Governance failures behind our Silent Spring

Governance failures behind our Silent Spring

Dr Trevor Hancock

26 February 2019

701 words

Last week I wrote about the devastation of the world’s insect population, caused to a significant extent by intensive farming and pesticide use. The management of pesticides in Canada has been a travesty for decades, but this failure of governance to protect human health and the environment is hardly a new problem.

Fifty-seven years ago, in Silent Spring, Rachel Carson named the problem: we live in “an era dominated by industry, in which the right to make a dollar at whatever cost is seldom challenged”. Carson’s biographer, Linda Lear, notes on her website that “Carson believed the [US] federal government was part of the problem (and) identified human hubris and financial self-interest as the crux of the problem”.

This is very clear when it comes to regulating pesticides. I cut my environmental health teeth fighting the pesticide industry and Health Canada in the early 1980s, when I was an Associate Medical Officer of Health in the City of Toronto. We were recommending a ban on 2-4 D in the city, on the grounds that controlling dandelions in parks and gardens – known as cosmetic pesticide use – was less problematic than risking the potential health effects. I came to an early recognition that the Health Protection Branch of Health Canada functioned more like the industry protection branch.

I went on to co-found the Canadian Association of Physicians for the Environment (CAPE). For years, CAPE has fought to reduce or eliminate both cosmetic and in some cases agricultural pesticide use. It has done so based on evidence, the application of the precautionary principle, and its professional and public interest concern in protecting health and the environment.

In its work CAPE and its many community and environmentalist partners have tangled constantly with the Pest Management Regulatory Agency (PMRA), established within Health Canada in 1995. On its website, CAPE notes “gaps and flaws in this review process leave Canadians inadequately protected from health and environmental risks associated with the use of toxic pesticides.”

But CAPE is not alone in its criticism. The federal Commissioner of the Environment and Sustainable Development, part of the office of the Auditor General, has undertaken three reviews of the PMRA since 2003, and they disclose some serious flaws. In 2003 the Commissioner reported “Overall, we conclude that the federal government is not managing pesticides effectively. We found weaknesses in many areas . . . (which) . . . raises serious questions about the overall management of the health and environmental risks associated with pesticides”. But note, this comes after decades of criticism from health and environmental organisations acting in the public interest – and still the PMRA could not get it right.

Again in 2015, the Commissioner had serious concerns, noting numerous problems and concluding that in a number of important areas PMRA “had not always acted in a timely manner to fulfill its statutory objective of preventing unacceptable risks to the health of Canadians and the environment from the use of pesticides”. In fact, for three of the most widely used pesticides in Canada – atrazine, glyphosate and neonicotinoids as a class – we have lower standards and are years if not decades behind Europe in protecting the health of Canadians.

Atrazine, a herbicide that is still registered and used in Canada, although declining, was banned in Europe in 2003. Glyphosate is a widely used herbicide that is a probable human carcinogen according to the World Health Organisation – but not according to the PMRA, which seems to think it knows better. And neonicotinoids are widely used insecticides that are linked to harm to bees and other beneficial insects. The EU banned them for all outdoor agricultural use from the end of 2018, but the PMRA has taken only small steps to reduce their use.

The fundamental problem is that the PMRA – and government more generally –does not see its prime function being to protect the health and wellbeing of the public or the environment. Instead, its key objective seems to be the short-term and purely profit-oriented aims of industry. In their blind pursuit of economic growth and their misplaced confidence in dodgy corporate science, governments turned a blind eye to all the warnings, while we all suffer the consequences.

© Trevor Hancock, 2019

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Silent Spring is getting closer

Silent Spring is getting closer

Dr Trevor Hancock

20 February 2019

701 words

Fifty-seven years ago, in her eloquent and powerful 1962 book Silent Spring, Rachel Carson – a marine scientist who worked for many years for the US Fish and Wildlife Service – warned of the consequences of the widepread use of DDT and other new pesticides. It is astonishing to re-read this classic now, so many years after it was written. There is the clarity of thinking and the pleasure of good writing, of course, but it is the prescience that takes your breath away.

