Kyoto, Canada’s commitment on the chopping block - Climate change and Health

Public Health professionals who speak out on the Kyoto agreement may find themselves in a career limiting position.  That was apparent over a decade ago when a prominent Alberta Medical Health Officer took the provincial government of the day to task (and now is the leader of the liberal opposition in the province).

For its strengths and weaknesses, the key contribution of the Kyoto agreement was a near global acceptance that climate change was occurring and that we humans should be doing something to mitigate the potential consequences.  After 14 years, 191 countries have ratified the agreement, the sole and most notorious country to renege on ratification being the United States.

Canada has little to be proud about in its efforts to control greenhouse gases.   Its emissions have increased by some 50% since Kyoto was signed and clearly far off its agreed to committment. Depending on the list Canada produces about 5.5% of the global greenhouse gases 6^th or 7^th among nations. Emissions from China, US and India respectively combine for just short of half of all global emissions.  Collectively however, while Kyoto was designed to lead to a reduction of 5% by the end of its expiry in 2012, greenhouse gas emissions have increased about 25%.  Overall a failing effort.

Kyoto was based on the assumption that binding targets would work, without any method of enforcement.  It did not predict the growth of emerging economies that the start of the decade heralded.   Each year, countries reunite to continue the dialogue - this year it is currently being held in Durbin where discussions centre on how to save Kyoto.  

Remember, this is the world of our grandchildren we are discussing.  Most of us will just be carbon sequestered in the ground when the impacts really hit hard.

So the leaked item of the day suggests that Canada will acknowledge its failings by withdrawing from the Kyoto agreement. Timely given the current conference, so is there truth to the rumour?  Perhaps it is just a political trial balloon, gauge the reaction without doing a formal poll.  If real, the action is a typical Harperism. Rather than continue to ignore Kyoto as is the tacit government policy, fly it in the face of the those that are willing to demand change.  Canadian emission control efforts have been undermined throughout the conservative government years already.

Canada undertook a fair health vulnerability assessment published in 2009.  It remains unique in being a federal document that is not available on-line.  If you wish a copy, you can make a request by following the link at Health Canada climate change assessment.  The first link is to the Environment Canada overall assessment report which is and has always been available on-line.   Why Health Canada will not include the on-line version is a mystery for which I would welcome some intel (contact me at drphealth@gmail.com).

The lack of knowledge is the major reason for the lack of specificity – predicting the impact of climate change on Canadians is like predicting earthquakes.  While ice packs may melt, and dry regions become drier, the potential for larger areas of food producing lands exists and some industries and processes will benefit from the predicted climatic change.  

In the absence of real commitment to emission reduction globally from the major producers countries including ourselves, the action by the Canadian government to withdraw or not withdraw is no more than political posturing.  So who is the government attempting to appease?  It likely will spell the death knell for sections and departments federally that study and regulate carbon emissions, it will migrate the dialogue away from attempting to halt climate change and it may eliminate the political embarrassment of treating Kyoto as a sham.

It will not however change the dismal record of our country, the inevitable incremental changes that carbon dioxide accumulations will cause, and the need for communities to build resiliency and adapt to the change.  The change will be slow and steady with more extreme events being documented than previous. 

The major risks for global human health will be twofold: in low lying countries where flooding will reduce land availability and displace millions; and certain arid areas will reduce local food production and extend periods of localized famine.  Changes in distribution of infectious diseases, heat exposure, and extreme weather events may draw more attention than the insidious changes that will impact the greatest number. 

Many animal species have adapted to change in the past through migration and evolution, or the weakest of species have failed.    Will we survive, thrive, or dive?

PS - CBC coverage on Canada's waivering committment is commendable, worth checking out. http://www.cbc.ca/news/world/story/2011/11/28/pol-durban-conference.html 

2011/12 influenza season – news on the cusp.

Two recent public health stories worth watching.   Last week, US reported on a swine reassortment on the H3N2 strain that was crossing into humans.  Three children in one day care in Iowa.   The variant had been identified about a dozen times previously and half dozen times this influenza year.  Whether this is signal of a potential new human to human transmissible variant is perhaps too early, however influenza watchers are likely beginning to raise cautionary flags. US announcement of H3N2 reassortment

In a much less publicized scenario, a US researcher has done genetic manipulation of the currently circulating H5N1 avian influenza such that it develops transmissibility between ferrets.  Ferrets you wonder?   Turns out ferrets are reasonably good influenza model for humans. The story got more attention because of the potential efforts of Homeland Security to block the publication of the findings as a potential threat to national security than for the actual risk that the study engendered.

