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

Pollution and health: A neglected issue

Dr. Trevor Hancock

30 October 2017

702 words

Perhaps the most startling claim made by the Lancet Commission on Pollution and Health, in its October 19^th report, is that “despite its substantial effects on human health, the economy, and the environment, pollution has been neglected” and its health effects “underestimated in calculations of the global burden of disease”. Considering all the attention that pollution issues have garnered over the years, that seems, on the face of it, a rather preposterous claim.

Yet dig a little deeper and the reason for that claim becomes apparent. In essence, while pollution certainly gets a lot of public and media attention, for the most part that has not translated into public policy that effectively curbs pollution. On the contrary, “in many parts of the world, pollution is getting worse”, particularly air, chemical and soil pollution in rapidly developing low and middle-income countries. Meanwhile the health and environmental consequences have been largely ignored, accepted as the cost of doing business, the price of development.

Contrary to previous estimates, which have found a lower burden of disease and premature death due to pollution, the Commission – which included three Canadians, including Professor Bruce Lanphear at SFU – concludes that “diseases caused by pollution were responsible for an estimated 9 million premature deaths in 2015 – 16% of all deaths worldwide”. To give some sense of proportion, the commission points out this is “three times more deaths than from AIDS, tuberculosis, and malaria combined and 15 times more than from all wars and other forms of violence”.

But these are ‘only’ deaths; on top of this we need to include all the illness and disability associated with pollution. The costs are enormous; the productivity losses are estimated to be up to 1.7 percent of annual health care spending in high-income countries and 7 percent in some rapidly developing middle-income countries.

And yet all this is an underestimate. Of the three main categories of pollutants, the Commission argues, only one group has been sufficiently well studied that the health effects are well understood and included in their estimate. This category includes in particular the links between indoor and outdoor air pollution and a number of conditions such as heart disease, chronic lung disease and cancer.

The big culprit here, according to the Commission, is combustion of fossil fuel and – in low income countries – biomass. This accounts for “85 percent of airborne

particulate pollution and for almost all pollution by oxides of sulphur and nitrogen” with the biggest problem being coal (which is why we need to close down the coal industry and drastically reduce fossil fuel use).

The second category is pollutants where we have some evidence of links to health problems and growing evidence of causation, but not enough to quantify the burden of disease. This includes associations between soil pollution with heavy metals and toxic chemicals at mines and industrial sites, and between fine particulate air pollution and conditions such as diabetes, and some diseases of the central nervous system.

The third category is, in many ways, the most troubling. It includes “new and emerging pollutants” such as certain pesticides (e.g. neonicotinoids and glyphosate), nano-particles, pharmaceutical wastes and substances that disrupt endocrines (hormones) or the developing neurological system. Moreover, some of these are widely dispersed in the environment and in our own bodies and the bodies of many other species, the phenomenon of ecotoxicity I referred to last week.

In light of the likely significant but as yet unquantified health effects of the second and third categories, the Commission believes that its estimate of 9 million deaths “could thus be the tip of a much larger iceberg”. So why is this significant health problem neglected? Why does any government in its right mind allow its population to be exposed to these pollutants at levels that are known to harm health?

I will explore the roots of this neglect in my next column, but sadly, I think that part of the reason is that, as the Commission notes, “Pollution disproportionately kills the poor and the vulnerable. Nearly 92% of pollution-related deaths occur in low-income and middle-income countries”. You can’t help but think that the cynical and sinister calculus is that these lives are cheap, and they don’t matter.

© Trevor Hancock, 2017

Protecting health in our chemical society

Dr. Trevor Hancock

23 October 2017

701 words

Last week The Lancet – one of the world’s leading medical journals – published another in its series of Commission reports on various aspects of Planetary Health, this time on pollution and health. Next week I will delve into the report in some detail, but first I want to go back 36 years, to when I was the co-author of a major report for the Local Board of Health for Toronto on the health impacts of our chemical society. We sought to document the overall health, social, environmental and economic impacts of our widespread use of chemicals, and suggest actions we should take to reduce or eliminate those impacts.

Our report – Our Chemical Society – defined a chemical society as “one which believes its quality of life is, in large measure, dependent upon, and directly related to, the widespread production and use of chemicals”. We noted that at that time there were 60 – 100,000 chemicals in commercial use. Of these, 34,000 were on the US EPA’s 1978 Toxic Effects List, very few of which had been adequately tested.

