Month: August 2017

More alcohol means more injury

Dr. Trevor Hancock

13 August 2017

696 words

Alcohol policy is a fraught area. Like most people, I enjoy a drink or two, but unwise alcohol use does considerable harm and some form of regulation is needed. The era of prohibition has taught us that such an approach is bad public policy, but we have to strike the right balance between alcohol use and public safety. This is especially important for those who are put at risk of harm by the behaviour of others; the evidence suggests we don’t have the right balance at present.

A 2011 study of alcohol-related deaths in Canada from the Centre for Addictions and Mental Health (CAMH) in Toronto suggested that alcohol contributed to many unintentional injury deaths (almost 1 in 4 poisoning deaths, 22 percent of drowning deaths, 1 in five fire deaths, 1 in seven motor vehicle crash deaths and 13 percent of deaths from falls), as well as many intentional injury deaths (more than a quarter of homicides and suicides).

Importantly, while some unintentional injury deaths occur to the person who is consuming alcohol – which is a form of voluntary risk – others, more seriously, occur among those who are put at risk by people who are drunk, which is involuntary risk. These are vital distinctions, because we are more tolerant of voluntary or self-imposed risk than we are of involuntary risk.

In a seminal article in 1969, Chauncey Starr, then Dean of Engineering at UCLA, reported that people were willing to accept voluntary risk (skiing injuries, for example) at a level roughly 1,000 times greater than their tolerance for involuntary risks such as exposure to environmental pollution. In general people seem to be willing to accept a lifetime risk of death from involuntary or imposed risk, such as exposure to environmental pollutants, of around one in a million. This suggests that an acceptable level of lifetime voluntary or self-imposed risk is about 1 in a thousand.

Thus there are two aspects of alcohol use and injury to consider; how to protect people from self-harm and how to protect people from being harmed by drunks. I am most concerned with protection from those who are drunk and agree with a team of researchers, also from CAMH, who suggested in a 2015 report that such involuntary risk “could be used as a benchmark for national alcohol policies”.

They reported that a 2008 Australian study found that the risk of death caused by other people’s drinking was higher than 1 in 100,000, more than ten times the 1 in a million rate usually deemed acceptable. Since the main causes of involuntary risk to others from drinking are due to alcohol-related traffic injuries, work place injuries and violence, the study suggested these are the areas to focus on.

Thus it is good news that the federal Justice Minister, Jody Wilson-Raybould, has suggested reducing the blood alcohol limit from the current 80 milligrams to 50 milligrams. She noted that the fatal crash risk “is almost double at 50mg, almost triple at 80mg, and rises exponentially above that level” and pointed to experience in Ireland, where such a reduction, “combined with obligatory testing for alcohol, produced a 50 per cent reduction in deadly road accidents”. Sounds good to me.

But we need to do more than that. A recent report by a team based at the Centre for Addictions Research of British Columbia at UVic looked at the health and safety benefits of the Swedish government’s alcohol monopoly, and the potential impacts of deregulation and privatization. One scenario involved opening 1,200 private liquor stores, the other involved allowing alcohol sales in 9,600 grocery stores.

They found the first scenario would likely result in a 34 percent increase in drunk driving, 21 percent more assaults, 22 percent more hospital stays and 41 percent more deaths. The second scenario was worse, with 58 percent more cases of drunk driving, 34 percent more assaults, 33 percent more hospital stays and 66 percent more deaths.

Clearly, deregulation and privatization is bad for health; sadly, we are already too far down that path, and many innocent people are injured as a result. It is time to reverse course and make alcohol less accessible and more expensive.

© Trevor Hancock, 2017

 

Safe communities prevent ‘accidental’ injuries

Dr. Trevor Hancock

7 August 2017

699 words

Two weeks ago I pointed out that most injuries are unintentional. The BC Injury Research and Prevention Unit notes that in the five year period 2010 to 2014 the main forms of unintentional injury – falls, unintentional poisoning and transport-related deaths – accounted for more than 6 in 10 of all deaths due to injury in BC and more than two-thirds of acute hospitalisation for injury in 2013/14.

Of these the most important are falls, which have been responsible for about 600 deaths annually in recent years in BC and account for more than half of acute hospitalisation for injury. Overall, the costs of falls in 2010 was $1.2 billion, about one third of the total costs of all injuries in BC, with about half of that due to direct health care costs.

Falls are the leading cause of injury hospitalisation for every age group except under age 1. Most of these falls, and most of the costs, occur among older adults, accounting for about half of the health care cost of all falls. But we shouldn’t ignore the other half of falls in those under age 65.

