I say Epidemic – You say Fear Mongering

By Ted Bruce

Debates on public health issues are a staple of life. Unfortunately, they often involve a false dichotomy. Those promoting individual choice argue that public health advocates are “no fun” trying to create a “nanny state” by banning all those tasty treats and indulgences like cheap happy hours and supersized pop. On the other hand, those seeking regulation may too readily use scare tactics in support of their arguments. I’ve been known to demonstrate this tendency myself. For example I may have been a bit over the top in arguing that those in favour of the new alcohol regulations in BC think that there’s nothing wrong “with a couple cheap double rum and supersized cokes after work to set you up for the drive home from work”. Who needs evidence when you can undermine your opponent with an “insightful” analysis like that?

When we get beyond the rhetoric though, these debates are critical as they force us to bring evidence to bear on an issue and help to educate the public about the need for important public health measures. A good example at the moment is the current debate on electronic cigarettes and whether they are actually a good thing because they may help some people reduce their addiction to tobacco. It is actually a critical issue and is becoming a well informed debate with better evidence and clearer arguments on both sides.

What we sometimes forget, however, is the importance of stopping long enough to recognize our past accomplishments and highlighting these. By demonstrating the value of population health interventions we can better help people understand the need for public health policies. This is especially important when pejorative statements like “nanny state” or “government paternalism” are used to counter public health evidence. The image of public health is an important commodity in winning the public over to effective interventions. In the electronic cigarette debate, actions to restrict electronic cigarettes may move quickly because of the credibility of public health that comes from the tobacco story we tell. The Canadian Public Health Association’s campaign on the greatest public health accomplishments is a good example of building trust in public health.

obesity report

A recently released report by the Fraser Institute on obesity in Canada has been slammed by many in the public health community.

The importance of celebrating our successes and using these in shaping a case for public health interventions was brought home to me by the recent Fraser Institute report on obesity in Canada. They analyzed a very selective data set on weights to suggest that there is no need for public health interventions that they describe as “government paternalism” – yes they invoke that language to shore up their case – to deal with what they argue is not an epidemic of obesity. (It is worth noting that in the report they also characterize Canadian anti-smoking efforts as an “increasingly draconian war on the tobacco industry”.) There are many available critiques of the Fraser Institute report discrediting many of the arguments they put forward but an important one was by the Canadian Public Health Association and the Dieticians of Canada. Notable in this response is the comment on the success in combating obesity and the need to do even more.

It would be easy to rant about the Fraser Institute report being biased. It is important to critique their arguments and evidence to show where it is wrong. But as importantly, we must reinforce the successes of population health approaches to build confidence and trust in the voice of public health. Rhetoric is loud and can hide the evidence the public Ted Profileneeds to consider. Public health builds a credible voice by speaking out on its successes and demonstrating its value. It is this credibility that helps the public take the time to examine the evidence and draw sound conclusions. Sometimes it is important to brag a little.

– Ted Bruce is the past-president of the PHABC

Further Reading:

Obesity is a Public Health Concern | Dieticians of Canada – News Release | April 28, 2014 | http://www.dietitians.ca/News-Releases/2014/ObesityPublicHealth.aspx

12 Great Acheivements in Public Health | Canaidan Public Health Association | http://www.cpha.ca/en/programs/history/achievements.aspx

Obesity in Canada: Overstated Problems, Misguided Policy Solutions | The Fraser Institute | April 28 2014 | https://www.fraserinstitute.org/research-news/display.aspx?id=21119

In the News:

Canada’s obesity ‘epidemic’ exaggerated and the health risks overstated, Fraser Institute says | By Sharon Kirkey | The National Post | April 28 2014 | http://news.nationalpost.com/2014/04/28/canadas-obesity-epidemic-exaggerated-and-the-health-risks-overstated-fraser-institute-says/

The fight for democracy is a public health fight too

By Dr. Trevor Hancock

A couple of weeks ago I was in Manchester for the International Conference on Urban Health, and spent a couple of hours at the People’s History Museum. Manchester is such an interesting city, because it was the first industrial city, and it has a powerful history of social and political reform. Perhaps most dramatically Marx and Engels worked there together (Engels’ description of conditions in Manchester is hair-raising), much of the Communist Manifesto was written there, and there are many other examples of social and political reform. The fight for democracy came out of these workplaces, streets, and cities, and in many ways it was a fight motivated by concerns for the health and wellbeing of the population.

