Remember Peace as a public health prerequiste

Canada remembers its fallen today.   The gallant efforts of Canadian forces to maintain peace and protect those values that we cherish.  In its most recent mission in Afghanistan, Canada has lost 158 military and 4 non-military brothers and sisters, whose lives deserve rememberance and celebration.

International efforts to maintain peace have often been successful.  This year saw up to 30,000 people die in Libya.  Other hotspots include Afghanistan where in the first 6 months civilian deaths were up nearly 30% over 2010 when at least 2500 persons died. 

The Iraq conflict has claimed over 100,000 lives in total with some estimates over ½ Million.   Mexican drug wars killed about 15,000 in 2010.

Counting the number of wars is not easy, but there are some 40 current conflicts globally.  Ten of these result in more than 1000 deaths per year,.  About half the conflicts are intranational (civil conflicts).  Notably is that collectively in these wars, up to 70% of the deaths are amongst civilians rather than military personnel.

The Ottawa Charter on Health Promotion defined peace as one of the pre-requisites for health.   On this day of rememberance, scan your eyes to both our Canadian military heroes, and also to the global community that continues to strive for global peace and to our fallen civilian neighbours. 

Influenza immunization - the unspoken public health questions

Yes,  I recommend influenza vaccination and something that even healthy people should consider getting.   There are experts,  and back up experts, and other experts,  that have reviewed and combed the evidence  and keep coming up with the same conclusions.  So I shan’t bore you with the reasons.   You can have more fun looking at the anti-influenza immunization propaganda anyway. 

However, we have influenza issues in public health that need resolution.   First, time to stop overstating the problem and celebrating the success.  Without vaccine, some 4000 Canadians would die annually in an average year from influenza.  There is no doubt hundreds to low thousands may die each year, but the widespread use of vaccine, nearly one in 3 Canadians,  makes a huge difference to the hospitalization and mortality stats.  So the message should be influenza vaccine now saves thousands of lives in Canada in each and thousands more hospitalizations.  Where is the data that shows what good we are doing, not the bad that might happen if we don’t do it? Please stop saying that influenza kills thousands in the country annually, that is just not a factual statement anymore.

Supposedly,  H1N1 only killed 428 Canadians.   How do you reconcile the numbers to the public when we immunized 40% of the population and we say that influenza kills thousands in a normal year?  Of course we immunized so many and didn’t communicate the number of lives that were saved – Where are those numbers?  The public will likely never hear how the program was of benefit. 

There are legitimate science question about the vaccine and disease control that the experts will pose and seek answers, and the details of who, how, what and when may get refined over time.  The petty debates that are played out in the public eye contribute to distrust in the vaccine and the system. 

We have 2 and maybe 3 provinces doing universal immunization (Ontario, Alberta  - and Saskatachewan if the resident wants it).  How come we don’t have consensus on the value of the program after nearly a decade in Ontario? Will the politicians decide before the professionals do? Inconsistency is perhaps our greatest enemy. 

The system for delivery is so varied from public health to private practitioners.  Western provinces are moving to pharmacist delivery and where is that taking us?  Public health is great at building things and passing them along, is it time to put influenza vaccine almost solely into the hands of other providers? Are we hanging on to a dinosaur in wanting to retain mass public clinics? 

There are 8 different influenza vaccines now available and it is great that we now have multiple home grown providers.  Where is the proliferation of vaccine types taking us?  Does privatization of production have a cost along with its value?

Influenza vaccine needs to be provided to those who work with the highest risk individuals, yet we continue to play roulette with their lives when we allow non-immunized staff or others to set a foot into high risk facilities.  The vaccine is not great in those that need it the most, so we should use the old public health approach and build the circle of protection.

The Weather Channel, Google and others have developed more effective surveillance systems for public communication while public health practitioners have utilize the old stand-bys that are not as sensitive.  

The vaccine is changing the natural progression of the disease, and this is probably a good thing.   We in public health need to change with the times too.  Influenza will be with us no matter what. The major vaccination fights have been won and it is time to move on to other important public health issues and leave the operational delivery to others to maintain.     

Health care spending in Canada - Lets face the real facts.

“Health care spending cannot continue to rise faster than the rate of growth”. 

“We need to reverse the upward trend of health care spending”. 

