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Friday, November 7, 2008

Overheard

These are some of the things I overheard at Canadian Medical Association President Dr Robert Ouellet’s lecture, hosted by the Fraser Institute at a Montreal bar and restaurant yesterday evening...

Two audience members waiting for the lecture to begin, on Barack Obama:
“He’s got such high expectations he can’t help but fail.”
“He could slit someone’s throat and these college kids would still love him.”
“John F Kennedy looks positively right-wing compared to him.”
“He wants to bankrupt us! We should find someone else to sell oil to.”

Dr Ouellet on the reason why the public is reluctant to let go of bans against expanding the role of the private sector in healthcare:
“It’s a religion.”
“‘Profit’ is a scary word here. Why?”

Dr Ouellet on Canadian healthcare reform:
“I’m not a patient. I’m an impatient.”

Dr Ouellet on Canadian healthcare reform and Obama, seemingly at the same time:
“Hope is not a strategy.”
“Can we do it? Yes we can.”

An audience member on personal responsibility and libertarianism:
“The healthcare system must ask people to be responsible. That is to say that smokers, drinkers, those kind of people, who take up a large portion of the costs of healthcare... these people who are very irresponsible... should be refused care. I pay taxes for taking care of smokers!”

Dr Ouellet on the idea proposed by the audience member above:
“As a doctor, I can’t accept that. That’s clear.”

Fraser Institute host Tasha Kheiriddin, co-author of Rescuing Canada’s Right: Blueprint for a Conservative Revolution, on the gifts presented to Dr Ouellet to thank him for speaking:
“A stopwatch, to measure wait times... And a bottle of wine, to take solace.”

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THE INTERVIEW: Dr James Orbinski's war

In his path from a practice in small-town Orangeville, Ontario, to his acceptance of the Nobel Peace Prize on behalf of Doctors Without Borders (Médecins sans frontières) in 1999, Dr James Orbinski (pictured above, on the left) saw more suffering and misery than just about anybody on the planet. He was there in war-torn Somalia, in famine-stricken Sudan, in Afghanistan under Taliban rule, in Kosovo during the Serbian war, in Zaire's refugee camps during the civil war, in Rwanda during the genocide. He's dodged bullets and negotiated with rebel army leaders. He survived in spite of suffering post-traumatic stress disorder and contracting pneumonia from his chain-smoking, and he rose to international president of Doctors Without Borders.

Born in England and raised in Montreal before he became a doctor around the world, Dr Orbinski now teaches global health and politics at the University of Toronto and remains active in international humanitarian activism with his own organization, Dignitas, which focuses on HIV prevention and treatment in the developing world.

This year has seen has the publication of Dr Orbinski's engaging memoir, An Imperfect Offering: Humanitarian Action in the Twenty-First Century, and the release of an excellent new Canadian documentary about him, titled Triage: Dr. James Orbinski's Humanitarian Dilemma.

I spoke to Dr Orbinski about the film, his book and his life.

In Triage, you return to some of the places where you witnessed genocide and murder, in Rwanda and Somalia. What did it feel like to go back?

Well, I’ve been back and forth to Rwanda many times since the genocide, and I have been back and forth working in Africa many, many times over the last 18 years now. That was for Somalia my first return, but I did almost return a number of years ago when I was international president of MSF (Médecins sans frontières). We had two people who had been shot and I was literally on my way and the issue resolved and it wasn’t necessary for me to go to the country, so I went somewhere else. I have been back and forth many times in various situations, but even still going back was a difficult experience.

If you hadn’t become a doctor, what do you think you might have ended up doing?

I had actually applied and was accepted to a PhD program in international relations at the University of Ottawa. I was very interested in international issues and international affairs. It was a strong interest even as a young man. Obviously I found a way of melding, or bringing medicine to bear for those interests, and now I teach at the University of Toronto, cross-appointed to political science and medicine, to focus on global health.

Medical humanitarian work is often about political advocacy and raising awareness as well as medical care. But in a place like Somalia, the political situation has refused to improve.

As human beings, war is part of what we do. It is not a new phenomenon. And sadly it is likely to remain part of the range of options that we choose in terms of how we behave. So in a way to expect that NGOs will somehow erase the scourge of war is unrealistic and I think that for humanitarian organizations like MSF that focus on the direct relief of suffering of victims in war, that their action is highly effective when it is allowed to do what the organization wants to do. And those are political choices. War has rules and it has laws. One of the rules is victims of war have a right to humanitarian assistance. And that the belligerents in war have a duty to respect international humanitarian law, to use force proportionately, to use force in a manner that discriminates between combatants and noncombatants, and to obey the laws of war in the sense that they will not commit war crimes against humanity. As long as those rules of war are respected, then humanitarian organizations can be very effective in what it is they are trying to do, which is the direct relief of suffering.

You have seen lots of violations of those laws you just named.

War is part of what we do, but I would also say we decide politically what are the rules of war, and we change them. For example, in the mid-90s, largely driven by civil society organizations, NGOs, the convention that banned the use of land mines was agreed to, and that has had a profound impact on the number of civilians who are affected by land mines, in the same way that largely NGOs pushed for the creation of the International Criminal Court in the late 90s. that court now has legal international status, and people who engage in war crimes -- or allegedly engage in war crimes -- can be brought to the International Criminal Court where they will stand trial. Those are two examples of the rules getting better to actually reduce the amount of suffering that exists for victims in war, and to hold those who are responsible for violations of the laws of war responsible for those infractions.

Do you ever find it difficult to be optimistic about things like the International Criminal Court, given that it has not always been respected, such as in the case of Saddam Hussein never coming in front of the court?

I think there were very specific political choices made around the illegal and unjust invasion of Iraq, including the way in which the leader of that country, Saddam Hussein, would be dealt with post-war. That was an American-led invasion and an American-driven political process that quite frankly I profoundly disagree with at all levels. But others around the world who have allegedly engaged in war crimes have been brought before the International Criminal Court, so it's not a failure.

I don't mean to say it is. But do you find it difficult to be optimistic when even some of the biggest successes are not universally accepted?

