Public Health &
Public Safety:
What are the gaps &
How do we fill them ?
Einstein meets Darwin
Queen`s University
September 12, 2008
Carolyn Bennett M.D.,M.P.
Einstein
``insanity is doing the same thing over
and over again and expecting
different results…..``
Darwin
``It is not the strongest of the
species that survives,
not the most intelligent,
but the one most responsive to
change.``
Patient as Partner
Doctor
Multidisciplinary
Hospital
Community
Women’s health movement
= Social determinants of health
Poverty
Environment
Violence
Equity
Education
Shelter
Ongoing health Dilemmas
The urgent at the expense
of the important.
The politics of FEAR……
SILOS
Jurisdictional nonsense
Germs don`t respect borders
Ongoing global health Dilemmas
POLITICS……
Transparency
Capacity
Global Health
International Development
Humanitarian Crises
Pandemic Preparedness
HIV / AIDS
Ebola, building capacity….
– not included in 0.7 target
Minister of Handwashing
Chronology
Turn of century …. urbanization
1918 Spanish flu
Depression
Tommy Douglas – goal of medicare
‘tyranny of the acute’
Lalonde Report
Ottawa Charter
SARS
Tsunami
Katrina
overdue for pandemic
SARS Canada Spring 2003
44 deaths
Median age 75 years - >83% were >60 years
Underlying chronic disease a problem
Requires close contact during active illness
Health workers at greatest risk
Antibiotics and anti-virals not effective
Economic problems and disruption far from
problem
Good Luck and Good management
BC Regional model more effective
Governance – top down ?
WHO
EU CDC
CDC
PHAC
– INSP
– BCCDC
– ??? Ontario Public Health Agency
– Local public health
WHO
EU CDC
CDC
PHAC
– INSP
– BCCDC
– ??? Ontario Public Health Agency
– Local public health
Governance – top down ?
Lessons learned from SARS
Failure of Communication and Science
Naylor’s 4 C’s – November 2003
–
–
–
–
Collaboration
Cooperation
Communication
Clarity – who does what, when
Germs don’t respect borders !!!!!
The Mushroom Syndrome:
SARS and Family Medicine
Ontario College of Family Physicians
SARS briefing
Scarborough clinic
Sharing information
Data
Pandemic Influenza
Inevitable ?
Preparation is good for our health….
– like Y2K
Warning signs ?
–
–
–
–
Fujian strain of flu
SARS
H5N1 – bird
WNV
Tamiflu debacle
Central command & control ?????
Alberta
Ontario
Correct.
Manitoba
Quebec
B.C.
Aborig.
N.W.T.
Sask.
Newf.
Military
Nunavut
RCMP
PEI
Yukon
N.B.
Vets
Learning from our SARS Sisters
Hong Kong
– Public Health Agency
Hanoi
– VSF
Bangkok
– Xray system
Soup lady should dish out facts
Winnipeg Free Press, Mon Oct 3 2005
(sorry, no URL; subscription site)
Public Health Minister Carolyn Bennett
says what bothers her about a flu
pandemic is delivering chicken soup to
victims.
……..At last month's annual meeting of the
Canadian Public Health Association, she
told Canadian Press that mutual support
among citizens is one of the most
important elements of the response to a
pandemic.
Then she added: "The part that bugs me
most is the bottom-up part. Does every
Canadian know who their three
neighbours are...and would we be able
to get them the chicken soup and not
get infected?"
Florence … Dec. 2004
Lady with the Lamp
Meticulous records
Statistician
Clusters of disease
“To understand God’s thoughts we must study
statistics, for these are the measure of His
purpose.” Florence Nightengale
Paris heat wave
CNN…. August 25, 2003
France heat wave death toll set at 14,802
PARIS (AP) — The death toll in France
from August's blistering heat wave has
reached nearly 15,000, according to a
government-commissioned report
released Thursday, surpassing a prior tally
by more than 3,000.
