United Nations General Assembly adopts universal health care resolution
The United Nations (UN) General Assembly has unanimously adopted a resolution to encourage governments to transition to universal health care systems. Providing affordable and high-quality health care services to all plays an “intrinsic role” in “achieving international development goals,” states a news release from the 67th session of the General Assembly in New York City, New York (www.un.org/News/Press/docs//2012/ga11326.doc.htm).
The resolution, Global health and foreign policy, urges UN member states to adopt and maintain health systems that don’t require users to pay for essential medical services, as out-of-pocket expenses can deter the poor from seeking treatment or impoverish those who do receive medical care (www.un.org/ga/search/view_doc.asp?symbol=A/67/L.36).
Governments need to “urgently and significantly scale up efforts” to make universal health care coverage an important element of their international development agendas, states the resolution, because it is “the right of every human being to the enjoyment of the highest attainable standard of physical and mental health, without distinction as to race, religion, political belief, economic or social condition.”
The resolution recognizes, however, that moving to a universal health care system can be challenging, and that each country will have to consider its particular “epidemiological, economic, sociocultural, political and structural context.”
Still, universal health care is worth pursuing, despite the challenges, because it is one of the “pillars of sustainable development and is central to poverty reduction,” UN Secretary-General Ban Ki-moon suggested in a recent note that stated “150 million people each year suffer severe financial hardship — called financial catastrophe — because they fall ill, use health services and need to pay for them on the spot. Many have to sell assets or go into debt to meet the payments” (www.un.org/ga/search/view_doc.asp?symbol=A/67/377).
An additional 100 million people are pushed under the poverty line each year because of overwhelming medical bills, an “unacceptable paradox” since poor health also prevents people from working, suggested the secretary-general.
“The links between better health, the economy, environmental sustainability and social progress are well established: people who are healthy are better able to learn, to earn and to contribute positively to the societies in which they live.” — Veronique Hynes, Ottawa, Ont.
Old South US states continue to trail health rankings
Vermont continues to be the healthiest state in which to live in America, according to the United Health Foundation.
The northeastern state topped the nonprofit private foundation’s 2012 edition of America’s Health Rankings for the sixth consecutive year (http://cdnfiles.americashealthrankings.org/SiteFiles/Reports/Americas-Health-Rankings-2012-v1.pdf). It was followed in the rankings by Hawaii, New Hampshire, Massachusetts and Minnesota.
The five least healthy states in which to live? Mississippi, Louisiana, Arkansas, West Virginia and South Carolina.
“Vermont’s strengths include its number one position for all health determinants combined, which includes ranking in the top 10 states for a high rate of high school graduation, a low violent crime rate, a low incidence of infectious disease, a low prevalence of low birthweight infants, high per capita public health funding, a low rate of uninsured population, and ready availability of primary care physicians. Vermont’s challenges are a high prevalence of binge drinking at 18.5 percent of the adult population, a moderate occupational fatalities rate at 3.9 deaths per 100,000 workers, and a median cancer death rate at 185.0 deaths per 100,000 population.”
“Mississippi and Louisiana are tied for 49th and rank last this year. These 2 states have been in the bottom 3 states since the 1990 Edition. Mississippi ranks well for a low prevalence of binge drinking and a low violent crime rate. It ranks in the bottom 5 states on 12 of the 24 measures including a high prevalence of obesity, a high prevalence of a sedentary lifestyle, a low high school graduation rate, limited availability of primary care physicians, a high prevalence of low birthweight infants, and a high prevalence of diabetes. Mississippi ranks 49th for all health determinants combined, so its overall ranking is unlikely to change significantly in the near future.”
“Louisiana ranks well for a low prevalence of binge drinking and a high rate of childhood immunizations. It ranks in the bottom 5 states on 13 of the 24 measures including a high prevalence of obesity, a high rate of children in poverty, a high prevalence of low birthweight infants, a high prevalence of diabetes, and a high rate of cardiovascular and cancer deaths.”
The methodology used in crafting the rankings was revised over that of previous years to reflect a growing understanding of the importance of the social determinants of health. To that end, the annual study was undertaken using a new process that surveyed more cellphone users and a more ethnically diverse segment of the population. “This has caused the reported prevalence of many of the behavior measures, such as smoking, obesity, binge drinking, and diabetes, to be reported as higher this year than last year. This change may or may not reflect an actual change in the behavior being measured, but it does represent a dramatic improvement in how well the estimates actually measure the behaviors.”
“For a state to improve the health of its population, efforts must focus on changing the determinants of health. If a state is significantly better in its score for determinants than its score for outcomes, it will likely improve its overall health ranking in the future. Conversely, if a state is worse in its score for determinants than its score for outcomes, its overall health ranking will likely decline over time.”
