Peace and war. Remembering the tragic toll of global violence and celebrating those that serve for our protection

In an annual tradition for DrPHealth, it is time to reflect on our progress (or lack thereof) in addressing global peace.   Three deaths in the past month of Canadian military personal on Canadian soil are a sobering reminder of the costs of a path other than peace.

2013 has seen two new armed conflicts and one resolved with 33 active conflicts – a number that has remained fairly constant for the past decade.  Seven of these are defined as wars with over 1000 deaths.  The formal listing of conflicts is found though the Uppsala Department of Peace and Conflict datasets accessible at UCDP/PRIO data files.   Wikipedia maintains a good list as well and lists 12 conflicts with over 1000 annual deaths and 29 additional conflicts.  Slight variance in definitions leads to inclusion of issues like the Mexican drug war as an armed conflict with Wikipedia and not a conflict under the PRIO guidelines.

The newest conflict being in the eastern regions of the Ukraine where so far this year an estimated 3700 people have died.  Four of these conflicts appear to have taken over 10,000 lives with the Syrian Civil War accounting for roughly 40% of all global armed conflict deaths in 2013 at nearly 75,000.  The ISIS conflict is now the second largest global cause of war related deaths while the South Sudanese  conflict has abated going into 2014 and the current year deaths estimated at only 10% of 2013 where deaths exceeding 10,000. 

At nearly 2 Million cumulative deaths the Afghani civil conflicts involving the Taliban  and 4.5 Million in the tensions between North and South Korea these have the largest cumulative toll.  The Korean conflict approaching 70 years and the Taliban insurgency 35 years speaking to the challenges of intergenerational conflicts in which families are in a constant state of potential crisis.

While total numbers of war related deaths are not easily tracked, the listing in Wikipedia once again suggests deaths in 2013 as about 100,000.   The positive news is that cumulative through early November in 2014 would suggest these numbers have decreased by about a third.  In addition to the Ukraine, the surging conflicts are in Libya, Nigeria and Central African Republic where combined deaths exceed the cumulative toll from Ebola.

Four Canadian have lost their lives in military duty, two within training exercise and Warrant Officer Patrick Vincent and Corporal Nathan Cirillo in targeted killing on Canadian soil.  Fallen Canadians

The shooting of five RCMP with three deaths in Moncton in June, combined with one car crash and one on duty sudden cardiac event round out the list of those that have died in the service of protecting the people of our country from the effects of conflict.  Officer Down

In a tribute to those that serve to protect us, homicide in Canada continues to edge downwards with current rates about half of their peak in the mid 1970’s.  In honour of those that do serve, celebrate the success of their efforts Homicide in Canada 

It’s here at last!!!! – the 2014 Canadian Public Health Officers report

At least this year there were a couple of Tweets as the report was released on October 29.  It should be the public health event of the year and we should be celebrating like a gallery opening for an artist.  It is the release of the annual (or so) Canadian Public Health Officer’s report.  This year brought to you by our new leader-in-arms, Dr. Greg Taylor.

Regrettably once again, what should be a huge celebration has been relegated to a silent launch.  Media attention is non-existent. There were no press releases or media briefings, so why should the media be aware?  The Minister of Health (what’s her name? One year of Minister Ambrose posting ) has made no notes or acknowledgement.  It appears that this annual event is looked forward to by the government with even less gusto than the Auditor General’s report.  ‘Tis a shame.

The easy to read, very focused and only slightly government promoting document is well worth the 15 minute read despite the 110 pages.   This year’s focus being on the future of public health, with a delving into three emerging public health topics in depth, ageing, climate change, and digital informatics.  To its credit the entire report does not once mention Ebola, which these days is a real accomplishment.

In a carefully crafted call to action, the report challenges the public health community to proactively address the public health issues of ageing.  Not through the lens of seniors needing care, but through the lens of the majority of persons past retirement age who are relatively healthy and wanting to maintain and sustain their relative well being in independent settings.   The report only falling off this to address the incoming tide of challenges faced by those with diagnosis of dementia, one of the few causes of mortality that is currently increasing. 

