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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 beforetheir 8th year.This is natures law.Why try tocontradict it?
Rousseau
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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
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Life Expectancy at birth
World Health Report 2006
30 Years
50 Years
75 Years
80 Years
1700
Bronze Age
1900
1980
2003
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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 PerspectiveGDP & Life Expectancy
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35000
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USA
Cana
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Austr
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Unite
dKi
ngdo
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Swed
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Spain
Hung
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Braz
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Swaz
iland
Indo
nesia
India
Cuba
Keny
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Som
alia
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G
DP
percapita(
USD$)
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ifeExpectancy
(years)
GDP per capita ($)Life ExpectancyCIA World Factbook/World Health Report, 2006
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Urbanization-
Climate Change-
Globalization-Economic Gaps-
Technology-
Social Change-
The Basics Still Matter-
Health & 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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BC AB SK MB ON QC NB PEI NS NL
Dollars$000's
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Rate
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 etal. 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 inChildren
Where Better or More TimelyTreatment 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 ResourcesChild DevelopmentWorking Conditions
Choices and Coping Income and Social StatusHealth Services
Social Support Network
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Mortality and Relationships
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30-49 50-59 60-69 30-49 50-59 60-69
age
Most Connected Least Connected
Most Connected Least Connected
FemaleMale
Males
Females
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Future Cause of Death Before Age 70Among 100,000 Smokers Now Aged 15
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Smoking MVA Alcohol Suicide Murder Hantavirus Mad Cow
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Sui
cideRateper100,0
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0 1 2 3 4 5 6
Total Number of Cultural Factors Present
Cultural Factors: Self-government
Land claimparticipation
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
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Distortions
Health Imperialism
Health Determinism
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Public Health Functions(Not Just Programs but a way of understandingpopulations problems and their solutions)
Population Health Assessment
Disease & Injury SurveillanceHealth Promotion
Disease and Injury Prevention
Health Protection
Emergency Preparedness & Response
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Prevention and Health PromotionFocus 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 bettertogether?
Advocate-What needs to be done at policy legislativelevel?
Cheerlead- Encouraging and not getting in the way.
Enable- What we do directly to change thedeterminants
Mitigate- Picking up some of the pieces, so it isntworse
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Success is 10% inspiration
and 90% perspirationStephen Leacock
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Saskatchewan Hepatitis A
1994 - 1999
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1994 1995 1996 1997 1998 1999
Year
#ofCases
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 Adults
NPHS, 1994(*BMI 30, or ~ 30 lbs overweight for 54 person)
Source: Katzmarzyk PT. Can Med Assoc J2002;166:1039-1040.
No Data
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Obesity Trends* Among Canadian Adults
CCHS, 2000(*BMI 30, or ~ 30 lbs overweight for 54 person)
Source: P.T. Katzmarzyk, Unpublished Results.Data from: Statistics Canada. Health Indicators, May, 2002.
No Data
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Obesity Trends* Among Canadian Adults
CCHS, 2003
Source: P.T. Katzmarzyk, Unpublished Results.
Data from: Statistics Canada. Health Indicators,June, 2004.
No Data
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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 $38 billion
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Pandemic Canada 1918-19By todays population: 150-160,000 deathsbut
General better health and nutrition
Antibiotics for secondary infections
Vaccines and anti-virals
Not post WWI Magnified in trenches & mass
population movements
Not multiple underlying infections
Good health care and better understanding
However, many developing countries similar
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Just in Case Medicine? 1
Antivirals for Prophylaxis- lack of
studies to demonstrate effectiveness
Risk of earlier resistance?
May not be effective against pandemicvirus
Side effects
Ability to deliver?
Who gets and why?
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Just in Case Medicine? 2
N95 vs surgical masks(possible exceptions-eg high risk procedure., cull infected birds)
Droplet Spread (practical difference between
demonstrating can find virus and that it actually causesinfection by other means)
N95 proper fit needed and difficult to wearlong term
May actually increase risk in wrong setting Supply and access issues
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Large Cities on a sunny day
Mexico City
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Highest concentration in last 650,000 years
!!
! ! ! !! ! !!$
$
$$$$$$$$$$$$$$$$$$$$$$$$$$
# ##
## #
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900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000
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280
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360
380
CO2
Concentration(ppmv)
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
Storms
/Winter
Source: Lambert 1996
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Great Weather Disasters 19502005Economic and Insured losses(as at November 30, 2005)
2005 Geo Risks Research, Munich Re
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1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
Year
BillionUS$
(2004
values)
Economic losses
(2004 values)
Insured losses
(2004 values)
Trend economic
losses
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 Mortalityfor 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
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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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Ive got it
too Omara strangefeeling likeweve just
been goingin circles
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What Expertise orPerspective Dont
We Need?
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Th h lth f th
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The health of the
public is the foundationupon which rests the
happiness of the peopleand the welfare of thestate. Disraeli
Courage, my friend, its
not too late to make theworld a better place.