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Saturday, 29 June 2013

Canada Day - a time to celebrate: Our weather and its impacts on public health

Its Canada day weekend, and time to celebrate a country that regales in its diversity of culture and geography.  In a country filled with many riches, we routinely celebrate the diversity of the weather.  Canadian weather opens conversations across the country and brings us together across four and half hours of time zones, from ocean to ocean to ocean.  And the weather never ceases to amaze and strike awe.  

Our thoughts go to Albertans and others struggling to recover from under silt that has infiltrated nooks and crannies, including hundreds of homes.  With it comes the dreadful task of cleaning up after such flooding.  Tragically, but perhaps amazingly, only four lives were lost. The cleaning bill will be in the billions.

Then the awful reminder of the impacts of heat waves, with the loss of life of a two year old north of Toronto from leaving a child in a vehicle. The recent killer tornadoes in the US which took the lives of a couple of dozen persons to floods in India that have killed over a thousand are further reminders of the global weather threats that surround us.   

As we head into what appears to be a sweltering heat wave for parts of the country, with predicted record ever high temperatures in areas of the US, it is time to reflect and recognize that while we enjoy and revel in our diverse weather, it is a force of nature that requires reverence. 

Readers are urged to review the blog postings on the Canadian weather that kills  and the celebration of Canada’s contributions to Communicating the health risks of weather .   They remain some of the best documented materials on health impacts of Canadian weather and the heroic efforts taken to reduce risk through solid communications. 

Most of Canada will be able to enjoy sunshine through the Canada day weekend – do so safely in the sun, and safely with the reminder of how weather can suddenly turn a pleasant day into a tragic event. 

Sunday, 23 June 2013

Social engineering - case examples of government manipulated substance related issues

Most Canadian health professionals will have caught two key pieces of legislation tabled by the Harper government.   The first were regulatory changes to the 2001 Medical Marihuana Medical Access Program.   

Lest we forget, the original legislation was passed during the Chr├ętien years, so these subtle changes are unilateral efforts to address some legitimate concerns with the legislation, comply with the Supreme Court decisions on reasonable access to marijuana for medical purposes, and align the Harper regime’s tough on drugs mentality.

The outline of the changes are found at regulation changes .  Most notably is the opening comment “following broad consultation with stakeholders” .   The exact same words were used in a December 2012 press release.  The wording of the final regulation does not appear to be majorly modified from the initial postings in February 2012 – begging the question, other than stating that there was broad consultation – what was the real input from the health community?  While the normal public process supposedly was followed, there is not a public consultation document to be found.  

The full regulation can be found at legal text   

The second major announcement was the Respect for Communities Act linked to the Controlled Drugs and Substances Act, currently referenced as C-65.  The Act was introduced for first reading June 6 and its progress should be trackable at Parlimentary bill tracking  for the current house sitting.  At least the press release didn’t attempt to suggest communities had been consulted, only the Canadian Police Association has been given status in the release statement.  Very notably, no health organizations, local governments, or user groups are quoted.  Official media release .  The legislation effectively gives police veto status on such sites.  A power akin to public health officials vetoing the courts from applying mandatory minimum sentencing.   And, the later makes more sense as the evidence demonstrates ineffectiveness on all fronts. 

The similarly in these two processes is that for a government that is supposed to speak for the people, it is clear that not only is it ignoring the public, but it is using its massive public relations machinery to misdirect Canadians in a fashion that makes it appear that the Harper position is supported.  

In a society where our Constitution Act guarantees certain freedoms of expression and opinion, ensures reasonable judicial process, and provides for equality irrespective of disabilities – why are we tolerating social manipulation in the name of “good government”?  Public health has at times been accused of social engineering, however the textbook example of social manipulation is entrenched in the parliamentary halls of Ottawa.  

Wednesday, 19 June 2013

Refugee health globally and domestically – the reality does not reflect the Harper government depiction.

