Public Health and a secure society
BY DR PAULA STEWART
© 2014 FrontLine Security (Vol 9, No 2)

“A Healthy and Active society is a Secure society.”
This outcome depends on the availability and support for training, education and physical fitness and the availability of proper employment, remuneration and accommodation for all.

Predictable challenges of the coming decade
Let’s first explore the premise that: “A Healthy and Active Society is a Secure Society”. According to the World Health Organization, “health is a resource for living – it is the ability to realize aspirations, satisfy needs, and cope with a changing environment.” If you extrapolate this to the community level, then a healthy community is also one that has resources for living, and is able to realize its collective aspirations, satisfy its needs, and cope with a changing environment.”

Relating this to a secure society means that if the community’s security is threatened, from within or without, it has the resources to respond effectively. This occurred, for example, in Ottawa in the 1990s when an outbreak caused by the meningococcal bacteria caused the deaths of six high school students. The Ottawa Public Health Unit organized a successful immunization program for 80,000 students that involved the school boards, schools, health care providers, hospitals, community organizations and volunteers. The community collectively came together to deal with a severe threat to their internal security.

Protecting health and safety is an ongoing effort for all provincial and municipal governments. For instance, some challenges that the Leeds, Grenville and Lanark Public Health Unit has been dealing with in our region that affect the health and security of our communities are poverty, age structure, water and healthy living.

1. Poverty
About one in ten families live in poverty in this area. Poverty increases the risk of many health problems including injury, diabetes, and heart disease. Individuals living in poverty report they are under a lot of stress and this influences anxiety, depression, tobacco and substance use – and quality of life. Food security is also a big issue, as families don’t have enough money to buy sufficient healthy food. This means children come to school without a good breakfast, which in turn affects their ability to learn.

Poverty is an issue for any community, as a whole, for several reasons. For example, a community relies on its children and youth for on-going sustainability. If children aren’t able to learn and complete school, the chances of being able to work and contribute to the community are reduced. Also, the increase in health problems among people living in poverty means that tax-base resources go to the provincially-funded health care system that would otherwise be used for community needs such as grants for infrastructure development, roads, education, and social services.

Much can be done at the community level to reduce the impact of poverty on its residents. I think rural-based communities can do this particularly well because they are so familiar with their own community, and connections are strong. For example, in Perth, the Community Food Table has expanded the traditional notion of food security (giving people food) to an interactive program where participants and volunteers are fully engaged in the community garden, meals, cooking classes, Dads& Kids sessions, after school programs, and many other programs. The Community Health Centres in Portland, Lanark Village, and Smiths Falls/Merrickville provide a range of programs that help people be healthy and stay connected to their communities. In Leeds-Grenville, committed organizations led by the United Way, and the Leeds-Grenville Social Services and Public Health Unit, are working together to mitigate the effects of poverty among residents in the community.

2. Changing Demographics of Communities
Most of the communities in Lanark, Leeds and Grenville have an aging population. Young people often have to leave the community for further education and jobs. The exception are areas close to Ottawa, like Mississippi Mills and North Grenville. As people retire, the tax base decreases. This comes at a time when all municipalities are faced with an ageing infrastructure and the need to invest in repairs and new construction. Schools also face a decreased enrolment which influences their viability. The Upper Canada School Board has responded by placing the grade 7 and 8 program in the high schools, and that requires a major adjustment within the school social structure.

3. Water for Drinking and Recreational Use
Many of the smaller towns in this area do not have a municipal water system. This means residents have their own wells and septic systems, which are close together and are aging. The presence of fractured rock without a lot of ground cover means that the water aquifer can be easily contaminated by agricultural run-off, old septic systems that are not functioning well, and other surface contaminants.

Towns that have a municipal water system and sewage disposal system are challenged with aging infrastructure and a system that is not always able to meet current needs.

Although our region has an abundance of lakes and rivers. Some of them, such as the Upper Rideau Lake, are having difficulty with algae blooms that occur in warmer water due changes in the climate and nutrient composition of the lake. This affects the quality of life of residents and can also lead to health problems.

4. Healthy Living
Being physically active on a regular basis, healthy eating, mental health and resiliency, and avoiding tobacco, substance misuse and injury all promote good health. While many people are living a healthy life, many more could make choice adjustments that would increase their quality of life, decrease the risk of health problems like cancer, lung disease, heart disease, diabetes, or even help manage chronic conditions they currently have.

The Healthy Community Partnership – with membership from the Public Health Unit, municipalities, community health organizations, the YMCA, the Food Matters Coalitions, and the Heart and Stroke Foundation – has created a vision for the Lanark, Leeds and Grenville community: “Healthy people in Lanark, Leeds & Grenville live, learn, work and play in healthy communities.” (healthyllg.org/_resources/HCP_Vision.pdf)

While each individual makes his/her own choice about health-related behaviours, the environment he/she lives in has a profound impact on that choice. Therefore, the partnership, along with several community organizations, has identified that it is essential that:

  • all community members have the opportunity to make the choices that enable them to live a healthy life, regardless of income, education, or ability; and that
  • healthy community environments promote well being and quality of life, and contribute to integrated community sustainability (cultural vitality, economic health, environmental responsibility and social equity).

