Health and the Environment: Inseparable companions

Environmental issues are taking an ever increasing place in science and politics.  The optimists will be happy, the pessimists would ask how can you ever put environment, science and politics into the same sentence.  With the Keystone pipeline filling US election debates, and the Northern Gateway pipeline debates causing a stir north of the border, should we be at all surprised at the “Harper” government’s announced intention to streamline approval processes for environmentally sensitive projects. 

A few environmental health stories have been popping up on the radar.  

March 22 was World Water Day.  Did it flow right past you?   The week of March 19-23 was Canada Water Week; the Canadian celebration that we continue to have one of the highest per capita water usages of any country in the world, although slightly behind the US in this respect.  While Canada collectively has more than its fair share of fresh water, water stewardship and prudent use are sustainable habits to be promoted.  Areas of the country suffer from water shortages, and many communities still do not have access to quality drinking water.   

The second story is a dire prediction from the OECD that by 2050, air pollution will surpass poor water quality as the leading environmental cause of death globally, to an estimated 3.6 million lives each year.  OECD outlook summary.  Most of this increase will be in non-OECD countries with South Asia and India having the greatest impact.   The full document which can be linked from the webpage, has many interesting gems hidden and includes estimates of greenhouse gas emissions, global economy growth, and water demands.  If there is a consistent theme to the OECD document, look to most of the change occurring because of Brazil, Russia, India, Indonesia, China, and South Africa.

Domestically, while pipelines have dominated the news,  a small piece of Nova Scotia on reduction of coal gas emissions was notable.   Nova Scotia was the first province to place hard cap reductions in emissions and is leading the political charge in achieving reductions and this piece is a joint federal-provincial initiative to meet these targets while reaffirming the Canadian commitment to the revised greenhouse gas emissions reduction targets which Canada bought into in Copenhagen in 2009 when they abandoned any efforts to meet the Kyoto accord commitments.   Nova Scotia - federal commitment on coal gas emission reduction.   Check out the previous DrPHealth posting on GHG reductions http://drphealth.blogspot.ca/2011/12/kyoto-bali-cancun-now-durban-are.html 

Remember Earth Day is April 22^th   http://www.earthday.ca/pub/ .  While the protecting the environment may at times conflict with health promoting ideals, there is a reasonably intimate relationship to monitor activity in both realms. 

Consider participating in Earth Hour - Saturday March 31, from 2030-2130.  Lights out for the environment

Canadian Drug Policy and Brave Public Health Professionals lend their voice

Another esteemed group of leading public health have put their support behind reforming public health drug policy in Canada.   Released in Open Medicine March 28 2012, it further builds on the work done by The BC Health Officers Regulating Psychoactive substances and some of the work from done by the Stop the Violence.   This was touched on in DrPHealth Dec 1, 2011. 

Not surprising one of the authors (Dr. Evan Wood) is associated with the Stop the Violence group and another with the BC health officers (Dr. Perry Kendall). A third author (Dr. Robert Strang) masterminded the Nova Scotia alcohol strategy discussed in DrPHealth October 7, 2011.  The final author (Dr. Moira MacKinnon) is no slouch in facing tough public health issues.  Three of the four are provincial Chief Public Health Officers, and have held their positions for many years, are highly respected in their provinces and therefore more able to speak openly publically on politically sensitive issues. 

Their counterparts in other provinces and at PHAC seem to have relegated their Chiefs to cautiously going on public display when politically convenient.  No doubt all of them work diligently in the back corridors of their respective governments to influence health policy.  It is not surprising to hear colleagues who question where is the provincial CMHO?  As Manitoba’s ex-CMHO (Dr. Joel Kettner) knows only too well, the current populist governments are not keen on public scrutiny.  Occasionally this site gets inquiries why it insists on providing a voice of anonymity to public health professionals who can be under the political microscope. 

On the other hand the public health community is somewhat incestuous and not surprising that convergence of thought is beginning to occur around the drug policy topic. Good that the authors have reached out to a new audience with the message.

The contents of the Open Medicine article are reiterations of work already released but previously have not been subjected to a scientific peer review process.  Open Medicine is a predominately Canadian entity with global aspirations and an electronically based medical journal targeting mainstream health care.  In this respect the publication of the article targets the recipients of the current failed drug policy approaches – clinic offices, emergency rooms, and hospitals. 

Kudos to these voices of public health that have spoken up from the wilderness and carried a politically sensitive message to health professionals more broadly, and to the media nationally CBC coverage of publication  

Tuberculosis in Canada: A travesty for Inuit populations. A concern for inner city street oriented populations

TB used to be something that touched every family in one way or another, so its rapid decrease over the 20^th century turned a common illness into something that few of us would consider ourselves at risk of contracting.  March 24^th was World TB day, a celebration of the success, a reminder of how far we have to go, and a caution of some of the disturbing new trends that are occurring.

