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

Creating mentally healthy communities

Dr. Trevor Hancock

2 October 2017

700 words

The communities in which we live are both physical places and social spaces, and both affect mental wellbeing. A report released by the California–based Prevention Institute in September delves into this issue. (In the interests of transparency, I volunteer on their Executive Advisory Board, although not involved in the preparation of this report.)

Beginning with a framework that identifies factors in the community most related to medical conditions that show the greatest disparity (and thus are related to environmental, social and economic conditions and the behaviours they shape), the Institute looked at how those factors relate to mental health. They found seven factors in the broad categories of ‘People’ (our social spaces), ‘Place’ and ‘Equitable opportunity’ that “have a particularly strong impact on mental wellbeing”.

There are three social factors – Social networks and trust, Participation and willingness to act for the common good, and Norms and culture; three aspects of the physical environment – Look, feel and safety, Housing, and Arts and cultural expression; and one in the area of equitable opportunity – Living wages & local wealth. Since I dealt with poverty last week, I will focus here on the ‘People’ and ‘Place’ factors.

The report notes the considerable body of evidence that “strong social networks and connections correspond with significant increases in mental and physical health”, as well as less violence and addiction and even improvements in academic and economic performance. These strong and positive social connections must be built in families, networks of friends and in schools, workplaces and places of worship – even through connection with pets and therapy animals.

A related strategy is to build community capacity to participate and act together to improve things; there is a positive and reciprocal relationship between community and individual empowerment and there is good evidence that empowerment has significant health impacts. This can include efforts to build a more participatory democratic system. Evidence from Brazilian cities such as Porto Alegre and Belo Horizonte has linked participatory budgeting with improvements in housing, utilities such as water and sanitation, health centres and cultural and recreational facilities, all of which are themselves determinants of health.

The third social factor – which is related to the first two – is to change the community’s culture and social norms. We have seen this with respect to smoking and to drinking and driving, both of which are now much less socially acceptable than they were a few decades ago.

Now we see efforts to change the social norms around bullying in school and on the internet, gender and racial discrimination and harassment in the workplace, domestic violence and other issues that have led to significant mental health impacts. The report notes “Positive social norms that foster inclusion and respect for all persons can enhance individual self-esteem and wellbeing”.

The physical environment also has an impact on mental wellbeing. Unattractive, poorly-maintained neighbourhoods are more common in disadvantaged groups. People living there are less likely to have good-looking schools, good parks nearby, shade trees, attractive streetscapes or public art. Moreover, access to attractive, safe, walkable neighbourhoods and parks facilitates physical activity, which in turn improves mental health.

Unpleasant environments convey the message that ‘you don’t matter’, which makes peole feel neglected and worthless, less empowered and less able to take action on these issues. Arguably, people living in such neighbourhoods actually need extra investment in higher quality, better maintained built environments to make up for the deficits in the determinants of mental health that they experience in many facets of their lives.

Then there are the homes we live in. Being homeless is of course a major threat to mental wellbeing, but poor housing quality is also a threat to both mental and physical health, as is insecure tenure. We also need to look at how housing design supports – or fails to support – social connection; high-rise buildings are generally worse performers here.

Finally, there is good evidence that “music, dance, and all forms of artwork foster mental wellbeing”, as well as community solidarity; the report suggests ensuring that people have access to the spaces and resources needed for artistic expression.

Like Rome, mentally healthy communities cannot be built in a day – but they can be built.

© Trevor Hancock, 2017

 

Good mental health needs a good start in life

Dr. Trevor Hancock

25 September 2017

699 words

Not only is poor mental health very costly to manage, it also represents a large burden of human suffering and loss of human potential and – to the extent it is preventable – a tragic societal failure. So it is good to see that – finally – we are beginning to pay some attention to improving the mental wellbeing of the population.

The evidence is clear that good mental health begins in infancy and childhood; a good start in life can create more positive and resilient young people, better able to handle adversity when it occurs.This evidence must be used to inform and guide the work of the new Ministry of Mental Health and Addictions, the health care system, the government as a whole and indeed the whole of society.

