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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.