Supervised Drug Consumption Sites - Toronto and Ottawa sitting in dark ages

Canada is blessed with Andre Picard.  He is Canada's only public health reporter and for those who don't follow the Globe and Mail column, it is highly recommended of what might be considered an antiquated form of blogging. His contributions are insightful and to be respected.  Mr. Picard has received citations as the inaugural national Public Health hero in 2005 from CPHA, and commendations from the Public Health Physicians of Canada (formally NSSCM) amongst others.  Andre Picard at the Globe and Mail

A recent posting deserves the attention the public health community. While much has been written on this site relative to supervised drug consumption  insights into INsite  Supreme court decision  , the next phase of the debate is initiating and implementation in Montreal, Toronto and Ottawa.   As BC demonstrates reduction in HIV transmission that have not been shared across the country you might think that policy makers would ask the question "Why" and what is different.

The April 11th Globe and Mail posting on the debates in Ottawa and Toronto are disheartening.  Ottawa has  backed away from many basic harm reduction activities under the current local government and now has one of the highest HIV and Hep C transmission/incidence rates in the country - duh?  Who is kidding who? Why would any local government want to have such a tarnished reputation. It will likely take the son or daughter of a politician that contracts one of these illnesses at a young age because of an inability to access harm reduction equipment before the urgency and crisis becomes reality. SIS Ottawa and Toronto.

Read also the study which recommended implemenation at http://www.scribd.com/doc/88882905/TOSCA-Report-Short-Version-2

In the more enlightened environment just to the east of Ontario, Quebec is supposedly more actively pursuing appropriate services for drug users which may include supervised drug consumption.   

Drug user services Quebec  

Our society has effectively ensured that someone who knowingly infects another with HIV is subjected to the full force of the law.   Hence politicians who knowingly make decisions that result in infections of others with HIV should be considered accountable under the same laws. The supreme court decision actually references supervised injection sites as "been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada."  

The other piece of good news, is that at least the issue is being discussed and acted upon in Canada and was discussed in what is one of the top 10 viewed postings.  HIV in Canada  .  Our colleagues to the south face a tsunami of  impacts from benign neglect.  

Surfing the net for Public health stories

On April 11^th, a surge in visits to this site occurred with nearly 100 hits in a day.  Notable is the surge appears to be coming from our US friends and the interest in the site and comments are welcomed. This blog is predominately focused on Canadian public health issues, however our countries are inseparably entwined and public health issues know no boundaries.

Lots in the in-box worth discussing – with a focus on a determinants of health and inequities.

Socioeconomic status:  Screening for poverty – another contribution from the folks at St. Mike’s in Toronto speaking about the need for screening for poverty in family practice. It seems to have initiative a series of articles in the blogosphere as well.   Relatively high level discussion about how poverty contributes to poor health.  Lacking is any tool for undertaking screening that would make it easy for health care providers to incorporate into their health assessments.  Healthy Debate - screening for poverty  and Kevinmd blog in response . 

Literacy and health – a topic for blogging unto itself.  This nifty BMJ article better documents risks of health literacy as it relates to mortality.   Lower health literacy, higher risk.  Just as importantly, in the random sample of seniors from the UK survey on ageing.  The hidden gem in the data that isn’t mentioned is Table 1 is the very neat nice gradient of how literacy levels are better in younger populations, with over 75% of the 50-59 age group in the high literacy bracket.   BMJ article on low literacy .   Well worth the read for those that are advocating for more literacy instruction. You might also want to read the criticism incorporated into Dr. Schreker’s blog mentioned below. 

Personal health practices:  As evidence mounts on the health benefits of exercise that exceed the reductions in disease risk factors, the race is on as to what form of exercise has the best benefit.   An entry in the cycling category confirms the intuitive about cardiovascular diseases.  The study does not seem to lay to rest concern about the injury risks of cycling Cycling as a health intervention   .  Walkers, swimmers and those with your favourite exercise need their own evidence reviews.

On the flip of exercise was a nice piece on foods that have more sugar than a Twinkie.  You will likely be surprised even though you no doubt someone who thinks they are health conscience  Huffington Post high sugar foods  (see the nifty formula on estimating sugar content of yoghurt submitted in the comments)

To close – two blogs on social inequities – another from the St. mike’s site http://healthydebate.ca/ the blog at Healthy equity missing in action   and a more optimistic view from Ottawa’s Dr Ted Schreker who speaks to igniting a social movement about inequities based on evidence A social movement based on evidence 

Happy surfing.   

