DrPHealth – time to begin to wrap up the blog site

Over the past 4 years, there have been over 430 posts and over 35,000 viewers. 

For the dedicated reader, you will note that there have been no posting for the past 6 weeks. It seems that the time has come to allow the site to remain active as there are some very good unique resources that are not synthesized in other locations, and many pages that are now outdated and should be viewed with a skeptical eye.

Just as importantly, the main audience for this site has been public health workers in Canada.   Where the first few years were predominately Canadian readers, and in the mid-years about half;  Now both Russian and US viewers outnumber the primary target audience.  While such international interest is appreciated, it begs the question as to whether the primary mandate is being met

The site was started when there was as relative dearth of on-line resources.  Now there is a plethora. Blogs have popped up, and more importantly, are better evidence synthesis sites that use rigorous approaches. 

Twitter was merely a curiosity.  Facebook was still a personal sharing site and not the information source it has become.  The growth in both to meet professional and private needs speaks to their effectiveness.  The growth of interest from the international community also speaks to the rapid uptake of Web based systems.

Overall the effort has been successful in communicating out.  The site however was not well used for stimulating dialogue amongt professionals.  And while there have been a smattering of guest contributions, a prime purpose of protecting anonymity makes the site open to question for its legitimacy (a valid concern from the media), and in many instances experts in various areas would prefer their pieces to carry proper attribution. 

Still to come may be an important series on discrimination and health, and given the recent events in the US, this has become even more pressing. 

Your thoughts and comments are still welcomed.   The drphealth@gmail.com address remains active and monitored.  

Incarceration, HIV, Hepatitis C and the lack of access to clean drug consumption supplies in Canada

A guest contribution from a health profession trainee.  Extracted from a letter to their professional body requesting advocacy action.  

Incarcerated populations have rates of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection 15 and 39 times greater than the general population, respectively. Sharing of injection equipment can account for a large proportion of the increased rates seen in these populations. Due to the illegality of drugs, there are high rates of incarceration among intravenous drug users (IVDUs). High incarceration rates for IVDUs lead to an increased proportion of people who inject drugs within prisons, and there is evidence showing little change in their drug use patterns once in custody. As there is a scarcity of sterile injecting equipment relative to drug supply and demand, high rates of needle sharing occur.  A 2010 survey of Canadian inmates found that half reported sharing needles. As well, some individuals report initiation of injection use while in prison.

Current policy is to focus on interception of drugs before they enter prisons. There has been less than a 1% decrease in prison drug use during increased efforts to reduce drug entry (1998-2007). A Correctional Service Canada (CSC) survey of prisoners found that 40% reported using drugs since arrival at their current institution. It is evident that the current emphasis on drug interception has not proven effective.

Prison needle distribution programs (PNDPs) have been implemented successfully in several countries, for many years. Switzerland, Germany, Spain, Moldava, Kyrzygstan, Luxembourg, Romania, Portugal, Iran and most recently, Australia, have all implemented some PNDPs. Analysis of the effectiveness of those programs reveals reduced spread of HIV and HCV, as well as reduced needle sharing. There has been no increase in drug use or safety issues for the prisons involved; staff at the PNDP prisons report increased feeling of safety. 

The health of incarcerated individuals rarely comes to public awareness as these individuals are sequestered from society. In reality, the incarcerated population is extremely fluid, particularly in provincial facilities where inmates serve sentences less than two years. Disease contracted in the prison system does not remain confined there; incarcerated individuals are released to the community. Statistics from CSC estimate that between 2000 and 2002, the number of individuals released into community with HIV and/or HCV increased by 60% and 13%, respectively.

The World Health Organization (WHO) recommends that “prison authorities in countries experiencing or threatened by an epidemic of HIV infections among IVDUs should introduce needle sharing programs urgently and expand implementation to scale as soon as possible”. In concert with this recommendation, various national agencies have called directly on the Government of Canada, CSC and the provincial correctional bodies to implement PNDPs, including: CSC’s Expert Committee on AIDS and Prisons, the Correctional Investigator of Canada, Canadian Medical Association and the Canadian Human Rights Commission.

Join in the call - contact your federal and provincial Ministers responsible for corrections.  Clean needles are just one of the adjuncts needed in corrections facilities in order to maintain minimum wellbeing.   

How Canada Performs: A National report card with international comparables.

