Dr. Trevor Hancock – Healthy people, healthy communities, a healthy planet

We need progress on Genuine Progress

Dr. Trevor Hancock

27 March 2018

701 words

While from a public health perspective there was much that was welcome in the BC Government’s recent Throne Speech, there was an important omission. The agreement between the NDP and the Green’s in 2017 included this clear commitment: “Develop a genuine progress indicator for British Columbia covering a range of indicators”. This was to be “developed in consultation with business and industry, communities, not-for-profit organizations and individuals”.

As far as I can tell there has been little or no action thus far, although I am told the government is working on it. This may sound like a minor and somewhat esoteric issue, but in fact it is absolutely fundamental to re-orienting our society and economy to one that is fit for purpose in the 21^st century: human-centred, socially just and ecologically sustainable.

Currently our main indicator of social progress is Gross Domestic Product (GDP) – despite the fact that one of its key architects, Simon Kuznets, warned the US Congress back in 1934 that “the welfare of a nation can scarcely be inferred from a measure of national income”. The GDP measures ‘marketed economic activity’; basically, the goods and services that we buy and sell. Among its many failings, two stand out: It fails to discriminate between expenditures that improve society and those that harm it, and it fails to count many activities that improve society.

Good ways to increase GDP include encouraging smoking – the economic activity of the tobacco industry and the economic activity of the health care needed to treat its victims all add to GDP; burning down buildings, starting wars or having oil spills. Just think of all the GDP that would be added in clean-up costs if one of Rachel Notley’s tankers spilt its cargo of bitumen off our coast.

Secondly, GDP ignores many things we do that make life better, because no money changes hands. Volunteer activity is not counted, yet, Statistics Canada reports that in 2013, 44 percent of Canadians volunteered. Moreover, on average volunteers contributed 3 hours each a week.

At the average hourly wage of $22.85 in 2013, this translates into $44.7 billion not included in GDP. But that is just the monetary value; StatsCan also tells us that volunteering “contributes to ‘social cohesion’ or ‘social capital’ . . . by increasing social trust, reciprocity and sense of belonging in communities”. But in their obsession with GDP, our economic decision-makers ignore all that.

Which is why we need a better measure of progress, such as the Genuine Progress Indicator (GPI). A 2013 article in Ecological Economics by some of the world’s leading ecological economists explained that the GPI starts with much the same data as the GDP “but adjusts them using 24 different components, including income distribution, environmental costs, and negative activities like crime and pollution, among others”. GPI also “adds positive components left out of GDP, including the benefits of volunteering and household work”.

The GPI gives us a dramatically different assessment of our social wellbeing and progress – or lack of it. The authors looked at the global GPI and that of 17 countries (comprising more than half the world’s population) across five continents over a 50 year span from 1950 to 2003. They found that global GPI peaked in 1978, and that “Life Satisfaction in almost all countries has also not improved significantly since 1975”. Moreover, while the GPI per person increases along with GDP at lower levels of GDP per person, it does not increase beyond about $7,000 GDP per person – about the level of China in 2003.

In other words, beyond a certain and rather modest level of GDP per person, any gains in GDP are offset – or even more than offset – by increasing social and environmental harm. Moreover, further increases of GDP do not make us more satisfied with our lives. Thus they conclude “GDP growth is no longer an appropriate national policy goal”.

But we don’t know whether or not we are making progress in BC – although the evidence suggests we are not – because we don’t have the GPI in place. The government should live up to its commitment, make this a priority and get the consultation underway; we need to make progress on measuring genuine progress.

© Trevor Hancock, 2018

 

Does mental health matter most?

Dr. Trevor Hancock

20 March 2018

701 words

There is an interesting common thread underlying many of my recent columns. It is the question in my title: Does mental health matter most? By which I mean, in high-income countries in the 21^st century, does mental health matter more than physical health? Which in turn means, in terms of public health, does mental health promotion and the prevention of mental disorders matter more than preventing heart disease, cancer and other physical disorders?

There are many threads to my emerging argument. To begin with, the 70 year-old definition of health from the World Health Organisation is that health is a state of complete physical, mental and social wellbeing. Since social wellbeing is primarily about how we feel about and respond to our links to and relationships with others in our families and communities, it means a significant part of the definition is really about our mental wellbeing.

