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

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3. The Lessons of Columbus?

4. 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. 5 Life Expectancy at birth Many factors go into improving health outcomes: Pease and stable ecosystem, food and shelter, education, sustainable resources, child development, working conditions, income and social status, health services, social supports Hence, life expectancy in Canada has steadily improved and continues to rise. Many factors go into improving health outcomes: Pease and stable ecosystem, food and shelter, education, sustainable resources, child development, working conditions, income and social status, health services, social supports Hence, life expectancy in Canada has steadily improved and continues to rise.

6. 6 Quality of Life Not only about how long we live, it�s about maximizing the number of healthy years we live. Many ways to monitor: Well-being Ability to Function Healthy life expectancy Historically, the significant improvement in life and quality of life expectations are due to: improved nutrition, more broad availability of adequate housing, smaller families, better sanitation and clean water, advent of pasteurization and immunization Not only about how long we live, it�s about maximizing the number of healthy years we live. Many ways to monitor: Well-being Ability to Function Healthy life expectancy Historically, the significant improvement in life and quality of life expectations are due to: improved nutrition, more broad availability of adequate housing, smaller families, better sanitation and clean water, advent of pasteurization and immunization

7. 7 A Global Perspective GDP & Life Expectancy Source: CIA World Fact Book (2004-2005 Data), Available at: http://www.odci.gov/cia/publications/factbook/rankorder/2004rank.html (Accessed April 2006), The World Health Report, 2006 (2004 Data), World Health Organization. Available at: http://www.who.int/globalatlas/dataQuery/reportData.asp?rptType=1 (Accessed April 2006) Source: CIA World Fact Book (2004-2005 Data), Available at: http://www.odci.gov/cia/publications/factbook/rankorder/2004rank.html (Accessed April 2006), The World Health Report, 2006 (2004 Data), World Health Organization. Available at: http://www.who.int/globalatlas/dataQuery/reportData.asp?rptType=1 (Accessed April 2006)

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9. 9 Historical Reasons for Improved Life expectancy Improved Nutrition Adequate Housing Smaller Families Sanitation and Clean Water Pasteurization and Immunization

10. 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

11. 11 Infant Mortality, Family Physicians, GDP and Health Spending in Canada NOTE: Slide without territories. Source: GP/FP: Canadian Medical Association, 2006 Infant Mortality: 2001 Rates, Statistics Canada, 2005 GPD: Statistics Canada, 2004 Health $ per capita: CIHI, 2005 NOTE: Slide without territories. Source: GP/FP: Canadian Medical Association, 2006 Infant Mortality: 2001 Rates, Statistics Canada, 2005 GPD: Statistics Canada, 2004 Health $ per capita: CIHI, 2005

12. 12 Cataract surgery- not all positive outcomes Cataract surgery. Distribution of post-operative changes in Visual Function Assessment score. Data were missing for 3% of patients. Interpretation: Not all cataract surgeries produced positive patient outcomes; in fact the result is worse vision for approximately 26%. This study questions the appropriateness for surgery indications as the threshold for cataract surgery in this region is very low (the mean VFA was 79 in this study compared to a range of 64-77 reported elsewhere). Other international published studies of patients who received cataract surgery show worse outcomes ranging from 5.5% to 36.7%. A few studies also have shown a significant change quality of life measures � both positive and negative. Measuring patient outcomes using the HRQOL and VFA are feasible, at reasonable cost and could be included into an accountability framework for health services. Red Flags: Critics may argue over the HRQOL used ie. methodology debate rather than outcome debate. Also the bias introduced by the lack of surgeon participation in the second study should only bias in the favour of potentially more negative HRQOL changes being identified. Cataract surgery. Distribution of post-operative changes in Visual Function Assessment score. Data were missing for 3% of patients. Interpretation: Not all cataract surgeries produced positive patient outcomes; in fact the result is worse vision for approximately 26%. This study questions the appropriateness for surgery indications as the threshold for cataract surgery in this region is very low (the mean VFA was 79 in this study compared to a range of 64-77 reported elsewhere). Other international published studies of patients who received cataract surgery show worse outcomes ranging from 5.5% to 36.7%. A few studies also have shown a significant change quality of life measures � both positive and negative. Measuring patient outcomes using the HRQOL and VFA are feasible, at reasonable cost and could be included into an accountability framework for health services. Red Flags: Critics may argue over the HRQOL used ie. methodology debate rather than outcome debate. Also the bias introduced by the lack of surgeon participation in the second study should only bias in the favour of potentially more negative HRQOL changes being identified.

