Thanksgiving Appetizers: Sizzling topics in Public Health

There is never a shortage of short snappers to be gobbled up around Thanksgiving time.   Here’s a set of appetizers themed just on sexual and reproductive health issues.

A small study that confirmed something that has been stated in the past, HPV is not limited to girls who have engaged in intercourse, hence the provision of HPV vaccine to sexually naive girls prior to first intercourse is further justified.  NBC report on HPV risk.

A  synthesis of interventions to reduced the behavioural outcomes of sexually transmitted illnesses amongst activities that showed strong evidence for improving knowledge and self-efficacy.  The critical link of then tying this to changes in behaviour such as condom use demonstrated some benefit and concluded the further research is required to identify what is most effective and how to further improve outcomes. behavioural interventions for preventing STIs.  The good news is that the programs did not negatively impact measures like earlier sexual initiation which advocates opposing sexual health programming frequently vocalize as a concern.

A review looked at different strategies for cervical cancer screening and actually recommended that for resource constrained areas a different strategy than for resource rich areas. cervical Ca screening    A DrPHealth plea that a new criteria for screening programming is that they not exacerbate inequities. 

For those engaging in higher risk sexual activities, the question on pre-exposure prophylaxis for HIV prevention received a review concluding that there is a benefit HIV pre-exposure prophylaxis.  Now if only we can expand cheaper HIV treatment programming in developing countries. 

This week is International breastfeeding weeks and a review article demonstrates the definite value of exclusivity to 6 months and lesser but useful benefit of partial breastfeeding during the first four months Breastfeeding duration .   Canada continues to improve on breastfeeding measures with increased initiation and duration and well worth celebrating each year  Breastfeeding review 2011.

May the Canadian Thanksgiving weekend be filled with family, friends and happiness. Thanks to the loyal readers, and to the new readers who have picked up traffic on this site in the last few weeks.  Your support and promotion of the site is integral to its success and continuation. 

Fighting fat. The politics of obesity interventions

In the fall of 2010 the pan-Canadian Ministers of Health released a report on Curbing Childhood Obesity in Canada.  This was followed in June 2011 with a descriptive monograph of Obesity in Canada.  This site has addressed the issue of weight control on numerous occasions October 2011 , March 2012, June 2012.

In the short time since the formal national dialogue has begun on curbing youth obesity, there is lots beginning to happen.  One would expect a shotgun approach to finding out what works, and what doesn’t.  Lining up are the academic community on one side, looking for the research dollars from the trickle of beginning to flow from places like CIHR.  On another side are entrepreneurs looking for a share of a burgeoning market, whether in specialized camps, training facilities, weight loss programs or snake oil supplements to curb appetites.  On a third side are a group of funders who have historically funded children’s health care and looking to enter into the market and new issue specific groups like the Childhood Obesity Foundation .  On a final side are the traditional program structures of health and education  who are being expected to retool their operations to accommodate new weight control initiatives, and where such retooling is often an impediment dragged by inertia and the inability to stop doing other important work.

Speak to those in the know, and the solution lies in prevention.   Solid family and school healthy eating, supported by a community that encourages healthy foods.  Reduction of fast food marketing and access to youth, reduced screen time and increased daily physical activity.  The problem is that prevention isn’t sexy.  There is nothing to fix, and the costs to existing programs and products that might lose are enormous.  Industry interests from Apple to Burger King, from Game Boys to X-Box have investments that are dependent on recruiting new converts to their products. 

There are however developing school based and after hours interventions for youth identified as at risk for weight problems.  While listed as “prevention”, these early intervention programs are an integral part of addressing weight concerns amongst populations that have yet to habituate lifestyles.   The Canadian Obesity Network provides a list of combined prevention and early intervention programming that is a good reference Canadian Obesity Network  although the site is a bit dated in its postings and appears inactive since summer 2011.  

The third component is in intervention based programs.  Whether hospital based bariatric services like offered in Winnipeg, Shape Down in BC, Pediatric Obesity Clinics that are sprouting up associated with children’s hospitals.   These will be necessary intervention based treatment programs until effective prevention and early intervention are in place.  Such treatment programs however should be short lived if other prevention and early interventions are effective and supported.   It would be a shame to see major funding shifts that focus on treatment without matching such dollars with prevention. 

A late addition comes out of Wellesley Institute blog http://www.wellesleyinstitute.com/news/childhood-obesity-in-ontario-why-we-must-act-now/#.UGuHb0ea0UA.twitter . Another corporate style program forwarded via Twitter, and a community based demonstration project information on SCOPE. 

So the last question is probably the toughest and comes from the Wall street journal as New York City has waded further into government’s role in addressing obesity, who’s responsibility is it to prevent obesity, society or the individual?   Obesity prevention responsibility .  A more fundamental philosophical question is whether obesity  and weight problems are even a disease?  While they are a risk for illnesses, do they meant the criteria for being an illness themselves?   Your opinions are welcomed as a comment.   