Among other national trends identified in the report is a continuing decline in preventable hospitalizations, “over the last 11 years from 82.5 to 66.6 admissions per 1,000 Medicare enrollees,” as well as a decline in the number of deaths from cardiovascular disease. In both cases though, the report notes, rates are higher among some ethnic groups. In the case of preventable hospitalizations, for example, the rates are highest among black people and Hispanic people. “In particular, disparities were greatest for hospitalizations related to chronic health conditions such as diabetes, hypertension, and asthma. Compared with non-Hispanic whites, rates of admission for these conditions were about 3 to 5 times greater among blacks and approximately 2 to 3 times greater among Hispanics.”
The report also noted that the tough economic climate is having an impact on health. For example, the percentage of children in poverty increased from 16% in 2001 and 21.4% in 2012. “Children in poverty is an indication of the lack of access to health care, including preventive care, for this vulnerable population. Infant mortality improved significantly in the 1990s but has largely stagnated between 6.5 and 7.0 deaths per 1,000 live births for the last ten years. The nation’s overall infant mortality rate is consistently higher than other developed countries, and significant racial and ethnic disparities exist.”
“For a population to be healthy, it must minimize health disparities among segments of the population, including differences that occur by gender, race or ethnicity, education, income, disability, geographic location, or sexual orientation,” the report added. — Bonnie O’Sullivan, Ottawa, Ont.
Assessing Canada’s cancer system
Cancer was the leading cause of death in Canada in 2012, claiming more than 75 000 lives, but an assessment of the Canadian cancer system suggest some progress has been made in areas such as prevention, screening, diagnosis, treatment and research.
Plunging smoking rates in some jurisdictions and improved screening and treatment for colorectal cancer are among the positive trends indicated in The 2012 Cancer System Performance Report by the Canadian Partnership Against Cancer, an independent organization funded by Health Canada (www.cancerview.ca/idc/groups/public/documents/webcontent/2012_system_performance_rep.pdf).
The percentage of average-risk Canadians age 50–74 who are up to date on colorectal screening rose from 38% in 2009 to 43% in 2011. Improvements in colorectal cancer treatment have also been implemented more widely across the country. In five provinces, for example, the percentage of patients in advanced stages of the disease who received radiation before surgery rose from 40% in 2007 to 49% in 2009.
“The randomized data does show that there appears to be a benefit from preoperative radiation as opposed to postoperative radiation, which was always the standard in the past,” says Dr. James Brierley, a radiation oncologist at Princess Margaret Hospital in Toronto, Ontario. “So it’s taking time for people to switch their practices.”
Encouraging statistics in the prevention of tobacco-related cancers indicate that 18% of recent smokers age 12 and up reported quitting in the past two years. Newfoundland and Labrador had the highest quitting rate, at 26.7%. Overall, 20% of Canadians age 12 and up are smokers, according to the report, down from 23% in 2003.
One consistent concern noted in the report was the considerable variation across provinces for various types of screening and treatments. Though the overall colorectal screening rates were up, for instance, they ranged from a low of 22% in Newfoundland and Labrador to a high of 64% in Manitoba. Other areas with interprovincial variation include mastectomy rates, percentage of early-stage breast cases treated with radiation therapy as per guidelines, participation in organized provincial breast cancer screening programs and implementation of standardized symptom screening tools.
Another problem is the lack of progress made in the area of pancreatic cancer, according to Dr. Heather Bryant, vice president of cancer control at the Canadian Partnership Against Cancer. “We really haven’t made the progress in this cancer that we’ve made in others,” she says. “We just haven’t enjoyed the same kind of success in pancreatic cancer. We don’t have a great understanding of its risk factors, so we haven’t made great changes in incidences, and so it’s just something that we wanted people to turn their attention to.” — Adam Miller, CMAJ
Progress stalls in global fight against malaria
Plateaued funding and weak surveillance systems are threatening recent gains in the global effort to reduce worldwide cases of malaria by 75% by 2015, according to the World Health Organization (WHO).
An estimated 1.1 million malaria deaths have been averted over the past decade because of increases in interventions, but the target of reducing the global malaria burden by 75% (set by the World Health Assembly in 2007) is unlikely to be met without new sources of funding and improved tracking in endemic regions, according to WHO’s World Malaria Report 2012 (www.who.int/malaria/publications/world_malaria_report_2012/wmr2012_no_profiles.pdf).
“The fight against this disease needs to be integrated into the overall development agenda in all endemic countries,” Director-General Dr. Margaret Chan states in the report’s foreword. “We cannot achieve further progress unless we work tirelessly to strengthen health systems and ensure that sustained and predictable financing is available.”
