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Monday, 23 September 2013

Fear and terrorism: Facing a new public health threat

It is the tool of terrorism.  It is not the bombs, nor the shootings – but the fear that what happened in a mall in Nairobi, or night club in Bali, or on the subway in Toyko, or office building in New York - could just strike the place where I live, shop, play or work. 

Fear invokes stress.  Stress involves a persistent elevated level of cortisol, and is associated with with a variety of short term and long term health consequences.  Insommnia, irritability, distraction, right through to reduced sexual desires.  Chronic stress invokes cardiac problems, changes in appetite, habituation to substances, withdrawl,  and may progress to manifest phobias that impair even normal functioning.

The global impact invoked by a tragedy like the Kenyan mall attack is far greater than the dozens who have been murdered and the over hundred who have been injured.  It will cause flashbacks to events that may have touched our lives, and for North Americans it is the collapse of the World Trade Centre. 

No, having flashbacks is not normal, it is a manifestation of the chronic fear being fueled. For some the flashbacks may be just recollection of memories, for others initiation of fear symptoms associated with the wake of an event that they are recalling. 

The infrequent but constant flow of terrorist events, the wide variety of locations affected, the broad geographic distribution must make many ask that fearful question “could I be where the next attack occurs”.

Having societies succumb to the fear is the very defeat that terrorism strives for. Lacking amongst the glorified media reporting of the event, are social efforts to help individuals grapple with the mental health consequences caused by such events and their glorification. 

Perhaps we wonder why mental health symptoms appear to be on the rise, and while terrorism is not the only cause, it provides a legitimate reason to have the discussion.

Canada’s aboriginal peoples are on their own healing process of truth and reconciliation, the culmination of a systematic effort to evoke chronic fear.  Perhaps we can learn from their experiences and share the successes as our world faces the faceless threat of terrorism. 

Thursday, 19 September 2013

Acid Rain, Air Quality and the Success of the International Joint Commission.

A good news story deserves praise.  Here’s one that gets almost no publicity. 

Back in the 80’s canoeists in Quebec through New Brunswick enjoyed sparkling clear water on lakes. 

Fishermen were out of luck and the trees were dying.

The cause was acid rain.  Ask yourself when was the last time you heard the term even used?

The response was a joint Canada US response that has morphed into the International Joint Commission.  The result has been bilateral substantive improvements in the precursors to acid rain, with recovery documented in many previously sterile areas.  A tribute to the governments of the day, the role of environmental groups to affect policy, and transboundary collaboration to solve a common problem.

Twenty years of the joint commission looking at a broader range of air quality issues documents some of these successes, identifies other beneficial gains such as reduction in precursors of ozone.  While the document is very self-congratulatory, it is rare to be able to line up and compare results from both sides of the border.  The long term trends for specific pollutants of interest are as well graphed as in any publication and worth perusing. 

The document does not speak to the improvements in health outcomes expected from the air quality work but based on the demonstrable improvements from the work achieved by this undercelebrated, underrated International Joint Commission.   Read the report at Air Quality Agreement 2012 report

Wednesday, 18 September 2013

Truth and Reconciliation's contribution to improving the health of Aboriginal peoples

Today opens the national event of the Truth and Reconciliation Commission meetings with sessions in Vancouver expected to draw thousands from across the country. And while there has been some attention from media, the event is not receiving the attention that befits its purpose, and not the same level of attention that has being paid by Canada’s Aboriginal peoples. 

It is in part about the atrocities of the residential school system, more generally about the dark Canadian history of Colonialism and how First Nations peoples were disempowered, abused and decimated.   A sensitive and enlightening review was provided in the Vancouver Sun

UBC went so far as to close their university system, a massive undertaking, in support of the event. 

Understanding the issues is the first step in healing.  Dialogue is the second.  The TRC process has helped with the dialogue and has attempted to build understanding.   We all have a role to become better personally informed. 

Most discussions of the reconciliation process cautiously avoid mention of how the current Canadian government has undermined First Nations, reduced funding for social programs, limited direct dialogue and systematically continued the century long process of neglecting the Crown’s commitments under the various Canadian treaties. It is propagation of the darkness.  

The good news is found in the considerable improvements in health, education, social and economic wellbeing that have been gained in the past two decades.   Aboriginal peoples carry the excessive burden heaped upon by centuries of disparity. It has taken over seven generations of systematic oppression to come to this point.  It will take many generations to complete the healing process.  

