The Daily - June 15, 2010
12 Great Achievements leave more to be done: Butler-Jones
A centennial is a time to celebrate, but Chief Public Health Officer Dr. David Butler‑Jones reminded participants Monday morning that each of the 12 Great Achievements of CPHA’s first 100 years points to work that has yet to be done. Public health can look to the past with great pride, “but we need to carry that legacy forward,” Dr. Butler‑Jones said.
Despite advances in safer, healthier foods and clean water, Canada has seen recent outbreaks of listeria, as well as the safe water crises in North Battleford, Saskatchewan and Walkerton, Ontario. Many Aboriginal communities, in particular, “cannot count on their water supply.”
The fundamental goal of infectious disease control dates back to the beginning of public health in Canada, but H1N1 was just the most recent of a series of new and novel infections.
In environmental health, air pollution is a challenge around the world, while climate change will shift patterns of infectious and other diseases. Social disruptions due to sea level rise will fall most heavily on low-income people living in low-lying areas.
“I focus on mental health, and
one of the major achievements so far is the attention directed in that
area through the formation of the Mental Health Commission. That’s also
going to be our next big challenge—changing attitudes in society toward
people with mental illness, thinking of mental health on a continuum,
and making sure that good care is provided to people who need
it.”
- Ottawa
“Even in the last six years,
one of the greatest achievements is that now, at every public health
event I attend, equity and social determinants are at the forefront of
the agenda. When I started, not that long ago, that wasn’t the case.
What’s ahead, I hope, is more meaningful work and partnership related
to health equity.”
-
Sudbury
Tobacco companies continue to market their wares to children. On a visit to Vietnam, Dr. Butler-Jones said he saw cigarettes for sale on every street corner, at a cost of 25 cents per pack.
Motor vehicle accidents are still the biggest killer and disabler of Canadian youth.
The reduction in cardiovascular disease was an “amazing achievement. And yet, with childhood obesity, this may be the first generation of children not to live as long or as well as their parents.”
Emphasis on healthier mothers and babies must continue to address the preventable, life-long challenges that many children will face.
Much has been done on the social determinants of health, but the gaps continue to widen.
Universal policies have led to better health outcomes for seniors, but “what about the children? There are many lessons yet to be learned.”
Workplaces are safer, but may not yet be healthy places to work. “It’s not always chemical toxins that create toxicity in the workplace,” Dr. Butler‑Jones said.
Similarly, family planning has decreased unwanted pregnancies, but more remains to be done.
Food safety, security need new approaches
The influence of global trade is one of the most pressing issues in food safety and security today, while food-borne illness is a major cause of preventable illness, death, and economic disruption. With many countries in the global south relying on food exports to maintain economic stability, consumer countries like Canada need more stringent and up-to-date legislation governing food imports.
“The Food and Drug Act is 1950s legislation—it didn’t envision the global trade we see today,” said panelist Paul Mayers of the Canadian Food Inspection Agency during Monday’s “farm to fork continuum” session.
Thinking on food safety has expanded from protection against food-borne illness to consideration of nutrition and healthy food choices, said panel moderator Karen Rideout of the National Collaborating Centre for Environmental Health. Similarly, the concept of food security must expand to include an understanding of the influence of poverty on people’s food choices.
Tension between growing local food movements at the consumer level and the need for regulation emerged as a key concern. While local food movements can promote some facets of food security, they can be hampered by overly restrictive legislation.
“How do we protect our food but also support these kinds of movements and organizations?” Rideout asked.
Wayne Roberts of the Toronto Food Policy Council said government must play an enabling role through communication and education, rather than solely functioning as a regulator.
A fundamental element of public policyBy Hon. Marc Lalonde Over the last several decades, one of our country’s major public health achievements was a significant assumption of responsibility by governments, based on the realization that public health is a fundamental element of public policy. But we now face a considerably more difficult task. Today’s challenge is to mobilize public opinion behind policies that lead to significant public expenditures and, consequently, have significant implications for taxation. While citizens often support grand new initiatives, democratic governments are between a rock and a hard place when it comes to enacting the necessary legislation. The most significant public health measures often deliver results over longer time spans, their effects only visible long after the next election, but the public judges governments based on short-term results. This creates a conundrum for those who seek a culture of healthier public policy. Cultural change is not something a government can legislate, and it does not occur overnight. But in an era when people are continually bombarded with information, it can be difficult to keep an issue current long enough to achieve systemic change. As public attention shifts from one crisis to the next, public health advocates can be hard-pressed to make the case for consistent, persistent, coordinated, long-term action. Our past achievements in areas like vaccination and tobacco control required sustained effort. An equivalent effort is needed today to ensure that action on public health is seen as more than a passing fad, with only a limited hold on the public consciousness. Hon. Marc Lalonde was Canada’s Minister of National Health and Welfare from 1972 to 1977. |
National strategy would denormalize violence
Discussion at the annual town hall meeting hosted by Prevention of Violence Canada pointed toward the development of a national strategy to denormalize violence.