There are some 8.8 Million global cases per year of TB and 1.1 Million deaths (add 350K for combined HIB/Tb) annually WHO 2011 TB report  .  In Canada we are fortunate to only have 1600 cases annually with rare deaths.  Total numbers of cases globally and in Canada continue to trend downwards which is the cause for celebration.  TB in Canada 2002 report  and the February 2011 pre-release of the 2009 report 2009 pre-release report on TB in Canada provide some good information on the Canadian situation. 

What is notable is of the 1600 cases, nearly two-thirds are amongst new Canadians.  Not surprising that many provincial programs are targeted at this population.   Only 15% are amongst non-Aboriginal Canadian born individuals.  Aboriginal populations make up just over 20% of the cases, but have an incidence rate that is nearly 30 times higher than non-Aboriginal Canadian born populations, and of this Inuit populations suffer rates that are 5 times higher than their Aboriginal colleagues nationally (yes that is a relative risk of nearly 150 compared to non-Aboriginal Canadian born persons).  The rate amongst new Canadians is about 13 times higher than non-Aboriginal  persons. 

Missing in these statistics however is the resurgence of TB  as outbreaks in city cores. What proportion of those Canadian born non-Aboriginal populations are street oriented in their lifestyles was not identified. In fact, trying to find any information is a challenge.  Toronto, Vancouver and Kelowna have all openly acknowledged outbreaks in street oriented populations.   It would be surprising to learn that other cities did not have similar experiences.   Numerous US cities have had outbreak experiences  and the CDC summarized some of this in Emerging infectious diseases march 2011.  A similar analysis for Canada would be welcomed.   

Did you catch the bit about the 2009 report pre-released in 2011?   Such subtleties are usually driven by political vulnerability, in this case no doubt the rates of TB in Inuit populations.  So with some kudos to the federal government came an announcement for World TB day of a strategy with some funding, as well as updated information on TB in Aboriginal peoples TB in Canadian Aboriginal populations , be sure to check the related links as well.

TB is alive and well - and still a problem for very specific populations. 

Equity and taxation – An effort at a rebalancing policy.

For several years there has been discussion of how do we even consider increasing taxes to support revenues rather than continuing drastic cutting measures that seem to be the politically acceptable solution.   Kudos to some Ontario physicians, likely led by Michael Rachlis,  that are rallying around a call for increasing taxation to the highest income earners. 

Their message – “Tax us. Canada’s worth it”.  

The focus is on policy that clearly advocates for increasing taxation, and uniquely the call is coming from the very group that would be impacted.   Almost all physicians would fall into the top 10% (<$100000 annual taxable income), and the vast majority would fall into the top 1% (>170,000).  Only a handful would have taxable incomes in the top 0.1% (>640,000) which would be more typical of corporate CEO salaries and investment earners. 

While the campaign is aimed more at Ontario, there is a clear message to the federal  government as well.  The expected increased income federally would be about $3.5B.   That is actually only an increase of 1.5% in expected revenues. 

As it is budget week in Canada, unlikely that major policy shifts will be announced federally, but just to recap where Canada stands budget-wise from 2011-12. Canada’s accumulated debt is about $586B just over twice the annual expenditures of government.   We spend some $33B in servicing the accumulated debt.  In 2011-12, Canada’s expected deficit was just short of $30B, that was down from $56B during the bailout years of 09-10.  

Canada’s Gross Domestic Product is estimated at $1.58Trillion, the 14^th largest economy globally.   That puts the government debt to GDP ratio at about 37%.  However, given the large propensity of debt accumulated at provincial and other public sector governments, the collective debt to GDP ratio is about 86%.  On an international basis that puts Canada in a much more precarious position.  The inserted global map puts Canada into perspective and more in keeping with European nations. Of course one can and should argue if debt to GDP is a valid indicator of progress, it is the measure that the International Monetary Fund tracks most closely. Public debt ratios   .   Noting that the graphic puts Canada as having a higher ratio than the US, but the IMF listing puts the US at a 95% ratio.  The disparities likely reflect the uncertainty in the calculations. 

So – having laid out the fiscal argument, who better to argue for increasing taxes than those that will be affected by such a policy.  Kudos to the group.  Be an advocate, ask your physician if they are aware of the campaign and have signed on?

While the sign up is designed for physicians, other public health professionals should read the backgrounder  on the current skewed taxation structure in Canada.  www.doctorsforfairtaxation.ca.  Notable as well are the low corporate taxation rates and the lack of estate taxation, both of which if modified slightly could greatly improve the fiscal reality.  