Ask any classroom how many people like getting their report cards, and perhaps a few stellar students will sheepishly lift their hands.  Having our performance assessed is not a favourite pastime for most of us.

This shyness away from grading extends to government performance as well.  In a confederation, one of the strongest roles that a central government can play is in monitoring and reporting on the activities of its members (provinces).  However, in keeping with Canadian mentality, this is frowned upon, and even when the federal government moved to reporting provincial performance as a condition of the 2003 Canada Health Accord, this was vehemently rejected by the provinces. 

In fairness, collective performance is often influenced by so many factors outside of the control of the responsible organization – in this case the provinces.  

Tell that to Bay Street, where performance is monitored and measured essentially in real time. Corporate entities are continuously under scrutiny for delivery of their outcomes, and in a day and age where triple or quadruple bottom lines are measured, it is not limited to performance in fiscal deliverables.

Hence we now have CIHI reporting out on health authority performance (subprovincial level activity) May 2012 and that only occurred since MacLean’s magazine was printing the information in previous years.  Other agencies have taken up the call with Coalition for active health kids, Unicef, Lung association on influenza, and the Canadian Pediatric Society annual report card on children eg 2012 report.

So when last week the economic think tank called the Conference Board of Canada released their score card on health in Canada, while the provincial governments might shudder, the media coverage was extensive.   British Columbia’s government was lapping up the highest ranking, while those with poorer scores such as Manitoba and Newfoundland still felt obliged to respond  rather than discredit the methodology.  How Canada performs.      

      

Where we continue to fail is that the arms length bodies that are now holding us accountable for performance, have minimal ability to influence the decision process that could change the system.  

If we were to look south of the border, CDC seems to be able to much more readily report on state and county level health information, and ultimately influence resource and policy decisions.

The Conference Board of Canada report card may be a step in the right direction and notable that a predominately corporate entity is having such influence on improving social outcomes.   

HPV vaccine debate in the Toronto Star. Unmasking the dark side of the media

The Toronto Star HPV saga dominated the airways beside the rage against anti-vaccinators as initiators, propagators and disseminators of measles.  Two highly incongruent stories, both highlighting the passionate debate around immunization.  

Some might say neither with tragic consequences yet in Canada, others will point to a mounting toil of preventable cervical cancer.  Irrespective of your view, both illustrate the challenge of bringing science to the public. 

Most child and youth immunization rates are slipping gradually.  HPV coverage is increasing.   Both reflect choices of parents and are less impacted by the needs or opinions of the persons receiving the vaccine.  

The Toronto Star original article spoke about the dark side of vaccination Dark side of Gardasil  

While not fully retracted the story, the Star has published an op-ed piece Feb 11 response which counters the original allegations. The publisher and editor-in-chief have come as close as possible without actually issuing a retraction or apology in stating the article “let the readers down”  Feb 11 CBC coverage

Where to from here?  Vaccination decision for most childhood illnesses have an outright acceptance currently running around 80%, that is at least four out of five parents follow the advise of their health care provider because they are just that “their health care provider”.  A trusted source of health information on which they depend.  

The doubters and objectors for most vaccines are in a total minority.   While a very small percentage of the population truly want to contrary, the majority prefer the comfort of being in the majority.  Each and everyone who should receive a hero’s medal for not only trying to protect themselves, but for the contributing to the protection of their community.

It remains to be seen if the Star will bow to the pressures of advertisers, readers, journalists and politicians in refraining from stirring the vaccine pot.   It seems like a good journalistic and business decision to review its reporting.  

Anything that is provided universally is going to have its share of coincidental events.  In the meantime, those that remember the horrors of facing these illnesses and the devastation they have caused in our lifetimes need to speak up to and share their wisdom, and the media have a duty to be truthful in their reporting - something the Star fell short on this time.  

Ebola control - a real public health success story that is not being told enough.

A great global public health success is being played out in West Africa. Perhaps overshadowed by the challenges associated with the treatment side of the equation in grappling with Ebola.

Treatment however does not reduce the number of new cases, it may reduce mortality, and there is some evidence that mortality rates are decreasing from an initial 50% and down to about 40%.  Good news for all those involved in treatment.

But the real story lies in the prevention of cases.  The past 6 weeks have seen what was an average of 600 to 700 cases per week, has dropped over 80% down to just over 100.  (124 for the week leading up to February 4  WHO weekly surveillance data.  The outbreak curve information embedded below. 