There are in essence two key approaches: First, creating supportive environments that protect people from known risk factors and provide a positive, mentally healthy situation. Second, providing resources and programs that enable people – especially children – to become resilient, with the skills they need to manage life’s ups and downs. In practice, these two approaches interact and need to complement each other.

One of the key strategies, as with health in general, is to reduce the level of poverty in our society. A 2010 Statistics Canada report noted that Canadians in the lowest income group are 3 to 4 times more likely than those in the highest income group to report low levels (poor to fair) of mental health. Living in poverty is a very stressful situation, and so not surprisingly is associated with higher levels of anxiety and depression, among other things. The effects of poverty are compounded in Indigenous and some other communities by the legacies of colonialism, racism and discrimination, making these important upstream mental health risk factors to combat.

In a 2007 background document, the Ontario Division of the Canadian Mental Health Association (CMHA) noted “losing stabilizing resources, such as income, employment, and housing, for an extended period of time can increase the risk factors for mental illness”, especially for those who may already be pre-disposed to mental health problems. Because of the importance of poverty reduction, CMHA Ontario “has been calling for poverty reduction strategies that increase access to economic and community supports for vulnerable populations”. CMHA BC has also recently welcomed the poverty reduction measures brought in by the new BC government.

Infants and children are particularly vulnerable to the adverse effects of poverty and colonialism on the family and community environments in which they develop. A 2016 report from the UK’s Faculty of Public Health noted that poverty in the early years leads to poor cognitive performance, while in adolescence “it increases risks of depression, substance abuse, and early sexual and criminal activity”. It is not hard to see how these impacts can lead to the perpetuation of the cycle of poverty.

Efforts to buffer the effects of poverty and colonialism, even while working to reduce them, begin in infancy, indeed, even before birth. High-risk or vulnerable parents (e.g young, poor and single mothers, or parents with mental health or addiction problems) should be identified and provided with supportive services, both to improve their health in pregnancy and to help them develop better parenting and coping skills. A study from the University of Ireland found that “high quality early childhood enrichment provided through preschool results in enduring gains in children’s social and emotional wellbeing, cognitive skills, problem behaviours and school readiness”, especially among more disadvantaged children.

But while it might seem intuitive that high-risk families are the ones who need to be reached, it is well-established in public health that the majority of cases for most conditions do not occur in the high-risk population but in the far more numerous moderate and low risk populations. So all families need to be reached, assessed and offered services, with those found to be at risk provided with more focused, intensive and tailored support, proportionate to their need, an approach known in the UK as proportionate universalism.

So any government that is genuinely interested in ensuring the long-term mental wellbeing of our society needs to invest in poverty reduction, support for parents, especially the most vulnerable, and early child development.

© Trevor Hancock, 2017

 

Look upstream to improve mental health

Dr. Trevor Hancock

11 September 2017

703 words

A colleague once remarked that people are so busy dealing with the important that they don’t have time to deal with the critical. That applies to the healthcare system as a whole. It is so busy dealing with people who are ill or injured that it doesn’t give much priority to looking upstream and trying to stop people becoming sick in the first place.

That especially applies to the field of mental health and addictions, which has been described as the orphan of the health care system, neglected and underfunded. But in fact mental health problems are among the most common and most expensive health problems today. The Centre for Addictions and Mental Health (CAMH) in Toronto reports that “the disease burden of mental illness and addiction in Ontario is 1.5 times higher than all cancers put together”.

CAMH reports that “in any given year, 1 in 5 Canadians experiences a mental health or addiction problem” (including dementia) and that “mental illness is a leading cause of disability” and can markedly shorten life. Not surprisingly, people with mental illness have high rates of unemployment and work absence; at least half-a-million employed Canadians are off work due to a mental health problem every week. The overall societal cost of mental illness cost in Canada in 2011 was estimated in one study to be about $42 billion, with half that being health care costs.

This is why the creation of a new Ministry of Mental Health and Addictions in BC is an interesting development. Time will tell whether it proves to be an important strategy to focus attention on a long-neglected issue or whether, as some have suggested, it divides resources and attention and becomes a problem. One thing is for sure; it highlights the growing importance of mental health problems in society.

But simply managing the problems of people with mental disorders or addictions is not enough; we need to reduce the toll of mental health in our communities. This means the new Ministry needs to focus on why people develop mental health problems in the first place, how we can prevent that happening, and how we can improve the overall mental health of the population.