Add to this the relationship between the mind and the body – our state of mind affects our neuro-hormonal and immune systems, and the latter is involved in allergy, auto-immune disease, and the detection and elimination of both infection and abnormal cancer cells – and our state of mind assumes an even greater importance.

Another important issue is the changing pattern of disease and death. Globally, the World Health Organisation noted last year, “Depression is the leading cause of ill health and disability worldwide” – depression, we should note, is only one form of mental ill health. WHO also notes that there are “strong links between depression and other non-communicable disorders and diseases” and that “depression increases the risk of substance use disorders and diseases such as diabetes and heart disease”, while pointing out that “the opposite is also true . . . people with these other conditions have a higher risk of depression”.

We can also see the importance of mental health in the decline in life expectancy in the USA in each of the past 2 years, the first time this has happened in more than 60 years. But that decline is driven not by physical disorders such as heart disease and cancer but from the so-called ‘diseases of despair’; alcohol and drug use and suicide, which are largely mental and social disorders. And as I pondered in my last column, we may need to consider whether the growing concern about the state of our environment is adding to that despair.

Another factor to consider is the impact of poverty and inequality. Absolute poverty is unhealthy because people lack the basic necessities for life and health – clean water, food, shelter and so on – and we have some of that in Canada. But for the most part our problems are now those of relative poverty. Kate Pickett and Richard Wilkinson, in their book “The Spirit Level”, showed that in high-income countries, a range of health and social outcomes are not related to national income per person, but to the degree of inequality.

It seems that being lower in the ‘pecking order’ of society is harmful to health because we experience inequality as a lower sense of self-esteem and self-worth, relative powerlessness and even helplessness. All of which are mental and social experiences that, again, can translate into physical conditions.

The implication is that if we want to have a healthy population we need to pay much more attention to mental and social wellbeing than we have been doing. We need to provide more funding to research focused on understanding the root causes of mental and social health problems, and to policies and programming for preventing mental and social health problems, as we do to understanding and preventing heart disease and cancer – because we have under-invested on the mental health side.

Beyond that, we need to give at least as much attention to promoting mental and social wellbeing as we do to promoting physical wellbeing and fitness, recognizing that they are mutually beneficial. What would it take to create mentally healthy families, schools, workplaces, colleges and universities? How do we help people maintain mental wellbeing in the face of adversity, or as they age? How do we re-focus our society – including public health – to ensure mental health matters at least as much as physical health – maybe more.

© Trevor Hancock, 2018

Solastalgia: The painful result of reviling nature

Dr. Trevor Hancock

13 March 2018

699 words

In my last column I described gazing with horror upon a clearcut; what I was experiencing was – in a small way – what today would be called ‘solastalgia’ – “the pain or sickness caused by the loss of, or inability to derive solace from, the present state of one’s home environment”. In my case, it was not my home environment, but I can well imagine what the impact would be on people for whom that forest was part of their home environment.

The term solastalgia was coined 15 years ago by Glenn Albrecht, an Australian philosopher. He derived it in part from the idea of nostalgia, which means home-sickness. In the 19^th and into the 20^th century, he wrote, it was considered a medical condition caused by a desire to return to one’s home. But while nostalgia is related to removal – voluntarily or involuntarily – from one’s home environment, Albrecht was interested in something different; dramatic change in the home environment where you still live.

He believes that we derive comfort and solace from our home environment, but that when it is radically changed, we suffer distress. He suggested that this is particularly true for Indigenous people around the world, who may not only have been displaced from their home environment, or seen that home environment radically transformed, but at the same time suffered the radical disruption of their culture. (Note that the Truth and Reconciliation Commission referred to this as amounting to cultural genocide.)

Radical environmental change – and thus solastalgia – can arise from both natural and human-created sources. Natural sources include volcanoes, earthquakes and tsunamis, hurricanes, forest fires, droughts and floods, while human sources include war, resource development and extraction (e.g. deforestation, mining) and urban (re)development. These are not entirely separate, of course; human actions – particularly those that drive climate change – contribute to several of the examples of ‘natural’ changes that I mentioned.

Contributing to the problem is both the speed and the scale of change; mostly these events happen in a matter of minutes, hours or days, or at most over a few years. And increasingly, they happen at a large, even global scale. As a result, they can “undermine a personal and community sense of identity, belonging and control”, leading to a sense of hopelessness, or even despair.

