Tyler’s story – The price of failure

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

 

Distorting climate science is bad for our health

Distorting climate science is bad for our health

Dr. Trevor Hancock

20 August 2019

701 words

Last week I critiqued the errors and distortions in an article by Gwyn Morgan presenting what he claimed to be a set of ‘little-known facts’ and myths about climate change (“Climate change myths and utter hypocrisy”, 4 August 2019). This week, I turn to some of the other examples of misrepresentations, half-truths and obfuscation in that article.

First, Morgan completely misrepresents the Intergovernmental Panel on Climate Change (IPCC) in writing that they “would have us believe that fossil-fuel emissions are the sole reason for climate change”. They do nothing of the sort. In fact, in the IPCC’s 2014 Synthesis Report Summary for Policymakers, Figure SPM.2 shows that in 2010 CO2 was accountable for 76 percent of total annual anthropogenic (human-created) greenhouse gas (GHG) emissions; the remaining 24 percent is due to other greenhouse gases – methane (which does come in part from the fossil fuel industry), nitrous oxide (also comes in part from fossil fuel combustion) and fluorinated gases.

The chart also shows that CO2 from fossil fuel combustion and industrial processes accounted for 65 percent of all GHG emissions in 2010 – up from 55 percent in 1970, while CO2 from forestry and other land use accounted for 11 percent – down from 17 percent in 1970. So while the contribution of fossil fuels has grown since 1970, the IPCC is clear that it is far from the sole reason.

Morgan also asks: “But what about urbanization and deforestation”? As noted above, the 2014 IPCC report also shows that forestry and other land use contributes to GHG emissions. Indeed, just after Morgan’s column was published, the IPCC released a special report on climate change and land, which is hardly ignoring the issue.

Morgan then minimises the data on rising sea levels. Again citing NOAA data, which states that sea levels “continue to rise at the rate of about one-eighth of an inch (3.2 mm) per year”, he writes, correctly, that “At that rate, a house built 10 feet above sea level today would still be nine feet, seven inches above sea level in 40 years“. But this serves to downplay the serious and legitimate concerns about sea-level rise. In fact the same NOAA website notes “Sea level rise at specific locations may be more or less than the global average due to local factors”.

Indeed, a recent Government of Canada report projects 75 – 100 cm (2.5 – 3.25 feet) increases in sea level along Canada’s Atlantic coast by 2100, with northern BC and the lower mainland seeing 50 – 75 cm (1.6 – 2.5 feet) increases. In referring to the report, Professor John Clague, an earth sciences professor at Simon Fraser University, notes “[A few millimetres per year] may not seem like a lot to many people . . . But if it’s accompanied by strong storms, you really have an exacerbated effect”.

Morgan also seeks to minimise Canada’s contribution to greenhouse gas emissions, writing that we contribute a “miniscule 1.6 percent” of global CO2 emissions; what difference can we make, he implies. Well, apart from ignoring the fact that we are only 0.5 percent of the global population – so we are emitting more than three times our ‘fair share’ – this is simply an argument for doing nothing. If this attitude were adopted by all governments it would result in no action; exactly what much of the fossil fuel industry wants.

Morgan also derides the declaration of a climate emergency, claiming it is not a national but a global emergency. But a recent Environment and Climate Change Canada report – which Morgan fails to note – reports that Canada is warming twice as fast as the world average, and Canada’s North is warming even more rapidly, which certainly makes it a national issue.

In fact, the reason it has become an emergency is largely due to the deliberate misrepresentation of the science, and attacks on the scientific community by the fossil fuel industry and its political supporters over recent decades. This has resulted in ‘business as usual’, eroding the window of opportunity for action, so what was not an emergency has become one, threatening the health of millions of people. This is a cost the fossil fuel industry seems willing to impose on us.

© Trevor Hancock, 2019

Facts matter in discussing fossil fuels

Facts matter in discussing fossil fuels

Dr. Trevor Hancock

14 August 2019

700 words

In an article first published in the Financial Post and re-published here two weeks ago, Gwyn Morgan – “a director of five global corporations, including the founding CEO of Encana Corp.” – put forth a “list of little-known facts” about climate change. His article elicited a flurry of supportive and dismissive letters. What none of them really did was to take a hard look at these supposed ‘facts’, which often turn out to be mathematically unsound, scientifically illiterate, distorted or misleading. If this is representative of the quality of thinking and the level of mathematical and scientific literacy among the directors of global corporations, no wonder we are in such trouble.

But while tempting to ignore his article, it cannot go unanswered. It is in its way a classic example of the misleading propaganda that the fossil fuel industry puts forth in its attempt to minimise the significance of climate change at the expense of the long-term wellbeing of humanity and the natural systems upon which we depend.

Citing a 2018 report from the U.S. National Oceans and Atmospheric Administration (NOAA), one of Morgan’s first ‘facts’ is that “The concentration of CO2 in the atmosphere is now one molecule per 2,500 molecules, compared with one molecule per 3,000 molecules 50 years ago. That’s an average growth rate of just 10 molecules per year.”