She could have been writing today when she states: “Along with the possibility of the extinction of mankind by nuclear war, the central problem of our age has therefore become the contamination of man’s total environment with such substances of incredible potential for harm”. Future historians, she wrote, “may well be amazed by our distorted sense of proportion” in seeking to “control a few unwanted species by a method that contaminated the entire environment”. And she warned “Future generations are unlikely to condone our lack of prudent concern for the integrity of the natural world that supports all life.”

Well, the chickens are coming home to roost. In a very disturbing and unusually blunt review of the state of the world’s insects in Biological Conservation in January, Australian entomologists, Francisco Sánchez-Bayo and Kris Wyckhuys describe “the dreadful state of insect biodiversity in the world, as almost half of the species are rapidly declining and a third are being threatened with extinction”.

Insects, they note “are at the structural and functional base of many of the world’s ecosystems”, so the results of these losses, which “may lead to the extinction of 40% of the world’s insect species over the next few decades”, will be “catastrophic to say the least”. As the Australian cartoon strip ‘First Dog on the Moon’ notes, “this is literally the biggest news story in the world” and should be front page news.

Much of the data with which they are working is for Europe and North America, since there is good historical data to allow for the determination of trends. However, they note that “insects are not expected to fare differently in tropical and developing countries”, because the underlying causes are now world-wide.

The root cause, they state, is “the intensification of agriculture over the past six decades . . . and within it the widespread, relentless use of synthetic pesticides”. In addition, loss of habitat through urbanization, introduction of invasive species and climate change all contribute to the decline.

So “the conclusion is clear: unless we change our ways of producing food, insects as a whole will go down the path of extinction in a few decades”. They go on to call for “a serious reduction in pesticide usage and its substitution with more sustainable, ecologically-based practices”.

Interestingly, this links to and reinforces the dietary prescription of both the recent EAT-Lancet Commission on healthy and sustainable diets and the new Canadian Food Guidelines that I wrote about recently. One of the benefits of a low-meat, plant-based diet is that more people can be fed on less land, allowing for a less intensive form of agriculture.

But insects are not the only victims, serious though that is; humans are affected too. Rachel Carson warned us – and our governments – a long time ago that “For the first time in the history of the world, every human being is now subjected to contact with dangerous chemicals, from the moment of conception until death.” And she pointed out that these new chemicals, “to which the bodies of men and animals are required somehow to adapt each year” have “no counterparts in nature” and are “totally outside the limits of biological experience.” Thus we cannot adapt, nor can other species – certainly not in any timely manner.

Finally, Rachel Carson notes “We have subjected enormous numbers of people to contact with these poisons without their consent and often without their knowledge.” This amounts to an unethical and completely unauthorised experiment to find out what happens when you expose entire human and non-human populations from before birth and throughout life to a toxic soup of chemicals. That is a disgracful failure of governance, which I will dsicuss next week.

© Trevor Hancock, 2019

 

 

Why we still need to love this planet

Why we still need to love this planet

Dr Trevor Hancock

11 February 2019

700 words

The proximity of Valentine’s Day and the plan by a UVic Student, Antonia Paquin, to create love letters for the Earth for Valentine’s Day, put me in mind of the work of Dr. Helen Caldicott, an internationally renowned Australian physician and anti-nuclear activist. Now 80 years old, she sprang to fame in part due to a short film of a lecture she gave on the dangers posed by nuclear weapons. Made for Canada’s NFB, “If You Love This Planet” won the Academy Award for best documentary in 1982 – helped perhaps by the US Justice Department officially labelling it “foreign political propaganda”.

Dr. Caldicott was no stranger to controversy. In the 1970s she helped lead the opposition to French atmospheric testing of nuclear weapons in the Pacific. She went on to lead Physicians for Social Responsibility (PSR), a US-based anti-nuclear organisation founded in 1961. In the early 1980s I was an Associate Medical Officer of Health in the City of Toronto, and we too were inspired by her work, and by the work of the Canadian branch of PSR, which later became Physicians for Global Survival (PGS).

Like Health Departments in many other cities around the world at the time, we did a report on the expected health impacts of a one-megaton nuclear weapon air burst above Toronto. The findings were devastating, shocking the public and politicians alike and contributing to the global movement to limit nuclear weapons, which ultimately led to several treaties to limit nuclear weapons. The international umbrella group International Physicians for the Prevention of Nuclear War, co-founded by American and Soviet physicians, won the Nobel Peace Prize in 1985 for its work.

