The Story of Prevention By Kelly Chu “I can’t breathe,” rasps a 40-ish year old male as he collapses onto the hospital bed gasping for air. Beside him, paramedics unload an unconscious woman, a known diabetic with a previous history of uncontrolled sugar for years. Still, another person stumbles in – “I have chest pains,” moans the middle-aged obese male. This is a typical scene in the emergency department. This is real. This is smoking, diabetes, hypertension, cholesterol, obesity, and inactivity in its full glory. The end result? Chest pains, heart attacks, lung cancer, death…. Even if a person survives their emergency visit, s/he will most likely still experience great morbidities and suffer for a great number of months or years. What can we do about it? Even if we’re not necessarily medical personnel, we can all help to reduce this trend of chronic diseases. And we start by making changes, beginning with eliminating the key risk factors. Smoking It was cool to smoke back then. But by the time we’ve realized that smoking is a severe health risk causing many cardiovascular and pulmonary conditions, too many people are already addicted and find it difficult to quit, or find no reason to quit. Everyone is exposed to smoking. Whether it’s you who smokes, or your neighbour that smokes, we are all exposed to cigarette smoke, either first-hand or second-hand. We can start by eliminating cigarette smoke in public places, passing a law that bans smoking in public places. With a smoking ban, the environment outside remains fresh and safe to breathe in – the perfect example of a healthy urban space. Our young and old and all those in between are protected from lung diseases and asthma attacks while respecting individual’s rights to smoke in their own homes. Many provinces in Canada have instituted either a partial or complete province-wide smoking ban in public places. For those who do smoke, a sin tax can be imposed upon tobacco. Financial costs are a huge disincentive to continue smoking and will help prompt smokers to consider quitting smoking. Additionally, a sin tax on those who inflict damage upon themselves – whether it be lung cancer, chronic obstructive pulmonary disease, exacerbation of asthma, or any number of cardiac conditions – will also help to cover some of their own healthcare costs due to the effects of smoking. Our young may find it beneficial to learn about the effects of smoking early on before they start smoking. At the University of Alberta, the medical school has been running Butt-Out for years, an anti-tobacco campaign targeting elementary and junior high students. Students were taught about the components of cigarettes – nicotine, tar, cyanide, formaldehyde, ammonia and other chemicals – and reflected upon whether they really wanted to inhale rat poison into their bodies. They then collaborated in a group discussion of the effects of smoking – black teeth, black lungs, yellow skin, wet mucus, cough – and they all agreed that smoking is bad. Sedentary As developed countries become more and more service-oriented, employees tend to be more and more physically inactive. With inactivity, comes the corollary of obesity. Public parks, skating rinks, swimming pools, and recreation centres should be a part of any healthy urban design. They are often part of the urban design but are not necessarily a part of each community. For example, a public swimming pool may serve 6-7 communities and is situated deep within one community, meaning that people from the neighbouring communities must travel a fair ways to access the facility. Each of these facilities need to be made fairly accessible (ie: 1 facility shared between 2-3 communities as opposed to 6-7 communities) and should serve a certain radius or certain number of the population to prevent overcrowding of the facility which may dissuade some people from coming. In addition to location, affordability is another key factor to accessibility. Government subsidy of access to public recreational facilities are likely to encourage more people to become more physically active. Municipal governments may also consider subsidy of company gyms for employees. Often, office and corporate workers work long hours and prefer staying within the building for convenience (ie: don’t have to leave downtown and lose their parking spot, or they want to stay indoors on cold winter days). If there is a gym available within the same building, workers are often more inclined to use the facilities and will be more physically active. Unfortunately, accessibility to these recreational facilities and parks doesn’t necessarily equal participation. Mini reward programs where individuals gain points for engaging in physical activity (ie: earn 1 airmile for every 10 minutes of physical activity or earn 2 points for every extra kilometre walked/ran from last week), or double the points where individuals bring a friend along, may encourage participation. Besides reaping in the benefits of being physically fit, participants win rewards too! Bringing a companion wins double the rewards because now an additional person will also become more physically active! A daily log of improvement in physical activity (here, in steps taken) is shown. Although accessible recreational facilities and parks are desirable to serve a certain radius or number of population, encouraging physical activity doesn’t always mean that new recreational facilities and parks need to be built. Some cities may lack the resources to ensure a facility per couple of communities. In such cases, scheduled monthly city walks/runs on weekends help encourage physical activity and increase group participation as well as a sense of community well-being. Up to the day of the walk/run, radio and tv stations can promote the city-wide walk/run as a family and community event. On the day of the walk/run, certain roads (preferably a scenic route to encourage future participation) are closed off for walkers and runners. Or it doesn’t have to be a walk/run but different