Evidence for the existence of solastalgia has been found among Australian farmers facing drought; residents of the Hunter Valley, a major coal mining area in Australia; people in Appalachia affected by mountain-top removal for coal-mining and people in Arizona affected by a large wildfire, to name but a few.

Here in Canada, as reported by Livia Albeck-Ripka in a November 2017 article in the New York Times, climate change and warming in the Nunatsiavut region of Labrador is having an impact on mental health among the Indigenous communities. Research conducted by Dr. Ashlee Cunsolo, director of the Labrador Institute of Memorial University, “found that the melted ice, shorter winters and unpredictable weather made people feel trapped, depressed, stressed and anxious, and, in some cases, led to increased risk of substance abuse and suicidal thoughts”. Sadly, I suspect, that may be the case across the Arctic.

I think what makes it worse is when we understand that the damage we see, and that pains us, is caused, in part or in whole, by thoughtless human action. Thus solastalgia is likely to become more prevalent as we enter the Anthopocene – a new geologic epoch characterised by massive human impacts on the Earth that will leave their mark in the geologic and fossil record – and the full extent of human impact on the Earth becomes increasingly apparent.

In fact, I have been wondering recently if solastalgia is contributing to what in the USA are called the diseases of despair; death and disease due to alcohol and drug use and suicide. I don’t think it is something people are necessarily conscious of, but surely the almost daily drumbeat of stories about how we are harming the earth has an impact. As Glenn Albrecht wrote, “Many people sense that something is wrong with our relationship with the planet. This unease might just be an expression of deep-seated solastalgia”.

© Trevor Hancock, 2018

 

Our health depends on revering, not reviling nature

Dr. Trevor Hancock

6 March 2018

700 words

I first came to Vancouver Island about 30 years ago, on vacation, and have never forgotten the sight of my first clearcut. I found it appalling and gut-wrenching, and it prompted me to write a letter to the Times Colonist. In it, I described what I had seen as ecocide, and likened it to genocide. I also wondered how we had managed to raise a generation of people who so hated nature that they could do that to the forest in the name of profit.

It elicited an interesting and revealing response. A professional forester in BC wrote to the College of Physicians and Surgeons in Ontario asking that my medical licence be revoked, on the grounds that I was unsuited to be a physician because I let emotion distort my scientific reasoning and thus my judgement was clearly impaired. (The College forwarded me his letter but otherwise, correctly, ignored it.)

What his response revealed was two things: First, that he didn’t understand that emotion and compassion must be part of a physician’s make-up if they are to be a good practitioner, and second, that in his view, any emotional response to the forest – and thus to nature – was wrong. This indifference to and lack of an emotional connection with nature is the basis of our modern society; it enables many of the large corporations that dominate our society and economy to exploit nature for profit, with little regard for the consequences. And that, in a nutshell, is our modern problem.

So where did it come from, this insensitivity to the natural world, this desire to dominate rather than live with nature, to be apart from our natural ecosystems rather than seeing ourselves embedded in them? The American historian Lynn White, in a famous 1967 article titled ‘The historical roots of our ecological crisis’ (and note that it was recognised as such 50 years ago), suggested that Western society has adopted a set of values deeply rooted in Christianity, which has always taught that “it is God’s will that humans exploit nature for their own purposes”.

He wrote: “The whole concept of the sacred grove is alien to Christianity”, and that “for nearly 2 millennia, Christian missionaries have been chopping down sacred groves, which are idolatrous because they assume spirit in nature”. White believed that the effect of “destroying pagan animism”, which had formerly protected nature from man, was to make it “possible to exploit nature in a mood of indifference to the feelings of natural objects.”

But he recognised that there had been at least one attempt to change that Christian narrative by “the greatest spiritual revolutionary in Western history, Saint Francis”, who “tried to substitute the idea of the equality of all creatures, including man, for the idea of man’s limitless rule of creation”. It is interesting that we now have, for the first time ever, a Franciscan Pope; could that be a sign of a more significant change in our values?

But there is another force at work here; we are now an urban species, and that is moving us away from and even making us fearful of nature. This leads to what Richard Louv, in his book ‘Last Child in the Woods’, called nature deficit disorder – kids with no relationship to nature, and even fearful of it. This is dangerous; at a time of ecological crisis, we are raising a generation of kids that will not respect, cherish and protect nature, that may even fear and revile nature. It is not a cheery prospect.

