2018 — A year of change in Canadian public health

2018 was the year Canadians were allowed to begin freely self-medicating with cannabis and nicotine vaping products.

It was a year when a study revealed unproven stem cell procedures were available across the country.

And it was a year that continued the explosion in home genetic testing, with DNA-testing kits topping this season's gift lists once again.

"2018 feels to me like there has been a lot of changes," said Kerry Bowman, bioethicist at the University of Toronto. "And I see the changes as more of a movement towards people deciding for themselves what they will do in health care."

Legal cannabis a 'national uncontrolled experiment'

When cannabis became legalized in October, a commentary in the Canadian Medical Association Journal called it a "national uncontrolled experiment" because the long-term health effects are unknown.

The Canadian Medical Association (CMA) is not convinced that there is enough evidence for doctors to prescribe medical cannabis to their patients.

"The CMA remains concerned about the lack of clinical research, guidance and regulatory oversight for cannabis as a potential medical intervention," the CMA states on its website.

But the hesitation by health professionals to embrace medicinal cannabis was not a surprise to medical historian Heather MacDougall at the University of Waterloo.

"We have no scientific foundation for this because it has been an illegal substance, and therefore no genuine research could be conducted on it."

Now the research on the health effects of cannabis will be happening in real time.

"What about the precautionary principle?  Do we really understand this drug?" – Kerry Bowman, bioethicist , University of Toronto

"It's ironic," MacDougall said. "With most other things in the past, the research came first."

"It's a powerful chemical," said Timothy Caulfield, University of Alberta professor and Canada Research Chair in Health, Law and Policy. He is researching the impact of many of the recent changes in Canadian health care.

"I suspect, once we start doing good research on this, good clinical trials, that we are going to see benefit, hopefully. But right now it's so premature and you're seeing this market just take off."  

In 2018 Canada became the second country in the world to legalize cannabis. (CBC)

Bowman said he's not opposed to cannabis legalization as a bioethicist. But it raises interesting questions from a scientific perspective.

"What about the precautionary principle?" he said. "Do we really understand this drug?"

Will legalization of cannabis lead to the legalization of other illicit drugs?

"From a historian's standpoint it's going to be important when we look back on this," MacDougall said. "Is it the first step toward an actual recognition of drug use as part of the social determinants of health?"

Prof. Kerry Bowman, a bioethicist at the University of Toronto, said 2018 developments showed Canada putting less focus on evidence-based, randomized controlled trials. (Craig Chivers/CBC)

Year of Big Vape

2018 was also the year of Big Vape, when it became legal in Canada to sell nicotine vaping products, creating a dilemma for public health officials. On one hand, vaping can be a harm-reduction policy aimed at smokers trying to quit.

But it's also exposing teenagers who might never have sampled a cigarette to a potential nicotine addiction.  

A University of Waterloo public-health researcher released data to Health Canada two weeks ago showing that Canadian teen vaping has reached levels comparable to the U.S. And just this week, the U.S. surgeon general announced that teen vaping has become "epidemic."

After it received the new teen vaping data, Health Canada said in an email it "will assess what additional actions are warranted, and leverage additional authorities in the Tobacco and Vaping Products Act."

On Thursday tobacco giant Altria, maker of Marlboro cigarettes, announced it was buying a 35-per-cent stake in the vaping giant Juul Labs Inc.

Juul's popular vape stick officially went on sale in Canada in September.

Canadians pay for unproven cell therapies

In another uncontrolled national experiment, a study in September revealed that 43 clinics across Canada are selling so called "stem cell" procedures, even though they're technically not stem cells, and they have not been proven to be either safe or effective.  

You could characterize it as a massive collective of anecdotes and testimonials. It just  legitimizes  something that's unproven.– Timothy Caulfield , University of Alberta

Still, Canadians are paying thousands of dollars to have their own bone marrow or fat cells extracted and then reinjected into various parts of their body to treat pain, injury, and other conditions including lung disease and hair loss.