Well, the title of my book is An Imperfect Offering. Nothing is perfect. Even what is imperfect only can come into existence by those who strive to create something better. The whole point of the book and the film is to invite the viewer or reader into a place where they can understand the importance of taking responsibility for the world in which they live and not simply giving up, and not simply saying everything is broken, there is no point to trying to fix it, and not simply retreating into some sort of utopian dream but actively engaging in the world and working, trying through concrete, realistic, practical initiatives to make it better.

That's an admirable philosophy, especially for some like you, who has seen all the things you have seen.

And I guess the question then would be how did he arrive at that position?

Right. How do you just decide to be an optimist? It seems like that sort of thing is simply built into how we think, or it's not.

It's actually a very simple rational choice. Frankly, I've seen the alternative. I've seen what happens if one doesn't work to make the situation better. I have seen genocide, I've seen famine, epidemics, AIDS, tuberculosis, cholera, meningitis, measles, that if one simply walked away from what is possible to do the results are self evident. Genocides happen, epidemics spread, people die of famine. In each of those circumstances, an alternative is possible. For me, I choose the alternative, which is to work practically in the focused and targeted way to improve the situation. It's a choice.

What’s your most salient memory from Rwanda?

The last chapter of the book is titled "Ummera." That is a Rwandan word that means "Find your courage and go on." It comes from a moment during the genocide when I was treating a woman who had been basically brutalized with a machete. She said to me, when I was overwhelmed by her situation and by the many hundreds of other patients on the street that day, she said to me, "Ummera. Find your courage and go on." That is my most significant memory and in essence the tenor of the book and the film, it's about making that choice.

The Canadian military commander Roméo Dallaire was also in Rwanda during the genocide, when you were there. His psychological problems since then have been well documented. Was that a worry for you and colleagues?

After the genocide I saw a counsellor. I had post-traumatic stress disorder, there is no question about that. But the question that is more important is what do you do with what you now know, and for me my choice was very clear, to continue working with MSF, and subsequently to continue engaging with the world. After the genocide I worked in Zaire, in Zambia, and then did a Master’s degree in international relations and was elected president of MSF and played my role there. And through the access to medicines campaign subsequently I was involved with starting a nonprofit drug company for neglected disease. I was a co-founder of Dignitas, I am on the board of War Child, a founding member of the board of the Stephen Lewis Foundation. All that demonstrates is what is important is what do you do with what you now know, and it is not simply a matter of the experience of my own dissonance with what I now know, its what I do with that is what matters. It is the same with General Dallaire. Certainly his own dissonance with what he now knew was difficult, there is no question, but again the more important question is what did he do with that. And in the first instance, like myself, he sought medical treatment. But that is not the end of it. He then engaged the world, and took what he knew in a view to improving the world, however imperfect the effort.

Did you ever imagine when you were younger that you’d someday be giving a Nobel Peace Prize lecture?

I had no possible idea.

What was going through your mind at the time?

I was very nervous, but I wanted to take the opportunity to speak out on behalf of the people of Chechnya at that time. That was a decision that we at MSF had made together, we wanted to use the moment as an opportunity to bear witness to the suffering of the people of Chechnya, and we did. That was the opening comment of the speech.

Did the Russian ambassador ever speak to you again after that?

He certainly squirmed in his seat.

What do you make of the Canadian mission in Afghanistan, which hasn't really succeeded in enabling humanitarian workers to work safely?

In my mind there's a very dangerous mixing of humanitarian, development, political and military objectives in Afghanistan, and the lack of clarity around the relationship of each of those objectives, one to the other, is part of the problem that now exists in Afghanistan. It's not a problem that is unique to Canada's involvement in Afghanistan -- there are 34 NATO members states active in Afghanistan. It is not clear to me what is the state security purpose in Afghanistan? What is the military goal of NATO’s involvement in Afghanistan? What are they trying to achieve? When that question is asked publicly one often hears a miasma of answers that confuse humanitarianism, development, diplomatic goals and military goals, and there is no clear answer to that question. The consequence is that there is confusion on the ground, there is a lack of humanitarian space. You are absolutely right that many, many humanitarian organizations find it impossible to work in Afghanistan. MSF for example had five people assassinated in Afghanistan in 2004. There are staggered stops and staggered starts to development programs, all of which is a function in my mind of the lack of a primary objective. Why are NATO member states at war in Afghanistan? What are they trying to achieve?

Who’s your humanitarian hero?

I personally don't think there is any such thing as a humanitarian hero. Humanitarianism in the way I have described it, at its most elemental, is about being a decent human being. I would shudder to think that that somehow is elevated to realm of heroism and therefore sits beyond realm of normal human conduct.

One of your predecessors as president of Doctors Without Borders is the group’s co-founder, Dr Bernard Kouchner. He’s since gone a very direction than you have. He moved into politics, acting as governor of Kosovo and now the French foreign minister, and he’s become the face of military humanitarian intervention.

Kouchner and MSF parted because of differences in opinion of what the organization is and could be. MSF maintains the view that humanitarianism is about the direct relief of suffering in war and responsibility of humanitarian workers to bear witness to that and to assist and push governments to assume their responsibilities to respect the rules of war. Kouchner took a much more politicized view, and talked about the droit d’ingérence, the right of states to intervene. He took a vision that created a mixing of humanitarian and political roles that makes it difficult to practise either effectively. As Minister of Foreign Affairs, it is a very particular role. It is not a humanitarian role.

Do you think you might follow Dr Kouchner’s example someday in the sense that he saw public office as the way he could best effect change?

I’ve made my choices thus far and I am very happy with those choices. I am a professor now at the University of Toronto, and at St Michael’s Hospital as a research scientist, and I am involved deeply in international health and global health issues. I am happy with what I am doing.

Is it difficult to convince Canadian physicians to volunteer for international medical aid?

There's always a need for more experienced healthcare professionals, not just doctors. The majority of people that work with MSF and even the Red Cross in a medical capacities are nurses. Organizations like MSF and Dignitas are constantly looking for skilled nurses, lab technicians, physicians and others. You are always looking for the best.