Happily, BC has developed quite a strong focus on the prevention of mental health problems and on mental health promotion in the past decade. Its 10-year mental health strategy, adopted in 2010 and updated in 2017, states “Research tells us that doing a better job of promoting mental wellness, preventing mental illness and harmful substance use, and intervening at the beginning of illness, especially for our children and youth is a wise investment”.

As with much else in public health, what this means in practice is that we need to look well beyond the health care system, to society as a whole. A recent report from the UK’s Faculty of Public Health suggests what needs to be done.

First, we need to focus on childhood factors, and in particular, family relationships. Infants and young children need to feel secure in their attachment to their family, which enables them to develop trust in others. Failure to do so “leads to lifelong problems in learning, behaviour, resilience, coping, and both physical and mental health”. Adverse childhood experiences such as abuse, neglect, parental substance use or mental illness compound the problems, and call for early intervention.

In addition to good parenting, the school environment is also important: “The school ethos, mental wellbeing of teachers, relationships with peers and prevalence of bullying all matter”. And as young people transition from school to college or work – “a time of upheaval and uncertainty” – strong relationships with caring friends and adults are important, while loneliness is a problem. This continues into adultood, where stable relationships and mentally healthy workplaces are important, while unemployment increases the risk of anxiety or depression by 4 to 10 times.

Good mental health benefits us all, but clearly is a much bigger issue than the new Ministry can address on its own. It will need to engage the whole of government and the wider society – schools, workplaces and communities – in creating a mentally healthy society. In my next column, I will discuss in more depth how this can be done.

© Trevor Hancock, 2017

 

Public health should not be part of health care

Dr. Trevor Hancock

11 September 2017

699 words

It used to be the case in much of Canada that public health units were autonomous or semi-autonomous organisations at the local level, often aligned with and sometimes part of local government. The Medical Officer of Health (MOH) was the Chief Executive and had a staff of public health nurses, public health inspectors, epidemiologists, dental hygienists, community nutritionists and others. While they worked to some extent in collaboration with the health care system, especially family doctors, they were largely able to focus on the local community and work with a wide range of partners outside the health care system.

But in recent years, in most of Canada, we have seen public health brought firmly within the health care system. This has been a mistake, in my view, for one simple reason; most of what determines our health lies beyond the scope of that system. As a result, much of the work of public health to protect and improve health has to focus on actions beyond health care. But health care system managers – who are constantly facing budgetary challenges – are understandably focused on trying to achieve what they can within the scope of their operations.

This has two negative consequences. First, these health care system managers – very few of whom have public health training – see much of what public health does or tries to do as beyond the scope of the sector. Second, when they see public health staff engaged in work that, to them, is beyond scope, they are likely to try to re-direct that work towards more ‘useful’ clinical care.

This reduces the effectiveness of public health, which is a problem not only for the population as a whole, but for the health care system itself. At a time when the system is struggling to meet the demands for care placed upon it, it is extremely short-sighted to reduce the effectiveness of the only part of the system that is fully dedicated to reducing the burden of disease in society.

In particular we have seen senior health care system managers reduce the power of MOHs and break up public health units. It is now not uncommon to see MOHs – community medicine specialists with years of extra training in public health – reduced more to an advisory role, marginalised and with few staff, while public health nurses report through a separate part of the organisation and public health inspectors through yet another.

As a result, we have seen some frontline public health nurses moved into being primary care nurses and community nutritionists becoming more like dietitians, doing one-on-one care rather than community-based prevention.

This marginalisation can also be seen at the provincial level; in BC, most of the staff and budget for public health programs are separate from the small Office of the Provincial Health Officer, and this is seen in other provinces too, and now at the federal level. Moreover, the bureaucrats who are in charge increasingly do not have public health training, and may indeed have no health background at all.

The most extreme form of this approach is seen in New Brunswick, where the government recently announced a major reorganisation of its system of public health services. While the Office of the Chief Medical Officer of Health stays with the Ministry of Health and its “existing mandate and legislative responsibilities . . . will remain the same”, most of the staff have been dispersed to three other Ministries. In essence they are getting rid of public health as a cohesive whole.

