Look upstream to improve mental health

Look upstream to improve mental health

Dr. Trevor Hancock

11 September 2017

703 words

A colleague once remarked that people are so busy dealing with the important that they don’t have time to deal with the critical. That applies to the healthcare system as a whole. It is so busy dealing with people who are ill or injured that it doesn’t give much priority to looking upstream and trying to stop people becoming sick in the first place.

That especially applies to the field of mental health and addictions, which has been described as the orphan of the health care system, neglected and underfunded. But in fact mental health problems are among the most common and most expensive health problems today. The Centre for Addictions and Mental Health (CAMH) in Toronto reports that “the disease burden of mental illness and addiction in Ontario is 1.5 times higher than all cancers put together”.

CAMH reports that “in any given year, 1 in 5 Canadians experiences a mental health or addiction problem” (including dementia) and that “mental illness is a leading cause of disability” and can markedly shorten life. Not surprisingly, people with mental illness have high rates of unemployment and work absence; at least half-a-million employed Canadians are off work due to a mental health problem every week. The overall societal cost of mental illness cost in Canada in 2011 was estimated in one study to be about $42 billion, with half that being health care costs.

This is why the creation of a new Ministry of Mental Health and Addictions in BC is an interesting development. Time will tell whether it proves to be an important strategy to focus attention on a long-neglected issue or whether, as some have suggested, it divides resources and attention and becomes a problem. One thing is for sure; it highlights the growing importance of mental health problems in society.

But simply managing the problems of people with mental disorders or addictions is not enough; we need to reduce the toll of mental health in our communities. This means the new Ministry needs to focus on why people develop mental health problems in the first place, how we can prevent that happening, and how we can improve the overall mental health of the population.

Happily, BC has developed quite a strong focus on the prevention of mental health problems and on mental health promotion in the past decade. Its 10-year mental health strategy, adopted in 2010 and updated in 2017, states “Research tells us that doing a better job of promoting mental wellness, preventing mental illness and harmful substance use, and intervening at the beginning of illness, especially for our children and youth is a wise investment”.

As with much else in public health, what this means in practice is that we need to look well beyond the health care system, to society as a whole. A recent report from the UK’s Faculty of Public Health suggests what needs to be done.

First, we need to focus on childhood factors, and in particular, family relationships. Infants and young children need to feel secure in their attachment to their family, which enables them to develop trust in others. Failure to do so “leads to lifelong problems in learning, behaviour, resilience, coping, and both physical and mental health”. Adverse childhood experiences such as abuse, neglect, parental substance use or mental illness compound the problems, and call for early intervention.

In addition to good parenting, the school environment is also important: “The school ethos, mental wellbeing of teachers, relationships with peers and prevalence of bullying all matter”. And as young people transition from school to college or work – “a time of upheaval and uncertainty” – strong relationships with caring friends and adults are important, while loneliness is a problem. This continues into adultood, where stable relationships and mentally healthy workplaces are important, while unemployment increases the risk of anxiety or depression by 4 to 10 times.

Good mental health benefits us all, but clearly is a much bigger issue than the new Ministry can address on its own. It will need to engage the whole of government and the wider society – schools, workplaces and communities – in creating a mentally healthy society. In my next column, I will discuss in more depth how this can be done.

© Trevor Hancock, 2017



Public health should not be part of health care

Public health should not be part of health care

Dr. Trevor Hancock

11 September 2017

699 words

It used to be the case in much of Canada that public health units were autonomous or semi-autonomous organisations at the local level, often aligned with and sometimes part of local government. The Medical Officer of Health (MOH) was the Chief Executive and had a staff of public health nurses, public health inspectors, epidemiologists, dental hygienists, community nutritionists and others. While they worked to some extent in collaboration with the health care system, especially family doctors, they were largely able to focus on the local community and work with a wide range of partners outside the health care system.

But in recent years, in most of Canada, we have seen public health brought firmly within the health care system. This has been a mistake, in my view, for one simple reason; most of what determines our health lies beyond the scope of that system. As a result, much of the work of public health to protect and improve health has to focus on actions beyond health care. But health care system managers – who are constantly facing budgetary challenges – are understandably focused on trying to achieve what they can within the scope of their operations.

