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Wednesday, 30 April 2014

Public Transit - moving the masses in a sustainable fashion. Transportation and Health Part 4

New Yorkers have turned the tide on obesity.  And while the aggressive approaches to trying to limit trans fats, lower consumption of sugar filled fluids may seem obvious solutions, one of the major reasons is that New Yorkers are walking more.  Just as European cities have increased density, so to have some US cities.  Encouraging commutes by efficient public transit or even just walking a few blocks.  The advantage of the transit, is most commuters walk to the local transit stop to start their commute, and subsequently finish the commute with a walk to their final destination. 

A well written and detailed paper out of New Zealand has documented this impact with the average increase in daily walking by about 1.2 km for public transit users.  Public Transit trips offsetting an average of two car trips daily and 45 km of vehicle travel.   New Zealand analysis of public transit

While some cities have made transit the easy solution, many still cater to the car.  The greater the density, the less the dependence on vehicles.  And, as transit riders know, the shorter the distance to commute the more comparable various forms of transit become relative to time spent on the commute. 

Youth today are decreasingly obtaining the time honoured measure of adulthood – the driver’s license.  Seniors may have their licenses revoked or limited.  A variety of medical conditions also push commuters to public transit including such things as seizure disorders, recent cardiac events, not to mention the plethora of reasons why driver’s licenses may be suspended for driving infractions.  Hence at any given time, a significant fraction of the population is being actively steered towards the public transit system.

Canadian data on transit ridership are dated, based predominately on the Households and the Environment survey of 2007.  The highest proportional use of public transit being in Manitoba, BC, Ont and Quebec, all of whom saw ridership in the 40-45% range where transit was readily available.  Ridership being highest in youth and young adults, and in lower to low middle income brackets.  Over 2/3rds of Canadian households indicated that they lived within five minutes of public transit, with 40% using regularly.  Public Transit in Canada 2007

Perhaps the unstated question is given that public transit is comparable in use to the car by volume of commuters, why hasn’t transit received the same level of public infrastructure investment that arterial roadways and bridges have.  The answer is found in the demographic profile of the transit user. Younger, lower economic likely more ethnically diverse and a higher proportion of new Canadians.   The very antithesis of the profile of the typical voting public.  Hence roads to service the car may become central to political aspirations as a method of vote purchase.

Monday, 28 April 2014

Moving to active transportation: A Public Health winner: Transportation and Health Part 3

To facilitate the shift to more active forms of transportation requires tangential thinking that puts the fuel driven vehicles to the side and accommodates a variety of forms of transport.  Few would question the need for sidewalks to keep pedestrians safe.  Now consideration must be given to not only the time honoured bicycle, but also bladers, long boarders, scooters, golf carts, and whatever novel means of active transport that innovation may conceive (rickshaws, snowshoers etc….)

The current discourse focuses on accommodating cyclists has learned much about how to make cycling safer.  The more cyclists, the safer the streets (check out the Washington Post ).  Ideally, physically separate lanes dedicated to cyclists alone.  However, even road lines help, and some physical barrier like cones or even tin cans make the separation safer.   The downside is the cost of road construction and maintenance for distinct lanes.  Moreover, accommodating cyclists only does not address the need for sharing the road with bladers, boarders and other newer forms that also quality as active transport. 

Wait though, this thinking assumes that roadways should be primarily constructed to support increasing vehicle capacity. It turns out, and has been shown in enough locations, that decreasing vehicle access, decreasing vehicle use, decreases congestion and increases active transportation.  So why do we continue to politically cater to the whims of the vociferous drivers insisting on pouring public funds into the very infrastructure that clogs up our body’s arteries? 

In 1969 supposedly 12% of students were driven to school.  By 2012 only 12% of students were walking to school.  In Canada merely 2% of students bike to school, in Denmark, Netherlands and China that proportion is 40-50%.  In the US, it is only 1%.  The latest trend being the re-establishment of the walking school bus.  Accompanied by adults along set routes and times, students join the “bus” on the way to school.  A pleasant retreat back to active mode of animating youth into physical exertion as part of the daily routine rather than just part a course of physical education. The added advantage being the inherent social networking that collective commutes share.  

While scooters may not seem a form of active transport, for the disabled, elderly and shut-ins, they have reopened access to the outdoors and increased mobility for those that might otherwise deteriorate more quickly.  Although the limited evidence available suggests that scooters contribute to more rapid decline, the research is at best limited to draw conclusions.