The only way to develop a reverence for nature is to experience its beauty, its sometimes awesome power, which is why we need to get kids outdoors – and why we need to bring nature into our cities and our lives. And we need to re-create a spiritual connection, perhaps simply on a personal level, or through a modern-day form of animism, or through a Franciscan-inspired Christianity or other spiritual and religious beliefs that are more in harmony with and see the spirit in nature.

Ultimately, saving us from ourselves is not a technological but a spiritual quest to live in harmony with and as part of – not separate from – nature.

© Trevor Hancock, 2018

 

Looking upstream at the opioid crisis

Dr. Trevor Hancock

20 February 2018

701 words

I am increasingly concerned with the inadequacy of our approach to the opioid crisis, both as a society and in the field of public health. There is no question that when people are dying in large numbers we need to respond, and that has been happening. Safe injection sites, the distribution of naloxone kits and similar efforts are important.

But this response is sadly inadequate; it repeats the ‘upstream’ story that I told in the very first column I wrote, in December 2014, one that is fundamental to the public health approach. In essence villagers living on the banks of a river are so busy rescuing drowning people that nobody has time to go upstream to learn how they are ending up in the river and stop them being pushed in.

A recent in-depth look at opioid deaths on Vancouver Island in the Times Colonist (30 December 2017) did a good job of interviewing a wide range of experts, families and frontline workers, but none of them discussed the need to go upstream and find out why people are turning to opioids in the first place and try to stop that from happening.

We know that “Canada and the United States now have the highest rates of prescription opioid use in the world”, as Toronto’s Centre for Addiction and Mental Health and Addiction noted in 2016. And we know why that is the case: the most important factor that has “contributed to the development of the prescription opioid crisis . . . has been the liberalization of opioid prescribing for the treatment of chronic non-cancer pain”, according to Canada’s EvidenceNetwork.ca.

As I have noted before, these harmful prescribing practices by physicians have been encouraged and supported by the pharmaceutical industry’s marketing, and by a failure on the part of both Health Canada and the provincial Colleges of Physicians and Surgeons to protect the public from both big pharma and unwise physician practices.

So if I were a Minister of Health or Finance in Canada, I would be looking to the example of tobacco and planning to take the relevant pasts of the industry to court – and ensuring that Health Canada and the provincial Colleges do a much better job of protecting the public in future.

But this still does not answer the important questions: Why are so many people needing or wanting opioids? The role of public health is to keep asking these ‘why’ questions, to keep pushing upstream to look for answers.

The answer seems to be that people are experiencing both physical and psychological pain. A 2009 study published in the Canadian Medical Association Journal that looked at more than 3,000 opioid-related deaths in Ontario found that there was a high use of medical services in the year before death, with most of them seeing a physician within a couple of weeks of death. The most common diagnoses at those visits were mental health problems and pain.

So the question is – is there more pain now, are we handling it less well – or both? Some suggest that increasing work demands and stressful work environments lead to more mistakes and more injuries; I recall a study many years ago that found that people’s life stress events score predicted their likelihood of injury.

Couple that with the increase in part-time or contracted-out work with fewer health and other benefits, the decreased role of unions and reported poor training and services in pain management, and one can see where that leads; less time off to heal, less support in healing, more need for a quick fix while carrying on working.

Then there is the psychological pain, in part engendered by chronic pain, loss of function and perhaps loss of income. Add to that the ‘diseases of despair’ that I discussed a few weeks ago, high levels of inequality and a constant state of fear, anxiety and envy driven by the media and marketing worlds, and it is not hard to see why some people are hard hit, and turn to drugs.

If I were the Minister of Health, the Premier or the PM, I would be setting up an expert panel to look for answers to these upstream questions and suggest remedies.

© Trevor Hancock, 2018

 

Doing well, but doing much harm

Dr. Trevor Hancock

12 February 2018

700 words

The principal purpose of any government and society should be to maximise human and social development for all its citizens – but, we now understand, within the limits of this one small planet. A new study shows how well we are doing in achieving human and social development, but how much environmental harm we are doing in the process.

Led by Daniel O’Neill at the University of Leeds – and a UVic alumnus – the study looks at 150 countries in terms of how well they meet a set of human and social development thresholds and whether on a per person basis they exceed a set of biophysical boundaries.