That work is not over, as the recent decision by the US and Russia to pull out of the Intermediate Nuclear Forces Treaty demonstrates. Nuclear war remains the greatest single threat to the health of people and myriad other species, and to the survival of human civilisation. But we now face an equally serious, slower but more certain threat; human-induced global ecological change, in particular climate change. And once again, physicians have been mobilising for many years to protect health.

In 1992, PSR expanded its mission to address these global environmental threats, as did Helen Caldicott, whose 1992 book “If You Love This Planet” was focused not so much on the nuclear threat but on the ecological threat. And here in Canada, I was one of the co-founders in 1993 of the Canadian Association of Physicians for the Environment (CAPE), whose mission is to better human health by protecting the planet.

The current President of CAPE is Dr. Courtney Howard, an ER physician based in Yellowknife. She reminds me of Helen Caldicott – smart, passionate, eloquent and seemingly tireless. She is particularly focused on climate change, and has led the Canadian work on the Lancet Climate Countdown Report, an annual international report on the health impacts of climate change.

Most recently, CAPE was on Parliament Hill in February 5th, along with representatives from the Canadian Medical Association, the Canadian Nurses Association, the Canadian Public Health Association and the Urban Public Health Network, calling on federal parties to recognize that climate change is the greatest public health challenge of the 21st century, and to make climate solutions a priority in the 2019 federal election.

Finally, back to Antonia Paquin’s plan for love letters to the Earth. It’s an important idea at two levels. First, it’s a youth-led initiative, part of a growing global movement of young people rising up and saying ‘enough’ – witness the high school climate strikes, including here in Victoria, inspired by the 15 year-old Swedish activist Greta Thunberg. I am grateful to the young people who are organising and leading these strikes.

Second, it’s about changing our relationship with the Earth. We have lost our connection with nature, seeing it as an object apart from us that is there for us to exploit, rather than as something we are part of and dependent upon. If we are to save the Earth and ourselves from ourselves we need to re-establish a reverence for nature, we need to be able to feel the pain we are inflicting on the Earth, we need to love this planet.

© Trevor Hancock, 2019

 

Local councils are right to sue fossil fuel industry

Local councils are right to sue fossil fuel industry

Dr Trevor Hancock

6 February 2019

697 words

Considerable derision has been heaped on Victoria City Council for endorsing a class action lawsuit against the fossil fuel industry, seeking financial compensation for the added costs the City will incur as a result of climate change. But far from complaining, we should be praising them, and other local municipal councils that are also preparing to sue. Not only are they being prudent managers of the public purse, seeking to protect taxpayers from added costs, they are also being leaders in addressing climate change.

The City’s latest action follows its November 2017 letter to 20 of the world’s largest oil and coal companies in which the City asked them to “pay your fair share of the costs of climate change that face our community”. The City took the view that “You cannot make billions of dollars selling your product, knowing that it is causing significant financial harm to communities around the world, and not expect to pay for at least some of that harm”.

The costs are significant; a 2012 report from the BC government on the cost to adapt flood protection to meet the rise in sea level predicted by 2100 found the cost for Metro Vancouver would be $9.5 billion. Note this is only the cost associated with sea-level rise; it does not include costs from other aspects of climate change such as forest fires and air pollution, severe weather events and so on. Nor does it include the health costs of climate change.

Victoria was not even the first in BC to act – that honour goes to the District of Highlands, which sent a letter in July 2017. Since then, letters have gone from Saanich, Colwood and View Royal, Sooke has voted to send one, and in September 2018 the Association of Vancouver Island and Coastal Communities sent a letter on behalf of its 53 local government members. All of this is supported by a West Coast Environmental Law campaign to hold the fossil fuel industry to account known as Climate Law in Our Hands.

Filing a lawsuit can have several beneficial effects. First, it can force open the files of the fossil fuel industry, so we can see just how much they knew about global warming and its relationship to their products, when they knew it, what they may have done to hide this evidence, what they may have done to create doubt in the minds of the public and what their lobbying efforts with governments may have been.

