Welcome to DrPHealth

Please leave comments and stimulate dialogue. For those wanting a bit more privacy or information, email drphealth@gmail.com. Comments will be posted unless they promote specific products or services, or contain inappropriate material or wording. Twitter @drphealth.

Sunday, 30 March 2014

Air pollution kills 7 million annually, one in eight global deaths. Fact, fiction, fallacy or fantasy?

The WHO caught a bit of attention when on March 25th it announced that there were 7 million deaths annually from deteriorated air quality due to air pollution.  That is actually one out of every 8 deaths globally every year and the largest single environmental cause of death.

Fact, fiction, fallacy or fantasy?

Foremost is the fact that air pollution kills, and kills more people that we have tended to acknowledge in the past.  The increased levels of mortality are in part due to increased pollution, particularly in the Indo-China region where rapid development has not been linked to pollution control measures that have benefited regions like Europe. 

Increased numbers are due to an increased recognition of the role of air pollutants in activating inflammatory cascades that contribute to heart attacks and strokes.

Further contributing to the increased numbers are better measures of exposure and the ability to model exposures where measurement is not readily available.

The fiction in part is the headlines read as if these are societal pollutants, whereas nearly one-third of the deaths are due to indoor air pollution, the most common cause being inefficiently and incomplete combustion in cooking and heating fires.  Interventions are possible at the individual level, where outdoor pollution is controllable only through societal level change.  While those individual interventions are achievable, they are not achievable without concerted effort and affordable cleaner wood or coal burning indoor appliances.

The fallacy component comes through in that of the 7 million deaths, 5.9 are linked to SE Asia and Western Pacific areas (Indo-Chinese corridor), an area that represents at most 60% of the global population, putting the risk for inhabitants substantially higher than any other region.

Sadly, there is no fantasy in this story.  Without drastic and immediate intervention, air pollutants will continue their rapid increase in developing countries that rely on organic fuel consumption for electricity as well as basic needs like heat and cooking.  Read the WHO story, including the attributions of death by location at WHO media centre

Finding trends in air pollution levels in China is not easy, however there is some reported at Pollutant trends for China. The report at least demonstrates the rapid short term increases in the middle of last decade.   Information from India is even scarcer.    

While it is easy to decry the increased pollution, it was noted in global summits on climate change that developing countries were being penalized by expectations that developed countries could not (would not) achieve and concurrently would stifle economic expansion integral to a community vibrancy that supports health.  

Wednesday, 26 March 2014

Obituary for the Canada Health Accord. The death of an ambitious public health care agenda

On March 2014, a decade old pan-Canadian accord on health will expire and quietly turn to dust.  There will likely be no funeral, no testimonials, no accolades, merely the turning of the clock to a new relationship.

The 2003 accord on health care reform  laid out an ambitious agenda for health care reform, with some benchmarks to demonstrate value, and a price tag well in excess of $100 Billion.  The agreement was signed by then Prime Minister Chrétien leading the liberals who three years later lost to the Harper-led conservatives and the start of a slow waning death of collaboration between the provinces and federal government on health.  The demise of the Health Canada of Council is another victim of the lack of sustained federal commitment Obituary for the health Council of Canada

In its defense the accord has achieved certain changes.  Primary health care has once again being re-positioned as a driving force in the health care system, although another decade or two would be required to achieve the sorts of reforms needed to support a sustainable health system.  Improved accessibility to general practitioners has been measured over the last few years. The Canada Health Infoway has made significant strides in modernizing the electronic health record structures but falls short of comparable systems in other countries.  Patient safety has perhaps benefited the most over the last decade from the added attention through initiatives such as Safer Healthcare Now.  Aboriginal Health has come closer to receiving the attention that eliminating the disparity deserves. 

Accountability was a major theme in the 2003 accord.  The Health Council reports HCC reports , combined with a focused approach by CIHI CIHI indicator series  , and annual reporting by the Chief Public Health Officer CPHO reports  of Canada amongst others has contributed to a better understanding of what is and what is not working.  If only more would listen. 