Become informed and join the dialogue.   Truth and Reconciliation Commission home page  

Tuesday, 17 September 2013

Peace in the age of atoms, chemicals, and guns

Syria has been accused, and apparently evidence demonstrates, the use of chemicals as part of warfare.  

Not surprising, it is just one of many instances where chemicals have been used in combat.  The global outrage is heartening and perhaps the prelude to a new round of disarmament.  Or perhaps that is merely optimistic thinking. A vision of peace is one we can all hope for and express. 

The modern age of chemical warfare was heralded in World War one with tear and chlorine gases used despite global treaties banning their use.  An estimated 85000 persons died at the hands of chemicals, with over a million others injured. 

Sulphur based Mustard gases became dominant in the 30’s and into WWII.  Tens of thousands died in Italian invasions in Africa, and thousands through the second world war.  Again ignoring a global treaty signed in 1925 precluding the use of gas in warfare. Japan utilized blistering agents in skirmishes with China though the 30’s.  Throughout WWII both sides utilized various forms of chemical warfare.

The US frequently used chemicals, namely herbicides , in Vietnam resulting in hundreds of thousands of infant deformities in addition to direct impacts. Again in violation of existing treaties.

Chemicals resurfaced in the 80’s war between Iran and Iraq killing tens of thousands on both sides of the war. 

Complacency with chemical warfare has been extended by most developed countries in testing, production, distribution and sales.  While use is supposedly precluded, only in upstream bans on production and research will progress truly be made.

While several countries have moved to reducing or eliminating military stockpiles, a pan-global approach to total disarmament and destruction has yet to be firmly attempted.

Perhaps in the wake of some 1400 Syrian deaths, such discussions might have a notion to start.

Then again, perhaps in the wake of another mass shooting using military weapons, gun control might take foot in the US.

It is only with hope and dialogue, that peace can be gained.  And peace, is one of the prerequisites for health entrenched in the Ottawa Charter on Health Promotion. 

Thursday, 12 September 2013

Income data released. What a shame - Statistics Canada has become a front for a political message.

Quietly Statistics Canada has delivered on their promised release of the third component of the National Household Survey, previously known as the census.  The last of the releases supposedly delayed by analytic errors  DrPHeallth August 2013 .

The highlights and high level detail are accessible at NHS third data release .   The local details can be accessed through the Stats Can portal at

Some observations,  and readers are encouraged to form their own opinions.
An excessive emphasis is placed on the valuation and attention to government sources of income such as old age security and employment assistance.
A clear emphasis that financial independence was more associated with self-employed income.
Avoidance of discussion of the maldistribution of income.
An emphasis on how those in the lowest deciles of income receive their income and how those in the highest deciles carry a disproportionate share of income tax.
Minimal analysis of the very high income earners who have been the target of poverty advocates -  data are presented by deciles only.

Who said that data is objective?   Most statisticians will tell you that data can be manipulated and presented in a fashion to convey specific messages.   Clearly Statistics Canada has presented a very biased selection of data and hidden information which those advocating for healthier distribution of resources would have found beneficial in supporting their arguments.  Even the detailed tabulations hide what is a mounting concern, the rich are getting richer and the poor are getting poorer Statistics Canada data tables  A small section on high income earners is buried in the national geographic data release buried below the provincial listing that reemphasizes the value placed on non government transfer income Stats Can national geographic data.   

That the data were delayed by an analytic glitch may remain the party line.   More likely the data were withheld so that the presentation format aligned with specific political agendas.  A further embarrassment on Statistics Canada, once revered for its independence, now a tool to support political agendas. 

Readers are encouraged to mine the income data and please comment on their interpretation of the findings.  For those daunted by trying to navigate the Statistics Canada website, access to various geographic aggregations of the data can be found at Focus on Geographic Series 

September 13 - catch the Globe and Mail analysis on how the National Household survey information on poverty is acknowledged as unreliable.  More evidence the government decision to eliminate the long form census was not based on protection of privacy, but a systematic elimination of social issues that federally can be ignored. 