“Violence remains all too commonplace through all life stages,” Chief Public Health Officer Dr. David Butler-Jones told participants. Much violence is hidden, but its everyday consequences ripple through society, with implications far beyond law enforcement.
The public health community has a role in responding to violence “because it’s preventable,” Dr. Butler-Jones said. “It’s no wonder that a kid in Regina or Moose Jaw who grows up with violence has no sense of future. The education system sometimes seems irrelevant, there are no good adult mentors, the only group that seems to pay attention to him is the local gang, and the only way he can get respect is to do violence. Given those circumstances, I can see many people choosing the same things.”
Dr. Butler-Jones stressed practical strategies to prevent violence, noting that “public health is less about what we do or programs we deliver than it is about what we influence.”
Shannon Turner, past co-chair of Prevention of Violence Canada, recalled that the 2009 town hall meeting had passed a motion calling on Dr. Butler-Jones to issue a national report on the cost of violence and the importance of violence prevention. The H1N1 crisis delayed that work, but “we will be pursuing the motion,” Turner said.
Liz Haugh, president of the Ontario Public Health Association, said violence “encompasses so many public health issues, and it’s huge because it’s hidden.” Ontario has had “some smidgen of success” with workplace violence legislation, she said, and similar small steps will gradually add up.
CPHA Chair Cory Neudorf traced local efforts in Saskatoon to move violence higher on the public health agenda. Working with families and children, the regional health unit looked at a collection of strategies to raise awareness, develop policy, link family interventions with school health initiatives, and connect violence prevention with mental health promotion.
“There are lots of ways to get involved” at the local level, he said.
Coordinate communications to contain outbreaks
Effectively responding to an outbreak like H1N1 demands consistent communication among all sectors of the health care system, but particularly among provincial and regional health authorities and family physicians. In the midst of a crisis, when treatment protocols can change rapidly, the ability to communicate electronically with family physicians would markedly improve the public’s understanding about the treatment, if any, that people should seek.
The panel discussion on the collaboration between public health and primary care sectors during the recent H1N1 outbreak underscored the importance of preparation and planning during the assessment and vaccination stages.
Dr. Terry-Nan Tannenbaum of the Agence de la santé et des services sociaux de Montréal said that prior to H1N1, the two sectors operated too independently. However, “The experience has improved the relationships. Overall, it has been a benefit, despite all the errors we made, because at least we know each other now.”
Improved communication infrastructure would also assist in the collection of data to measure the system’s efficacy. Noting that only the Globe & Mail newspaper furnished public statistics on H1N1 immunization rates across the country, Dr. Vivek Goel said the CPHA should rightfully carry out this essential task.
Public Forum: Where politics, poverty, and public health intersect
Moderator Paulette Senior, CEO of YWCA Canada, said she’s always taken aback when international colleagues ask what it’s like to work in a rich country, with a highly-touted health care system and relatively low levels of violence. As Canada’s largest provider of shelter for women leaving domestic abuse, “it’s difficult to see women’s health and the violence that affects their lives as anything but an epidemic needing immediate action.” “The first solution is putting the public back into public
health...” Dr. Carolyn Bennett, MP for St. Paul’s and former minister of state for public health, issued a call for coordinated action on the social determinants of health. “The first solution is putting the public back into public health,” she said. “It is only when we as politicians are with people like you that the titanium goes back in our spines and we go back to fight for what we know is right.” Political will is one of the determinants of health, she said, because “you can magically watch the political will rise” when the public is engaged and knowledgeable.
France Gélinas, provincial MPP for Nickel Belt, said front-line work on public health, social determinants, and health status must be supported by government policies and legislation. Ontario made poverty a low priority during seven years of record economic growth, she said. But after the recession hit, the province adopted its Open Ontario plan to encourage economic growth through foreign investment. “Anything that could be perceived as negative by investors is quickly shut down,” so government spending on poverty remains an afterthought. Dr. David McKeown, Toronto’s medical officer of health, recalled Dr. Charles Hastings’ efforts a century ago to position low income and poor housing as Toronto’s two leading public health problems. In a very early example of media advocacy, Dr. Hastings hired a photographer to document living conditions in low-income districts downtown—and some of the photos are on display this week at CPHA’s public health expo. “When you look into the faces of the children living in those slums, you get the sense that low-income housing has improved a bit, but the disparities between low- and high-income individuals in this city have not.” Jessica Yee, founder of the Native Youth Sexual Health Network, encouraged participants to challenge themselves and “activate change” by working with disadvantaged communities to dismantle hierarchy. Non-profits and community agencies are a part of the system, she said, and “it’s important to deconstruct how we recreate the same situation we’re trying to change.” |
The intersection between politics, poverty, and public
health was the focus of last night’s public forum hosted by the Ontario
Public Health Association.