I had the great good fortune to begin my public health career working for the City of Toronto’s Department of Public Health. Having watched the growing challenges facing public health in BC and other provinces, I am convinced that Ontario – where public health still is municipally based – has it right; public health does not belong in the health care system.

But I would go further; public health does not belong within the Ministry of Health. We need municipally-based public health units, with secure provincial funding, under a separate Ministry of Population and Public Health. Then public health could do its job without having to worry about being further harmed by the health care system.

© Trevor Hancock, 2017

 

 

Why did Mary die? Dig deep to find causes

Dr. Trevor Hancock

3 September 2017

698 words

In some ways, public health is like that annoying kid who is always asking ‘why?’. Why did this person become sick? Why did they die? It’s a bit like peeling an onion – there is always another layer to the story, another reason why.

Every year, we get a list of the leading causes of death, which is not that different between men and women. The leading causes in Canada in 2013 were cancer (30 percent), heart disease (20 percent), stroke (5 percent), chronic lung disease, unintentional injuries, diabetes, influenza and pneumonia, and Alzheimer’s disease. Between them they accounted for almost three-quarters of all deaths.

But what lies behind these numbers – what are the ‘causes of the causes’, and for that matter, the causes of the causes of the causes? What is left out or overlooked? How complete is the picture we are given? What are we not being told?

We can think about several levels of cause of death. The first, which is what these standard statistics show us, are the clinical diagnoses. But even here there are challenges. For example, why do we separate out heart disease from stroke, when both are forms of vascular disease? And why do we cluster cancers together when it is widely understood that there are many different forms of cancer, with many different causes.

The second level is the behaviours which lie behind the clinical cause of death. Smoking, alcohol or drug use, physical inactivity, unhealthy eating, dangerous driving – the usual litany of unhealthy behaviours which governments and others like to scold us about and encourage us to change. Usually, these are framed as ‘lifestyle choices’ and personal responsibility.

Yet these risk behaviours are embedded in and shaped by the third level of causes – our family, school, workplace and community environments, which shape and may constrain us socially and physically. We are also shaped by our built environments, where we spend the vast majority of our time and where we are car-dependent and inactive, and largely separated from nature. And we are influenced as well by our community’s social and cultural norms; some religious communities, for example, reject childhood immunisation.

We are also subject to enormous commercial pressures in the shape of advertising, much of which encourages unhealthy behaviours (check out the the food and drink ads, or the driving behaviour shown in most car ads these days), and we are buffeted by economic pressures that can lead to unemployment or low wages, debt, stress and even hunger and homelessness.

Indeed, we have a mountain of evidence that poverty and poor education results in large inequalities in health and underlies many deaths. We can think of all of these as risk conditions or risk environments, which in turn facilitate and support risk behaviours. But none of these upstream causes of death appear in the official statistics, which means they don’t get the attention they deserve. So it is the role of public health to raise these more profound and important questions and push for solutions at a community and societal level.

This can get complicated. Consider Mary, who died of a stroke; why did she die? Because she had high blood pressure which was not detected or, if it was, was not well controlled, perhaps because she is a woman and lived in a rural or low-income community or on a reserve, where health care is less accessible. Or perhaps she could not afford the medication.

But why did she have high blood pressure in the first place? A genetic presdisposition? Obesity? A high salt diet? – Canadian diets are much too salty, and the Canadian food industry, has resisted efforts to regulate salt content. A stressful life and work situation? Some combination of all these, and more?

So what did Mary die of: A stroke? High blood pressure? A high-salt diet? A stress-filled life? Inadequate health care? Rurality? Poverty? Only the first of these will show up in the standard mortality statistics, which tells us what someone died from – but not why. Which is why publiic health keeps asking ‘why?’ Because if we can understand why people get sick or injured or die, maybe we could prevent it happening.

© Trevor Hancock, 2017

 

 

Monitoring community well-being is complicated

Dr. Trevor Hancock

28 August 2017

701 words

There are three important questions in planning a healthy community: Where do we want to be, how do we get there, and how well are we doing? The first concerns the development of a common vision and common goals, the second to a shared strategy, and the third to establishing a process to monitor and report on progress.