Wednesday, 11 September 2013

Health regions, politics, power and chaos. Alberta as a case study

Anyone who has watched the antics of Alberta’s health authority structures over the years must be left with a sense of amazement, and some comic relief.  From CEOs running through malls eating cookies, to public inquiries into queue jumping, the symptoms of abnormality were rampant.  And that is just for those looking in from the outside, the stories from within the hallowed halls are truly astounding and DrPHealth would welcome some anonymous comments to share with across the country. 

Regional health authorities were designed for three purposes.
1.       To save money
2.       To depoliticize health care decisions
3.       Possibly, to improve health outcomes.

On the third of the outcomes they appear to have delivered reasonably well even though the evidence they would was meagre in the beginning. Albeit that despite the billions of dollars that rolls through their finance offices, formal evaluations on health outcome improvements have been incredibly scarce, almost making one believe that even the architects were questioning whether they believed they could deliver on improved care.

As for saving money, it was short term gain and very long term pain.   Professional unions have wielded their expanded power and leveraged salary increases that well outpace inflation.  And for the naive observer that looks at the increase only in terms of hourly wage and typical benefits, they represent only a portion of the gain.  Increased numbers of steps provide for much higher pay for persons with years of experience, few if any workers start at the first step of the wage scale any more, restrictions on who is offered overtime and extra shifts means those in the system have stuffed their wallets and purses.  Administrative wages have soared even higher though compared to individual hospital CEO’s in Ontario it would appear that executive wages have only been allowed to trot instead of gallop upwards.

Ah, but in the purpose of depoliticization there have been mostly clear benefits.   Health regions are the perfect dumping ground.   Provincial MLAs can point their fingers at the health regions, redirect complaints to the region, and for the most part advise the region that they have a job to keep health off the front pages.  The public have come to believe that health regions make all the decisions and they are to blame, hence the target of their fury.  

Governments do not win elections on health, but they sure can lose them.  Recent elections have left voters begging the question why was health hardly debated by any of the parties?   

So, what does a government do with a health region that is behaving badly?   Replacing boards has occurred uncommonly.   CEOs turn over with greater rapidity.  And, on occasion, government rides the white horse into the forum and destabilizes the power structures catapulting the region into a state of chaos from which their is blind hope that a better world will arise.  

Thus was the case in Alberta on September 10.  A purge of five senior and highly experienced executives as a prelude to trimming a few of the 80 VPs, (yes that is eighty vice-presidents).   Calgary Herald

Weep not for the senior executives, somewhere in their contracts are golden eggs that will finance a luxurious retirement, and they are likely welcoming the relief from years of executive decision processes.  Most will be gobbled up quickly because of their knowledge and experience.  More sympathy to the VPs who are much less protected and less marketable in the future. 

For the front line worker, or even middle manager (several notches below a VP in Alberta), the disarray results in decision gridlock.  Nothing will be approved and status quo will remain.  Chaos looms for another 2 years for an organization that has never really been given the opportunity to stand on its own two feet.  Budgets will be frozen and overall cost of the system will be stagnant.   Good people in health care, will continue to do good work with what they have. 

It has become clear that at least in Alberta, health regions are not meeting any of the goals of regionalization. Perhaps this is the precursor to finding a new way to preclude power silos developing in health. 

Thursday, 5 September 2013

Abortion access decreasing in parts of Canada - is there evidence of an impeding public health crisis?

Dr. Wendy Norman is taking on the country on an issue that many politicians and health care providers might prefer not receive any attention.  Its this lack of attention that is leading to a gradual and consistent reduction in access to pregnancy termination.

Abortion  providers are a threatened species, not just in feeling threatened in their lives, but fewer are taking up the curettes in support of women who are making a choice.  

The legal environment in Canada has been very stable for decades on the issue.  Consistently private members bills have failed in attempting to redefine life, restrict access, require counselling, or a host of other impediments and barriers that could be imposed on a woman who is making an informed and often difficult choice.  Even the most conservative striped leaders have learned quickly to avoid bringing the issue to the political forefront, a sign that such actions are not in the best political interests of the party.

South of the border, the predominant libertarian groups are the very ones imposing their personal values on others – inconsistent with their core ethic.  Amazingly in Canada, where social values are considered important in decision processes, respecting the decision of an individual have become appropriately entrenched.

So why have providers become scarce.  In a society which values diversity and respects personal freedom, it seems that on the issue of abortion we are less tolerant.  Peace abiding individuals, often with clearly defined moral standards engage in intimidation of both women seeking abortion and providers.  In many communities, the names of abortion providers are guarded secrets, and not uncommonly providers move between communities to provide pregnancy termination.   Homes have been vandalized, property defaced, and physical attacks. 