Unfortunately many initiatives are only partially implemented, half complete, and areas like public health that were predominately ignored have fallen to the reform wayside.  For the provinces, there is a significant health transfer component that was linked to the agreement that also expires. With no renewed agreement in the works, provinces and health care workers may only begin to appreciate what the 2003 accord achieved.   At what cost both financially and in terms of lives remains to be seen, and likely will not be adequately documented.

If there is an opportunity for a newly defined relationship, there is currently no open dialogue occurring, and the signals from parliament hill have repeatedly alluded to a federal government slinking away from a cornerstone of Canadian society - universal health care.

We can only hope that the 2003 accord does not rest in peace, that the ghosts of the past arise to haunt and provoke the leaders of this decade into some form of resurrection. 

Monday, 24 March 2014

Obituary for the Health Council of Canada: Where does public health care go now?

It is somewhat of a distorted honour to be allowed to write one’s one obituary, but the Health Council of Canada has done just that in its final report before funding is eliminated on March 31.  In the 2003 pan-Canadian health accord which is also set to expire, the council was formed.  Those accords have perhaps begun to turn the direction of the health care system with a re-emphasis on primary health care and the Health Council of Canada was charged with monitoring that progress.

In its final report to Canadians, it outlines what it sees as accomplishments in its short life. Perhaps it might be better viewed as a short history of Canadian Health Care for the past decade as it richly touches on the pressing issues of electronic health records, pharmaceuticals, primary health care, home and community care, telehealth, wait times and access, aboriginal health  and patient care and safety among others.  Read the report at Highlights of health care reform  

Two areas it perhaps failed in were in the mental health and addictions (perhaps because of the Mental Health Commission of Canada having taken a lead) and Public Health.

The passing of the council is perhaps the most tangible and obvious change associated with a more disconcerting situation.  It marks the extraction of the federal government from any formal involvement in health with some minor exceptions.  International issues, quarantine at the borders, federal public services and federal lands, and First Nations under treaty.   Noting that even for First Nations the federal government is slowly divesting itself of long term responsibility through redefined relationships with the First nations and provinces in what may be a constructive change.

To those who served on the Health Council of Canada, our heartfelt thanks.  Given the lack of attention, the relative dismissal of its work, and the strained relationship with the federal government, it persevered and leaves a legacy that others will have to live up to.

Most importantly though, it was the only body in place that attempted to hold the system accountable through cross jurisdictions comparisons.  That function falls to the wayside and the system once again becomes accountable only to itself. 

Wednesday, 19 March 2014

The Moose is Loose Again – Measles fever

BC is grappling with an outbreak of measles amongst a community which chooses not to immunize because of secular interpretations.  The community is wellknown in public health circles, and has been steadfastly adherent to those beliefs through multiple outbreaks of vaccine preventable diseases.  For the most part, the relatively insular community has limited transmission to neighbouring communities and their cooperation with public health professionals is an unwritten story of successful application of basic communicable disease control.  

Perhaps that is changing as this outbreak seems to be contracting more attention and in typical measles fashion – it is spreading.  Over 100 BC cases to date have been identifying with recent cases outside of the index community. Note that disease numbers will augment quickly and are only provided for the date of posting and should not be relied upon. Not to be ignored, there are similar importations noted in a related religious community in Alberta, and cases are being reported in PEI.  Sporadic cases in Ontario and Manitoba are also noted with no intent of being all-inclusive.

Concurrently Los Angeles County has reported a cluster of some 32 cases – several of which are linked to the Phillippines where thousands of cases have occurred and dozens of deaths since late 2013.   The country is currently engaging in a vaccination blitz trying to reach over 2 Million residents.

Exportation from the Phillippines has led to cases in Taiwan, other SE Asia countries and the UK.
While there doesn’t appear to be a clear link to the Phillippines, the outbreak occurred in the wake of typhoon Haiyan in November 2013.   Recall massive international aid efforts were mobilized, and the Phillippines became the centre of international relief, with innumberable aid missions, many originating within religious communities. One of which likely donated the unwanted scourge of the measles virus from a well-intentioned aid worker. 