I have no idea from where he gets “10 molecules per year”. I suspect he is subtracting 2,500 from 3,000 and then dividing 500 by 50 years, which is mathematically incorrect. Bear with me, there is some math involved, but it’s important to understand attempts like this to pull the wool over our eyes.

If the baseline is 3,000 molecules, and 50 years ago I had one molecule, then today, with one molecule per 2,500 molecules, I would have 1.2 molecules of CO2 per 3,000 molecules, an increase of 0.2 molecules per 3,000 molecules over 50 years, or 0.004 molecules per 3,000 molecules per year, far below the 50 molecules he suggests – which might make it seem even less important.

But he fails to point out that the increase from 1 to 1.2 molecules per 3,000 is a 20 percent increase in the proportion of CO2 over the past 50 years. In fact, it is more than that. The NOAA report he refers to notes that the CO2 level in December 1969 was 324 parts per million and in December 2018, almost 50 years later, it was 409 ppm. This is an increase of 85 ppm of CO2 over the past 50 years (much less than Morgan’s 500), which is a 26 percent increase.

To put this in context – which Morgan does not – at a global average of 405 ppm in 2017, “carbon dioxide levels today are higher than at any point in at least the past 800,000 years”, according to the NOAA’s Climate.gov website. Moreover, “the annual rate of increase in atmospheric carbon dioxide over the past 60 years is about 100 times faster than previous natural increases, such as those that occurred at the end of the last ice age 11,000-17,000 years ago”. That is why we have global over-heating and rapid climate change, with all the harm that results, including harm to human health.

Furthermore, “10 molecules per year” is a nonsensical statement without reference to a volume or a denominator. Ten molecules per year globally? In a millilitre? Per million molecules? I can only assume that “just 10 molecules per year” is an attempt to downplay the importance of parts per million of CO2 and to make the scientific concerns seem silly in every day terms – after all, who cares about “just 10 molecules per year”?

Now all this may seem a bit abstract, but it is vitally important, because public discussion needs to be informed, not mis-informed, if we are to make good decisions. If the media are going to continue to publish this sort of article they should come with a warning: “Caution – this article may be mathematically and scientifically illiterate and a misrepresentation and distortion of the facts and thus may be hazardous to your health and that of your descendants”.

Next week, I will discuss other problems with Morgan’s article.

© Trevor Hancock, 2019

 

One Planet Saanich – Thinking globally, acting locally

One Planet Saanich – Thinking globally, acting locally

Dr. Trevor Hancock

7 August 2019

700 words

I noted last week that Saanich is one of five municipalities around the world participating in a One Planet Cities initiative organised by Bioregional, a UK-based NGO. The idea is simple: How do we reduce our overall ecological footprint (about half of which is carbon emissions) to just take our fair share of the Earth’s resources, instead of the 3 – 5 planet’s worth we currently use?

Based on Bioregional’s ten ‘One Planet’ principles, the initiative addresses the ‘usual suspects’ of sustainability – energy, transportation, food, materials and waste, water, green space and so on. But Bioregional begins with three principles about people and community: Health and happiness, equity and the local economy, and culture and community. This helps us focus on why we are doing this; to enable us all to lead good quality lives, within the ecological constraints of our one small planet.

During the first year, which just ended, twelve Saanich-based organizations have created One Planet Action Plans or Scans. In addition to the municipality iteself, these include several schools, a college, businesses, NGOs and a church (see www.oneplanetsaanich.org for details). So what exactly are they doing, or planning to do?

First, Saanich itself has conducted a Sustainability Scan of the municipality. Based on Saanich’s Ecological Footprint, the report identifies several priorities related to reducing food waste and adopting a more plant-based diet, reducing the energy consumed in our buildings and infrastructure, reducing dependence on fossil fuel-based transportation and reducing the overall consumption of ‘stuff’ (consumable goods).

Importantly, the Scan notes the many potential areas of synergy between the ten areas of action defined by the Principles. For example, it looks at how a focus on local and sustainable food production with reduced meat and dairy consumption and reduced food waste can improve health and wellbeing, reduce environmental impact from animal wastes and intensive agriculture, strengthen the local economy, reduce water consumption and waste production and reduce the energy use and greenhouse gas production that contributes to global heating.

We can see how these ideas carry forward in the action plans of the twelve pioneering local organisations. The four schools (Artemis Place, Reynolds Secondary, Claremont Secondary and Mount Douglas Secondary), as well as Camosun College, all have initiatives that address food production, consumption or waste and provide hands-on learning in school gardens, land conservation or farming. In addition, there are projects in rainwater collection, a clothing swap and surveys and advocacy in support of public transportation.