The second section acts as a primer for climate change and public health.  Nothing extraordinary or controversial other than a federal leader actually acknowledging that climate change is real and is happening, that should not be overlooked and credit to the CPHO for being so forthright in making the obvious a statement of fact.  Those who have followed the climate change and health discussions for the past two decades will note a distinct shift away from efforts to mitigate to a wholesome discussion on how public health has a role in adaptation.

The third section braves a topic that public health’s current innovators are exploring in how better to use the digital world.   In our opinion the weakest of the sections filled with longer discourse and less concrete recommendations, particularly where better examples of digital utilization exist, however DrPHealth acknowledges that after 414 posting and 3 ½ years of blogging and Tweeting, that perhaps we have a slightly skewed view of the digital world. Potential biases aside, the section could have been so much more given our current state of experimentation. Granted the section calls for research, evaluation and most importantly adoption by public health providers – something with which even we would concur.

After perusing the three sections, the reader should be left with a nagging question – is this the go forward agenda for Dr. Taylor?   There are many aspects in the report that reflect his thinking and we can hope that this is an initial statement of his vision for the future of the Public Health Agency of Canada, our national guide in public health matters.

Don’t stop reading at this point.   Just when you think the report is done lies the hidden gem.  Do not skip the Appendix A.  In the twenty pages of the appendix, the report lays out a solid statistical foundation on the Health of Canadians.   Ideal for future reference, and perhaps mandatory reading for any trainee and provider in public health to stay current on trends in health and wellbeing in Canada. 

The full report is available on line at 2014 CPHO report  or downloadable from the same link as a .pdf for future reference.

This is the first real action by the newly appointed Dr. Taylor, and deserving of a “well done Greg”.  We look forward to more of your leadership and willingness to test the boundaries. Perhaps next year you could add a press release? 

Child care and public health policy. Where is Canada heading?

The Harper government announcement on child care and family support is a pre-election activity that is drawing considerable attention with vastly differing opinions on its value. Globe and Mail coverage   

How can anyone question the value of putting money into the hands of parents so that they can provide better care? Detractors of the government will find subtle reasons, but where will this policy take Canadians? 

The downsides of the issue. How far really does $720 per child take any parent?  When child care can cost upwards of $50 per day.  It amounts to not even a month’s care. 

That the benefit will be applied January 1, but only first paid out in June, just a few months before the election smells of buying vote.  Parents and families will receive a nice retroactive pay check as the campaigning starts.   No doubt more than a few will be confused that the future cheques and benefits will reflect similar sized payouts unless they support the incumbents.

Digging deeper and most disconcerting, while the benefit increases the affordability of child care for those in need, it does nothing to improve availability or quality of care.

On the second half of the announcement is a step towards addressing a long standing inequity in Canadian tax laws that actually encourage families to obtain two incomes rather than having a single large earner.   The value however is predominately to be gained by higher incomes earners, hence a mitigating effort by the government by limiting the benefit to a maximum of $2000.  For the far left an unacceptable tax benefit for the rich, for the far right an unacceptable limitation on an inequity.  From a policy perspective, for a government that  made a promise, perhaps keeping no one happy is the sign of reasonable policy development.

It has been a decade since Paul Martin promised a universal child care program for Canadians, and an issue that Harper first dismantled and now is reconstructing in his own image.  A step forward, but not necessarily a stride in the right the direction. 

Perhaps most disconcerting in all of this policy development, is that there was no public discourse.  There was no public input, debate or opportunity for refinement.  Once again, our prime minister has taken a dictatorial approach to leadership, albeit the perception being that of a benevolent despot.

Distracted driving, road health and a celebration of a public health success

Ontario and BC took a step upward in addressing the epidemic of carnage on the road caused by distracted driving.  It was merely a handful of years ago when debates were being held on the safety of cell phone use while at the wheel, now texting has become the major culprit.

Humans will continue to invent technologies that modify health risk and in doing so will keep the public health workforce gainfully employed.

In typical fashion when threats are being first addressed, the statistics are sensationalistic and perhaps inflated, but the numbers promoted by the CAA are staggering culminating in the conclusion that driver distraction now contributes to 20-30% of motor vehicle collisions CAA distraction information page

That impressive number can be contextualized within the continuously decreasing number  and rate of fatalities and collisions on our roads, a real testament to the efforts of the road health/safety community. 