This has two negative consequences. First, these health care system managers – very few of whom have public health training – see much of what public health does or tries to do as beyond the scope of the sector. Second, when they see public health staff engaged in work that, to them, is beyond scope, they are likely to try to re-direct that work towards more ‘useful’ clinical care.

This reduces the effectiveness of public health, which is a problem not only for the population as a whole, but for the health care system itself. At a time when the system is struggling to meet the demands for care placed upon it, it is extremely short-sighted to reduce the effectiveness of the only part of the system that is fully dedicated to reducing the burden of disease in society.

In particular we have seen senior health care system managers reduce the power of MOHs and break up public health units. It is now not uncommon to see MOHs – community medicine specialists with years of extra training in public health – reduced more to an advisory role, marginalised and with few staff, while public health nurses report through a separate part of the organisation and public health inspectors through yet another.

As a result, we have seen some frontline public health nurses moved into being primary care nurses and community nutritionists becoming more like dietitians, doing one-on-one care rather than community-based prevention.

This marginalisation can also be seen at the provincial level; in BC, most of the staff and budget for public health programs are separate from the small Office of the Provincial Health Officer, and this is seen in other provinces too, and now at the federal level. Moreover, the bureaucrats who are in charge increasingly do not have public health training, and may indeed have no health background at all.

The most extreme form of this approach is seen in New Brunswick, where the government recently announced a major reorganisation of its system of public health services. While the Office of the Chief Medical Officer of Health stays with the Ministry of Health and its “existing mandate and legislative responsibilities . . . will remain the same”, most of the staff have been dispersed to three other Ministries. In essence they are getting rid of public health as a cohesive whole.

I had the great good fortune to begin my public health career working for the City of Toronto’s Department of Public Health. Having watched the growing challenges facing public health in BC and other provinces, I am convinced that Ontario – where public health still is municipally based – has it right; public health does not belong in the health care system.

But I would go further; public health does not belong within the Ministry of Health. We need municipally-based public health units, with secure provincial funding, under a separate Ministry of Population and Public Health. Then public health could do its job without having to worry about being further harmed by the health care system.

© Trevor Hancock, 2017



Why did Mary die? Dig deep to find causes

Why did Mary die? Dig deep to find causes

Dr. Trevor Hancock

3 September 2017

698 words

In some ways, public health is like that annoying kid who is always asking ‘why?’. Why did this person become sick? Why did they die? It’s a bit like peeling an onion – there is always another layer to the story, another reason why.

Every year, we get a list of the leading causes of death, which is not that different between men and women. The leading causes in Canada in 2013 were cancer (30 percent), heart disease (20 percent), stroke (5 percent), chronic lung disease, unintentional injuries, diabetes, influenza and pneumonia, and Alzheimer’s disease. Between them they accounted for almost three-quarters of all deaths.

But what lies behind these numbers – what are the ‘causes of the causes’, and for that matter, the causes of the causes of the causes? What is left out or overlooked? How complete is the picture we are given? What are we not being told?

We can think about several levels of cause of death. The first, which is what these standard statistics show us, are the clinical diagnoses. But even here there are challenges. For example, why do we separate out heart disease from stroke, when both are forms of vascular disease? And why do we cluster cancers together when it is widely understood that there are many different forms of cancer, with many different causes.

The second level is the behaviours which lie behind the clinical cause of death. Smoking, alcohol or drug use, physical inactivity, unhealthy eating, dangerous driving – the usual litany of unhealthy behaviours which governments and others like to scold us about and encourage us to change. Usually, these are framed as ‘lifestyle choices’ and personal responsibility.

Yet these risk behaviours are embedded in and shaped by the third level of causes – our family, school, workplace and community environments, which shape and may constrain us socially and physically. We are also shaped by our built environments, where we spend the vast majority of our time and where we are car-dependent and inactive, and largely separated from nature. And we are influenced as well by our community’s social and cultural norms; some religious communities, for example, reject childhood immunisation.