“Time to turn down the curve”

“Health care spending cannot be let rise above 30% of the provincial budget”

“Health care spending cannot be let rise above 40% of the provincial budget”

“Health care spending is almost at 50% and we can’t let it eat up more of the provincial budget”

I’ve heard enough quotes by senior system administrators over the years to fill a book.  If they had been successful we would not be consistently facing crisis mode for the past multiple decades, during which it has never gone away. They also would not have announced the plethora of CT scanners, then MRI scanners, then new hospitals, expanded in-patient units, dialysis units, ICUs, CCUs, NICUs  etc.  The flagships that buy the public votes.

CIHI released its annual spending report to the sounds of $200 Billion chinking through the till for 2011. CIHI health care spending report .  Good luck finding the information, but it is there.  We now spend nearly $3800 public dollars per person on health care annually in the country, with the territories being hit with expenditures that are over twice this level.  Add in private payments and that number increases to $5800, a gap that continues to widen as a higher proportion of health costs are being borne by consumers.

To surpise many, hospital spending has proportionately decreased over the past 35 years from 55% to 37% of the dollars.  Physician costs have remains proportionately at 18-20% with minor fluctuations. Drugs have over quadrupled to almost 9%.  Public health has supposedly doubled from 4.4 to 8.9% - though one has to wonder if that includes all community based services, or truly public health/preventative services, and is down from a peak of 9.4% in 2007.  Administrative costs have declined to a 35 year low of 1.8%.  

More questions are burried in the detailed provincial data.  The health status of Canadians does not vary to the same extent as public expenditures.  Ranging from a low of 3400 in Quebec, to a high of 5300 in Newfoundland, expenditures don't correlate well with health status.  Public health investments vary from a low in Newfoundland of 3.1%, to a high in Saskatchwan of 9.2% - again raising questions on definitions, however a 300% variance across the country undermines the value of the data and the universality of our current Canada Health system.

There is much to the report, including placing Canada middle to bottom of the OECD pack for many public expenditures, and debunking many of the political propaganda on the dire and imminent demise of the health care system.  The facts by CIHI is perhaps the one document worth reading unless you enjoy pouring over the detailed data tables accessible on the site.   

Kudos to CIHI, but given the future rests in home care, community based services and public health in the pure sense of prevention, perhaps these could be detailed out in the future.  Phooey on those that continue to engender a sense of imminent failure and collapse, fear is not a good motivator for change.

Occupy movement – what are you fighting for? The Inequity Rebellion

 “1-2-3-4 what are we fighting for” was the rage at Woodstock in 1969, sung by Country Joe McDonald.  It was an anti-Vietnam protest song that reflected a generation that was rebelling. Fast forward now some 42 years –almost two generations and the new generation “Y”ers are starting to speak out.  The 2011 Occupy movement is the current rage globally and founded in Canadian roots Adbusters.   

The focus of the revolt is the 99% speaking out against the 1% who now constitutes almost 25% of the income in the US.  

Most notably is how this share of the income has grown disproportionately over the decades since the peak of the anti-Vietnam protests. The challenge in the Occupy movement, is that while the streets have been filled and the tent cities have been erected, the knowledge and passion on the lines reflects the lack of focus of a generation squeezed by outdated economic policies, challenged to break into job markets and pushed out of decision making.   The internal rage looking for an outlet, and the Occupy movement has provided the same.   It is a subtle form of revolution that can be criticized for its lack of specificity, but should not be overlooked as future social leaders begin to encroach on traditional government structures.

While the Conservatives effectively won a majority nationally, there was a second message arising from portions of the country that were quietly revolting. The insertion of significant youth into the opposition and the rise of the New Democratic Party are reflections of a discontented generation, further isolated by a financial crisis that they have carried the burden, but clearly own only a fraction of the reason. 

On the surface, public health professionals might distance themselves from what is a revolt against financial policies and rampant consumerism – but lets remember the real reason.  This is a movement against inequities, and a key driver of poor health is the inequitable distribution of wealth.  If you did not view the Wilkinson lecture that was posted a week ago, take the 15 minutes today to look at it  Wilkinson lecture .  Here is the synchronicity with the public health agenda manifest for all to see. 

The death of a 20 year old at the Occupy Vancouver site can either be a martyrdom of the cause, or the start of the slow demise of the “inequity rebellion”.   The least we in public health can do, is support their noble efforts.