Where the disconcerting flaw in logic may arise is the impact imposed by aggressively increasing penalities where education and options have not been sufficiently explored.  Ontario’s new fines of up to $1000 for driving with a handheld device and BC has added demerit points to tickets associated with distracted driving.  Whether either will modify behaviours sufficiently remains to be seen. 

BC is no doubt celebrating in the wake of successfully addressing impaired driving through fines, suspensions and insurance costs and such success reinforces that enforcement can be a primary driver in behavioural change. Despite these progressive actions, speeds on BC highways have increased with many divided highways having limits of 120 km/hr – and the impact of such a move will need evaluation.

Both efforts are to be applauded, and other provinces should be encouraged to refine regulations to address more than cell phone use where such remains uniquely identified.  Distracted driving has been an offense for much longer, the change being that the definition now incorporates explicitly items such as handheld devices.

Our roads are becoming safer through the combined efforts of vehicle engineering, road design, driver training, enforcement, and public education.  Such a success is deserving of a public health high five.  

Ebolaphobia - when prudent caution becomes an irrational fear

Events of the last week demonstrate the level of irrationality that public fervor can escalate to amid the fear of the unseen. The irrationality verging on a new phobia aptly called Ebolaphobia and suffered by those yielding unreasonable power.  The pinnacle of inappropriate behaviour was achieved in the high level quarantine of a nurse returning from West Africa.

Canada is no less implicated in this irrationality.  Current policies essentially preclude health care workers from participating in care efforts as Canada has rescinded permission for participation pending a review of its policies.  The number of Canadian workers in West Africa has eroded to merely sixteen workers with plans only to send a small number of relief deployments once the processes with the Canadian policies are met.

These health care worker heroes are returning from months using high level protective equipment when the highest risk time for infection is early in their sojourn and disease development overseas most  likely. 

Currently upon their return, they are stripped of their autonomy, essentially placed under house arrest, and deprived of the professionalism for which they have demonstrated a level of valour that many of us admire and should be aspiring to. 

It does not make sense.

For some who are employed, provinces and employers may provide salary support to remain off work.  For physicians, having giving up to two months income to volunteer, they are further deprived of an additional three weeks income while segregated from society.

Canada has actually been relatively logical in some of its approaches, with screening occurring at the points of entry, and travelers with any risk reported to their local Medical Officers of Health who can provide support and monitor wellbeing while balancing the needs of the individual and risk to the population.  It is this balance of protecting the public and respecting the person that these professionals have been trained.

That has not precluded organizations issuing the paychecks of the MOHs from expecting disclosure of names, imposing unreasonable additional limitations, and certainly such organizations have diverted limited public funds to alley the phobias demonstrated by health care workers who would never possibly be exposed to anyone remotely linked to West Africa countries.  It behooves those in the public health community to apply a level of professionalism and skill that is exemplary.  Collectively we need the ongoing avenues to reflect on our ethics in meeting this challenge.

Political led responses have historically led to tragic consequences for individuals.  Leper colonies, Canada’s quarantine islands, tuberculosis sanatoriums, are further examples of where the political reaction has exceeded the bounds of rationality and undermined any ethical sense of autonomy.  

On November 1st Canada announced a preclusion on visas for any person from countries with widespread and persistent intense transmission. A move that violates an international convention that Canada was instrumental in negotiating in the wake of the impact travel restrictions during SARS had on the Canadian economy without adding to disease control. Such actions verge on idiocy.  http://news.nationalpost.com/2014/11/01/canada-wont-issue-visas-to-residents-of-countries-with-widespread-ebola/    

November 10, is the absence of any rational reason, Canada has announced that all travellers from countries with persistent intense transmission would be placed in a 21 day quarantine, unless they were health care workers returning who had used appropriate protective gear.  The number to be affected is likely very low, but such action is unwarranted.  Who is making these perverse decisions? 

Were we welcoming back military heroes from risking their lives to protect our country, we would do so with open arms and with social and economic supports.

Let us consider treating our health care warrior heroes similarly.  They are protecting our country by fighting an unseen enemy on foreign soil so that our borders may be safe. 

Thanks to those who have made the effort, and a voice of encouragement for those with skills to consider using them to protect not just our country, but our global community while truly saving lives.  

