Join CPHA

The Daily - June 17, 2010


Security, solidarity, systems are key global drivers

Security, solidarity, and systems—three concerns on the global agenda—“can bring the transnational nature of health issues to the attention and agenda of all countries, big and small, rich and poor alike,” said Dr. Tim Evans of the James P. Grant School of Public Health, speaking at the Wednesday morning plenary.

The challenges of global health “cross national borders in an increasingly interconnected and globalized world,” he said, noting that current trends and crises “represent enormous opportunities and challenges that cannot be ignored by any nation state.”

Infectious disease has long been identified as a threat to national and economic security, as the 2003 SARS outbreak illustrated, Dr. Evans said. During and after SARS, questions were raised about whether nations like Canada were prepared to respond to such threats. Concerns arose not only about vaccine production, but about equitable access to vaccines.

The concern for equality or solidarity is a major global driver, Dr. Evans said. Inequities across countries are coming to be seen as “both avoidable and unfair.” Redistribution of wealth and social stratification are both on the global agenda: “It’s clear that health systems do not necessarily gravitate toward equity,” he said, echoing the WHO’s Commission on Social Determinants of Health. “Social injustice is killing on a grand scale.”

One of the greatest challenges is the magnitude of global health systems.

“It is a five to six trillion dollar industry that grows faster than most GDPs, and its most common form of financing is out-of-pocket payments at point of service, impoverishing 100 million persons annually,” Dr. Evans said. “It’s an extremely resource-intensive industry.” The sheer size of the systems involved can result in unsafe care and in failing to act on the knowledge of what works.

An effective response to global health complexity must involve promoting global health research, Dr. Evans said. Just as the knowledge of the determinants of health has expanded, research must expand to include a “full spectrum of measurable determinants of health.”

Dr. Evans said health care workers must be trained to respond to the complexities of global health. He suggested mid-career training and shifting the educational paradigm to include flexible approaches as good places to start.

 

Brock Chisholm: Controversial Canadian led formation of the WHO

Physician and military officer, administrator and internationalist, Dr. Brock Chisholm was the largely unknown Canadian who become the first director general of the World Health Organization in 1948.

Dr. Chisholm served at a time when nations’ main health priority was to keep out diseases from elsewhere, said medical historian John Farley, author of Brock Chisholm, the World Health Organization, and the Cold War. “He saw beyond that. He demanded that the WHO be run by world-thinking civil servants.”

Rather than running “single disease campaigns, where you go in and control the disease and everyone gets better… [Dr. Chisholm] …thought the social issues of poverty and medical infrastructure were just as important as going after disease,” Farley said. This put him at odds with Cold War decision-makers who saw national disease-control campaigns as a tool for winning hearts and minds around the globe.
 

Prison populations particularly vulnerable

All health issues—not only infectious diseases—facing prison populations should concern public health, concluded a panel Tuesday.

Prison populations are especially vulnerable, with determinants that are “very dear to public health,” said Dr. Jane Buxton of the B.C. Centre for Disease Control, who reported on medical students who visited prisons during their practicums. For many students, this was their first encounter with a vulnerable population, and a chance to revisit stigmatizing views.

Dr. Robert Strang of the Nova Scotia Department of Health Promotion and Protection spoke about his province’s move to make the health system responsible for providing health care in prisons. A survey of inmates entering penitentiaries uncovered some startling results: one-third of those surveyed had attempted suicide at some point in their lives.

“Mental health is a critical piece for health care in a correctional setting,” said Dr. Strang. “Every Nova Scotian deserves the same level of health care, whether they are in a correctional facility or not.”

Many forensic psychiatric inmates are obese, in part because of second-generation antipsychotic medications, said Dr. Sue Pollock of the Public Health Agency of Canada (PHAC); she described a project that intervened in this population’s lifestyle habits to counter this effect.

A participant who identified himself as a physician in an Aboriginal health organization noted the disproportionate numbers of Aboriginal inmates in Canadian prisons. In response to his query about fetal alcohol screening in prisons, another participant noted that the Correctional Service of Canada has been carrying out research in this area.

 

Injury prevention groups team up

The report from a groundbreaking collaborative study on injury prevention was released yesterday afternoon at the CPHA conference.

CEOs of Canada’s four leading national injury groups–Safe Communities Canada, Think First Canada, SMARTRISK, and Safe Kids Canada—teamed up to conduct the study on lowering Canada’s incidence of preventable injury and death. The report, One Voice, Safer Canada, calls for those working toward injury prevention to unify their efforts, promote the cause, and increase the impact of all four contributing organizations.

Each day in Canada, 35 people die, 580 are hospitalized, and 14 become disabled due to injury. Aside from the heavy toll this takes on injured victims and their families, the annual economic burden totals nearly $20 billion. Of the 23 members of the Organisation for Economic Co-operation and Development (OECD), Canada ranks 18th in injury mortality for children and youths.

