Chronic pesticide poisoning from persistent low-dose exposures in Ecuadorean floriculture workers: toward validating a low-cost test battery.

Chronic pesticide poisoning is difficult to detect. We sought to develop a low-cost test battery for settings such as Ecuador's floriculture industry. First we had to develop a case definition; as with all occupational diseases a case had to have both sufficient effective dose and associated health effects. For the former, using canonical discriminant analysis, we found that adding measures of protection and overall environmental stressors to occupational category and duration of exposure was useful. For the latter, factor analysis suggested three distinct manifestations of pesticide poisoning. We then determined sensitivity and specificity of various combinations of symptoms and simple neurotoxicity tests from the Pentox questionnaire, and found that doing so increased sensitivity and specificity compared to use of acethylcholinesterase alone--the current screening standard. While sensitivity and specificity varied with different case definitions, our results support the development of a low-cost test battery for screening in such settings.

The Cuban experience in public health: does political will have a role?

The role of political will in public health has been largely ignored. In Cuba, however, for the past 50 years, political will has been the ultimate, encompassing intersectoral action in public health. The excellent achievements in population health in Cuba during these 50 years have been widely recognized. Researchers have sought to explain this "Cuban paradox" by focusing on a large array of public health factors, including health promotion, primary care activities, and intersectoral action on health determinants. These factors constitute necessary but not sufficient conditions to achieve good health outcomes. This article defines political will and uses the experience of Cuba to illustrate the potential role of political will in public health. The authors suggest a framework for the evaluation of political will aimed at achieving good health, examining the "Five R's of political will," five observable features that may provide systematic information on the direction and realization of political will: (1) renewal of commitment, (2) reform of the system, (3) resource development, (4) review of performance, and (5) responsible management. These five features focus the spotlight on the consistency between health goals and public discourse and action.

Conspicuous consumption: characterizing high users of physician services in one Canadian province.

OBJECTIVES: To examine medical care use and costs, patterns of morbidity and co-morbidity, and other patient characteristics of high users of physician services in British Columbia. METHODS: This population-based study uses physician claims, hospital discharge summaries and vital statistics data linked at the level of the individual to compare characteristics of high users, other users and non-users of physician services in the Province of British Columbia, Canada. The study included all enrolled adults in the universal health care plan during fiscal year 1996/97. High users were defined as the most costly 5% of users of fee-reimbursed services. Key variables included age, sex, an ecological socio-economic status indicator and a comprehensive set of morbidity indicators, derived from the diagnoses recorded on the utilization records. RESULTS: The top 5% of users consumed a disproportionate 30% of spending on physician services. High users were overwhelmingly characterized by a significant burden of morbidity. Over 80% had at least six different types of morbidity during the study year compared with fewer than 20% of other users. High users were also much more likely to have major diagnoses that were both acute and chronic in nature. Co-morbidity involving psychosocial and chronic medical conditions was also very common. CONCLUSIONS: High users of physician services are overwhelmingly characterized by multiple and complex health problems. Policy tools based on a philosophy of deterrence such as cost-sharing are unlikely to have much impact on their costs and will likely do considerable harm.

Who's the fairest of them all? Which provincial pharmacare model would best protect Canadians against catastrophic drug costs?

BACKGROUND: Public prescription drug plans vary markedly across Canada. To address perceived inequities in coverage across provinces, the February 2003 First Ministers' Accord on Health Care Renewal committed to ensuring that all Canadians have reasonable access to catastrophic drug coverage. A national standard for "reasonable" catastrophic coverage has yet to be formally defined. OBJECTIVE: To compare the private financial burdens from prescription drugs that Canadian households would face if each of the current provincial pharmacare models were adopted as the national standard. METHODS: Through simulation modelling, we computed household private financial burden by applying the cost-sharing rules from provincial drug plans to a nationally representative set of 4,860 household types differing in size, age composition, income and drug expense levels. The proportions of households that would face private out-of-pocket payments exceeding critical, or catastrophic, percentages of household income were calculated. RESULTS: Private financial burden due to prescription drug costs varies considerably across provincial pharmacare models. Comprehensive, tax-financed pharmacare models that limit out-of-pocket expenditures to a given percentage of income, such as those found in British Columbia, Saskatchewan, Manitoba and Ontario, provide the greatest protection against catastrophic prescription drug costs. There appears, however, to be no "gold standard" for an acceptable financial burden to be borne by patients.

Intersectoral action for health at a municipal level in Cuba.

