Ooops, we have overshot the Earth’s capacity

Ooops, we have overshot the Earth’s capacity

Dr. Trevor Hancock

23 July 2019

699 words

Tomorrow, July 29, is Earth Overshoot Day, according to the Global Footprint Network; the day each year on which “humanity’s demand for ecological resources and services in a given year exceeds what Earth can regenerate in that year”. In other words, it is the day on which our overall Ecological Footprint (EF) exceeds the carrying capacity of the Earth.

The Network measures the EF by converting our demand for food, fiber products, timber, land for urban infrastructure, and forest to absorb our carbon emissions from fossil fuels, into a single unit: the land and sea area in hectares needed to meet that demand. Actually, it is an underestimate, because it does not include some impacts that cannot be measured that way: air pollution or toxic chemical wastes, for example, or species extinctions.

This ‘footprint’ is then compared to the biocapacity of the Earth, which is the amount of land and sea (forest lands, grazing lands, cropland, fishing grounds, and built-up land) needed both to replenish the resources we use and to absorb the wastes we produce. The most important of those wastes is carbon dioxide, the main driver of global overheating; it has more than doubled since 1970 and now makes up 60 percent of the entire global EF. At the same time, this should serve to remind us that climate change is not the only challenge we face; 40 percent of the EF is not carbon dioxide, but our use – and over-use – of forests, foodlands, fish, minerals and other materials.

We have been exceeding the Earth’s biocapacity for 50 years, beginning in 1969 – ironically, the year we set foot on the moon. At the global level in 2016 (the latest data available), we used the equivalent of more than 1.7 planet’s worth of biocapacity overall, which is clearly unsustainable – we only have one Earth. The Network estimates that if present trends continue, we will need the equivalent of two Earths by 2030.

The date of Earth Overshoot Day has gotten steadily earlier in the year, as population has grown and the economy has boomed. The good news is that the rate at which Earth Overshoot Day moves up on the calendar “has slowed to less than one day a year on average in the past five years, compared to an average of three days a year since overshoot began in the early 1970s”. However, it is still moving in the wrong direction.

But high-income countries such as Canada use far more than their fair share of the Earth’s biocapacity, which means they have a much earlier Earth Overshoot Day. Canada’s EF in 2016 was the equivalent of 4.75 Earths, putting our Overshoot Day on day 77 of the year – March 18th. Ever since then, we have been using more than our fair share of the Earth, while others get much less – in fact, not enough in many cases to meet their basic needs for adequate levels of human and social development.

So what should we take from this? Perhaps the most important point is that while the climate emergency is real and must be addressed urgently, at the same time we have to act on all the other aspects of our EF. We need not just a climate strategy but a One Planet strategy; how do we reduce our EF to the equivalent of one planet’s worth of biocapacity – our fair share – which would be an almost 80 percent reduction for Canada as a whole. And how do we do so while maintaining a decent quality of life and good health for everyone who lives here?

The Earth Overshoot website has some useful ideas, focusing on five key areas for action: How we design and manage cities, how we power ourselves, how we produce, distribute and consume food, how we help nature thrive, and how many of us there are.

Overall, they estimate that in order to use less than 1 Earth before 2050 we need to move Earth Overshoot Day back by five days every year. This is of course a huge challenge – but so was getting to the moon. Its amazing what we can do when we put our minds to it.

© Trevor Hancock, 2019

 

Fixing primary care? Help people help themselves and others

Fixing primary care? Help people help themselves and others

Dr. Trevor Hancock

16 July 2019

700 words

In two previous columns I suggested a more thoughtful approach to fixing the primary care crisis would be to reduce the need and demand for care in the first place. Reducing the need for care means reducing the burden of disease within society. This requires both a government and society-wide provincial population health strategy and a much stronger commitment to public health and clinical prevention within the health care system.

The second main component is a comprehensive self-care strategy, an important way to reduce unnecessary or inappropriate demand for care by those who are sick. Any front-line health care worker will tell you that a significant number of people seeking care have minor and self-limiting conditions or chronic diseases that they could largely manage themselves, with some knowledge and support. Others do not have a medical problem so much as a social problem and may just need companionship, support and something to do.

