Gambling - Toronto taking chances with the public's health

When someone comes along and announces $3 Billion in development, heads will turn.  It is in the fine print that the centrepiece of the development is a new casino for downtown Toronto.  Vancouver, Montreal and other major cities have recently debated the relative harms and benefits of expanded access to gambling and its health consequences. 

For provinces the addiction to revenues from gambling is in the billions and reflects other sin taxes and fossil fuel incomes that support a diverse range of social and health programming. Reducing such incomes means either increasing revenue from other sources like taxation, or cutting programs.  Moreover, the dependence on gambling revenues is sufficiently scared that advocacy efforts opposing expansion of the industry, research on reducing harms and efforts are prevention are actively discouraged.

Hidden deep inside the Canadian Centre of Substance Abuse is a good resource with links to existing data on gambling CCSA weblinks.   Oddly, becomes gambling income is a provincial revenue source, national information is more readily accessible through credible groups like Statistics Canada.  Hidden is that gambling amounts increased from the early 1990’s when casinos became more widely abundant, though to the last five years where total revenues have leveled out. The Stats Can report includes the following graphics. 

Gambling can be typed into gaming activities like bingo; lotteries; paramutual betting like horseracing; casinos and slots; video lottery terminals (VLTs); and on-line gaming.  The graphics represent a good sense of the shifting gambling dollar.   Provincially, gambling increase going west.   The coalition of gaming research organization production from 2012 provides an excellent resource on the current utilization of gambling in Canada Canadian Partnership for Responsible Gambling.  Safety in numbers through collective sharing of statistics, but also an excellent example of comparative data between provinces which is sometimes challenging to find for other health issues. 

Hidden deep in these documents is the consistent identification of 2% of the adult population have problem gambling issues.  Problem gambling is known to be associated with financial problems, relationship difficulties, violence, and suicide. Although, an Alberta study suggests that gambling is not the risk for health outcomes, but merely a covariant – similar to early work on smoking and health UAlberta economics study on gambling and health. 

The successful work on defraying the impacts of casino expansion in Vancouver might form an excellent model in public health advocacy for the wellbeing of the community, if one could only find solid documentation still posted on-line. Publication bias remains a significant barrier to putting the public’s health centre stage in the debates.

Good luck Toronto. Hopefully Toronto Public Health will provide outstanding leadership on an uncomfortable topic. 

Bullying and its Tragic Consequences - A public health issue deserving consistent intervention

The tragic events surrounding the suicide of Amanda Todd in BC re-raises the long standing issue of school “bullying” and the potential fatal outcomes.  It poses questions on what went wrong? but how well are we doing in facing the issue?

Data are not rigourous, but work suggests up to 2/3rds of middle school students have been bullied  and an equal number just consider bullying part of school life.  One in 8-12 of these students being bullied at least weekly and a similar number being the instigator of bullying.  At Grades 4-6 the rates of bullying are about one-quarter of students.  Rates amongst males are slightly higher than females and more likely physical whereas female bullying more likely verbal.  More on what we know in Canada can be found at a Public Safety Canada website Bullying - Public Safety Canada and  a non-profit stop bullying group.

Canada has had its share of high profile consequences from bullying, with Amanda Todd being the most recent.  Another BC situation resulted in murder charges associated with the death of Rena Virk in 1997.   In the wake of Columbine in the US, imitative behaviour led to another school shooting in Alberta.

Bullying activity peaks in Grades 6-8, but the consequences are lifelong.  Perpetrators of bullying are eight to ten times more likely to engage in other delinquent behaviour and subsequently to be associated with gang activity, sexual harassment, and other criminal activity.  Bullys are also more likely to continue abusive behaviours in the workplace, relationships, and with children and elders.  Victims of bullying are more likely to have episodes of depression including suicide.

Prevention of bullying can be facilitated by numerous packaged programs which are provided to the school setting (eg PREVnet  Bullying.org ).    The best solutions likely rest in comprehensive school engagement on the issues of bullying throughout the students experiences and include developing social skills and camaraderie, education, family and student counselling, intervention and enforcement.

Racial tension, sexual orientation, religious beliefs, academic achievement, physical stature and gang association are all well established characteristics associated with bullying. The forms of bullying expand to the available modes of interaction, and considerable attention is being paid to the import of cyberbullying through social media, in particular Facebook or other forms where filtering and censoring of messaging is minimal.

While knowledge of bullying is increasing, little exists on what might have been considered normal school yard behaviour in the past.  Is bullying increasing, or actually decreasing as schools have recognized their contribution to development social skills in addition to rote knowledge development.

Schools are asked to perform many functions beyond that of just education of the traditional 3 “R”s.  Enlightened school districts are willing to step forward and address issues of health, wellbeing and self-esteem.  Pressures from other inclusion programming such as children with special needs can detract from addressing common issues such as relationship development, building collaboration, exceptional students, delinquency and  bullying.  The further form the walls of the school, the less the perceived role of the school setting – yet where else will such issues be resolved?

Public health professional need to be engrained into the school setting to assist in identification of school health needs, both for immediate management, but just as importantly for the lifelong impacts that have their roots at school.