That is an amazing story and a tribute to the public education, public guidelines, body disposal, infection control, contact tracing, isolation procedures that have been implemented in response to the outbreak.

Yes there have tragically been 834 health care workers who have developed Ebola.  That however is only 4% of all the cases and the only group amenable to improved infection control in the treatment facilities. A mere fraction of the reduced incident cases. 

Noone should understate the contribution of these health care heroes working on the front lines.   However, where are the celebrations of those whose contribution is now saving hundreds of lives a week through reduced incidence.  It is typical of public health professionals to undersell their success and not celebrate too early, but perhaps a nod in the right direction that acknowledges their efforts to date and some support for continuing efforts are warranted.  In typical fashion, the vast vast majority of aid resources are directed to the treatment and management sites, not to the public health efforts. 

Thanks to the WHO and all those who have been involved in planning and implementing the fundamental public health interventions that have reduced this epidemic to the point that full containment is well within reach. 

Kudos to all public health professionals who have been involved. 

The Moose (measles) is loose again - and this time antivaxers are having the finger pointed at them.

Once again the moose is loose. 

Measles showed up in Disneyland in mid-December 2014.  The bastion for middle class North American children, the hallmark of all our childhood and most importantly the icon of healthy and safe families.  Yes there is something wrong with the picture of Disneyland being the source.   While only 84 cases were reported to date, this outbreak has the makings of something that could irritate North American for months.

Moreover this time the antivaccination movement is taking it on the chin. Over half the cases were confirmed as unimmunized, and only 8% had received two doses of vaccine.  The strain can also be linked back to the Philippine outbreak March 2014 which was traceable back to sub-Saharan Africa endemic illness that spread to the Netherlands unvaccinated community, that spread to the Phillippines through aid workers post the devastating November 2013 typhoon Haiyan.  

As Mickey would say “It’s a small world after all”

Measles is targeted for elimination, but until international efforts of all stripes come together, this is a persistent plague that will stay with us for decades.  The reasons behind the challenge in control were documented following another point source spread in the US, the 2012 Superbowl February 2012 that was more readily contained as the exposed population a tad older than the typical Disneyland crowds.

What is so notable in this event is the spread is being driven by the unimmunized and underimmunized, for which sufficient susceptible populations exist that transmission has the potential to sustained in the right circumstances. The calls for tighter controls on personal choice exemptions, increased mandatory requirements, improved documentation will once again remain in public’s eye through the core of the outbreak.  The defining event will be tragedy associated with someone who is ill.

So back to the demographics of the first generations at Disneyland.  Middle class, mostly likely insured, well off enough to afford a trip to Disneyland, likely well nourished – these are not the children that will suffer irreparable damage and death from measles.  They will recover and their parents may be steadfast in their belief that measles is a mild illness.   If, the virus spreads to a lower income gradient, undernourished and uninsured children – it will be at arms length from the causative agents of spread.  Moreover the very agents of spread will be the most vocal on the issues of personal choice, having dissociated themselves from any negative repercussions.

Good on those that are taking the antivaxers to task, its time the collective voices speak up for the public good. 

Mental Health Promotion in action: #BellLetsTalk

It is one of the largest health awareness events that we have seen in this country, and credit to Bell Canada and in particular to the leadership of Clara Hughes.  Give that lady another medal for her astounding performance.

Mental health consumers and professionals alike have striven to increase awareness of mental health issues in the country for decades.  It has been the dogged determination of a concerted charitable effort that has finally helped break through the barrier.

Throughout the day innumerable statistics and stories have been posted on #BellLetsTalk, couched in a fund raiser of 5 cents per tweet for the whole day, the attention seems to be coming from all directions and a wealth of information in just the 140 character Tweets.

If you have not done so, contribute a retweet, but more importantly search on the hash tag and scan through the richness that Canadians have revealed.  Just after this posting, Clara Hughes announced that over 100 Million texts, tweets, likes etc had been sent.  Slightly less than last year's record, but really - that is three for every Canadian, an incredible level of engagement. 

We know that mental illness will affect at least one in five, severe persistent mental illness affecting about 3% of the population, anxiety disorders are one of the most common diseases and rarely reported or treated.  The list goes on and on – learn more at #BellLetsTalk

Canada's children under the global spotlight. A continuing public health crisis

An op-ed published on the plight of Canada’s children deserves a quick read.  Published in Victoria of all places, renowned as a centre for retirement in Canada, the article by University of Calgary professor Nicole Letourneau hits hard at the neglect of Canadian children in comparison to our developed country peers.

