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?  

Budget cuts, taxation, the 1% and populist governments

Lord Acton in 1887 penned the infamous quotation “power tends to corrupt, and absolute power corrupts absolutely”. 

With a US election being fought over the economy, and hidden Budget Act clauses that will, in the absence of a balanced budget, require all departments to accept a specified global budget reduction.   Canadian initiatives dependant on government funding, who were operating on a shoestring, are seeing those shoestrings being cut.  BC announcing that the price of natural gas will significantly compromise revenues and drastic cutting is required to balance the budget – and knowing full well that Alberta depends greatly on natural gas royalties and Saskatchewan has developed a more recent dependence – expect to see similar responses from all Western provinces soon.  All in all, governments are seeing revenues decline, and as a result are doing the only politically acceptable action – cutting all that spending that in the eyes of ratepayer organizations represents government waste.

It has become heresy to consider changes to the taxation system that would see even modest general tax revenue increase.  Albeit that some jurisdictions are toying with hitting the upper crust of income earners with a pittance of an increase.  It is fitting that the Occupy movement is "celebrating" its one year anniversary, and discouraging that the results have been far less than needed.  

Lacking in the debate is the link between the benefits of research, education, environment, social service etc. and sustainable civil societies.  We are cutting our feet out from under us and soon there will be very little to stand on.

The logical consequence, is what Lord Acton spoke to – that those in power will fall to those who have little to lose by fighting for the power.  It is Egypt, Syria, Afghanistan, and innumerable other countries that have gone before.  It is the Occupy movement with redoubled force.   Leaders of the underclass, the socially deprived, the underprivileged, and the oppressed will rise.   The followers are those that feel hopeless and are given a sense of hope, the helpless who are offered help.  Is it surprising that history is replete with examples of mutiny, civil upheaval, rebellion and revolt? 

Is it surprising that the political leadership has myopia? Any surprise to see the ruling Greek government overthrown?  Are there surprises in the dethroning of middle Eastern governments?

What will this look like in Canada and North America?  Probably too early to assess, but expect incumbent governments to slide out of power as have the Liberals in Quebec.  BC and Nova Scotia are due in 2013, and Ontario holds onto a precarious minority government. 

This is less about the political stripes of the incumbent governments, as it is about the disconnect between those living in middle and upper class settings from the realities that drive their sustainable future.  Few are like the Doctors for Fair Taxation that are openly pleading "tax me, tax me - Canada's worth it".    Equity and taxation blog

So here is the point for comment and debate.   How do we begin to shift the civil culture to regain the post-war social movements that of itself led to the development of a thriving middle class?  Do we hold out hope for another global technological marvel like the microwave, the Internet or the mobile smart phone?  Or do we depend upon the emerging economies like China, India and Korea to drive a global resurgence that will save the traditional developed countries that are breaking under burgeoning debt?

Governments listen to the populace, so how do we convince the populace of the need for reformation that does not indebt our future generation?  Please opine your thoughts, suggestions and questions as comments to this posting .   

Asbestos - Canada supposedly acknowledges chrysotile as bad - but why the change of heart?

In a relatively surprising move the federal Tories have reversed their position on asbestos. 

This is good news – one has to think.   For years just about every major health organization in Canada has denounced Canada’s persistent opposition to placing chrysotile asbestos on the Rotterdam Convention on international trade of hazardous substances.  The stalwart embedded and immovable position of the federal government against such opposition was baffling at best.

One might think the election of the Parti Quebecois which occurred just 2 weeks ago might have something to do with it, or perhaps that is being too conspiratal? 

That a truce existed between the Quebec Liberals and federal Tories might seem implausible, but stranger bedfellows have amicably survived tortuous relationships.  It was puzzling at times to note how little federal Tory bashing the Quebec Liberals engaged in.

That the province’s federal representation shifted from the Bloc to the NDP as the loyal government opposition last year would also have changed the political ambiance surrounding this issue.  No jurisdiction likes to be penalized for voting against the government. 

So, at the risk of alienating a constituency that clearly has stated that it did not want to align with the federal Tories, doing a one-hundred and eighty degree turn would upset a few voters in the Thetford Mines area, Asbestos and the odd investor. The gains across the country will exceed this minor loss – hence the decision makes good political sense, saving lives may be unimportant in the policy shift.