We are also subject to enormous commercial pressures in the shape of advertising, much of which encourages unhealthy behaviours (check out the the food and drink ads, or the driving behaviour shown in most car ads these days), and we are buffeted by economic pressures that can lead to unemployment or low wages, debt, stress and even hunger and homelessness.

Indeed, we have a mountain of evidence that poverty and poor education results in large inequalities in health and underlies many deaths. We can think of all of these as risk conditions or risk environments, which in turn facilitate and support risk behaviours. But none of these upstream causes of death appear in the official statistics, which means they don’t get the attention they deserve. So it is the role of public health to raise these more profound and important questions and push for solutions at a community and societal level.

This can get complicated. Consider Mary, who died of a stroke; why did she die? Because she had high blood pressure which was not detected or, if it was, was not well controlled, perhaps because she is a woman and lived in a rural or low-income community or on a reserve, where health care is less accessible. Or perhaps she could not afford the medication.

But why did she have high blood pressure in the first place? A genetic presdisposition? Obesity? A high salt diet? – Canadian diets are much too salty, and the Canadian food industry, has resisted efforts to regulate salt content. A stressful life and work situation? Some combination of all these, and more?

So what did Mary die of: A stroke? High blood pressure? A high-salt diet? A stress-filled life? Inadequate health care? Rurality? Poverty? Only the first of these will show up in the standard mortality statistics, which tells us what someone died from – but not why. Which is why publiic health keeps asking ‘why?’ Because if we can understand why people get sick or injured or die, maybe we could prevent it happening.

© Trevor Hancock, 2017



Monitoring community well-being is complicated

Monitoring community well-being is complicated

Dr. Trevor Hancock

28 August 2017

701 words

There are three important questions in planning a healthy community: Where do we want to be, how do we get there, and how well are we doing? The first concerns the development of a common vision and common goals, the second to a shared strategy, and the third to establishing a process to monitor and report on progress.

I have long been involved in the development of community indicator systems, and it is complex and challenging work. Typically, good systems cover a dozen or so ‘domains’, each of which can contain a number of indicators. But how do you measure progress across so many fields without swamping people in hundreds of indicators?

One approach is to compile indexes that combine a number of different measures and generate a single number. The GDP is an example of this, although it is more of a misleading indicator; its main alternatives, such as the Genuine Progress Indicator and the Happy Planet Index, do the same thing, but using different measures based on different underlying values.

This illustrates an important point; our choice of indicators reflects our values and our aspirations. But it also drives our actions; we manage what we measure. So if we don’t measure something – our community’s level of creativity and artistic engagement, for example – then we won’t pay much attention to it and won’t do a good job of managing it.

A more useful approach than developing a single index is to acknowledge the complexity of a community, define a set of domains and within those domains identify a few key indicators that stakeholders and community members find useful. That is what the Regional Outcomes Monitoring (ROM) Collaborative has been doing here in the Capital Region.

After extensive consultation, the Collaborative has identifed a set of ten domains that are important to community wellbeing: Affordable and appropriate housing, food security, economic security, thriving children and youth, lifelong learning, inclusive and connected communities, healthy and safe environments, accessible human services, recreation and active living, and connection to arts and culture. Within each of those, key indicators are being identified, but that is harder than it may seem.

Part of the problem is that within each domain there are dozens, even hundreds of potential indicators to choose from. Take the example of arts and culture. The first question is, what do we mean by ‘arts and culture’? Watching a film or play, visiting a gallery, attending a concert or festival, reading about arts and culture?

How about active engagement with the arts by participating in them? That might include playing in a band, singing in a choir, folk dancing, taking art classes or being in an amateur theatre group. And beyond that, what about making your living in the arts, which is a significant part of our local economy.

If we take these three categories – audience/spectator, participant, full or semi-professional – then what do we want to know? Here, equity is an important issue; we want everyone to be able to be involved with and benefit from arts and culture. So we need to know who is involved (and thus, more importantly, who is not that we might want to reach out to), how accessible arts and cultural activities are to different groups (old and young, rich and poor etc,), how well-funded the arts are, and what economic benfits we derive.

