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  1. 1. Lecture 8Lecture 8 Sustainable Health Care andSustainable Health Care and Emerging EthicalEmerging Ethical Responsibilities, VulnerableResponsibilities, Vulnerable Populations and EnvironmentalPopulations and Environmental Health and ChildrenHealth and Children
  2. 2. Goals Today • Reminder: Thursdays Lecture: Feb 5: – from 1-2:30 in Cadboro Commons, Haro Room , “The Application of a Population Health Approach to Seniors Health Services, by Dr. Kelly Barnard and Dr. Weiman Hu. • In-class exercise – continued discussions and report back • Precautionary Principle (Ch14) goes to Feb 9th . Today we discuss, Sustainable health care (Ch17), Vulnerable Populations (Ch15) and begin Environmental Health and Children as Vulnerable Populations
  3. 3. Sustainable Health Care and Emerging Ethical Responsibilities • LE in the world; 46 in 1958 to 66 in 1998 • Canada LE 82.2 years women, 77.1 years men • However in long run human health requires a healthy ecosystem • Estimates 25% of health problems are environmental in origin
  4. 4. Sustainable Health Care and Emerging Ethical Responsibilities • Environment affects health • Health care services affect the environment • US health care generates 3 million tons of solid waste per year: – Human tissues, blood, biohazardous wastes( heavy metals and radioactive wastes
  5. 5. Sustainable Health Care and Emerging Ethical Responsibilities • Mercury in health care products • PVC incineration releases carcinogenic toxins • IV bags release toxins into patients • Degree to which health care processes and services affect the environment is hard to assess
  6. 6. Sustainable Health Care • The current environmental crisis is a function of population growth, consumption patterns and technology • Scale of consumption is represented by the “ecological footprint” • Estimate of how much space it takes to generate the energy, food, pasture, consumer goods to maintain each of us. • Estimates suggest humanity uses 1/3 more resources and ecoservices than nature can regenerate
  7. 7. Sustainable Health Care • US ecological footprint 9.6 ha per capita • Canada 7.2 on average • World 1.7 per capita available • Challenge is to reduce our footprint and reduce consumption
  8. 8. Sustainable Health Care and bio- ethicists • Bedside concerns and environmental global well-being • Societally, health care has a responsibility to meet current needs in a sustainable way • Humans have a responsibility to the natural world • 80% of world’s wealth benefits only 20% of population • Justice and sustainability require more equitable allocation of resources
  9. 9. Ecosystem health • Fosters the importance of people’s connectedness with others and with the natural world • Tensions between: – Individual vs whole society – Sustainability vs social justice – Sustainability vs health
  10. 10. Tensions • Individual to whole: from a physician/health practitioner focus emphasis is on physician- patient relationship • -emphasizing do all that is possible rather than do no harm, or do consider the environmental impacts of health care
  11. 11. Tensions • Environmental sustainability and social justice • Mutually reinforcing goals of population health • Yet their scale is so broad • Scope of world’s present distributive injustice • Sheer number of people struggling to live with very little
  12. 12. Tensions • Sustainability vs Health • 20th century gains in health attributed to economic development • Improved health through industrial and technological growth that: – Stabilized food supplies – Processed sewage – Cleaned and transported water – Developed vaccines – Medical surveillance – Medical technologies
  13. 13. Tensions • Sustainability vs Health • Today, intensity of agriculture, industry and energy sectors is connected with increasing health problems
  14. 14. Justice Considerations in Canada by Draper and Mitchell, 2001 • 1982 Warren County decision catalyzed environmental justice movement • PCB site near low income primarily African-American community • Post- environmental equity, environmental racism, environmental classism emerged in literature • 1999 in Canada (CEPA) acknowledges that environmental protection is essential to Canadians well- being.
  15. 15. Justice Considerations in Canada by Draper and Mitchell, 2001 • Canadians should have the right to safe air, water and soil. • McMaster School of Geography and Geology and the Institute of Environment and Health is the most active environmental justice group.