When fear becomes a phobia itself

Canada collective is grieving the tragic events of October 22 and the loss of one of our country defenders Cpl Nathan Cirillo.   Terrorism has struck close to the heart of the country and unmasked our fears.  

For some the events and actions will be remembered for the heroics and a system that contained the damage when the horror could have been much worse.  For others, the sensationalist reporting and stirring into a frenzy will feed percolating fears.  Terrorism survives because it incites fear.  It restricts individual freedoms not through edict, but by activating phobias.

Decision makers are not immune to becoming phobic.  We can expect calls for enhanced security in parliament, in government buildings, in public places, in critical infrastructure.  Perhaps we can learn from the misguided response south of the border where dollars from social programs into homeland security.  The thousands that die annually from preventable deaths because services are not available in order to reduce the risk for an unseen threat.  

Terrorism has struck home.  The threat of terrorism will test our collectivity, rationality and our confederation.  The stresses and phobic reactions will fertilize our fragile mental wellbeing.  

The best words to recite and remember at this time were written by Calixa Lavallée in 1880.   

O Canada!
Our home and native land!
True patriot love in all thy sons command.

With glowing hearts we see thee rise,
The True North strong and free!

From far and wide,
O Canada, we stand on guard for thee.

God keep our land glorious and free!
O Canada, we stand on guard for thee.

  O Canada, we stand on guard for thee.

Ebolaied – (pronounced 'E-bowl-a-eye-d') - The latest public health concern.

No disrespect intended for a disease that has tragically taken the lives of over 4500 people and the numbers will continue to mount

Ebolaied is the latest public health threat.  The manifestations being irrational fear mixed with overzealous misplaced responses while misappropriating scarce resources from more important issues.  The symptoms among public health professionals being drooping eye sockets with insommia initiated shadows.  The pathognomonic symptom being the rolling of eyes upon utterance of the word ‘Ebola’.

From Tyvek space suits to unnecessary quarantines, the actions of the misinformed and sometimes purposefully misdirected have resulted in spiraling escalation of actions in the name of public health that are unwarranted and unreasonable.  

So in the midst of this overreaction, there are so things to be amused. 

The best line we have heard is the one where all we needed to do to respond to Ebola was take the CDC plan for the zombie apocalypse and replace the word ‘zombie’ with ‘Ebola’ CDC zombie apocalypse planning.   

Some of the more real responses  can only be met with irreverent laughter. CNN’s sensationalist reporting of the poor lab worker who was on holiday on a cruise;  The youth wheeled through a Nigeria airport with a plastic bag over their head as they had returned from an Ebola zone; The Air Canada pilot who refused to fly a biologic specimen requiring Ebola testing to Winnipeg; The closure of borders; The quarantine of persons returning from Africa thousands of kilometers from any outbreak zone.   Share your horror stories in the comments section of what stupidity you have witnessed.

And the irrational fervor continues to mount, dressed in parascience and the worse than the worst case scenarios with little attention to facts.

Don’t expect the overreaction to wane in the near future, or at least not until evidence mounts of control happening in the three West African counties impacted (with Guinea making fair progress while Sierra Leone and Liberia have extension into large urban settings which will confound control activities).

Moreover, as the phobias mount, continuity of food supplies and other essential services will become more problematic.  As health services are exhausted treating Ebola, other diseases will break through and the death tolls from non-Ebola disease as a consequence of the outbreak will exceed the primary outbreak.

No doubt much could have been done to more effectively respond to the initial outbreak that began back in March.  For the dozen global deaths outside of the outbreak zone perhaps these might have been avoided by more aggressive early control.  Now however, we have passed the point of reason and entered an arena fit for barbaric human combat where the price is paid in unnecessary human lives.

The positive arising from the horrific situation will include better treatments, improved mass mobile treatment facilities, perhaps an effective vaccine, for a time period improved international outbreak management, and it appears local infection control programming will get a boost.  Whether international aid efforts and approaches to managing countries in crisis will benefit remains to see.

For all colleagues suffering from Ebolaied, be assured you are not alone – we will survive and congregate over a favourite beverage to share the war stories, as we bemoan the lack of resources needed to prepare for the next global onslaught caused by an emerging pathogen.