The eleven social outcomes are derived from analyses of social needs embodied in the Rio + 20 Conference and the UN’s Sustainable Development Goals (SDGs). Nine of these relate to meeting basic human needs such as food, clean water and sanitation, income and education, while two measure human wellbeing; self-reported life satisfaction and healthy life expectancy (years of life without illness or disability).

For each of these, the research team defines an admittedly subjective threshold they believe is consistent with a ‘good life’. For example, the thresholds for access to improved sanitation facilities, access to electricity, secondary school enrolment and an income above US$1.90 a day are all set at 95% of the population, while the threshold for healthy life expectancy is 65 years.

The biophysical boundaries are of two sorts; five are based on ‘planetary boundaries’ per person (climate change, land use change, nitrogen and phosporus flows and freshwater use) and the remaining two are our overall ecological and material footprints, compared to suggested maximum sustainable levels.

Obviously, the ideal position would be to meet all eleven social thresholds without exceeding any of the biophysical thresholds. Worryingly, the study finds, “no country meets basic needs for its citizens at a globally sustainable level of resource use”, but the country that comes closest is Vietnam, which meets 6 of the 11 social thresholds while only exceeding one of the biophysical boundaries.

In fact, only three countries meet all eleven social thresholds – Germany, Austria and the Netherlands – but in doing so they also cross most of the seven biophysical boundaries. Canada is about the middle of the pack of a group of high income and largely Western countries that meet many of the social thresholds but exceed most if not all of the biophysical boundaries.

In our case, the two social thresholds we miss – but not by much – are equality and employment. But we don’t just exceed the biophysical boundaries, we blow way past them. Our carbon dioxide (CO₂) emissions are almost 11 times higher than they should be, our nitrogen and phosphorus flows 15 – 16 times, and our ecological footprint about 4 times higher; only in freshwater use are we below the boundary.

It is not just whether a country exceeds a biophysical boundary, but by how much; clearly, exceeding it by 10 percent is a lot better than exceeding it by 500 percent. When we compare Canada with countries that do as well or better than us both socially and environmentally – Germany, Austria, The Netherlands, Japan, France, Sweden, Finland, Denmark, Belgium, Australia, the Czech Republic, Ireland and Slovenia – we don’t do well.

Only Australia has higher carbon emissions and a higher ecological footprint; the rest – omitting Australia – meet or exceed our social achievements while having on average two-thirds of our carbon emissions and 72 percent of our ecological footprint per person. Clearly, we must learn from them so we can be more like them; that would be a useful first small step.

But it is nowhere near enough, because on average they still use more than seven times their fair share of carbon emissions, and almost three planet’s worth of ecological footprint. Thus the study’s authors conclude “if all people are to lead a good life within planetary boundaries, then the level of resource use associated with meeting basic needs must be dramatically reduced”.

This is the most important challenge of the 21^st century, second only to avoiding full scale nuclear war. Clearly, we have a lot to learn – but at least we are beginning to understand the challenge.

© Trevor Hancock, 2018

Alberta proclaims its right to pollute

Dr. Trevor Hancock

6 February 2018

699 words

The David Suzuki Foundation’s ‘Blue Dot’ campaign aims to enshrine the right to a healthy environment in the Canadian Constitution, and last year the federal government’s Standing Committee on Environment and Sustainable Development urged the government to enshrine it in law. Beyond these efforts to ensure that we humans (and, by implication, other species) have that right, there is also a move to give nature itself legal standing.

Indeed David Boyd, an environmental lawyer and a Professor of Law, Policy, and Sustainability at UBC, has just published a book on the rights of nature. In it he reports that courts in some countries have recognized that “endangered species have the legal right to exist”. But not only do species have rights, so too do entire ecosystems.

If you think that is far-fetched, consider that New Zealand has granted legal recognition as persons to both the Whanganui river – the third-longest in the country – and the Te Urewera region – previously a national park. The 2014 Act that established Te Urewera states it “has all the rights, powers, duties, and liabilities of a legal person”, with those rights “exercised and performed on behalf of, and in the name of, Te Urewera by Te Urewera Board”.

