Post on 31-Dec-2015
1
Dr. David Butler-JonesChief Public Health OfficerCIPHI June 26, 2006
Sinclair Lecture PresentationOctober 19, 2006
2
“One Half of children die before their 8th year.This is nature’s law. Why try to contradict it?”
Rousseau
The Lessons of Columbus?
•Traveling Into the Unknown• He Found the Wrong Place• Named the Wrong People
• Introduced Unintended Consequences•Became Famous
•Go Figure
4
Ethical Principles
• Organizing Principle: to protect and
promote the public’s health• Ensure equity and distributive justice• Respect the inherent integrity of all
persons• Use the least restrictive means• Optimize the risk benefit ratio• Work with transparency and accountability
5
Life Expectancy at birth
World Health Report 2006
30 Years
50 Years
75 Years80 Years
1700Bronze Age
1900
19802003
6
Quality of Life
Country Healthy Life
Expectancy
Life
Expectancy
Japan 75 82
Australia 73 80
Canada 72 80
Sweden 73 80
United Kingdom 71 78
United States 69 77
Cuba 68 77
India 54 62
Kenya 44 50
Nigeria 42 45
7
A Global Perspective GDP & Life Expectancy
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
Country
GD
P p
er
cap
ita (U
SD
$) .
0
10
20
30
40
50
60
70
80
90
Life E
xp
ecta
ncy (years
) .
GDP per capita ($)Life ExpectancyCIA World Factbook/World Health Report, 2006
8
Urbanization-Urbanization-
Climate Change-Climate Change-
Globalization-Globalization-
Economic Gaps- Economic Gaps-
Technology-Technology-
Social Change-Social Change-
The Basics Still Matter-The Basics Still Matter-
Health & Global ChangeHealth & Global Change
9
Historical Reasons for Improved Life expectancy
• Improved Nutrition• Adequate Housing• Smaller Families• Sanitation and Clean Water• Pasteurization and
Immunization
10
A balance of Approaches?
Competing influences reducing CHD deaths– clinical treatments vs risk factors– evidence from studies in the USA, UK and
New Zealand: 40% of the reduction comes from better
treatments 50-60% from a reduction in risk factors
Bandolier, July 2004 at http://www.jr2.ox.ac.uk/bandolier/band125/b125-2.html
11
Infant Mortality, Family Physicians, GDP and Health Spending in Canada
0
10
20
30
40
50
60
70
BC AB SK MB ON QC NB PEI NS NL
Do
lla
rs $
00
0's
.
0
2
4
6
8
10
12
14
Ra
te
GDP per capita (2004) Health $ per capita (2005)
GP/FP per 10,000 (2006) Infant Mortality Rate per 1000 (2001)
12
Cataract surgery- not all positive outcomes
Wright et al., CMAJ, 2002; 167(5):461-6
13
Getting a New Heart?
• Cardiac transplantation showed a survival benefit only for patients with a predicted high risk of dying on the waiting list - (Deng, De Meester, Smits, Heinecke and Scheld on behalf of the Comparative Outcome and Clinical Profiles in Transplantation (COCPIT) Study Group, BMJ 2000;321:540-5)
• -Transplantation only improved survival of medium and high-risk patients compared with medical therapy - (Lim et al. Journal of Heart and Lung Transplant 2005;24(8):983-989)
• -A survival benefit is anticipated only for severely ill patients (Krakauer, Lin and Bailey Journal of Heart and Lung Transplantation 2005;24(6):680-689).
14
Stress Test Screening
Cost per Year of Life Saved___
• Male 60 yr. $24,600
• Female 40 yr. $216,000
15
What Can Be Done About Accidental Deaths in Children• Where Better or More Timely
Treatment Might Have Made A
Difference? 20%
HSC
16
17
The Health of the Population
Peace and Stable Ecosystem Food and Shelter Education Sustainable Resources Child Development Working Conditions Choices and Coping Income and Social Status Health Services Social Support Network
18
Mortality and Relationships
0
5
10
15
20
25
30
35
40
% mort
30-49 50-59 60-69 30-49 50-59 60-69
age
Most Connected Least ConnectedMost Connected Least Connected
FemaleMale
Males
Females
19
Future Cause of Death Before Age 70 Among 100,000 Smokers Now Aged 15
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Smoking MVA Alcohol Suicide Murder Hantavirus Mad Cow
20
0
20
40
60
80
100
120
140
Su
icid
e R
ate
per
100
,000
.
