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October 28, 2015 Pallium Canada Symposium What Makes a Problem a Public Health Issue? The Case for Palliative Care Ross Upshur BA(Hons), MA, MD, MSc, CCFP, FRCPC Head, Division of Clinical Public Health Professor, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto Objectives 1. To explore the inter‐relationship between Public Health and Palliative Care 2. To make a positive case for the public health significance of high quality palliative care 3. To base this in both “evidence” and “ethics.” 1 October 28, 2015 Pallium Canada Symposium Format • • • • What is Public Health? Four Questions Five good reasons Conclusions 2 October 28, 2015 Pallium Canada Symposium Definition of Public Health • Public health is what we, as a society, do collectively to assure the conditions for people to be healthy. Institute of Medicine • The science and art of preventing disease, promoting and protecting health • Uses community interventions, disease control and principles of epidemiology and biometry 3 October 28, 2015 Pallium Canada Symposium Public Health Functions • To assemble and analyze community health needs for disease prevention, health promotion and protection • To develop health policy through scientific knowledge • To assure the community by providing health protection services Public Health Functions • • • • • • Health Protection Health Promotion Disease & Injury Prevention Population Health Assessment Surveillance Emergency Preparedness 4 October 28, 2015 Pallium Canada Symposium Public Health Achievements (CDC) • • • • • • Vaccination Programs Food Safety Infectious Disease Control Water Safety Family Planning Tobacco Control What is a Public Health Problem? • • • • • Prevalence of condition or exposure Impact of condition on society Condition is preventable Effective interventions available Equity considerations 5 October 28, 2015 Pallium Canada Symposium Public Health: Thick and Thin • Thin: Narrow concepts of disease prevention, focus on morbidity and mortality • Thick: Broader SDOH, holistic in orientation 6 October 28, 2015 Pallium Canada Symposium Four Key Questions 1. 2. 3. 4. What health event is to be prevented? What practices and behaviours will be promoted? Who is being protected from what harm? Are we improving community health in an equitable manner (i.e. Special consideration for marginal and vulnerable populations)? Five Good Reasons 1. 2. 3. 4. 5. Demographics and Population Shift Unmet Need Feasibility Accountability Justice and Equity 7 October 28, 2015 Pallium Canada Symposium 8 October 28, 2015 Pallium Canada Symposium Unmet need 9 October 28, 2015 Pallium Canada Symposium Feasibility 10 October 28, 2015 Pallium Canada Symposium WHO Public Health Strategy 1) Appropriate policies; 2) Adequate drug availability 3) Education of policy makers, health care workers, and the public 4) Implementation of palliative care services at all levels throughout the society. Accountability • • • • Measurement Capacity exists Benchmarking a standard quality exercise Target can be set , action taken Global Good Death Index 11 October 28, 2015 Pallium Canada Symposium Ethical Considerations • Minimize harm • Protecting vulnerable persons • Vulnerability occurs when persons or populations are unable to optimally protect themselves from hazards or advocate for their own best interests, thus requiring enhanced protections. Public Health Ethics vs. Bioethics • • • • Population focus vs. focus on individual Community perspective vs. focus on the person Social determinants vs. individual agency and responsibility Systems of practice vs. individual decision making 12 October 28, 2015 Pallium Canada Symposium Public Health as Social Justice • Gostin and Powers: “Our account of justice stresses the fair disbursement of common advantages and the sharing of common burdens. It captures the twin moral impulses that animate public health to advance human well‐being by improving health and to do so by focusing on the needs of the most disadvantaged.” Who bears the responsibility? • “For public health strategies to be effective, they must be incorporated by governments into all levels of their health care systems and owned by the community .” (WHO PH Strategy) • Community engagement and education required • Leadership from Palliative Care AND Public Health Communities • Imaginative Collaboration Needed 13 October 28, 2015 Pallium Canada Symposium Four Key Questions 1. 2. 3. 4. What health event is to be prevented? What practices and behaviours will be promoted? Who is being protected from what harm? Are we improving community health in an equitable manner (i.e. Special consideration for marginal and vulnerable populations)? Conclusions • Compelling reasons for better integration of public health and population health perspectives into palliative care • Will take champions and leaders to bring about change • Significant moral failure not to move in this direction 14 October 28, 2015 Pallium Canada Symposium Jonathan Lear Radical Hope • In the face of a cultural challenge…there is ever more pressure to explain things in the traditional ways, yet there us an inchoate sense that the old ways of explaining are leaving things unsaid. And yet one does not yet have the concepts with which to say it. 15