Gun Control, Fluoridation and the Public's Health

Please contribute comments or email to drphealth at gmail.com  

With a blog title like this, no doubt the hits to this site will be up.   The posting on fluoridation from November 1 resulted in 3 times more page views than any previous posting.   Two options, first is that the posting was widely circulated within the dental public health community.  More likely, that search engines are constantly roving the web for triggering terms – and fluoridation invokes a passionate response in those that are not supportive. It is great to know that such fervency persists in our society. 

The key issue for the day is the Harper government’s unwavering obsession to kill the long gun registry in Canada.   I expect another passionate response shall ensue. I will concede that I actually had no preset opinion and tried to ask the questions that I would like answered to help me decide what to think.  Follow through the logic and see if you concur with the opinion. 

First question – what has happened to homicide rates in Canada since the introduction (and prior) of gun registry? Homicide rates have been consistently declining in Canada for nearly 4 decades.   No there was not a large step reduction post registry implementation Globe and mail report on Stats Can release on homicide rates  

Second question – what happened to homicide rates in our neighbours to the south over the same time period?  Homicide rates peaked in the US in 1980s and have been steadily decreasing at a rate that is proportionately comparable if not better than reductions in Canada. 

Third question:  what proportion of homicides are caused by long guns? Firearms only contribute to roughly 1/3^rd of Canadian homicides Violent crime in Canada - statistics Canada .   Of all firearms homicides, long guns are implicated in 23%, this is down from 36% prior to the 1991 commencement of more rigorous gun control.   (the registry was introduced in 1996).

Fourth question:  What is the rate of homicide per long gun?  There were some 7.8 Million registered firearms, of which about 90% are long guns.   Long guns were responsible for about 40 homicides in 2010, or a rate of 5.5 homicides per Million long guns.  Any attempt to measure the rate of registered long gun, or where all legal aspects were complied with would take this low rate even lower.   

Fifth question:  How much money will be saved?   There’s a question for the politicians to play with, but looking at their claims the registry cost $2 Billion. Unlikely, and that number is more likely inclusive of a broad range of interventions some of which related to gun control, and some of which will continue irrespective of proposed changes.  The current annual cost the government claims is supposedly $22M, however with the elimination, there will be no job losses, so please tell me how any money will be saved?   The RCMP report the savings will more likely be in the order of $1-4 Million per year and I will concede I’m more likely to believe their estimate.

Sixth question:  What actually will be lost and what stays under the legislation?  While the long gun registry is being executed, owners still require a license and completion of the training and licensing process. Rules for securing firearms will not change.  Immediate accessibility to firearms will not necessarily be increased if people comply with existing legislation. Those 10% of guns considered restricted or prohibited which are inclusive of handguns and automated guns still require certification and will be registered and there will continue to be a gun registry infrastructure to be maintained.   7.1 Million bits of information on the current location and ownership of long guns will be lost.  

Perhaps the Harper obsession may be justified. Nonetheless, the failure to come clean on; What the savings actually are?  What is being retained and lost? and What the risks are? contribute to the distrust surrounding the change.   It is being positioned more as a political coup and populist action designed to appeal to conservative roots (and as with the ship building contracts, likely to penalize Quebec for its lack of political support) than as a potentially rationale and logical action based on facts.   Not surprising from a government that tends to ignore facts and science in their decision processes already.

At the end of the day, we should recall that the presence of a firearm in a household substantially increases the risk for a suicide (and probably a homicide) within that household.  The long gun registry debate has detracted from discussing the risks of long gun ownership, something that professionals may wish to focus attention on. It is time to move on, since at this point this government isn’t likely to listen to passionate or rationale arguments anyway. 

WHO conference on social determinants of health – Where does Canada stand now?

In follow up to Canada’s embarrassing political absence from the WHO social determinants of health conference drphealth October 18 2011, the collective global wisdom passed the Rio declaration which should be widely read and distributed WHO Rio declaration on social determinants.

Canada was supposedly represented by the Chief Public Health Officer (CPHO) Dr. David Butler-Jones as the senior Canadian official.   A contingent of an additional 6 senior representatives were involved, one of who was on the conference advisory committee. A solid Canadian government administrative representation.   A smattering of additional Canadian participants were also registered attendees to the conference. Regrettably drphealth was not invited to enjoy the sunshine. 

The declaration speaks to the inequities that exist, and that addressing the inequities is a shared responsibility of all sectors of government, society and the international community.  It affirms that inequities are unacceptable.   It speaks to the previous WHO leadership work which rightly deserves recognition. 