In a separate piece, the Health as if everyone counts blog also published a piece on the shortcomings of the Ontario Drummond report, in particular the implications of the policy of tax reductions since 1995 and the impact that implementing redistributive taxation now would have on stabilizing Ontario revenues Ted Schrenker: Life A.D. (After Drummond) part 2

Are we starting to see a pro-taxation revolution in the works?   

Health inequity – Time to stop blaming the victim; Lessons from Greece

For years we have accumulated the evidence linking inequity with excess disease burden. Recently there have been honest efforts to try to reduce these disparities.  There are some detractors that espouse the survival of the fittest and there are those that would blame those affected for making poor choices.

What if there was a natural experiment?  One that randomly plucked members of society and stripped them of their social status?  One that threw large numbers of persons into poverty?  One that undermined the social fabric that was designed to keep the society cohesive and tended to the vulnerable?

So it is with Greece.  Until about 2007 Greece was a shining example of a European Union member, GDP growth at a healthy 4% per year and many aspects of its society given as examples of what to do, rather than what not to do.  In just a few years this noble and ancient land has been crushed by the economic tide.   Citizens thrown into unemployment and social services cut deeper than a bone, supposedly so that the “nation” can survive.  

Not surprisingly, the first reports are coming forth of the health chaos that is developing.  Malaria has had resurgence, tuberculosis is up, HIV transmission is becoming problematic again as sex trade and drug use increase. Greeks suffering resurgence in disease.   As better data is generated, perhaps we should expect that further declines in health status will be noted.  Many who have been thrown into distress were previously successful persons who through no fault of their own other than living in Greece, have been thrust into a dire and challenging situation. 

Should this not be enough evidence of the fragility of our societies to changing health equity? 

And Greece is unlikely to be the only EU member to crumble.  It is merely the forerunner and natural experiment in unmasking the inequities.

Of course, perhaps our memories are not so good.  Similar health declining reports came out of the Soviet republics after Perestroika.  Places like the Ukraine suffered greatly in the post-Soviet  era until economies were stabilized – and that was during a time of good economic  growth internationally.  

And really, who is benefitting from ensuring that the Greek nation does not default?  Is this not a question of following the money? And the trail likely ends at foreign investment firms who have lent from their deep pockets with reasonable knowledge of the risk.   Domestic investors have already had their savings bonds paid out at a fraction of their value as part of the required economic salvation package, this approach to devaluation was the typical approach when government funds became scarce and one should ask why is this not the route being taken to cope with the economic collapse?  

Just as with the banking industry bailouts, the damage is being shared amongst those that were not involved in taking the risk. Those who knowingly took the risks are not the ones on the street seeking a handout for their next meal. 

They are too often the ones who have spoken up to chide the very victims of social inequity. Perhaps it is time to blame the perpetrator and not the victim.  

Mould: Much maligned, misinterpreted and far too often missed mediator of malaise

Mould – the word engenders images of slimy growths on old bread and cheese.  It stimulates revulsion and the immediate reaction to discard food as having gone bad.  Do these microscopic creatures that form vibrant colonies deserve such a tainted reputation.

Some moulds are beneficial like the penicillin producing species and those used in producing cheeses, sake, soy sauce, salami and other foodstuffs. Others are known for their association with illness; alfatoxins and liver cancers; ergots which were implicated in the psychiatric manifestations associated with the Salem witches and several others that are specific nephrotoxins or neurotoxins.  However saying that moulds are bad is like saying all bacteria are bad.   We just need to know our moulds better, and given there are thousands of them, our general knowledge is limited.

Considerable attention has been drawn to the issue of moulds in housing, but perhaps not the concerted attention of public health authorities – in part likely because it affects such a large proportion of the population

Moulds received considerable attention in the ‘90s in what is actually a public health myth. “Toxic mould” – Stachybotrys chartarum,   the nickname was the result of an investigation of pulmonary hemorrhage in infants.   In 2000 CDC reevaluted the original investigation and raised questions about whether such an association existed MMWR March 9 2000.  In essence the retraction of the widely disseminated and well entrenched “knowledge” that moulds could cause death in particular circumstances.  What a great public health controversy given millions spent in remediation and the continued propagation of the fallacy that Stachybotrys chartarum was associated with a severe allergic response that could result in death.  

Not to belittle the problems with mould and housing which is our focus of attention.

