Canada's Chief Public Health Officer releases his annual report once again under the usual cone of silence.

No doubt you saw the headlines about the 2011 Chief Public Health Officer’s report?   No – well you can join the nearly 35 Million other Canadians that once again won’t get formal notice that the annual report has been released.   Somebody in PHAC issued a Tweet.  That level of communication is progress over previous years.  

This year’s report is on Youth and Young Adults.   CPHO report 2011 

Kudos to Dr. David Butler-Jones and his staff.   The report is packed with valuable information, and injected within enough political propaganda to keep government masters content and not embarrassed by the release. In part it reads like a public health text book, but woven in are the seeds planted that could potentially germinate into action.  The lack of a concrete plan or action steps and the cursory handling of issues related to inequities based on socioeconomic status might be understandable compromises.  There is a reasonable handling of Aboriginal inequities.  There is almost no consideration of the geographic disparities that exist in the country. 

The report is recommended reading, albeit that you will find few surprises.  

Perhaps next year the CPHO could issue a news release?   Who knows, in two years he might be allowed to actually speak to the public about his findings, that would be a novel way of letting us know how healthy we actually are. 

Whistleblowing - a fine art with potential dramatic consequences

Two items recently caught my attention.  On a global level, Wikileaks has stopped undertaking their core business of making government documents transparent through publishing them on the Internet.   Their reason – lack of money.  The cause – the major credit card companies have refused to process on-line credit card contributions in support of their work.  Why?   The credit card companies received pressure from the US government and other governments which effectively applies an economic blockade against what they perceive as an on-line security “threat”.

The second more personal story is from a nurse who wrote an op-ed piece for a paper that was critical of the quality of service provided in a Canadian emergency department.   The reaction was swift with intimidation from peers, reprimands from managers, and a formal complaint to their provincial professional licensing body.  

Some countries, provinces or organizations have formal policies to protect ‘whistleblowers’.  That act of disclosing what many know, but few are willing to state for fear of retribution.  Given the two real recent examples, the fear of retribution appears justified, irrespective of the legal protection that may exist. 

The nurse appears to have been informally vindicated by their professional body but I worry that the personal impact will negate any further attempt by them to rectify similar wrongs.

This blog is in part designed to provide a forum for sharing public health truths, perhaps a veiled attempt at some whistleblowing combined with a forum for discussing current controversial public health events.  There is a level of anonymity to the writer which provides a thin layer of separation from what occurs during the public health professional day to the nighttime efforts of sharing shadowy truths. I’ve had my knuckles wrapped enough times to know that it hurts, and that the fingers still work the next day.  I’ve not yet had my hands cut off, but I have seen public health people who have suffered the consequences of speaking openly including amongst others - Alberta’s current leader of the opposition Dr. David Swann (speaking out on climate change issues in Alberta) and the past chief MOH in Ontario Dr. Richard Schabas (speaking out on government policy changes).  Their stories, and those of others speak to the fine line that we walk daily.

A word of advice, if you feel a need to disclose something, be sure that you:

1.      Discuss the matter with trusted professional peers. 

2.      Advise those that you are accountable to of what you intend to say, and how.   Governments and big health care organizations are used to criticism; they do prefer not to have any surprises. 

3.      Invite the input and suggestions of those that may deem the information potential problematic, there may be a middle ground that meets your needs in a way that meets their needs. 

4.      Where needed, engage in a conflict resolution mechanism that can be mutually beneficial and meet a need that improves the health of those that we serve. 

As I am reminded by friends, it is very thin ice that this blog has wandered on.  It is however ice that is worth skating across for the time being.  

If you have a story to share, or public health “truth” you would like revealed, email me at drphealth at gmail.com.

Refugee health - Canada's effort to compromise basic human rights

Please help this site grow by sharing the link with public health colleagues.  Please leave comments,  or email to drphealth at gmail.com  

The Preventing Human Smugglers from Abusing Canada’s Immigration System Act. Is probably not a piece of legislation that most Canadians have heard about.  It has been touted by the Minister of Public Safety as an effort by the government to stop repeats of the boat refugees that arrived on Vancouver Island in 2010.   The act is known as C-4, can be found at Bill C-4 as of October 2010 .  As of October 27^th it remains in second reading and its progress could falter or proceed.  The Bill challenges our fundamental values as Canadians and members of the global community.

Despite the rhetoric of right wing Republicans south of the border, most economists and social scientists would acknowledge the value of freer movement of goods and people across borders. Our tolerance for freer movement is challenged when the established rules are challenged by innovative means. Using ships to move large numbers of potential refugees is an example. Refugees are usually defined in accordance with the Geneva Convention of 1951 as

 owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country

The definition does not include economic reasons. Recently the movement of persons not using immigration processes has sometimes been driven by economic threat or the hope of economic prosperity. 