So it is disgraceful to see the Alberta and federal governments moving in the opposite direction in their attempt to ram Kinder Morgan’s Trans Mountain pipeline through BC. In doing so they are, in effect, proudly asserting Alberta’s right not only to pollute its own land, waters and people, but those of BC and the rest of the world.

Mr. Trudeau’s defence of his actions is that we need to get Canada’s resources to market, that we need the jobs, that we can protect the environment – especially BC’s coast – and, bizarrely, that increasing exports of oil from Alberta dirty oilsands is necessary if we are to meet our greenhouse gas emisson reduction targets. He is dangerously wrong on all counts.

Not all resources must be mined, used and exported; the sorry story of asbestos proves that point, although it took a long time to overcome stubborn government support for this industry. The last asbestos mine in Canada closed in 2011 and Canada finally agreed to ban the use of asbestos as of this year – 20 years after the World Health Organization declared asbestos a carcinogen in 1987

Not all jobs are good; we need 21^st century clean energy jobs, not 20^th century dirty energy jobs.

And this decision hardly protects the environment or human health; on the contrary, it expands the local harm done in Alberta by enabling expansion of the oilsands, while threatening BC’s land, waters and coast with a dramatic increase in the flow of diluted bitumen (dilbit) in the pipeline and increased tanker traffic along our coasts. Few believe that a so-called ‘world class’ disaster response system will be much use when a big tanker goes down in a heavy gale, as will surely happen one day.

Finally, the Pembina Institute, citing a 2015 Carnegie Foundation report, notes that “The oilsands are still one of the most carbon intensive oil sources on earth”; it also cites 2017 World Bank data that show that “if Alberta were an independent nation-state it would surpass Qatar to have the highest per-capita greenhouse gas emissions in the entire world”. At a time when we desperately need to reduce greenhouse gas emissions in Canada and globally, why on earth would we be facilitating the expansion of this industry. We need to leave the carbon in the ground.

David Boyd argues “if nature has rights, then humans have responsibilities”. It is time we accepted our responsibility to the natural ecosystems of which we are a part, and upon which we ultimately depend for our wellbeing, indeed our very survival. This is far more important than Alberta’s right to pollute. In the face of this situation, the BC government should go much further than it has so far. It is time to petition the courts to give legal standing to our endangered orca and salmon and our threatened coastal and forest ecosystems; in doing so, we can protect the health of people here in Canada and around the world.

© Trevor Hancock, 2018

 

Family doctors deserve more of our respect

Alternative title: The generalist is an important specialist

Dr. Trevor Hancock

31 January 2018

701 words

Last November the Royal College of General Practitioners (RCGP) and the Medical Schools Council in the UK released a disturbing report. They surveyed 3,680 medical students from 30 medical schools throughout the UK, finding that by the time they reach their final year “more than three quarters of medical students report hearing negative comments about general practice” – what we would call family practice – “from clinicians, educational trainers, and/or academics”.

The report – Destination GP – built on a 2016 report from Health Education England and the Medical Schools Council that noted “Recruitment into general practice has become a major issue”. That earlier report found what it called ‘professional tribalism’ from specialists who “perceive primary care of ‘lower status’”; this, the report says, is unacceptable.

The level of denigration is astounding; Nine out of 10 of those surveyed felt their fellow students had negative perceptions of general practice, more half found doctors in specialty areas where they were placed were negative about general practice, and of the three-quarters who heard negative comments, 25 percent heard it suggested that GPs were of lower status and 15 percent heard general practice described as “undemanding and easy”.

As a result, says the RCGP, “some medical students considering a career in general practice are being discouraged and deterred from joining the profession, or abandoning it for other medical specialties”. This adds to the challenges faced by the NHS in recruiting GPs for a variety of reasons, including workload and status.

This situation will be familiar to the many patients across Canada who are having trouble finding a family physician. Sadly, it seems, some of the same attitudes to family practice exist within the medical profession here in Canada, according to an article by Roger Collier in the Canadian Medical Association Journal this January. It also is familiar to me, both as a former family physician and as a public health physician; we too are sometimes seen as not being ‘real doctors’ and not practicing ‘real medicine’.

What I think is really going on here is a wider phenomenon, found across many professions and disciplines, rooted in a societal tendency to value specialism over generalism. This attitude fails to recognize that generalism, perhaps better described as holistic thinking, is a specialty in its own right. Rather than knowing more and more about less and less, holistic thinkers know about a great many different things and work to synthesise and integrate them, looking for what Gregory Bateson called ‘the pattern that connects’. That is the value of family practice – understanding the whole person and their family in the context of their life and work.