For those diehards cyclists that have never hung up their helmets, those experimenting in long boarding or thinking of trying some new mode of transport they remain the innovators that take risks and suffer the consequences. While overall safety profiles have tended to improve over time, where active transporters and cars collide, the car rarely is the loser. 

There is much to be learned from the global analysis of what many other countries have learned, investing in public transit and active transportation results in decongestion of the roadway and improvements in individual health – what should be a winning combination.  Long term sustainability of our communities actually depends on it.  More information on sustainability in transport planning can be found at http://www.embarq.org/ with a specific analysis of Saving Lives through sustainable transport  an excellent monograph on the migration away from car dependence on roads.

Those interested in learning and following more on trends in transportation, check out Twitter @BrentToderian out of Vancouver. To review past tweets is in of itself an education in transportation planning. 

Thursday, 24 April 2014

Cars: Our love and addiction to the vehicle may be making us sick. Transportation and health Part 2

Traffic.  We all hate it, we all want it fixed.  But how is that best done?  And why is a Public Health blog talking about traffic congestion anyway?  What’s public health got to do with it?

The basic transport unit has become the car.   Canadians currently own about 1.5 cars per household, or some 21 Million licensed vehicles on the roads.   In support of the fossil fuel dependent engines a massive oil and gas infrastructure has developed, some 900,000  km of roadway have been developed, Unlike  raising a family, Canada’s 24 Million licensed  drivers are expected to be trained, licensed and continue to demonstrate competency.

Regrettably some 2000 persons die each year from motor vehicle collisions. The good news is that the number that has been decreasing over the past few decades, as have serious injuries and all injuries.  The reasons engender speculation from reduced distance traveled to greatly improved engineered space for occupants of the vehicle (seat belts, air bags, structural integrity). 

Beyond the obvious of motor vehicle crashes, is the insidious impact that vehicular dependence has imparted to waistlines.  The average Canadian now commutes 25 minutes in either direction to their place of work.  That is nearly an hour of sedentary activity per day.  The dream of a single home in the suburbs has become the nightmare associated with overweight.  Not that the car is the sole contributor to the expanding girth, but in places where vehicular commutes are being replaced by active transportation, weight reductions and better control are being documented. 

Innovative approaches to maximize the use of the single vehicle have included rides-sharing (car pooling), high occupancy lanes on major commute thoroughfares, and car sharing.  Of these only car sharing invokes an increase in active transportation as access points to the jointly used cars often require a short walk to parking locations. 

Collectively road transportation accounts for three times the total global contribution of the transportation sector to greenhouse gas emissions.  In Canada road transport accounts for 18.5%  of all emissions. The total contributions of greenhouse gases being a small piece of the story of the contribution of road transportation to airshed contamination from fine particulates, diesel and carbon particulates, ozone, and nitrous oxides.  While efforts to reduce vehicle related pollution has been successful, much of the individual car gains have been onset by the increased population use of vehicles.

And by design or just human nature, housing which is in proximity to roadways tends to cater to lower socioeconomic groups and are avoided by those with wealth to purchase quieter settings.  This contributes to poorer health outcomes amongst those in proximity to more pathogenic pollutants pollutants such as diesel and carbon particles that are relatively reactive and disperse with distance from the roadway.

Two areas receiving more recent attention relate to the impact of road transport on noise, where noise is seen by some as the major contributor to increased stress amongst nearby residents and as much or more of an issue for health impacts from pollutants in its contribution to cardiac outcomes from chronic stress. The second area relates to the mental wellbeing, and while noise is one contributor, increasing evidence speaks to the chronic stresses associate with prolonged commutes.  While some drivers may enjoy a stressfree music filled commute, many commutes are associated with stressful driving conditions and the long term impact of such commutes is showing its wearing effect.

The future of the car speaks to increased automation, safety improvements that may reduce impacts on those hit by a car, shifting dependence on non-renewable resources to renewable energy use and cleaner fuels such as natural gas – little of this speaks to the need for treating the addiction and reducing our dependence on single-person fossil-fueled transport units (the car)

Tuesday, 22 April 2014

Transportation and health: Part 1

This series of issues will tie together some of the current thinking on the interrelationship between transport and health.   Similar series on the interrelationship between health and the built environment (April 30 – May 7th 2012 Part 1) ,  Oil and Gas (Synthesis posting Dec 27 2013) , and Weather and health (Jan 24, 26, Feb 13 2012).

