Tobacco Control South of the Border - Something to learn from

The American Lung Association recently released a great report on tobacco issues in the US that is worth reviewing US lung association tobacco report card   

The short version is that after years of slow progress, tobacco control has not progressed much during 2011.  No new strengthened state laws were passed and Nevada lightened its requrirements.  No state increased taxes, New Hampshire actually reduced the tax.  Many prevention and tobacco reduction programs saw the impact of funding cuts.

The few gains that were achieved appeared within the federal government’s reach.  New warning lables, expanded cessation benefits for federal employees, and improved funding for state quit smoking activities. 

Seems like the winds of tobacco control are blowing in the opposite direction down south.  

The detailed report provides a great set of metrics by which provincial and Canadian initiatives can be measured.  But typical pan-Canadian initiatives lack the accountability that our American cousins are demonstrating in such a good report.   

Hepatitis C – A case of Inequity based on disease diagnosis.

The Krever commission report into the Canadian Blood system was a significant watershed event for public health in the country.  Link to access page for Krever commission report  .  While driven by the transmission of HIV to blood recipients, the inquiry occurred at a critical time when new developments were occurred on Hepatitis C.

 Those that have been around hospitals long enough knew well about the post transfusion problem of non-A non-B hepatitis, the existence of which was likely known as early as 1974.  It was not until the 1988 that the Hepatitis C virus was actually identified, and not until the early 1990s that appropriate virus specific testing was widely available.   (Recall that the HIV was ’discovered’ in 1982 and the virus identified in 1983 and testing was available in 1985)

Now some quarter of  Million Canadians are infected with Hepatitis C, and about 8000 new infections annually.  About 20% of those infected are unaware of their infections.  Nearly two-thirds of new infections are associated with injection drug use, but 15% with sexual activity and 10% through drug inhalation.  

While there is evidence that the incidence is decreasing, just as with HIV, data are often sparse and inadequate.  The lack of markers of duration of infection make dating of exposure difficult.   Some notable information on new infections that deserves attention  Hep C epidemiology from PHAC  .  Males have only a slightly higher rate of new infection compared to females.  The incidence is highest in the 15-35 age group.  Notably that incidence rates in females 15-24 are higher than males.   Aboriginal rates are 3-5 times that of non-Aboriginals and a cause for concern. 

75% of persons infected with the virus develop a persistent infectious state and are capable of transmitting to others.  Most of these will develop some evidence of liver disease over the duration of their lives, up to 20% will have evidence of cirrhosis, and 5% will succumb to the direct effects of the disease.   The later are probably lower estimates given our lack of understanding.  Antiviral therapy can be provided based on certain criteria, which unlike HIV drugs, are more often supplied at the patient’s cost than as a public good.   The ability to comply with the medication regime is a consistent criteria for treatment, and the use of intravenous drugs can be, and is often, taken as a reason for not prescribing them.  Genotype specific durations of therapy may increase treatment success, however successful sustained response only occurs in about ½ of patients who are provided the medication.  

There are about 4 times as many Canadians infected with Hepatitis C than HIV.  A similar ratio exists globally.  Yet, we persist in treated those infected with Hepatitis C very differently from those with HIV. 

So why the inequity based on disease?   In the early years HIV received considerable attention because of transmission not only to persons with blood dyscrasias (Haemophiliacs) but also to populations of men who have sex with men (MSM) who are well integrated into society and often in positions of authority and leadership.   Hepatitis C, which also affected the Haemophiliac population circulates more predominately in intravenous drug users and frequently associated with very high rates in prison populations.  Not the sort of population that readily influences positions of power.  Some of those with Hepatitis C infection are for a variety of reasons more challenged with personal resources and yet are frequently required to pay for their own treatment.  Even politically, the current government expanded the inequity when it moved to eliminate funding for Hepatitis C initiatives after taking power while sustaining a greater degree of support for HIV based initiatives.  Within the health care system, inconsistent support exists for dedicated Hepatitis C clinical management whereas clients with HIV have near assured access.   Training physicians in the management of Hepatitis C has been underwhelming in its success while infectious disease specialists ensure widespread management for those infected wtih HIV.

Inequity based on disease – you bet!!!  Hepatitis C is perhaps destined to be the lost illness.  The last laugh may belong to the disease, while both Hepatitis C and a HIV present technical problems in vaccine development, Hepatitis C may get there first.  