Harmful or potentially harmful chemicals are pervasive in our lives. Some are intended to be inhaled, consumed or applied to our bodies, including food additives and synthetics, tobacco and alchohol, pharmaceutical drugs, cosmetics and toiletries, including scents and air fresheners. But many others are not, but get into our environments and ultimately our bodies anyway; they are in the paints, solvents and fabrics we use and and the materials with which we build and furnish our homes, schools and workplaces. Some, of course – the pesticides and herbicides – were designed to be toxic to various life-forms.

Much of this exposure has occurred since the end of the Second World War, after which the chemical industry really took off. One consequence is a phenomenon known as ‘ecotoxicity’; the widespread contamination of ecosystems and food chains with low levels of muliple persistent organic pollutants and heavy metals. As a result we – and all other species – carry a body burden of dozens, even hundred of these chemicals, with health consequences that are largely unkown – and probably unknowable, because of their potential interactions.

In the face of this onslaught we recommended taking a much tougher line on controlling chemicals, suggesting that “it is better to ban a product subsequently found to be safe than to permit the use of a product subsequently found to be harmful”. Because once a chemical is out in the environment, you can’t take it back or remove it – only nature can. Thus we suggested reversing the onus of proof; no longer treating chemicals as if they were human, and thus innocent until proven guilty, but guilty until proven innocent.

To tackle the vast backlog of safety testing, we suggested introducing the concept of social utility, prioritising for testing those chemicals judged to be likely to have high utility and putting others – such as yet another scented product – at the back of the line, and thus not on the market. We argued for stronger controls on the advertising and marketing of chemicals, and we urged people and organisations to try to be as chemical-free as possible. In addition, we urged the passage of an Environmental Bill of Rights, greater public involvement and transparency in the regulation of chemicals and even a Select Committee or a Royal Commission to investigate the situation.

Fast forward 36 years and not much has changed – certainly none of what we recommended has happened. The Lancet Commission reports that “pollution has been neglected” and its health effects under-estimated, noting that “more than 140,000 new chemicals and pesticides have been synthesised since 1950”. Of these, the 5000 chemicals produced in the highest volume “have become widely dispersed in the environment and are responsible for nearly universal human exposure”.

Moreover, “fewer than half of these high-production volume chemicals have undergone any testing for safety or toxicity” – note that is ANY testing! It is as if we are subjects in an unauthorised experiment to which we have never given consent. Why have governments allowed this to happen? Why does human health count for so little? We should be outraged, and we should insist that governments placed human wellbeing ahead of corporate profit and the economy.

© Trevor Hancock, 2017

Seeking common vision and common action

Dr. Trevor Hancock

15 October 2017

702 words

There is an emerging community-based movement in the capital region – and elsewhere around the world – that recognises that ecological, social and economic conditions and human wellbeing are not separate issues but are inextricably linked. Here in Victoria a number of related initiatives have sprung up, mostly in just the past couple of years, that are working to address these intersecting issues holistically, but in somewhat different ways.

Several of these initiatives came together last month at one of the Conversations for a One Planet Region that I have been organising this past year. The Conversations are just that, an attempt to get the conversation started here on what it would mean – and what it would be like – to live in a region that only had an ecological footprint equivalent to our fair share of the Earth’s resources. Since we currently use the equivalent of 5 planets’ worth, this would be an 80 percent reduction; how do we do that while maintaining a high quality of life and good health for all?

Greater Victoria Acting Together (GVAT) is “a broad-based coalition of local groups and community organizations” working to advance the common good. Its focus is on “relational learning and capacity building”, through which it seeks to build respect and trust across sectors and give civil society a greater voice.

Creatively United for the Planet works to celebrate those who are making a difference in our region, “showcasing local change-makers and grassroots solutions for a better world”. They do so through community events (such as the Earth Day Festival), sharing engaging stories and videos and – coming soon – through a series of community TV programs on Shaw.

Cities for Everyone “supports more affordable housing and transportation in order to provide security, freedom and opportunity for people with all incomes and abilities”; it has a strong focus on more ecologically sustainable urban development in order to achieve this purpose.

Then there is Common Vision, Common Action. This past weeekend I was involved in a most unusual non-partisan policy conference, (full disclosure: I was a member of the organising committee). The conference brought together 100 or so participants to establish “a regional agenda for social and ecological justice”. While not explicitly about health, it was very much about how to improve the wellbeing of all the people who live here, while at the same time ensuring the ‘health’ of the natural systems of which we are a part and upon which we depend.

