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Thursday, 31 July 2014

Healthy public policy – time to revisit an old friend

The 1986 Ottawa Charter on Health Promotion was an initiation for many to the new language and fledging technology of health promotion.  28 years later it appears to be a stale old hat for some and for others raises hackles and invokes a defensive response.  Words like enabling have had their time in the limelight and faded.  Advocacy has been removed from legitimate discourse.  Yet there remains in the Charter a foundational culture which has thrived over the past three decades.

Two years after the Ottawa Charter, the second international conference on health promotion in Adelaide focused attention on the component of building healthy public policy.  Reviewing the conference proceedings remains relevant today Adeliade healthy public policy conference.  Interwoven into the proceedings were the sprouts of the discussions on inequalities and equity that were arising from the European Region of the WHO and the focus of the 5th conference in Mexico City in 2000.   Accountability surfaced as a major driver of health improvement in Adeliade and the seeds were sown for the 6th conference in 2005 in Bangkok on building partnerships. 

The policy discussion circled back for the 8th conference in Helsinki 2013 Statement for health in all policies.  Where Adelaide focused on the micropolicy issues with the basis that health must of course drive policy, Helsinki delegates recognized that health was often not adequately incorporated into the complexity of policy decisions. 

Have we spent 25 years of banging our heads in frustration?  If so why, and even if we did, what did we learn?

Fast forward to the establishment of the National Collaborating Centres.  One of which is dedicated to healthy public policy NCCHPP within INSPQ.  Given that Quebec is often ahead of the rest of the country it is perhaps fitting that the centre is housed in Montreal.   The wealth of resources are veritable goldmine although the introductory course comes with a price tag, the supporting documents that can be accessed on the site will help converge thinking around policy analysis, logic modelling, knowledge synthesis, impact assessment, economic evaluation, ethics, engaging democracies, advocacy and more.   

Spend a few minutes, hours or days combing through the site.  It does not win awards for usability but should win awards for the applicability of content. 

Wednesday, 30 July 2014

Ebola - Threat analysis, reassurance and practical advice

Every once in a while an emerging disease threatens a number of people and draws considerable interest.  Based on global reactions, the threat posed by contagions has been embodied within the Ebola Virus.  Its repeated emergence with devastating consequences, followed by years of acquiescence bolster its image as the deadly monster lurking on unsuspecting human prey and attacking without warning. Ebola has received its share of attention by DrPHealth as well with a more definitive review in August 2012 at which time there were only a collective 2270 cases ever recorded.  

Hence it deserves a few more lines in the face of over 1200 cases to date in an outbreak that is reporting a 60% fatality rate.   Moreover where most previous outbreaks have occurred in the central jungle regions in the Ugandan, South Sudan, Congo,  Gabon  areas, this outbreak has centred around the Guinea and West Africa (putting the distance between epicentres about the same as from Vancouver to Toronto, or Halifax to Regina). 

Those keen on following its path should familiarize themselves with the WHO Ebola surveillance site
Sustained transmission in this outbreak is predominately through contact with infected blood and body fluids of infected persons.  Typical outbreaks occur through initial contact with infected animals (monkeys or pigs).  The natural reservoir of the virus appears to be fruit bats of which some species extend across the sub-Saharan regions from West to Central Africa where outbreaks have been noted. 

Prevention is through the most basic of infection prevention techniques, and while pictures of high level space suits with self contained breathing seem to dominate the graphic symbolization of the Ebola threat, much less rigourous infection prevention activities would likely be just as effective – of course who would want to try when such barrier techniques are readily available and the consequences of contracting the illness are so dramatic.

Hemorrhagic fevers are nasty illnesses.  Acute onset, high fevers, with rapid involvement on intestinal tract, muscle pains, kidney and liver.  Typified by low platelet counts which result in bleeding that can be terminal augment the fear about the disease.  It is not something that goes unnoticed when it occurs although speculation exists on less severe forms that may contribute to the sustaining of outbreaks.  

The risk to persons outside the area is far lower than rare infectious diseases that sporadically occur within Canada.  Exportations of Ebola have been very uncommon and countries like Canada  have viral hemorrhagic fever protocols that cover a host of potential threatening agents and overlap the bioterrorism response protocols.  As with any emergency response the key is to know the first few steps, and as public health workers to be able to provide advice on patient isolation, limitation on an invasive testing without laboratory containment in place, and how to contact the PHAC emergency line for national support on any suspect case.