I have long been involved in the development of community indicator systems, and it is complex and challenging work. Typically, good systems cover a dozen or so ‘domains’, each of which can contain a number of indicators. But how do you measure progress across so many fields without swamping people in hundreds of indicators?

One approach is to compile indexes that combine a number of different measures and generate a single number. The GDP is an example of this, although it is more of a misleading indicator; its main alternatives, such as the Genuine Progress Indicator and the Happy Planet Index, do the same thing, but using different measures based on different underlying values.

This illustrates an important point; our choice of indicators reflects our values and our aspirations. But it also drives our actions; we manage what we measure. So if we don’t measure something – our community’s level of creativity and artistic engagement, for example – then we won’t pay much attention to it and won’t do a good job of managing it.

A more useful approach than developing a single index is to acknowledge the complexity of a community, define a set of domains and within those domains identify a few key indicators that stakeholders and community members find useful. That is what the Regional Outcomes Monitoring (ROM) Collaborative has been doing here in the Capital Region.

After extensive consultation, the Collaborative has identifed a set of ten domains that are important to community wellbeing: Affordable and appropriate housing, food security, economic security, thriving children and youth, lifelong learning, inclusive and connected communities, healthy and safe environments, accessible human services, recreation and active living, and connection to arts and culture. Within each of those, key indicators are being identified, but that is harder than it may seem.

Part of the problem is that within each domain there are dozens, even hundreds of potential indicators to choose from. Take the example of arts and culture. The first question is, what do we mean by ‘arts and culture’? Watching a film or play, visiting a gallery, attending a concert or festival, reading about arts and culture?

How about active engagement with the arts by participating in them? That might include playing in a band, singing in a choir, folk dancing, taking art classes or being in an amateur theatre group. And beyond that, what about making your living in the arts, which is a significant part of our local economy.

If we take these three categories – audience/spectator, participant, full or semi-professional – then what do we want to know? Here, equity is an important issue; we want everyone to be able to be involved with and benefit from arts and culture. So we need to know who is involved (and thus, more importantly, who is not that we might want to reach out to), how accessible arts and cultural activities are to different groups (old and young, rich and poor etc,), how well-funded the arts are, and what economic benfits we derive.

In practice the choice of indicators is limited by the local availability and/or cost of the data. It may not be collected at all, or the sample size at the local level may be too small, which makes the data unreliable, or it may only be collected occasionally. Often, that means relying on data that is routinely collected locally, but may not be what we are really interested in. This may mean we need to do local surveys and data collection that meets our local needs, but that can get expensive.

So it is a juggling act, and the answer is never perfect. We need to recognise that indicators are based on value-driven choices, so the key question is what sort of community do we want to be, then how will we measure our progress in getting there – but measure it we must.

© Trevor Hancock, 2017

 

 

Safe communities prevent violence with compassion

Dr. Trevor Hancock

21 August 2017

700 words

Safety means different things to different people. In Europe, the Safe Communities movement has mainly focused on preventing unintentional injury (so-called ‘accidents’). But in the USA, and to a large degree in Canada, it has focused more on prevention of intentional injury, even though this is much less common than unintentional injury.

There are two main forms of intentional injury; deliberate injury to oneself (suicide and attempted suicide) and deliberate injury of others (homicide and assault); the latter are often what people have in mind when they think about a Safe Community, although homicide and assault are much less common than suicide and attempted suicide.

A 2015 report from the BC Injury Research and Prevention Unit (BCIRPU) found that between 2010 and 2014 suicide accounted for almost one quarter of all injury deaths in BC, while homicide represented only 2 percent. Similarly, while attempted suicide and self-abuse accounted for 5.5 percent of hospitalisation for injury assault was just 2.7 percent.

The BCIRPU also reported that unintentional injury resulted in more than 1,400 deaths, 30,000 hospitalisations and 435,000 ER visits in 2010, while intentional injury accounted for over 560 deaths (over 500 were from suicide) but only 4,000 hospitalisations and 17,000 ER visits. Nonetheless, the total costs of violence in BC that year was $157 million, including $84 million in health care costs.