0 1 2 3 4 5 6Total Number of Cultural Factors Present
Cultural Factors: • Self-government •Land claim participation • Education *• Health services *• Cultural facilities *• Police/fire services *
* In the presence of community control
Aboriginal Youth Suicide by Factors Present
Chandler & Lalonde, 1998
21
Policy in the New Age?
“We must do something;
This is something;
Let's do this”
“First do no harm”?
22
Traps
•Macro Avoidance
•Micro Paralysis
Distortions
• Health Imperialism
• Health Determinism
25
Public Health Functions(Not Just Programs but a way of understanding populations problems and their solutions)
•Population Health Assessment•Disease & Injury Surveillance•Health Promotion•Disease and Injury Prevention•Health Protection
•Emergency Preparedness & Response
26
Prevention and Health Promotion Focus and Misconceptions
• Focus =Healthiest Population per Resources• Health Has Inherent Worth, However Achieved• Greatest Health from Outside of Health
Services• Not a Panacea - Both Benefits and Liabilities• Not Last Resort of Failed Treatment• Spectrum = Promote-Prevent-Treat-Care• Expertise?- It’s Easy To Do, Poorly
27
Addressing The Determinants
• Partner- Who can we work with, to do it better together?
• Advocate- What needs to be done at policy legislative
level?
• Cheerlead- Encouraging and not getting in the way.
• Enable- What we do directly to change the determinants
• Mitigate- Picking up some of the pieces, so it isn’t worse
28
“Success is 10% inspiration and 90% perspiration”
Stephen Leacock
Saskatchewan Hepatitis A
1994 - 1999
0
100
200
300
400
500
1994 1995 1996 1997 1998 1999
Year
# of
Cas
es
First Nation Other
Vaccine program
30
Health Benefits for Low Income Families SK
• working poor in better health than on social assist
• Family Health Benefits results in better health management
• Hospital and physician use was lowest among the FHB
• Prescription drugs, chiropractic and optometric increased
• Poor health status may precede receipt of welfare (health status measured by physician service use)
• - all support the need to use a population health approach to health policy and planning (as the authors indicate)
31
A problem?
• Breakdown of community and social supports • Mental wellbeing• Vision and focus on the public good? • 55% of adults inactive• 36% of adults overweight• 23% of adults obese• Tobacco-use remains highest health risk • 2,700 babies with FASD every year• 11% of youth that drink =frequent binge drinking• Etc.
32
Obesity Trends* Among Canadian AdultsHPS, 1985
Source: KatzmarzykPT. Can Med Assoc J 2002;166:1039-1040.
(*BMI 30, or ~ 30 lbs overweight for 5’4” person)
No Data <10% 10%-14% 15-19% 20%
33
Obesity Trends* Among Canadian AdultsNPHS, 1994
(*BMI 30, or ~ 30 lbs overweight for 5’4” person)
Source: KatzmarzykPT. Can Med Assoc J 2002;166:1039-1040.
No Data <10% 10%-14% 15-19% 20%
34
Obesity Trends* Among Canadian AdultsCCHS, 2000
(*BMI 30, or ~ 30 lbs overweight for 5’4” person)
Source: P.T. Katzmarzyk, Unpublished Results. Data from: Statistics Canada. Health Indicators,May, 2002.
No Data <10% 10%-14% 15-19% 20%
35
Obesity Trends* Among Canadian AdultsCCHS, 2003
Source: P.T. Katzmarzyk, Unpublished Results. Data from: Statistics Canada. Health Indicators, June, 2004.
No Data <10% 10%-14% 15-19% 20%
(*BMI 30, or ~ 30 lbs overweight for 5’4” person)
36
Sri Lanka
Outbreaks/Emergencies/disasters =
usually small numbers relative to
routine preventable mortality.
However- if we screw up,
we have little credibility for anything else.
