US supreme court decisions favours Obama health care reforms

The historic and far reaching US supreme court decision supporting President Obama's health care reforms "largely unscathed" by the court decision is a significant victory for US public health professionals.   There will be innumerable analyses of the decision, but a relatively concise and well written one is found in the Washington Post http://www.washingtonpost.com/politics/supreme-court-to-rule-thursday-on-health-care-law/2012/06/28/gJQAarRm8V_story.html  .

Hidden in the final decision is that the 9 judges were split predominately on ideological lines, with four dissenting conservatives issuing a scathing minority report that questions numerous points of legality.   Four liberal judges backing the formal court final decision.  And a moderate single voice predominately leaning in favour of the decision.   Such a fine line between passing and falling, based not so much on legalities but on ideology of the courts members.

And while a major political victory for Obama during an election year, the comment of his rival Romney was that the first thing he would do if elected would be to repel the reforms.   The debate is not over, and may in essence come down to the single and solitary issue on which the November US election is run.   Regrettably, the often dominate libertarian lifestyle may surpass the collective utilitarian good.   Stay tuned.

Public Health in the News: People, Quebec Tobacco law suit, Gambling advertising, Cosmetic pesticides

Today is one of those historic public health days.  The US Supreme Court will determine the constitutionality of providing health care to all Americans.   Put differently, it gets to decide whether it is legal to let some 20% of our southern neighbours die prematurely because of their personal financial barriers to health services, or if there is anything to be said about the “We” in “We the people….  ”.   More on the decision in a future blog.

It was with concern and dismay that the February stroke of Canada’s first and only Chief Public Health Officer was announced several months after the event.  Fortunately his quick mind, biting wit and perseverance for Canada’s public health was not affected, the stroke limited to motor functions in one of the lower limbs, or so the media reports say.  May all of public Health wish David Butler-Jones a full and fulfilling recovery. 

For those following the movement of key public health folks will note that Andrea Corriveau has returned as the CMHO for the Northwest Territories after a three year stint in a similar position in Alberta.  James Talbot has moved from deputy to CMHO for the province in a deserving career step that has had its share of Albertan propensity to see public health folks move in and out of favour. 

Manitoba remains under the leadership of Margaret Fast since the untimely departure of one of Canada’s solid public health leaders in Joel Kettner.  No doubt there are other recent movements as well of lifelong public health contributors to be celebrated.

Quebec has joined with most of the other provinces in suing tobacco firms for unnecessary and preventable health care costs associated with misrepresentation of the tobacco product. In this case $60B.   The story in French at Lapresse on Quebec tobacco law suit 

Have you noticed the surge in advertising related to gambling?   No doubt one of the next logical targets for public health advocates is to begin to constrain this addiction, and government addiction to the revenue carried on the backs of their citizens.   The story from Ontario about advertising that suggests that to get away from family you should go to the casino hit a few raw nerves Forget your family - The Star.    

The Ontario College of Family Physicians released an updated literature review on the impacts of pesticides in the ongoing efforts to limit toxic effects OCFP and pesticides.  This group has been one of the leading driver of pesticide reduction efforts in the country and clearly has been effective in Ontario.   There efforts did not however sway the BC government committee that dismissed certain scientists and used anecdotal evidence on the failure of weed management strategies  in a couple of situations as sufficient rationale to recommend against a cosmetic pesticide regulation for the province BC cosmetic pesticide committee report.   The truth likely lies somewhere between this extreme positions.   The Scandanavian “substitution” principle adopted in Europe nicely handles the debate more than the much debated “precautionary” principle.  Substitution principle 

Something to deaden the sweet tooth

A few years back we received a listing of the top 20 calorific drinks.  A condensed version of the list can be found at 20 most calorific drinks, the original supposedly in Men’s Health May 2010.  Starbuck’s was rightly roasted with 3 servings of their Vanilla Frappucinno (290 cal) , Peppermint While Chocolate Mocha with whipped cream (660 calories) and White Hot Chocolate with whipped cream (520 calories).  A Dairy Queen MooLattee coming in at 870 calories, Baskin and Robbins ice cream soda at 960 calories, McDonald’s triple thick chocolate shake at 1160 calories and the cream of the crop was Cold Stone PB&C at an amazing 2010 calories.