Beyond the national paranoia related to bioterrorism, why the legitimate concern about the study findings?  For those that have kept an eye on this disease since 2000, you would be aware that it continues to spread globally WHO avian influenza page with the most recorded activity in 2011 in Egypt.  Some caution in interpreting the statistics in that not all countries are monitoring for H5N1, and predominately only severe cases are likely being tested.  The notable characteristic of avian influenza remains its almost 60% human mortality rate amongst confirmed cases.  So if the virus developed the ability to transmit between human, it would be a potential nightmare.  

The real issues around the avian influenza scenario clouded the pH1N1 planning as pandemic planning has been working from an assumption of much higher mortality and severity of illness than was manifest in the “milder” version of pH1N1.

Overall influenza activity globally has been lower than average so far this year.  The heralding of an long term care outbreak of H3N2 in Alberta combined with the reassortment identification in the US should put everyone on alert and push for the final efforts to provide vaccine protection to as many as possible.

In the midst of preparing for the disease season, there are always questions about the vaccine.  The question that needs to be posed, is that has the wider spread use of the vaccine already impacted the natural course of annual circulation such that we are reaping the benefits of much lower deaths and morbidity?  Perhaps an insidious form of herd immunity, and the resultant apathy towards the illness may be our greatest threat. 

Watching the false starts, the various influenza offenses and corresponding human defences manouveurs can be almost as exciting as a Grey Cup, and just as nerve-wracking.  For those active in public health, it is far from a spectator sport. 

Black Friday – Commercialism, entrepreneurialism and the public’s health

Hopefully ,  few of you arose early enough to camp out for the store openings.  Perhaps it is fortunate in Canada the November weather really is not conducive to standing outside. So this phenomenon may be predominately a US problem.   While 90% of the  blog followers are Canadian, 5% are from the US and the remaining 5%f from a wide variety of locations globally. 

The concept of Black Friday deserves scrutiny, and at least somebody asking the question what is the cost on personal and population health? 

It was not too long ago that store hours were restricted to less than a full week. Hours were limited to the daylight.  Then brilliance prevailed,  and stores became more consumer friendly in their access (health care may get there yet but is decades behind in Canada, further ahead to the south).   But, there might be a limit.  Stores are operating with special hours on the biggest shopping day in the US.  The upcoming Xmas hours take often lower paid workers away from their families, disrupt their daily routines, and teeter on the edges of labour laws.  Some stores will now even operate 24 hours a day until Christmas.

On one side of the argument is why the heck?  Is this abuse of workers and unnecessary?  The other side says it is more money into the hands of workers seeking employment, more stimulation of the economy, more purchasing of products – and a dollar spent is a dollar earned somewhere to be spent in stimulating the economy further. Hence overall a good thing, right? 

We know shift work is dangerous to one’s health.  It is classified as a probable carcinogen according to IARC IARC monograph on shift work .   So at a minimum, nighttime work hours is not a good thing for individual health.  We also know that economically vibrant communities have healthier populations and that is very positive at a population level .  If the extended hours did not result in more sales, then most businesses would not offer them – so something of an economic good must be happening.  Does the balance favour better or worse public health?

Perhaps we need to reassess the root issues our consumerism driven society.  Many economist will argue it is the efforts of small entrepreneurial business that leads to sustainable growth.  Just as an observation, I don’t see many small businesses opening at 4 am.  Big business is under the microscope, but who is looking into the lens?   With the so called one percent retaining 25% of the income, unlikely that they are representing the views of small business.  And the diversity of small businesses lend resilience to a community's health and economy.

Are we stifling our economic growth, and consequently our population health by acquiescing to consumerism?  Perhaps more importantly, is anybody concerned with the public’s health actually measuring the consequences of this trend?

I’ll do my part and will not be lined up when the doors open, perhaps I may avoid those stores that propagate an unhealthy behavior that seems to be creeping north across the border. 

Food security - A recent addition to the public health agenda

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Food security has emerged as a major public health policy driver over the last decade, but has its roots entrenched from the 1930s depression years.   Canada’s action plan in 1998 Canada's action plan on food security set out a path that laid out 10 priorities starting with the right to access food, the reduction of poverty, promotion of safe and nutritious foods, safe food, reemphasizing traditional foods, supporting production and sustainability, addressing fair trade, and then wandering into protecting peace as a precursor to food security and finally a mechanism to monitor food insecurity.