But the health impact of violence does not come from just physical assault and injury, it includes mental and emotional harm, and the costs are not just in health care but in emotional trauma and disrupted lives and communities, effects that can last decades, lifetimes, even generations. Violence can take many forms, including bullying, harassment, abuse and neglect, and can occur in many settings and affect many groups, but several categories stand out.

First comes domestic violence, which includes child and elder abuse and neglect as well as spousal/intimate partner violence. Harassment, bullying and sometimes violence is found among young people in schools and among adults in workplaces, while elder abuse and neglect can be seen in care facilities. Finally, there is violence in the community, everything from on-line abuse and harassment to road rage, sexual assault and random or targeted assaults, including racist and Islamophobic violence and abuse.

In all these settings, certain groups are more vulnerable and/or more targeted, including women, children, the elderly, Indigenous people, LGBTQ people and various ethno-racial or religious groups – and clearly, people can be members of several of these groups. But what this tells us is that much violence is deeply rooted in cultural and social values that have to do with power, on the one hand, and fear and hatred on the other. So violence prevention will take significant social and cultural change.

I have always been impressed by the work of Irvin Waller, a criminologist at the University of Ottawa and a world expert on prevention of violence. He is clear that this is much more than simply a matter of law and order, policing and punishment. Just as public health advocates for upstream interventions to keep people healthy rather than downstream interventions to fix them when they are sick, Waller provides the evidence that “reductions in violence against women, street violence and homicides by 50% are all achievable within a five to ten year period by investments in early prevention” – and observes that this is a cheaper approach to reducing crime.

He points to “investments in people such as youth outreach, positive parenting programming, and social interventions in emergency rooms”. And he adds there is evidence that “modifications in school curricula to make achievement in life skills and healthy relationship skills stop violence”. So, he asks, “why not make them as important and measured as writing, reading and arithmetic?”.

This approach – what Waller calls ‘compassionate community safety’ – was epitomised recently by Ted Upshaw, the Public Safety Advisor for Halifax and a former RCMP inspector. In a session on healthy communities at the Canadian Public Health Association conference earlier this year, he discussed the importance of social justice, respect, good quality housing and neighbourhoods, access to parks and other social and community benefits if we are to create safe and healthy communities. It makes sense to me.

© Trevor Hancock, 2017

More alcohol means more injury

Dr. Trevor Hancock

13 August 2017

696 words

Alcohol policy is a fraught area. Like most people, I enjoy a drink or two, but unwise alcohol use does considerable harm and some form of regulation is needed. The era of prohibition has taught us that such an approach is bad public policy, but we have to strike the right balance between alcohol use and public safety. This is especially important for those who are put at risk of harm by the behaviour of others; the evidence suggests we don’t have the right balance at present.

A 2011 study of alcohol-related deaths in Canada from the Centre for Addictions and Mental Health (CAMH) in Toronto suggested that alcohol contributed to many unintentional injury deaths (almost 1 in 4 poisoning deaths, 22 percent of drowning deaths, 1 in five fire deaths, 1 in seven motor vehicle crash deaths and 13 percent of deaths from falls), as well as many intentional injury deaths (more than a quarter of homicides and suicides).

Importantly, while some unintentional injury deaths occur to the person who is consuming alcohol – which is a form of voluntary risk – others, more seriously, occur among those who are put at risk by people who are drunk, which is involuntary risk. These are vital distinctions, because we are more tolerant of voluntary or self-imposed risk than we are of involuntary risk.

In a seminal article in 1969, Chauncey Starr, then Dean of Engineering at UCLA, reported that people were willing to accept voluntary risk (skiing injuries, for example) at a level roughly 1,000 times greater than their tolerance for involuntary risks such as exposure to environmental pollution. In general people seem to be willing to accept a lifetime risk of death from involuntary or imposed risk, such as exposure to environmental pollutants, of around one in a million. This suggests that an acceptable level of lifetime voluntary or self-imposed risk is about 1 in a thousand.

Thus there are two aspects of alcohol use and injury to consider; how to protect people from self-harm and how to protect people from being harmed by drunks. I am most concerned with protection from those who are drunk and agree with a team of researchers, also from CAMH, who suggested in a 2015 report that such involuntary risk “could be used as a benchmark for national alcohol policies”.