Every day billions of people move from home to school to work and to play.  It is part of our nomadic nature to move.  The average Canadian commutes 30 minutes in either direction from home to work/school and back.  That amounts to the equivalent of two weeks of each year of our lives omits trips for shopping, socializing, recreating and vacationing. 

Yet, the impact that changing transportation technologies have had on our health has received relatively little attention.   Sure enough there is a journal of Transport and Health that released its first issue in March 2014 Journal of Transport and Health , and the European office of the WHO recently released a monograph that is worth skimming for a more in-depth analysis Transport, Environment and Health

The five sections will look respectively at:
1.       Introduction
2.       Whither goes the car?
3.       Planning for active transportation
4.       Public transit
5.       Mass transit

With outcomes of interest related to equity geographically and economically, stimulating physical activity, reducing air pollution, mitigating climate changing, noise, mental wellbeing, social support,and  injuries.

As the definitive monograph on all potential impacts of transportation on health has not yet been written, consider this as an opportunity to contribute by commenting and responding.  Of special interest are those health impacts not identified in the discussion. 

Sci-fi enthusiasts will appreciate that futuristic forms of transport such as teleportation, antigravity devices, warp speed, among other imaginative and currently implausible mechanisms, all seem to inherently be presented as wasteless, environmentally friendly and predominately without impacts on health.   Lacking such visionary guidance, where do our current modalities steer us?

 Follow over the next two weeks as we explore the linkages between transportation and health. 

Monday, 14 April 2014

Foodborne illness – CBC grossly overexaggerates restaurant related illness. How common is it really?

CBC’s Marketplace has been running pieces on foodborne illness as related to restaurants.  Central to their arguments are that there are 2 Million episodes of foodborne illness each year related to restaurants and lay claim that this number comes from Health Canada Marketplace reports on food safety .  The report then does a wonderful job then of analyzing restaurant inspection reports for five large Canadian cites.  A job well done.

PHAC reports that one in eight Canadians experience an episode of foodborne illness each year or about 4 Million cases.  Marketplace suggest that Health Canada reports 50% of episodes of foodborne illness are restaurant related.   In digging, this was not a number that was confirmable (any reader who can find the primary source please leave a comment).  There is a report by the other CBC (Conference Board of Canada) on food safety that references 50% of “where the source of contamination or the location of consumption is known”. Conference Board of Canada documents can be accessed from their website on registration. This references an article in the Journal of Food Protection which could not be accessed  but raises many questions. 

As such the CBC has initiated a myth and elevated the severity of the problem to a level much greater than it may actually be.

DrPHealth analyzed foodborne outbreak and restaurants noting that only about 0.01% of cases of foodborne illness are associated with defined outbreaks.  DrPHealth August 26 2013.   Hence there is a major disconnect between the CBC report of estimated number of restaurants associated illness and reported outbreak cases, even if assumed as 1%.   Remembering back to the Conference Board document on which the CBC has based its estimate of 2 Million, the 0.1-1% are the limited number of known sources of foodborne illness – suggesting closer to 40,000 cases that are restaurant associated illnesses per year.  The reality is this is not a clearly identified number. 

PHAC has produced some documents on the estimates of foodborne illness in Canada PHAC food safety. Of note, the major organism for food borne illness now being recognized as Norovirus causing two-thirds of foodborne illness.  Norovirus can be associated with contaminated fomites (serving spoons at buffet tables are a favourite examples). 

Notable also in this discussion was a revision of estimated foodborne illness estimates that previously had suggested one in three Canadians per year and have been reduced to one in eight.  Estimates of foodborne illness in Canada .  Previous exaggeration of the numbers contributes to the suspicion one should bring to the table regarding the current estimates of restaurant attributable illness.

In the wake of significant cuts to CFIA, reductions in Health Protection programs, and increased autonomy of environment health officers over food-related issues, there is an agenda that is unstated in respect to the credibility, accountability and role of public health inspection.

Not that any of us wishes to eat at a facility that does not adhere to the strictest of food safety guidelines and the Marketplace reporting identified innumerable hazards of concern in many large chains. 