You mentioned earlier that humanitarian work is essentially being a good human being. Is it the duty of physicians, if they have the ability, to help in international humanitarian medical work?

There are number of issues. It is certainly my view that it is the duty of the physician to act and relieve suffering where he or she can, if it is present in your community. But the question is, where is your community? I think it's a choice. I don't think there is an inherent duty or ethical responsibility to work with a humanitarian organization that works overseas or in war zones. It's a choice.

These days in Canada, there’s a lot of talk about how we have a severe doctor shortage. After working in places like Somalia and Zaire, does the notion that Canada is so short on doctors that we have to recruit from those very places bother you?

It does. It really is an inaccurate description of reality. In Malawi, a country of 12 million people, there are 100 doctors for the entire country. Twelve million is roughly the population of Ontario. If we had 100 doctors in Ontario, you can well imagine what the healthcare system would be like. In Canada, the United States, continental Europe, Australia, New Zealand, the United Kingdom, between 24% and 28% of our medical practitioners are foreign trained medical graduates. Of that 24-28%, roughly 78% come from countries like Malawi. In Manchester, England, for example, there are more Malawian doctors working there than in the entire country of Malawi. In much of the developing world the single most significant healthcare issue today is the brain drain of human resources from the developing world to the north. We are poaching their human resources -- in my view unnecessarily so. The problem has been defined largely as a supply problem, a shortage of doctors. But that is inaccurate. The problem is also a demand problem. In my view it is completely unrealistic for a person to expect a doctor to take blood pressure and diagnose hypertension and treat hypertension, for example, when it's perfectly possible for a well trained nurse or nurse practitioner or physician assistant to delivery basic primary healthcare. In my view the challenge here is in the first instance to develop human resource policies for healthcare that actually meet the genuine needs of our society. And the second major issue within that is to reshape the conception of appropriate demand. In practical terms that means training nurse practitioners, physician assistants and nurses to delivery effective primary healthcare, and that is well within the realm of what they can do.

You have young children. It seems like it would now be much more difficult for you to justify working in a war zone and risking your life. That's a big consideration for a lot of doctors who are thinking of volunteering.

No question.

Do you think your war doctoring days are over?

My primary responsibility now is as a father. No one can replace me in that responsibility. While I have that responsibility, I have to be very careful that my other choices allow me to meet that responsibility.

Can you estimate how many people you’ve treated in your career?

A lot.


Photo: Steve Simon, courtesy of White Pine Pictures

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What's in the news: Nov. 7 -- Chemicals, Dr Death, MD testing

A round-up of Canadian health news, from coast to coast to coast and beyond, for Friday, November 7.

Two chemicals found in plastic used in medical equipment can leach into water-based solutions contained in tubes, pipettes and culture plates, potentially changing the chemical content of the solutions and therefore corrupting experiments, a team of researchers from Alberta, Nova Scotia and Georgia reported in Science today. [Science abstract] If these chemicals -- quaternary ammonium biocides and oleamide were the ones the researchers examined -- can get into lab samples, could they be entering our bodies as well? "It's very difficult to say whether we should be worried from a health point of view about this," the lead author, Andrew Holt, told The Globe and Mail. [Globe and Mail]

Coincidentally, a very good and quite unsettling new documentary about that very subject -- chemicals unexpectedly leaching into our bodies via plastics -- aired last night on CBC. The Disappearing Male repeats tomorrow night on CBC Newsworld if you didn't catch it. [CBC]

"Canadian physicians and the provincial colleges should implement revalidation for all physicians," declared an editorial in the latest issue of the Canadian Medical Association Journal, expressing a controversial sentiment that is sure to stir up plenty of ill will in some corners of the medical profession. "The standards must include an external assessment of physician competence, rather than relying exclusively on self-assessment," wrote lead author Dr Wendy Levinson. "Some form of rigorous external testing is needed to make physicians work to meet the bar." [CMAJ] Here's an early taste of the backlash: one Nova Scotian FP told CBC News, "What we do every day is not really a book learning thing... To say, in fact, that because you pass an exam makes you a good physician every 10 years is absolutely wrong." [CBC News] Toronto emergency physician Brian Goldman, of CBC Radio's White Coat, Black Art, acknowledged doctors' concerns but nevertheless agrees with Dr Levinson. "Have no fear, colleagues," he wrote. "You'll get used to it. And Canadians will have even more confidence in their physicians." [White Coat, Black Art] Expect things to get heated.

In Newfoundland's troubled Eastern Health authority, a freezer holding cancer patients' stem cells malfunctioned in September and now doctors are concerned the cells are unusable. [Canadian Press]

There was plenty of good news for the Democratic Party this week, but some not so good as well. In Florida's 15th Congressional district, Stephen Blythe lost his race to the Republican candidate, Bill Posey. The name Stephen Blythe may ring a bell for readers of Canadian Medicine: he is a unique American politician by virtue of being the only one to be able to speak with real authority about Canada's "socialized" healthcare system, having actually practised medicine in Canada. He was employed by the government of New Brunswick's public health insurance plan when he lived in Maine, in order to treat residents of a remote New Brunswick island only accessible through the United States, called Campobello Island.