Rudolph Virchow, 1821 (Source: http://en.wikipedia.org/wiki/Rudolf_Virchow)

Rudolph Virchow, 1821 (Source: en.wikipedia.org/wiki/Rudolf_Virchow)

Remember, it was an investigation into the causes of typhus in Upper Silesia that led Rudolf Virchow to his famous 1848 statement that “medicine is a social science, and politics but medicine writ large”. He said this in response to Prussian politicians (to whom he had reported) telling him his report was a political report, not a medical report, because he recommended that what was needed was the “introduction of Polish as an official language, democratic self-government, separation of church and state, and the creation of grassroots agricultural cooperatives”.

Why does this come to mind now? Because I believe what we are seeing in the state of democracy around the world, and especially here in Canada, is a vitally important political and ethical issue with profound implications for public health. We have already seen that the Harper Government has almost always acted in opposition to the evidence and the interests of public health (climate change, asbestos mining, gun control and safe injection sites, to name but 4 issues – see my July 24th 2013 blog). We have seen that they have muzzled their own scientists, destroyed their libraries, laid many of them off, cut the funding to environmental groups and gone after them using the Canada Revenue Agency and other means, all in an effort to silence those who oppose their blindly pro-business, anti-environment and anti-public health agenda.

But now, and most egregious and dangerous of all, they are trying to pervert democracy in Canada with their so-called Fair Elections Act (in the double speak of the Republican-style naming of Bills that the Harper government has adopted, we know a “fair” act will be anything but fair!). Just this week, a group of international scholars and political scientists sent an open letter to the Globe and Mail in which they write:

(we) are concerned that Canada’s international reputation as one of the world’s guardians of democracy and human rights is threatened by passage of the proposed Fair Elections Act. We believe that this Act would prove [to] be deeply damaging for electoral integrity within Canada, as well as providing an example which, if emulated elsewhere, may potentially harm international standards of electoral rights around the world. In particular, the governing party in Canada has proposed a set of wide-ranging changes, which if enacted, would, we believe, undermine the integrity of the Canadian electoral process, diminish the effectiveness of Elections Canada, reduce voting rights, expand the role of money in politics, and foster partisan bias in election administration.

Read full letter: http://www.theglobeandmail.com/news/politics/letter/article17561359/

The Globe and Mail itself, in an unprecedented series of five editorials, has denounced the Bill and the process (see http://www.theglobeandmail.com/news/politics/scholars-denounce-conservative-governments-proposed-fair-elections-act/article17561354/   for links to these editorials).

The Harper government’s attacks on public health and the environment will only be strengthened by the rigging of elections to give them an unfair advantage and a continuing mandate. We must all oppose this undemocratic Bill on grounds of democracy, social justice, environmental sustainability and public health, all of which are threatened by this government and its dangerously undemocratic tendencies.

Trevor Hancock crop_0

Dr Trevor Hancock is a Professor and Senior Scholar, School of Public Health and Social Policy at the University of Victoria.

Ethical healthcare in British Columbia

By Ted Bruce

I read with interest the article in The Tyee by Christine Boyle and Seth Klein entitled Imagining a Moral Economy for British Columbia.

The article laid out the rationale and the potential for us to re-think economic development and base our decisions about the economy on a set of moral principles. The principles they articulate include ecological justice, equality and shared good.  The article resonated with me in part because of the work PHABC has been doing to bring attention to the Corporate Determinants of Health: see the recent commentary in the Canadian Journal of Public Health by PHABC’s Dr. John Millar.

But it also reminded me of the need for a moral foundation for the health care system.