Communicating the Health Risk of Weather – A Canadian Public Health Celebration

If you are in Calgary and don’t like the weather, wait 15 minutes

Ottawa has the perfect four season weather – every day.

I’m sure you have your own collection of favourite Canadian weather sayings.   

It should be no surprise that Canadians would be innovators in many aspects of communicating weather – we have enough of it.   We can face hurricanes in Nova Scotia, stranded in a blizzard in Inuvik, frozen to the ground in Saskatoon, or drowning in torrential rains in Haida Gwaii  – the amazing thing is can all happen in a single day.

So here are some international innovations that you probably don’t realize have Canadian roots, and were designed as ways of communicating risk to protect the public’s health.   Likely topping the list in most Canadian minds is the UV index launched by Environment Canada in 1992.  The index was adopted internationally with minor refinements in 2000 as the standard tool for communicating Ultraviolet ray exposure risk. 

Not surprisingly, Canada has taken an active role in communicating the impacts of cold through the wind chill factor.   Some may recall the less than successful first attempt when Canada developed and reported wind chill as kcal/hr/m2.   Through the 70s and 80s this migrated to the more commonly used temperature equivalent and finally Canada played a coordinating and science contribution to the international standardization of the wind chill index and its temperature equivalent presentation in 2001.

More surprisingly, the humidex index was a fully Canadian innovation developed in 1965.  It does however differ from the later developed US heat index although there one might perceive similar reports given both present as equivalent temperatures. Canada is very actively involved currently in refining messaging and responses to heat Health Canada heat risks.  It is notable that different Canadian major cities use different approaches to determining when heat requires a public response.  Adaptation to heat also means that while temperatures of 40 C might only raise an eyebrow and barely start a sweat in the Okanagan, Nunavik may need to issue heat advisories at 17 C. 

The most recent contribution on the list of Canadian meterological innovations is the Air Quality Health Index (AQHI), a uniquely Canadian risk communication tool for what is likely the most important weather related public health threat.  Developed jointly by Health Canada and environment Canada, it is now available to just over 60% of Canadians. While the long term causes of air pollution are predominately anthropogenic (mad-made), the short term variation is largely driven by meteorological conditions.  Environment Canada AQHI The index is the first international index that uses public health impacts as the outcome for communicating  risk and the first to utilize the mixture of multiple pollutants using the more readily monitored measures of air quality. 

So who knew that behind the scenes of the Meterological Services of Canada, Weather Network and MétéoMédia were such marvellous Canadian innovations?  Innovations that not only make it easier for us to answer the question, “what is your weather like today? “, but also tools designed to communicate public health risk so we can make informed healthier choices as part of our daily routine.  

Canadian Weather that Kills – how do various extreme events stack up?

Achy joints in cold damp weather?  Headaches when the wind blows?   Sometimes it seems that popular beliefs regarding our wellbeing and the weather are better developed than rigorous medical evaluations.  If there is something that Canadians can agree upon, we have no shortage of weather to open conversations with.  It should not be surprising that the most visited website in Canada is the official weather site of the Meterological Services of Canada Weather office . 

We do know that heat can kill, so can cold.  Floods, lightening strikes, tornados, hurricanes and other extreme weather events are notorious for racking up mortality statistics, and presumably related morbidity.   There are other issues that are weather related like avalanches, ultraviolet light exposure and air quality that also contribute to our wellbeing. 

We spend a substantive budget on weather forecasting and reporting, for which there are some 1 ½ Million forecasts issued every year.  With that comes some 15000 severe weather warnings, in part designed as a way for individual Canadians to make healthier choices.  So the question that is seeking an answer, is which of these risks is likely the most concerning.   It appears that while some attempts have been made, none are public since the approaches used vary from counting bodies to sophisticated Poisson regression techniques with define lag times.  

Here goes an attempt, from least to most, and an invitation to readers to contribute to helping define weather attributable mortality in Canada (please either post a comment or send to drphealth@gmail.com).  