Family physicians have old adages that tell an important story: Most minor problems will get better on their own, you only need to provide reassurance and apply the ‘tincture of time’. Indeed, in previous times, families and their neighbours knew about self-care and generally did a pretty good job of looking after minor ailments and injuries. But there is knowledge and skill involved in knowing what can and what cannot be managed without seeking care. However, in professionalising all care we have effectively de-skilled people, so they have to seek care.

The good news is that BC does have the 8-1-1 program, HealthLinkBC. This phone-line and online service (https://www.healthlinkbc.ca/) has nurses and navigators available 24/7 to help with non-emergency health concerns. The former provide health and treatment advice, while the latter help find health information or health services. The program also has dietitians and exercise professionals (available M-F, 9 – 5) and pharmacists (available 5pm to 9am every night).

There is also a Chronic Disease Self-management Program, provided by Self-Management BC (https://www.selfmanagementbc.ca) to “help people with chronic conditions to manage daily challenges and maintain an active and healthier life”; more than half the group programs in 2016 were for chronic pain self-management. The program provides both community-based group programs (in 2016 they were provided in 89 percent of BC communities with a population over 3,000) and online group programs, as well as a Health Coach phone support system for those needing extra support.

For those that have a social problem, especially related to loneliness, isolation, and similar problems, the answer is likely to be what the UK’s National Health Service calls ‘social prescribing’. People are referred to social agencies, community groups and others who can help link them to the connections and support they need. BC does not have a social prescribing program, although earlier this year the Ministry of Health contracted with the United Way of the Lower Mainland to develop over the next three years “up to 48 demonstration projects in communities in all regions of BC, based on innovative and promising program models”. One of the three program streams includes social prescribing, “for seniors at risk of frailty, to increase social support, physical activity and good nutrition”.

But a comprehensive approach to self-care is much more than managing minor ailments and injuries or helping people manage their chronic diseases, important though those are. It begins with having the knowledge and skills to keep yourself and your family healthy and safe, and that includes working with your community, local organisations and local government to make your community more healthy.

Self-care also includes having training in first aid, including CPR and trauma management, to manage emergencies until the first responders arrive. The final aspect of self-care is helping people prepare for the end of life by supporting them in preparing living wills or advance directives and in having the necessary conversations with family, care providers and friends so their wishes are known and can be respected

Here in BC we have made a start, but we need a comprehensive self-care strategy if we are to take the pressure off primary care by reducing unnecessary and inappropriate demand for care. This must include investing in teaching self-care in schools and the community, as well as increasing community-based supports.

© Trevor Hancock, 2019

 

 

Fixing primary care? Create a prevention strategy

Fixing primary care? Create a prevention strategy

Dr. Trevor Hancock

9 July 2019

701 words

Last week I proposed that to fix primary care we need to focus on reducing the demand for care, rather than just increasing the supply of care. This requires first of all adopting a ‘whole of government’ and ‘whole of society’ approach, acting beyond the health care system to improve the health of the population and especially to reduce the excess burden of ill health attributable to poverty.

The second component is to create a comprehensive prevention strategy within the health care system, which also has two main elements: Strong and effective public health services and an effective clinical prevention system. Right now, we are weak in both areas in BC, and for that matter across the country, in spite of clear evidence that prevention within the health system should be a priority.

Since I have several times written about the need to strengthen public health services I will not repeat that argument here, other than to note that a 2017 systematic review of 52 studies of the return on investment for public health interventions found that “local and national public health interventions are highly cost-saving”.

Yet despite a 2004 BC Legislature report recommending “Funding for public health activities should gradually increase from about 3 percent of total health expenditure per annum to at least 6 percent per annum”, the Auditor General reported in 2017 that “In 2015/16, health authorities spent $525 million or 4 percent of expenses on population health and wellness services”.

But I want to focus on clinical prevention, which is the set of preventive services you should be getting from your family physician or primary care team. Importantly, this does not include the ‘annual physical’, although many still seem to think it should. But the Canadian Task Force on Preventive Health Care, which was established in 1976 to make recommendations on what works in this important area of primary care, recommended against the annual physical as long ago as 1978.