That's not all for the medically pertinent American Congressional elections news: Dr Jack Kevorkian, only out of prison since last year, was routed in his bid to become a representative for Michigan. Campaigning in part on his claim that assisted suicide is constitutionally protected, he earned 2.7% of the vote as an independent candidate, losing to the Democrat. He doesn't plan to run again, telling the Associated Press, "This system is too corrupt." [Associated Press] The Wall Street Journal has a count of the number of physicians elected to Congress this year. [Wall Street Journal Health Blog]

In very exciting and fascinating news from south of the border -- besides the election results, I mean -- an American doctor appears to have "functionally cured" a patient of AIDS by transplanting bone marrow from a donor whose immune cells contained a genetic mutation that confers resistance to AIDS. A research firm is working on potential applications of the idea to develop gene therapies. [Wall Street Journal]

Canadian blood reserves are in less peril of running dry than they had been last week. "The skies are bluer, but we're still not out of the woods," a Canadian Blood Services spokesperson told the Canadian Press. So far, no surgeries have had to be canceled due to the shortage. [Canadian Press] The reserve stock, down to two days' worth last week, is now up to three days of blood. [Moncton Times & Transcript]

University of Calgary researchers, in collaboration with scientists in Egypt, Scotland and the US, are doing some futuristic work on how the aging process might be manipulated and slowed. A new study appeared in this month's Nature Cell Biology. [Calgary Herald] [Nature Cell Biology abstract]

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Ireland drops free HPV vaccination as Canadian debate persists

On Tuesday, Ireland suddenly reversed its decision to pay for all 12-year-old girls to receive vaccination against the cervical cancer-causing human papillomavirus (HPV), blaming the current economic situation for squeezing the government's budget.

"The economic situation has rapidly and seriously deteriorated. Public resources, including those for health, are very scarce indeed and will remain so," Health Minister Mary Harney (right) said in a statement. The free vaccinations were due to begin next September.

Opposition health critic Dr James Reilly, the former president of the Irish Medical Association, called the decision "a slap in the face to people who believe in prevention being better than cure." (He resorted to an Obama-like appeal in an otherwise hard-hitting release, saying, "The Minister says she cannot find €10 million out of €16,000 million. I say, 'Yes we can.'")

"[O]ne euro's prevention is as good as two euros of cure," the head of the Irish Cancer Society told the Irish Times.

Are Canadian provincial finance ministers now kicking themselves for not anticipating the costs of subsidized vaccinations? There have been no suggestions that HPV vaccine programs should be cut or delayed in Canada, but in light of Ireland's move it doesn't seem impossible. An argument about cost-effectiveness has persisted throughout the last few years in Canada, as provincial governments (with a federal infusion of $300 million) opted to go ahead with funding.

An article in the Canadian Medical Association Journal last year examined the programs' costs and potential for savings, and included a detailed discussion of cost-effectiveness. One expert suggested provinces might want to give only two shots rather than the typical three, or focus vaccination efforts on high-risk subpopulations.

In an op/ed published last year in the National Review of Medicine, Dr Neil Arya questioned the wisdom of spending so much money on a project with no longterm data to guide decision-making: "Is Gardasil the most cost effective measure for Public Health? A BC Cancer Agency study projects health care costs to be six times those saved with 26 year followup. Putting resources of the order of magnitude of investment in Gardasil into determining barriers to PAP smear screening and promoting education and novel ways of approaching the issue such as self administered PAP smears could prove more cost effective."

The provinces, however, seem more likely at the moment to run deficits rather than to make cuts to social programs -- particularly in healthcare. (Deficit spending received a boost yesterday when Prime Minister Stephen Harper tentatively endorsed the idea for the federal government.) Social program cuts are typically regarded as political suicide, and Canada has been less hard-hit by the global credit crisis than many other countries, so it seems for the moment that Ireland's misfortune is not likely to be a harbinger of things to come for Canadian policy.

Photo: Progressive Democrats

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Thursday, November 6, 2008

What's in the news: Nov. 6 -- Newfoundland row, "Obamacare," and more

A round-up of Canadian health news, from coast to coast to coast and beyond, for Thursday, November 6.

Newfoundland's Eastern Health authority fired its laboratory program director, Terry Gulliver, yesterday. He was called as a witness last month by the Cameron Inquiry, regarding the province's erroneous hormone receptor tests. At the commission, it was revealed that he had violated the health authority's policy by allowing a tissue-staining machine to be sold. [St John's Telegram] Later yesterday afternoon, an Eastern Health executive refused to explain the firing to reporters. [St John's Telegram] The province's lab technologists are incensed by the decision, reportedly. "He was trying to do his best when there was very little funding and we are really shocked that is has come down to this level," said one. [St John's Telegram]

Saskatchewan Health Minister Don McMorris announced a major new review of the province's healthcare system, including the role the private sector should play. The Canadian Press gave their story a tough lead: "Saskatchewan, the birthplace of medicare, wants to overhaul its health-care system and officials won't rule out privatizing some elements." [Canadian Press] Saskatchewan is currently governed by the conservative Saskatchewan Party, which replaced the left-wing NDP in last November's election.

Canada's new industry minister, Tony Clement, speaking about his replacement at Health Canada, Leona Aglukkaq: "I’ve known her for a couple years obviously as [I was] federal minister [of health and] she was the provincial minister for Nunavut and I encouraged her to run for parliament so I feel like I’m her older brother almost. She’s going to do a great job... I’m convinced." [Huntsville Forester]

What's the word on Ms Aglukkaq up north? "Leona!! Dont' become the next Sarah Palin... please don't drop the ball..." [Nunatsiaq News Talk-Back]

Here's a tough question: What is Ontario's best course of action when it comes to trying to reconcile the province's fast-growing health spending and the new deficit? There may not be a really "good" solution other than trying to cut some of the expenditures while attempting to offend as few people as possible, wrote Carol Goar. [Toronto Star] It seems to me that Dalton McGuinty is in for trouble over the next few years. The decisions he'll have to make on balancing the budget and controlling departmental spending amount essentially to a 'Damned if you do, damned if you don't' scenario. Perhaps he'll change his mind about running for federal Parliament after all, if it indeed looks like his Ontario Liberals won't be able to grab another majority in 2011.