Where's the Beef? The tainted meat is a public health scandal

The massive beef recall in Alberta is on one hand unfortunate, on the other hand likely was predictable and preventable.

A visit to a slaughterhouse is not a Sunday picnic.  Employee turnover amidst the blood, guts and odours is very high and most staff are minimally trained for the importance of their jobs.  Wages are low, and in the Brooks XL meats facility employees are sometimes bussed 1-2 hours each way to get to the operation as housing in the area is not affordable. Many workers in abbatoirs and slaughterhouses contract intestinal infections from their work in their first weeks of employment, a time when taken sick leave is not seen as an option.  

Federal meat inspection is provided by CFIA, who in the last round of the Harper government’s budgetary cuts saw very significant reductions in field staff.   Just a few weeks ago the CEO of CFIA left “under mysterious circumstances” with few details released.

One might recall in the wake of the Listeria outbreak from Maple Foods, the CEO publicly apologizing.  Notable in their absence are the directors of XL foods.  Moreover it is the premier of the province that is the goat put forth to steadfastly defend Alberta beef in the wake of the US border closure to beef from the facility. A statement to the well known shady nature of the management of XL foods. 

E. Coli O157:H7 rates in large food animals have a similar seasonal incidence as in humans, a definite peak in the summer years.  The human illness often blamed on inadequate BBQing with minimal evidence that is the culprit. The point being that summer is the time that animals arriving for slaughter should be expected to have the highest carriage rates. 

Alberta is home to about 5.5 million cattle waiting their turn to be loaded into stock trucks, often in the cloak of night, transported to the slaughterhouse, corralled in line to the kill zone where a nail is ‘humanely’ riveted causes as painless a death as possible. With winter approaching and reduced feedstocks available, livestock operators try to get as many cattle to market as possible to reduce wintering costs. 

Anyone looking to brew a perfect storm for an E. Coli outbreak need look no further than a system that is efficiently designed to ensure beef, pork and poultry make it to Canadian plates with minimal publicity, minimal cost and minimal illness.  The Canadian food safety system was for the most part excellent and a source of international pride.  It has taken its share of hits, in part because the system identifies and publically reports its problems.   

The XL meats situation however was a forecast-able storm and went unscathed for too long.  The question is whether lessons will be learned on the prevention of similar situations through recognizing the public good of the food supply chain? or will this just be another Harper search for a scapegoat to sacrifice? 

Follow the debates and discussion on the Safe food for Canadians Act that is currently working its way through the house. It is currently through second reading and before senate committees.     No doubt the interest in the matter will change in the weeks ahead. http://www.inspection.gc.ca/about-the-cfia/acts-and-regulations/initiatives/sfca/eng/1338796071420/1338796152395  

Courageous Conversations: Speaking out on Determinants of Health: An air of optimism.

A friend of DrPHealth just published a posting at one of the better health news sites in Canada called healthydebate.  Dr. Dutt is also a prodigious Twitter under the handle of @Monika_Dutt . http://healthydebate.ca/opinions/the-role-of-medical-officers-of-health-in-addressing-health-inequities  

Another friend of the site Dr. Ted Schrenker who blogs under “Health as if everybody counted”. His blog is linked to and accessible from the Community Health continuing education activities CHNet-works .

Their two recent postings share a common theme.  Dr. Dutt’s focusing on the role of Medical Health Officers in addressing health inequities Healthy Debate September 24 , Dr. Schrenker in two part posting focusing on those who “get it”, and looking beyond the traditional borders of the health system for allies.   People who get it Part 1 and Part 2 .

These both are concurrent with the very powerful posting by an actuary Robert Brown in the Globe and Mail on the dangers of providing more health care more health care does not mean better health   

IN August MacLeans ran an interview with the foremost international expert on inequities and determinants, Sir Michael Marmot Macleans interview 

Add further that Sir Michael Marmot was a keynote speaker at the CMA meetings, and the new president of the CMA talks about inequities and determinants of health as if she were indoctrinated into the language of public health.   CMA meetings.

The common theme is that the rhetoric is changing, that more of the discussion focuses on inequity, and as Sudbury Department of Health led by Dr. Penny Sutcliffe is demonstrating, we can make a difference.  Through a CHSRF funded training fellowship, the department of health provides fact sheets on ten promising practices to reduce inequities in health sdhu promising practices documents.

Once again the discussion returns to Michael Marmot as one of the leading voices on what actions on determinants have been shown to be effective.   Start at his home page UCL profile Michael Marmot and check out the impressive list of publications. The most notable of the articles being one that is not readily available on-line, but in the Annual Review of Public Health (2011) 32: 255-36, authored by Friel and Marmot and looking at action on reducing inequities between jurisdictions.   Well worth trying to track down the material.