Hookah pipes – a new generation of smoking hazard

This posting receives significant ongoing visits and is one of the most visited blog postings for this site.   For those interested in the hookah topic, please see the update on science of Hookah posted DrPHealth February 17 2014     

The use of waterpipes stems from the 16^th century somewhere in the Indo-Persian region.  It is a product of the introduction of tobacco from the New World to European and subsequently Asian cultures.  Ironically, the intent in the use of waterpipe was to purify tobacco smoke by passing it through water before inhalation to reduce already suspect health impacts of the time.  The dating to only the 16^th century raises interesting questions on what historic value do certain practices need in order to be considered of “cultural significance”. 

The cooler and moister smoke makes for deeper inhalations rather than the more traditional “puff” of nicotine-seeking behaviour associated with cigarettes.  The process of heating tobacco also results in lower temperatures of the smoke, suggesting the potential for a different chemical mix. That the tobacco is heated by charcoal or other burning substances rather than directly burning the tobacco adds more chemicals to the mix.   Rather than the typical 7 minute cigarette, Hookah sessions tend to run 40-60 minutes.  During that time users will supposedly inhale anywhere from 100-200 times the smoke volume of a cigarette.   Granted, the weekly consumption totals will be highly varied as Hookah sessions are much less frequent. To complicate the analysis further, more recently there has been the shift from using tobacco to tobacco-free alternatives raising questions on different substances, their chemical composition when burnt and their potential health risks.

Newer technologies, newer forms of recreation, and once again public health authorities are needing to race to determine if the new form is safer or more harmful than the standard cigarette.   Similar debates have occurred with smokeless tobacco, pipes and cigars.  The WHO took an initial step in 2005 with a preliminary advisory report WHO and water pipes  and suggested that waterpipe smoking of tobacco is a serious potential health hazard. 

Initial work has focused mostly on the toxicology.  Simply put, there is nothing to suggest that Hookah tobacco smoke is any less toxic than cigarette smoke – in fact evidence leans to a greater complexity of potential health risks.  Some comparisons between tobacco and tobacco-free products suggest that the difference is minimal although nicotine is substantively reduced.   The following table was taken from a report that is not published but compares typical water pipe sessions with tobacco and tobacco free substances with a reference single cigarette. 

Shihadeh, Does switching to a tobacco-free waterpipe product reduce toxicant intake?  (undated manuscript)

The second step in the public health analysis takes to looking at human health impacts.  For this, Akl et al undertook a systematic review in 2010 http://ije.oxfordjournals.org/content/39/3/834.long  and found for tobacco related waterpipe smoking had elevated risks for lung cancer (Odds Ratio 2.1),  respiratory illness  (2.3) and Low birth weight (2.1).  Other associations were not seen as significantly increased.  The quality of the evidence for the review was considered very low to low – suggesting much to be done in epidemiological analysis before definitive health statements can be made.

The dilemma for the public health professional becomes to what extent does definitive negative health impact have to be proven before interventions are undertaken to reduce waterpipe use and its associated disease impacts?   As the popularity of the social event of sharing the Hookah increases, especially amongst youth, the need to intervene must be balanced with sufficient evidence to be able to legally defend any protective interventions.  It is truly an emerging public health threat.  

Chocolate – healthful or not? - Hoppy Easter

At a time when we should look to global peace, irrespective of your religious affiliation, you are referred you back to previous postings where the tragedies of the current violent world are documented Peace as a health prerequisite   War and Peace DrPHealth.  

How about something a bit lighter to commemorate the global celebration of peace?   For whatever reason (and there are a few theories), chocolate has become synonymous with the Easter season.   This poses the question of whether this delectable substance has more benefit than harm?

The first obstacle in the debate is defining what is chocolate?  The Dairy Milk, Cadbury, Mars, Hershey’s Kisses or chocolate bunnies that adorn certain homes and may be the target of chocolate egg hunts are far from the pure cacao originally cultivated in Central and South America for thousands of years.  Pure ‘cacao’ and its refined product ‘cocoa’,  have been subjected to innumerable health studies and enjoy claims of reducing migraines, reduced LDL lipoproteins, faster muscle recovery, reducing dementia and as an aphrodisiac.  The later appears more lore than evidence based, but indulge yourself in self-reflective research and make your own assessment.

The Mars company has invested extensively in researching flavinoids, a component of cocoa.  One might think the purpose is self-serving, however as privately owned corporations go, the Mars family has little more to gain in advancing personal profits and the curiosity based exploration of science deserves passing commendation. The lack of prolific evidence of benefit is knowledge unto itself.  Now if only more companies would invest in any branch of scientific research we would all benefit.

Regrettably however, cocoa is frequently mixed with milk products, sugars, and fats – diluting what pure benefit cocoa might bring forth.   Cocoa diluted down to as little as 15% (usually less than 1/3rd) with the remainder being saturated fat and simple sugars which are known to contribute to cardiovascular problems, diabetes and obesity.  Those added calories and fats likely at a minimum negate any value of pure cocoa extract contents.