The hallway conversations at a stem-cell research conference in Vancouver yesterday were about the next American president, Barack Obama, who has said he will lift the restrictions on stem-cell research put in place by George W Bush. Dr Clayton Smith, an American doctor and scientist who came to UBC in order to conduct stem-cell research, wondered aloud to the Vancouver Sun about whether American researchers in Canada might now consider returning to the US. [Vancouver Sun]

Still no word on the final count for Proposition 101 in Arizona, the ballot initiative that would outlaw universal health insurance in that state. The "no" side is still ahead, but the vote remains too close to determine a definite winner. [Arizona Republic] Columnist George F Will recently suggested that if Proposition 101 passes, it could law the groundwork for a serious legal challenge to any mandated national health insurance plan that a Democratic Congress could create. [Washington Post]

Want a sneak peek at what "Obamacare" might look like? The Massachusetts experience with universal, mandated health insurance has had mixed results: just about everyone in the state is now covered, but the costs have been enormous. [Boston Globe]

Rheumatology is fast becoming the exclusive purview of female physicians, wrote Canadian rheumatologist blogger Rheumination. In his post, titled "Kind of makes sense," he said that women seem to be choosing rheumatology not because of the pay -- which is the lowest of all internal medicine specialties -- but because most of the patients are female, much like obstetrics. [Rheumination]

An essay on blood transfusion safety, financial interests, George W Bush and preemptive strikes, by a Canadian transfusion specialist. [Musings on transfusion medicine]

A Canadian medical aid organization, funded by the Canadian International Development Agency, is ramping up its assistance to the Cuban healthcare system. [news release]

Dr Michael Crichton, author of medical and scientific thrillers like Jurassic Park, The Andromeda Strain and numerous other popular books, has died of cancer. Didn't know he was a physician? It's true. His writing career began while he was studying medicine at Harvard in the 1960s to help pay the tuition. An early nonfiction work dealt with patients' hospital experiences. He later created the TV drama ER, currently in its final season. He was 66. [New York Times] [CNN]

The Globe and Mail and the National Post's reporting on prostate cancer hasn't been very good, concluded a team of nursing researchers from UBC in an article published last month. "Representations of prostate cancer in Canadian newspapers predominately replicate detrimental ideologies and perspectives of men's health... hegemonic masculine ideals, such as competition and stoicism." There were also insufficient references to the negative effects of treatment, they reported. [Sociology of Health & Illness abstract]

Uh oh. Yet another tainted Halloween candy story, this time from Ontario: a Pickering fifth grader found a DayQuil capsule inside a sealed box of Smarties. [Toronto Sun]

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Wednesday, November 5, 2008

The healthcare implications of Obama's win

In two and a half months, the United States will bid adieu to George W Bush and welcome Barack Obama as the new president. What does that mean for healthcare?

President-elect Obama will certainly move forwards almost immediately after his inauguration on proposed legislation to expand the State Children's Health Insurance Program (SCHIP) that President Bush vetoed twice. The Democrats' victory, and control of both houses of Congress and the presidency, may in time bring about major reforms to the way health insurance works for adults as well -- he has proposed altering requirements for employers' provision of insurance, and he has pledged to offer an affordable government plan to many of the uninsured -- but the outlook isn't particularly bright at the moment. Reuters ran an article today titled, "Even with mandate, Obama faces health care pain." Brookings Institute analyst Henry Aaron commented, "This [the current health insurance situation] isn't the classic crisis that lets someone show his greatness... It is a bunch of messy problems that really are political minefields."

Thomas Buckmueller, a University of Michigan health economist, told WebMD that economic reality could put health reform in danger. "I am not extremely optimistic that major reform will happen, but this seems to be the best chance we have had in a long time," he said. Commonwealth Fund president Karen Davis said, "I have no inside track, but I would bet that in this economic climate it is far more likely that changes will be phased in over time."

The success of legislation to enact insurance reform will depend largely on two variables: a) Congress's willingness to provide the major outlay of cash that will likely be required to fund an expanded public insurance plan, which willingness itself will depend upon b) the economic outlook, which quickly rose over the past few months to become the central concern of Americans, surpassing health reform and the wars in Iraq and Afghanistan.

Jeff Goldsmith laid out the Democrats' options very clearly and interestingly in Health Affairs today.

Beyond health insurance reform, what else do the election results mean for American healthcare?

Some in the business world aren't pleased about the news. European pharmaceutical companies' stocks tumbled today because of fears that a Democratic president and Democratic Congress will enact legislation to bring down the prices of prescription drugs purchased by government-run health insurance plans, Reuters reported. American healthcare and pharmaceutical stocks were down today as well. However, the S&P/TSX Capped Health Care Index (which tracks Biovail, Cardiome, CML and MDS) was doing just fine when I checked the price this morning, but given the last few month's volatility it's impossible to extrapolate what that will mean for the Canadian pharma industry in the future -- or even in a few hours, for that matter.

STATE REFORMS
Besides the implications of the presidential election, some of the state results from the election will affect healthcare. Several states voted on ballot initiatives that pertain to healthcare, including:

Arizona: Proposition 101, "Medical Choice Act," an amendment to the state's laws suggested by two surgeons, would have banned universal healthcare in Arizona. But the most recent word is the vote did not pass, with the "no"s barely beating the "yes"s. Some news outlets still say it's too close to call, however.

Michigan: Medical marijuana was legalized in Michigan, making it the 13th state to do so, reported the Wall Street Journal Health Blog. (Meanwhile, in Massachusetts, marijuana has been decriminalized.)

Washington: The state of Washington legalized medically assisted suicide, with the vote passing by a fairly wide margin.

ODDS AND ENDS
An odd piece of election health news: Mortality due to car crashes is higher on US election days than on other October Tuesdays, said a study by Canadian researchers published in the Journal of the American Medical Association last month.

Image: Barack Obama / Flickr

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What's in the news: Nov. 5 -- QC election, candy meth, and more

A round-up of Canadian health news, from coast to coast to coast and beyond, for Wednesday, November 5.

It's official: Quebec's National Assembly has been dissoved at the request of the premier and a provincial election has been scheduled for December 8. [CBC News] Candidates' posters from last month's federal election were still up here in Montreal until about last week yet here we go again. Quebecers last voted just over a year and a half ago. In that election, Jean Charest's Liberals were reduced to a minority in the legislature but recent polls have indicated Mr Charest's renewed popularity and the opposition ADQ's decline.