This past week, a listing of ten top calorific deserts Top 10 desserts top ten calorific deserts.    Promoted by the current North American bacon bit fad that has worked its way into a Burger King sundae and tops the scales at a mere 510 calories per sundae.  Dairy Queen blizzards (size not listed) topping just over 1000 calories.  Our favourite for sharing amongst a whole table of friends is the Cheesecake Factory Chocolate Tower Truffle Cake at 1679 calories, or about 40 calories a forkful by our calculations.   Its the amazing Keg offering of a Carrot Cake a la mode that tops in at 2344 calories to definitely take caution of. 

If your stomach is not already tumbling and heaving, how about taking a quick look just at volume and what has happened over the years in terms of normalizing soft drinks sizes.   Megasizing soft drinks  can be put in perspective by thinking 10-15 calories per 30 ml (ounce).  so going from 200 ml - or about 75 calories, up to nearly a 4 litre cup (128 ounces) containing some 1500 calories - gives some sense of how marketing impacts individual choice.

There are very few naturally occurring drinks other than milk and water that humans are used to. Tea and coffee without any sugar or milk also make the list if you needed something more.   In a day and age where we are all struggling to keep a bit thinner, cut the calories from what you drink, and steer clear of the deserts. 

If nothing else, take a look at the links to do a bit of behavioural desensitizing.  

Drowning in data – Making sense of health indicators.

Alice slipped down the rabbit hole and subsequently through the looking glass into a world fantasized by a mathematician, filled with symmetry and logic – and designed to please the literary masses.  Her enduring stories have captured the imagination of children and adults alike, and been the subject to innumerable academic analyses.   Her creator is the envy of many scientists having mastered the ability to utilize storytelling to convey logic and information.  Although his stories were predominately for entertainment, we are faced with similar challenges in trying to convey stories told by reams of data that bombard the wires.

This past week saw the start of the release of the most recent round of the Canada Community Health Survey.  Buried in the home site are links to community or region specific information in addition to provincial data.   CCHS 2011 release  No doubt you as a reader can dig deep and develop your own story about trying to access information.   Humourously, Stats Can must have a bug in their program for dating webpages, with posting years in the future being commonplace.  It is the sort of oversight that undermines the importance of the data that was released.

There are some interesting stories to be told:

Good news

·         Tobacco use continues to trend downwards in both genders and all age groups. 

·         Physical activity continues to trend upwards in most age-sex categories. 

Not so good news

·         Heavy alcohol consumption continues to trend upwards in particular in middle aged persons.

·         Overweightness continues to trend upwards although some suggestion that stabilizing and optimists might think there was some reduction in the past couple of years.  

·         The proportion of the population adhering to 5 fruits or vegetables daily is not trending in the right direction.

For those that wish to put Canada in the context of our global neighbours, check out the WHO 2012 world health statistics report.  WHO 2012 report   This is a data dense and unwieldy 178 page document that describes regions and countries by over 100 indicators.   A rich source of information, lacking in the literary prose of Lewis Carroll, but certainly making one feel like they have slid down into a world of numeracy where graphs and numbers abound.  Enjoy the ride, or perhaps better advise would be to assume the rabbit hole is filled with water and practice treading water to stay afloat.   

The case for, and the effectiveness of, action on determinants of health

Happy National Aboriginal Day - celebrate our heritage


Since bouncing onto the Canadian public health stage in 1994, the determinants of health (DofH) have been battered about as a new technology – more often as a descriptor of problems than a technology to be applied to the problem with measurable success. DrPHealth on determinants of health  

The past year has seen the world congress in Rio with the declaration that Canada has yet to pronounce upon DrPHealth on world congress , the WHO Commission report was released in 2009 and readers are encouraged to follow the Commissions work and activity Commission final report  

This past few weeks, four new items for those that have the DofH in their toolboxes

From Australian is a monograph on the cost of inaction.  Australian monograph on cost of inaction   While this is another descriptive study looking at health inequalities, it attempts to put some monetary value to the cost of disparity.   It also is a good insight to how another country grapples with determinants.  While Australia has its own set of governmental challenges, public health is much more closely held at the national level.

From the National Collaborating Centre on Determinants of Health http://www.nccdh.ca/   as review on intersectoral action in addressing determinants.   Intersectoral collaboration from NCCDH  As has become an increasing trend in systematic reviews, there is as much on why no conclusions can be drawn because of poor methodology in most studies, as there are gems to be found in the handful of studies that met the muster criteria for inclusion.

Fear not, at least groups like Ontario Health Promotion have issued an E-Bulletin on planning to action Ontario Health promotion e-bulletin  which lays out a generic framework for action on determinants without worrying too much on the lack of scientific foundation, and encouraged collection of information on effectiveness as the process proceeds.