A video has been developed by the partnership that describes what a healthy community looks like, and is available on the Healthy Community Partnership website (www.healthyllg.org). It has been endorsed by several community organizations and members of the public, and has been presented to both upper tier governments in Lanark and Leeds-Grenville. It is now being presented to each municipality for their endorsement.

This is the first step in raising awareness about the importance of a healthy community, and encourages everyone to consider what they can do to make it happen. Much is already being done by municipalities, schools, child care setting, health care organizations, the business community and the public. It is an exciting time for our community!

Inoculation Controversy
A few years ago, the H1N1 virus inoculation program posed certain challenges. Some critics felt that the imposition of a totally new program reduced the role of the family physician, complicated and confused some patients, and did not optimize the available resources.

In fact, the 2009/2010 influenza season was very different than previous ones. A new form of the virus affected young people rather than the usual older age group and also affected many more people. The influenza virus changes a little every year but this was a significant change and many people had no immunity against it.

The novelty of the virus meant a new vaccine had to be developed, manufactured and distributed within a very short timeframe. The existing facilities had to manufacture two vaccines – one with the new strain, and one with the strains based on last year’s circulating virus – within the time frame they normally did one.

This was a perfect storm for a very challenging influenza immunization program – fear and heavy demand in response to a number of deaths in young people, delay in producing the vaccine, and the challenge in ensuring the vaccine got to those most vulnerable first.

Given the shortage of the vaccine, the Ministry of Health and Long-term Care took the lead to ensure there would be equitable access to the vaccine across the province and that it would be given to the most vulnerable first – people with chronic health problems, children, and teens.

The Ministry decided to use the 38 local public health units to deliver the vaccine in community clinics because those units had the staff to be able to do this efficiently, and had the community connections to be able to set up clinics quickly in all parts of the province – rural and urban. They also could be counted on to follow guidelines to give the vaccine to those most at risk. This strategy generated considerable reaction from both the community and health care providers because primary care providers were not directly involved initially.

The annual influenza immunization program is now provided by physicians and nurse practitioners and, as of 2012, by pharmacists, as well as at public health clinics in communities. Public health provides vaccine to these service providers based on their orders. This system works very well. In 2013, most of the influenza vaccine in the community was provided by primary care providers and pharmacies. Public health clinics provided easy access to the vaccine for those who had difficulty contacting their primary care provider or in communities without pharmacies.

I would certainly prefer to use the existing system described above if there is another large influenza outbreak. In reality it will depend on the outbreak itself and what is most feasible given the context. The Ministry of Health and Long-term Care is entrusted with that decision.

Pandemics
Many Canadians do not appreciate how lucky they are to live in such a resource-rich, wealthy and democratic country. Our public health services are one of many ­elements to ensure their well being in case of disasters of all kinds.

The Ebola outbreak in West Africa is suffering from the lack of an organized ­public health system that would include public health services, primary care, hospital and government support, among others. The virus is not easily spread yet it is spreading rapidly through the involved countries due to this management deficit.

A well-organized public health component of a health system would be able to do the following:

  • Conduct surveillance – identify who is sick, when, where, and what the exposure was. This allows public health workers to understand how it is moving within the community and develop containment strategies.
  • Education – provide education to the community as a whole on how to ensure they don’t become ill and when to seek medical attention. If the community is used to public health units providing this type of information, as in Canada, then the communication channels will already exist and people will have basic knowledge from other contexts that can be added to during any future crisis situation.
  • Follow-up – provide counselling to family members on how to decrease the risk of becoming ill and when to seek medical attention. Public health would also identify people at increased risk post-exposure, and ensure they are monitored and know what to look for in terms of early symptoms. This information and understanding will reduce  the spread of the virus by people who leave the area when they are unknowingly incubating the disease – as is happening now with Ebola.
  • Health care team – Provide information to the health care team on infection control procedures in the clinic and the hospital. Provide additional support as needed.

In Ontario, the well-organized public health and health care system has already provided information on Ebola to all service providers, hospitals and public health units. Specific precautions have been identified for infection control in all settings. Hospitals have identified which ones will receive individuals who might have Ebola. Our local public health units have sent information to schools about what to do if a student who has visited the affected countries presents him or herself at school with a fever. Plans are underway in our health unit to respond to a possible case within the community with follow-up as needed. Surveillance will use the existing, well-developed methods.

When it comes to addressing significant health problems that can threatened the health of the population, we are truly fortunate to live in a resource-rich, wealthy and democratic country. Our very wealth though, also contributes to health problems associated with excess – eating too much abundant unhealthy food, or excessively using vehicles at the expense of active transportation with regular physical activity, or relying on the health care system to fix us when we could have prevented health problems.

Appreciating the benefits of our society and ensuring that all benefit from them equally, actively engaging in promoting and protecting our health and working together to create healthy environments will truly make a “healthy, active and secure society”.

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Paula J Stewart MD, FRCPC is the Medical Officer of the Health Unit in Leeds, Grenville and Lanark District in Ontario.
© FrontLine Security 2014

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