Public Health has a duty to be objective and state the facts.  The Marketplace reporting sensationalizes a legitimate concern, but one where there is a large expenditure of dollars in the regulatory environment which might be questioned if the facts were presented without bias.  

Friday, 11 April 2014

Influenza antiviral debate - is there a benefit? or "take a pill already"

This week saw the release of an updated review of influenza antiviral therapy and suggesting that such drugs have limited value.

The following are two reviews, sent by different individuals, which challenge or affirm the media interpretation of the documents.   Both are worth reading and provide that deeper level of insight that readers should seek when faced with trying to figure out what such in-depth documents proport to say, then are abstracted by a communications person seeking media attention, who then read the abstract, perhaps the summary, and seek opposing positions so as to give the sense of “balanced” journalism, Anti-antiviral stance  and  Science based medicine review

Those wanting to dig deeper should scan or read the full review Cochrane review.  Notable is the filtering inserted as the full review is abstracted  and then subjected to public relations conversion to lay language.

Having said that, oseltamivir and its siblings were not approved as a panacea, nor did they claim more than about a 10% reduction in symptom duration.  Guidelines for their use in Canada recommend use in those at high risk, and acknowledge that those wishing to reduce symptom duration may benefit.  Canadian antiviral guidance.   It must also be acknowledged that several contributors to the Canadian guidelines have stated potential conflicts of interest, which does not mean their opinions are biased, only that objectivity may be affected.

The Canadian guidelines are rationale and reasoned, and focus on annual influenza strains.  Given a novel strain, significantly underlying medical condition, or developing severity, influenza antivirals have a place and will likely remain as an emergency stock as the best available option for preventing death and complications.  

Wednesday, 9 April 2014

The Squeezed Generation - GenSqueeze: Trying to prevent an impeding public health crisis for young families

If you haven’t heard about Paul Kershaw and Generation Squeeze, you should do some researching. 
The issue is a simple one.  In developing one of the best countries to age in, we have developed a country that is squeezing young families into a state of unaffordability.  Social investments have disproportionately benefited those of us in our waning years while shifting a financial burden from which young adults may never recover. 

From the GenSqueeze website some of the key messages have been condensed to “tweetable” clips, written out in full below.
·         In 1976, on average, Canadians age 25-34 worked 5 years to save a 20% down payment on their home. Today it takes 10 years and in BC, 15.
·         High housing prices are the primary source of wealth for Boomers, and the primary source of debt for GenSqueeze.
·         While the economy doubled since 1976, average wealth for Canadians aged 25-34 fell 41%. At the same time, average wealth grew 176% for those aged 55-64.
·         Canadians barely reduced CO2 emissions per person since 1976, so GenSqueeze and their children are inheriting the cost of environmental change.
·         Today, younger Canadians work and study more to have less. Their earnings have dropped by 11% since 1976, even though they are twice as likely to have post-secondary education.
·         The squeeze tightens when starting a family. Families can lose up to $15k in household income after their baby is born, even with parental leave benefits. Plus, child care services are hard to find and often cost more than university.
·         There’s a generational spending gap in Canada. Governments spend $12k on benefits and services per Canadian under 45, compared to $45k per retiree.
·         Government spending on medical care and pensions has grown by billions since 1976, but spending on families with young children hasn’t changed.
·         Canadian governments spend as much subsidizing livestock and agriculture as child care and parental time at home with a new baby.
·         Increases to pension & medical care cut poverty for retirees from 29% in 1976 to 6% today--less than any other age group in Canada. We can repeat this success for Gen Squeeze.
·         Our campaign is about narrowing the generational spending gap, not eliminating it.
·         A Better Generational Deal could start by increasing government spending per Canadian under 45 from $12k to $13k, maintaining spending per retiree around $45k.
·         We can safeguard our medical care and retirement security without sacrificing our children’s present and our grandchildren’s future.
·         A New Deal for Families can save GenSqueeze $50k before their children start school, giving them a chance to pay off student debt, reduce housing costs, make shorter work weeks affordable and/or help save for retirement.
·         Everyone benefits from a Better Generational Deal to Reduce the Squeeze. Find out more at www.gensqueeze.ca  

Do check out the GenSqueeze website and sign up to support an effort that is a real investement in our future families. 

Sunday, 6 April 2014

Autism: An apparent increasing incidence means it is time to focus attention as a public health issue.