“It’s an international disgrace that we’re number 18. The status quo is unacceptable,” said Paul Kells of Safe Communities Canada, who lost his son to a workplace accident in 1994. Kells said Canadians don’t think about injuries until someone they know is affected, so there is much to be done to raise public awareness. “It’s time to walk the talk.”

Conference participants greeted the new study results with enthusiasm. A medical officer of health remarked that a pan-Canadian organization set up to deal with injury issues at a provincial level would make the job easier at a municipal level. With so much happening in the injury prevention arena, an umbrella group that takes a knowledge-brokering role could greatly assist front-line efforts, another participant

noted.

One participant warned that turf issues might prevent some groups from buying in; another applauded the organizational plan but offered a caution about the conflicts and duplications that could arise.

Rebecca Nesdale-Tucker of Think First Canada responded, “We’re not taking an ‘us-against-them’ attitude. We want to move the whole movement forward. It will take time.”

The four collaborating organizations plan to have the new structure in place within the next year. Some existing organizations and some prominent individuals working in the field have already announced their interest in partnering with a new national entity.

 

Engage youth to improve mental health

Asking the right questions, partnering with youth, and using schools as a natural entry point can make all the difference for youth facing mental health challenges, said speakers at a session Tuesday.

The New Mentality (TNM), a youth- and adult-led project to reduce the stigma of mental illness has been cutting a new pathway toward changes in the mental health system. The pilot project, which uses a youth-adult partnership model, aims to make the voices of the vulnerable heard, engaging youth as leaders, facilitators, or group members.

“It’s more than youth and adults working together,” said Marie-Josée Cleroux, a trained youth speaker with TNM. “We value power-with, versus power-over.”

As far back as 1993, a phone survey of youth by the Canadian Psychiatric Association indicated that 19% of young people had had suicidal thoughts and 5% had attempted suicide, said Dr. Ian Manion of the Provincial Centre for Excellence for Child and Youth Mental Health at Ottawa’s Children’s Hospital of Eastern Ontario (CHEO). Teens indicated that stigma and embarrassment kept many of them from seeking help, even when they had suicidal thoughts. Ottawa’s Youth Net program found that 45% of young men with suicidal thoughts had never told anyone before.

Asking questions and creating a safe environment can make the difference, Dr. Manion said. “Ninety-six per cent of educators we surveyed were very or extremely concerned about student mental health in their school board.”

While schools are not responsible for meeting all their students’ needs, issues that directly affect learning become schools’ responsibility, Dr. Manion said, noting that schools are uniquely positioned to screen for mental health problems among youth.

“The Mental Health Commission of Canada has decided that school-based mental health is a priority for them,” Dr. Manion said. This means creating partnerships with teachers, not necessarily adding to their already heavy workload.

 

Small water systems create complex issues

A recently tabled bill in Parliament would mean water systems in First Nations communities meet basic provincial standards—but Bill S-11 does not address the critical issue of funding to ensure compliance, said participants in a Tuesday afternoon session.

Currently, First Nations water systems are not covered by any government regulation; and although a countrywide audit of these water systems is underway, a final report is not expected for at least a year.

During the session, hosted by the National Collaborating Centres for Public Health (NCCPH), participants discussed a number of issues regarding small drinking water systems (SDWS). NCCPH representative Mona Shum said that the SDWS project was complicated, in large part because of the profusion of regulatory bodies and policies that surround the topic.

Participants agreed on the need to clearly establish whether problems with SDWS in Canada are real or perceived, because unless people are convinced there is an actual risk, policy-makers will not be motivated to act.

When asked to share ideas about how NCCPH could help improve SDWS oversight, participants suggested providing more risk communication tools, examining the feasibility of using public health nurses to disseminate information about water-borne illnesses, and providing a Consumer Reports-style review of small water safety test kits typically used in small and remote communities.

 

In Aboriginal Health, the Living Context Tells the Story

By Madeleine Dion Stout

Canada cannot deal with the public health issues facing First Nations, Inuit and Métis without looking at our social, political, and economic context.

The field of public administration defines policy as “action or inaction taken on a set of related problems.” On that continuum, the cultures and nations that most Canadians know collectively as Aboriginal peoples have mostly seen inaction. This is the living context that sheds light on the prevailing health conditions in Aboriginal communities.

The statistics on First Nations, Inuit, and Métis health tell the story, particularly for the northern and remote communities that face the most severe disparities and inequities. In Aboriginal communities across Canada, infant mortality rates are 20 times higher than in the general population, Type 2 diabetes is three times as prevalent, and suicide rates are five to 11 times higher. Earning ability among adult males is about half the Canadian average, and as high as Canada places on the United Nations Human Development Index, Aboriginal people place far lower.

So it should be no surprise that one of the most significant public health advances in the last 100 years has been the resistance by First Nations, Inuit, and Métis people to health disparities and inequities, and to wider exclusionary practices that date back to the British North America Act of 1867. A promising development is the number of Canadians who are now beginning to see themselves as treaty-signers along with us, since that recognition is a first step toward reconciliation.