Bill C-4 however is relegating such economic refugees, some of whom may have other well-founded fears of persecution in their country of emigration, to a status of human condition that would not be acceptable.  The Bill permits the suspension of the legal protections afforded refugees arriving by more traditional modes of conveyance.  Foremost is the ability to detain such individuals for up to 12 months without legal counsel – and that period of detention can be extended indefinitely only subjected to an administrative review every 6 months. 

The intent of the legislation, as this government has stated with other legislation, is to provide teeth to address the criminal intent nature, not the partial victims of human smuggling.  However, the intent has been lost in the legalization of the terms of the Bill.  The Bill is as applicable to children as to adults, and would be a direct contravention of the UN Convention on the Rights of the Child.  See the commentary on the Canadian Pediatric Society publication on this matter Table of contents for Pediatrics and child Health, scroll to commentary piece New Canadians are major contributors to the social fabric of our country and their contributions within a single generation have substantive added value to our social and economic wellbeing.   While mass “smuggling” may be a newer modality for entry into the country, the knee jerk reaction of erecting barriers to new settlers of this land seems short sighted and ill-perceived. Detention is a threat to individual health .   Imagine what would have occurred if the original Aboriginal inhabitants of our country had placed such bureaucratic and unfriendly barriers to the arrival of “boat people” arriving from Europe.

Emergency preparedness - are you taking the right chances?

Last Thursday, BC and numerous states participated in a large scale emergency preparedness event to simulate the impacts of an earthquate in the region. http://www.shakeoutbc.ca/index.html.   530,000 people in BC practiced the drop, cover and hold, or at least learned how to grapple with the first moments of the 'big one'.  In total some 8.9 Million North Americans participated in the exercise

Tragically, just 4 days later, Turkey suffered a 7.2 magnitude earthquake that has flattening communities and killed hundreds of people.  The numbers will grow as at least a 1000 are missing.   We need only look back at Japan and Haiti as other recent examples of large scale events of mass destruction.

Most parts of the country are at risk from some form of natural disaster ranging from fires, floods, tornados, blizzards, ice storms, tsunamis or earthquakes and others, which have the potential to kill, maim and displace people.  Oftentimes the immediate event results in prolonged recovery where more disease and death are not uncommon.

How prepared are you?   The old adage that be prepared for 72 hours before you get help, was actually based upon California planning where it was expected that it would be at least 72 hours before contact would be made, not before help was available.  Plan for a minimum of a week - you will not regret being prepared.

Canada's infrastructure for emergency preparedness has waxed and waned with political stripes and the economy.  Emergencies must be handled at a local level, provinces and federal bodies providing support.  Often, local groups are overwhelmed and the assistance is welcomed if it is available.  

Start with your self and your family.   Develop a plan, and Public Safety Canada has reasonable guidelines to work with at http://www.getprepared.gc.ca/index-eng.aspx 

The scouting movement got it right.  "Be prepared".    Or in the words of a great public health pioneer Louis Pasteur - "Chance favours the prepared mind".

Sterilization incident - just the tip of the iceberg

This week, nearly 6800 people who received service from a physician’s office in Ottawa are receiving letters advising them that the sterilization practices were inadequate and the potential exists for the transmission of the bloodborne infections of Hepatitis B and C and HIV. This is merely the most recent in a series of situations where inadequate sterilization has been identified.   It will not be the last.  If anyone has information on the effectiveness of such public notifications, please post as a comment, or email to drphealth@gmail.com. 

The first wave on incidents were amongst hospitals, or more exactly specific services within hospitals with poorer infection control practices.  This high profile situation is different as it is a community based health care worker where problems have been identified.  CTV item on Ottawa clinic

While tattoo parlours and other personal service establishments are often subjected to health inspections, no such progam has existed for community based health care workers.  Physicians, dentists, nurse practitioners and others are regulated by their own professional bodies and not public health inspectors.  In office inspections are almost unheard of and are usually only instigated following multiple public complaints.   It is another dirty secret that deserves to be cleaned up. Office standards for sterilization exist but are not routinely enforced.  Infection prevent has pedominately been a limited to hospitals and occassionally residential care settings.  Incidents like this are just the start of unmasking the extent of poor office based health care practices. 

The chances are supposedly less than one in a million that any disease will be transmitted. Reading the comments to the CTV story is worthy for all public health professionals, while not reflective of all the general population, it does reflect extreme views.  There are at least two commenters claiming that their current infections are secondary to the physician’s office, and a handful of individuals who are stricken by the anxiety of having been told, but not yet reassured by negative testing. There are several comments taking shots at the Medical Officer of Health for the handling of the process, despite being the agency of last resort to ensure transparency and clear that perhaps other agencies should be responsible and failed to act. 

Fortunately, transmission of these viruses outside of sexual transmission or sharing of injection works is not common.  Hepatitis B immunization has become the norm.  Hepatitis C is rarely transmitted sexually and improved blood system screening and reduced injection use may help stem the tide.  There are newer approaches to HIV disease control that show promise to increase control – and that includes encouraging everyone to be tested routinely. There will however be many more incidents, lots of anxiety and concern, and the occassional preventable illness before a more universal approach to protection is achieved.   