PHABC has called for greater investment within the health care system on upstream prevention and health promotion. Similar to the “moral economy”, a health promoting system would be based on a strong set of ethical principles – those articulated by public health. The core principles of public health concern themselves with questions of equity, social justice and the distribution of health and risk. Public health recognizes that health is situated within the social, political, and economic environment and if the health care system is to be effective it must attend to the relationship between these aspects of society and the individual. In short, improvements in the health of the population and the reduction in health inequities – ostensibly the goals of the health care system – depend upon addressing poverty, racism and inequality.

In fact the current approach to health care, with its focus on treating sick individuals, is nearing collapse under the weight of an unlimited demand for more service and an attempt to respond to this demand primarily by improving efficiency of services geared to these already ill individuals. Many would say that addressing the social determinants of health is not the job of the health care system. But there is an important and under developed role for health care to focus on health promoting factors – to keep people healthy, to address health inequities through targeted programming and to show leadership to encourage and facilitate inter-sectoral actions to address the social determinants of health such as poverty.

It is time we redesigned our health care system based on the ethics or moral foundation underlying public health.

– Ted Bruce is the past-President of the PHABC.

Healthy Corporate Citizen Award

Corporations are an ever increasing part of our lives not just through the products and services they produce and provide, market and sell but through their involvement in shaping society through their increasing dominance in the social, political and economic life of our communities. Corporations affect our health in both direct and indirect ways.

In order to raise awareness of the role of the corporate sector in public health and in the potential for corporations to provide leadership in improving health, PHABC has created a Healthy Corporate Citizen Award.

The award is intended for a corporation, financial institution or producer/worker cooperative in British Columbia that demonstrates a broad and comprehensive commitment to promoting health through a range of policies, products/services and practices. The award is not intended to reward a specific policy, product/service or practice but rather is intended to recognize a broad commitment to addressing the determinants of health (e.g., housing and food security) that can be influenced by corporate activities (e.g., paying a living wage) and to avoid contributing to dangerous or unhealthy policies, products/services and practices (e.g., marketing unhealthy food).

PHABC members or organizations that wish to self-nominate must submit a general statement of nomination of no more than 500 words. In addition, the nominator must comment on the performance of the nominated organization in regard to specific criteria.

If you are interested in making a nomination pleasecontact PHABC (staff@phabc.org) to get more information on the criteria for the award.

Advocacy is Not Always Popular

By Dr. Trevor Hancock

Public health is political – always was, always will be. Ideologically, we believe in the collectivity, in using the power of the state to manage, control, tax, enforce and even punish (we do all these, for example, with respect to tobacco control, perhaps the most lauded public health success in the past 50 years).

Whether we are trying to control tobacco and alcohol use, unsafe food system practices, unhealthy working conditions, environmental pollution or junk food, we are going to irritate powerful ideological and thus political opponents; both those who believe in individual freedoms more than in collective responsibility and those who believe in unfettered free enterprise.

Nothing new in that: In the 15th century, Carlo Cipolla tells us in his 1976 book Public Health and the Medical Profession in the Renaissance, that the Health Officers for the Boards of Health complained about the hostility of the merchants, who in turn complained that their economic well-being was disrupted by the regulation of trade and commerce by the Boards, who were trying to enforce quarantines to control the spread of infectious diseases such as the plague.

It is not our role to try to be ‘neutral’ in these situations; we are not neutral, we are very clearly pro-health, which means we are very clearly opposed to health-damaging activity, no matter the source. If we are not biased, we are not doing our jobs. If we do not speak out in oppostion to policies, programs and practices harmful to health, be they from the public, private, non-profit, faith, academic or any other sector, we are not doing our jobs.

You only need to look at the recent policy positions of the Canadian Public Health Association to see such opposition in practice.

Opposed to minimum sentences

In favour of firearms control, opposed to closing the gun registry

Today twenty-eight medical, nursing, allied health and suicide prevention organizations and thirty-three professionals in the same fields, released an open letter to Members of Parliament in order to underscore the importance of the gun registry in helping to prevent domestic murders, accidents and suicides.

“For almost twenty years the Canadian Public Health Association has advocated for stronger gun laws including the licensing of all gun owners and registration of firearms because of their potential to prevent death and injury. We are seeing encouraging results from Canada’s progressive gun laws. Firearm related deaths in Canada have reached a 30 year low and of particular note is the dramatic decline in the misuse of rifles and shotguns, the target of the 1977, the 1991 and the 1995 legislation.”