The definitions of food security tend to emphasize various components of this agenda.   Two that I share are “Food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life”  (Canada’s action plan).   Another commonly referred to by Hamm and Bellows  “A situation in which all community residents obtain a safe, culturally acceptable, nutritionally adequate diet through a sustainable food system that maximizes self-reliance and social justice.”

The food security agenda is coming to a critical juncture.  The efforts to meet the diverse agenda have sometimes resulted in feet in two camps.  The food security agenda has migrated to the positive perspective of ensuring an abundance of food, emphasized nutritional value, addressed security through food policy and food coalitions and supported local production.  The food insecurity agenda has looked to community kitchens, good food boxes, poverty reduction, and inequity reduction.   While both are laudable, there are divergent and sometimes conflicting components.   The evidence for supporting the agenda is grounded in improvements in food consumption behaviours, numbers of programs available and numbers of policies implemented.  Less evidence exists in measuring successes in reducing hunger. 

There are valid reasons in this political environment for placing less emphasis on the insecurity and hunger agenda.  There is a dissertation thesis focused on food security agenda development that flagged barriers for emphasizing the hunger component; lack of successfully evaluated initiatives,  volume of NGO activity in addressing insecurity issues, the politics of “poverty”, the tension between universal (aka food security) and targeted (aka food insecurity) approaches, that hunger dilutes the food security agenda, and the poor understanding of the logic connection between food insecurity and food security.  

There are tensions between the food security and food safety components of public health that have not been resolved and result in internal discord.

There are also disciplinary tensions around food security.  The public health nutrition community has led the movement forward.  The institutionalization of the food security agenda means that other public health and non-public health professionals need to be active and own the deliverables. Concurrently public health nutritionists must do what public health has been so successful in accomplishing over the century, that is having allowed for health improvement agendas to move to the mainstream and be integral to business operations in health and other sectors, nutritionists need to step back from owning the issue.  As a broader multidisciplinary team addressing food security, we all need to be thankful for the leadership that has been demonstrated by nutritionists, and we need to utilize the expertise and skills that this group of professionals have brought to the table without discounting their contributions

Food security is here to stay. We are faced with divergent paths that can be followed at this juncture.   Strong and respectful leadership can take the agenda to a new level.   Persistent inconsistencies and disagreements can impede progress.  What will your role be?

Breast Cancer Screening Recommendations - when science and passion collide

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Many of us scratch our heads at our neighbours who refuse immunization despite "expert interpretation" of the scientific evidence, continue to smoke in the face of illness or indulge in unhealthy foods while still knowing the consequences.   No doubt you could provide many examples of attitudes and behaviours that defy the public health practitioners logic.

Along come new recommendations on breast cancer screening based on evidence Breast Cancer screening recommendations . These recommendaations are from the Canadian Task Force on Preventative Health Care.  This is a reincarnated group that all health practitioners should look to for guidance on preventative activities http://www.canadiantaskforce.ca/index.html. The efforts of the task force are an extension of activities that have been undertaken in Canada since the 70’s. 

The current iteration of the task force reaffirms the recommendation to not do mammography screening on low risk women age 40-49 and are now reversing recommendations on clinical and self examination of the breast such that these are no longer recommended to be advised or routinely performed.  There are recommendations on when mammography is highly recommended for women 50-74.

I have faith in the scientific review process that has prompted this high powered group in reviewing the literature to conclude as they have, even if they are light on the population epidemiology skill set.   The challenge that will arise is the outcry of passionate health devotees that perceive that they are being deprived of access to what they value as a needed health intervention.  This is the diametrically opposed end of the spectrum of those disbelievers that challenge the evidence to avoid engaging in health improving activities – this equally robust group of individuals will dismiss the proposed recommendations, claim that they are being denied access to medical services, and undermine the credibility of the task force’s actions.  Similar, but perhaps less strident responses occurred to the US counterpart’s recommendation against prostate cancer screening released last month http://www.uspreventiveservicestaskforce.org/uspstf12/prostate/prostateart.htm .