Perhaps it is the fall atmosphere, but there is air of optimism in circulation and the winds are changing.  The next steps will be in continuing to further normalize discussion on inequities and actioning work that leads to reductions.  This may well be the public health success for the decade. 

Emerging infectious disease: To worry or not to worry - That is the public health question.

Two human cases of coronavirus have been identified in the past week, both acquired in the middle east.  One case expired,  the other requiring medical evacuation to the UK indicative of severe illness. Coronavirus is the family of viruses from which SARS was bred.  The good news is so far no indication of spread to other humans, and in particular health care workers who are often the first affecting by novel infectious organisms. 

If you go fast rewind back to 2001-2002, the first cases of SARS were reported as a severe respiratory illness in Guangzhou about a month prior to the Hong Kong Metropolitan hotel even with widespread transmission.  BBC on Coronavirus

So, to worry or not to worry, that is the public health question that is faced on a daily basis. 

Here in Canada we are into the second week of a widespread E. Coli ground beef recall that has engendered angst nationally without causing human illness, while a small cluster of cases has occurred in Alberta for which a source has not been identified. The recall certainly has had lots of publicity and media coverage. As of October 1, there have been four cases of human illness linked to the recalls, a posting on October 1 discusses the broader implications of food safety. 

Those following West Nile Virus will know 2012 as one of the bumper years for human illness, but by reading the newspapers it is almost a non-issue.  Over 2500 cases and 120 deaths in the US.  DrPHealth West Nile Virus

Of course, the nine cases and two deaths of hantavirus near Yosemite national parks have authorities scambling and the public in panic over their exposure.

Meanwhile 18 persons have died from Ebola in the Congo amongst 41 cases.  There was some minimal coverage of the unrelated prior Ugandan outbreak earlier this year DrPHealth Ebola

The 13 deaths amongst 180 cases of Legionella in Quebec City have received plenty of airtime and coverage, as much for the controversies associated with not sharing information as for the severity of the illness. DrPHealth Legionella

To top all of this off would the North American wide pertussis outbreak with over 20,000 cases DrPHealth pertussis   

What makes a novel emerging illness one that attracts public attention, and what makes it old and uninteresting item that doesn’t make it to the news?   Lots has been written on risk communication and risk management which drives the development of communications to the public.   Many of the above stories have been ones where public health has been a witness and the storylines have followed competent journalists that can access the very communication networks that public health professionals do such as Promed.  Perhaps a point for some researcher to assess how and why stories get into the public eye, and how best for professionals to address these national and international stories.  For just as we ask the question, so do our neighbours – should I worry or not?  

Contraception and costs: Why are intervention costs public, but prevention a private affair?

In no situation is it more clear how Canada does not value prevention compared to treatment than in looking at the issues of contraception.

Of course, one risks the deluge of philosophically based and theology arguments on the value of life, we shall spare that discussion.  In Canada, life under the legal definition begins with birth, and even if you prefer some other time frame like 20 or 26 weeks gestation, the following still holds. 

Children are precious and priceless.  The cost to the medical system of caring for and delivering a child without complications is about $2000 to the physicians or midwives, and a similar amount in terms of hospital based costs.  

The costs for an infant born that requires intensive care will run $2000 or more per day in the NICU. This is a key point given that pregnancies that are unplanned are more likely to have complications resulting in NICU care. 

The cost of a pregnancy termination is about $500 in a clinic and twice that in a hospital.  Both are publically funded in Canada. Similar costs in the US with prices increasing with gestation.

The costs for the standard emergency contraceptive (morning-after) pill is in the range of $35-60 and usually not covered by insurance benefits. 

The costs for most routinely used contraceptive options are in the range of $25-45 per month, are not covered by the public system but often are covered by private insurers.  Private insurance is rarely helpful given most young adults are still in the education system or just beginning employment where benefits may be limited. 

While the economics are not exact, the point to be made is that we are willing to fund the costs for the interventions necessary for pregnancy and delivery, we are willing to fund the costs for pregnancy termination – but we are not willing to fund the prevention costs of emergency contraception prior to pregnancy implantation or to fund contraception to prevent pregnancy.  The relative health care costs are comparable between these paths, the social costs of unplanned pregnancy are massive in comparison.  

While sexual health clinics may provide support to some of those most in need in defraying the costs, most young women carry the costs independently.  Those on income assistance are often expected to include contraception costs within their assistance levels. Ultimately it is gender inequality that requires correction. 

Even with relatively right wing leaning governments, the economic arguments should be on the table.  Only when the issues of theology are interspersed in the arguments do we shy away from the discussion on what is the right social choice. 