I also see this holistic, generalist thinking under-valued in academe, another institution where specialization is (over) valued. Students tend to get funneled into narrowly conceived channels where funding and publication is to be found, while interdisciplinary programs – while given rhetorical support – are in practice difficult to establish and maintain.

Yet many of the challenges we face in the 21^st century are complex, cut across and involve many sectors, and interact as complex systems. They cannot be solved by narrow specialists, who indeed may make the problem worse. We need people trained in holistic thinking who understand complex systems and how to manage them.

This is certainly true of public health, my specialty for 35 years. In a column in the Canadian Medical Association Journal a recently, I pointed out our vast scope of practice. In addition to being trained in medicine, public health physicians need to have a broad knowledge of the social sciences, from anthropology to psychology, community development to political science.

Because of the importance for health of the built environment, we need a grounding in the design professions (architecture, engineering, and urban planning), while our interactions with the natural environment require knowledge of toxicology, environmental health and ecology. Finally, because of our involvement in policy-making and regulation, we need an understanding of public administration and public communication.

I believe that family practice and public health are among the most challenging and complex specialties in all of medicine, requiring the best and brightest as their practitioners. They deserve far more respect, both within and beyond the medical profession, as specialties in their own right.

© Trevor Hancock, 2018

Pandora’s box and the Canada Pension Plan

Dr. Trevor Hancock

21 January 2018

703 words

The World Economic Forum (WEF) released its 2018 Global Risks report last week. One business reporter dubbed it ‘the Pandora report’, and that is a pretty fair assessment. If you have an interest in the welfare of future generations – or for that matter, young people alive today – it makes for sober reading.

In their preface Klaus Schwab, the founder of the WEF, and Borge Brende, the President, write: “Globally, people are enjoying the highest standards of living in human history. And yet acceleration and interconnectedness in every field of human activity are pushing the absorptive capacities of institutions, communities and individuals to their limits. This is putting future human development at risk”.

To this, they might have added the absorptive capacities of the over-stretched natural systems that provide the basis for our life and wellbeing, and that underpin our society and economy. Because when you look at the risks the report considers to be most likely and to have the greatest impact, as assessed by about 1,000 of their multi-stakeholder communities, almost all the greatest threats are environmental.

In terms of impact, only weapons of mass destruction are seen as having a greater impact than extreme weather events, followed by natural disasters, failure of climate-change mitigation and adaptation, and water crises. Overall, when likelihood and impact are combined, these last four are the top global risks, followed by cyber-attacks, biodiversity loss and ecosystem collapse, large-scale involuntary migration and man made environmental disasters

In short, as the Executive Summary bluntly states: “We have been pushing our planet to the brink and the damage is becoming increasingly clear. Biodiversity is being lost at mass-extinction rates, agricultural systems are under strain and pollution of the air and sea has become an increasingly pressing threat to human health”.

So while Prime Minister Trudeau is in Davos, Switzerland, this week for the meeting of the WEF, let us hope he pays more attention to the environmental consequences of our current economic system, and their implications for human health. If he were to do so, perhaps he would eschew the narrow, short-term economic gains that have guided his choices on the Kinder Morgan pipeline and other short-sighted and harmful decisions that further encourage the fossil fuel industry.

Since climate change lies behind most of the leading global risks we face, the last thing we should be doing is supporting the further growth and development of this industry. Instead we should be divesting from fossil fuels, transferring all the many subsidies they enjoy to the conservation, renewable and clean energy sector, and setting up transition support programs for the workers that will be displaced.

In thinking about this, Mr. Trudeau and his Finance Minister, Mr Morneau, might be helped by these nuggets from the WEF report: the World Bank announced in December 2017 that it was placing a moratorium on financing upstream oil and gas-related investments after 2019, while Norway’s Wealth Fund announced in November that it was divesting from oil and gas shares. Indeed, the time is swiftly coming, if it is not already here, when it will be fiscally negligent for pension-fund managers to invest in fossil fuels.