So – if you are to partake of the sacred bean, do so with the purest of cocoa, and in moderation!  

As a sobering final thought; Nearly half of currently global cocoa production comes from the Côte d’Ivoire, with another 1/6^th from other Western Africa countries.  Countries of which are renowned for exploitation of children for labour, including harvesting of the cacao bean. 

Electronic Health Records - so much spent and so far from achieving the goal

Canada Health Infoway  Canada Health Infoway  has spent $1.6Billion since 2001 trying to build electronic health record infrastructure. Te previous blog speaks to some of the success in improving convenience with telehealth.   Much of CHI spending has gone to support laboratory infomatics, radiology picture archieving systems (PACS), and a dribbling into electronic medical records.   Admittedly standards have been set internationally on data infrastructure to facilitate communication  between systems, however where are we?  To read a rather scarthing report of Canada Health Infoway specifically the Office of the Auditor General  report at 2009 OAG report Chapter 4 

Major health care facilities have aligned behind a small cadre of electronic backbones that integrate hospital encounter data with financials.   They are poor long term management tools for patients.   Electronic medical record systems are better designed for repeated episodic care coordinated from a single office and were only available to 17% of people in 2009

Most provinces have stand alone pharmacy systems that track medication dispensing.  Several attempts have been made for integrated public health information systems, that minimally interact with other health care systems.  Laboratory data is aligned behind the lab providing the service and not the client to the whom the values are important.  Same goes for radiology.   Residential care information is almost non-existent and home care encounters are among the least electronically documented services.

Clearly lacking are the full system structures that take a holistic view of the patient/client, case manage their needs through multiple health care provider encounters – and most importantly where the information is accessible from multiple providers.  No doubt care has improved, both in the doctor’s office on management of chronic diseases, and during acute episodic care.  We are still several leaps from delivering on the vision of a truly functional electronic health record.  

Canadians trail their international counterparts in electronification of health records – this in a supposedly universal care environment.  Not surprising, tracking of finances has been a better driver of improved electronic health records than has the Canadian covenant on universal health care.  

Professionals hide behind cloaks of confidentiality and other feeble excuses like the need for a pan-Canadian immunization register.  Patients live in relative ignorance of the threat to their wellbeing that lack of interconnectivity imparts.  Fundamental changes in how we do health can save huge costs, yet relatively little is being done to require change, caught up in legal debates and vaguely veiled ethical issues.

As for being your own keeper of your heath information – just try to pull together an integrated health record based on your interactions with the health system.  Expect to pay for photocopying of “your” files, and deep resistance to releasing “your “ medical records to yourself rather than a health professional to whom you have entrusted your care.  And don’t be surprised about the gaps in information, many records are irretrievable prior to electronification – and at some point data management becomes problematic and even electronic records are stored in cyberlimbo.

Until patients demand change, and demand that the providers of health care contribute your data in a fashion that you can control, expect slow and less than methodical progress on data integration.  In the meantime, there are many radiologists that appreciate being able to access the publically funded PACS system from the comfort of their bedroom rather than having to visit the hospital.  Pathology samples that are being sent across provinces in digital format for interpretation so local health systems can reduce costs. ECGs that are being read digitally from who knows where?  Has this convenience improved the care that you receive?   Unlikely. 

Telehealth: A real public health contribution - or at least a major convenience

Telehealth has come to Canada in a big way.  One success of the Canada Health Infoway, a future blog will speak to the relative failure of other initiatives. 

 Gone should be the day long excursions of rural residents to the specialist for a 15 minute consultation. From the comfort of a telehealth unit, dermatologists and psychiatrists can examine and assess a patient and even begin treatment.  Specialists can do assessments and follow-up visits remotely saving both patient and physician time and effort.   Surgeons can complete pre-surgery work without the patient ever needing to leave their home community until time for the surgery.  Even some physical examination can be done remotely as sound, look and touch can be digitalized.

Of course many diagnostic images can be obtained in one city and interpreted almost instanteously in another.  Pathology specimens can be batched together for specialized interpretation anywhere.   Electronic impulse recordings (ECD, EEG etc.) digitalized, and sometimes even interpreted electronically.  Photos of wounds, ulcers, rashes and other skin disorders can be channeled to health care providers overseeing care to diagnose and to monitor treatment progress .

In the most forward thinking of interventions, surgery can be done remotely using robotic tools managed by the artist in a different location.  