Reaffirming its recommendation in 2017, the Task Force noted ”routine annual checkups do not offer sufficient health benefits to justify the expense or effort”. Instead, they recommended a preventive visit with a primary care health professional. . . to provide preventive counseling, immunization, and known effective screening tests”, based on the individual’s specific risks and the appropriate timing for each test.

Happily, we in BC had reached that conclusion several years before. In a 2009 report from the Clinical Prevention Policy Review, which I co-chaired while I was a medical consultant in Population and Public Health at the BC Ministry of Health, we asked and answered the question – ‘what is worth doing in clinical prevention’?

The resulting Lifetime Prevention Schedule (LPS), a first for Canada, is available online. It includes 15 preventive services that meet three criteria: They are clinically effective, would have a significant population health impact if 90 percent of those eligible to receive the service got it, and are cost-effective.

The LPS includes hearing loss screening in newborns, obesity prevention and management in children and youth, and breastfeeding promotion and depression screening for women in the perinatal period. (It does not include prenatal care, which is covered by separate guidelines from Perinatal Services BC or immunizations, which are covered by the BC Immunization Schedule.)

For adults, the Schedule includes a number of services aimed at prevention or early detection of the most common chronic diseases – heart disease, several forms of cancer, alcoholism, diabetes and HIV. The age and frequency of the services is related to age, sex and risk profile.

Our review also posed two other questions: What is the best way to provide the preventive service, and what is the best systematic approach to supporting implementation. The latter includes training for providers, education of the public, an effective information system – including automated reminders for providers and recalls for patients – and proper payments.

However, although a prevention fee for physicians was created, a comprehensive, systematic and well-funded clinical prevention strategy has yet to be implemented, and professional and public awareness and implementation remains low. This is a missed opportunity, one that is cost effective and would have a significant population health impact. It should be addressed as a matter of priority.

© Trevor Hancock, 2019

 

Fixing primary care? Focus on the demand

Fixing primary care? Focus on the demand

Dr. Trevor Hancock

2 July 2019

702 words

The primary care crisis has been getting a lot of attention in the community and in this newspaper recently. But the focus so far has been on the supply side – we need more doctors and other primary care providers, more services and a better system, everyone says. I have seen little or no discussion about the demand side; how do we reduce the demand for care, so that we don’t need as many care providers? After all, we would all be better off – economically, socially and of course in terms of health – if fewer people were unhealthy and needing care.

Two key demand reduction strategies have been consistently ignored, downplayed and underfunded by governments in BC and across Canada for years. The first is a serious provincial-level and society-wide commitment to promoting the health of the population and preventing disease and injury; it includes a serious commitment to clinical prevention, which I will explore next week This will reduce the need for care by reducing the burden of disease, injury and disability in society. The second missing strategy is to reduce the demand for care by increasing people’s capacity for self-care, so they don’t need to seek care for health issues they could manage themselves; I will discuss that in two weeks’ time.

Sadly, the neglect of prevention is not limited to the health care system, but is a society-wide problem. The decision by the Victoria Police Chief to disband the Crime Prevention Unit, and by the federal and provincial governments to invest in the Alberta tarsands pipeline and the LNG industry respectively are recent prime examples of short-term thinking, with expensive and health-damaging long-term consequences.

Part of the problem is that governments, like businesses, are focused too much on the short-term. The next election is at best four years away, and you want to show impact quickly. While some prevention can indeed show benefits over the short-term, it often only does so over a period of many years, even decades or generations. So we get short-term fixes to gain votes or make money, and pass on the real challenges to future generations to cope with – let them make the hard choices.

It does not help that the NDP has not shown much commitment to prevention over the years. Too often, both here and elsewhere in Canada, the emphasis has been on increasing services and expanding access, rather than looking at reducing demand.

So what would a provincial health care demand reduction strategy look like? First, the government would have to recognise that the creation of a healthier population is not simply the responsibility of the Ministry of Health, but of the whole government and the wider society. A 2011 report from the Senate of Canada provided guidance: Governments should establish a Population Health Committee of Cabinet, chaired by the Premier, and develop a provincial population health improvement strategy involving all Ministries.