As a society we have frequently espoused the concept of prevention, but here amongst other gloomy examples, policy does not follow prose.

Health Evidence.Ca recently released a summary of a Cochrane synthesis on the effectiveness of emergency contraception from a Chinese team.  Unfortunately in Canada we have limited choice to the aptly named “Plan B”, and while over the counter in most provinces, it still under the counter in Saskatchewan and only available by prescription in Quebec.  The evidence review is accessed at Emergency contraception review

Canada Health Act and the Shouldice Clinic - an Opportunity to focus on the real issues?

Ontarians have been blessed and cursed by the Shouldice Clinic for decades.  Established in the 1940’s, it is a family owned independent facility that balances its books by billing the provincial health system (OHIP). Its speciality and expertise is in fixing hernias, and outcomes are exceptionally good.   Seems the owners are interested in selling to another private interest, a company traded on the TSE stock exchange. 

So a debate rages over the appropriateness of the sale to a company that specializes in running health care facilities and already owns facilities in Ontario. 

The Canada Health Act is clear on the need for “public administration” of health services.  Such discourse has fueled many a debate and sparked labour outcries relative to contracting of services as “privatization”.  The principle is a clear one, the government holds and dispenses the funds that pay for the coveted Canadian health system (or in reality some 14 distinct systems between the provinces, territories and federal services such as First Nations)

The Canada Health Act (Section 9 Canada Health Act )  however only covers “comprehensiveness” as it relates to physician, dentists and hospital services. (and only those services deemed as non-“elective”).  Sure there has been lots of debate about expanding the definition to include residential care, home care and pharmacare.  However it has not happened. 

We widely engage in different styles of ownership of other health services for things like long term care and home care.  We have tended to covet in the public realm services for the public good or marginalized populations like public health and mental health.  

In reality, most physicians and dentists are private businesses already.  The provincial payment plan provides for the public administration and distribution of public funds to these private businesses. 

Long term care and home care are a mish-mash of public own, non-profit, for profit publically traded companies and privately owned.  There are even some of these facilities and services that are privately owned and exclusively private pay outside of the health system.  Despite the non-inclusion in the Canada Health Act, the majority have fallen to not only publically funded, but also in many cases publically administered.  Most provinces retain some regulatory oversight to ensure that even for private pay settings, vulnerable people in long term care settings are not abused.  When abuse occurs, irrespective of the involvement of the public administration, it is unacceptable to us as Canadians that such persons were not protected, so the demand for public administration is high. 

Hmmmm, even if we look to public health and mental health, there are innumerable contracts in place for provision of various services ranging from clinical activities, education, harm reduction, program coordination.  Such contracts may be rendered to non-profits, private individuals or even businesses.  Perhaps more disconcerting is that there is less public oversight of private pay activities in these fields.

Of course, there are all the other health services that are neither covered by the Canada Health Act, provincial insurance programs, and sometimes not even self-regulated.  Most such services are limited to private pay – some depending on Worker’s Compensation or employee insurance programs.  Speech therapy, some physiotherapy, chiropractic, naturopathic, herbalist, massage, hypnotists – the list and types of “professionals” deserves its own posting.

Then there is the whole mix up about pharmaceutical programs which are a bizarre mixture of public coverage, welfare, employment insurance, and private pay.  Not surprising that the inability to afford drugs leads to complications that require other insured health services. 

And, can someone please explain why dental services are explicit in the Canada Health Act but since most dental services are excluded from provincial insurance plans (a requirement for inclusion in the provision of the Canada Health Act for overbilling penalties), that Canadians are driven into private pay or employment benefit approaches to payment?  It is a highly inefficient use of funds though no doubt highly lucrative arrangement for practitioners.

Discouraging in all this debate is the lack of quality evidence to inform good decision making on how service governance impacts the outcomes we are trying to achieve.  One can clearly look to comparisons between countries to show where Canadian publically administered services rank well on population outcomes and limit the development of inequities, but perhaps dampen innovation and experimentation.

The main point, is that under public health administration we already permit a wide variety of public, private and other structures to oversee the provision of health services.  That public administration can range from legislative oversight, disbursements of public funds, regulatory investigation structures, contracting between agencies through to the direct provision of service. 

So the debate over the Shouldice Clinic is merely a minor variation on an existing theme. A few experts  have contributed their thoughts if you want to dig into the detail Picard on Shouldice  Healthy Debate on Shouldice. 

But rather than fight over the Shouldice Clinic, can we be brave enough to open the discussion on what we as Canadians want as the outcomes of our health system and use that to define what belongs in the Canada Health Act?  He grand matron of the Act Monique Bégin (Minister of Health in 1984) has repeatedly stated it was designed as the first step.  Can we get a pan-Canadian government accord brave enough to take the second step?