of the circle of Parliament Hill.

Some will wonder who the council was? and others may actually think that the loss is unfortunate. 
The questions should be if this is strategically intentional of a federal government that continues to slide away from providing any leadership in health? or is this a consequence of the widespread constriction of federal spending and a natural death?   

Certainly the painful cuts to PHAC likely will have more consequence than the loss of Health Council. 

Monday, 15 April 2013

Canadian scores on public health report cards – Children, women and hospitals

UNICEF released its 11th annual child wellbeing report card looking at rich countries.  Canada ranked a dismal 17 of 29, although the US ranked 26th.  The Netherlands topped the rankings and followed closely by most Scandinavian and then European countries.  

If you dig into the details several points in defence of Canada should be noted.  Canada was the highest ranked non-European country, and the US was the second highest non-European country.  All the other developed countries globally were not ranked due to lack of data, so how Canada stacks up to its other Anglophone peers of Australia and New Zealand cannot be determined. In addition, there are many indicators for which neither Canada or US data were available for ranking. 

The scale is based on five dimensions, Material wellbeing, Health and Safety, Education, Behaviour and risks, and Housing and Environment. Canada ranking mid range (11-16) on four of the scales, and a poor 27th on Health and Safety.  The US ranking poor on all five dimension. Each dimension other than Behaviour and risks is based on four indicators, the Behaviour and risk dimension being based on 10 indicators.

Canada scoring poorly on childhood poverty (no surprise there), infant mortality rates, immunization rates, participation in post high school education, childhood obesity, being bullied, homicide,  .  Canadian youth scored poorest by having the highest rate of cannabis use in the past year at over 25%, and nearly 5% higher than the second poorest ranked country

Canada did score very well on educational achievement by age 15, and fruit consumption  ranking second, third lowest in youth smoking,  and seventh in exercise and air cleanliness.  There is a good discussion of the use of the Early Development Index in Canada as a best practice and its adaptation by Australia. 
The full report is available at UNICEF report on state of child

Another report card on gender equity from late 2012 is worth reviewing World economic forum report on gender equity that uses a similar approach to multiple indicators build into four dimensions.   This report ranks 135 countries and places Canada 21st, as well as providing multiple years for comparison.

The third report card that has garnished considerable interest nationally is the CBC Fifth estate CBC Fifth estate rate my hospital.  Disappointingly has been the reaction of the hospitals and provinces to the release of the information.   This is Canadian Institute of Health Information (CIHI) data that is provided to hospitals routinely, and perhaps finally when given to the media, a level of accountability might be attained.  Most hospitals have either used the data to make a statement of pride, or dismissed the data as not relevant to their service areas.  

Efforts to ranks and hold administrations, governments or providers accountability for their actions are to be commended.  It is only through transparency and public discourse will veiled problems be brought to the surface and addressed.  It was the efforts of groups that began comparing specific intervention outcomes between hospitals that led to quality improvement.  Such efforts were initially dismissed, and not are embraced as quality improvement efforts.  The big question, is our leaders big enough to stand up and embrace these reports as challenges to drive local and national improvement activities? 

Thursday, 11 April 2013

Public Health Plans make it to print in Ontario and BC

In the past two weeks, public health plans were released in Ontario and BC.  By the media coverage, it is obviously a noteworthy event as neither appears to have stimulated any public attention.   If you were to read both of these documents, you might think they were developed by sister teams looking at the same information.  Of course, that could be perceived as reassuring that within public health, there is concurrence on what we are trying to do.  Ontario Plan  and BC framework

On the other hand, it may also reflect that current deliverables are so short of the objectives that incremental planning needs to be laid out.  The documents are so broad that specific actions are so unclear that broad stroked high level plans are what is needed.   Neither document is earth shattering or remarkable new and could have been predominately written two decades ago.  While Ontario’s speaks of the need for big planning, BC’s was driven by a plethora of plans and a sense that a single overarching framework was needed. 

The good news is equity and reducing inequities takes a much bigger stage than previous documentation.   

Both touch on populations with greater needs or those that are exposed to greater risks.  While the language is politically correct, it is finally entrenched. 

While both seem comprehensive, look carefully at what is missing.  Both speak of the need for indicators that will be developed and what gets measured, gets modified.  The devil will be in the detail, and both documents lack those details. The BC plan provides for more specific short term targets, Ontario's a longer term strategic plan.  Ontario's directed at the public health community, BC's supposedly looking to a whole of government/society framework as the needed implementers.

They will make good overview documents for students of public health sciences as an introduction to the scope of work that needs to be done.  

The major concern with documents of this nature is the interpretation that these are the priority areas and anything not embraced in the plans becomes ripe for picking when resources get scarce.  

Monday, 8 April 2013

Discrimination, prejudice, racism and health status

Culture and ethnicity, biologic endowment and gender are all determinants of health.   They are all components on which individuals may be discriminated.  Hence discrimination and determinants are foundational in assessing health.

While visible minorities are  the mostly widely acknowledged and perhaps studied of the discriminating characteristics, religion has historically been one of the most divisive, and the one that perhaps has resulted in the most human suffering.  Centuries of bloodshed between Christians and Muslims from the crusades to ongoing civil strife in several countries today have demonstrated how characteristics other than gender and skin colour may profoundly affect our safety and wellbeing.