OBJECTIVE: To consider how Cuba's acknowledged achievement of excellent health outcomes may relate to how health determinants are addressed intersectorally. METHODS: Our team of Canadian and Cuban researchers and health policy practitioners undertook a study to consider the organization and practices involved in addressing health determinants in 2 municipalities (1 urban and 1 rural). The study included a questionnaire of municipal Health Council members and others involved in health and non-health sectors, key informant interviews of policy makers, focus groups in each municipality and examination of three common case scenarios. RESULTS: Regular engagement of different sectors and other agencies in addressing health determinants was quite systematic and comparable in both municipalities. Specific policies and organizational structures in support of intersectoral actions were frequently cited and illustrated in case scenarios that demonstrate how maintenance of regular linkages facilitates regular pursuit of intersectoral approaches. CONCLUSIONS: The study demonstrates the feasibility of examining processes of intersectoral action for health processes and suggests that further examination in evaluating factors such as training, particular practices, etc., can be a fruitful direction to pursue comparatively and with analytical designs.

Network analysis as a tool to assess the intersectoral management of health determinants at the local level: a report from an exploratory study of two Cuban municipalities.

Intersectoral action on health determinants has long been recognized as an important factor in achieving better population health. Nevertheless, there is no process that provides empirical evidence to policy-makers on the extent of intersectoral collaboration. We aimed to fill this gap by conducting case studies in two municipalities in Cuba, a country well known for its intersectoral practice and good health outcomes. We surveyed an intentional sample of key members of Health Councils - virtual intersectoral spaces in Cuba - about links and related actions they had with other sectors on eleven health determinants. Using network analysis we were able to produce measures to evaluate and characterize the network of sectors. Findings show that the two municipalities were similar in reported importance of health determinants, extent of long-term engagement in intra-sectors actions and level of collaboration with other sectors for virtually all determinants. Municipalities also showed similar overall levels of collaboration for most determinants when considered as a network of different sectors (network density). However municipalities showed differences in the central role played by some sectors (centrality index). We further used the network analysis blockmodeling technique to typify the municipal Health Councils. We found that while one Health Council can be typified by a single well connected network structure, the other has two distinct structures with more sparse connections. We conclude that intersectoral collaboration can be assessed by the use of network analysis measurements. This approach is novel and provides evidence to decision-makers about their role and their effort towards collaboration in achieving better health outcomes.

Social and environmental determinants of Aedes aegypti infestation in Central Havana: results of a case-control study nested in an integrated dengue surveillance programme in Cuba.

OBJECTIVE: To characterize the social and environmental risk factors associated with the presence of Aedes aegypti in order to improve community dengue control. METHODS: A case-control study with 'cases' being households with entomologically confirmed A. aegypti infestation; personal interviews in Central Havana, a densely populated inner city area characterized by overcrowded housing and irregular water service. The participants were residents of 278 houses with infestation and 556 houses without infestation. RESULTS: Greater risk of infestation was associated with lack of preventive measures, such as no larvicide in the water tanks (OR = 2.21) and use of flower vases for religious practice (1.93), not being economically active (1.64), vulnerable populations with higher risks in households with older people (1.52) and households with children (1.94). CONCLUSIONS: Efforts to reduce infestations should continue to focus on water tank sanitation and improving housing conditions, but also engage community religious leaders to help promote safe practices. Vulnerable populations should be especially targeted by prevention activities. A surveillance programme can produce evidence to guide interventions.

The doctor is out: physician participation in the Rationed Access Day work stoppage in British Columbia, 1998/99.

BACKGROUND: In 1998/99, the British Columbia Medical Association (BCMA) asked physicians to withdraw elective services on a series of 20 Rationed Access Days (RADs). This work stoppage was called to protest continued free proration triggered by total physician billings exceeding a fixed budget cap. This paper examines how physicians' practice activity changed on RADs, the rates of participation in this job action and characteristics of those physicians who participated. DESIGN: Population-based cohort study of physicians based on administrative data. POPULATION: All full-time physicians billing the provincial healthcare plan. METHODS: Participation in the RAD initiative was inferred by comparing physicians' average daily billings on RADs, Sundays, holidays and regular weekdays. Using thresholds established from these distributions, the number of RADs observed by each physician in 1998/99 was calculated and examined in relation to their demographics, location and prior years of practice activity. RESULTS: For the 4,131 physicians studied, average daily payments on RADs were similar to those on Sundays and holidays but much lower than those on non-holiday, non-RAD weekdays. Using billing thresholds of $200 (for GPs) and $400 (for specialists), we found a high degree of participation with the study population observing a median of 15 of the 20 scheduled RADs. While there were some differences in participation among age groups, geography and the prior years of practice activity, the differences were small. INTERPRETATION: This study found high solidarity in the BCMA's 1998/99 RAD initiative. Most full-time fee-for-service FS physicians appeared to participate in at least three-quarters of the 20 scheduled RADs.