age-appropriate activities (ie: soccer, ball hockey, potato sack races, rope skipping) along different stretches of the road. This is a simple example of promoting a healthy urban space without having to tear down old buildings and erect new facilities. Having discussed adult and family activities, I now turn to school-aged children. They should maintain mandatory physical education classes. The advent of video games and instant messaging is decreasing young children’s physical activity. Unfortunately, it’s easier to gain weight in today’s obesity epidemic than lose weight so ensuring our young children have at least a good headstart in life is essential. Poor Diet A major problem in developed countries is a growing reliance on fast food and convenience food. This contributes to the growing obesity epidemic and its associated health problems. To start addressing this obesity epidemic, in addition to increasing physical activity, affordable healthy food must be readily available in place of greasy fast food or junk food. People don’t necessarily like fast food or junk food more than healthy foods, but it’s just that fast food and junk food are more available and convenient. This is especially true in our increasingly modernized and complex societies where people are working longer hours than in the past and are too tired to pack lunch or cook a healthy dinner after work. Making affordable healthy food alternatives (ie: salads, yogurt, fruit juices with no added sugar) a requirement at all fast food joints and vending machines will help address this convenience issue and is an example of a healthy urban space. Another strategy is the instalment of government-subsidized cafeterias for healthy food and the addition of a fat tax on unhealthy foods where people who cause harm to themselves by eating too much fatty foods will help to cover some of their own healthcare costs. The other issue surrounding food is proportions. Proportions are larger today than ever before as vendors are discovering more ways of making more profits. At the University of Alberta, students from the medical school visited several elementary and junior high schools to teach them about food proportions, to eat smaller meals more frequently rather than large meals 2-3 times a day, and to eat more fruits and vegetables and less meat (which is the tendency of the majority of the population). Similarly, the adult population may benefit from this teaching too. This teaching may take place in the form of public health educators teaching shoppers at grocery stores on proportionalities and healthy foods. Or it may take form as images at the end of a shopping cart such as this picture at http://www.capitalhealth.ca/NR/rdonlyres/euw7gwxxifrh2f6wae5zazo33pbnl6idh3jm3jf7 3gmsipkxvfovn5guhhpjpkvriakubcqpahtjzso3pvdyu5j5x3g/ShoppingCart_WithText.jpg Constant reminders such as these healthy food teachings and shopping cart images are part of a healthy urban design. To Wrap It All Up Central to all these ideas is a universal healthcare system, which is also integral to a healthy urban design. The universal healthcare system ensures that those who slip through the crack will get the care they need to help get them back on their feet. Healthcare should be available to everyone equally based on those who need care most urgently and not on who can afford care. For those with chronic health problems, regular health visits to interdisciplinary teams (ie: physician, nurse practitioner, public health clinics, or nutritionist/dietician) are recommended for continuity of care. Evidence suggests that continuity of care enhances the relationship between the healthcare professional and patient, leading to uptake of preventive care, increased compliance to therapy, increased satisfaction, and improved health. This continuity of care is linked to a reduced use of emergency departments and hospital beds. As overcrowding of emergency departments is very common worldwide, a healthcare system that functions properly and prevents people from flooding the hospitals is a sign of a healthy city. It is unknown whether continuity of care improves the health of the young and those without chronic health problems, but perhaps by making health check-ups mandatory at certain ages with a standardized questionnaire (ie: asking about smoking and smoking cessation, diet and physical activity), physical exam (ie: breast exam to detect breast cancer, rectal exam to check for prostate cancer), and bloodwork (ie: checking cholesterol and blood sugar levels to detect for heart problems and diabetes), problems may be detected earlier on. This is like taking your car in for regular maintenance to make sure it’s running properly. Similarly, mandatory check-ups at certain ages help make sure people are healthy. To conclude, it is simply not enough to target just one area of health since human health is determined multi-factorially. The ideas about smoking cessation, increasing physical activity and improving diet all work together to improve health and to decrease chronic health problems. These ideas are a higher level of healthy urban planning where problems can be resolved. Too often, ideas are fixated at lower levels of urban planning where we strive to rescue people dying of chronic diseases rather than preventing them from acquiring the disease initially. What happens when an institution keeps rescuing people downstream while a different institution keeps letting people slip between the cracks upstream? The downstream institution works harder and harder at rescuing people but finds that it is getting more and more overwhelmed till eventually comes the day where it can no longer function properly. To prevent a city’s system from failing and to keep its habitants healthy, a higher level of healthy urban planning is needed to tackle problems upstream. My colleagues in the Fit City Competition and I all have good ideas to keep this system functioning. Together, our ideas can change the world.
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