13. 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. 14 Stress Test Screening Cost per Year of Life Saved___ Male 60 yr. $24,600 Female 40 yr. $216,000 Source:Source:

15. 15 What Can Be Done About Accidental Deaths in Children Where Better or More Timely Treatment Might Have Made A Difference? 20% HSC Source: HSCSource: HSC

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17. 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. 18 Mortality and Relationships

19. 19 Future Cause of Death Before Age 70  Among 100,000 Smokers Now Aged 15

20. 20 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 In the 5-year study window: When no cultural factors were present a suicide rate of 137.5 per 100,000 was found When all 6 cultural factors were present there were no suicides within the study time frame Overall, their analysis found a strong linear relationship between suicide risk and the number of cultural factors present. Source: Chandler, MJ, and Lalonde, C. 1998. Cultural continuity as a hedge against suicide in Canada�s First Nations. Transcultural Psychiatry, 35(2), pp. 191-219. In the 5-year study window: When no cultural factors were present a suicide rate of 137.5 per 100,000 was found When all 6 cultural factors were present there were no suicides within the study time frame Overall, their analysis found a strong linear relationship between suicide risk and the number of cultural factors present. Source: Chandler, MJ, and Lalonde, C. 1998. Cultural continuity as a hedge against suicide in Canada�s First Nations. Transcultural Psychiatry, 35(2), pp. 191-219.

21. 21 Policy in the New Age? �We must do something; This is something; Let's do this� �First do no harm�?

22. 22 Sign illustrates importance of not letting a possible hazard distract us from a very real, already existing, major hazard.Sign illustrates importance of not letting a possible hazard distract us from a very real, already existing, major hazard.

23. Traps Macro Avoidance Micro Paralysis

24. Distortions Health Imperialism Health Determinism

25. 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. 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. 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

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29. Saskatchewan Hepatitis A 1994 - 1999

30. 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. 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. Despite the efforts and accomplishments of the many programs that are provided across Canada, the following data raise serious concerns about the future health of Canadians. 55% of Canadians are not physically active or moderately active (CCHS, 2004); 36% of adult Canadians are overweight and 23% are obese (CCHS, 2004); The eating habits of adult Canadians fall substantially short of standards for good nutrition as recommended by Canada�s Food Guide. Tobacco-use remains the risk factor, which contributes the most towards the burden of disease in Canada; The incidence of FASD is about 9 per 1,000 live births (ref. Chudley et al. in CMAJ March 1, 2005) or 2,700 babies each year; and 11% of school-aged youth who drink, report frequent binge drinking (2 to 3 times per month).. NOTES: Only 33.4 % of Canadians consume the recommended number of servings of fruits and vegetables per day (CCHS, 2004).Despite the efforts and accomplishments of the many programs that are provided across Canada, the following data raise serious concerns about the future health of Canadians. 55% of Canadians are not physically active or moderately active (CCHS, 2004); 36% of adult Canadians are overweight and 23% are obese (CCHS, 2004); The eating habits of adult Canadians fall substantially short of standards for good nutrition as recommended by Canada�s Food Guide. Tobacco-use remains the risk factor, which contributes the most towards the burden of disease in Canada; The incidence of FASD is about 9 per 1,000 live births (ref. Chudley et al. in CMAJ March 1, 2005) or 2,700 babies each year; and 11% of school-aged youth who drink, report frequent binge drinking (2 to 3 times per month).. NOTES: Only 33.4 % of Canadians consume the recommended number of servings of fruits and vegetables per day (CCHS, 2004).

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37. 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. 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.