Canada’s record on gender equity remains relatively poor, despite premiership positions being held by women in the largest provinces and covering 85% of the population.   Currently ranked  21st and the US 22nd, the placing for Canada has slipped from 14th in 2006.   world Economic Forum gender report 2012  

Discrimination takes many forms.  The challenge to the reader is to determine if you are truly discrimination free.   At the extreme level, overt racism and acts of hatred are manifest.  Perhaps this interpretation of discrimination justifies many lesser obvious and potentially damaging acts.

Less overt are symptoms such as:
  • ·         Inappropriate Terminology: Using language that can be offensive, even where such language might be perceived as commonly acceptable. 
  • ·         Paternalism:  Addressing issues with paternalistic approaches where certain groups are involved
  • ·         Commission:  Disinterest in inequity issues suffered by specific groups.
  • ·         Avoidance behaviour:  Feeling discomfort or actively avoiding communicating or engaging members of the group
  • ·         Ignorance:  Lack of effort to become further educated on the traditions or issues facing a group.

In reality, we are all members of minorities and not only potentially the instruments of discrimination but also the recipients.   Think of the number of settings where your opinion or some personal characteristic causes a reaction because it is not carried by the majority, and the sense of disempowerment you feel when your perceptions are ignored or debased.  

Nationally and globally significant strides have been made in reducing the manifestations of discrimination – but given the impact on individuals and communities, it is an issue on which silence is not acceptable.  

Thursday, 4 April 2013

Avian influenza – preparing to take flight?

Attention has been drawn to southeast Asia once again for an emerging novel influenza strain.  The past few weeks have seen reports of now nine H7N9 influenza cases associated with three deaths.
April 5th update - 14 cases and six deaths. 
April 10th, 33 cases, 9 fatalities.
April 14th, 49 cases, 11 deaths
April 29   115 cases, 23 cases, 9 provinces in China and first case amongst a person returning from China.  

Historically H7 strains have been associated with poultry, and outbreaks of generally mild illness have been reported  since 1999 in at least United States (H7N2),  Italy (H7N3), Canada (H7N3), the, Mexico (H7N3),  United Kingdom (H7N3, H7N2) and Netherlands (H7N7).   The Canadian outbreak in lower Fraser Valley in 2004 resulted in widespread culling of flocks, but only two human illnesses, both mild and in occupationally exposed persons.

So the nine, non-epidemiologically linked spread across cities in four adjacent provinces in China, raise new concerns about the potential for broader dissemination.  WHO surveillance has improved since the first B5 bird influenza cases back in 2000, and augmented by SARS and can be tracked at http://www.who.int/influenza/human_animal_interface/en/  .

The H7 avian influenza is antigenically distinct from H5 bird flu that has continued to creep globally since 2003 and associated with over 600 cases but a markedly high mortality rate of nearly 60% amongst confirmed cases.  To date vaccine development has focused on H5 strains with candidate options similar to the adjuvanted pandemic vaccine used in Canada as the model. 

The good news from China is intensive investigation of case contacts have not identified others with illness and only two possible clinical cases which predated a confirmed case and virus was not identified.

While innumerable emerging viral illnesses occur with few progressing to illness, monitoring activity is a routine public health surveillance for which considerable depth and expertise is dedicated within Canada, US, China and most other countries – feeding into the global efforts of the WHO.

Follow the developments on Twitter #H7N9  

Tuesday, 2 April 2013

Canada's embarrassing intention to withdraw from global treaty on desertification and drought.

Canada again singled itself into global embarrassment by declaring its solo intention to withdraw from a 1995 pact that fights global desertification and drought.  154 countries are signatories to the efforts to mitigate the impacts, most of which are secondary to anthropogenic actions at the sites and through global climate change impacts which we all contribute to.

The Canadian rationale, is that the program is expensive and has not demonstrated value.  The decision was made behind closed Cabinet doors and not publically released.  Questions were to be directed to the Canadian International Development Agency which just had its funeral plans enshrined in the federal budget. 
And, just one month in advance of a major conference specifically designed to evaluate the impacts and benefits of the program. 

The total expense of being signatory to the pact was less than $150,000 per year for the past two years, put in perspective, that is just less than the base salary of one member of parliament,  or the supplemental salaries on top of this for two cabinet ministers. 

Perhaps the most condemning editorial comes from The globe and Mail April 1 and not an April Fool’s joke.  The Harper government is continuing its spiral from providing support to those in need and continuing to bolster corporate welfare. Having just recently announcing that the big six banks are considered “too big to be allowed to fail”, it has little heart for the failure of poverty stricken African Sarahan region countries who have already failed.

Droughts have traditionally accounted for 50% of extreme weather related deaths globally.   Since the 1990s and global mobilization on the issue, death rates have plummeted to less than 1% of the previous decades and accounting for just less than 1% of extreme weather deaths.

Desertification occurs in dryland areas, generally poverty stricken situations where some 10-20% of global drylands have already degraded to desert like conditions.  These drylands are home to a third of the global population.  The program supported by the UN convention summarizes the impacts and value of their work at UNEP desertification

Should we be surprised at the insane actions of the Harper government?  Probably not,  as is the health of the banking system not more important than global social capital?  Or perhaps it is the skewed view of blue suits unwilling to walk in the footsteps of those unable to afford shoes.