Public Health &Public Health &Public Safety:Public Safety:

What are the gaps &What are the gaps &How do we fill them ?How do we fill them ?Einstein meets DarwinEinstein meets Darwin

Queen`s UniversityQueen`s UniversitySeptember 12, 2008September 12, 2008

Carolyn Bennett M.D.,M.P.Carolyn Bennett M.D.,M.P.

Einstein

``insanity is doing the same thing over and over again and expecting different results…..``

Darwin

``It is not the strongest of the species that survives,

not the most intelligent,

but the one most responsive to change.``

Patient as PartnerPatient as Partner

Doctor MultidisciplinaryDoctor Multidisciplinary

Hospital CommunityHospital Community

Women’s health movementWomen’s health movement

= Social determinants of health= Social determinants of health

PovertyPovertyEnvironmentEnvironmentViolenceViolenceEquityEquityEducationEducationShelterShelter

Ongoing health DilemmasOngoing health Dilemmas

The The urgenturgent at the expense at the expense

of the of the importantimportant..

The politics of FEAR……The politics of FEAR……

SILOSSILOS

Jurisdictional nonsenseJurisdictional nonsense

Germs don`t respect bordersGerms don`t respect borders

Ongoing global health DilemmasOngoing global health Dilemmas

POLITICS……POLITICS……

TransparencyTransparency

CapacityCapacity

Global HealthGlobal Health

International Development International Development

Humanitarian CrisesHumanitarian Crises

Pandemic PreparednessPandemic Preparedness

HIV HIV / AIDS/ AIDS

Ebola, building capacity….Ebola, building capacity….– not included in 0.7 targetnot included in 0.7 target

Minister of HandwashingMinister of Handwashing

ChronologyChronologyTurn of century …. urbanizationTurn of century …. urbanization1918 Spanish flu1918 Spanish fluDepressionDepressionTommy Douglas – goal of medicareTommy Douglas – goal of medicare‘‘tyranny of the acute’tyranny of the acute’Lalonde ReportLalonde ReportOttawa CharterOttawa CharterSARSSARSTsunamiTsunamiKatrinaKatrinaoverdue for pandemicoverdue for pandemic

SARS Canada Spring 2003SARS Canada Spring 200344 deaths44 deaths

Median age 75 years - >83% were >60 yearsMedian age 75 years - >83% were >60 years

Underlying chronic disease a problemUnderlying chronic disease a problem

Requires close contact during active illnessRequires close contact during active illness

Health workers at greatest riskHealth workers at greatest risk

Antibiotics and anti-virals not effectiveAntibiotics and anti-virals not effective

Economic problems and disruption far from Economic problems and disruption far from problemproblem

Good Luck and Good managementGood Luck and Good management

BC Regional model more effectiveBC Regional model more effective

Governance – top down ?Governance – top down ?

WHOWHO

EU CDCEU CDC

CDCCDC

PHACPHAC– INSP INSP – BCCDCBCCDC– ??? Ontario Public Health Agency??? Ontario Public Health Agency– Local public healthLocal public health

Governance – top down ?Governance – top down ?WHO WHO

EU CDC EU CDC

CDC CDC

PHAC PHAC–INSP INSP –BCCDC BCCDC–??? Ontario Public Health Agency ??? Ontario Public Health Agency–Local public health Local public health

Lessons learned from SARSLessons learned from SARS

Failure of Communication and ScienceFailure of Communication and Science

Naylor’s 4 C’s – November 2003Naylor’s 4 C’s – November 2003– CollaborationCollaboration– CooperationCooperation– Communication Communication – Clarity – who does what, whenClarity – who does what, when

Germs don’t respect borders !!!!!Germs don’t respect borders !!!!!

The Mushroom Syndrome: The Mushroom Syndrome: SARS and Family MedicineSARS and Family Medicine

Ontario College of Family PhysiciansOntario College of Family Physicians

SARS briefingSARS briefing

Scarborough clinicScarborough clinic

Sharing informationSharing information

Data Data

Pandemic InfluenzaPandemic Influenza

Inevitable ?Inevitable ?

Preparation is good for our health….Preparation is good for our health….– like Y2Klike Y2K

Warning signs ?Warning signs ?– Fujian strain of fluFujian strain of flu– SARSSARS– H5N1 – birdH5N1 – bird– WNVWNV

Tamiflu debacleTamiflu debacle

Central command & control ?????

Ontario

Quebec

Aborig.

Sask.

Newf.

RCMP

Yukon

N.B. Vets

PEI

Nunavut

Military

N.W.T.

B.C.