October 15 - CIHR has also responded to the bullying issue and published a short piece on bullying at http://www.cihr-irsc.gc.ca/e/45838.html   

Justice and incarceration. A hidden Public Health issue

Stats Canada just released annual incarceration statistics which are accessible at adults in justice system.  .  Hidden in the release is that incarceration is slightly up for the first time while many other measures indicate reduced persons under supervision.  Note that roughly 1/3^rd of incarcerated persons are in federal facilities, and of the remaining half are sentenced and half are in remand awaiting action by the courts. That such a large proportion are awaiting court action should in of itself be considered unacceptable. 

Those incarcerated represent about ¼ of the adults who are under supervision of the correction system, with the majority on probation. As for youth, nearly 15,000 are under the oversight of the correction system. youth 12-17 involved with justice system 

Look carefully at the two charts and the summaries.  Specifically what conclusions would you draw on the rate of youth crime?   As presented and on the surface, the data might suggest substantially lower rates in youth.  Certainly the overall reduction in incarceration and persons under supervision is highlighted.  The minor blip of an increase in 2010-2011 of those in facilities is opposite to the overall trend of the past decade and perhaps partially related to tougher economic conditions.

If you look carefully at the actual rates of persons under supervision, the units of presentation are per 100,000 for adults and per 10,000 for youth – making the youth under supervisions numbers look much smaller. Put differently, 0.6% of all adults and 0.8% of youth 12-17 are actively involved with the Canadian justice system. Why the higher rate in youth?  Why the differential presentation of the data? 

Another question is given the reducing number of persons in custody, why are we redefining minimum sentences – to boost jailhouse business?  Why are we looking at building new facilities for an expected increase in incarcerated persons?   And most importantly, why in the face of advice to the contrary, does the Harper government ignore the facts and openly propagate misleading information on crime in Canada. 

Canada is a relatively safe place and becoming safer with time. 

The justice system already imposes barriers to rehabilitation and re-integration into society such that the wellbeing of those ever involved with the justice system is compromised as an additional penalty for their actions - something that has lifelong implications. Such added implications are not inherent in a society where maximizing individual potentials is to be prompted.

While considerable focus is placed on reforming the health care system, where on the pundits on justice reform in a similar fashion that might lead to improvements in social and health wellbeing? 

Sex, Fraud, and Assault. The Supreme court decision on HIV disclosure for persons with low viral loads

Beware of news released on the day before a long weeked, it tends to be controversial, unwanted, and politically divisive.  A curious day to release a Supreme court decision on HIV disclosure.  Previously the standard was an absolute need to disclose HIV status as such was considered a risk for bodily harm, and persons could be found culpable of aggravated sexual assault.  This decision was based on a 1998 court case involving transmission of HIV to a person subsequent to the failure to disclose.   Subsequent decisions have expanded the definition to not require the standard of HIV transmission, hence an absolute requirement for persons with HIV to disclose their status.  Putting aside the small percentage of long term low viral HIV positive persons, this likely was a reasonable decision at the time. The science standard was predominately one of reasonable probability that transmission could occur and hence persons not informed in advance of engaging in mutual consenting sexual relations were seen as having not had sufficient information to make an informed choice.

Now, aggressive antiretroviral therapy can result in reduction of viral particles to levels that are typically not detectable by routine laboratory tests.  Starting in Switzerland, legislative or judicial decisions have slid towards recognizing that transmission of HIV is highly unlikely in persons with negligible viral loads and therefore the standard of informing partners might not be required.

However, it is known that persons with non-detectable viral loads are unlikely to have been cured and still have the potential for resistance development and recurrence of viral activity.

The Canadian courts have placed the second standard of still requiring the use of a barrier method – a prudent action for persons engaging in sexual activity who are not intimately familiar with each other. 

The reaction of various HIV organizations has been interesting.  Many denouncing the Supreme Court decision as failing to recognize the autonomy of someone carrying the HIV virus.  An odd reaction given the decreased standard of protection that the courts will now be applying.  Ultimately many would argue that sexual relations are a buyer beware scenario. Negating the foundational communication that forms the basis of relationships and making sex a recreational activity.

Even in other forms of recreational activity some forms of protection are mandated, whether helmets for hockey players or automatic release bindings for skiers.  Football helmet butting is resulting in serious punishments and use of performance enhancing drugs are banned as of lifelong health protection.  

The Supreme Court decision is likely reasonable given our current knowledge and respects many of the Canadian values surrounding intimate relations and sexual assault.  Questions will remain such as what is a reasonable level of proof of low viral loads, one day? one month? one year? since the last viral load test.  Some will question the need for and importance of the barrier protection if viral loads are negligible, however that standard was not tested in the court decision. 

As for buyer beware mentality, in a society where power is equitable distributed between all persons, choice is inherent in decision making, and communication is transparent – perhaps there is an argument that the buyer carries some burden of responsibility – but we live in an imperfect society and depend on the courts to act in the best interests of all members.  It is notable that the basis of the decision is the test that the consenting individual would not have engaged in sexual intercourse had they known the peson was HIV positive, in essence the HIV positive person having committee fraud by withholding information that a reasonable person would have used in being a buyer. 

Read the full decision as written by Chief Just McLachlin herself at Supreme court decision  

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