Opposed to continuing support for the mining and expert of asbestos

CPHA calls once again on the Government of Canada to support the listing of chrysotile asbestos under the Rotterdam Convention, and as well urge the GOC to take actions to:

  1. Introduce legislation to ban the mining, use, and export of asbestos
  2. Cease funding the Chrysotile Institute

In favour of supervised injection facilities

CPHA commends and supports the Supreme Court of British Columbia’s ruling granting Insite, Canada’s first supervised injection facility (SIF), a constitutional exemption from the application of sub-section 4(1) and 5(1) of the Controlled Drugs and Substances Act (CDSA).

Clearly, the CPHA policy positions, based on public health values and evidence, are in opposition to declared federal policy and practice.  The Harper government, it has recently been revealed, has an enemies list – their word, not mine. Not an opponents list – an enemies list.

Well, if standing up for good public health policy and practice makes us not just opponents of the government, but enemies, so be it. We should all be on the list; I certainly hope I am on it, and will be offended if I am not! (see my letter to the Globe and Mail, July 18th)

Trevor Hancock crop_0

So are you on the enemies list? If not, why not?

Dr. Trevor Hancock is a Professor and Senior Scholar, School of Pulic Health and Social Policy at the University of Victoria

Great Ideas Have Long Lives

By Ted Bruce

The election is over and, as they say, the hard work starts. The spin doctors, backroom strategists, pundits and pollsters take a break and the world of policy development and advocacy carry on. Policies that are essential to improve the health of the population require a long and sustained effort. Public health policy work is arduous and although there are quick wins for the most part the complex web of causality requires multiple policy and program interventions implemented over a long time. And often efforts must push against countervailing forces that at times seem insurmountable.

But they are not insurmountable and the ideas behind population health are not easily dismissed. Social justice, fairness, health and wellbeing are foundational to the notion of reducing health inequities and preventing disease before it sets its roots.

The election campaign proved an opportunity to raise awareness of health inequities and the importance of poverty reduction and disease prevention. In looking at the election campaigns, political party platforms and the media and political dialogue, there was certainly considerable interest in the idea of poverty reduction. Although there was not agreement on the policies needed to reduce it, it is safe to say that it will likely maintain momentum as a post election topic. The need for a new prevention paradigm for health care did not get much discussion. Clearly, public health has a way to go to captivate the political dialogue on that issue.

This is not new. These issues have been at the forefront of public health for a long time and will continue so. Why? In part because the alleviation of human suffering and the promotion of health and well being are central to public health and the root causes of health inequities must be a central focus if public health is to be successful in its mission to improve health for all citizens – not just some citizens. And the policy agenda is complex. The solutions require a huge paradigm shift in a policy environment that has diminished the valuing of public services and has emphasized individualism over collective action. And they require considerable vision and commitment on the part of government and non-governmental leaders. Election time is a window to push for that vision. Post election is a time to continue to educate the public, to bring the evidence forward to the decision-makers and to do the hard work of policy change.

PHABC’s website for the election has some great resources for the continuing dialogue about health inequities, poverty reduction and disease prevention. PHABC has had considerable feedback that an on-line toolkit and the social media campaign were an effective contributor to the dialogue on public health. As co-chair of the PHABC Policy Advocacy Committee, I know this strategy will continue.

Change does not come easy. There are risks associated with change but great ideas deserve risks.  Health and well being for all citizens, social justice and public health – these are great ideas. Elections come and go. Great ideas have long lives.

– Ted Bruce is the past-president of the PHABC

Public Health is ROI

By Dr. Marjorie MacDonald

Earlier this week, I posted a blog on this website about the economic benefits of prevention. After writing the blog, I realized that in the US, it is National Public Health Week with the theme “Public Health is ROI” (return on investment). Since this deals with the focus of my earlier blog, I thought I would post a weblink from APHA on this very theme.

National Public Health Week — Public Health is ROI: Save Lives, Save Money (video by the American Public Health Association)

–  Marjorie MacDonald is the President of Public Health Association of BC