While the conference was non-partisan it was very much political, in that it sought to create a common platform and “a framework for advocacy and action among residents, community organizations, candidates and local governments from now until the 2018 municipal elections and beyond”.

The conference began, in a spirit of reconciliation, by focusing on the Indigenous peoples who lived here for thousands of years before European colonisation began a couple of hundred years ago. Joan Morris, a member of the Songhees Nation, talked about the pain, suffering and loss that Indigenous people had experienced as a result of colonialism, and that continues to this day.

She was followed by Paul Cheoketen Wagner, a wonderful storyteller and activist from the W̱SÁNEĆ (Saanich) Nation. In his very moving remarks he told us we must seek and demonstrate leadership that values all of life, human and non-human, and that we need to love and protect this place as we would love and protect our own children.

In the policy discussions that followed, the participants sought to express these values and sentiments across a range of issues that are largely within the realm of or subject to the influence of local government: Land use and housing, transportation, food and water systems, ecological areas and parks, education, energy systems, arts and culture, and systems of governance, inclusivity and economics.

The result is a draft plarform that proposes a wide range of policy initiatives – and advocacy actions directed to the provincial and federal governments where the local power is absent – that people of good will can work from and run on; people who cherish this place, the planet itself and the wellbeing of all the people who live here and all the life on our planet.

© Trevor Hancock, 2017

 

Should we try social prescribing?

Dr. Trevor Hancock

9 October 2017

701 words

A central theme of my columns is that health is determined by a wide range of factors, most of which are not within the realm of the health sector. Which means that most of the interventions that will help us be healthy are outside the health care system. One of those interventions, first promoted by the UK Department of Health in 2006 and now being developed in England, is social prescribing.

In a report earlier this year, The King’s Fund – a well-respected independent charity working to improve health and care in England – describes social prescribing as a service that provides a “means of enabling GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services”. Given that in the UK about 1 in 5 patients consult their family physician for what are mainly social problems, it makes sense to refer them to social rather than medical care and support.

In the 1970s I worked as a family physician in a community health centre with many marginalised and vulnerable people; many of the problems I saw were not medical problems, and could not be solved with medical interventions. The people I saw were precisely the sort of people The King’s Fund suggested are most likely to benefit from social prescribing: Those with “mild or long-term mental health problems, vulnerable groups, people who are socially isolated, and those who frequently attend either primary or secondary health care”.

The basic idea of social prescribing is very simple: Given that a broad range of environmental, social and economic factors affect health, and that many voluntary and community sector organisations are working to support people in these areas, how do we connect people in need to these organisation and their programs? The types of services that people need, the King’s Fund report notes, include “volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice and a range of sports”.

Social prescribing involves a primary care practitioner referring a patient to a ‘link worker’ in the community/social care sector. These workers, who may be paid or volunteers, interview the patient and link them to a suitable community or voluntary sector program. Some of these programs fall into the area of local governments, involving a variety of recreational activities.

There are two main reasons for undertaking social prescribing: Improving health and reducing costs. So does it work? Well, there is some evidence that it might, with some studies showing improved health and wellbeing, and even some reductions in use of primary, emergency and specialty care. But whether or not it is cost-effective remains to be seen, partly because most of the studies have only looked at the experience over 12 months or so, while the benefits are likely to accrue over the longer term.

So while there is emerging evidence that it seems to work, it is too early – and the research to date has been too weak – to give a definitive answer. But there are enough interesting examples and information to suggest it may be worth trying here in BC, given the new government’s commitment to support and expand community health centres (CHCs) – or what should perhaps be thought of as community health and social care centres. This provides an opportunity to implement social prescribing, at least on a pilot basis.

There are a few key issues to address. First, social prescribing itself requires funding and support for the link workers or navigators. Second, the agencies and especially the community organisations and NGOs that provide the services will likely need increased funding and support to meet the increased demand that can be expected. Third, any implementation needs to be set up with a strong evaluative component, and it needs to be evaluated over a number of years.

Finally, and perhaps most important, this needs to be seen as a replacement for, and not an addition to healthcare expenditure. If indeed social prescribing succeeds in reducing demand for health care, the resulting savings need to be transferred out of the health care system and into the social care system that are providing these benefits. After all, much of what determines health lies beyond health care, and funding should reflect that reality.

© Trevor Hancock, 2017

 

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