Not that we should be retooling our systems to respond to the current threat, there are far more likely infectious agents lurking in our own neck of the world.  

Wednesday, 23 July 2014

Marketing to Children and Youth - a significant unattended public health issue.

Only in Quebec is food advertising directed at children supposedly precluded. However the effectiveness of this intervention is limited by the volume of non-provincial markets that cloud the Quebec airways.  More central to the discussion is why have we not seen national or other provincial leadership on this issue.  As usual Quebec remains a decade ahead of the rest of the country in many of its public health initiatives and should be appropriately commended.

Several groups have called upon federal regulators to limit targeted marketing to children including Canadian Pediatric Society   and Hypertension Advisory Committee.  Others have alluded to the need to address marketing without attempting yet to take a stance and something we should be carrying to respective organizations to engender a firmer policy.  

A recently posted primer on Marketing to Children and Youth by the Nova Scotia Department of Health is a must read.  It clearly identifies the pitfalls that marketing to youth can lead to including

·         Marketing can normalize unhealthy behaviour and encourage unhealthy consumption of unhealthy products.
·         Marketing tactics can negatively impact mental and emotional health and well-being.
·         Marketing can limit our freedom of choice.

The well written review holds no punches when it comes to displaying a disdain for current marketing techniques used by many businesses to influence youth decisions.  Certainly not your typical government sanitized publication.   

The commentary takes specific aim at:

·         Alcohol
·         Processed Food
·         Sweetened Beverages
·         Energy Drinks
·         Hypersexuality
·         Tobacco

In an uncommonly but refreshing fashion,  the document provides a solid list of to-dos for public health professionals and lays out a specific provincial plan for Nova Scotia that would be applicable everywhere except in Quebec. 

Monday, 21 July 2014

Forest Fires, Air Quality and Public Health risks and advice

For most Canadians, our interaction with forest fires is through the news.  Pictures of candling trees shooting flames high in the sky and jumping from treetop to treetop.   For many of us, that reality becomes closer to home with periodic episodes of degraded air from fire smoke generated sometimes thousands of kilometers away.

The actual number of fires nationally is actually fairly constant and may even be decreasing. The area burned seems to fluctuate more widely. Moreover province by province analysis see wide variation in fire activity from year to year justifying the interprovincial movement of fire suppression crews as needs shift in a less than predictable manner (there is minimal correlation to the El Nino:La Nina cycles)

Predicting fires, fire behavior, smoke impacts and health impacts has become a significant Canadian operation.  Despite the headlines garnished by fires on the outskirts of communities that impinge on residential areas, the vast majority of Canadian wildfires are located in sparsely or inhabited areas.   Great information is available on fire location and activity at Canadian Wildland Fire Information System and the Canadian Interagency Forest Fire Centre  

From a public health perspective the key issues relate first and foremost to those in the path of fires and their safety for which the number of deaths and injuries from forest fires annually are counted on fingers and often associated with fire suppression efforts.  Secondly are the largescale impacts of smoke dispersion. 

BC developed the BlueSky forecasting system based on particulate matter in 2010 and has expanded to Western Canada and more recently to Eastern Canada.  More recently Meterological Services of Canada (MSC)have started limited user testing of a Forest Fire Smoke Forecasting system.  Both systems rely heavily on remote satellite sensing information combined with meterological forecasting information. The MSC modelling is expected to bring a greater level of sophistication and geographic precision.

Some areas have done better measuring and modelling of predicted health outcomes.  A recent comprehensive review by the National Collaborating Centre on Environmental Health provides an international state of the art understanding of the impacts, surveillance and advice to be provided during a forest fire smoke event.   The synthesis of which is copied below as found in the general advice synthesis though directed to BC for some reason even though forest fire smoke is a national concern.