For the real keeners, there is an international forum from the WHO for persons working on Determinants of Health http://www.actionsdh.org/ .   It is only through collaboration and sharing of experiences that the technology will be applied effectively and efficiently.

Dive in and take a shot at your favourite determinant. 

Inequity - Communicating the message.

A piece from the Winnipeg Free Press is the latest item where the media are supporting and driving the public health agenda of reducing disparities.   Winnipeg Free Press June 18, 2012  Masters of storytelling, such heartfelt pleas echo the public displays of discontent in the Montreal student strike, the Occupy movement and even the efforts of doctors for fair taxation Equity and taxation – the status quo is being whittled away.  

Yet, despite the crashing Greek economy with unemployment approaching 25%, the conservative leaning incumbents were returned with the plurality and asked to form a coalition government. This contrasts with the election of the left leaning French Socialist party presidential candidate.

As powerful as the media can be in expressing the message – it is further enlightening to read the personal reactions to the Winnipeg piece.  No wonder there is such resistance to addressing the increasing disparity in the country.  Clashing values of personal happiness against societal altruism are played out in the words of individuals responding to the article.

Just as the G20 countries prepare to meet in Mexico to further discuss the current global financial crisis that has banks and businesses suffering such that public tax dollars are being poured by the billions in corporate welfare while personal welfare programs are cut to balance budgets.  Buried deep in the throes of the bureaucracy is this December 2011 OECD report Divided we fall:  an overview of growing income inequalities   an economic analysis of inequality globally.  A Canada specific summary is available at Canada report, US at US report  

Note Figures 9 and 11 – which display Canada’s inequality in respect to other developed countries.  Figure 11 (pasted below) adjusts for the impact of universal health care and makes Canada look as good as any of measures. Using any of the three Gini coefficient measures in the document, Canada remains higher than the OECD mean – and higher means more inequality.  (for more on Gini coefficient  Gini coefficient September 14, 2011 ). Figure 12 also below,  is most disconcerting for North Americans as it shows the increasing proportion of wealth held by the top 1% of income earners, with the US in the not so enviable position of number 1 and Canada number 3.

Figure 11

Figure 12

Why, in the midst of such forces as left wing leaning social and health professionals and right wing leaning economists – both of whom have been signalling warning signs of the dangers of propagating the long term trend of increasing disparity, do we continue to have political decisions which fly in the face of facts?  Truthfully, the OECD report is dry, unexciting, lacks story and personification – reminiscent of many public health reports.  While the number crunchers may get thrills from reading the report, it likely had little impact on policy decisions in any OECD country.

Good governance is the ability to provide leadership amidst conflicting value structures with an aim for the greatest benefit.  While the media may be the new modality messaging inequality, the media have also been the drivers of populism as the goal of governance rather than leadership.   There was a notable subpiece to the Montreal student demonstrations on the success of the new generation to win the use of new communications media http://www.ctv.ca/CTVNews/Canada/20120618/social-media-quebec-student-protests-120618/ .  The press have long influenced public opinion and have been the puppeteers of political winners and downfall of political losers.  We in public health have a lot to learn about moving from number crunching to pulling at heart strings.  

Father's (and Mother's) Day celebrations - Demographic changes as presented by Dr. Hans Rosling

June 17^th is Father’s Day, and the second of the parental celebrations. 

Please take this as a chance to celebrate both Mother and Father's Days and to discuss the changing dynamics of family structure in Canada and globally.   Statistics Canada has special releases on the changing role of mothers Stats Can and Mother's Day  and fathers Stats Can and Father's Day.   Note the very significant increases in dual income families and single income families led by mothers over time. 

For those that have followed the great discussions over the decades on family planning and control of global population growth along with the Malthusian predictions of overpopulation and nonsustainability will welcome recent demographic information. Considerable progress has been made in many countries, with the global fertility rate now resting close to global replacement levels.  

Take 15 minutes and watch the international public health expert Hans Rosling from Sweden’s Karolinska Institute discuss what is happening with population growth, in the latest instalment as it relates to the impact of religion (and income) on fertility rates.   Hans Rosling on religion and babies .  You will need audio to appreciate the presentation.

If you have more time, learn more about Hans Rosling and listen to his presentations, some of which are listed below.  Most notably is the ability to use time trending to display how quickly change is happening globally with demographic predictions for the future.  

200 years and 200 countries   just 5 minutes and absolutely amazing.

Global population growth - 10 minutes

Best stats ever - 20 minutes

New insights on poverty - 20 minutes

Dataset and mindsets – 20 minutes   

His skills as an educator are phenomenal and a learning experience in of itself.