The Canadian Blood Services employees' union claimed that the current unexpected shortfall in blood reserves is the result of the elimination of 51 jobs in August, reported the St Catharines Standard. "These cuts are having a negative impact on how our members are doing their jobs," said Ontario Public Service Employees Union Canadian Blood Services and diagnostics division chair Sean Allen. "We don't want to slam our employer, but they are doing too much, too fast and it's not working." A Canadian Blood Services spokesperson said Mr Allen's allegations are false, and the job cuts were part of an "optimization plan" that simply eliminated redundant positions. [St Catharines Standard] Read Canadian Medicine's coverage from last week of the blood-supply crisis.

Despite concluding that Claudio Castagnetta's death after being shot by a Taser last fall wasn't caused by the shock, Quebec coroner Jean Brochu recommended in his report released yesterday that anybody shot by a Taser should receive an in-hospital medical examination as soon as possible. Most of the recommendations pertain to monitoring of police detainees and response time by guards to medical emergencies. [Government of Quebec]

Canada has the fastest declining mortality rate from pancreatic cancer in the world, tied with Switzerland, according to a new British study published earlier this year. Canada's admirable decreased mortality rate stands in contrast to rising mortality rates observed worldwide outside of North America and Western Europe. [HPB: The Official Journal of the International Hepato Pancreato Biliary Association]

A third hospital in Saskatchewan has admitted to reusing syringes to inject drugs into patients' IV bags. [Canadian Press]

A position statement printed in the new issue of Canadian Paediatric Society's journal, Paediatrics & Child Health, recommended uniform age-of-consent legislation for childrens' and teens' advance directives, or end-of-life resuscitation wishes. [Paediatrics & Child Health]

New data on the spread of MRSA in Ontario reveals the infection has never been more widespread, and has increased in prevalence by more than 50% in the last three years. [Globe and Mail]

Last Thursday, I wrote, "Halloween scares are overblown... mostly." Turns out it was a shrewd decision on my part to append that adverb to the end of my headline, because there was at least one incident this year. In Ramsey, Minnesota, a seven-year-old trick-or-treater (costume: "ghoulish skateboarder") arrived home at the end of the night and emptied out his candy bag to find, among the lollipops and chocolates, $200-worth of crystal meth and $85 in cash. [Minneapolis-St Paul Star-Tribune]

Jim Boothroyd is blogging for independent BC online newspaper The Tyee about the recent 7th International Conference on Urban Health. [part one] [part two]

An excellent essay on medical student burnout. [New York Times]

A drum-maker in London, England, died after inhaling anthrax in the animal skins he imported to make the instruments. [Agence France-Presse]

"You'll shoot your eye out!" Airsoft guns, which fire little pellets by mechanical means at relatively slow speeds, can be dangerous for kids' eyes, said an article published in last month's Canadian Journal of Ophthalmology. [Canadian Journal of Ophthalmology (PDF)] The best part of the article comes near the end, when the authors describe a related 2006 study in which three scientists fired Airsoft guns at dead human and pig eyes in a laboratory and recorded how much damage they inflicted.

Religion doesn't confer any particular benefit for patients diagnosed with breast cancer, a new study from Ottawa reported. [Journal of Behavioral Medicine]

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Tuesday, November 4, 2008

Canadian Blog Awards add new 'health blog' category

The annual Canadian Blog Awards will feature a "Best Health Blog" category for the first time this year.

Last year, health blogs were grouped into the "Sci/Tech" category. The 2007 winner in that group was Weighty Matters, by Ottawa family physician and obesity specialist Yoni Freedhoff.

Anyone is eligible to submit nominations. The rules are available here, and the "Best Health Blog" category is located here. The nomination period closes November 22 and final voting will take place in December.

INTERNATIONAL AWARDS
The 2008 Weblog Awards just put out a call for nominations, as well. They have categories for "Medical/Health Issues" blogs and for Canadian blogs.

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What's in the news: Nov. 4 -- Drugs, Tasers, lawsuits, and more

A round-up of Canadian health news, from coast to coast to coast and beyond, for Tuesday, November 4.

Even Liberal MP Dr Carolyn Bennett is excited about the new Conservative health minister, Leona Aglukkaq. "I love her," Dr Bennett told Christina Spencer of the Toronto Sun. "She's really smart, she knows how government works, she knows how to get things done." [Toronto Sun]

Hospitalizations in British Columbia related to illegal drug use have risen 37% over the last five years, a new study found. Many more people are injured by alcohol and tobacco, but those numbers are waning while drug-related morbidity is becoming more common. [Canadian Press]

Alberta's chief medical examiner, Dr Graeme Dowling, repeated the scientifically questionable assertion that people who die after being shot with a Taser typically are victims of a drug-induced condition called "excited delirium." An autopsy is scheduled for today for Gordon Walker Bowe, who died Saturday in Calgary after perhaps being Tasered. [Edmonton Journal] "Excited delirium" is not a real diagnosis, as Ryan Bergen wrote last year. [National Review of Medicine] A Canadian blog, Truth... Not Tasers, written by the family of a BC man who died after being shot by a Taser, has been chronicling the recent news. [Truth... Not Tasers]

Nurses in Quebec are getting increasingly frustrated with the government's intransigence when it comes to paying what is required for recruitment to "staunch the flow" of RNs leaving the province and to make up for the coming wave of retirements. [Montreal Gazette]

Canadian physicians are at risk of facing more "wrongful birth" lawsuits -- suits against doctors for failing to identify birth defects in utero -- unless they follow carefully a controversial set of clinical practice guidelines issued last year. The guidelines said that all pregnant women should be offered prenatal genetic screening. [Canadian Medical Association Journal] [Canwest News Service] I covered this topic last year when the guidelines were released by the Society of Obstetricians and Gynecologists of Canada (SOGC). One of the reviewers of the guidelines expressed some concerns about the neutrality of the counselling offered by family physicians, to whom the responsibility to discuss genetic screening with patients has been falling more and more often in recent years. He told me, "We as medical geneticists are trained to counsel and make sure it is non-directive, but other physicians often do not know how to do it and just tell patients what should be done." A review article from Ottawa, which was still in preliminary draft when I wrote my article, demonstrated that "family physicians are not prepared to counsel patients on test results," one of the authors told me. [National Review of Medicine] The new CMAJ warning should be of concern to doctors, certainly, but it's clear that not all doctors agree with the SOGC's guidelines.