Since this is actually a societal problem, it will also be important to set up a BC Population Health Council to advise the Committee and assist in making changes in society. In addition to select Ministers, such a Council would consist of leaders from all sectors – business, labour, the non-profit sector, academic and faith communities and others; there is a precedent in the Premier’s Council on Health established in the late 1980’s in Ontario – and abruptly disbanded by newly-elected Conservative Premier Mike Harris in 1995, proving that then, as now, Conservatives are not supportive of prevention either.

Such an appraoch would mean examining the health impacts of existing and proposed policies across all sectors, and in particular looking at and recommending policies in both the public and private sectors that will reduce the excess burden of disease related to poverty. This will require a technical support group of public health experts and policy analysts, probably best led by the Provincial Health Officer.

So we have a choice: Continue to accept that there is a large burden of disease and to see this as a problem of supply, which we can never fully fix, or see it also as a problem of demand, and make a serious, long-term, society-wide commitment to improve the health of the population. Which would you prefer?

© Trevor Hancock, 2019

 

Highrises are not the answer

Highrises are not the answer

Dr. Trevor Hancock

25 June 2019

699 words

An important contributor to our large ecological footprint is urban sprawl, an energy and resource-hungry form of development that we cannot afford. It also is bad for our health, in a myriad of ways, a topic I explored in my column for 22nd November 2017.

According to the first book on the topic, in 2004, those health impacts include higher rates of physical inactivity and obesity due to driving rather than active transportation; respiratory and cardiovascular disease due to air pollution; more traffic injuries and deaths resulting from car-dominated transportation; and impacts on mental health and social wellbeing.

Obviously, both from a health and an environmental perspective, we have to stop urban sprawl, concentrating all further growth within the existing urban boundary. But that can run into resistance from neighbours, who may not want infill developments. This tends to push new developments into more concentrated areas, and one response is high-rise development. That certainly seems to be an increasing response in Victoria.

But high-rises come with their own health problems, especially for children. In 2007 Dr. Robert Gifford, an environmental psychologist and a Professor at UVic, published a review of the evidence on the consequences of living in high-rise buildings. While acknowledging that such research is difficult and that there are many other factors to consider, such as socio-economic status, family type and building location, he nonetheless concluded:

“the literature suggests that high-rises are less satisfactory than other housing forms for most people, that they are not optimal for children, that social relations are more impersonal and helping behavior is less than in other housing forms, that crime and fear of crime are greater, and that they may independently account for some suicides.”

In particular, he noted, “No evidence we could find shows that high rises are good for children”.

So what is the answer? There are in fact a number of good options. The first is what Todd Litman, an internationally recognised transport and urban development expert based here in Victoria, suggests: “moderate-density housing in walkable urban neighbourhoods”. Moderate and even high density, we should recall, characterises some of the world’s most popular cities; think of Copenhagen or Paris. As to walkable, Melbourne has adopted the principle of the ‘20-minute neigbourhood’, “giving people the ability to meet most of their everyday needs within a 20-minute walk, cycle or local public transport trip of their home”.

To make such housing livable we could use courtyard housing, a traditional form that creates shared space where residents can gather, but that nonetheless separates the public and the private realms of housing. In a 2014 report for Abbotsford Council, social planning consultant Cherie Enns noted such housing “creates a safe and nurturing place for children and youth, and provides a social connection”, which suggests it can address the problems that highrises fail to address.

Moreover, Litman suggests, such housing should be built everywhere, an approach he called the 1.5% solution. In a July 2018 commentary in the Times Colonist he pointed out that Victoria’s population grows at 1.5 percent annually and suggested that the city’s neighbourhoods should all grow by that amount, which in practice would mean between 25 and 125 new units every year, some of it infill, depending on the neighbourhood, surely not a huge challenge?

Moreover, these forms of housing would also be more affordable, in part because clustered housing is more energy and space efficient, and in part because people would not need a car, and certainly not the 2 or 3 cars a suburban family may need.