For those of us who are veterans of the ‘tobacco wars’, this all sounds very familiar. The tobacco industry was also sued because it was making money by selling a product it knew to be harmful, and then concealing that harm and casting doubt on the evidence in the minds of its users. In fact the Centre for International Environmental Law, in its research into the Tobacco Industry Archives (one of the fruits of the legal action against the tobacco industry) found close ties between the oil and tobacco industry, noting “the oil companies have benefitted from the tobacco playbook in their fight against climate science.”

Second, when a company is sued this has to be reported to investors, so it becomes an investment risk. Third, there is a degree of public exposure and awareness, which helps to change the social and political conversation and may lead to a loss of market appeal. Fourth, the prospect of facing law suits and negative public opinion may encourage the companies to shift away from fosil fuels.

Finally, if found liable, any costs awarded would not only help reimburse taxpayers but would raise the price of fossil fuels. This would be helpful – if unwelcome in some quarters in the short term – because we should pay the full cost of the fossil fuels we use. If we did, we would make very different choices.

Far from deriding local governments for being irresponsible, critics should be chiding the provincial and federal governments for failing to take action themselves. It would be a lot more effective if the BC government took on the case on behalf of local governments to recover their costs, adding in the provincial costs as well.

© Trevor Hancock, 2019

 

 

 

 

Many global health threats linked to global change

Many global health threats linked to global change

Dr Trevor Hancock

29 January 2019

701 words

The World Health Organisation (WHO) recently released a report on the top ten threats to health in 2019. Strikingly, several are related to global ecological change, marking perhaps a turning point in the recognition of the health implications of the rapid and massive ecological changes we are causing.

The first threat is air pollution and climate change. The WHO reports that nine out of ten people around the world breathe polluted air every day, causing around 7 million deaths annually, mainly from heart and lung diseases and cancer. About half the deaths are due to outdoor air pollution, mainly due to emissions from industry, transport and agriculture. Indoor air pollution from heating and cooking with biomass fuels is an important factor in the other half of the deaths.

Troublingly, about 90 percent of those deaths are in middle and low-income countries, according to the 2017 report of the Lancet Commission on Pollution and Health. This is a pattern seen in most of the other major health threats facing the world today.

The major source of air pollution is the burning of fossil fuels, which of course is also the major cause of climate change. While the WHO estimates that climate change will contribute to about 250,000 additional deaths each year between 2030 and 2050, many see that as a considerable underestimate. Emerging evidence suggests the impact of climate change on health and society will be more serious and more rapid than we used to think.

The second major health threat is non-communicable or chronic disease – heart disease, cancer, lung disease, diabetes and the like – with “over 85% of these premature deaths in low- and middle-income countries”. The first three of the five key factors cited by the WHO – tobacco use, physical inactivity and the harmful use of alcohol – are not obviously linked to global ecological problems.

But the remaining two – unhealthy diets and air pollution – are very much related to global ecological problems. I have addressed air pollution above, while I noted in last week’s column that our agricultural system and the highly animal-based, highly processed diet it is increasingly designed to produce is not only bad for our health, it is also a major contributor to several global environmental problems. These include greenhouse gas emissions, land degradation, pollution, water depletion and loss of habitat and biodiversity.

Fragile and vulnerable settings are number four on WHO’s list of the top ten global health threats: “More than 1.6 billion people (22% of the global population) live in places where protracted crises . . . and weak health services leave them without access to basic care”. These places are made vulnerable by “a combination of challenges such as drought, famine, conflict and population displacement”.

Many of these challenges are in part or in whole due to climate change, which is only going to get worse. Drought and floods – both caused or exacerbated by climate change – lead to displacement and famine, while rising sea levels, rising temperatures and increasing severe weather events will result in increasing numbers of eco-refugees. The UN High Commission for Refugees estimates that every year since 2008 there has been “an average of 22.5 million people displaced by climate or weather-related events.” The Intergovernmental Panel on Climate Change expects these numbers to increase throughout the 21st century.

The fifth threat identified by WHO is antimicrobial resistance, which “threatens to send us back to a time when we were unable to easily treat infections”. Among the factors contributing to this problem, WHO notes, is the overuse of antimicrobials not only “in people, but also in animals, especially those used for food production”; again, we see our animal-based diet and agricultural system is a problem.