Ontario created a new team of 17 permanent occupational health specialists to monitor healthcare professionals' work safety conditions. [news release]

The University of Toronto came out on top of this year's ranking of the top medical/doctoral research schools in Canada, followed by McGill, University of Alberta, University of British Columbia and McMaster. U of T finished first in every category. [Research Infosource (PDF)]

Two studies in the new issue of Pediatrics strike me as questionable, mostly for their insinuation that there's no need to be too concerned about the difference between correlation and causation. One shows that playing violent video games is associated with increased aggression in kids. [Pediatrics abstract] The other demonstrates that teenage girls who watch lots of "sexy" television shows are more likely to be pregnant within three years. [Pediatrics abstract] [Reuters] The authors of the sexy-TV study admit, "... there is the possibility that we did not account for all factors that may alternatively explain the relationship we uncovered." At some point, doesn't the absence of proof of causation -- in other words, to explain why this should be interesting to us in the least -- make these studies all but useless? One could just as easily write the above papers as "Kids who are going to become more aggressive tend to enjoy violent video games" and "Sexually active teens like thinking about sex." That's a little simplistic, sure -- but you get the idea. One reader, a psychologist from Texas A&M, felt the same way I did about the video game study; he tore it apart in a response to the journal.

Autism may be linked to residency in an area with lots of rainfall, a new study suggested. [CTV News] [Archives of Pediatric & Adolescent Medicine abstract] An accompanying commentary tried to explain why the study is likely useless, and why it is nevertheless worthwhile to conduct and publish despite the "possibility (likelihood?) that nonprofessionals are going to misinterpret and misuse it." [Archives of Pediatric & Adolescent Medicine abstract]

This week's edition of Grand Rounds, a collection of the best writing from health bloggers, was published today. It includes details about US presidents' health problems over the years, from Jefferson's depression and Taft's obesity to Kennedy's colitis and George H W Bush throwing up on the prime minister of Japan. [Nurse Ratched's Place]

Canada's new dominion carilloneur is a former physician. What's a dominion carilloneur, you ask? That's the person who plays the bells at Parliament Hill. [CBC News] [Ottawa Citizen]

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Monday, November 3, 2008

The best health policy writing on Tuesday's US election

It's finally here. Tuesday marks the culmination of the seemingly never-ending battle for the US presidency between Democratic Senator Barack Obama and Republican Senator John McCain.

This year's election has featured an unusually large amount of discussion about health insurance reform -- as opposed to the scant attention paid to the topic in the debates leading up to last month's Canadian election -- and change is in the air. That change may come as a result of a presidential initiative, but perhaps more likely is a change pushed through a Democratic-majority Congress. The Democrats appear to have learned their lessons since the dramatic failure and political disaster of Hillary Clinton's early-90s health insurance reform attempt, and the consensus opinion will almost surely be a measured and decidedly unradical push to insure millions of the uninsured while maintaining the large role that private firms currently enjoy in providing insurance.

We've compiled a list of the most interesting writing that's come out lately on the subject of the American election and health reform.

  • A very comprehensive and well researched New York Times editorial, published last week, provided excellent synopses of the two candidates' plans, as well as an overview of what some nonpartisan experts have said. The Times endorses Obama's plan hesitantly, importantly pointing out, "Neither candidate has persuasively explained how he would pay for his plan." To readers (and taxpayers), that failure to explain how the plans would be funded merited more than a couple of paragraphs at the end of the editorial. Take a look at the letters to the editor in response: their content sounds vaguely Canadian. "Your editorial accurately describes the candidates’ plans. But it doesn’t reveal how inadequate they are," wrote a representative of Physicians for a National Health Program. "These plans continue to rely on a privately run insurance system that has shown itself to be too costly, too inflation-prone and too unreliable to meet our needs." That sentiment was echoed in most of the letters' messages.

  • A pair of front-page stories by Amy Goldstein in the Washington Post last week analyzed the two candidates' visions for healthcare. The article on McCain's proposal is here, and Obama's is here.

  • Health Affairs proposes a compromise reform plan, taking the best pieces from Obama's and McCain's ideas, in "Blending Better Ingredients for Health Reform," by Mark V Pauly.

  • One of the major obstacles to achieving tangible reforms is that lack of understanding of how health insurance actually functions, write Katherine Baicker and Amitabh Chandra in"Myths and Misconceptions About U.S. Health Insurance," in Health Affairs.

  • An older article, "Yankee Doodling," from February, in the British Medical Journal, bemoaned the absence of a genuine plan to repair the primary care mess.

Illustration: Shutterstock

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What's in the news: Nov. 3 -- Aglukkaq on TV, new film, and more

A round-up of Canadian health news, from coast to coast to coast and beyond, for Monday, November 3.

Newfoundland and Labrador's Commission of Inquiry on Hormone Receptor Testing, also known as the Cameron Inquiry, wrapped up witness testimonies on Friday. A lawyer representing patients injured by the errors in cancer treatment testing and by the subsequent cover-up lauded the commission, telling CBC News that Newfoundlanders "wouldn't have known a tenth that has come out through the inquiry process." [CBC News] The last witness to testify was a woman who was never notified about the testing errors and didn't find out about them until the inquiry was made public. Her breast cancer has returned and metastasized. [Canadian Press] The final report by the commission is due by February 29, 2009. [Commission of Inquiry on Hormone Receptor Testing]

Canada's new health minister, Inuit rookie MP Leona Aglukkaq, appeared on CTV's Question Period yesterday to discuss her plans. [Question Period] Some highlights: "In Canada we have one of the best healthcare systems." The somewhat surprising question: does Ms Aglukkaq see a comparison between herself and Sarah Palin, because they both brought their newborns to work with them? (She says she plans to keep bringing her baby to work in Ottawa.) Her adopted parents were an elder and a hunter. Is she the only one in federal cabinet to ever kill a caribou? I'd say yes, definitely. Lowlights: a bit of excess wonkery, her "unique perspective" goes unexplained, and her first priority is to get to know her staff.