Manitoba

Correct.Alberta

Learning from our SARS SistersLearning from our SARS Sisters

Hong Kong Hong Kong – Public Health AgencyPublic Health Agency

HanoiHanoi– VSFVSF

BangkokBangkok– Xray systemXray system

Soup lady should dish out facts

Winnipeg Free Press, Mon Oct 3 2005(sorry, no URL; subscription site)

Public Health Minister Carolyn Bennett says what bothers her about a flu pandemic is delivering chicken soup to victims.

……..At last month's annual meeting of the Canadian Public Health Association, she told Canadian Press that mutual support among citizens is one of the most important elements of the response to a pandemic.

Then she added: "The part that bugs me most is the bottom-up part. Does every Canadian know who their three neighbours are...and would we be able to get them the chicken soup and not get infected?"

Florence … Dec. 2004Florence … Dec. 2004

Lady with the LampLady with the LampMeticulous recordsMeticulous recordsStatisticianStatisticianClusters of diseaseClusters of disease

““To understand God’s thoughts we must study To understand God’s thoughts we must study statistics, for these are the measure of His statistics, for these are the measure of His purpose.” purpose.” Florence NightengaleFlorence Nightengale

Paris heat waveParis heat wave

CNN…. August 25, 2003CNN…. August 25, 2003

France heat wave death toll set at 14,802 France heat wave death toll set at 14,802 PARIS (AP) — The death toll in France PARIS (AP) — The death toll in France from August's blistering heat wave has from August's blistering heat wave has reached nearly 15,000, according to a reached nearly 15,000, according to a government-commissioned report government-commissioned report released Thursday, surpassing a prior tally released Thursday, surpassing a prior tally by more than 3,000. by more than 3,000.

  

                  

  

                                                                                               

2003 Paris Heat Wave2003 Paris Heat Wave

Nearly 15,000 people in France, most Nearly 15,000 people in France, most of them elderly, died from heat-related of them elderly, died from heat-related deaths during the heat wave that hit all deaths during the heat wave that hit all of Europe. of Europe.

French authorities say about half the French authorities say about half the people who died as a result of the heat people who died as a result of the heat wave died in their homes, not in wave died in their homes, not in hospitals or nursing homes hospitals or nursing homes

2003 Paris Heat Wave2003 Paris Heat Wave

Critics suggest many seniors were Critics suggest many seniors were abandoned by their families heading to abandoned by their families heading to vacation spots for the traditional August vacation spots for the traditional August holiday. holiday.

The French government cut more than The French government cut more than $150 million in elder funding earlier that $150 million in elder funding earlier that year year

VictimsVictims

The Poor: who either had no working air The Poor: who either had no working air conditioning or could not afford to turn it on. conditioning or could not afford to turn it on.

The Elderly: who were hesitant to open The Elderly: who were hesitant to open windows and doors at night for fear of crime. windows and doors at night for fear of crime.

African Americans: many blacks lived in African Americans: many blacks lived in areas of sub-standard housing and less areas of sub-standard housing and less cohesive neighborhoods.cohesive neighborhoods.

SurvivorsSurvivors

Hispanics: had an unusually low death Hispanics: had an unusually low death rate due to heat. Hispanics at the time rate due to heat. Hispanics at the time lived in places with higher population lived in places with higher population density, and more social cohesion. density, and more social cohesion.

Elderly women: who may have been more Elderly women: who may have been more socially engaged, were less vulnerable socially engaged, were less vulnerable than elderly menthan elderly men

Israel – Israel – January 2005January 2005

Surge capacitySurge capacity

Real time facts.. beds, icuReal time facts.. beds, icu

Communication with health care personnelCommunication with health care personnel

Training, training, trainingTraining, training, training

Blame Hippocrates?Blame Hippocrates?

Affirm Hygeia

HYGEIA: Goddess of Health

Fleeing the Medical Model,Fleeing the Medical Model,Embracing the Medicine WheelEmbracing the Medicine Wheel

WHO Commission on Social WHO Commission on Social Determinants of HealthDeterminants of Health

The Commission on Social Determinants of The Commission on Social Determinants of Health (CSDH) supports countries and global Health (CSDH) supports countries and global health partners to address the social factors health partners to address the social factors leading to ill health and focus on health leading to ill health and focus on health inequities. It draws the attention of society to the inequities. It draws the attention of society to the social determinants of health that are known to social determinants of health that are known to be among the worst causes of poor health and be among the worst causes of poor health and inequalities between and within countries. The inequalities between and within countries. The determinants include unemployment, unsafe determinants include unemployment, unsafe workplaces, urban slums, globalization and lack workplaces, urban slums, globalization and lack of access to health systems. of access to health systems.

The Causes of the CausesThe Causes of the Causes

VersusVersus

The CausesThe Causes

social determinantssocial determinantsvs.vs.