Finally, ninth on the list is dengue fever, an unpleasant and occasionally fatal infection spread by mosquitoes. Climate change is increasing the distribution of these mosquitoes, which WHO reports are “spreading to less tropical and more temperate countries”.

This list of threats to global health shows us that now, more than ever, we must pay attention to the links between the health of the environment and our own health. The good news is that when we protect the environment, we almost always protect our health.

© Trevor Hancock, 2019

 

 

 

 

Many global health threats linked to global change

Many global health threats linked to global change

Dr Trevor Hancock

29 January 2019

701 words

The World Health Organisation (WHO) recently released a report on the top ten threats to health in 2019. Strikingly, several are related to global ecological change, marking perhaps a turning point in the recognition of the health implications of the rapid and massive ecological changes we are causing.

The first threat is air pollution and climate change. The WHO reports that nine out of ten people around the world breathe polluted air every day, causing around 7 million deaths annually, mainly from heart and lung diseases and cancer. About half the deaths are due to outdoor air pollution, mainly due to emissions from industry, transport and agriculture. Indoor air pollution from heating and cooking with biomass fuels is an important factor in the other half of the deaths.

Troublingly, about 90 percent of those deaths are in middle and low-income countries, according to the 2017 report of the Lancet Commission on Pollution and Health. This is a pattern seen in most of the other major health threats facing the world today.

The major source of air pollution is the burning of fossil fuels, which of course is also the major cause of climate change. While the WHO estimates that climate change will contribute to about 250,000 additional deaths each year between 2030 and 2050, many see that as a considerable underestimate. Emerging evidence suggests the impact of climate change on health and society will be more serious and more rapid than we used to think.

The second major health threat is non-communicable or chronic disease – heart disease, cancer, lung disease, diabetes and the like – with “over 85% of these premature deaths in low- and middle-income countries”. The first three of the five key factors cited by the WHO – tobacco use, physical inactivity and the harmful use of alcohol – are not obviously linked to global ecological problems.

But the remaining two – unhealthy diets and air pollution – are very much related to global ecological problems. I have addressed air pollution above, while I noted in last week’s column that our agricultural system and the highly animal-based, highly processed diet it is increasingly designed to produce is not only bad for our health, it is also a major contributor to several global environmental problems. These include greenhouse gas emissions, land degradation, pollution, water depletion and loss of habitat and biodiversity.

Fragile and vulnerable settings are number four on WHO’s list of the top ten global health threats: “More than 1.6 billion people (22% of the global population) live in places where protracted crises . . . and weak health services leave them without access to basic care”. These places are made vulnerable by “a combination of challenges such as drought, famine, conflict and population displacement”.

Many of these challenges are in part or in whole due to climate change, which is only going to get worse. Drought and floods – both caused or exacerbated by climate change – lead to displacement and famine, while rising sea levels, rising temperatures and increasing severe weather events will result in increasing numbers of eco-refugees. The UN High Commission for Refugees estimates that every year since 2008 there has been “an average of 22.5 million people displaced by climate or weather-related events.” The Intergovernmental Panel on Climate Change expects these numbers to increase throughout the 21st century.

The fifth threat identified by WHO is antimicrobial resistance, which “threatens to send us back to a time when we were unable to easily treat infections”. Among the factors contributing to this problem, WHO notes, is the overuse of antimicrobials not only “in people, but also in animals, especially those used for food production”; again, we see our animal-based diet and agricultural system is a problem.

Finally, ninth on the list is dengue fever, an unpleasant and occasionally fatal infection spread by mosquitoes. Climate change is increasing the distribution of these mosquitoes, which WHO reports are “spreading to less tropical and more temperate countries”.

This list of threats to global health shows us that now, more than ever, we must pay attention to the links between the health of the environment and our own health. The good news is that when we protect the environment, we almost always protect our health.

© Trevor Hancock, 2019

 

 

 

 

Planning to feed a One Planet Region

Planning to feed a One Planet Region

Dr Trevor Hancock

22 January 2019

702 words

The concept of a One Planet Region is simple: We need to reduce our collective impact on the Earth so we – and others around the world – can live within the ecological and physical constraints of this one small planet we all share. But at the same time, we want to maintain a high quality of life for all, both locally and globally.