Yet another report from Saskatchewan of syringes being reused to inject meds into IV lines. [CBC News] Alberta's acting chief medical officer organized a conference call with provincial chief medical officers from across Canada to discuss the issue. [Canadian Press]

Now for some good public health news from Saskatchewan: there were only 19 cases of West Nile virus in the province this year, compared to 1,454 in 2007, and zero deaths from the disease this year, compared to four last year. [Canadian Press]

A new documentary chronicles the tragic story of Andrew Bagby and Shirley Turner, both doctors who moved on from Memorial University to practise in the United States. Dr Bagby was shot to death in 2001 after Dr Turner told him she was pregnant and he told her he had been seeing another woman. She headed back to Newfoundland, where she was born, before being charged with his murder; her lawyers delayed extradition for some time. Less than two years later, she killed herself and her one-year-old child in Conception Bay, Newfoundland. The film, Dear Zachary: A Letter to Son About His Father, by a friend of Dr Bagby, has been making the festival circuits. [IMDB] [New York Post] A review in the New York Times, published Friday, called the film "a polemical rant against the Canadian justice system for coddling a dangerous sociopath." [New York Times] The filmmaker's goal, he told the Los Angeles Times, is to pressure Canada to reform its bail and extradition laws. [Los Angeles Times] The film has received lots of press this year. [Reuters]

Nova Scotia has centralized its various regional breast cancer screening programs in an effort to make the process more efficient and better organized. The goal is to reduce wait times for screening. [news release]

A man from London, Ontario, will ski to the south pole to raise awareness of colon cancer. He's due to leave on Sunday. You can follow Thomas Davenport's adventure online. [news release]

Don't miss this great story by Dr Liana about practising medicine in East Timor, called "On breaking points." [Med Valley High]

Saskatoon urological surgeon Kishore Visvanathan is back on the topic of annoying PowerPoints, this time complaining about Mac-PC compatibility issues and some doctors' refusal to bridge the gap. [Plain Brown Wrapper]

I was pleased to learn of a relatively new blog by a Canadian physician today: Physician, Heal Thyself is written by orthopedic surgery resident and recent MBA grad Jesse Shantz of Winnipeg. [Physician, Heal Thyself] Dr Shantz's site is the latest addition to our database of Canadian physician blogs, available on the left-hand sidebar of Canadian Medicine or by clicking here to see the full list on our homepage.

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The death of convergence theory

Canadians and Americans aren’t so different: Tim Hortons and Dunkin’ Donuts, poutine and disco fries, professional hockey and professional wrestling -- there’s some truth behind that “51st state” joke. But despite our similarities, there’s a glaring difference between us that we can’t seem to reconcile: health insurance.

This year, in which a Canadian federal election preceded the American one by just three weeks, serves as a case in point.

Throughout the Canadian campaign, the mere mention of expanding the role of private insurance set off public apoplexy. During the American campaign, a Canadian-style single-payer system has been deemed equally ludicrous as its converse in Canada, the thinking apparently being that letting the government run the health insurance plan is tantamount to asking a five-year-old to change your car’s oil: it’s sure to be messy, expensive, frustrating, and somebody’s likely to get hurt.

Both the American and Canadian interpretations of health insurance reform can’t be correct. Where’s the truth in all of this?

It has been suggested for years that in reality neither of us is right, that some sort of ideal compromise existed. Eventually the United States and Canada would, after experimentation and study revealed an enlightened pathway, reach an effective, sensible equilibrium between private and public health insurance -- or so the theory went. This notion is known in comparative health policy studies as “convergence theory” and was especially popular in the early ’90s, when the Democrats were ascendant and Hillary Clinton was hard at work on drafting legislation to create a national health plan for the U.S.

We all remember what happened: the plan was destroyed by a combination of its own complexity, dissent within the Democratic Party, private-industry lobbying, and Republican scaremongering. The last fifteen years saw Canadian and American health policy remain as far apart as ever.

But, lo and behold, convergence theory was back again this year as the Democratic primaries saw the return of talk about universal healthcare and insurance mandates from Clinton and John Edwards. For a time it looked as though Canada was back in vogue in Washington. But University of North Carolina at Chapel Hill professor Jon Oberlander, the author of the 2003 book The Political Life of Medicare, recently warned me about the turn of events, “There might be more of a convergence in rhetoric than in reality.” Right he was. Barack Obama won the nomination and the party once again adopted a relatively centrist platform in the general election.

Canada’s single-payer approach is far from perfect, of course. Wait times are dangerously long in some cases, remuneration for physicians is lower than in the U.S., and medical technology lags behind. But for all its shortcomings, the overall cost of delivering healthcare is half in Canada what it is in the U.S. while health outcomes and mortality rates are essentially equivalent, and the discrepancy in healthcare quality between rich and poor is vastly reduced in the Canadian model.

Nevertheless, the prospect of following the Canadian example has lost what little currency the idea once had in the United States; a Canadian-style schema is as anathema to mainstream politics as ever. McCain’s plan would move the U.S. even further still away from Canada. And keeping in mind Obama’s modest tax plan has been blasted as Communist, just imagine what a call for universal healthcare would do to him; his campaign realized early on it was political suicide to propose anything like what exists north of the border.

“There are still a lot of people in the U.S. for whom ‘socialized medicine’ is still a dirty word,” Oberlander told me. “That’s why when John McCain calls Barack Obama’s plan ‘socialized medicine’ the campaign wants to shoot that down immediately. Those are fighting words here.”

Regardless of who wins on Tuesday, over at least the next four years Canadian healthcare will remain as foreign to Americans as ketchup chips or Bob and Doug McKenzie. Meanwhile, at the other end of the spectrum, Canadian forays into private health insurance have been few and far between, and severely limited in scope by existing laws.

In practice, convergence theory looks to have been a failure.


This essay was first published yesterday at KevinMD.

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