With more than $300 billion in investments, the Canada Pension Plan (CPP) is one of the largest state-owned investment funds in the world. Its Investment Board is accountable to the government and reports to Parliament through the Finance Minister. But in a 2015 report, the Canadian Centre for Policy Alternatives (CCPA) estimated that about 22 percent of the CPP’s Canadian investments are in fossil fuel producers or pipeline companies.

This is considerably higher than the 4–9% of funds the CCPA estimates are invested in fossil fuel stock by the 20 largest public pension funds, meaning “the CPP is more exposed to climate policy risk”. For example, the BC Investment Management Corporation, which manages the BC public sector’s pension funds, was estimated to have about 8 percent of its holdings in fossil fuels.

For the sake of the environment, our health and the security of our pensions, it is time the CPP and other public pension funds followed the lead of Norway and a growing number of investors, disclosed their fossil fuel holdings and started to divest from fossil fuels.

© Trevor Hancock, 2018

 

 

Misery and health: The diseases of despair

Dr. Trevor Hancock

14 January 2018

702 words

Last week I wrote about happiness and health. Interestingly, we live next door to a nation that has put the pursuit of happiness into its founding document as a central purpose – and is spectacularly failing to achieve its aim.

The 2012 World Happiness Report noted that “the U.S. has experienced no rise of life satisfaction for half a century”, while the 2017 version of the Report found happiness in the USA has actually been declining for most of the past decade. The opposite of happiness is misery, which seems to be where the US is headed, and that shows up, in health terms, in what have become known as the ‘diseases of despair’ – alcohol, drugs and suicide.

A November 2017 report – Pain in the Nation – released by the Trust for America’s Health and the Well Being Trust, notes that “Drug-related deaths have tripled since 2000 . . . Alcohol-induced deaths grew by 37 percent from 2000 to 2014 [and] . . Suicides increased by 28 percent from 2000 to 2015”. The combined effect has been to actually lower life expectancy in the USA in the past two years – the first time in 60 years that has happened.

As I noted in a March 2016 column, and as this report confirms, these diseases of despair are found particularly among White middle-aged Americans with less than a college education. Among this group, life expectancy has declined 20 percent, while deaths from drug overdoses, alcohol poisoning, liver disease and suicide all tripled.

“These trends are a wake-up call that there is a serious crisis in this country”, states Pain in the Nation. The report went on: “They are signals of grave underlying concerns facing too many Americans – about pain, despair, disconnection and lack of opportunity – and the urgent need to address them”.

Not coincidentally, in December 2016 the Washington Post reported a study by Penn State University professor Shannon Monnat that found Donald Trump performed better “in the counties with the highest drug, alcohol and suicide mortality rates” than had the Republican nominee in 2012. This was particularly so in the Rust Belt states of the (de-industrialising) Midwest, as well as in New England.

The authors of Pain in the Nation propose to address these issues is through a ‘national resilience strategy’ that focuses largely upon individual and to some extent collective interventions intended to enhance resilience among people and communities and to identify problems early and intervene. While these are useful and important strategies, in my view they do not go far enough, because they do not address the upstream causes that lie behind the dramatic increase in the ‘diseases of despair’ they document.

The 2012 World Happiness Report noted that in the five decades during which there has been no increase in happiness, “inequality has soared, social trust has declined, and the public has lost faith in its government.” Moreover, this occurred while at the same time “income per person has increased roughly three times”; clearly, money is not buying happiness.

Indeed, the noted economist Jeffrey Sachs points out in the 2017 World Happiness Report, in a chapter on ‘Restoring American happiness’, that “the situation has gotten worse in recent years: per capita GDP is still rising, but happiness is now actually falling.” Sachs writes that about half the decline in happiness can be related to four social factors: “less social support, less sense of personal freedom, lower donations, and more perceived corruption of government and business”.

Here in Canada, we cannot afford to be smug. We too have an opioid addictions crisis and a lot of alcohol-related deaths; a 2015 OECD report shows that US and Canadian alcohol consumption per person and the proportion of deaths attributable to alcohol are similar, while our rates of suicide are not that dissimilar from the US (13.5 in the USA v 12 in Canada per 100,000 in 2014).

Nationally, the latest life expectancy data only goes to 2014, but here in BC, life expectancy peaked at 82.9 years in 2014 and declined by about 2 months to 82.74 years in 2015 and 2016. We need to learn from the USA that the pursuit of happiness is more than just the pursuit of money.

© Trevor Hancock, 2018