UNICEF rankings show how Canada stacks up against other developed countries UNICEF state of child 12 2014  and the 2014 report focused specifically on the impact of the recession globally on hardest hit nations and changes over the 2008-2013 period. Oddly much of Canadian statistics are excluded from the main UNICEF report, but are found in a companion Canadian document at Canadian companion UNICEF 

·         Canada’s performance remains dismal overall but some good trends are noted

·         Child poverty increased overall by 2%

·         Children are more likely to be living in poverty than adults and seniors in Canada

·         Canada still ranks 20 of 41 countries in poverty rates, and a whopping 16% absolute less than Norway where only one in twenty children lives in poverty.

·         10% of Canada’s youth either not employed or in school, however this fairs better than most countries (rank 7)

·         Canada ranked 34 of the 41 countries in the perception that children’s opportunities have declined

·         Canada ranks 32 of the 41 countries on perceptions of increased stress on children.

Both the global report and Canadian companion are excellent documents that detail the impacts of the recession and lessons to be learned from global comparisons.  Canada’s performance close to dismal based on the op-ed Times-Colonist January 11.

Both documents are to be commended for lengthy discussions of the economic rationale for supporting children, and both speak of the successes that others have accomplished.

Time for Canada to step to the plate at more than the tokenism expressed in addressing income  splitting amongst high single income earning families. 

Canadian women continue to be denied a health benefit available globally. The case of politics and mifepristone

Canadian women are being denied a health benefit that is widely available in the US and Europe.  Why? because for some bizarre reason, despite being on the WHO list of essential medications, despite twenty-five years of global distribution, despite fifteen years of approval and distribution in the US, despite political upheavals and protests in Australia it had been banned and now approved for use, despite all  this, Canadian regulators suggest that they need “more information” before approval can be considered in Canada. See Globe and mail coverage of delayed decision on abortion pill  

The Canadian regulator system tends towards precaution and conservatism and that has served Canadians well in many instances.  This however should be called what it really is – blatant political interference in the regulatory process.  The government will likely move to an election this year, and merely is clearing the plate of a potential ideological embarrassment if a Conservative government were to issue an approval, they stand to alienate the far right.

Shame on such political pettiness that women in Canada are continued to be denied a more comfortable and perhaps safer alternative to pregnancy termination.

Abortion evokes a variety of emotional responses that span the continuum and have entrenched camps at both extremes of the spectrum. The health ethics of abortion have long been clarified with the duty to support a client in their choice.  That in Canada we would continue to utilize technologies that are antiquated and may not be as safe is astounding.

Mifepristone is not an innocuous drug.  It has a very intended purpose that disrupts endocrinological responses and induces uterine endometrial degeneration, essentially mimicking processes involved in normal menstruation.  Its pharmacological targeting is more appropriate than the one approved medical regime in Canada which combines the cytotoxic drug methotrexate with misoprostol which is better known for its gastric protection action than its use in obstetrical induction as a cervical ripening agent and stimulator of uterine contractions.  The non-medical alternative remains the Canadian mainstay of pregnancy termination using the invasive procedure of vacuum extraction. 

The technical details aside, that politics have played into what is supposed to be a non-political regulatory approval process fuels further concerns of the interference politicians have played on government scientists and silencing of their voices The Canadian muzzling of scientists October 2013 .  In this case scientists should be speaking up loudly in addition to the voices of women (and men) who are being subjected to abuse by being denied a treatment alternative that ultimately leads to a higher likelihood of physical attack on their bodies.  

I

n any other legal realm, this would be considered violence against women.  

Picard hits a home run: Hospital congestion not just an influenza problem

A national treasure, André Picard once again tells it like it really is.  Influenza is not the cause of the winter bed surges – its bad management and planning.   The increased volume of influenza hospitalizations may hit a 1% surge above background levels, whereas some hospitals are looking at over 25% excess populations  above bed numbers - and doing nothing other than blaming something over which they perceive they have no control. Jan 7 - a calculation of current admitted clients by number of beds in one are of close to 1 Million population, suggests overall impact on bed utilization is 3%  - well below the reported capacity overflow for the same area. if you have local statistics, please share them and help debunk the myth

Well done André – hit a knockout punch to ring a few bells.   Hospitals manage very well planning for holiday slowdowns, planning for reduced services on weekends, and coping outside of the 8-5 work day.  They even have demonstrated marvelous capacity to respond to labour strife with strikes and walkouts, without poorer health outcomes.