‘choose health’‘choose health’

Evolution of the Healthy Canadians TreeEvolution of the Healthy Canadians Tree

Evolution of the Healthy Canadians TreeEvolution of the Healthy Canadians Tree

““Reorienting health systems”Reorienting health systems”

FROMFROM

a health a health CARECARE system system

TOTO

a true system for a true system for HEALTHHEALTH

Public Health 101 Public Health 101

1.Do you think we should have 1.Do you think we should have a:a:

A) strong fence at the top of the cliffA) strong fence at the top of the cliff

B) state of the art fleet of ambulances and B) state of the art fleet of ambulances and paramedics waiting at the bottom ? paramedics waiting at the bottom ?

2. Would you prefer:2. Would you prefer:

A) Clean airA) Clean air

B) Enough puffers and respirators B) Enough puffers and respirators

for all for all

3. Would you prefer that wait-times 3. Would you prefer that wait-times were reduced by:were reduced by:

A) a falls program to reduce preventable hip A) a falls program to reduce preventable hip fracturesfractures

B) private orthopaedic hospitals and more B) private orthopaedic hospitals and more surgeonssurgeons

4.Should we invest in:4.Should we invest in:

A) early learning, child care, literacy,the A) early learning, child care, literacy,the early identification of learning disabilities early identification of learning disabilities and bullying programmesand bullying programmes

B) increase the budget for young offenders’ B) increase the budget for young offenders’ incarcerationincarceration

5.Should we:5.Should we:

A) assume that the 'grey tsunami' will A) assume that the 'grey tsunami' will bankrupt our health care system bankrupt our health care system

B) include our aging population in the B) include our aging population in the planning of strategies to keep them wellplanning of strategies to keep them well

6. Is the best approach to food 6. Is the best approach to food security:security:

A) food banks and vouchersA) food banks and vouchers

B) Income security,affordable housing, B) Income security,affordable housing, community gardens and community community gardens and community kitchens and a national food policykitchens and a national food policy

7. Pick the one that is NOT correct7. Pick the one that is NOT correct

Pandemic Preparedness should focus onPandemic Preparedness should focus on

A)A) Tamiflu for allTamiflu for all

B)B) Working with the vets to keep avian flu a Working with the vets to keep avian flu a disease of birdsdisease of birds

C)C) Making sure people wash their hands Making sure people wash their hands especially the doctors and nursesespecially the doctors and nurses

D)D) Research on vaccinesResearch on vaccines

E)E) Community care plans for our most vulnerableCommunity care plans for our most vulnerable

8.Governments should boast about:8.Governments should boast about:

A)A) how much they spent on the sickness how much they spent on the sickness care system care system

B)B) the health of their citizens, leaving no-the health of their citizens, leaving no-one behindone behind

Romanow ReportRomanow Report

Discussion paper # 8 Discussion paper # 8 – Zimmerman & GloubermanZimmerman & Glouberman– Complex Adaptive SystemsComplex Adaptive Systems– HIV/Aids Brazil vs AfricaHIV/Aids Brazil vs Africa

GloubermanGlouberman and and ZimmermanZimmerman

Complicated and Complex Systems: What Complicated and Complex Systems: What Would Successful Reform of Medicare Would Successful Reform of Medicare Look Like?Look Like? (2002) (2002)

- Submission to the Romanow Commission- Submission to the Romanow Commission

Bottom upBottom up

Strong common purposeStrong common purpose

Local wisdom, local knowledge to get it Local wisdom, local knowledge to get it donedone

Complexity TheoryComplexity Theory

Simple : following a recipeSimple : following a recipe

Complicated : putting a rocket on the Complicated : putting a rocket on the moonmoon

Complex : raising a childComplex : raising a child

The solutions are complexThe solutions are complex

For every complex human problem, there For every complex human problem, there is a neat simple solution, it’s just that it’s is a neat simple solution, it’s just that it’s wrong… wrong…

HL MenckenHL Mencken

Health Goals for CanadaHealth Goals for Canada

Overarching Goal

As a nation, we aspire to a Canada in which every person is as healthy as they can be –

- physically- mentally - emotionally- and spiritually.

Health Goals for CanadaHealth Goals for Canada

Basic Needs(Social and Physical Environments)

Our children reach their full potential, growing up happy, healthy, confident and secure.

The air we breathe, the water we drink, the food we eat, and the places we live, work and play are safe and healthy - now and for generations to come.

Health Goals for CanadaHealth Goals for CanadaBelonging and Engagement

Each and every person has dignity, a sense of belonging, and contributes to supportive families, friendships and diverse communities.

We keep learning throughout our lives through formal and informal education, relationships with others, and the land.

We participate in and influence the decisions that affect our personal and collective health and well-being.

We work to make the world a healthy place for all people, through leadership, collaboration and knowledge.

Health Goals for CanadaHealth Goals for Canada

Healthy Living

Every person receives the support and information they need to make healthy choices.