2003 Paris Heat Wave
Nearly 15,000 people in France, most
of them elderly, died from heatrelated deaths during the heat wave
that hit all of Europe.
French authorities say about half the
people who died as a result of the
heat wave died in their homes, not in
hospitals or nursing homes
2003 Paris Heat Wave
Critics suggest many seniors were
abandoned by their families heading to
vacation spots for the traditional August
holiday.
The French government cut more than
$150 million in elder funding earlier that
year
Victims
The Poor: who either had no working air
conditioning or could not afford to turn it
on.
The Elderly: who were hesitant to open
windows and doors at night for fear of
crime.
African Americans: many blacks lived in
areas of sub-standard housing and less
cohesive neighborhoods.
Survivors
Hispanics: had an unusually low death
rate due to heat. Hispanics at the time
lived in places with higher population
density, and more social cohesion.
Elderly women: who may have been more
socially engaged, were less vulnerable
than elderly men
Israel – January 2005
Surge capacity
Real time facts.. beds, icu
Communication with health care personnel
Training, training, training
Blame Hippocrates?
Affirm Hygeia
HYGEIA:
Goddess of Health
Fleeing the Medical Model,
Embracing the Medicine Wheel
WHO Commission on Social
Determinants of Health
The Commission on Social Determinants of
Health (CSDH) supports countries and global
health partners to address the social factors
leading to ill health and focus on health
inequities. It draws the attention of society to the
social determinants of health that are known to
be among the worst causes of poor health and
inequalities between and within countries. The
determinants include unemployment, unsafe
workplaces, urban slums, globalization and lack
of access to health systems.
The Causes of the Causes
Versus
The Causes
social determinants
vs.
‘choose health’
Evolution of the Healthy Canadians Tree
Evolution of the Healthy Canadians Tree
“Reorienting health systems”
FROM
a health CARE system
TO
a true system for HEALTH
Public Health 101
1.Do you think we should have
a:
A) strong fence at the top of the cliff
B) state of the art fleet of ambulances and
paramedics waiting at the bottom ?
2. Would you prefer:
A) Clean air
B) Enough puffers and respirators
for all
3. Would you prefer that wait-times
were reduced by:
A) a falls program to reduce preventable hip
fractures
B) private orthopaedic hospitals and more
surgeons
4.Should we invest in:
A) early learning, child care, literacy,the
early identification of learning disabilities
and bullying programmes
B) increase the budget for young offenders’
incarceration
5.Should we:
A) assume that the 'grey tsunami' will
bankrupt our health care system
B) include our aging population in the
planning of strategies to keep them well
6. Is the best approach to food
security:
A) food banks and vouchers
B) Income security,affordable housing,
community gardens and community
kitchens and a national food policy
7. Pick the one that is NOT correct
Pandemic Preparedness should focus on
A) Tamiflu for all
B) Working with the vets to keep avian flu a
disease of birds
C) Making sure people wash their hands
especially the doctors and nurses
D) Research on vaccines
E) Community care plans for our most vulnerable
8.Governments should boast
about:
A) how much they spent on the sickness
care system
B) the health of their citizens, leaving no-
one behind
Romanow Report
Discussion paper # 8
– Zimmerman & Glouberman
– Complex Adaptive Systems
– HIV/Aids Brazil vs Africa
Glouberman and Zimmerman
Complicated and Complex Systems: What
Would Successful Reform of Medicare
Look Like? (2002)
- Submission to the Romanow Commission
Bottom up
Strong common purpose
Local wisdom, local knowledge to get it
done
Complexity Theory
Simple : following a recipe
Complicated : putting a rocket on the
moon
Complex : raising a child
The solutions are complex
For every complex human problem, there
is a neat simple solution, it’s just that it’s
wrong…
HL Mencken
Health Goals for Canada
Overarching Goal
As a nation, we aspire to a Canada in which
every person is as healthy as they can be –
-
physically
mentally
emotionally
and spiritually.
