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

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

What does it mean to be a safe community?

Dr. Trevor Hancock

23 July 2017

701 words

When people talk about the qualities of a healthy community, one of them is that it be safe. But what ‘safe’ means depends in part on who you are, as well as where you are from and what threat or harm we are considering. Indeed, safety isn’t just about physical harm, but perceptions of fear and insecurity – as anyone who has ever walked down a dark lonely road at night knows only too well. And war, of course, is an intensely dangerous situation for any community, but not one I am considering here.

Some groups in society feel less safe – and are less safe – than others; women, Indigenous people, people of colour, youth, seniors, people who are LGBTQ and others experience different sorts of risk, and thus creating a safe community is a complicated task.

In the late 1980’s, when I was helping the European Region of the World Health Organisation (WHO) develop the Healthy Cities program, they were also developing a Safe Cities program. While it never made sense to me that they would develop these as two separate programs, what I found interesting, coming from North America, was that Safe Cities in Europe was focused mainly on injury prevention, not safety in the sense of protection from crime and violence.

This points to one of the challenges in creating a ‘Safe Community’ initiative; what threat are we discussing and seeking to prevent? In public health we tend to think of safety in terms of its opposite – harm – and the physical consequences of harm, namely injuries. Normally we classify injuries as either intentional or unintentional.

Intentional injuries include both violence (“the infliction of fatal or non-fatal injuries by another person, by any means, with intent to kill or injure”) and self-harm, which includes both attempted and completed suicide. Unintentional injuries, not surprisingly, are defined as “not purposely inflicted, either by the person or anyone else”, according to the BC Injury Research and Prevention Unit (BCIRPU). These are what we usually call accidents, although that term is often avoided these days, since many ‘accidents’ are due to human error of some form and thus not truly accidental.

When we think about a safe community, only too often our thoughts turn to keeping us safe from crime and violence. But we would be mistaken to put most of our efforts there, because in fact most of the injuries that we experience are not due to violence but come from unintentional and self-inflicted injury.

The BCIRPU reports that in the five year period 2010 to 2014 the four leading causes of death due to injury in BC were, in order, falls, suicide, unintentional poisoning and transport-related deaths. Between them, they accounted for almost 9 in 10 deaths due to injury. Of these, three are considered unintentional and accounted for more than 6 in 10 deaths, while suicide accounted for almost one quarter of all injury deaths; homicide was a distant fifth, with only 2 percent of all injury deaths.

Injuries don’t only kill, of course, they result in disability ranging from minor and brief to severe and lifelong, and often result in hospitalisation. Falls are by far the most common cause of hospitalisation for injury, accounting for 46 percent in 2013 – 14, with transport-related injuries a distant second (11 percent) and attempted suicide third (5.5 percent); assault, which is intentional, comes in 7^th at just 2.7 percent.

Injuries are not only very expensive in human terms, they also exact a high economic cost. A 2015 BCIRPU report found that in 2010, injuries cost BC $3.7 billion, or more than $800 per person, of which health care costs were $2.2 billion – more than $500 per person or $2000 for a family of four. Again, unintentional injuries account for most of the costs – 84 percent in 2010.

So from the perspective of safe communities in BC, as in Europe, the primary focus should be on the prevention of unintentional injuries, particularly falls, transport related crashes and accidental poisoning. Of these, injuries due to falls are the number one priority. So in my next three columns, I will look at three different aspects of a safe community; preventing unintentional injury, violence and self-harm.

© Trevor Hancock, 2017

We are being marketed to death

Dr. Trevor Hancock

17 July 2017

699 words

My two latest columns discussed the marketing of alcohol and unhealthy foods, especially high sugar foods, just a few of the many products that produce ill health, injury and premature death. Clearly the industries that market these products are less concerned with the wellbeing of the population than their own profits. The question is, why do we allow this, and how can we stop it?

Tobacco marketing is the poster child for how to market a harmful product to the public and fight like hell to be able to continue to do so in the face of all the evidence. One reason that some of the products being marketed are called ‘the new tobacco’ in the public health literature is because they clearly look to tobacco marketing as a model, and employ many of the same techniques that industry used to try to fight off controls over its sales and marketing.

These techniques include denying and casting doubt on the evidence, hiding evidence of harm, attacking the scientists who produce the evidence, raising issues of free speech and their right to market a legal product, making political donations and lobbying hard at all levels, supporting art and sport organisations that make them allies, opposing regulation and taxation, initiating lengthy court cases, and funding (but not publicly) supposed citizen organisations that support the right to buy and use the product.

Let’s look at some of the products that have been called ‘the new tobacco’, and more generally at the business of marketing, which I believe is generally bad for our health. The most obvious ‘new tobaccos’ currently are sugar and the related issues of unhealthy fast foods and childhood obesity (my topic last week); two others are the fossil fuel and auto industries.

Perhaps the closest cousin to tobacco marketing these days is the fossil fuel industry. Some companies in particular have been fostering climate change denial and attacking both the science and the scientists, while cultivating powerful political allies, especially in the USA. In a report on this issue, the Centre for International Environmental Law states that based on its research into the documents in the Tobacco Industry Archives, there have long been close ties between the two industries and that “The oil industry used the tobacco playbook in its fight against climate science”.

