David Butler-Jones Sinclair Lecture (1)

7/31/2019 David Butler-Jones Sinclair Lecture (1)

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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

0

5000

10000

15000

20000

2500030000

35000

40000

45000

USA

Cana

da

Austr

alia

Unite

dKi

ngdo

m

Japa

n

Fran

ce

Swed

en

Spain

Hung

ary

Braz

il

Swaz

iland

Indo

nesia

India

Cuba

Keny

a

Nige

ria

Som

alia

Country

G

DP

percapita(

USD$)

0

10

20

30

40

5060

70

80

90

L

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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20

30

40

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60

70

BC AB SK MB ON QC NB PEI NS NL

Dollars$000's

0

2

4

6

8

10

12

14

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

0

5

10

1520

25

30

35

40

% mort

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

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

Smoking MVA Alcohol Suicide Murder Hantavirus Mad Cow


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0

20

40

60

80

100

120

140

Sui

cideRateper100,0

0

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

0

100

200

300

400

500

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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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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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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'

' '' '

'

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''''' ' ' '

'

900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000

260

280

300

320

340

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

0

20

40

60

80

100

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

0

10

20

30

40

50

60

70

80

90

100

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.

David Butler-Jones Sinclair Lecture (1)

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