A measles outbreak started in May 2013 in a related religious community in the Netherlands where over a thousand cases occurred and nearly a hundred hospitalizations by August Eurosurveillance report.  Careful detective work would likely uncover a link between between outbreaks, and given advances in genetic epidemiology, it will only be a matter of time before clarity on how at least four continents are now juggling with significant increases in measles activity.

See the previous posting on measles in Canada and why this is not a real surprise Moose is loose

Welcome to the global community. 

Sunday, 16 March 2014

Sugar by any other name would taste as sweet, and be just as deadly

The WHO is undertaking an unusual step in going to a public consultation regarding proposed sugar guidelines.  Invited members of the public can submit comments  by March 31.  Unlike most of the media attention that suggests the guidelines are a fait á complet,, there is still opportunity to contribute to a global effort.   Keep the link to follow the progress.   WHO sugar guideline consultation

Interestingly, one must submit a 4 page declaration of interest prior to registering as a commenter, and further the recommendations are only released once the declaration is completed.  The key recommendation that has received attention is that no more than 10% of caloric intake come from sugar and consider reducing this to 5% .  For most of us, the 10% is approximately a 50% reduction from our current diets.  By the way, the WHO already adopted a 10% guideline back in 2002 and presumably the fuss is about the reduction to less than 5%.

Why all the secrecy? (and if anyone has leaked a copy of the guidelines on-line, DrPHealth would be happy to post a link).  There is enough concern and evidence of the past history of “Big Sugar” on impacting dietary guidelines, and even leading astray on a path of expanding girths.   Link back to DrPHealth the Men who made us Fat.  In truth, throughout the several years of postings on this site, sugar has been added to many pages, and not to sweeten the material.   The first of these, a post Number 15 Sugar, how sweet it isn't  closed with a call for action

… where is the dialogue on how can we systematically reduce caloric intake through changes in how we prepare foods?   For our society that is expanding at the waistline, tough choices will need to be made on how to revert to sustainable and healthy diets.  Leaving it to consumers to "choose" the healthy option is abandoning our neighbours - something a civic society would not consider acceptable.    

The food industry will be the barrier and there is no evidence they are interested or willing to respond.  And while the WHO guidelines are a progressive step – we already have a government unwilling to move on salt limitations on processed food.  With such sourpusses in power, they need their sugar coating to have even an allusion of sweetness.  

The revised guidelines are a step, and only a baby step until stricter requirements are issued on marketing of higher sugar products just as such limitations were required  and effective in reversing the trends in tobacco consumption. 

Sunday, 9 March 2014

Celebrating gender equity, while reflecting on the gap that still is to be closed.

March 8th is International Woman’s Day  - it was a chance to reflect on progress and shortcomings of efforts to achieve gender equity. 

While major strides are obvious over time periods of decades to centuries, the gaps between genders remain unacceptable.  On the surface from a health perspective, women enjoy a five year advantage over males, a gap that was greatest at 7.5 years around 1980 and has slowly been decreasing while both genders have continued to enjoy steadily increasing life expectancy.

The UN Development Program produces occasional reports on human development, the site is a wealth of data and international analytic information.  The  most recent version in 2013  continues just a three year tradition of reporting on gender inequality (page 158).  Northern European and Scandinavian countries  lead the index with the Netherlands, Sweden and Switzerland holding the top three rankings.  Canada places 18th, the US 42nd  Where Canada performs well is equal and high rates of secondary education in both genders.  Performance is average on labour force participation with 71% of males and 62% of females over 15 in the labour force, average on proportion of national government seats held by females (28%), poorly on teen fertility and maternal mortality. In all categories Canada preforms better than the US. 

A key policy direction in Canada has been towards pay equity, with several provinces implementing formal direction such as the Ontario Pay Equity Act of 1987.  However, progress has been slow in decreasing the gap.  The Conference Board of Canada has an excellent site monitoring Canada’s progress and international ranking on gender income gap, reported in 2010 as having slowly dropped to 19%  but only ranked 11th of 17 peer countries and on par with the US performance. 