  16. 16. Justice Considerations in Canada by Draper and Mitchell, 2001 • 1990s characterized by federal and provincial government focus on deficit and debt reduction • Sharp reductions in environmental agencies followed – E.g., Environment Canada’s budget cut by 35% – In Ontario the Common Sense Revolution closed water testing laboratories in 1996 without considering the capacity of local municipalities to take on manage water. – In BC, water quality monitoring positions lost
  17. 17. Environmental Health Indicators • Merging environmental issues with human health impacts - environmental health indicators • (see handout from Canadian J of Public Health) • Global, regional, local indicators that describe overall quality of the environment • Highlight factors that influence environmental quality and that have potential impact on human health
  18. 18. Environmental health and sustainable development • To date 130 indicators have been compiled by the United Nations Commission on Sustainable Development • Urban/housing indicators: – HABITAT II, – WHO- Healthy Cities Movement – Canada – Population Health Most countries face problems of global significance
  19. 19. Vulnerable Populations • Children and Workers • Children: – Developmental processes – Unique patterns of exposures • Workers: – Exposures to toxins often higher than for general public
  20. 20. Vulnerable Populations • Traditional Risk Assessment • Ignores special risks of children, workers, elderly, immuno-compromised • assumes everybody is a 70kg adult male • Certain populations deserve special consideration • But all lives are important
  21. 21. Vulnerable Populations • Children’s diseases today: • New pediatric morbidity • Classic infectious diseases reduced • Asthma (doubled in recent years), childhood cancers, neurodevelopmental, congenital birth defects, second-hand smoke
  22. 22. Vulnerable Populations • Children’s diseases today: • 10-20% genetic; rest ? • LEAD: neurological behaviour, IQ loss, disabilities • In utero exposures to PCBs and methylmercury affect intelligence • Last 50 years, 80,000 new synthetic compounds developed
  23. 23. Children’s Exposures • Air, water, food crops, communities, waste sites, homes • Fewer than half chemicals tested for potential toxicity • Especially to fetuses, infants and children • Pound for pound children drink more water, eat more food and breathe more air than adults • Hand to mouth behaviour and living close to the ground can also increase risk
  24. 24. Children’s Exposures • Metabolic pathways are immature • Undergo rapid growth and development and therefore organs/brain/tissues more vulnerable to toxins disrupting developing systems • Exposures in childhood can produce illness at later stages of life
  25. 25. Case Studies of Children’s Health • 1904 Queensland, Australia epidemic of lead poisoning in young children; – Ingestion of lead paint playing on verandas lead to banning of lead paint – 1950s leukemia in Hiroshima and Nagasaki exposure to ionizing radiation due to atomic bombings – Subsequent studies established the sensitivity of infants and fetuses to radiation
  26. 26. Case Studies of Children’s Health • 1960s: Minimata Japan epidemic of cerebral palsy, mental retardation, convulsions due to ingestion of fish/shellfish contaminated with methylmercury • Source of mercury was a plastics factory discharging mercury into the bay; bioaccumulated up the food chain
  27. 27. Case Studies of Children’s Health • “Subclinical toxicity”: Dose-dependent continuum in which clinically obvious effects have their subclinical counterparts Needleman in the US: film Kids and Chemicals (Feb. 16) will feature his work
  28. 28. Workers • Many environmentally induced diseases observed in workers: – E.g. cancer of the scrotum/testes in chimney sweeps – Coal miners lung cancers
  29. 29. Workers • Workers constitute well- defined groups • Nature and extent of exposures is known • These features lend them to epidemiological studies • Occupational toxins may be transported home on clothing of workers
  30. 30. Workers • Occupational diseases (OD) are underdiagnosed • Physicians have little training in OD • One problem is that many diseases present the same • Long latency period is a barrier
  31. 31. Occupational Diseases • Lung Disease – Asbestiosis, pneumoconiosisi, lung cancer, asthma • Musculo-skeletal back, trunk, neck • Cancers other than Lung – Leukemia, bladder, stomach • Occupational Traumas: – Loss of limbs, amputations, fractures • Disorders of reproduction – Infertility, teratogenesis • Noise-induced hearing loss • Dermatological conditions – Rashses, scalds, burns • Psychological disorders: – Alcoholisms, drug dependency
  32. 32. Prevention of Occupational Disease • Primary Prevention – Eliminate or reduce hazardous exposures • Secondary Prevention – Effectively identify work-related illness through symptoms/screening procedures • Tertiary Prevention – Reduce complications and disability caused by existing disease
  33. 33. Effective Prevention Strategies to reduce exposures o Substitute a less hazardous material o Engineering controls, e.g., ventilation, process isolation or enclosure o Alteration of work practices: e.g., wet sweeping asbestos o Administrative controls: worker rotation, time away from hazard o Personal hygiene programs e.g., showers at end of workday o Protective equipment: respirators, gloves, ear plugs, muffs o Biological markers: to assess exposure – blood-lead levels
  34. 34. Effective Prevention Strategies to reduce exposures o More widespread testing of chemical substances---pre- market evaluation o Occupational surveillance systems ___________________ Children -Longitudinal studies -right to know legislation -surveillance systems for children’s diseases
  35. 35. PSR to DPSEEA models • PSR Pressure-state response • PSIR Pressure-state- impact-response • DPSEEA Driving forces, pressures, state, exposures, health effects and actions
  36. 36. References • McCally, M. (2002) Life Support: Environment and Human Health Chapters 15 (Landrigan and Garg) and 17 (Jameton and Pierce) • vonShirnding, Y.E. (2002) Health and Environment Indicators in the Context of Sustainable Development, CJPH, Sept-Oct, S9- S15. • Draper, D. and B.Mitchell Environmental Justice, Canadian Geographer.