Health Goals for CanadaHealth Goals for Canada

A System for Health

We work to prevent and are prepared to respond to threats to our health and safety through coordinated efforts across the country and around the world.

A strong system for health and social well-being responds to disparities in health status and offers timely, appropriate care

Next stepsNext steps

Choose indicatorsChoose indicators

Work with stakeholders to determine Work with stakeholders to determine meaningful targetsmeaningful targets

Empower `bottom up`Empower `bottom up`– Strong common purpose, local wisdom, local Strong common purpose, local wisdom, local

knowledge to get the job done….knowledge to get the job done….

GISGIS

If a picture is worth a thousand words, If a picture is worth a thousand words,

A map is worth a thousand pictures….A map is worth a thousand pictures….

Maps at CDC or HHS shouldn’t stop at Maps at CDC or HHS shouldn’t stop at the 49the 49thth Parallel !!!! Parallel !!!!

powerful graphical and

analytical dimension to public health 1.

Brings together the fundamental epidemiological triad of person, time, and the often-neglected place.

• • 1.The spread of diseases over time

2.Spatial patterns of outbreaks 3.Population groups at risk

4.Availability and access to health care 5.Program intervention planning and assessment

GIS Map Generator -PHACGIS Map Generator -PHAC

With the Public Health Map Generator, you can produce high quality, detailed maps of your own health data, in combination with extensive geography from our spatial data warehouse…

GIS User

*******

The Public Health Map Generator is a secure, web-based mapping application, accessible only to clients registered with the GIS Infrastructure at the Public Health Agency of Canada. All of the Infrastructure’s

services, including the Public Health Map Generator, are available at no cost to all public health professionals in Canada.

Scotland – Honourable Andy Scotland – Honourable Andy KerrKerr

Health outcomes down to postal codeHealth outcomes down to postal code

Letter from Family DoctorLetter from Family Doctor

InterventionsInterventions

Already paying offAlready paying off

ResearchResearch

Evidence-informed practiceEvidence-informed practicePractice-informed evidencePractice-informed evidence

Courage to fund what worksCourage to fund what worksCourage to stop funding what doesn`tCourage to stop funding what doesn`t

Complex adaptive systems…Complex adaptive systems…

Research

Practice Policy

Research

Practice Policy

KT

Research

Practice Policy

KT

Political will

Research

Practice Policy

KT

Political will

Appliedresearch

Research

Practice Policy

ENGAGED CITIZENS

KT

Political will

Appliedresearch

Putting the Public back intoPutting the Public back intoPublic HealthPublic Health

Civic Literacy ….. individualCivic Literacy ….. individual

Civil Society…. Community ActionCivil Society…. Community Action

ProgressProgress

First MoS Public Health 2003-2006First MoS Public Health 2003-2006

Public Health Agency of CanadaPublic Health Agency of Canada

Chief Public Health OfficerChief Public Health Officer

Public Health Network for CanadaPublic Health Network for Canada

Health GoalsHealth Goals

National Collaborating CentresNational Collaborating Centres

Knowledge Networks for the SDOH CommissionKnowledge Networks for the SDOH Commission

A beginning……A beginning……

Global Health Security Action GroupGlobal Health Security Action Group

Canada-Asia Regional Emerging Infectious Canada-Asia Regional Emerging Infectious Disease Initiative $15MDisease Initiative $15M

Global Public Health Intelligence NetworkGlobal Public Health Intelligence Network

International Health Regulations 2005International Health Regulations 2005– Still dependent on country`s capacity Still dependent on country`s capacity

((? willingness) ? willingness) to identify, verify and manage an to identify, verify and manage an outbreak.outbreak.

Global Pandemic Influenza Global Pandemic Influenza Readiness Conference, Readiness Conference,

Ottawa 2005Ottawa 2005

Animal-human healthAnimal-human health– WHO, IOE, FAOWHO, IOE, FAO

Capacity and SurveillanceCapacity and Surveillance

Risk CommunicationRisk Communication

ResearchResearch– access to vaccines and antiviralsaccess to vaccines and antivirals

Beyond borders…. Beyond borders…. SARS as a teachable momentSARS as a teachable moment

Beyond silos Beyond silos – DepartmentsDepartments– DisciplinesDisciplines

Beyond jurisdictional squabblingBeyond jurisdictional squabbling

Germs don’t respect bordersGerms don’t respect borders

Neither do the social contagionsNeither do the social contagionsNor the humanitarian imperativesNor the humanitarian imperatives

““We are not tinkers, who patch and mend what We are not tinkers, who patch and mend what is broken. We must be watchmen, guardians is broken. We must be watchmen, guardians of the life and health of our generation, so of the life and health of our generation, so that stronger and more able generations may that stronger and more able generations may come after.”come after.”

Dr. Elizabeth Blackwell Dr. Elizabeth Blackwell first woman physician in North Americafirst woman physician in North America