African public health associations thank SOPHA
On the 25th anniversary of SOPHA, leaders from Tanzania and Malawi—two of the 30 countries that have partnered with SOPHA—discussed their challenges and successes in forming public health associations in Africa.
Dr. Wen L. Kilama, former chairperson of the Tanzania Public Health Association (TPHA), said SOPHA found “common cause” with TPHA and initially helped the association hire staff and secure office space. TPHA grew steadily, establishing five chapters in the country, convening annual scientific conferences and developing a model chairperson succession strategy to maintain leadership. In 1997, TPHA hosted the 8th Congress of the World Federation of Public Health Associations, increasing its own visibility and garnering some unexpected financial donors.
“We were barely making ends meet without CPHA’s support, and now we help support other public health associations,” Dr. Kilama said.
Dr. Yohane Nyasulu, president of the Malawi Public Health Association (MPHA), said regular technical visits from CPHA, along with support from TPHA, have enabled his organization to sustain itself since 1994. CPHA provided support for strategic plan development, project organization, and project reporting and accountability, all skills that have strengthened the MPHA. In 2008, with CPHA’s financial assistance, Malawi was able to address water and sanitation issues in low-income areas. The three-year project raised MPHA’s visibility, increased its membership, and attracted new partners.
Dr. Naresh Singh of the Canadian International Development Agency (CIDA) said a true measure of success is a public health organization’s ability to sustain itself long after financial assistance has ended. As a graduate of the SOPHA program, the Tanzania Public Health Association stands as a role model in this regard.
Margaret Hilson, former director of CPHA’s International Secretariat, said public health associations provide needed support for immunization programs and other government initiatives. A big success story is their role in aligning their respective ministries of health with the global tobacco control programs of the World Health Organization. “Through the World Federation of Public Health Associations, shared scientific evidence, and a shared purpose, we have been strengthened in the face of a politicized public health problem,” Hilson said.
Paradis outlines future challenges
Reducing social
inequalities, improving the health and well-being of First Nations, and
tackling international health problems will be key challenges over the
next couple of decades, Dr. Gilles Paradis told participants
in a Monday afternoon plenary
session.
Dr. Paradis, director of McGill University’s Transdisciplinary Training Program and scientific editor of the Canadian Journal of Public Health, identified knowledge generation and utilization as one of the most important tools for addressing these problems through an effective public health system.
Public health professionals are often confronted with unacceptable inequalities that run counter to the social solidarity at the heart of Canadian society. A hundred years after CPHA’s formation, Dr. Paradis said it’s shameful that First Nations are systematically disadvantaged and neglected by public authorities, left to cope with life conditions that other Canadians would never accept. This situation points to a “moral debt” to support economic, social, and cultural development for Aboriginal communities, giving them the leverage to expand their own education, health, social services, and infrastructure financing.
“For the future, we’re going to be
dealing with blurring and blending across borders, and across
increasingly diverse nations and communities. We’ll be learning how to
meet each other’s needs, listen to each other, and help each other
achieve better health outcomes.”
-
Baltimore
“Because I’m not from public health, I
would say one of the crowning achievements of public health has been
their ability to take the best learnings from other fields and
disciplines and apply them. I’ve been really impressed with my
introduction. The challenge is to prioritize: it’s a multisectoral,
very broad-based field, and there’s a lot to be done.”
-
Toronto
Meanwhile, the growth of international travel, population displacement, instant access to electronic information, environmental and political change, and armed conflict have all contributed to the internationalization of public health, Dr. Paradis said.
Vast disparities in purchasing power and GDP are matched by stark differences in the public health challenges faced by countries of the south and the industrialized north. Africa, Asia, and South America will be hit hardest by climate change and resulting population displacements. Poorer countries also bear the greatest burden of chronic disease, and receive the “export of poisons like tobacco and asbestos” from wealthy regions of the globe.
Dr. Paradis cited H1N1 as the latest evidence that the notion of frontiers and borders is obsolete for public health in the 21st century. He called on public health to manage the negative consequences of globalization, while building solidarity between countries of the north and south.
Ethics survey reveals philosophical rift
Public health professionals and medical philosophers draw drastically different conclusions on ethical questions, leading one researcher to conclude that public health professionals must take a more direct interest in the ethical implications of their work.