Would the fact that the owners of the Jeffery mine were unable to conjure up sufficient private capital to match the mysterious loan guarantee, effectively killing the mine reopening proposal anyway have anything to do with the change of heart?  Perhaps it just enhanced the opportunity.

The deeper cynics might even question whether Canada’s apparent reversal of decision is actually that.   Seems the last few rounds of negotiations the Canadian contingent was absent during the votes on chrysotile asbestos, so they didn’t actual oppose the listing.  They had looked to countries that import from Canada to veto the proposition.  Such deals may still persist despite the political rhetoric.

Speaking of political rhetoric – if anyone can find a formal government position other than the Industry Minister Paradis’ speech in Thetford Mines please let drphealth@gmail.com know or post a comment for others.  Words don’t have the same commitment as seeing it in writing.

The important question on this change of heart, is will Canada move to ban exports of asbestos as well?  Placing a substance on the Rotterdam convention on hazardous goods does nothing more than require that the exporting country appropriately label,  and the importing country acknowledge it is receiving the material. 

Sadly, many  workers in partially developed countries with less stringent worker safety regulations have knowingly been given a death sentence by working with Canadian asbestos. 

Tobacco use Reduction - A Need to target high use groups: Chronic Mentally Ill and Aboriginal populations

Irrespective of where you are in the country you must have noticed the dramatic decline in public smoking in the last decade.  While the cliques of smokers still mingle, their enclaves have moved from the front door to the side, and fewer individuals congregate over the coveted ritual of tobacco smoke inhalation.   Though unlikely to be designated an endangered species yet, smokers have moved from the mainstream to the sidestreams. 

With such profound cultural change having occurred, and a consistent half to one percent absolute reduction in smokers per year, tobacco reduction professionals need to be thinking more about how to support success.  Two specific groups have been resistant to reducing use of the weed; those with chronic mental illness and the Canadian Aboriginal population. Depending on the area of the country, these populations may represent 25-50% of the smoking population.  

It is timely that Cochrane published a review of effective practices on tobacco prevention for Indigenous Youth Cochrane review of smoking prevention in Indigenous Youth. 

Disappointing was that only two studies were identified, neither of which demonstrated effectiveness of their interventions. 

A NEJM editorial from a year ago looked at the issue of smokers with mental illness NEJM July 2011 smoking and mental illness and provides a succinct tabulation of effectiveness of interventions. 

If we are going to continue to reduce tobacco consumption in Canada, more of the same will have some effects, but targeting those groups with known elevated tobacco consumption rates will be needed as the final push to making smokers an endangered species is being made.  

Key in making tobacco history is going to be efforts that specifically determine how to increase successful reduction efforts for these two populations.  The first step may be better user engagement and demonstration that tobacco is a significant concern.   For those with mental illness who smoke, life expectancy can be shortened by 25 years.  Less is documented on the direct impact of smoking on Canadian Aboriginal peoples with the lack of information likely a barrier to describing the problem.  

World Suicide Prevention Day - light a candle for a loved one

September 10^th is world suicide prevention day and worthy of celebration.  While significant strides have been made in reducing many causes of death.  This site has touched on suicide on several occasions Suicide and crash of the stock market  Suicide action in Canada .

Statistics on suicide were amalgamated by Stats Can in preparation for the day Stats Can compilation .   Reproduced below is the graphic of suicide rates in the country, and while on the surface the decline is reassuring, the recent economic decline should result in suicide increases that may be perceived in 2009.  Suicide rates are closely correlated with economic vitality. 

Health evidence.ca issued a compilation of articles looking at suicide prevention Suicide prevention articles with Health Evidence   which speaks to the state of the art on suicide prevention, and a relative abundance of information for youth interventions with a dearth for general population interventions. 

Minister Aglukkaq statement is worth noting some of the current actions Minister's message Sept 10, 2012  , including a private member’s bill that is currently in progress and can be found and tracked at legislative tracking Bill c-300 . While the bill only requires a framework be developed and updated, it is progress to making suicide a national issue of concern. December 17th - the private members bill was passed on Dec 14th, both a tribute to the work of MP Harold Albrecht and a memorial to those that have suffered  losses. 