A closing note on equity in executive positions which has gained prominence of an indicator.  The Human Resource Council of Canada reports on diversity and makes specific note of the differences between non-profit and for profit sectors, with women having a majority of managerial roles and overall jobs in the non-profit section although disproportionately less managerial positions by 6%.  While women constitute just less than half of the workforce in the for – profit sector, they hold only just above one third of the managerial roles.    HR Council diversity

A far cry from the pre-60’s eras from which women’s liberation movements and feminism arose, and a far cry from countries where women remain repressed and precluded from social inclusion.  Nonetheless the goal of equality is one that deserves celebration and a reminder that we have a long way to go

Wednesday, 5 March 2014

Assessing Minister of Health Ambrose's first 8 months in office. Not even close to a passing grade

Minister Ambrose has been in office for 8 months and it makes sense to evaluate her performance to date. 

What performance?

Fifteen public messages, aka press releases, only one of which relates to Ministry business, the remaining fourteen reiterated disease specific days, weeks or months.  

She has a similar number of public appearances with Ministerial statements, most if fairly neutral topics and neutral to right wing territory.  She has grappled with only one small crisis, namely a minor blip in drug continuity supply.   She has only released one minor funding announcement, and minor policy announcements at best.

She currently has the following legislation on the order table

C-2 an act to amend the Controlled drugs and Substances Act which is the latest iteration of the legislation to lay out the conditions necessary for supervised drug consumption sites (previously known as the respect for communities act which died on the order table)  DrPHdealth July 2013 , further restricts access to currently illicit drugs, and tightens up rules for medical exemption presumably for medical marijuana users  

C-17 to amend the Food and Drugs Act which appears to tighten up some loopholes in therapeutic devices section and provides widespread ability for the government to utilize regulations for the management and control of substances, devices and therapies under the act.

The relative value of the two pieces of legislation can be taken for their worth.  The first is more likely more anti-health than protective of health.  There were no health pieces of legislation passed during the first session of the 41st parliament.

Hence we are faced with the formula for longevity as a Minister of Health, do nothing, say nothing and be seen nowhere.  (see New Minister of Health DrPHealth July 2013)    By these criteria her performance is very in line with what was anticipated on all five predicted measures.

By any reasonable Canadian assessment of a Minister of Health, her performance to date would be considered a dismal failure.

Not surprising given the régime that she is working within. 

Monday, 3 March 2014

Redistribution through taxation improves economy and reduces inequality - says IMF

When the Occupy movement suggested striving for equity by redistribution from the 1%, they were for the most part dismissed, and rudely evicted from their camps.

So when the International Monetary Fund suggests that increasing taxing the rich and striving for equity, will the political community begin to listen.  Not only is it recommended, but the IMF comes out suggesting that it is healthy for the economy, CBC report .  And while conservative journalist like Huffington Post are quick to find the faults and shortcomings, even they acknowledge that there is some basis in the discussion.  Warren 
Buffet has added his voice to the need to increasing taxation of those who are economically privileged.    

While the study is authorized by the chief economist, it is referred to as a staff discussion note and not a formal position document, no doubt in recognition that many heavy hitters on both sides of the border will not take a liking to the message.  The methods draw on accepted economics approaches and rely heavily on the use of the Gini coefficient. 

There are some interesting discussions by the authors at the IMF home page, and the full document is accessible Redistribution, Inequality and Growth.  Kudos to the IMF for taken aim at an analysis of the traditional ultraconservative thinking that taxation is bad, and that economic growth is driven by those with the most resource investing in the economy.    

Don’t expect current fiscal policy to shift quickly, however such work will fuel opposition parties looking for a niche that appeals to the public, and focusing attention on tax increases for those in financial power positions will be an attractive position for the 90-95% of the population who have household incomes less than $100K

Not that this is news either, the Conference Board of Canada discussed late in its paper on income inequality how tax redistribution was failing in Canada  because of changes to taxation policies. 

As the evidence begins to mount, heads will start to turn.  Those who currently have money and power will not readily give up either.