On Sunday, Dr. Barry Pakes of Toronto’s Dalla Lana School of Public Health reported on a survey he conducted for his Ph.D. research. Among health units as geographically close as Toronto and Peel, “people in different areas answered the questions differently, even though the medical evidence was clear” on issues like contact follow-up in infectious disease control.
After talking to field practitioners and public health philosophers, Dr. Pakes concluded that “people hold very heterogeneous views on all the really basic stuff about what defines public health, what are legitimate means to achieve our ends, and whether we’re trying to minimize mortality and morbidity or improve equity and fairness. People sit at tables and argue the details of the programs, but they’re really arguing about underlying meta-ethical principles. They just don’t realize it.”
When Dr. Pakes piloted his survey at a public health ethics conference, “the physicians duly answered the questions and provided some data for me. The philosophers scratched out the questions. It was a profoundly disturbing comment. This was the reality—sometimes you have to make a decision. These ivory tower philosophers were just not ready for it.”
He cited four reasons for public health to involve itself more directly in ethical deliberations: it’s the right thing to do, it’s a professional duty, it provides a broader framework for truly tough decisions, and “if we don’t, it will be done by someone who understands public health far less.”
Disease control and vaccination
A monday morning Ask the Experts session, hosted by the Canadian Coalition for Immunization Awareness & Promotion, dealth with a variety of front-line issues in infectious disease contraol and vaccination.
Field research sets tobacco priorities
Localized tobacco prevention and cessation programs are not high priorities for most public health units across Canada, according to a recent literature review contracted by the CPHA. Moreover, little is being done at the local level to minimize the availability of tobacco products, or to address the vulnerabilities of young adults.
“We need the field to tell us what’s important, and what they think our role should be,” Greg Penney, CPHA director of national programs, said at a pre-conference workshop.
Workshop participants suggested that the CPHA could help public health unit representatives learn which local tobacco initiatives are working (and which are not) outside their own provinces and territories. As advocates of tobacco control, public health unit representatives see that they have the potential to influence public opinion, which may in turn influence public policy.
In a recent telephone survey, key informants identified many potential roles for the CPHA, including building a national tobacco public health network, and becoming a conduit for best practice information.
The CPHA will make recommendations to Health Canada in March 2011, said CPHA project coordinator Randi Goddard.
Health inequities need close attention: Fridkin
The second century of public health in Canada will begin with a deeper understanding of health inequities, particularly between Indigenous peoples and other Canadians, and an increased focus on climate change as a cause of continuing health crises, said CPHA student board member Alycia Fridkin, a doctoral student in interdisciplinary studies at the University of British Columbia.
“Population health has improved so much over the last several decades,” she said. “But although we’ve had great advances, there are growing disparities between the people with the poorest health and those with the best health. “As certain infectious diseases re-emerge and chronic disease receives increased attention, “we need to remember that these health problems affect different people disproportionately.”
Inequities are most prominent “when you look at the health of Indigenous peoples in Canada,” Fridkin added. Over the next decade and beyond, she said public health must play a prominent role in improving Indigenous peoples’ health, in partnership with Indigenous leaders.
Climate change will lead to serious health impacts across all jurisdictions and populations, but “the people who currently experience multiple marginalizations will be hit hardest,” she said. That observation makes reducing inequities an issue of social justice and fairness, and positions environment and sustainability as an area where public health professionals must play a prominent role.
Public health veteran recalls clinical roots
The reconstruction of Europe after the Second World War and the onset of the Biafran War in 1967 were the backdrop for the work of a generation of public and international health practitioners. Their achievements in the last several decades paved the way for the advances that are still to come in the second century of public health.
Dr. John Owen of Saskatchewan joined CPHA in 1967, and is one of the association’s longest-standing members. He recalled a career that brought him from basic clinical and public health work outside Birmingham, England, to a lectureship in preventive and social medicine in Nigeria, to public health assignments in the South Pacific and the United States, to one of the earliest health education surveys in Saskatchewan.
“Nowadays, not all people working in public health have any routine clinical attachments or duties,” he said. “My public health career in Britain was largely clinically oriented, which gave me experience in infectious diseases such as tuberculosis, school health, well-baby clinics, and mental health. I do feel people in public health should retain that sort of meaningful connection to a clinical setting, depending on their experience and interests.”
The Daily is the official newsletter of the Centennial Conference of the Canadian Public Health Association, June 13-16, 2010 in Toronto. Views expressed are those of the individuals and organizations cited.
Editor in Chief: Judy Redpath,
CPHA
Editorial and Production: The Conference Publishers,
www.theconferencepublishers.com
Photo: Bard Azima, LivingFace
Photography