Section 7 almost appears to be a rewrite of the Canada Health Act.  Well not quite, but include 3 of the 5 Canadian principles (omits portability and public administration which are uniquely Canadian issues and includes equitable, effective and responsive).   Section 10 and the remainder of the document lay out a clear plan for addressing inequities through: (i) to adopt better governance for health and development; (ii) promote participation in policy-making and implementation; (iii) to further reorient the health sector towards reducing health inequities; (iv) to strengthen global governance and collaboration; and (v) to monitor progress and increase accountability. 

The declaration ends with a call for the endorsement by the 65^th World Health Assembly (WHA) which will be held in Geneva May 21-26, 2012.  The declaration also calls upon member states to affirm actions under the 62^nd WHA in resolution 62.14 – (which is also worth reading  62nd WHA resolutions and requires scrolling to the 14^th resolution on page 21) .  It would be worthwhile to ask the CPHO for an accounting of Canada’s performance in implementing the actions requested of the member states. 

The questions for the moment are will the Canadian government endorse the declaration itself? And will the Canada vote in favour of supporting the endorsement of the declaration at the WHA meeting next May?

I’d welcome anyone with additional information on Canada’s political response to share your comments in case there is a need to escalate this as a public issue. 

Fluoridation: A huge cavity developing in protecting oral health

Thanks everyone.  Yesterday this site received over the highest single day visit of 95 visitors. Please help it grow by sharing the link with public health colleagues.  Please leave comments or email to drphealth at gmail.com  

Fluoridation has been touted as one of the great public health interventions of the past century.  The past few years have seen the anti-fluoridationists slowly winning and succeeding in reversing past decisions.   This combined with ambiguously changing “professional” guidelines that went from 1.0 mg/L to 1.2 and now reduced to 0.7, must make members of the public suspicious of what the real story behind fluoride is.  Do we need it or do we not?   I’ve certainly had dental professionals advising that water fluoridation is not the panacea that it once was because of the innumerable alternate ways to receive fluoride combined with better oral hygiene.   This advice usually precedes a discussion as to what intensity of effort should be undertaken in the next community plebiscite to drop fluoridation.

The list of communities that have reversed fluoridation seems to be growing faster than new additions. About 45% of Canadians now benefit from water fluoridation and while that increased from 2002-2009, I would be shocked to learn that it has not decreased given the demise of fluoridation in some large Canadian jursidications recently.  Without changes to public policy this can expect to drop further. Provinces such as Alberta, Manitoba, Ontario, Nova Scotia and NWT provide fluoride to a majority of their residents. BC, Yukon, Nunavut, Newfoundland and Quebec leave over 90% of their populations unprotected.   Few provincial or federal political parties want to own the issue of pushing fluoridation.  

Like vaccine preventable diseases, many middle class parents are forgetting the horrors of poor oral hygiene and at times oral health professionals have become more concerned with the quality smile than the quality of health. The debate has become over the cosmetic problems associated with mild fluorosis (staining secondary to fluoride exposure) rather than the impacts of restorative treatment (which can now nearly mimic normal teeth).  Even the Health Canada information on fluoride is more about mitigating concerns than promoting the benefits Health Canada and you Fluoride  .  

Oral health is getting better Chief Dental Health Officer statistical report but is far from being acceptable.  Most children still have at least one experience with caries in their lives, with an average of 2.5 restorations, down from over 10 a few decades back.  The situation in Inuit communities is much bleaker Inuit oral health survey  with decay scores of 7 and numerous other poorer measures.   Other First Nations are likely similar and not yet as well documented.  Few First Nations communities have ever benefited from fluoridation. 

There is evidence that there is a correlation between poor oral health and some chronic diseases and poor school performance.  While the causal link may need to be better proven, chronic inflammatory processes may well contribute to exacerbating atherosclerosis;  pain and under nutrition to poorer school performance.

Aging infrastructure that needs costly replacing provides incentives for communities to reverse public decisions on fluoridation. Dental public health programs have been undermined across the country and are shifting to high needs populations for restorative care and abandoning the efforts at universal protection.  The lack of leadership may be the slow death bell for water fluoridation – or perhaps some enlightened Canadians could look to California that is a bastion for public health policy.  State law requires communities of greater than 10,000 to fluoridate. Now that seems to make a lot more sense that the perverse approach to requiring plebiscites for adopting fluoridation, and in the Calgary situation merely a Council vote to stop.  Clearly there is something wrong with this singular approach to protecting the public’s health.