While these new developments could be in residential neighbourhoods, we could also ‘mainstreet’ existing commercial and transit corridors by building 3 to 5 storeys with commercial on the ground floor and a mix of residential and offices above. The stretches of Tillicum and Hillside alongside or opposite their malls come to mind; this could create the sort of lively urban street that we find attractive in so many European cities.

So a choice between urban sprawl and high-rise towers is a false choice; both bring health problems with them, neither is the answer to our urban challenges. Instead, we need to re-create the urban village: livable, affordable, sustainable and healthy.

© Trevor Hancock, 2019

 

 

Dr. Trevor Hancock

25 June 2019

699 words

An important contributor to our large ecological footprint is urban sprawl, an energy and resource-hungry form of development that we cannot afford. It also is bad for our health, in a myriad of ways, a topic I explored in my column for 22nd November 2017.

According to the first book on the topic, in 2004, those health impacts include higher rates of physical inactivity and obesity due to driving rather than active transportation; respiratory and cardiovascular disease due to air pollution; more traffic injuries and deaths resulting from car-dominated transportation; and impacts on mental health and social wellbeing.

Obviously, both from a health and an environmental perspective, we have to stop urban sprawl, concentrating all further growth within the existing urban boundary. But that can run into resistance from neighbours, who may not want infill developments. This tends to push new developments into more concentrated areas, and one response is high-rise development. That certainly seems to be an increasing response in Victoria.

But high-rises come with their own health problems, especially for children. In 2007 Dr. Robert Gifford, an environmental psychologist and a Professor at UVic, published a review of the evidence on the consequences of living in high-rise buildings. While acknowledging that such research is difficult and that there are many other factors to consider, such as socio-economic status, family type and building location, he nonetheless concluded:

“the literature suggests that high-rises are less satisfactory than other housing forms for most people, that they are not optimal for children, that social relations are more impersonal and helping behavior is less than in other housing forms, that crime and fear of crime are greater, and that they may independently account for some suicides.”

In particular, he noted, “No evidence we could find shows that high rises are good for children”.

So what is the answer? There are in fact a number of good options. The first is what Todd Litman, an internationally recognised transport and urban development expert based here in Victoria, suggests: “moderate-density housing in walkable urban neighbourhoods”. Moderate and even high density, we should recall, characterises some of the world’s most popular cities; think of Copenhagen or Paris. As to walkable, Melbourne has adopted the principle of the ‘20-minute neigbourhood’, “giving people the ability to meet most of their everyday needs within a 20-minute walk, cycle or local public transport trip of their home”.

To make such housing livable we could use courtyard housing, a traditional form that creates shared space where residents can gather, but that nonetheless separates the public and the private realms of housing. In a 2014 report for Abbotsford Council, social planning consultant Cherie Enns noted such housing “creates a safe and nurturing place for children and youth, and provides a social connection”, which suggests it can address the problems that highrises fail to address.

Moreover, Litman suggests, such housing should be built everywhere, an approach he called the 1.5% solution. In a July 2018 commentary in the Times Colonist he pointed out that Victoria’s population grows at 1.5 percent annually and suggested that the city’s neighbourhoods should all grow by that amount, which in practice would mean between 25 and 125 new units every year, some of it infill, depending on the neighbourhood, surely not a huge challenge?

Moreover, these forms of housing would also be more affordable, in part because clustered housing is more energy and space efficient, and in part because people would not need a car, and certainly not the 2 or 3 cars a suburban family may need.

While these new developments could be in residential neighbourhoods, we could also ‘mainstreet’ existing commercial and transit corridors by building 3 to 5 storeys with commercial on the ground floor and a mix of residential and offices above. The stretches of Tillicum and Hillside alongside or opposite their malls come to mind; this could create the sort of lively urban street that we find attractive in so many European cities.

So a choice between urban sprawl and high-rise towers is a false choice; both bring health problems with them, neither is the answer to our urban challenges. Instead, we need to re-create the urban village: livable, affordable, sustainable and healthy.

© Trevor Hancock, 2019