CDC recently released updated estimates of the prevalence of autism spectrum disorder (ASD).  The project is a longer overview based on 11 sites and a series of reports.  The 2010 report being released in the past few weeks at ASD  March 2014, and previously for 2010 at ASD March 2012.  The reports are well worth reading as an initial attempt to begin treating autism as a public health problem.

Given the long standing misguided implications of those that chose to relate autism with vaccines, the main disservice has been the relative ignoring of autism as a public health issue. 

There are several theories why incidence is increasing, or at least diagnostic cases are increasing.  Better definitions, better and expanded diagnostic tools, greater public awareness, and more parental concern may be contributing.

There is some evidence of a genetic component.  Many theories suggest environmental factors without definitive conclusions or relationships.  If only a fraction of the dollars spent on disproving the vaccine-autism link had been better directed to treating autism as any other emerging illness.  In this respect, the relatively small investment in the Autism and Developmental Disabilities Monitoring Network is a pittance but a valuable investment.

The general incidence in 8 year olds in the collective study area was 1.5%.  Notable is that of the 11 sites reporting in 2010, there is a nearly 4 times difference in rates between the highest incidence site and lowest.  Males are 4.5 times more likely to be diagnosed than females.  In typical US fashion, significant variation exists between ethics groups.

Over time a higher proportion of those diagnosed with ASD area found in the normal or above normal intellectual ability with 31% below IQ range of 70 and an additional 23% in borderline intellectual range (76-85).

A nice summary also by the CDC looks at treatment and support options for children and those with autism CDC autism treatment options  Another autism controversy that has detracted from applying scientific rigour has been the debate between treatment types with widely touted highly intensive therapy costing tens of thousands per year advocated for by the autism community with minimal evidence of better outcomes than lower costing standard therapies.  The lack of rigourous trial methodology fuels the controversy. 

Public Health has been instrumental in reducing outcomes of disorders identifiable at birth, in mitigating the impacts on children with developmental and communications disorders, and placing emphasis on the needs of children in general.  Its time again to step to the plate, doubly so given this appears to be an emerging illness.  

Thursday, 3 April 2014

Radiofrequency emissions get a high exposure review

Some readers will have attended the meetings where opponents of any sort of radiofrequency (RF) emitter is being imposed on “their” space and causing a wide range of negative health effects.   The aluminum foil helmets to protect the brain, the plethora of citing of all the evils associated with RF

To their credit, RF is not visible and it is an imposition on one’s personal space (if on a planet of 7 Billion any one of us creature’s can lay claim to personal space).  More central to the conversation is the poor risk communication activities surrounding any of the variety of aspects of RF emissions.

At the request of Health Canada, the Royal Society of Canada convened and then cautiously released an expert working group’s review of RF and the proposed safety standards in Canada A Review of Safety Code 6  .  The proposed safety standard is operationally not likely to impact any current routine public exposure settings but may impact certain high exposure occupational settings. 

Not likely a document that will rate highly as an adjunct to risk communication, it is a detailed scientific review of RF.  It adds nothing to what is already synthesized elsewhere, however it does provide a central resource for anyone wanting to develop expertise in RF (and a recommended read for all residents in Public, Environmental, or Occupational Health).  The further added angle to the document is that it looks at the science from the perspective of whether the Canadian RF Safety Codes for human exposure are adequate.

The conclusion is the safety code is protective of human health. There are subtle potential modifications for consideration at one frequency range which is supplemented by the statement that there are no health impacts expected below the current safety code. 

Not surprising from a group of scientists, many of whom could stand to benefit from research dollars in their fields of interest, there is room for more research.  A somewhat detailed research agenda is laid out. 
There is acknowledgement of the number of persons claiming “electosensitivity” or “electrical hypersensitity” to radiofrequency emissions and a conclusions that there is a lack of evidence to support a causal relationship. 

Further the panel makes clear recommendations directed at Health Canada to improve its risk communication skills and tools. 

One can expect that “experts” who preach the ills of RF exposure will actually pull the document out and cite sections such as “significant” risks for potential exposure in certain settings, confirmation of IARC’s assessment that exposure to early higher energy mobile phones was a possible carcinogen, mobile phones are possibly weakly associated with increase in acoustic neuromas, and possible reductions in male sperm production.  While all these health associations are very weak if they exist at all, they are acknowledged within the document.  The plethora of review of negative associations is reassuring. 

It is a reference well worth keeping.