"You could characterize it as a massive collective of anecdotes and testimonials. It just legitimizes something that's unproven." Caulfield said.

"I know people who are having stem cell injections," said Bowman. "They're not particularly concerned about what the evidence says, and I find this surprising because the evidence isn't there yet."

U.S. health regulators have launched court action against some clinics using patient-derived cells to treat a variety of conditions.

Timothy Caulfield is University of Alberta professor and Canada Research Chair in Health, Law and Policy. He is researching the impact of many of the changes in Canada's health-care landscape. (CBC/Sam Martin)

But so far Health Canada has not taken action to stop Canadian clinics from performing the procedures.

In an email to CBC News this week, Health Canada said it has contacted all 43 clinics identified in the study "to gather information," and it is assessing it "to determine whether compliance and enforcement actions are warranted. Any incidents of non-compliance with federal regulatory requirements will be prioritized, and appropriate action will be taken."

Giving the gift of genetic tests?

Many Canadians are likely to find personal genetic testing kits under the Christmas tree this year. And soon they will be spitting their DNA into an envelope and waiting to receive potentially life-changing information.  

Caulfield has a study underway right now investigating the marketing of home genetic tests.

DNA test kits are on seasonal gift lists again this year.

"You have this sort of premature commercialization that really doesn't have the kind of health benefits that are promised.

"They're about empowerment and providing you with information which is somehow going to be valuable to you and allow you to live a healthier life. And there's very little evidence to support that."

One genuine public health experiment cancelled

There was one formal public health experiment about to get underway in Canada this year to investigate one of the country's most serious health problems — poverty.

But in July, just as a team of Ontario researchers had finished enrolling people for the basic income pilot project, the experiment was abruptly cancelled by the new provincial government, shortly after the election.

The three-year program was supposed to study the effect of income-support payments on quality of life, food security and other health indicators.

"This was a brilliant experiment," said MacDougall. "It's highly unfortunate this was cancelled."

She pointed to a similar experiment in Manitoba in the 1970s. When the data from that study was analyzed decades later, researchers concluded that providing income support improved the health of the entire community.

In October, Canada's chief public health officer warned that poverty is shortening the lives of people in the poorest neighbourhoods, where life expectancy is about three years lower than the Canadian average.

Disturbing data on public health 'emergency'

In the final weeks of 2018, there was new and disturbing data released about the impacts of another uncontrolled public health experiment — the widespread exposure to powerful opioid drugs that came on the market two decades ago. The drugs were heavily marketed to doctors who were encouraged to write opioid prescriptions to treat chronic pain.  

The Public Health Agency of Canada released statistics showing that in the first six months of 2018 opioids killed more than 2,000 Canadians. There have been more than 9,000 opioid-related deaths in Canada over the last 2½  years.

"Canada continues to experience a serious opioid crisis," the agency said in a news release last week. "Across the country, it is having devastating effects on the health and lives of many Canadians, their families and their communities."

On Thursday, an Ontario coroner's jury investigating the opioid overdose death of 43-year-old Brad Chapman called on the province to declare the opioid epidemic a "public health emergency."

This week the Journal of the American Medical Association published a review of almost 100 studies showing that opioids were not much more effective than ordinary over-the-counter drugs in relieving chronic pain.

So how will future historians see 2018?

"I think they will probably be struck by the number of different health-related events that took place in 2018," said MacDougall. "And by the fact that some of the fundamentals are still not being recognized or dealt with."

"A lot of this is about making money by selling products," said Caulfield. "All of these things are being portrayed to the public as if they're efficacious. They're not even being portrayed as if they're experimental, as if we need to do more research.

"You do want to have an honest portrayal of the science so that people can make informed decisions about the true value of this stuff. And once it's out there it's so hard to pull it back in."

Bowman said the changes are a sign that Canada is putting less focus on evidence-based, randomized controlled trials and a little less focus on the precautionary principle.

"The strongest driving ethical principle in Canadian health care has been autonomy, the rights and choices of the individual. And perhaps that very principle is deepening from a cultural point of view."

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