When Jennie Moore and Cora Hallsworth determined the ecological footprint of Victoria and Saanich last year they found, unsurprisingly, that we are consuming well above One Planet’s worth of ecosystem goods and services. But what may have been surprising for many is they found more than 40 percent of our footprint is related to food; this compares to the 26 percent of humanity’s overall global footprint that is related to food, according to a 2017 report from the Global Footprint Network

The extent of the impact of our global food and agriculture system on the Earth is not widely appreciated. But a 2017 study by Michael Clark and David Tilman in Environmental Research Letters notes that agricultural activities are the source of between one quarter and one third of all greenhouse gases, occupy 40 percent of Earth’s land surface and account for more than two thirds of freshwater withdrawals, as well as being a significant contributor to deforestation, habitat fragmentation, biodiversity loss and pollution.

Moreover, the UN’s Food and Agriculture Organization reported in 2014 that 75% of the world’s agricultural land is used for raising animals and that world average meat consumption per person doubled between 1961 and 2011. But meat production is a large contributor to global warming and other environmental problems, with beef being particularly problematic. A 2014 study in the Proceedings of the National Academy of Sciences found beef production has a much larger impact – between 5 and 28 times as much, depending on the issue – than the average of dairy, poultry, pork and egg production.

In their study of the Victoria and Saanich footprints, Moore and Hallsworth found more than half our food footprint was due to fish, meat and eggs, and another 18 percent was due to dairy production. So reducing our local footprint means changing our diet. Happily, a 2014 UK study found a low meat diet results in only 65 percent of the emissions resulting from a high-meat diet.

Two important reports that speak to the issue of food, health and the environment have come out this month. The first is from the EAT-Lancet Commission on healthy diets from sustainable food systems. Since 2015, The Lancet – one of the world’s leading medical journals – has drawn attention to the concept of planetary health, because “far-reaching changes to the Earth’s natural systems represent a growing threat to human health”. The Lancet has produced reports on the health impacts of climate change, pollution – and now, diet.

Authored by 37 leading scientists from 16 countries, the report states “food is the single strongest lever to optimize human health and environmental sustainability on Earth”. Their prescription is clear: To safeguard both planetary and human health “global consumption of fruits, vegetables, nuts and legumes will have to double, and consumption of foods such as red meat and sugar will have to be reduced by more than 50 percent”.

The good news is that “a diet rich in plant-based foods and with fewer animal source foods confers both improved health and environmental benefits”. They estimate their diet could prevent about 11 million deaths a year, globally.

Now Health Canada has issued its revised Canada Food Guide, and while not focused on the environmental benefits it concludes, on health grounds, that we should eat plenty of vegetables and fruits (about half our diet), choose whole grain foods and eat protein foods – not just lean meat, chicken, fish and eggs, but nuts and seeds, lentils, eggs, tofu, yogurt and beans.

I have noted before that a good food policy would be to follow Michael Pollan’s strictures: “Eat food, not too much, mostly plants”. If we are to shift to a One Planet Region, we need a One Planet diet, and that means a low-animal-based and high plant-based diet. The good news is we will be healthier for it too.

© Trevor Hancock, 2019

 

 

 

BC needs to invest in self-care

BC needs to invest in self-care

Dr Trevor Hancock

16 January 2019

695 words

Last week, in response to an editorial by Leah Collins, the Chair of the Board of Island Health (“Health care means more than hospitals”, 2 January 2019), I looked at the first of two ‘taps’ that have to be turned off if we are to reduce the size and cost of our healthcare system; reducing the burden of disease by improving the health of the population. This week I look at the second ‘tap’; reducing the demand for care by improving people’s capacity for self-care – a term that was not even used in her article.

Yet self-care is perhaps the largest part of health care; most of the time, most people with minor ailments and injuries or chronic diseases care for themselves and their families. But self-care is not just about managing illness; just as important is ‘health self-care’. This includes working with your neighbours, local municipality and others to help make your community healthy and safe and keeping yourself and your family healthy and safe through healthy living and using important preventive health services; the latter are included in BC’s ‘Lifetime Prevention Schedule’.

At the other end of the spectrum, preparing for the end of life by discussing your wishes with family members and preparing a living will and advance directives is also a form of self-care.

