Month: September 2019

Our health should be an election issue

Dr. Trevor Hancock

17 September 2019

701 words

To the extent health is an issue in the federal election, it will be about health care, as usual. Now I am not saying health care is an unimportant issue, but this focus on ‘health care as health’ is wrong for two reasons. First, health care is a provincial responsibility under the Constitution, so the federal government plays no real role in managing Canada’s various provincial and territorial health care systems.

Second, and more important, health is not health care, it is a much bigger issue – and one where the federal government can indeed play a major role. If we really want to improve health care, we must improve health, thus reducing the growing burden of disease and injury the health care system has to handle.

So as we think about the federal election, look at party platforms and promises, and engage with candidates, the question we should be asking is “What will you do to protect and improve the health of Canadians?” Here and in the next few columns I will discuss the policies I believe we should be looking for ro determine whether our political leaders really understand and care about the health of Canadians.

In this I am not alone. The Canadian Public Health Association (CPHA) has identified eight top election issues and has produced an excellent set of resources for citizens and public health professionals, giving easy access to the parties’ platforms and tools to help people engage candidates in their riding (see www.cpha.ca/election-2019)

CPHA’s priorities include such basic determinants of health as income, housing, early child education and climate change. They also focus on the opioid crisis, decriminalization of personal use of psychoactive substances, racism, and not surprisingly, on the funding of public health. To this list, I would add food, transportation and urban development, although the latter, like health care, is within provincial but not federal jurisdiction.

But over and above all of this is the need for a comprehensive and strategic approach to improving the health of Canadians. There was a time, in the 1980s and 1990s, when Canada was a world leader on these issues, but sadly that is no longer the case. As with so much else that is wrong with public policy, it is not lack of knowledge that leads to poor policy choices, but lack of wisdom, lack of a long term perspective and the inability to act in the public interest rather than in the interest of powerful corporate and institutional players.

The first step in making the health of Canadians a priority is to recognize that the Minister of Health is actually largely the Minister of Illness Care, and that it is the Cabinet as a whole, and the Prime Minister or Premier in particular, that is really the ‘Minister of Wellbeing’. Improving the health of Canadians depends more upon the Ministers of food, housing, education, finance, social development, environment and climate change and others than the Minister of health.

The Canadian Senate recognized this in a 2009 report that recommended “A new style of governance: leadership from the top to develop and implement a population health policy at the federal, provincial, territorial and local levels with clear goals and targets and a health perspective to all new policies and programs”.

Specifically, the Senate recommended creating a Cabinet Committee on Population Health (which should be chaired by the Prime Minister/Premier) that would develop and implement a population health policy. This policy would require an assessment of the health impact of policies in all sectors, and a spending review to determine where we would get the biggest health/human development return on our investment.

To this, I would add the creation of an independent Canadian Population Health Officer, reporting to Parliament (not to the government) on the effectiveness of public policy and programs in improving the health of the population.

The report sank like a stone! So if you are concerned with the health of the population and the sustainability of the health care system, you should ask candidates if they will commit to creating a Cabinet Committee on Population Health, displacing economic development as the central focus and instead putting development of human wellbeing at the heart of government.

© Trevor Hancock, 2019

 

The price of societal neglect of children

Dr. Trevor Hancock

10 September 2019

698 words

This is my final column about Tyler, the fictional but prototypical young offender whose story was told in a 2016 Public Safety Canada (PSC) report. Last week I discussed the value of support in the first three years of life to help parents create secure attachment, as well as interventions to reduce the occurrence or reduce the impact of Adverse Childhood Events (ACEs). The latter includes eliminating child poverty – which is always, of course, parental poverty.

Oddly, the PSC report did not include these early interventions, perhaps because they are for all children, while the interventions they reported on are all aimed at children already having problems or involved with the justice system. But nonetheless, for the two interventions described here, the estimated net savings for Tyler were in excess of $1 million. (A third program described in the report seems to be less effective in Canada than in the USA, where it was developed, so is not discussed here.)

The first program is SNAP – Stop Now and Plan, a Canadian program developed by the Child Development Institute in Toronto since 1987 and now recognized internationally. SNAP works with troubled children aged 6 – 12 and their parents and its goal is “to help children to stop and think before they act, and keep them in school and out of trouble”.

Public Safety Canada notes a 2007 study found that “delinquency, major aggression and minor aggression decrease significantly after participation in SNAP”, at a cost of less than $7,000 per participant. SNAP itself reports: “Recent research indicates that 68% of SNAP participants will not have a criminal record by age 19”, and that the return on investment is $7 for every dollar invested in the first year.