Moulds produce spores.  Spores can produce an inflammatory response when inhaled.   The extent of the inflammatory response is in part correlated with the burden of spores inhaled.   Inflammation can be manifest in eye, nose, throat, bronchial and pulmonary irritation.  More simply put, some cold symptoms and the potential for exacerbating asthma.  The following table gives some sense of the expected relative risk for symptoms in persons living in damp and/or mouldy housing

Symptom	OR (95% confidence interval)
Upper respiratory tract symptoms	1.70 (1.44-2.00)
Cough	1.67 (1.49-1.86)
Wheeze	1.50 (1.38-1.64)
Current asthma	1.56 (1.30-1.86)
Ever diagnosed asthma	1.37 (1.23-1.53)
Asthma development	1.34 (0.86-2.10)

Adapted from Mudarri and Fisk as quoting Fisk WJ, Lei-Gomez Q, Mendell MJ, (2007) Meta-analyses of the associations of respiratory health effects with dampness and mold in homes.  Indoor Air 17(4): 284-295.  

Persons living in moist climates, flood prone areas,  poorly ventilated housing and poorly built buildings with plumbing problems are more likely to have conditions that are ripe for the growth of mould. A US study suggests that is about half the US housing stock.   So put simply, the problem likely affects half the US population, and while there may be reasons to think slightly less prevalence collectively in Canada, it is still much higher proportion than something like radon. 

Prevention is based on good construction practices.  In this respect, it is not surprising that mould has become a significant concern of First Nations. The fundamental problem is not the mould but the lack of application of Canada Building Code standards and lack of building inspection in housing construction on many reserves. 

Early Intervention:  Following a known water event; flooding, plumbing incidents, sewage back up – rapid drying and cleaning is very important. 

Mitigation  is not easy.  Cleaning is integral to reducing overall burden and often not adequately emphasized. Nor is a single cleaning likely to be sufficient for long term elimination of moulds.   Replacing water damaged materials is beneficial, recalling however that mould spores will have been widely dispersed within air spaces following water damage.  The Cochrane collaborative posted a recent review on the value of certain mitigation activities Cochrane review on mould mitigation.  

Perhaps just as disappointing is given the huge controversies regarding mould, and the burden of illness that  mould invokes, is the lack of public health attention to the basic problem of housing and mitigation of mould.  A good economic analysis from the EPA is available at Reprint of EPA funded work from Indoor Air Journal  and estimates the annual US costs at $3.5Billion for asthma alone. 

So while mould has received a bad rap through the toxic mould controversy, please don't underestimate its role as a very important public health concern and chronic manifestations of malaise.  

Tobacco – a few quick puffs

Lots of tobacco smoke in the air these days.

The start of a Quebec class action civil trial is making headlines as lawyers argue for $27B in damages.  Quebec class action law suit.   While the Canadian legal system is renowned for its molasses  rate of flow, it is notable that this suit took over a dozen years to get to court, and will likely take years to work its way through the system.   A similar suit initially launched by the BC government in 1998 recently cleared a Supreme Court challenge on a point of pre-trial clarification on whether the federal government was co-liable with the tobacco companies for tobacco related damages July 2011 Supreme court decision .  Ontario, New Brunswick and Newfoundland have also initiated court actions since the BC challenge began.  All provinces have apparently passed enabling legislation to allow for such actions.

As of June 19, 2012, Canada will require new graphic packaging warning that cover 75% of the packaging material.  As of March 21, 2012, manufacturers and importers of cigarettes and/or little cigars will be prohibited from selling or distributing packages of cigarettes and little cigars that do not display the new health warnings.

Tobacco news from south of the border.  The 2012 Surgeon General’s report on Tobacco and Youth Surgeon General - smoking and youth 2012  was released this past week;   Nothing astonishing, just confirmation that smoking is bad for you, tobacco use rate reduction is slowing, advertising contributions to initiation, and cessation requires a multicomponent approach. 

While the Canadian judicial system has its problems, at least the Supreme Court of Canada under Justice McLachlin has been adamant that they do not establish policy.   Such is not apparently the case for our closest neighbours where political ideology is integral to court appointments.   An injunction against implementation of a Tobacco packaging labels was granted by a US district court judge which will delay what are now accepted as effective and useful interventions to prevent smoking initiation and encourage cessation.   The  Tobacco Free Kids press release provides an analysis indicating flaws in both the law and science.  While the decision has already been appealed, the US judicial process also moves slow enough that tens of thousands of preventable deaths will not be averted due to the decision of a judge – who has no accountability for sentencing these persons to death.   

And, on the day this was posted the following court backs packaging .  This report speaks to two court cases and references the one above.   The 2-1 decision of this appeals court is one that supports the government in requiring the labels.   If any reader out there can help differentiate the impact of the two decisions, I'm sure others would be interested.

May 17 - a late amendment but worth recording here.  Strong action by the Association of Attorney Generals in the US aimed at large movie studios to improve their performance on use of tobacco in movies with youth viewing audiences.  http://www.naag.org/movie-studios-should-stop-depicting-smoking-in-youth-rated-movies.php