Unlike here in BC, the importance of self-care has long been recognised by the UK’s National Health Servcice (NHS). Noting that patients and the public are “the biggest collaborative resource available to the NHS and social care”, the NHS encourages and celebrates self-care with an annual Self Care Week, organised by an independent charity, the Self Care Forum. In November 2018 the Forum convened a Self Care Summit “to examine how to accelerate self care in the population in order to help secure the health of the nation”.

Among the key points made at the Summit was that while many in the public “still believe that encouraging self care is about cost-cutting and saving money, self care doesn’t mean no care”, noted Helen Donovan of the UK’s Royal College of Nursing. “Self care is about common sense, about better use of services, prevention and earlier diagnosis” added Professor Ian Banks, a former GP and a Trustee of the Forum. Or as noted in a related report on how municipal councils support self-care: “Whatever the situation, there is one thing all people who self care have in common: they feel empowered and confident to take responsibility for their own health”.

At the same time, self-care can markedly reduce the load on the health care system, which benefits us all. The British Medical Association estimates that 50 percent of family physician appointments are related to ill health that could have been prevented, while “over 15 million GP appointments each year could be dealt with through self care”, the Summit report notes.

But self-care does not just happen, we are not born with innate self care skills. Nor is it simply a matter of providing information and advice. To be effective, self-care needs a dedicated and comprehensive system of support. One of the Summit’s key recommendations was to create ‘local self care communities’; another was to focus on both literacy – noting “people need good literacy skills to self care” – and health literacy; this needs to start in school, the report added, so that children “will grow up understanding how to look after their own physical health and mental wellbeing”.

But there seems to be no equivalent to the NHS commitment or to the Self-Care Forum in BC. To be sure, the BC Ministry of Health has for many years supported both HealthLink – a phone and online education and advice system – and a self-management support program for people with chronic diseases.

But what is missing is recognition of the profound importance of this most neglected part of the health care system. There is no strategic approach, no plan to establish a comprehensive self-care support system. As a result, we are failing to turn off the second of the two taps that feed into our strained health care system. It is way past time the Ministry of Health addressed this failing.

© Trevor Hancock, 2019

 

 

Island Health must focus on population and public health

Island Health must focus on population and public health

Dr Trevor Hancock

7 January 2019

698 words

The trigger for the weekly columns I have written over the past four years was an editorial on prevention in the Times Colonist in November 2014. In my response I wrote “in focusing on prevention in primary care, its prescription did not go far enough”. Fast forward four years to an editorial from Leah Collins, Chair of the Board of Island Health (“Health care means more than hospitals”, 2 January 2019); in response I am tempted to just reprint my first two columns – “Health care a small part of true health” and “What makes us healthy? Hint: It’s not health care”.

For while there is much that is welcome in what Ms. Collins writes, as was the case four years ago it does not go far enough. I agree that “we have to think and act more holistically when we think about the health of the population”, and that “keeping people healthy and thriving at home” and “working to take pressure off our hospitals” should be the aim. The strong commitment to primary and community care and addressing the inequalities in health experienced by Indigenous people is welcome.

But two key elements of an holistic approach are missing. An old adage is that if your bath is overflowing you should first turn off the tap, or at least reduce the inflow. For the health care system there are two taps that need to be turned off. The first is to reduce the burden of disease and injury (and ‘dis-ease’ – the mental and emotional discomforts of life) that the healthcare system has to deal with in the first place, by keeping people healthy and safe.

The second is to reduce the demand for care by improving people’s capacity for self-care – a term that was not even used in her editorial. Here I focus on strengthening Island Health’s approach by improving population health and reducing the burden of diseases to which the system has to respond; I will address self-care next week.

With respect to population health, much more is needed than the simplistic call to practice healthy living that comes at the end of the editorial. A mountain of evidence tells us that unhealthy behaviours are shaped by our social, economic and physical environments, our living and working conditions and the disgraceful marketing of unhealthy products. To simply shrug this off as a matter of personal choice and behaviour is unacceptable.

Instead we have to address the upstream determinants of our health. One of the most important of these is poverty and inequality, and Island Health sees the evidence of the health impacts of poverty and inequality every day. But oddly, while correctly recognising the inequalities in health experienced by Indigenous people, there is no apparent recognition that inequalities in health are experienced across the entire population by many other groups.