So you would think this program would be in place across Canada – and you would be wrong! SNAP’s website describes its plans to expand from the current 20 sites in Canada, of which only 4 are in BC; the Coquitlam and Nechako Lakes –Vanderhoof School Districts and two small community agencies in Vanderhoof and Salmon Arm.

The second program is the Youth Inclusion Program (YIP), which was developed in 2000 by the Youth Justice Board in the UK. It is a neighbourhood-based program that works with adolescents (age 12 – 17) and young adults (18 – 24) and is supported through PSC’s National Crime Prevention Strategy. It aims to create “a safe place where youth can go to learn new skills, take part in activities with others, and receive educational support” in areas where “where there is a strong need to reduce youth crime and antisocial behavior”.

The YIP also works. Two Canadian evaluations between 2010 and 2016 showed that participants reduced their risky behaviours – in one case by 67percent – at an average cost of between $8,500 per participant. But again, there were only 13 sites in Canada, with 3 in BC: Agassiz-Harrison, Smithers and Salmon Arm.

It is important to understand that as with so much else in society, the worst-case stories are the tip of the iceberg, and do not represent the whole picture. For every Tyler, we can be sure that there are many others whose problems were not as obvious or severe, but who nonetheless were problematic. In fact, the chances are that their overall impact on society is greater. The loss to society – not just economic loss, but loss of human potential and social wellbeing – is significant, and to a fair extent is preventable.

Any society that was truly caring and compassionate – and sensible – would realise that investing in creating the healthiest possible start for every single child in Canada would have huge health, social and economic benefits. So why don’t we do so – why is this not a national and provincial priority? Why is there not a Ministry of Healthy Child Development, instead of a hodge-podge of poorly funded programs across multiple ministries?

If we want to have fewer Tyler’s, we need to get very serious about this. Governments that fail to invest in a comprehensive healthy child development strategy are guilty of wasting a huge amount of human and economic potential. They are also guilty of neglect every bit as much as parents who neglect their children.

© Trevor Hancock, 2019

Tyler’s story – Early support is vital

Dr. Trevor Hancock

3 September 2019

698 words

Last week I told Tyler’s story, a fictionalized account of life to the age of 30 of “a prototypical adolescent offender in Canada”, highlighting “the most common risk factors that affect Canadian youth who become involved in crime”. But the whole point of the Public Safety Canada (PSC) report from which Tyler’s story comes is that the significant loss to society that Tyler represents – not just economic loss, but loss of human potential and social wellbeing – is to a fair extent preventable.

Brain development in infancy is astonishing. According to the Centre on the Developing Child at Harvard, 1 million connections are made in the brain every second – yes, every second – in the first three years of life. The Centre notes “As early experiences shape the architecture of the developing brain, they also lay the foundations of sound mental health”.

The late Clyde Hertzman, founding director of the Human Early Learning Project (HELP) at UBC, called the way in which social and emotional experiences shape the brain ‘biological embedding’, noting in a report he led for the World Health Organization in 2007 that it influences health and development over the long term.

So not surprisingly, then, supporting healthy brain development early in life is crucial for both mental and physical wellbeing throughout life. Lets look at some early interventions which were not included in the PSC report, but that might have had an even greater impact on Tyler’s story.

In a recent presentation at the Atlantic Summer Institute in PEI Dr. Chaya Kulkarni, discussed the work of the Infant Mental Health Promotion (IMHP) initiative at The Hospital for Sick Children in Toronto, of which she is the Director. Not only are the first three years of life are key, she noted, but the mother’s emotional state and level of stress during pregnancy can affect the emotional, behavioural and cognitive outcomes of the child she is carrying.

She emphasized that relationships are foundational to achieving the tasks of childhood and that secure attachment between the infant and the caregiver (usually the parent) is key, while isolation, indifference and neglect are traumatic. Dr. Kulkarni also stressed that infants can and do experience trauma, that it is possible to detect atypical developmental trajectories in the first 6 months of life, and that children do not outgrow their early mental health problems.

In recent years, there has been a growing recognition of the traumatic mental and physical health impacts of adverse childhood experiences (ACEs). These are things like physical and emotional abuse, neglect, caregiver mental illness, household violence and poverty, effects we can see at work in Tyler’s story. Such experiences are very stressful to infants and young children, and the more ACEs they experience, the greater the impact. Such prolonged stress is toxic, and “can have a cumulative toll on an individual’s physical and mental health—for a lifetime”, the Harvard Centre notes.