Consolidation of experts has significant advantages for provider groups and will improve efficiency.  Convenience for residents is greatly improved.  Medical transportation costs can be reduced where these are subsidized.   And for a relatively paltry cost that many communities can afford.  Most of the major obstacle of payment has been overcome.  Oddly, a good portion of current telehealth consultations could likely be achieved over the telephone and adequate compensation for such service is lacking expect in payments for full episodic care. 

Of course evaluations speak to the convenience of the service more than health impacts which demonstrate “no inferiority” to the service.   In a health system struggling to find dollars, its perhaps ironic that telehealth has received so much investment and praise.  It is tangible demand of the consumer for service oriented functions that has driven the improvements – a message that health consumers can and do have a voice that can be expressed and heard.  

Within larger communities, home monitoring of patients with congestive heart failure and chronic obstructive pulmonary disease are being trialed with real successes in reducing emergency and hospital care – all through the telephone or Internet.

There are advantages to telehealth for rural communities that lack health care facilities.  Such access is integral to community growth.   The next step will be trying to bring primary health care services to telehealth, and that has been only marginally undertaken in the most remote of regions. 

Expansion of urban (and rural) chronic disease remote (home) monitoring seems to be an impending reality and an added benefit if there is a good way to link the service to primary care provision. 

Star Trek views of electronified health providers are still fictional, however telemedicine has been piloted specifically for space exploration – and the benefits of this technology are being applied for the convenience of this expansive country.  

Canada`s 2012 Budget - Public health implications

If Jim Flaherty’s Canadian 2012-13 budget was sending a message on public health, it is two fold – one that health is a provincial responsibility and the federal government is getting out,  and secondly that the Conservative philosophy is that supporting big business will result in a healthier Canada.  On the latter the only comment is what did we expect when we elected a Conservative majority?   On the former, another cop out and downloading onto the provinces that are also reeling under financial pressures and squeezed by federal government offloading. 

The NDP will take up the national health care banner in defence.  We should be glad that somebody will, but it politicizes national health when a solid pan-Canadian pact that holds to the vision of the Canada Health Act is needed.  Flaherty has already indicated that he is willing to impose the new social pact on health with the provinces without negotiation.  It clearly is reminiscent of the school yard bully.

Drilling deeper, and remembering that often the devil is in the details that are not released.  What does the budget signal?

Increased support for health professionals, particularly pharmacists, in their health business efforts.  Changes to sales tax expectations will benefit other primary health care providers and expand the number of front line health professionals providing ‘service’.  

Solutions are being sought for the medical isotope production challenge – a good move for the federal government to be taking leadership in.

Expectations of increased presence and service by Health Canada and PHAC in the Territories – also good news.

CIHR will see funding go down $30M and then half this reinvested in research – read into this what you will.  It is a clear message on streamlining government administrations.

Gone is the Assisted Human Reproduction initiative – apparently the victim of a court decision that this is a provincial responsibility.  No doubt that there is no funding being transferred to the provinces to assume the costs.

More subtly in the reduced discretionary funding for advertising, apparently the truth in food advertising work will fall to the wayside .  This from a government that really did not savour loosing salt in its food when the recommendations of the pan-Canadian group came forward in 2010.  Score another one for the “Big Food Industry”.

More obvious is the announcement on streamlining of environmental assessments.  On the surface a clear message that prolonged debate over mega-projects will not be tolerated.  Where the details need to be flushed out is do environmental and health agencies have clear assessment protocols in place now?  They should and a sleeker assessment process would be appropriate and welcomed by all.  The slimmer approach should not mean rubber stamped approvals – just coordinated assessment. 

Ok, who are we kidding?  Environment Canada is loosing over 8% of its staff, how are they to undertake a streamlined assessment process with fewer staff?  It has taken decades to finally get public health impacts integrated into some of the mega-projects and consistency is already lacking. 

Not surprising the Liberal legacy of the Public Health Agency of Canada has had the first shovels of its grave dug when supposed streamlined ‘increased efficiencies in mergering the backroom activities of similar agencies such as Health Canada and PHAC’.  So expect the health assessment components of the mega-project assessments to take a big kick as well.

As the provincial budgets have been released, little positive in support of public health or investing in reducing inequities has been sounded.  Conversely, the hacking sound of slashing has yet to be heard prominently despite the tough times being felt on the front lines. 

In the midst of tough economic times which this blog has discussed (eg DrPHealth equity and taxation), the federal budget is receiving minimal criticism for what it has accomplished and what it threatened to do but didn’t.   Not surprising a more detailed health analysis of the budget is needed, and strong comment made about:

1.       Lack of federal leadership on health 

2.       Offloading of health costs onto the provinces

3.       Early warning signs to reducing the role of PHAC

Readers who are aware of other public health messages in the 2012-13 budget are invited to send their comments and add to our collective understanding.  Post a comment, or send an email to drphealth@gmail.com