So if Island Health is serious about reducing the burden of disease and taking pressure off its hospitals, it needs to be publicly advocating for, encouraging and supporting poverty reduction strategies. The Board must also adopt an active partnership role, working with and supporting the many other sectors whose actions impact the health of the population more than does health care.

There are a number of other important population health issues that are not addressed in Island Health’s editorial, including the built environment, climate change and other worrisome ecological changes. In addressing these and other population health issues, the Board should turn to its public health staff, the only staff whose sole function is to protect and promote the health of the population.

Given the need to reduce the burden of disease, you would think Island Health would invest in population and public health activities that address these upstream determinants of health. Yet in 2017/18, Population Health and Wellness got a mere 2.6 percent of Island Health’s expenditure, down from 2.8 percent in 2011/12; meanwhile, acute care received 55.3 percent, up from 54 percent in 2011/12.

I will believe Island Health is serious about improving the health of the population when I see it speaking out about and taking action on the upstream determinants of health and investing in and strengthening its population and public health capacity.

© Trevor Hancock, 2019

The intangible gifts that keep on giving

The intangible gifts that keep on giving

Dr. Trevor Hancock

1 January 2019

701 words

The other day, inspired by the recent gift-giving and gift-receiving season, I found myself musing on intangible gifts. In fact, I awoke from a dream in which I had asked a group with whom I was working to list the best intangible gifts they had ever received. For a couple of minutes I lay there wondering what those intangible gifts might be in my case – and then the floodgates opened!

The list starts with the love my wife and I have shared for decades, but that was quickly followed by all the close friends with whom I have a special bond, another form of love. In my case, they are mostly people with whom I have worked closely over the years, with deep roots in shared values, shared challenges and shared accomplishments; others are those with whom I have danced over my decades as a Morris dancer. Another gift of love and friendship is from my dogs, who not only give me trust and love, but ensure I go outdoors and walk twice a day.

Then there are the gifts of strangers, the random acts of kindness that lighten our days. The one that came instantly to mind was the taxi driver in Kolkota, India, some years ago, who found the much-loved vest I had left in his taxi – a gift from a friend – and took it all the way back to the hotel where he had picked me up, a long drive. I had been very upset at losing it and was overjoyed to get it back – and made sure to thank him with a gift of my own.

Another set of intangible gifts involve beauty, from the beauty of nature – the dawn, the Milky Way, a flower or a mountain view – to glorious buildings or wonderful furnishings and to art, be it a painting, a sculpture, music or other performance art. Related to that, perhaps, is the gift of humour – which is why I read the comics at the start of every day, although spontaneous humour is matchless.

But I am deeply mindful of the fact that I have been able to have these experiences in part because my basic needs are met, I have shelter, food and income. But while it must be harder to appreciate intangible gifts such as these when hungry, tired and cold, they are not beyond reach. Certainly people living in those situations tell of experiencing kindness or seeing beauty and finding comfort from those experiences.

So then I thought, ‘well, I can’t be the first person to have had these thoughts, so what does the great god Google have to say about intangible gifts?’. On the whole, it was not edifying. Googling ‘intangible gifts’ gave me a bunch of sites that were chiefly about buying people experiences. To be fair, the very first site, from GROW Counseling in Georgia, suggested support and encouragement, forgiveness, quality time, helping others and giving up an unhealthy habit. But a travel site had 52 ideas, most of which involved buying tickets or buying an experience, while DealNews suggested a number of gifts of online music and videos.

So I decided to see what Wikipedia had to say about intangible gifts, thinking I would get something a bit more philosophical; I couldn’t have been more wrong. Top of the list was information about the Gift Tax in the USA, and questions about what one can give to family members and what tax to pay. Then came an item about the gift economy, followed by a discussion on the value of intangible assets such as patents, copyrights, franchises, goodwill and trademarks.

Perhaps not surprisingly in this material age, it seems that intangible gifts have too often been monetized and commercialised. But what strikes me about the intangible gifts that matter to me is that nobody consciously gave them to me and they didn’t pay for them; they are experiences and memories of things that happened to me or that I came across, found, or sometimes went looking for. Intangible gifts such as these are fully portable and always with me, they trigger positive emotions and contribute to mental wellbeing. They really are the gifts that keep on giving.

© Trevor Hancock, 2019