Blogging with DrPHealth - Viewers Choice

Sometime next week, DrPHealth will turn over 10,000 views.  There will have been about 230 posting over the 17 months of contributions, suggesting an average of about 50 views per posting.  Blogspot has gotten better over the year of tracking individual posting views, but the number of tracked views is probably only about half of the views. 

A massive one day surge about fracking, which led to a historic high number of single day views prompted this posting about what do you as the readers say are the most important issues.  

There are some clear favourites amongst readers.  Not only do they have high numbers of views, but intermittently there are surges in activity around a particular posting.  Most continue to have views months after the posting. Except from the fracking post, the most frequently visited posts tend to be over several months old. 

Viewers who subscribe to an emailed version are not counted as there is no listing of the number of persons who receive the blog on a regular basis through email. 

So, here for everyone’s pleasure, are your favourite postings, in reverse order by volume of views. 

Views	Title	Link
51	Public Health hot topics	Feb 6, 2012
52	Canada`s 2012 Budget - Public health implications	Apr 2, 2012
54	The cost of US medical costs - Financial stress has a health cost itself	Dec 8, 2011
54	The Determinants of Health - moving description into solutions	Jan 9, 2012
55	Tweeting the public's health. Social media as a knowledge adjuvant	Dec 6, 2011
57	HIV progress in Canada – A great public health success story to start the New Year	Jan 3, 2012
59	Eggceptional news: Its no yolk. The myth has been laid	Aug 20, 2012
60	Healthy Build Environment Part 3: Health and social services, food stores and fast food outlets	May 3, 2012
67	Social injustice - Attawapiskat, Aboriginal Health and Janus	Dec 5, 2011
72	Hot public health topics worth reviewing: Provincial budgets, low sodium diets, smoking cessation and perinatal indicators	Feb 24, 2012
81	Electronic Health Records - so much spent and so far from achieving the goal	Apr 5, 2012
85	Smart meters –The role of public health in scientific controversy	Feb 3, 2012
102 115	Hookah pipes – a new generation of smoking hazard Telehealth: A real public health contribution - or at least a major convenience	Apr 10, 2012 Apr 3, 2012
122	Fracking - Is it an obscene public health word	Oct 18 2012
142	The Cost of Poverty in Canada - a potential way to reduce health costs	Jan 12, 2012

Thanks to everyone that makes DrPHealth worth continuing to post. 

Injury report 2012 - Prospecting for Public Health Gold

If information were gold, there is a whole mine out there to prospect through for nuggets called the Internet.  And just like a gold mine, public health surveillance in Canada tends to be filled with buried nuggets – not the ones that are shiny and easily found.   It is even more perturbing when the Public Health Agency of Canada documents, are transplanted and hidden in other locations and not readily available on the PHAC website. 

Today’s goldmine is a 2012 injury report spotlighting road and traffic safety amongst youth and young adults that was just released from PHAC in conjunction with several  groups like SafeKids, Traffic Injury Research Foundation and Transport Canada.

If you go to the PHAC site, you can order the document because it is not available there on-line   PHAC ordering information    or a short summary is available at PHAC posted html summary .  

Thankfully it has been posted in a few other locations traffic injury research foundation, Transportation Research Board; and summaries at Safekids.  

  

So, can somebody please tell us why PHAC remains cloistered - doing great work in behind the scenes, and yet has this incredible cone of silence when it comes to communicating, and a shyness on promoting its own excellent work?    Leave an comment, anonymous or otherwise. 

Fortunately there are a few effective prospectors out there that track down the nuggets and share the wealth. This one surfaced quietly through a Twitter posting.

While the focus of the injury report is on youth to age 25, the message is clear.  For the most part, we are doing well in reducing injury related health consequences associated with transportation. The graphic shows mortality rates extending back to 1950 and peaking in the 70’s.  Since then, and with the concerted efforts looking at vehicle and road engineering, as well as directed interventions on enforcement and driving behaviours, mortality and hospitalization rates have continued to decline. 

The gains have been less impressive over the last decade, despite the substantive increases in gasoline prices which are often thought to modify vehicle use behaviours. 

One might also be disappointed with the proportion of alcohol related crashes as not having improved over the past decade despite several interventions.  

Whether much stiffer penalties as implemented in several provinces in the last couple of years will again begin to move the curve downwards is yet to be determined.   Quite notable are the differences in alcohol use by type of vehicle. 

Finally is the not too surprising impact of injury from off-road vehicles highlighting the increasing importance of ATVs as a dangerous mode of transportation for youth and supporting the CPS and others call for age limits on ATV use.

For any golddiggers out there, if you come across other nuggets, please drop a line to drphealth@gmail.com.   Share the wealth.  Information is a major driver of change.  Protecting information is merely a way to express power over others and not in keeping with public health principles. 

Fracking – Is it an obscene word in Public Health?

In the space of a couple of weeks, this posting has had hundreds of hits, moreso than other postings on DrPHealth.  On one side it is a measure of the interest in fracking.  Please leave some comments so that others can benefit from what you find here.  

If you are aware what fracking is, you either live in oil and gas provinces, or deserve to be at the top of your class.

Fracking is the future of natural gas recovery and is opening up otherwise difficult to mine gas deposits located in predominately shale like rock formations.   It involves injection of high pressure fluid (water/salt water with additives) causing hydraulic fracturing of the rock and increasing accessibility for gas mining operations. 

Frankly, fracking is merely the lightening bolt for the expanding oil and gas industry.  An industry who have successfully argued in the past their technologies as safe and beneficial for health and environment and which are now sacred and untouchable from environmentalists and public health professionals. 

So in the midst of the quiet stalemate in provinces with long standing oil and gas operations like Alberta and Saskatchewan, novel reviews of the public health impacts of shale gas operations are coming forward from New Brunswick and struggling for legitimacy in BC. 

Hence the document released by  Dr. Ellish Cleary as Chief Medical Health Officer in New Brunswick is a bold and brave foray into the issues.  Coming from a province where an economic boon would likely be welcomed, the cautionary words on boost and bust economies and rapid industrial growth from such development investments are a courageous statement. Moreover the document is grounded in solid public health principles ranging from determinants of health, clear health delivery objectives and public health ethics.  For those not intimately involved in discussion with the industry, the document is an excellent example of taking a fundamental public health approach to a problem.   NB CMHO report on oil and gas industry

It is the sort of document that the industry might fear, but the type of material that is fundamentally grounded in principles and the need for appropriate information that decision makers will be challenged to ignore.   As the recommendations are based on a whole of industry perspective, it mitigates some of the past challenges about operation specific concerns such as debates over a particular sour gas well.  It also pushes hard for Public Health involvement in many aspects of the work to be done.

One can only hope that the province looks favourably on these common sense recommendations, and most importantly on the context of inclusion of human health as an outcome of interest in resource sector development.  

Kudos to New Brunswick and Dr. Cleary and thank you for displaying such courageous leadership. 

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