Communications advising people to:
• stay indoors: reduce time spent outdoors in order to protect health
• reduce outdoor physical activity: decrease physical exertion outdoors in order to protect health
• wear an N95 respirator: properly use a certified N95 half face respirator to reduce exposure to smoke
• activate asthma/COPD action plans: ensure that plans for self-management of asthma/COPD are in place, up-to-date, and adequate supplies (e.g., medication) is available
• use a home clean air shelter: spend time in a room in your home with cleaner air to reduce smoke exposure
·         Cancelling outdoor events: Decision that group activities that occur outside will not take place. Such activities include school activities (e.g., recess, outdoor classes and events), sporting events (e.g., tournaments, practices) and mass gatherings (e.g., arts and cultural events, athletic events).
·         Providing community clean air shelter(s): Spend time in a community based facility such as a mall or school that has cleaner air than outdoor air.
·         Augmenting air filtration in institutions: The use of in-duct or portable filtration to improve air quality and protect people in institutional settings including hospitals, nursing homes, long term care facilities, day cares, schools, and other institutions.

·         Evacuating: The urgent removal of individuals from a community in order to protect them from exposure to wildfire smoke.  

Friday, 18 July 2014

Early Child Education – why is Canada the worst?

Speak to any pediatrician, public health professional, educator or social worker about what would be the best investment we can make in the health and wellbeing of our children? if Quality child care does not top their list it will likely be second. 

So why is Canada so resistant to implementing such a program?  Nationally a program was thought about in the 80's, announced in the 90’s, the foundation built in 2003, and then slashed after the 2005 shift to the right.  The only province that has taken up the cause is Quebec.  Canada now ranks dead last in OECD countries in public support for early childhood education.  Over a time period where the wellbeing of children is sliding backwards, school preparedness is decreasing rather than increasing, and schools laying claims of increasing behavioural problems and poorer school performance, it is at best a disgrace and an embarrassment. 

What in the minds of some is a social frivolity and drain on public resources, is in fact both a social and economic necessity.  The evidence abounds.  The value has been demonstrated now for over 50 years. 
Were this an issue of a few people in a long term care facility that suffered from poor care, a community with unsafe drinking water, or a child in care treated poorly, there would be a national uproar, public inquiries, law suits and legal actions abounding. 

Why then, has a generation of children been abandoned in Canada?  And not only has programming not responded to the science, it has contracted.  A cohort of nearly a half million children a year denied the opportunity for reaching their full potential – and no adult standing up taking responsibility or even fingers being pointed at the causes.  We have members or parliament and senators rebuked, censored, resigning and occasionally criminally charged for spending a few thousand dollars inappropriately – yet no accountability for the loss of a future generation’s wellbeing!

As a starting point the following two graphs provide a snapshot of the high variability in the country on quality child care availability (as a percentage of children who have access to a space) and cost.  Quebec the stellar performer and the example of how to care for children successfully.

A relatively mild Globe and Mail editorial speaks to the need for a program without even mentioning the failure to deliver on a national commitment.  Many would argue the relative economic value of child care is in the range of $3 return for every $1 invested.  The social benefits to families are well documented.  However in the end, the real benefit is for the child.  Provided with a nurturing professional environment in which to explore, build brain function, learn new skills, socialize, normalize behavior and be physically challenged carry lifetime benefits for both the child and the society in which they will thrive.

Why then can anyone be so resistant to doing the right thing for our future?  

Friday, 11 July 2014

Hot times are spreading across Canada

Summer has hit, and it starting to hit hard, and in some places in Canada hit hard.

With all the advice out there on heat some things that just need to be reinforced.

  1. Do not leave children or animals in a vehicle, even for a minute.  While rare they cause the most public outrage
  2. Most heat associated deaths are amongst persons who have difficulty adapting to the hotter temperatures
    1. older persons
    2. some with debilitating chronic illnesses
    3. those that are dependant on others for their care and communication (including infants and young children)
  3. All of us are more acclimatized to cooler air and more temperate conditions.  We can't exert ourselves to the same extent as just a few weeks ago.  In a few weeks from now we might just be acclimatized enough (it takes about two weeks of constant temperature adjustment)
    1. If you live in the Okanagan, temperatures in the mid 30's may be tolerable while on the east coast the high 20's might seem too high, and up in Nunavut, heat related symptoms can start in the high teens.   There is no safe value for all of us. 
  4. Drink, and while water is best, anything will do.  Better without sugar
  5. Take those cooling breaks; swim, have a shower, go to the air conditioned mall. 
  6. Any symptoms are signs of too much heat, there is no sense talking about confusion or coma - do something when you feel the first symptoms. 
One of the most important tasks we can do - check on our neighbours daily, those that can't get out as often.

Save a life, it only takes a few minutes a day during these hot times.  