Refugee number globally have driven to the highest levels in over a decade and up nearly five times in just two years, driven by conflicts in Syria, Congo, and Mali.   In total some 43 Million persons are displaced individuals roughly two-thirds of who are internally displaced within their own country.  The past year seen 1.1 Million new international refugees.  

Host countries who are generous enough to share land and resources to accommodate displaced persons are led by Pakistan, Ethiopia and Kenya.  Through relocation programs, of the 11 Million international refugees, nearly 80% become accommodated in developing countries and in this respect the shining light is the USA which accommodates nearly two-thirds of refuges citizenship. 

Most refugees however have spent several years in living in accommodation of squalor, overcrowding and with the most minimal of health services.  The United Nations High Commission for Refugees (UNHCR) has developed a system for registration through placement that attempts to minimize health impacts and trauma.  

Yet, health statistics on those suffering the refugee process globally are hard to come across – there are many good examples of information from specific camps, but not aggregated. 

While the increasing numbers of refugees is a cause of concern, the work of UNHCR in keeping the issue relevant and on the agendas of countries globally deserves Nobel attention.  Read their annual report at UNHCR 2012 report   

Domestically, considerable attention has been given to the issue of the Canadian government reduction in health supports to refugees, many provinces or hospitals have quietly stepped in and assumed these costs.  The Canadian Minister of Citizenship and Immigration blaming the very victims of this international process for their plight.    Macleans report on Jason Kenney.   Such  behaviour should be considered unethical and most Ministers would be asked to resign.  

Wednesday, 12 June 2013

Alberta Health Board fired - what are the public health lessons and opportunities?

The interface between health boards and politics is fragile.   In a flash of merely hours, the entire Alberta Health Services Board has been dismissed, the provinces health system thrown into disarray and the foundations of years of construction razed with the swipe of a pen. 

At issue was an even more fundamental tension.   Governments have encouraged and support health taking a more entrepreneurial and business like approach to management.  Taking the direction to heart, the AHS built in pay incentives (aka bonuses) for senior executives (some 99 in Alberta).   The government directed the board to not fulfil its commitment to senior staff and the board refused.

When health boards become too strong and begin to exert power that exceeds that of their master, the master retains the right of execution.  In destabilizing the power structures in Alberta, government now has the opportunity to rebuild – and we all know during the process of rebuilding, expenditures decrease, planning comes to a screeching halt, and staff who lack of direction pursue nothing.  For a health system that was economically spinning out of control, and those costs driven predominately by unit delivery costs of which the vast component is compensation, this might be a logical step.

Might be because this is a province that has in the past made rash decisions without measuring its consequences – one of which led to the superboard.  It is also a province where eating a cookie in a mall can get you fired.   There are learnings for the whole of Canada that we can benefit from.

  • 1.       Health is inextricably related to politics in Canada
  • 2.       Health regions (school boards, municipal governments...) sit at the pleasure of government, so while government happiness is not a performance indicator, it is an important variable to consider.
  • 3.       Power destabilization is a highly effective mechanism for cost control and system control
  • 4.       During destabilized times, opportunities exist that the intrepid public health worker can monopolize on. 
  • 5.       During destablized times, risk is higher, but so is the potential gain.  Entrepreneurs truly understand the relative value of risk and gain – so if governments truly wish to bring a business attitude to health – here is the opportunity for innovators to shine.
Out of the ashes, the Phoenix will arise again.  More akin  is from Dr. Who, where in each incarnation, there is a different persona. 

Health boards were struck to act as a buffer zone between the public and front line workers, and politicians. Health systems are such an integral part of the Canadian culture, that they are the basis of loosing elections when tinkered with, and rarely the genesis of an election win. 

Good luck to our Alberta colleagues as they enter a period of chaos. 

Monday, 10 June 2013

Healthevidence.org - monthly update and can we scare youth from becoming criminals?