A Statistics Canada report based on the 2009/10 Canadian Community Health Survey noted that one-third of all self-reported injuries, many of which are falls, “occurred during participation in some type of sports or exercise” and this was the case in two-thirds of those aged 12 to 19. Among adults, work injuries are also an important factor; a 2015 article by Cindy Hunter in OHS Canada noted “more than 40,000 workers get injured annually due to fall accidents”.

Not surprisingly, a great deal of attention has been paid to preventing falls among older adults, given the high rate of falls and the high costs. The BCIRPU reports that “each year, one in three BC seniors (age 65+) experience at least one fall”, with the rate being “three times higher for seniors who live in institutional/residential facilities”. This is an area where BC has shown leadership, with a major effort to address this in seniors’ homes and other facilities.

But in addition to falls in institutions, seniors also fall at home and out in the community; a Statistics Canada report based on the 2009/10 Canadian Community Health Survey noted that “everyday activities like household chores and walking accounted for over half of their injuries”. A 2012 review of the evidence from around the world found several effective fall prevention strategies. These included group and home-based exercise programs and interventions to improve home safety, with some evidence for reviewing medications and gradually withdrawing some forms of psychotropic medicines.

In the UK, Help the Aged has focused on poorly maintained pavements, noting that “More than 2,300 older people fall on broken pavements every day”. Noting that municipal governments have reserve funds to pay for claims, they make the reasonable suggestion that “some of the funds councils hold in legal and compensation reserves should be spent on pavement repairs rather than compensation claims”.

One of my favourite stories about community injury prevention, which I came across many years ago, came from a small hospital in Wales. Recognising that falls in the home were a costly problem for the hospital, they very wisely decided to send their hospital carpenter out to fix seniors’ homes, which reduced the number of falls. Perhaps our health authorities should consider this.

We have often treated falls as ‘accidents’, but in the world of injury prevention, they are not seen that way; there is almost always a preventable human factor at the root of the problem. But there is a very wide range of falls, and they vary a great deal by age, so there are no simple solutions, no quick fixes or univesal approach. It might be said that it takes a whole community to prevent ‘accidents’; homes, schools, workplaces, sports organisations, health care facilities and many others.

One common factor, however – and one that is a significant contributor to all forms of injury – is alcohol use. So a centrepiece of any community injury prevention initiative should be improved control on the availability and price of alcohol, as well as on responsible use. I shall turn to this topic next week.

© Trevor Hancock, 2017

 

Public health and the new BC government

Dr. Trevor Hancock

30 July 2017

703 words

From a population health perspective, there is much that is welcome in the new government’s policies and priorities, as revealed in their platform and the Ministerial mandate letters. But from a public health perspective, there is cause for concern.

First, the population health perspective, which is the primary focus of my columns. As I have repeatedly stressed, much of what makes a community or society healthy is beyond the jurisdiction of the Ministry of Health. The major determinants of health are found upstream in the social, environmental and economic portfolios, and here there are many potentially good policies, assuming they can be put in place.

Poverty is one of the most important contributors to ill health and premature death, and child poverty in particular sets children up for a lifetime of challenges and problems that many can never fully overcome. It generates an excess burden of disease that the health care system has to manage, at considerable cost. Indeed, the health, social and economic costs of poverty are so high that they are unaffordable.

Under the previous government BC became known for having a high rate of child poverty, low minimum wage rates, low social assistance rates and no anti-poverty strategy. So it is very encouraging to have a Minister of Social Development and Poverty Reduction with a mandate to “Design and implement a province-wide poverty-reduction strategy with legislated targets and timelines”. As the Green Party platform notes, “alleviating poverty and homelessness will also have a strong, positive impact on people’s health”.

Other strong anti-poverty – and thus pro-health – policies include increasing social assistance rates, pilot-testing a basic income program and requiring the Minister of Labour to implement a $15-per-hour minimum wage by 2021 and “bring forward recommendations to close the gap between the minimum wage and livable wages”.

Unaffordable housing contributes to poverty, homelessness and ill health, so it is good to see that the Minister of Housing is required to work with a variety of partners to build 114,000 units of a mix of various forms of affordable housing, and to develop a homeless action strategy together with the Minister of Social Development and Poverty Reduction.

A second major threat to population health comes from the global ecological changes we are creating, especially climate change. So it is encouraging to see the new government taking this issue more seriously. They seem to recognise the economic opportunities of energy efficiency and conservation and a clean energy economy, including investing in public transit, and have committed to carbon reduction targets and a $50 a tonne carbon tax.