In practice the choice of indicators is limited by the local availability and/or cost of the data. It may not be collected at all, or the sample size at the local level may be too small, which makes the data unreliable, or it may only be collected occasionally. Often, that means relying on data that is routinely collected locally, but may not be what we are really interested in. This may mean we need to do local surveys and data collection that meets our local needs, but that can get expensive.

So it is a juggling act, and the answer is never perfect. We need to recognise that indicators are based on value-driven choices, so the key question is what sort of community do we want to be, then how will we measure our progress in getting there – but measure it we must.

© Trevor Hancock, 2017



Safe communities prevent violence with compassion

Safe communities prevent violence with compassion

Dr. Trevor Hancock

21 August 2017

700 words

Safety means different things to different people. In Europe, the Safe Communities movement has mainly focused on preventing unintentional injury (so-called ‘accidents’). But in the USA, and to a large degree in Canada, it has focused more on prevention of intentional injury, even though this is much less common than unintentional injury.

There are two main forms of intentional injury; deliberate injury to oneself (suicide and attempted suicide) and deliberate injury of others (homicide and assault); the latter are often what people have in mind when they think about a Safe Community, although homicide and assault are much less common than suicide and attempted suicide.

A 2015 report from the BC Injury Research and Prevention Unit (BCIRPU) found that between 2010 and 2014 suicide accounted for almost one quarter of all injury deaths in BC, while homicide represented only 2 percent. Similarly, while attempted suicide and self-abuse accounted for 5.5 percent of hospitalisation for injury assault was just 2.7 percent.

The BCIRPU also reported that unintentional injury resulted in more than 1,400 deaths, 30,000 hospitalisations and 435,000 ER visits in 2010, while intentional injury accounted for over 560 deaths (over 500 were from suicide) but only 4,000 hospitalisations and 17,000 ER visits. Nonetheless, the total costs of violence in BC that year was $157 million, including $84 million in health care costs.

But the health impact of violence does not come from just physical assault and injury, it includes mental and emotional harm, and the costs are not just in health care but in emotional trauma and disrupted lives and communities, effects that can last decades, lifetimes, even generations. Violence can take many forms, including bullying, harassment, abuse and neglect, and can occur in many settings and affect many groups, but several categories stand out.

First comes domestic violence, which includes child and elder abuse and neglect as well as spousal/intimate partner violence. Harassment, bullying and sometimes violence is found among young people in schools and among adults in workplaces, while elder abuse and neglect can be seen in care facilities. Finally, there is violence in the community, everything from on-line abuse and harassment to road rage, sexual assault and random or targeted assaults, including racist and Islamophobic violence and abuse.

In all these settings, certain groups are more vulnerable and/or more targeted, including women, children, the elderly, Indigenous people, LGBTQ people and various ethno-racial or religious groups – and clearly, people can be members of several of these groups. But what this tells us is that much violence is deeply rooted in cultural and social values that have to do with power, on the one hand, and fear and hatred on the other. So violence prevention will take significant social and cultural change.

I have always been impressed by the work of Irvin Waller, a criminologist at the University of Ottawa and a world expert on prevention of violence. He is clear that this is much more than simply a matter of law and order, policing and punishment. Just as public health advocates for upstream interventions to keep people healthy rather than downstream interventions to fix them when they are sick, Waller provides the evidence that “reductions in violence against women, street violence and homicides by 50% are all achievable within a five to ten year period by investments in early prevention” – and observes that this is a cheaper approach to reducing crime.

He points to “investments in people such as youth outreach, positive parenting programming, and social interventions in emergency rooms”. And he adds there is evidence that “modifications in school curricula to make achievement in life skills and healthy relationship skills stop violence”. So, he asks, “why not make them as important and measured as writing, reading and arithmetic?”.

This approach – what Waller calls ‘compassionate community safety’ – was epitomised recently by Ted Upshaw, the Public Safety Advisor for Halifax and a former RCMP inspector. In a session on healthy communities at the Canadian Public Health Association conference earlier this year, he discussed the importance of social justice, respect, good quality housing and neighbourhoods, access to parks and other social and community benefits if we are to create safe and healthy communities. It makes sense to me.

© Trevor Hancock, 2017