They reported that a 2008 Australian study found that the risk of death caused by other people’s drinking was higher than 1 in 100,000, more than ten times the 1 in a million rate usually deemed acceptable. Since the main causes of involuntary risk to others from drinking are due to alcohol-related traffic injuries, work place injuries and violence, the study suggested these are the areas to focus on.

Thus it is good news that the federal Justice Minister, Jody Wilson-Raybould, has suggested reducing the blood alcohol limit from the current 80 milligrams to 50 milligrams. She noted that the fatal crash risk “is almost double at 50mg, almost triple at 80mg, and rises exponentially above that level” and pointed to experience in Ireland, where such a reduction, “combined with obligatory testing for alcohol, produced a 50 per cent reduction in deadly road accidents”. Sounds good to me.

But we need to do more than that. A recent report by a team based at the Centre for Addictions Research of British Columbia at UVic looked at the health and safety benefits of the Swedish government’s alcohol monopoly, and the potential impacts of deregulation and privatization. One scenario involved opening 1,200 private liquor stores, the other involved allowing alcohol sales in 9,600 grocery stores.

They found the first scenario would likely result in a 34 percent increase in drunk driving, 21 percent more assaults, 22 percent more hospital stays and 41 percent more deaths. The second scenario was worse, with 58 percent more cases of drunk driving, 34 percent more assaults, 33 percent more hospital stays and 66 percent more deaths.

Clearly, deregulation and privatization is bad for health; sadly, we are already too far down that path, and many innocent people are injured as a result. It is time to reverse course and make alcohol less accessible and more expensive.

© Trevor Hancock, 2017

 

Safe communities prevent ‘accidental’ injuries

Dr. Trevor Hancock

7 August 2017

699 words

Two weeks ago I pointed out that most injuries are unintentional. The BC Injury Research and Prevention Unit notes that in the five year period 2010 to 2014 the main forms of unintentional injury – falls, unintentional poisoning and transport-related deaths – accounted for more than 6 in 10 of all deaths due to injury in BC and more than two-thirds of acute hospitalisation for injury in 2013/14.

Of these the most important are falls, which have been responsible for about 600 deaths annually in recent years in BC and account for more than half of acute hospitalisation for injury. Overall, the costs of falls in 2010 was $1.2 billion, about one third of the total costs of all injuries in BC, with about half of that due to direct health care costs.

Falls are the leading cause of injury hospitalisation for every age group except under age 1. Most of these falls, and most of the costs, occur among older adults, accounting for about half of the health care cost of all falls. But we shouldn’t ignore the other half of falls in those under age 65.

A Statistics Canada report based on the 2009/10 Canadian Community Health Survey noted that one-third of all self-reported injuries, many of which are falls, “occurred during participation in some type of sports or exercise” and this was the case in two-thirds of those aged 12 to 19. Among adults, work injuries are also an important factor; a 2015 article by Cindy Hunter in OHS Canada noted “more than 40,000 workers get injured annually due to fall accidents”.

Not surprisingly, a great deal of attention has been paid to preventing falls among older adults, given the high rate of falls and the high costs. The BCIRPU reports that “each year, one in three BC seniors (age 65+) experience at least one fall”, with the rate being “three times higher for seniors who live in institutional/residential facilities”. This is an area where BC has shown leadership, with a major effort to address this in seniors’ homes and other facilities.

But in addition to falls in institutions, seniors also fall at home and out in the community; a Statistics Canada report based on the 2009/10 Canadian Community Health Survey noted that “everyday activities like household chores and walking accounted for over half of their injuries”. A 2012 review of the evidence from around the world found several effective fall prevention strategies. These included group and home-based exercise programs and interventions to improve home safety, with some evidence for reviewing medications and gradually withdrawing some forms of psychotropic medicines.

In the UK, Help the Aged has focused on poorly maintained pavements, noting that “More than 2,300 older people fall on broken pavements every day”. Noting that municipal governments have reserve funds to pay for claims, they make the reasonable suggestion that “some of the funds councils hold in legal and compensation reserves should be spent on pavement repairs rather than compensation claims”.

One of my favourite stories about community injury prevention, which I came across many years ago, came from a small hospital in Wales. Recognising that falls in the home were a costly problem for the hospital, they very wisely decided to send their hospital carpenter out to fix seniors’ homes, which reduced the number of falls. Perhaps our health authorities should consider this.