Of note in the Minister’s statement are the added references to which should be added the national resource available at the Centre for Suicide Prevention http://suicideinfo.ca/ 

Great comments arising from the Surgeon General as well Surgeon General and suicide with data from down south.  

Suicide effects all of us .  Perhaps its impact is as well stated by the observation taht the Conference Board of Canada has relevant and timely information on Canadian performance Conference Board of Canada and suicide

The depth of information makes suicide an issue that needs to move beyond description into more rigorous program evaluation and determination of effectiveness.  In the meantime, think of those affected by suicide and remember the families and friends that have been left behind by such tragedies and light a candle in their memory. 

Inequity after health events - the determinants of recovery

A conversation with a colleague who is doing marvellous public health work using Twitter tweaked a topic that deserves deeper consideration. Follow her @Monika_Dutt.  
It is through the support of such colleagues that today's posting will mark a total of 9,000 views to the blog - thanks everyone 

We make much of the inequities in health as a precursor to illness and associated demand on health services.  For those that have argued the case to senior echelons the response is often “that is the function of the education system, employment, social services etc. – that is not the role of health”.  A Deputy Health Minster once openly stated that “poverty is not a health issue” even if it is an important social issue. 

How to reverse the tide and engage health decision makers in the discourse that the determinants of health are in fact  a health issue for those that have come in the front doors of the bastions of health services?

Those very determinants of health (and social determinants of health) are the determinants of recovery.  Determinants verses social determinants.  Low socioeconomic status and ethnicity  are clearly associated with such outcomes as poorer cancer survival Science daily 2008, even when adjusted for stage at the time of diagnosis   Science daily 2010. 

This extends to long term outcomes of cardiac events.  Several studies suggesting this was due to lower participation in cardiac rehabilitation eg. Danish study which begs the questions why is there a difference in participation rates and what are the barriers to those with lower income and education? 

This sort of analysis has also been done for cancer outcome and education eg Finnish study,  eg Swedish study.   Noting that the impact from the two studies was in the range of 6-25% improvement of highest education level compared to lowest.

Social support (including pet ownership) is found as a correlated of one year survival post coronary events eg CAST study

While the evidence is clear, the quality of the studies has room for improvement.  Perhaps the more important questions are:

·         Why is relatively little research on “determinant” impact on survival when the magnitude of the impact is greater than the comparisons between various pharmacological options? 

·         Why of the research, is there so little from North American contributions?

·         Why is so little written about inequities in recovery and the determinants when the impacts are so notable?

·         How can these effects be mitigated through targeted intervention?

It should not be a stretch to imagine the mediators for why social determinants like income, education, social support, housing, and food might impact both short term and long term health outcomes after health care interventions.  Compliance with medication may require adequate funds to purchase combined with supports in the home.   Cardiac rehabilitation is benefited by education, diet choices, and a supportive social environment.  

More basically, how can those struggling with basic social issues like low income, lacking food security, unemployed, poor housing, overcrowding, and social situations that engender hopelessness are going to have the resiliency to cope with a significant threat to their wellbeing.  While the studies mentioned relate mostly to cancer and cardiac, it does not take much to identify similar patterns for hip fractures, mental illness and congestive heart failure. COPD is impacted by the poorer air quality found in lower income areas of communities and poorer housing environments.  Ted Schrecker recently blogged on diabetes and its relation to income as a function of management of the illness Health as if everybody counted August 17 in particular as it relates to access to medications. 

So yes, the determinants of health are also the determinants of recovery.
And yes, as health professionals, administrators and governors -  we all have a role in measuring and mitigating such impacts.  

More health care doesn’t mean better health – an actuarial view that might stimulate change

For those in public health the Globe and Mail editorial is old news.  For something that is old news, it appears to be taking fire.