To be fair, most persons expressing their views in opposition of abortion do so in respectful and peaceful fashion – it is the few with extreme views that have engendered fear amongst providers.

Which leads to findings that Dr. Norman shares on how access is decreasing VICE blog posting   PLOS on line  and perhaps those opposing ‘freedom of choice’ for pregnancy women are being successful in reducing access.   Kudos to her for applying rigorous research methodologies to study a topic that many would shy away even though it is legal, permitted, and entrenched in our culture.

Thank you Wendy.

An important subnote to this is that abortion rates have been declining in Canada since the mid-1990s National Post November 2011 .  While fertility rates hit their lowest point in 2000 at 1.49 and have inched upward to 1.63 in 2011.  While birth control usage is not tracked, repeat surveys in high schools have tended to demonstrate both higher rates of contraceptive use in recent  sexual intercourse and older ages of initiation of sexual intercourse – both of which would contribute to overall reductions in pregnancy rates.  There has been some evidence in the last couple of years that these trends may be reversing and evidence of higher teen pregnancy rates has been reported Globe and mail January 2013

Tuesday, 3 September 2013

Back to school: A check list for healthier students.

September has arrived, and students everywhere have been scrambling to get back to school supplies and prepare for their great adventure.  Schools have become the de facto environment in which many of our youth develop their lifeskills. Hence optimization their chances for their future adult lives is a worthy investment.

Education levels are a strong predictor of adult health outcomes.   Those that succeed in school, are far more likely to succeed in employment, income and health status.  So tightly linked is the relationship that education is itself considered a determinant of health.  It is a modifiable determinant, and one that can be intervened on and measured. 

In sending our children back to school, there are lists of what to be sure students have.  A scan through multiple sites provided diverse recommendations, but some solid advise:

·         Immunizations are up to date.
·         Provide hand sanitizer and reinforce handwashing hygiene
·         Make water readily accessible and avoid sugary drinks and juices.
·         Lunches are healthy (and kids probably don’t need snacks if adequately fed)
·         Provide support to anxious children
·         Be sure vision, dental and general health have had routine care.
·         Help carry school materials safely in quality knapsack or rolling bag.

This positing is about what we in public health should be doing to ensure the elementary school environment is healthy:

1.       Does it provide both breakfast options and lunch programs?
2.       Are students scheduled to receive daily rigorous physical activity?
3.       Is there a healthy food, snack and vending machine policy?
4.       Is access available for handwashing or sanitizers in every classroom?
5.       Does the school participate in a comprehensive school health initiative?
6.       Does the school district have a healthy schools committee of the board?
7.       Does the school promote curriculum that address Healthy lifestyle choices?  Healthy relationships? Healthy preparation for adulthood?
8.       Is the school setting safe?  (Play equipment meeting CSA standards, fenced,
9.       Are the travel paths to the school secure (lighting, marked or attended crosswalks, avoiding main throughways)
10.   Are there health policies to address:
o   Management of emergency health conditions
o   Management of chronic health conditions and medications
§  Students with bloodborne infections
o   Violence, bullying, racism, discrimination
o   Behaviour concerns in classroom
o   Disabilities in students
o   Overweightness in students

In the middle and secondary school environment the needs become even greater, with:

·         Policies needed to address truancy, crime, violence, drug and alcohol use.
·         Programming to support healthy sexuality, pregnancy, child support to keep students in school, counselling for substance use, counselling for mental health conditions
·         Therapy for students with developing illnesses
·         Treatment for students with developing overweight and obesity concerns

A brief scan did not find a clear cut list for schools, additional submissions are welcomed through drphealth@gmail.com and perhaps we can provide public health staff going into schools (where they still go to schools) with something concrete to take in hand.

Our southern neighbours have mandated school nursing, and while the issues of the school nurse are different, there is a focal point for health issues in schools.  Canadian public health programming sometimes fills that gap, and sometimes neglects our future generation almost totally beyond checking on their immunization status.

Check out the Canadian Association of School Health or any of its diverse provincial partners.  There are a plethora of resources typical of educators, what is often lacking is the leadership or belief that student health is a priority for schools similar to the traditional three “R”s.