Weather condition	Estimated annual deaths	Notes
Floods	Annual rate of about 2 deaths	Natural Resources Canada reports 195 deaths over 168 flooding disasters for the 20th century
Lightening strikes	3-5	Excellent data provide an annual national incidence of 0.11 deaths per Million population
Avalanches	Average of 14 per year	Excellent statistics of 329 deaths over 30 years.  An extreme 1910 avalanche in Rogers Pass killed 62
Extreme episodic events – tornados, floods, etc	Average difficult to determine, likely <20.  Even the extreme events are <100.	Annual incidences vary widely.  The most tragic events in last 100 years:   Hurricane Hazel - 1954, 81 deaths, Escumina hurricane 1959 – 35 deaths; 1998 Ice storm – 28 deaths ;  Regina tornado 1912 – 28 deaths, Edmonton tornado 1987 – 27 deaths,
UV exposure	500-800	Based on all melanoma deaths and not attributing any to tanning salons
Heat	600-1000	Several studies have estimated excess deaths in Toronto at ~120 per year and Vancouver ~20 per year.   Using these as an incidence provides a rough estimate nationally.
Cold	~5000??????	The toughest estimate to obtain but the impact is likely in the order of several times the number of deaths caused by heat.  UK estimates put the heat:cold mortality ratio near 10 times.  A gross analysis of the number of excess deaths during winter months will provide an estimate of about 5000 excess deaths for Canada annually.
Air pollution	4000-20,000	Health Canada estimates of about 4000 while the Canadian Medical Association has issued an estimate of 20,000.  Estimates are based on times series regressions linking mortality databases with air pollution monitoring data

Were you surprised given our high attention to extreme weather events, avalanches and even heat based events?    More on air quality in a future posting.  

Waterborne outbreaks and Canada's dirty water secrets

Canadians are blessed with fresh water.  Our less than perfect drinking water infrastructure was discussed October 17, 2011 DrPHealth.   It was noted that there remain some 1800 drinking water systems on boil water advisories, with the highest proportion in BC, Saskatchewan and Newfoundland.  First Nations infrastructures are benefiting from a long term investment in improvements, a program which was renewed in 2011 with an additional $330 Million investment. The first five years of the plan saw 108 of 193 high risk systems improved. 

The converse of the lagging infrastructure is the history of outbreaks that have plagued Canadians.  First to reader’s minds will be Walkerton, and the likely North Battleford.  The known list however is  much longer.  Hence several studies that have looked at drinking water outbreaks are of interest.  From the PHAC enterics group located in Guelph came in 2005 article on  CJPH Waterborne outbreaks .  Just prior to the CJPH article was the work by Hrudey and Hrudey on Safe Drinking Water: Lessons from recent outbreaks in affluent nations .

A consultant’s report commissioned by PHAC and the National Collaborating Centre on Environmental Health (NCCEH) looked at outbreaks and retrospective data up to 2008 using different methodologies.   Finally NCCEH undertook a review of outbreaks in small water systems Small water system outbreaks 

There are consistent features that should be a reminder to all:

·         Lack of treatment or inadequate water treatment

·         Lack of source water protection

·         Problems in the water distribution system

And often associated with:

·         Precipitation event, spring thaw or change in demonstrable change in source water quality

·         Human mistakes in system operation.

To the above needs to be added several factors that should be addressed.

·         Disjointed or inconsistent regulatory oversight at a provincial level

·         Lack of recognition by government s and the public of the “public good” provided in drinking water (ie as a utility)

·         Lack of consistent national surveillance and reportability

There are several bright lights. Look to Quebec for both expertise and as an example. The responses of both Saskatchewan and Ontario in the wake of the two disasters are building solid systems - and perhaps shining examples of the legal liability that governments carry for failing in their public duty.  The National Collaborating Centres are collectively looking at issues related to small water systems.  Hopefully the collective work of these centres of excellence will contribute to reducing public vulnerability NCCPH small water system project.  

Core to Canada's drinking water problem is the misguided belief that we have a pristine resource in ample abundance that doesn't require the same level of rigorous pan-Canadian concern that we afford food, health care or the economy.  

Income inequity and debt – a major driver of health inequalities.

The Canadian Centre for Policy Alternatives has started an innovative display of what the Occupy movement was trying so hard to convey:  Wealth is getting increasingly sequestered in the top few percent of the population.    The full piece and the income clock are at http://www.policyalternatives.ca/ceo .   In short, by the start of the first workday on January 3rd, the top 100 executives in Canada had already made more than the average income for all Canadians  – their average annual wage is $8.4M.  Put in perspective, given the average public health workers now makes around $70K per year, that is four times more money that the entire earnings of a 30 year average public health employee. 

This site has written many  times about income inequity including the graphic on the widening income disparity that drove the Occupy movement . Living in tents the Occupy movement more than symbolically demonstrated the financial plight of unaffordable housing.  Yet "we" as a society,  removed their tents and forced them back to live in more expensive housing.  The very actions of a supposed civil society exacerbating the income disparity.   