It will take about US$5.1 billion a year to achieve universal coverage of malaria interventions, the report states, and that is more than double the US$2.3 billion a year in funding that is currently available. The WHO predicts that total funding from domestic and international sources will remain at less than US$2.7 billion between 2013 and 2015.
“There is an urgent need to identify new funding sources to maintain and expand coverage levels of interventions so that outbreaks of disease can be avoided and international targets for reducing malaria cases and deaths can be attained,” the report states.
The lack of funding has slowed initiatives such as indoor residual spraying programs and the distribution of insecticide-treated nets. Only 66 million nets are estimated to have been delivered from manufacturers in 2012, compared to 92 million in 2011 and 145 million in 2010, states the report. This problem will only get worse as the nets distributed in 2010 are set to pass their 2–3 year average useful life in 2013.
Inadequate malaria surveillance systems are also an ongoing problem, detecting only about 10% of cases, and the countries with the largest malaria burden tend to have the lowest detection rates.
“Stronger malaria surveillance systems are urgently needed to enable a timely and effective malaria response in endemic regions, to prevent outbreaks and resurgences, to track progress, and to hold governments and the global malaria community accountable,” Chan states in the report. “In as many as 41 countries around the world, making a reliable assessment of malaria trends is currently not possible due to incompleteness or inconsistency of reporting.” — Bonnie O’Sullivan, Ottawa, Ont.
Cutting down on Christmas casualties
The weather outside may not be the only thing that’s frightful this holiday season, as the National Health Service (NHS) in the United Kingdom is reminding people that Christmas is one of the most dangerous times of the year.
There were an average of 2481 additional deaths per year in England and Wales during the holiday season (Dec. 21–Jan. 19) between 2000–2010, according to an NHS report, Keep safe this Christmas (www.nhs.uk/Livewell/Healthychristmas/Documents/Keep%20safe%20this%20Christmas.pdf). The death rate spikes around New Year’s Day, when deaths climb to about 1766, while on Christmas Eve, an average of 1682 Britons are dying each year — a 10% increase from early December.
The root of the problem appears to be people breaking routine as they head out for the holidays, leading to a host of preventable deaths. Traffic accidents increase by 30% for women and 9% for men, accidental poisonings increase about 15% for women and 10% for men, accidental falls increase by 16% for women and 21% for men, and accidents by fire increase by about 40% for women and 27% for men.
The biggest cause of death over the holidays is accidents related to natural and environmental factors, such as exposure to cold, which increase by an average of about 103% for women and 145% for men.
Although the holiday season is anecdotally associated with suicidal tendencies for those most vulnerable or depressed, the data indicate that the rate of suicide over the holiday season only increased by 3% for women and 5% for men. Homicide also remained somewhat stable, accounting for an increase of 12% for women and remaining level for men, the report states.
Not surprisingly, alcohol may also account for preventable deaths during the holiday season. In 2007, there were 258 emergency admissions for acute intoxication on New Year’s Day and 176 on Christmas Eve, while the weekday average was about 59. Another sobering thought is that deaths where alcohol and drugs were the underlying cause increased by 13% above the daily average in December and January.
Although many people look forward to turkey dinner during the festive season, food poisoning rates increase dramatically over Christmas, which the NHS says may be due to the fact that 80% of people wash their turkeys before cooking them — a practice that can greatly increase the risk of spreading bacteria.
It may be time to think about throwing out those leftovers as well, as the report states that one in five people will risk food poisoning by eating turkey leftovers that have been in the fridge longer than the two-day recommended limit. — Adam Miller, CMAJ
US unveils overdue food safety standards
Food producers hoping to sell their products in the United States will be required to craft and submit food safety plans to the US Food and Drug Administration (FDA), while also demonstrating that they comply with “science-based” safety standards in the growing, harvesting and handling of fruits and vegetables, including the use of clean irrigation water and regular handwashing by farm workers.
The stiff new regulations, which were proposed as part of implementation of the Food Safety Modernization Act, essentially transform the FDA into a proactive agency that will seek to prevent food contamination, rather than merely investigating outbreaks after the fact. The FDA said roughly 130 000 Americans are hospitalized annually due to food-related disease, of which about 3000 die.
The first proposed rule compels food producers to develop safety plans, “perform a hazard analysis, and institute preventive controls for the mitigation of those hazards. Facilities would also be required to monitor their controls, verify that they were effective, take any appropriate corrective actions, and maintain records documenting these actions” (www.ofr.gov/(X(1)S(v3yf3je4uhgifjgft2sscuim))/OFRUpload/OFRData/2013-00125_PI.pdf). The degree to which companies must comply with the requirement will vary according to the size of their operations.