Healthevidence.ca, recently underway a revision and change of location to www.healthevidence.org, be sure to update your favourites. Monthly, a communication highlights the best of the synthesis reviews that have been added to their collection. For those not on the list, a smattering of the strong reviews for June are listed below with links that should work.  The downside of some of this, is that Health Evidence is going the way of Cochrane and publishing many reviews that disregard the value of the range of epidemiological studies.

The highlight of particular interest is on the effectiveness of programs to prevent juvenile delinquency, often through visits to local establishments of incarceration.  The main conclusion was that these programs were more harmful than helpful.  The studies however were all undertaken between 1967 and 1992 – begging the question why would such programs exist currently at all? Is this just a way of making the privileged classes feel good that they are doing something? It is a clear example of where programming based on fear, and programming entrenched in middle class beliefs and not program recipients views - are unlikely to work and can be harmful.    Juvenile delinquency prevention

Noting also that there is a reasonably good review as well on regulation change as an intervention to prevent aggression and injury in hockey.  

Review-level evidence on the effectiveness of public health and health promotion interventions:

Review Quality Rating

Friday, 7 June 2013

Screening for depression – shaky guidelines and more controversy with real implications for postpartum depression screening

The Canadian Task Force of Preventive Medicine recently released guidelines for screening for depression in primary care.   The current weak evidence does not support screening for either the general population or subpopulations which include postpartum period, family history, recent traumatic life events, chronic health problems and substance use. Canadiantaskforce Depression guidelines

More fundamental is that awareness of potential for depression should be included as integral in clinical evaluations remain supported.   Calls for additional research that actually look at randomized trials are integral to the recommendations. 

The Canadian recommendations are somewhat at variance to other bodies, but most have come to similar conclusions that clinical alertness is appropriate, that the screening is associated with high rates of false positivity, that systems must be in place for subsequent accurate diagnosis, treatment and follow-up.  The full clinical paper is accessible at CMAJ early release May 15 

Such a recommendation will undoubtedly shake the foundations of certain public health institutions that have been co-opted into routine postpartum screening for depression through the use of the Edinburgh tool or Whooley questions.  As with other well thought out recommendations for the Task Forces on preventative care, there will be the push back from those who believe that their practice is justified and should continue to be widely invested in and implemented.

Conversely that actual review takes a very narrow view of the current evidence and rejected most studies for poor quality – hence the overall conclusion of weak evidence.

There are a few lessons in this endeavour.  First, be sure of the evidence before implementing programs which appear to be of inherent good.  Second, before implementing widespread program and investment, find a solid evidence foundation that will stand up to rigorous scrutiny before shifting resources.   On this later point, public health has too often been the victim of well intentioned leaders and bureaucrats wishing to leave a legacy and demonstrate their contribution to the public good – at a very unfortunate cost. 

Monday, 3 June 2013

CIHI annual report - applying the equity lens

The Canadian Institutes of Health information are charged with reporting out on the health and wellbeing of Canadians.  Given the imminent death of the Health Council of Canada, CIHI will become the de factor form of accountability in the country, in a reality already are.  Of course, MacLeans does a better job of public communication, but dig into CIHI website for more data than you could possible internalize. 

The 2013 health report takes another step, and a cautious step towards reporting on population health in addition to facility performance. Credit to the CIHI team for recognizing and reporting on the continuum from health status, non-medical determinants of health, health system performance and the community context of the other three areas.  That CIHI correctly refers to the non-medical determinants is an added bonus and something readers should explore further DRPHealth Sept 16, 2011. However, they slide back into using the social determinants of health in the report body. 

The 2013 report looks heavily at socioeconomic status by neighbourhood in reporting health status. Not surprising, gradients are readily distinguishable in most of the measures reported on.

Appended are the details of certain health status information by health region or province – sometimes broken down by Aboriginal status, neighbourhood income quintile.

All in all, its 115 pages of data dense material which takes time to review the nuances.  But, just as a previous report emphasized preventable mortality and morbidity, this report lightly carries a subtheme that it disparity contributes across the continuum of the health realm, hopefully with the vision of moving towards equity.