Friday, 4 July 2014

Refugee Health cuts – a legal and rhetoric win, though not necessarily a win for refugees.

Federal Court Judge Anne Mactavish released her decision on the legal challenge that the cuts to refugee health were an infringement on human rights.   Read the decision carefully (paragraphs 1076 through 1097 if you are not interested in the full 268 pages) and what arises is somewhat reassuring and likewise somewhat disturbing. Decision on refugee health cuts

The good news in the decision. 
“the executive branch  has intentionally set out to make the lives of these disadvantaged individuals even more difficult”

“It has done this an effort to force those who have sought the protection of this country to leave Canada more quickly, and to deter others…”

“this treatment is indeed ‘cruel and unusual’”

“jeopardize the health, and indeed the very lives, of these innocent children in a manner that shocks the conscience and outrages our standards of decency.”

As such the program as structured violates section 12 of the Charter

She further challenges that the program is inequitably applied based on the designated country list and that distinction is a violation of section 15 of the Charter.

The bad news
“I have concluded that the 2012 “decisions” are not ultra vires the prerogative powers…”   meaning that the government acted within its powers.  “nor has there been a denial of procedural fairness” meaning they acted appropriate for implementing such changes. 

The charter is not a document that can be used to justify a right to state funded health care

That while international law is a valuable aid in interpretation, it is not binding on domestic rights or remedies.

The final bit of bad news is that the decision was immediately suspended for four months (in essence framing a suspension pending an appeal to the Supreme Court which could take years)

As the case involves just two persons, one of whom has subsequently been granted permanent residency, that its application to the thousands awaiting relief is not of value.  

Hence, round one goes to the refugee coalitions, but with big enough loopholes that the government need not aggressively respond in providing reasonable care to refugees in need of health services in the immediate future.  

Based on the reaction by the current immigration Minister Chris Alexander, an appeal is expected CBC coverage .  The orchestrator of the debacle (Jason Kenney) having safely moved aside to stir up a new hornet’s nest and running away before getting stung. 

Wednesday, 2 July 2014

DrPHealth celebrates 3 years in the world of social media

Loyal readers will be aware that DrPHealth went live in 2011 as a test of social media.  Its niche was in reaching out to Canadian public health professionals to provide a forum for discussing current events in the public health world.

Here we are, with 395 posts, 405 tweets, and nearly 28,000 views reflecting back.

The site has grown in use to an average of about 30 visitors a day, with ranges from just a handful to over 400 on one weekend.  The number of days with over 100 visits are about 10.   The current visitor tends to focus on a couple of posts, and weekly there are a small number that scan a dozen or two on a single visit. 

“Unusual” postings seem to garner the most attention with flurries of activity around fracking, Hookah, Cronuts, e-cigarettes when they first came out, and the (lack of) performance of the Minister of Health. The average post has about 30 specific visits, so those that don’t attract more than a dozen are subjects that lack interest but for which there seems no rhyme or reason.    Title style has little impact and readers seem immune to shock value headlines.  Subjects that are more positive in celebration seem to attract more visitors than those that lay out criticisms, almost a predictable pattern.  

 There are some supervisitors that when they retweet or forward a post to colleagues result in clear surges of visits. Comments remain relatively rare, and sparking dialogue has been an area of underperformance. 

Canadian visits are just below 50%, the US at about one-quarter, Russia at 10%, Germany, China, UK, Ukraine and France rounding out those that have more than 1% of all visits.  Twitter and Google being the prime traffic sources

Three years ago social media was in its childhood.  Bloggers and Tweeters have propagated to the point that following these sources of information has become a full time profession and unsustainable.  Like print news, one has to wonder about what will be the sustainable of these tools.   Search engine crawlers will be needed to follow these sources putting the onus back on the user to ask the right questions and not just try to stay informed from a generic professional perspective.  

As a reader you are invited and encouraged to participate in DrPHealth by leaving comments, writing guest postings, contributing material that would benefit from anonymity, following the blog or following on Twitter.   

Most importantly, it is whether you continue to visit the site that is the test of its ongoing relevance in meeting its mandate.   You can also contribute by ensuring the site or specific postings are distributed to colleagues who may not yet be familiar with this option.

We would love to hear from you in whatever fashion you choose. After all, while public health is about populations, only you benefit by your visit here.