The new regulatory environment is needed because of food safety challenges that “persist in today’s complex, dynamic, and global food system,” the FDA states in the proposed rule. “Today’s food supply is highly diverse and increasingly complex, with many new foods in the marketplace that pose new food safety challenges. New pathogens are emerging, and we are seeing commonly known pathogens appear in foods where they have not been traditionally seen. The population of individuals at greater risk for food-borne illness, such as those who are immune-compromised, is increasing. When illness outbreaks occur, they can have devastating impacts on public health and impose substantial economic disruption and cost on the food industry. The food safety challenge is only compounded by globalization, which has resulted in approximately 15 percent of the U.S. food supply being imported, including 80 percent of our seafood, 50 percent of our fresh fruit, and 20 percent of our vegetables.”
The second proposed rule substantially stiffens regulations for the handling of foods during production. In the area of hygiene, for example, firms will have to establish training programs for all workers and demonstrate that they have undergone such training (www.ofr.gov/(X(1)S(v3yf3je4uhgifjgft2sscuim))/OFRUpload/OFRData/2013-00123_PI.pdf). Farms and facilities will also have to demonstrate that they comply with water and soil requirements, including a prohibition against “the use of human waste for growing covered produce except in compliance with EPA [Environmental Protection Agency] regulations for such uses or equivalent regulatory requirements.” As well, they’ll have to show that they have adequate measures in place to prevent animals from entering crop fields and that they use sanitized processing equipment throughout the harvesting procedure. The new standards will not apply to producers of foods that are cooked before consumption or to farms “that have an average annual value of food sold during the previous three-year period of $25,000 or less.”
US Health and Human Services Secretary Kathleen Sebelius lauded the changes as a major advance in preventing food-borne illness. “The FDA Food Safety Modernization Act is a common sense law that shifts the food safety focus from reactive to preventive,” she stated in a press release (www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm334156.htm?source=govdelivery).
“The FDA knows that food safety, from farm to fork, requires partnership with industry, consumers, local, state and tribal governments, and our international trading partners,” FDA Commissioner Dr. Margaret A. Hamburg, added in the release. “Our proposed rules reflect the input we have received from these stakeholders and we look forward to working with the public as they review the proposed rules.”
The proposed rules have been submitted for public comment for 120 days. Food producers will have to implement changes within 26 months after the final rules are published.
The FDA also indicated that it will soon release new rules that will bolster oversight of foods imported to the US, as well as new controls on animal food facilities. — Wayne Kondro, CMAJ
Obituary: Dr. Peter Morgan, former CMAJ editor-in-chief
Former CMAJ editor-in-chief (1982–85) Dr. Peter Morgan of Lanark, Ontario, died at age 85 on Nov. 8, a few days after suffering a massive stroke. He is survived by Wynne Morgan, his wife of 48 years.
Described by his wife and friends as a kind, gentle man with a life-long dedication to learning, Morgan filled many roles in addition to those of physician and scientific editor: fantasy novelist, opera writer, Baha’i devotee and barefoot runner, to name but a few.
Morgan was born in Los Angeles, California, on Nov. 1, 1927. He graduated from Albany Medical College in New York in 1955 and practised for many years in clinical neurology and electroencephalography. In 1970, he moved to Canada to earn diplomas in epidemiology and community health at the University of Toronto in Ontario, where he later became an assistant professor in the department of preventive medicine and biostatistics.
With published papers on topics including mental health, acupuncture and computed tomography, Morgan was also no stranger to academic research. He joined CMAJ as an associate scientific editor in 1978, rising to editor-in-chief four years later. During his tenure at the journal, Morgan wrote many editorials on a wide variety of subjects, from primary prevention to running in heat.
Upon retirement, Morgan devoted much of his time to the arts. He wrote a 560-page fantasy novel called The Words of the Papermaker that he self-published in 2006 under the name Peter G. Angelin. Set on the double-mooned planet of Kazeltu, it is a tale of princes, princesses, poets and paper-makers who belong to diverse races “massed along the shores of the Long Sea, where the cultured city-state of Ayanalor and the corrupted megalopolis of Xhramdalu are hostile strangers” (www.xlibrispublishing.co.uk/bookstore/bookdisplay.aspx?bookid=29646).
Morgan did not limit his storytelling to prose. He also wrote an opera called Open House, which played at the Studio Theatre in Perth, Ontario, from Mar. 10–13, 2011. The “contemporary” production was a “simple and engaging story of a woman’s struggle to deal with loss and life” that drew upon popular musical styles such as jazz and rap, according to The Humm, a rural arts newspaper (www.scribd.com/doc/50887549/theHumm-March-2011). Some of the musical compositions from Open House will be played at a memorial celebration planned for July, Morgan’s favourite month. — Roger Collier, CMAJ