The Conference board of Canada has provided great graphic representation of the growing Canadian inequality Canadian income inequality.   

If you did not previously see the Sir Richard Wilkinson lecture on income inequality, take the 15 minutes now and  have a gander – it condenses the income inequality discussion.  Wilkinson lecture .     

It has been 20 years since the landmark Rio conference that laid the foundation for many pan-global collaborative efforts, some more successful than others.  The 2011 Rio conference on social determinants left with some great rhetoric and we now need to demand further action.   There are many gems from the conference discussions related to the impact of inequities.   Rio SDOH conference site 

Now as a reminder, we in public health are well endowed. Although we may whine about our relative plight compared to our professional colleagues.  The public health physicians amongst us, likely some of the more poorly paid physicians, still are in the top 1-2% of income earners nationally.  Before exhibiting professional envy, please remember most public health workers earn well above the median national income and are in the top quintile of wage earners.  This applies to those that are single income households, so for those in dual income situations, you are in even more fortunate circumstances.  Collectively we have a role to play in advocating for income equality.  Yet, there is the converse side that we are in part the earners that should be looking to contribute to this equality. 

As you review your bank statements and outstanding financial obligations, likely sharing with most Canadians in expanding debt, take a moment to consider how fortunate we actually are compared to the “average” Canadian.   The average Canadian household debt has reached a record 153% of annual income.   Irrespective of our incomes, we rise to a level of financial obligation which stretches our ability to repay, bolstered no doubt by lending institutions more than willing to establish a long term relationship.   Current university graduates and first home buyers are entering a market driven by the expectation of easy access to “credit” and long term debt repayment structuring.  It is the same fundamental flaws that lead to the subprime mortgage meltdown in the US which started the plunge into recession.

Yet, someone is making money on banks who continue to lend indiscriminately. It is the flow of dollars from those in debt to those that have resources.  From the 99% to the 1%.     From the south to the north. 

And social expectations drive students to post-secondary institutions and young families to suburban single family homes.   There are some fundamental cultural norms that will require readjustment to truly achieve sustainability while readjusting the income disparities that continue to expand.

A great Canadian commentary blog resource comes from Ted Schrenker who blogs at Health as if everybody counted.  Many of the postings relate to discussions on inequity in both a Canadian and international  context, and perhaps a more rigorous and academic analysis than DrPHealth will offer.  As an aside, noting his recent blogs and the continued dedicated  following for this site- there appears to be a role for  “professional commentary” on changing public health climates.  (Thanks Dr. Schrenker  for the endorsement of this site as well)

Qualitative research reaching new pinnacles

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Are you tired of the phrase “there is not enough evidence...”?   Especially when we “know” something is good and the research just hasn’t been formulated into a randomized double blinded controlled trial?   Great examples exist such as prenatal education, post natal visiting and supports, early childhood education and on and on... When the outcomes relate to full populations and not to sterile laboratory conditions the application of the rigour of evidence becomes diluted, and the conclusion is the “evidence is weak at best”.  

One could say that the Cochrane initiative has done a disservice to public health for failing to develop tools to synthesize “evidence” that is not readily subjected to the rigorous controlled trial methodologies.  Hence a 2012 tweet (about a 2008) paper caught our attention, about developing methodologies for systematically reviewing qualitative research Thematic synthesis of qualitative research .     

Qualitative methods, amongst other benefits,  tend to provide a more comprehensive identification of the issues that might be explored when reviewing a particular question.   By the very nature of the expectation, quantitative methods tend to focus on only one specific variable to determine its impact on the outcome.  For the purest in either research field the sense is sometimes that one should never let the other near as it is so different.   The reality is that we need to embrace both approaches and seek to use all the available information, so please get on the QualyQuanty boat.  In the simplest form, use the qualitative methods to identify the issues and questions that should be posed, and then take a comprehensive approach to reviewing each question as it relates to the quantitative evidence that is available – but where insufficient evidence exists an explicit statement on what is known and what is not known is required.  

The fields of systematic reviews and evidence based medicine need to step to the plate and provide such leadership in undertaking comprehensive knowledge synthesis that defines parameters that should be evaluated, not just look at what was researched.

And may the phrase “there is not enough evidence...” be banned from use in policy documents and research alike.  Its use is akin to a form of population health malpractice. Too often it has been interpreted as ‘what evidence exists does not support' a particular action, and that is a whole different conclusion.  Too many programs and interventions have withered to the phrase and with it, the health benefit such activities seem to have been providing.