Wealthy people are healthier, and poorer people are sicker. Anyone who has visited this site enough will find the recurring theme of inequity in health.  Scan through the older posting, including what happens when economies fail and wealthy people become poor people.  Health inequities  - stop blaming the victim

Of course, it takes an actuary to write a piece that spending more money on health care actually won’t necessarily improve health – it has a high probability of making us less healthy.   It is a short piece, but based on the number of references circulating in the twitterverse and blogosphere, it would appear to be a revelation of astronomical proportions.   More health care - globe and mail.   

Dig a bit deeper, and the debates in the comments on the editorial are more entertaining and more likely to tweak a few nerves on those with either left or right leaning tendencies.  The debate itself and the diversity of ideologies reflect some of the real challenges faced by public health professionals in changing the current care dominated culture.

A dedicated reader forwarded a relevant study that even more clearly demonstrates how people’s pre-existing ideologies result in diametrically opposed reactions to the same information.  The study in case is a review of responses to social media based on US political alignment – which is about as polarizing an example as the world currently has to offer.   APHA Social media and communications

Just as we know that changing individual health behaviours often requires progression through steps such as the transtheoritical model of change, some evidence supports that community decision making on health supporting actions like smoking control bylaws go through similar steps.  

Likewise why would we not expect populations to also need to go through such steps.   Who better to take the social discourse from one of pre-contemplative acknowledgement that we have a health inequity problem, into one of contemplation that a member of the financial community speaking out that action is needed.  Thank you Mr. Brown.  

Legionnaire’s disease - the tragedy of outbreaks and impact on colleagues

So far, eleven deaths and at neatly 170 illnesses have been reported in Quebec  City related to Legiononnaire’s disease, or Legionella pnuemophilia. 

For all the relatively quiet days in public health spent in slow progress on improving health, our colleagues in  Quebec have been facing what is likely continuous adrenalin filled stress that has lasted over a month, and will continue until resolved and then chronic stress  for years into the future.  It is a repeat of the blood system crisis, Walkerton, SARS, H1N1 and one of the major reasons for an integrated and geographically dispersed public health system.   Professional best wishes should be extended to the local health unit and INSPQ staff who are facing the stressful mystery of what is actually occurring, while further tragedies mount, public and media pressure is unrelenting, and the daunting challenge ahead of a legal inquiry that will take months to years.

In the wake of these events have fallen the professional careers of Roger Perrault, John Furesz, Donald Boucher (key figures for Canadian Red Cross who were only acquitted some 15 years after the Krever Commission report),   Murray McQuiggie (MOH for Walkerton), Colin d’Cunha (Chief MOH Ontario during SARS).  These are career ending events and the exit is not adorned with glitter for individuals who worked with the available information and resources to make what were quite possibly the right decisions at the time, but fail in the retrospectoscope when all the facts are available. Let us hope the names of Francois Desbiens and Chantale Giguere are not added to this list.  Quebec City has been a leader in many public health initiatives and innovations under their leadership.  

The current outbreak has reemphasized the risks associated with humid environments and air conditioning systems with a focus on two building structures.  Most Legionnaire’s disease is sporadic and not associated with a definitive source.  The US reports some 4000 cases per year, but only 12 outbreaks (and typically not more than a few dozen per outbreak).  Ontario reported 162 cases in 2011 and historically mirrored Canadian rates, suggesting Canada might have about 400 cases per year – putting the Quebec City outbreak in perspective as a significant and major outbreak and anomaly for what is the normal experience with this organism. 

The organism is found widely in the environment. A more relevant question is why do we not see more cases?   It can frequently be recovered from pipes, moist environments, biofilms, lakes, rivers, spas, swimming pools, decorative fountains, nebulizers, compost and potting soil.   An even more relevant question is given the number of sporadic cases indicating many people are exposed, why are outbreaks relatively uncommon?  and what characterizes outbreak scenarios since exposure must be relatively common routinely?

Those wanting to delve deeper into Legionella might review a series of presentation from a Public Health Ontario conference  Public heath Ontario workshop June 2012   pages 112- 126 speaking to the challenge of even identifying outbreaks.  Page 158 provides a community example showing outbreak versus sporadic distribution and puts outbreaks as a relatively uncommon scenario.  

Foremost is sympathy for individuals and families affected by the outbreak.  Remember also our public health colleagues who are likely strained by the disastrous situation.  Someday, it might be you. Are you ready for the task?