In recent times, we have seen a growing tendency to understand Aboriginal communities’ public health issues and trends through an Aboriginal lens. For many years, Canadians romanticized Aboriginal cultures and world views—and that, too, served a purpose, by keeping First Nations, Inuit, and Métis visible to the surrounding culture. But the shift to a more authentic understanding of Aboriginal cultures and traditions creates an essential cornerstone for effective public health practice in our communities.

As Canadians, Aboriginal people have seen some benefit from policies enacted to serve the entire population. But almost without exception, policies and programs to address the shocking health and socio-economic conditions in our own communities have either fallen short of implementation, like the report of the Royal Commission on Aboriginal Peoples, or been cancelled before their time, like the Aboriginal Healing Foundation.

The most bitter setback in recent years was the cancellation of the Kelowna Accord, a formal agreement among federal, provincial, and Aboriginal governments that included significant funding and policy reform for health services and facilities. The Accord called for immediate steps to mitigate tough, entrenched challenges like infant mortality, youth suicide, childhood obesity, and diabetes by 20% within five years and 50% within a decade. The goals were lofty. But the Accord has since been abandoned, the promised funding never came through, and the end result only perpetuated a history of colonial dispossession and impoverishment.

The latest variant on that history is a trend toward privatization of essential services, like rural water systems, that represents a profound challenge to the traditions and cohesion of First Nations, Inuit, and Métis communities. The traditional gift economy is well-represented in potlatch and sundance ceremonies that our people have often had to struggle to maintain. Now, the extension of privatization threatens to undermine and abuse that tradition, as surely as it will threaten our health.

Against this backdrop, it is more important than ever for all of Canada’s cultures to seize every opportunity for reconciliation. Aboriginal communities have been reaching out across cultures. As we see Canadians reaching out in turn, helping us to end the cycle of social suffering, health inequities, and structural violence, we will gradually take our rightful place in Canadian society.

Madeleine Dion Stout, MA, RN, is an honorary professor at the University of British Columbia School of Nursing and recipient of the 2010 National Aboriginal Achievement Award for Health.
 

Health researchers: Solid data drives policy

Solid research data is needed to effectively drive public policy, said speakers at the Wednesday morning session on health through the life course.

 

“What do we do to ensure that decision-makers’ needs are met?” asked Dr. Clyde Hertzman of the Human Early Learning Partnership, University of British Columbia. “The real challenge is to figure out how to narrow things down so we don’t lose credibility.”

“Indicator pollution” threatens to overwhelm researchers and decision-makers—there are simply too many important things to measure, which can dissipate research focus and lead to policy paralysis. Dr. Hertzman suggested that early childhood researchers focus on the 18-month platform, the Early Development Indicator, and the Middle Years Development Indicator.

Dr. Susan Kirkland, of Dalhousie University’s departments of Community Health & Epidemiology and Medicine, said her approach is “all about complexity.” In her research on aging, she includes factors from physical to psychosocial functioning, functional status, wellness, and quality of life.

Contextual factors must be identified in health research, Dr. Kirkland said. “It’s important that we continually think about the ways in which we measure these things—social and emotional resources instead of just physical capacities.” Challenges in research on aging include limited data sources—some of which exclude populations that are experiencing inequalities, like people in nursing homes, people on reserves, and those without homes.

Hope Beanlands of the National Collaborating Centre for Determinants of Health (NCCDH) pointed out, “We need to tackle the inequitable distribution of power, money, and resources, locally, nationally, and globally.”

 

Broaden perspectives, shed stereotypes to improve Aboriginal health

This is an exciting time for fostering inter-community communications, and Aboriginal voices are eager to be heard, said panelists during a Wednesday morning session.

“We must remember to recognize the expertise of Aboriginal communities, and not miss the opportunity,” said Dr. Janet Smylie, a physician and researcher at the University of Toronto. She noted that Aboriginal community members have evidence, and it is sophisticated.

Katherine Minich of the National Aboriginal Health Organization (NAHO) said all human beings are involved in a relationship with knowledge; this is a fundamental understanding among Canada’s 45,000 Inuit people.

“We need to challenge our roles and responsibilities to broaden environmental health,” Minich said. “The planet is a determinant of health.”

One way to challenge the status quo is to shed stereotypes. Dr. Charlotte Reading, a researcher at the University of Victoria, said half the Canadian women who are HIV positive are Aboriginal; this is linked to injection drug use and participation in the sex trade. But rather than stereotype this population, it is more useful to understand the historical, economic, and social conditions that drive them toward risky behaviour.

“As a researcher, I try to gather voices from the communities and share them with the National Collaborating Centre for Aboriginal Health (NCCAH), which brings them to the funders and decision-makers,” Dr. Reading said.

A speaker from the NCCAH, academic leader Margo Greenwood, said the movement toward community-oriented research, along with conference networking, has been very beneficial in promoting Aboriginal knowledge.

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