But the NDP platform and mandate letters do not go far enough. The carbon tax increase does not start until 2020, whereas the Greens committed to $10 per tonne increases starting in 2018; nor is there reference to promoting biking and walking, or zero-emissions vehicles, all of which are health-promoting. Troublingly, the NDP does not name urban sprawl as an issue and propose community and regional urban containment areas, as do the Greens. In these and other areas touching on the environment and sustainable development, not surprisingly, the Green Party platform is more comprehensive, detailed and health-enhancing.

 

But it is when we come to public health – that part of the health care system that is focused on protecting and improving health and preventing disease and injury – that the new government’s platform is most disappointing; they still seem to equate health with health care. The NDP platform makes no mention of wellness, no reference to obesity, tobacco or alcohol – all major causes of disease and premature death – and only a brief commitment to prevention, mainly in the area of mental health.

Contrast that with the more explicit and detailed commitments in the Green Party platform, which notes that “prevention is better than cure” and promises to “establish a Ministry responsible for health promotion, disease prevention and active lifestyles” and to re-balance the allocation of resources between prevention and acute care.

So from a population and public health perspective, the best option might have been a coalition government that took the best of both parties’ platforms. Failing that, let’s hope the new government can learn from and adopt the Green Party platform for health and wellness.

© Trevor Hancock, 2017

What does it mean to be a safe community?

Dr. Trevor Hancock

23 July 2017

701 words

When people talk about the qualities of a healthy community, one of them is that it be safe. But what ‘safe’ means depends in part on who you are, as well as where you are from and what threat or harm we are considering. Indeed, safety isn’t just about physical harm, but perceptions of fear and insecurity – as anyone who has ever walked down a dark lonely road at night knows only too well. And war, of course, is an intensely dangerous situation for any community, but not one I am considering here.

Some groups in society feel less safe – and are less safe – than others; women, Indigenous people, people of colour, youth, seniors, people who are LGBTQ and others experience different sorts of risk, and thus creating a safe community is a complicated task.

In the late 1980’s, when I was helping the European Region of the World Health Organisation (WHO) develop the Healthy Cities program, they were also developing a Safe Cities program. While it never made sense to me that they would develop these as two separate programs, what I found interesting, coming from North America, was that Safe Cities in Europe was focused mainly on injury prevention, not safety in the sense of protection from crime and violence.

This points to one of the challenges in creating a ‘Safe Community’ initiative; what threat are we discussing and seeking to prevent? In public health we tend to think of safety in terms of its opposite – harm – and the physical consequences of harm, namely injuries. Normally we classify injuries as either intentional or unintentional.

Intentional injuries include both violence (“the infliction of fatal or non-fatal injuries by another person, by any means, with intent to kill or injure”) and self-harm, which includes both attempted and completed suicide. Unintentional injuries, not surprisingly, are defined as “not purposely inflicted, either by the person or anyone else”, according to the BC Injury Research and Prevention Unit (BCIRPU). These are what we usually call accidents, although that term is often avoided these days, since many ‘accidents’ are due to human error of some form and thus not truly accidental.

When we think about a safe community, only too often our thoughts turn to keeping us safe from crime and violence. But we would be mistaken to put most of our efforts there, because in fact most of the injuries that we experience are not due to violence but come from unintentional and self-inflicted injury.

The BCIRPU reports that in the five year period 2010 to 2014 the four leading causes of death due to injury in BC were, in order, falls, suicide, unintentional poisoning and transport-related deaths. Between them, they accounted for almost 9 in 10 deaths due to injury. Of these, three are considered unintentional and accounted for more than 6 in 10 deaths, while suicide accounted for almost one quarter of all injury deaths; homicide was a distant fifth, with only 2 percent of all injury deaths.

Injuries don’t only kill, of course, they result in disability ranging from minor and brief to severe and lifelong, and often result in hospitalisation. Falls are by far the most common cause of hospitalisation for injury, accounting for 46 percent in 2013 – 14, with transport-related injuries a distant second (11 percent) and attempted suicide third (5.5 percent); assault, which is intentional, comes in 7^th at just 2.7 percent.

Injuries are not only very expensive in human terms, they also exact a high economic cost. A 2015 BCIRPU report found that in 2010, injuries cost BC $3.7 billion, or more than $800 per person, of which health care costs were $2.2 billion – more than $500 per person or $2000 for a family of four. Again, unintentional injuries account for most of the costs – 84 percent in 2010.

So from the perspective of safe communities in BC, as in Europe, the primary focus should be on the prevention of unintentional injuries, particularly falls, transport related crashes and accidental poisoning. Of these, injuries due to falls are the number one priority. So in my next three columns, I will look at three different aspects of a safe community; preventing unintentional injury, violence and self-harm.

© Trevor Hancock, 2017