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Dr. David Butler-JonesChief Public Health OfficerCIPHI June 26, 2006

Sinclair Lecture PresentationOctober 19, 2006

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“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

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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

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Life Expectancy at birth

World Health Report 2006

30 Years

50 Years

75 Years80 Years

1700Bronze Age

1900

19802003

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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

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A Global Perspective GDP & Life Expectancy

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Life E

xp

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GDP per capita ($)Life ExpectancyCIA World Factbook/World Health Report, 2006

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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

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Historical Reasons for Improved Life expectancy

• Improved Nutrition• Adequate Housing• Smaller Families• Sanitation and Clean Water• Pasteurization and

Immunization

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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

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Infant Mortality, Family Physicians, GDP and Health Spending in Canada

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GDP per capita (2004) Health $ per capita (2005)

GP/FP per 10,000 (2006) Infant Mortality Rate per 1000 (2001)

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Cataract surgery- not all positive outcomes

Wright et al., CMAJ, 2002; 167(5):461-6

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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).

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Stress Test Screening

Cost per Year of Life Saved___

• Male 60 yr. $24,600

• Female 40 yr. $216,000

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What Can Be Done About Accidental Deaths in Children• Where Better or More Timely

Treatment Might Have Made A

Difference? 20%

HSC

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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

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Mortality and Relationships

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% mort

30-49 50-59 60-69 30-49 50-59 60-69

age

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FemaleMale

Males

Females

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Future Cause of Death Before Age 70 Among 100,000 Smokers Now Aged 15

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Smoking MVA Alcohol Suicide Murder Hantavirus Mad Cow

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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

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Policy in the New Age?

“We must do something;

This is something;

Let's do this”

“First do no harm”?

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Traps

•Macro Avoidance

•Micro Paralysis

Distortions

• Health Imperialism

• Health Determinism

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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

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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

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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

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“Success is 10% inspiration and 90% perspiration”

Stephen Leacock

Saskatchewan Hepatitis A

1994 - 1999

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Year

# of

Cas

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First Nation Other

Vaccine program

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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)

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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.

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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%

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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%

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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%

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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)

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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.

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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

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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.

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CDC

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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

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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

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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?

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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

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Large Cities on a sunny day

Mexico City

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Highest concentration in last 650,000 years

900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000

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CO

2 C

once

ntra

tion

(ppm

v)

CO2 in at least the past 650,000 years

Year CDIAC

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1900 1920 1940 1960 1980 2000

Year

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Winter Storm Frequencyin the Northern Hemisphere

S

torm

s /

Win

ter

Source: Lambert 1996

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Great Weather Disasters 1950–2005Economic and Insured losses(as at November 30, 2005)

© 2005 Geo Risks Research, Munich Re

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Economic losses (2004 values)

Insured losses (2004 values)Trend economiclosses

Trend insured losses

160bn US$

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Warming Effects and Health

• Change in Disease Patterns

• Change in Eco Systems

• Water Quality

• Air Quality

• Extremes of Weather Events

• Social Migration

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Social Migration

• Job Displacement• Land Values• Population Shifts

– Disease patterns– Social structures– Economic changes

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WHO Estimated Mortality for Year 2000

Attributable to Climate Change

Patz et al., 2005

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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

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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

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“I’ve got it too

Omar… a strange feeling

like we’ve just been going in circles”

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What Expertise or Perspective Don’t We Need?

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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