A related example of unhealthy marketing is the auto industry. A 2011 article in the Journal of Public Health asked whether cars are the new tobacco. The authors concluded that “Private cars cause significant health harm”, including through air pollution and climate change due to fossil fuel combustion, but that “the car lobby resists measures that would restrict car use, using tactics similar to the tobacco industry”.

Another troubling aspect of auto marketing is the marketing of high speed and dangerous driving. A 2010 article in the journal Canadian Public Policy examined auto ads aired or published in 2006/07. The authors found that 27 percent of TV ads (and 10 percent of print ads) featured unsafe or aggressive driving; my impression is that TV ads have become even worse since then. This is socially irresponsible.

But let’s face it, the purpose of marketing is to persuade us to buy more of their products – why else would a business spend all that money? And therein lies perhaps the greatest danger. Because marketing feeds into and supports the dominant narrative of growth, it stimulates us to want and need more products, more ‘stuff’.

But endless growth within a finite system is impossible, as is becoming apparent as we move into the Anthropocene. Three percent economic growth coupled with one percent population growth translates into a 22-fold increase in demand by the end of this century. We can’t afford to increase our material demands and yet that is what most marketing is about.

That is why I believe that the marketing industry as a whole is in itself a threat to the health of the population. So instead of celebrating the ingenuity of the advertising industry, and all the clever ways in which it tries to trick us into buying more stuff, we need to re-think the role and responsibility of the marketing industry in the 21^st century.

© Trevor Hancock, 2017

 

 

Protect our kids from unhealthy advertising

Dr. Trevor Hancock

10 July 2017

700 words

As a public health physician I am dedicated to improving the health of the population and protecting them from harm. Thus it is troubling to me that so often we identify a threat to health – such as tobacco, alcohol or asbestos – provide clear evidence and solid proposals to protect the health of the public – and then little or nothing is done. Too often, governments seem to err on the side of protecting industry, rather than protecting the health of the population.

Which brings me to the marketing of unhealthy food and beverages to our kids, especially sugar-rich products they do not need and that are contributing to the epidemic of obesity, heart disease, diabetes and other health problems. Here is another situation where government is not doing enough to protect us from harm.

This is not just my opinion, but the opinion of the Heart and Stroke Foundation of Canada. Their 2017 report on the health of Canadians, ominously entitled ‘The kids are not alright’, notes predictions that “today’s children may be the first generation to have poorer health and shorter lifespans than their parents”. And they lay much of the blame on the fact that “today’s kids are bombarded with food and beverage marketing morning, noon and night, every day of the week”.

How much are kids exposed?: A lot more than you might think. These days, kids are not just exposed through TV and billboards. They spend almost 8 hours a day in front of screens, at home and in school. On average, they spend 2 hours watching TV, where they see “4 – 5 food and beverage ads per hour”. The other 6 hours are spent on their other screens – laptops, smartphones and tablets – where they see many, many ads.

So Heart and Stroke asked Dr. Monique Potvin Kent, an expert on food and beverage marketing and children’s nutrition, to review food and beverage advertising on children’s and youth’s top ten preferred websites. She found that “over 90% are for unhealthy foods — mostly processed foods and beverages which are high in fat, sodium, or sugar”. And she found “the most frequently advertised product categories on children’s favourite websites are restaurants, cakes, cookies, ice cream and cereal”; the same is true for teens, with the addition of sugary drinks.

Online advertising is cheap, and companies can place ads on sites that appear to be – and indeed are – educational. The report notes one of the top ten sites used by children is an educational math site, “but it is filled with ads”, including “lots of food and beverage ads”. In addition they can create their own websites, where ‘advergames’ – “video games with embedded advertising” can keep kids engaged and encourage them to share the site with their friends.

The report notes that industry self-regulation of marketing to children through their own Children’s Advertising Initiative (CAI) has failed; indeed, Dr. Potvin Kent found that “Three-quarters of the unhealthy ads viewed by children and youth were from companies that participate in the CAI”.

To their great credit, the Heart and Stroke Foundation takes a strong line on all this: “Both young children and adolescents should be protected from food industry tactics”. Specifically, they call for the federal government to “enact legislation to restrict commercial food and beverage marketing to children and youth ages 16 and under”. And they call upon provincial governments to “implement and enforce restrictions on the commercial marketing of foods and beverages to children and youth” and to “restrict exposure to food and beverage marketing in public places, including settings where children gather”.

These approaches have been implemented elsewhere and have been shown to work. One good example is Quebec, where advertising of all goods and services to children under 13 was banned in 1980. A 2011 study concluded that compared to Ontario there was “a 13% reduction in the likelihood to purchase fast food”; the report also noted that “Quebec has the lowest obesity rate in Canada among children ages 6–11 and the highest rate of vegetable and fruit consumption”.

It is time governments acted to protect Canadians from the unhealthy marketing practices of the food and beverage industry – we will all benefit.

© Trevor Hancock, 2017