The challenge here, is that the committee was disbanded for 4 years and this is their first set of recommendations.  Coming forth with recommendations that may be science based, but lack the public (and some professional) alignment undermines their potential great efforts.  Perhaps there are some suggestions on the need for public consultation, transparent peer review processes and generally building support for modifying those sorts of recommendations that are likely to result in condemnation by public opinion leading groups.  The process is a great one and very valuable to the health community.  It needs to be remembered that science is only one aspect of public policy development.

Meningococcal disease – the frightening aspect of public health, and a germinating success.

It is not common that I hear fear in people’s voices, but it happened a few times in the past week.  That sense of emergency and dread that fear causes.   The cause was a couple of unrelated cases of meningococcal disease.  Sure, the expected rate is 1 per 100,000 population per year (or roughly 1 in 5 Million in any given week) and we all need to be prepared to respond and manage the situations. Something most public health professionals will be involved with at least some point in their career – and it appropriately is handled as an emergency. Many in Canadian public health will have be engrossed in at least one Meningococcal C outbreak, the most recent that I recall being over the Western provinces in 1999-2001.  Fortunately all Canadian jurisdictions now provide childhood meningococcal programs, although variations exist in the primary, catch-up and reinforcement scheduling which confuses the best of professionals. Canada’s lack of a unified immunization approach unmasked once again.

Detailed statistics and vaccine recommendations can be found at NACI meningococcal disease update 2009.   

The mainstay for decades for preventing secondary transmission of meningococcal disease has been short term antibiotics.   Rates in the immediate period after a case amongst household contacts are nearly 1000 times higher than in the general population – sounds like a huge increase.  This converts to less than 1 in 100 household contacts.  For those further distant like health care providers involved in care, the rate may be 25 times the general population, or about one in 200,000 workers exposed to a case of disease. Public health should be treating the situation as urgent, but perhaps it is worth remembering what the risks actually are.  There are tangible and measurable risks for the antibiotics in use as well.  

The flip side of this coin is that up to 10% of invasive meningococcal cases result in a fatality, the highest rate being amongst meningococcal C serotypes which has twice the fatality rate as other serotypes.  The dread is often that meningococcal disease strikes healthy adolescents or young adults at the prime of their life.  As one person said to me, is this the “really really really bad meningitis”?  

There is evidence from the UK and Quebec that post vaccination programs result in the reduction in meningococcal illness.  The major gap in our defense has been the lack of an effective meningococcal B vaccine, and that may be just around the corner.  It is less likely that we will bid farewell to meningococcal illnesses in a similar fashion to Hemophilus influenza, but dramatic reductions could reduce the fear and anxiety that outbreaks and tragic deaths have fueled.

Antibiotic Awareness Week - are you using your antibiotics wisely?

It is National Antimicrobial Awareness Week.  Somewhat aligning with the start of the cold and influenza season where inappropriate antibiotic prescribing hits its peak.   This site has addressed the issue of superbugs and antimicrobial use on multiple occasions July 8, 12, August 29, 31, Sept 1, 2, 19 and 26.  But really, who is counting?   Its just one of those public health issues that needs a home, needs champions and needs to be addressed.  

Antibiotic stewardship is integral to reducing dissemination of antibiotic resistant organisms (ARO), prolonging the effective life expectancy of newer antibiotics, and most importantly reserving antibiotics for treating severe illness and saving lives.  There are not many new antibiotic opportunities coming down the pipeline to maintain protection from infectious disease. 

The Canadian Antimicrobial Resistance Alliance CAR-A has become the default organization for providing leadership in the country.  Notable about CAR-A is the focus on institutions and specialists, and the lack of public health involvement.  There are some good statistics, but minimal trending information on the antimicrobial surveillance tab.   The ability to compare geographic areas exists, although the format is not user friendly to identify where substantive variance in practices is in place, or variance in policies like formulary restrictions.

The Canadian track record is passable and better than some countries, but certainly not in the same league as Denmark or other Scandinavian countries where policy limitations are designed to prolong the use of antibiotics.

And where is PHAC, at least they have started to take a leadership role, but what are the objectives and the deliverables?  The focus of work is based on the group that has historically looked at animal based antimicrobial use, and while an issue it is not the main ARO problem.  Humans prescribing and using antibiotics are the primary problem and we know less about that than we do about animal husbandry management with antibiotics.

Add to this are efforts by other health care professionals to increase access to prescribing antibiotics, rather than reducing access by existing health care professionals to this vital service only when needed.   

Next time your health care professional offers you an antibiotic, at least ask if there is another alternative to be considered first.