Among the private sector participants, Beespot is working to build compact Green Passive House neighbourhoods, while the purpose of Bumblebee Electric Vehicles, which is a Community Contribution Company, is to accelerate widespread adoption of electric vehicles and solar energy products. In addition, both the Uptown retail centre and the Mt. Tolmie branch of the VanCity Credit Union are taking a number of actions.

The two NGOs are Haliburton Farms and Creatively United for the Planet. Haliburton is a community organic farm that has been advancing sustainable food in the region since 2001; it is linking its education work to the One Planet Principles and is accessing clean transportation options for deliveries with Bumblebee. Creatively United is focused on the arts and communication, and is creating videos to showcase local leaders who are providing positive and sustainable solutions. Finally, the Unitarian Church has initiated a Carbon Challenge to motivate members to change their driving and flying habits, install electric vehicle chargers, share recipes to encourage low-carbon food choices, and undertake advocacy to senior levels of government about climate action.

A celebration of the first year of work was held in June at the Horticultural Centre of the Pacific, and both the Mayor of Saanich, Fred Haynes, and the CRD Chair, Saanich Councillor Colin Plant, were there to acknowledge these pioneers. This is important, because we need political commitment to move this approach forward, increasing the number of participating organisations and expanding it to the whole of the CRD and beyond.

But while we can show leadership locally, we cannot do this alone. An important part of our local footprint comes from the activities of the provincial and federal governments and large corporations elsewhere. They too must become One Planet organisations, for all our sakes.

© Trevor Hancock, 2019

One Planet Communities – More than a climate change strategy

One Planet Communities – More than a climate change strategy (Published as ‘One planet’ communities look forward)

Dr. Trevor Hancock

30 July 2019

701 words

Last week I noted that on July 29th we reached Earth Overshoot Day – the day when humanity’s overall Ecological Footprint (EF) exceeded the Earth’s ability to replenish sufficient biocapacity to meet our demands.  However Canada, with an EF per person equivalent to 4.75 planet’s worth, passed its overshoot day on March 18th.  This week, I want to focus the issue more locally.

I live in Saanich, the largest municipality in the region. It also happens to be one of two local municipalities – Victoria is the other – that has had its EF estimated by Jennie Moore and Cora Hallsworth. The method they used – based on household expenditure data – gives an EF of 3.3 gigahectares (gha) per person, but this does not include two key components not considered part of household expenditure: Federal and provincial government services and the value of acquisitions of new or existing fixed assets (property, plant and equipment) by the business sector and governments.

Together they add a further 0.87 and 1.08 gha per person, so the total for Saanich is about 5 gha per person. This is roughly three times the Earth’s annual biocapacity, which is 1.7 gha per person, meaning Saanich’s Earth Overshoot Day is on day 122 of the year – May 2nd. So ever since then, we have been consuming more than our fair share of the Earth’s biocapacity.

Happily, Saanich’s EF is considerably less than the 4.75 Earths for Canada as a whole. This may be because most of our electricity is from hydro and we have a milder climate than much of Canada, so our energy use for heating and cooling is less. Additionally, we do not have heavy industry here, nor do we extract fossil fuels. In fact, we are more in line with European cities; a study of the Mediterranean region by the Global Footprint Network found the EF of 4 Italian and 2 Spanish cities ranged between 3.34 and 4.89 gha per person, or about 2- 3 Earths, while a separate study of three Portuguese cities found the EF falling within a narrower range of 3.76 – 4.08 gha, or about 2.5 Earth’s per person.

Nonetheless, with an EF of three Earths, we need to reduce our footprint by about 70 percent, but how do we do this while at the same time maintaining a good quality of life and good health for all who live here? There are important clues in the data on Saanich’s EF; roughly half is due to food, one quarter to transportation, one sixth due to buildings and the remaining one-tenth to ‘consumables’.

If we look at food, almost three-quarters is due to our consumption of animal products, while a similar proportion of transportation is due to private vehicle use and about the same proportion of the building EF is due to the energy used for heating and electricity; for consumables (clothes, electronics and other household goods), almost all of the EF is due to the energy and materials used in their production.

Put simply, we need to shift our diet to be more plant–based; move our transportation to more walking, biking and public transit (and working from home or close to home) and the use of clean energy vehicles; make our buildings more energy efficient and their energy sources clean and renewable, and buy less stuff, instead re-using and repairing. In many cases, these changes will also be good for health.

Importantly, while carbon emissions from fossil fuel use are a large part of the EF, there are many other aspects of our EF that need to be addressed, such as pollution, resource depletion and the loss of biodiversity. So all municipalities need to move from a focus primarily on climate action to a more comprehensive One Planet strategy.

Fortunately, not only has the EF of Saanich been measured, it is also the only local municipality that has an initiative underway to address the need to become a ‘One Planet’ community. It is the only Canadian municipality in an international project run by Bioregional, a non-profit consultancy in the UK that has been championing the ‘One Planet’ approach for almost 20 years. Next week, I will discuss the early work of One Planet Saanich.

© Trevor Hancock, 2019

 

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