So obviously we need to reduce the number of ACEs, and the evidence shows that there are several key things we need to do in the early years. The focus must be on the entire family, and on reducing the level of stress within the family. This includes reducing poverty, which is why the failure to eliminate child poverty, as the House of Commons pledged to do by 2000, is such a disgrace, a massive failure of our supposedly compassionate society that acts against our long-term interests.

Beyond that, we need to identify parents and infants that need support in becoming caring and attentive parents and developing strong attachment and positive relationships, and where necessary we need to be able to intervene to protect vulnerable children. This requires a significant investment in parent and infant health, because Dr. Kulkarni reports that there is no good system for protecting and improving infant mental health in Canada.

As the Harvard Centre notes: “By improving children’s environments of relationships and experiences early in life, society can address many costly problems, including incarceration, homelessness, and the failure to complete high school.” What a difference that might have made to Tyler’s story.

Next week I will return to the PSC report and the three child and youth interventions discussed in that report.

© Trevor Hancock, 2019

Tyler’s story – The price of failure

Dr. Trevor Hancock

27 August 2019

698 words

The 2018 annual conference of the Public Health Association of BC had a focus on violence prevention. One of the keynote speakers was Dr. Irvin Waller, a criminologist at the University of Ottawa and Canada’s leading expert on violence prevention. He shared the key findings of a 2016 research report from Public Safety Canada called Tyler’s Story. It is the fictionalised story of life to the age of 30 of “a prototypical adolescent offender in Canada”, highlighting “the most common risk factors that affect Canadian youth who become involved in crime”.

The report notes that “the majority of Canadians engage in some form of delinquent behaviour during adolescence”, but “most people eventually outgrow these behaviours”. However, more than 94,000 young people aged 12-17 years old – approximately 4% of the Canadian youth population – were accused of a Criminal Code violation in 2014. Of course, not all of them go on to a life of crime, but for those who do, it is a damaging and expensive experience, not only for Tyler, but for all the other people whose lives he touched and who were harmed by his actions.

It is an important story for those of us interested in improving the health of the population, because the story also estimated both the economic costs to society and, more important still, the potential inteventions that might have changed his life course for the better, and the potential savings.

Tyler did not get a great start in life. He was born to a young high school drop out and his father had a history of property crimes. Before the age of two, Tyler had come to the attention of the child welfare agency as his mother struggled to raise him largely on her own. Perhaps not surprisingly, he had behavioural problems which meant he could not attend daycare, but had to stay with a neighbour or at home with his father – now out of jail.

However, his father was abusive, and before the age of 5, Tyler was in foster care, and over the next 5 years had three foster homes, and thus three changes of school. He became aggressive and disruptive, was diagnosed with ADHD and given medication, and moved to a fourth foster home. A victim of teasing at school, he became violent and ultimately was suspended for fighting.

In high school, where he continued to be disruptive and was often suspended, Tyler hung out with a bad crowd and before long they were stealing to buy cigarettes, alcohol and marijuana. He was caught, of course, and in Grade 10 received his first youth sentence – probation. While still 16 he dropped out of school, and before too long, his aggressive behaviour ended in an assault charge and landed him a six-month sentence in a secure youth custody facility.

There he partnered up with a drug dealer, eventually was caught dealing cocaine and, now 18, was sentenced to an adult jail term. The pattern of assaults and drug dealing and jail continued, and by age 30, Tyler had spent 10 years of his life in custody.

And the cost of all this? The report’s authors estimate the costs to society at $1.4 million, largely from the child protection and justice system, but also costs for medical care for victims and for property damage. This does not include the stress and mental pain and suffering endured by his victims, nor does it include the health and social harm arising from his drug dealing. And this is just for one person’s action, never mind the hundreds, perhaps thousands more who are the larger population of which Tyler is a representative.

But as noted, the report also points to three proven evidence-based interventions that, had they been available and implemented, might have diverted Tyler to a different path, preventing much of this harm. The first of these, if implemented at age 6 – 10, might have saved society almost $1.2 million, not to mention the avoided mental and social harm, while the latest, at age 15 – 17, could still have saved almost $900,000.

More about this next week, along with ideas for even earlier interventions that might help change Tyler’s story.

© Trevor Hancock, 2019