37
New and re-emerging Epidemics -Principles
• Cannot completely prevent, but can reduce by
addressing underlying determinants• All emergencies are messy, but the mess should
be as short as possible• Basic Capacity for Outbreaks is the same as for
Prevention of Chronic Disease and Infection• Those who die are largely those with chronic
disease, poor health or poverty• Organization and Flexibility - rapid research and
analysis, control and prevention
38
Infections in history … a sampler
1/3 of Europe killed by plague-Middle Ages 90-95% pop of Americas lost post-contact Napoleon and Typhus in Russia 40,000 child deaths/ day-inf. and
malnutrition Afghan children 100X mort of US-Cdn.
soldiers HIV and Poverty in Africa 1 million deaths from Malaria/year etc. etc.
39
40
CDC
41
Estimates of Health Impacts in Canada During a Pandemic
• 11,000 to 58,000 deaths• 34,000 to 138,000 hospitalizations• 2 to 5 million outpatients(Most deaths due to secondary infections, e.g. pneumonia)
Economic costs:• health care: $330 million to $1.4 billion• societal (lost productivity): $5 to $38 billion
42
Pandemic Canada 1918-19 By today’s population: 150-160,000 deaths…but
• General better health and nutrition• Antibiotics for secondary infections• Vaccines and anti-virals• Not post WWI – Magnified in trenches & mass
population movements• Not multiple underlying infections • Good health care and better understanding
• However, many developing countries similar
43
Just in Case Medicine? 1
• Antivirals for Prophylaxis- lack of
studies to demonstrate effectiveness– Risk of earlier resistance?– May not be effective against pandemic
virus– Side effects– Ability to deliver?– Who gets and why?
44
Just in Case Medicine? 2
• N95 vs surgical masks (possible exceptions-eg high risk procedure., cull infected birds)
– Droplet Spread (practical difference between demonstrating can find virus and that it actually causes infection by other means)
– N95 proper fit needed and difficult to wear long term
– May actually increase risk in wrong setting – Supply and access issues
45
Large Cities on a sunny day
Mexico City
46
Highest concentration in last 650,000 years
900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000
260
280
300
320
340
360
380
CO
2 C
once
ntra
tion
(ppm
v)
CO2 in at least the past 650,000 years
Year CDIAC
47
1900 1920 1940 1960 1980 2000
Year
0
20
40
60
80
100
Winter Storm Frequencyin the Northern Hemisphere
S
torm
s /
Win
ter
Source: Lambert 1996
48
Great Weather Disasters 1950–2005Economic and Insured losses(as at November 30, 2005)
© 2005 Geo Risks Research, Munich Re
0
10
20
30
40
50
60
70
80
90
100
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
Year
Bill
ion
US
$ (2
004
valu
es)
Economic losses (2004 values)
Insured losses (2004 values)Trend economiclosses
Trend insured losses
160bn US$
49
Warming Effects and Health
• Change in Disease Patterns
• Change in Eco Systems
• Water Quality
• Air Quality
• Extremes of Weather Events
• Social Migration
50
Social Migration
• Job Displacement• Land Values• Population Shifts
– Disease patterns– Social structures– Economic changes
51
52
WHO Estimated Mortality for Year 2000
Attributable to Climate Change
Patz et al., 2005
53
Ethical Principles
• Organizing Principle: to protect and
promote the public’s health• Ensure equity and distributive justice• Respect the inherent integrity of all
persons• Use the least restrictive means• Optimize the risk benefit ratio• Work with transparency and accountability
54
Working Group on PH Ethics
• Identify and review Agency initiatives
pertaining to ethics
• Strategy & Framework to support ethical
decision-making
• Options and strategies to implement ethics
review mechanisms
• Contribute to national strategy for public
health ethics
55
“I’ve got it too
Omar… a strange feeling
like we’ve just been going in circles”
56
What Expertise or Perspective Don’t We Need?
57
Surviving Health Reform
• Embrace the Forest• Engage in Reflective Practice• Current Problems Often Were Once Solutions• The Simple Answer is: There Are No Simple
Answers, (But There Are Answers)• There Is Only One Answer (And That Is- There
Is More Than One Solution)• Focus on Application and Dissemination
““The health of the The health of the public is the foundation public is the foundation upon which rests the upon which rests the happiness of the people happiness of the people and the welfare of the and the welfare of the state.” state.” DisraeliDisraeli
“Courage, my friend, it’s not too late to make the
world a better place.” Tommy Douglas