We have often treated falls as ‘accidents’, but in the world of injury prevention, they are not seen that way; there is almost always a preventable human factor at the root of the problem. But there is a very wide range of falls, and they vary a great deal by age, so there are no simple solutions, no quick fixes or univesal approach. It might be said that it takes a whole community to prevent ‘accidents’; homes, schools, workplaces, sports organisations, health care facilities and many others.

One common factor, however – and one that is a significant contributor to all forms of injury – is alcohol use. So a centrepiece of any community injury prevention initiative should be improved control on the availability and price of alcohol, as well as on responsible use. I shall turn to this topic next week.

© Trevor Hancock, 2017

 

Public health and the new BC government

Dr. Trevor Hancock

30 July 2017

703 words

From a population health perspective, there is much that is welcome in the new government’s policies and priorities, as revealed in their platform and the Ministerial mandate letters. But from a public health perspective, there is cause for concern.

First, the population health perspective, which is the primary focus of my columns. As I have repeatedly stressed, much of what makes a community or society healthy is beyond the jurisdiction of the Ministry of Health. The major determinants of health are found upstream in the social, environmental and economic portfolios, and here there are many potentially good policies, assuming they can be put in place.

Poverty is one of the most important contributors to ill health and premature death, and child poverty in particular sets children up for a lifetime of challenges and problems that many can never fully overcome. It generates an excess burden of disease that the health care system has to manage, at considerable cost. Indeed, the health, social and economic costs of poverty are so high that they are unaffordable.

Under the previous government BC became known for having a high rate of child poverty, low minimum wage rates, low social assistance rates and no anti-poverty strategy. So it is very encouraging to have a Minister of Social Development and Poverty Reduction with a mandate to “Design and implement a province-wide poverty-reduction strategy with legislated targets and timelines”. As the Green Party platform notes, “alleviating poverty and homelessness will also have a strong, positive impact on people’s health”.

Other strong anti-poverty – and thus pro-health – policies include increasing social assistance rates, pilot-testing a basic income program and requiring the Minister of Labour to implement a $15-per-hour minimum wage by 2021 and “bring forward recommendations to close the gap between the minimum wage and livable wages”.

Unaffordable housing contributes to poverty, homelessness and ill health, so it is good to see that the Minister of Housing is required to work with a variety of partners to build 114,000 units of a mix of various forms of affordable housing, and to develop a homeless action strategy together with the Minister of Social Development and Poverty Reduction.

A second major threat to population health comes from the global ecological changes we are creating, especially climate change. So it is encouraging to see the new government taking this issue more seriously. They seem to recognise the economic opportunities of energy efficiency and conservation and a clean energy economy, including investing in public transit, and have committed to carbon reduction targets and a $50 a tonne carbon tax.

But the NDP platform and mandate letters do not go far enough. The carbon tax increase does not start until 2020, whereas the Greens committed to $10 per tonne increases starting in 2018; nor is there reference to promoting biking and walking, or zero-emissions vehicles, all of which are health-promoting. Troublingly, the NDP does not name urban sprawl as an issue and propose community and regional urban containment areas, as do the Greens. In these and other areas touching on the environment and sustainable development, not surprisingly, the Green Party platform is more comprehensive, detailed and health-enhancing.

 

But it is when we come to public health – that part of the health care system that is focused on protecting and improving health and preventing disease and injury – that the new government’s platform is most disappointing; they still seem to equate health with health care. The NDP platform makes no mention of wellness, no reference to obesity, tobacco or alcohol – all major causes of disease and premature death – and only a brief commitment to prevention, mainly in the area of mental health.

Contrast that with the more explicit and detailed commitments in the Green Party platform, which notes that “prevention is better than cure” and promises to “establish a Ministry responsible for health promotion, disease prevention and active lifestyles” and to re-balance the allocation of resources between prevention and acute care.

So from a population and public health perspective, the best option might have been a coalition government that took the best of both parties’ platforms. Failing that, let’s hope the new government can learn from and adopt the Green Party platform for health and wellness.

© Trevor Hancock, 2017