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41. 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 We cannot predict the impact of the next pandemic; impacts of previous pandemics have been very different. However, simple statistical models that project estimates based on a set of assumptions are helpful for planning purposes. The estimated economic impact of a pandemic influenza in Canada would be $10 to 24 billion ($5-38), excluding disruptions to commerce and society. The economic impact includes direct medical costs associated with hospitalizations, outpatient visits and drug purchases. The principal indirect cost was lost productivity i.e time off work, economic cost of a death. When a pandemic happens, financial markets will prove as vulnerable as unvaccinated humansWe cannot predict the impact of the next pandemic; impacts of previous pandemics have been very different. However, simple statistical models that project estimates based on a set of assumptions are helpful for planning purposes. The estimated economic impact of a pandemic influenza in Canada would be $10 to 24 billion ($5-38), excluding disruptions to commerce and society. The economic impact includes direct medical costs associated with hospitalizations, outpatient visits and drug purchases. The principal indirect cost was lost productivity i.e time off work, economic cost of a death. When a pandemic happens, financial markets will prove as vulnerable as unvaccinated humans

42. 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. 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. 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. 45 Large Cities on a sunny day

46. 46 CO2 in at least the past 650,000 years The human influence on the climate system is primarily through the effect of greenhouse gas and aerosol emissions on the make-up of the atmosphere and its role in the climate system. Atmospheric concentrations of greenhouse gases, which insulate the earth from heat loss to space, have been in remarkable balance over the past millennium. This is illustrated by the measurements of CO2 concentrations extracted from fossilized air in polar ice sheets, as shown, but also applies to other key greenhouse gases. In fact, concentrations of carbon dioxide (the most important of these greenhouse gases) appear to have never exceeded 300 ppm during at least the last 650,000 years. However, during the past century, its concentrations have increased by 31%. Other gases have also increased dramatically. There is clear evidence that these increases are due to human emissions, primarily from combustion of fossil fuels for energy purposes and due to deforestation. Data source: CDIAC online The human influence on the climate system is primarily through the effect of greenhouse gas and aerosol emissions on the make-up of the atmosphere and its role in the climate system. Atmospheric concentrations of greenhouse gases, which insulate the earth from heat loss to space, have been in remarkable balance over the past millennium. This is illustrated by the measurements of CO2 concentrations extracted from fossilized air in polar ice sheets, as shown, but also applies to other key greenhouse gases. In fact, concentrations of carbon dioxide (the most important of these greenhouse gases) appear to have never exceeded 300 ppm during at least the last 650,000 years. However, during the past century, its concentrations have increased by 31%. Other gases have also increased dramatically. There is clear evidence that these increases are due to human emissions, primarily from combustion of fossil fuels for energy purposes and due to deforestation. Data source: CDIAC online

47. 47 Analysis of intense storm events, based on surface pressure below 970 mb, indicate a significant increase in extreme winter storms in the last few decades. There are significant concerns about the quality of the historical data used for this study. However, experts suggest trends are too large to be explained by data problems. Analysis of intense storm events, based on surface pressure below 970 mb, indicate a significant increase in extreme winter storms in the last few decades. There are significant concerns about the quality of the historical data used for this study. However, experts suggest trends are too large to be explained by data problems.

48. 48 The above trends are primarily due to losses associated with weather disasters. However, the most recent pentad includes ~$100B for the Kobe earthquake disaster. While the industry suggests that much of the increase can be attributed to demographic factors, it is convinced that a significant factor is more frequent extremes. The climatological data for extreme weather events, particularly those associated with multiple climate factors, are inadequate to properly analyze long term trends for all events. The above trends are primarily due to losses associated with weather disasters. However, the most recent pentad includes ~$100B for the Kobe earthquake disaster. While the industry suggests that much of the increase can be attributed to demographic factors, it is convinced that a significant factor is more frequent extremes. The climatological data for extreme weather events, particularly those associated with multiple climate factors, are inadequate to properly analyze long term trends for all events.

49. 49 Warming Effects and Health Change in Disease Patterns Change in Eco Systems Water Quality Air Quality Extremes of Weather Events Social Migration

50. 50 Social Migration Job Displacement Land Values Population Shifts Disease patterns Social structures Economic changes

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52. 52 WHO Estimated Mortality for Year 2000 Attributable to Climate Change

53. 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. 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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57. 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

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