Yet, annually the surge occurs to align with the predictable wave of influenza.  And predictably the hospitals will argue for more beds, the emergency departments will complain of backed up patients, long wait times and poor quality care.  And come April, while the rhetoric reverberates, planning for a summer slowdown will be in full swing.

The cynics might reply with its just public health complaining and pushing more vaccine. If public health did a better job getting people to wash hands, cover their coughs, be immunized and even ensure that the walking ill don’t see it necessary to use the emergency room, that the hospitals would manage better.

Talk about victim blaming!!!  

That a large number of people inside and outside the hospital this year are gripping about the poor planning is a faint light that perhaps somebody might think differently.  With a dozen years at senior executive tables and nearly 30 years in the field, this writer’s skepticism is justifiably a learned response.  As one person said, “its like the movie Groundhog day.  We just keep repeating the same mistakes over and over and painfully slowly learn from our mistakes.

So good on you Picard for taking the system to task.  We deserve the criticism and we deserve chastisement for our failure to learn from the past.  

In this day and age, few senior executives last more than a couple of years – corporate history is so short that we are destined to repeat our errors, over and over and over again and sentenced to the annual winter surge to be taken in stride as a “normal”.  Besides, were it not for the winter surge, we would not have the numbers on which to argue for more beds, bigger emergency departments, more, more, more…. 

Thanks André.   We’ll be looking forward to your next home run. globeandmail ER congestion January 6 2014

2015 – What the New Public Health Year may bring. Predictions of what is hot and what is not.

2015 comes with no promises, but heck – why not stick a neck out and provide some predictions on where things are going in public health.

For the optimist, look to:

·         ·         Successful trials of candidate Ebola vaccines and the beginning of control on the West Africa outbreak. While not the biggest public health issues, it will continue to be the dominant media attraction for at least the first half of the year.

·         Mental Health issues will continue to receive appropriate and perhaps even expanded attention as a public health issue, more than just increased clinical services.

·         Improved involvement of public health in commenting on significant policy issues in some format of health assessment with some useful tools available to support the work

·         Further subtle migration of other health sectors to areas of prevention (without necessarily involving traditional public health experts)

·         Enhanced emergence of the specialized disciplines of public health economics and public health services research.

·         Tokenism to public health controls by implementing policy restrictions on flavoured tobacco and electronic nicotine delivery systems (/ENDS/e-cigarettes/vaping), with perhaps some attention to food advertising to children.

·         Continued general improvements in nutrition and diet – led predominately by market forces and social trends and not by organized public health responses. 

Social issue trends with significant long term health benefits.

·  ·         Increased attention to the issues of ethnic and racial discrimination as a public policy and public health issue

·         Further rhetoric on the maldistribution of wealth – without solutions

·         Attention being formally given to the issues of Canadian youth underemployment

·         Renewed attention to women’s health issues of gender equity, domestic violence, sexual discrimination and harassment. 

·         Persistent downsizing of governments and limiting growth in the health sector.

·         Continued shift in public policy power to the oil and gas megaindustries.

·         Continued migration from collective recreation to dependence on electronic communication devices

For the pessimist:

·         Further migration away from, and the disempowering of the traditional public health infrastructure

·         The continued disciplinization of public health in Canada to the detriment of the organization of public health

·         Continued flailing of the explicit poverty agenda with mere shuffling of the issues

·         Further government short selling of the future of children in the country. 

·         Expansion of faith based tensions and discrimination

And things that we might want but can expect are unlikely to happen:

·         Minister Ambrose taking a leadership role in forging federal-provincial health bridges

·         Real leadership from the Public Health Agency of Canada and the new Chief Public Health Officer

·         Multilateral international efforts to resolve tensions and expand peace

As with any list, DrP invites your suggestions and comments, posted to the website or with an assurance of anonymity if directed to drphealth@gmail.com.

Finally, renew your resolutions in support of your vocation as a public health professional. The list from 2012 remains as relevant today as from three years ago.  Dec 30 2011

May 2015 fulfill your best dreams and gift you with happiness and health