1

Sinclair Lecture Presentation October 19, 2006

Dr. David Butler-Jones Chief Public Health Officer CIPHI June 26, 2006

One Half of children die before their 8th year. This is natures law. Why try to contradict it?
Rousseau

The Lessons of Columbus?

Traveling Into the Unknown He Found the Wrong Place Named the Wrong People Became Famous Introduced Unintended Consequences

Go Figure

Ethical Principles
Organizing Principle: to protect and

promote the publics 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

Life Expectancy at birth

80 Years 75 Years

2003 1980

50 Years

1900

30 Years

1700 Bronze Age

World Health Report 2006

Quality of Life
Country Healthy Life Expectancy Life Expectancy

Japan
Australia Canada Sweden United Kingdom United States Cuba India Kenya Nigeria

75
73 72 73 71 69 68 54 44 42

82
80 80 80 78 77 77 62 50 45

A Global Perspective GDP & Life Expectancy

45000 90 80 70 60 50 40 30 20 10 0 40000 35000 30000 25000 20000 15000 10000 5000 0

US Ca A n Un A ada ite ust d ra Ki lia ng do m Ja pa Fr n an Sw ce ed en Sp Hu ain ng ar y Br Sw az az il i In land do ne sia

Country

CIA World Factbook/World Health Report, 2006

In di a Cu b Ke a ny Ni a ge So ria m al ia

GDP per capita ($) Life Expectancy

Life Expectancy (years) .

GDP per capita (USD$) .

Health & Global Change

UrbanizationClimate ChangeGlobalization-

Economic GapsTechnologySocial Change-

The Basics Still Matter-

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

70 60 14 12 10 8 6 4 2 0 BC AB SK MB ON QC NB PEI NS NL

Dollars $000's .

50 40 30 20 10 0

GDP per capita (2004) GP/FP per 10,000 (2006)

Health $ per capita (2005) Infant Mortality Rate per 1000 (2001)

Rate

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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.
Female 40 yr.

$24,600
$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

40 35 30 25 % mort 20 15 10 5 0 30-49 50-59 60-69 age Most Connected Most Connected
Males Females

Male

Female

30-49

50-59

60-69

Least Connected Least Connected

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Future Cause of Death Before Age 70 Among 100,000 Smokers Now Aged 15
18000 16000 14000 12000 10000 8000 6000 4000 2000 0
Smoking MVA Alcohol Suicide Murder Hantavirus Mad Cow

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Aboriginal Youth Suicide by Factors Present

140 120
Suicide Rate per 100,000.

Cultural Factors:
Self-government Land claim participation Education * Health services * Cultural facilities * Police/fire services * * In the presence of
community control

100 80 60 40 20 0 0 1 2 3 4 5 6
Total Number of Cultural 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?- Its 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

Mitigateworse

Picking up some of the pieces, so it isnt

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Success is 10% inspiration and 90% perspiration

Stephen Leacock

Saskatchewan Hepatitis A
1994 - 1999
500 400

Vaccine program

# of Cases

300 200 100 0

1994 1995 1996 1997 1998 1999

Year First Nation Other

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Health Benefits for Low Income Families

working poor in better health than on social assist

SK

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 Adults HPS, 1985

(*BMI 30, or ~ 30 lbs overweight for 54 person)

No Data

<10%

10%-14%

15-19%

20%

Source: Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

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Obesity Trends* Among Canadian Adults NPHS, 1994

(*BMI 30, or ~ 30 lbs overweight for 54 person)

No Data

<10%

10%-14%

15-19%

20%

Source: Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

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Obesity Trends* Among Canadian Adults CCHS, 2000

(*BMI 30, or ~ 30 lbs overweight for 54 person)

No Data

<10%

10%-14%

15-19%

20%

Source: P.T. Katzmarzyk, Unpublished Results. Data from: Statistics Canada. Health Indicators, May, 2002.

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Obesity Trends* Among Canadian Adults CCHS, 2003

(*BMI 30, or ~ 30 lbs overweight for 54 person)

No Data

<10%

10%-14%

15-19%

20%

Source: P.T. Katzmarzyk, Unpublished Results. Data from: Statistics Canada. Health Indicators, June, 2004.

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Outbreaks/Emergencies/disasters =
usually small numbers relative to routine preventable mortality.

However- if we screw up, we have little credibility for anything else.

Sri Lanka

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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 todays population: 150-160,000 deathsbut 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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CO2 in at least the past 650,000 years

380

CO2 Concentration (ppmv)

360

340

320

300

280 ' 260

$ $ $ $ $ $ $ $ $ Highest concentration in last 650,000 years $ $ $ $ $ $ ! $ $ $ $ #! !$ $ ' ' ' ! # ' ' ' ! ' '! ! !# '!#$ ' ' ' # $ $ # ' ! $$ ' ' ' $ ' ' ' '

900

1000

1100

1200

1300

1400

1500

1600

1700

1800

1900

2000
CDIAC

Year

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Winter Storm Frequency in the Northern Hemisphere

100

Storms / Winter

80

60

40

20

0 1900

1920

1940

1960

1980

2000

Year
Source: Lambert 1996

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Great Weather Disasters 19502005 Economic and Insured losses

(as at November 30, 2005)
100 90 80 70
(2004 values)

160bn US$

Billion US$

60 50 40 30 20 10 0 1950

Economic losses (2004 values) Insured losses (2004 values) Trend economic losses Trend insured losses

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Year
2005 Geo Risks Research, Munich Re

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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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52

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 publics 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

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Ive got it too Omar a strange feeling like weve just been going in circles

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What Expertise or Perspective Dont 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 public is the foundation upon which rests the happiness of the people and the welfare of the state. Disraeli

Courage, my friend, its not too late to make the world a better place.
Tommy Douglas