Health Goals for Canada
Basic Needs
(Social and Physical Environments)
Our children reach their full potential, growing up
happy, healthy, confident and secure.
The air we breathe, the water we drink, the food
we eat, and the places we live, work and play
are safe and healthy - now and for generations
to come.
Health Goals for Canada
Belonging and Engagement
Each and every person has dignity, a sense of belonging, and
contributes to supportive families, friendships and diverse
communities.
We keep learning throughout our lives through formal and informal
education, relationships with others, and the land.
We participate in and influence the decisions that affect our personal
and collective health and well-being.
We work to make the world a healthy place for all people, through
leadership, collaboration and knowledge.
Health Goals for Canada
Healthy Living
Every person receives the support and
information they need to make healthy
choices.
Health Goals for Canada
A System for Health
We work to prevent and are prepared to respond
to threats to our health and safety through
coordinated efforts across the country and
around the world.
A strong system for health and social well-being
responds to disparities in health status and
offers timely, appropriate care
Next steps
Choose indicators
Work with stakeholders to determine
meaningful targets
Empower `bottom up`
– Strong common purpose, local wisdom, local
knowledge to get the job done….
GIS
If a picture is worth a thousand words,
A map is worth a thousand pictures….
Maps at CDC or HHS shouldn’t stop at
the 49th Parallel !!!!
GIS Map Generator -PHAC
powerful graphical and
analytical dimension to public health
Brings together the fundamental epidemiological triad of
person, time, and the often-neglected place.
•
1.The spread of diseases over time
2.Spatial patterns of outbreaks
3.Population groups at risk
4.Availability and access to health care
5.Program intervention planning and assessment
With the Public Health
Map Generator, you can
produce high quality,
detailed maps of your
own health data, in
combination with
extensive geography
from our spatial data
warehouse…
The Public Health Map
Generator is a secure,
web-based mapping
application, accessible only
to clients registered with
the GIS Infrastructure at
the Public Health Agency
of Canada.
GIS User
*******
All of the Infrastructure’s
services, including the
Public Health Map
Generator, are available at
no cost to all public health
professionals in Canada.
Scotland – Honourable Andy
Kerr
Health outcomes down to postal code
Letter from Family Doctor
Interventions
Already paying off
Research
Evidence-informed practice
Practice-informed evidence
Courage to fund what works
Courage to stop funding what doesn`t
Complex adaptive systems…
Research
Practice
Policy
Research
KT
Practice
Policy
Research
KT
Practice
Policy
Political will
Applied
research
Practice
Research
KT
Policy
Political will
ENGAGED CITIZENS
Applied
research
Practice
Research
KT
Policy
Political will
Putting the Public back into
Public Health
Civic Literacy ….. individual
Civil Society…. Community Action
Progress
First MoS Public Health 2003-2006
Public Health Agency of Canada
Chief Public Health Officer
Public Health Network for Canada
Health Goals
National Collaborating Centres
Knowledge Networks for the SDOH Commission
A beginning……
Global Health Security Action Group
Canada-Asia Regional Emerging
Infectious Disease Initiative $15M
Global Public Health Intelligence Network
International Health Regulations 2005
– Still dependent on country`s capacity
(? willingness) to identify, verify and manage an
outbreak.
Global Pandemic Influenza
Readiness Conference,
Ottawa 2005
Animal-human health
– WHO, IOE, FAO
Capacity and Surveillance
Risk Communication
Research
– access to vaccines and antivirals
Beyond borders….
SARS as a teachable moment
Beyond silos
– Departments
– Disciplines
Beyond jurisdictional squabbling
Germs don’t respect borders
Neither do the social contagions
Nor the humanitarian imperatives
“We are not tinkers, who patch and mend
what is broken. We must be watchmen,
guardians of the life and health of our
generation, so that stronger and more able
generations may come after.”
Dr. Elizabeth Blackwell
first woman physician in North America