(Blood donors have these diseases screened for at each donation, and while not the place to have the first testing – one should ask why we are all not donating at least 2-3 times per year)

WHO conference on Social Determinants of Health - Canada goverment's absence an embarassment

Thanks to a reader for sending me the background for this blog.

Canada is a big country with lots happening, I welcome readers sharing current affairs that are related to public health, or ideas for topics.   Please leave comments or email to drphealth@gmail.com  

This week  the world will gather in Rio de Janerio for a WHO conference on Social Determinants of Health with a proposed global declaration.  Some 118 Member states, with 60 Ministers of Health  will be attending.  Guess who is boycotting – the Harper government.  Canadians have been instrumental in setting the agenda for the determinants, yet the current political ideology just isn’t sufficiently aligned with the past record and world reknown to even participate.   Look back at the previous blogs http://drphealth.blogspot.com/2011/09/determinants-of-health-original-versus.html  that identify the Canadian contributions.

If you are interested in expressing your displeasure at Canada’s absence, sign the petition at http://www.gopetition.com/petitions/tell-canada-to-show-up-for-health.html  .

If you are interested in watching the conference activities, including links to live webcasts http://www.who.int/sdhconference/en/ 

Drphealth blog is turning 2000.    It took roughly 90 days and 48 blogs for the first 1000 visits.   This week the blog will flip its second 1000 in only 28 days and 13 further blogs.   Help build the success and be sure to share the blog link with colleagues.  Thanks to readers across the country. 

Drinking Water in Canada - safe but not safe enough

Canada has one of the highest global per capita supplies of fresh water, and not surprisingly one of the highest per capita consumption rates of water.  Of course, none of us actually drinks 350 litres of water a day or use that much in our own households.  Most water goes into food and power production or industrial processes.  

We are also blessed with reasonably good quality fresh water.  Or perhaps it is the curse.  The perception of good quality likely resulted in a somewhat indifference to protecting water quality and a minimalistic approach to treatment for drinking water purposes.

Provincial variation in expectations, regulation, and even basic philosophy have resulted in a patchwork of drinking water supplies and highly variable safety from one community to the next, and in the most perverse situations variable risk within the same community.  Quebec with one of the older infrastructures, has a strong program and dynamic debate about ensuring water safety.  Once again an icon to be emulated in many respects.   Yet, 100,000 people were placed on a boil water advisory 2 days ago in Montreal’s West Island, although rectified in less than 48 hours. 

Along came Walkerton and shortly after North Battleford.   No surprise given the vulnerability of the drinking water supplies.   Perhaps forgotten are the 30 odd outbreaks of waterborne disease that were documented in BC in the 90’s.   It was however the tragedy of Walkerton that refocused attention on Canada’s vulnerable drinking water resource. 

Provinces have responded in a multitude of ways.  Most of Honourable O’Connor’s recommendations from the Walkerton inquiry have been acted upon, although there is debate on the effectiveness of the implementation. Clear onus was put onto the public health community as the guardians of the public's wellbeing.   And the obligations entrusted to public health professionals to protect the population from unseen threats was emphatically stated. 

Significant progress on reducing risk associated with drinking water in Ontario has been made.  Likewise in Saskatchewan where only a handful of large municipal systems were unable to meet treatment requirements by a fall  2010 deadline.   Alberta was well ahead of the curve, but private developed has resulted in lower the bar. Still some of the approaches to mass drinking water production and distribution could be a lesson for other provinces.  

Other provinces have been less diligent.  Nova Scotia allows for a mixed process for providing drinking water with differing expectations.  To learn how not to do drinking water, look to BC.  First Nations lands have often been subjected to inferior drinking water quality, and while the current federal government can only be minimally faulted for its record in remediation and substantive investment, the decades of neglect spanning numerous governments should not be forgotten.  It was the evacuation of the Kashechawan First Nation in 2005 due to unsafe drinking water that finally catalyzed in the current levels of investment.

Water is a public good and should at all times be treated as a utility.  We are fortunate in Canada to have reasonably good water sources, but they are not pristine and require proper treatment and safe distribution.  There may be good rationale for having private management, but drinking water should not be treated as a commodity as it is in some countries.   It is an essential element for survival with no options other than unsafe alternatives.   There is no reason for any person in the country to suffer from a drinking waterborne illness of any nature.  

Yet, some 1800 water systems in Canada are on some form of advisory, 1/3^rd of these in BC, with Saskatachewan, Newfoundland also with large numbers for their smaller populations.  The ability to even track and count is not easy, but perhaps the Water Chronicles effort http://www.water.ca/map-graphic.asp  is at least a start.   Transparency and provincial government accountability are required in this utility more than any other – yet in some provinces, such accountability is lacking. 

Drink up.  And no, you should not need to purchase bottled water, fortunately and despite the numerous underserviced communities, drinking water quality delivered to the vast majority of Canadians who live in large urban settings is safe and tasty.