Canadian Medicine

In the halls of Parliament, on the pages of newspapers across the country and in international scientific journals, the aftershocks from the Tuesday decision by the British Columbia Supreme Court's Justice Ian Pitfield, which saved Insite and ruled a portion of the Controlled Drugs and Substances Act unconstitutional, are still reverberating. (For more on the decision, see our article published Wednesday.)

PARLIAMENTARY DISSENT
Yesterday, the government launched a retaliatory rhetorical salvo against Justice Pitfield and the proponents of supervised injection. During a briefing at the House of Commons Standing Committee on Health, Health Minister Tony Clement announced that he will ask Justice Minister Rob Nicholson to appeal .

"In my opinion supervised injection is not medicine -- it does not heal... There exists today a significant degree of uncertainty in the research and so, based on this, I believe that priority must be focused on treatment and prevention. For these reasons, fellow committee members, I can inform you today that I will be asking my colleague, Rob Nicholson, the minister of justice, to appeal Judge Pitfield's decision at the earliest possible opportunity."

Mr Clement then tersely said, "Thank you," and sat down to a chorus of boos from the assembled Liberal Party, NDP and Bloc Québecois MPs, with some cheering from his own partisans mixed in.

What happened next could not have been pleasant for Mr Clement: he had to sit in front of a crowd of outraged opposition members, including the Liberals' medical corps of Drs Carolyn Bennett, Hedy Fry and Keith Martin. Both Dr Fry and Dr Martin have treated drug addicted patients in Vancouver's downtown eastside, where the safe-injection site Insite is located. The official line from the Liberals was tough but somewhat restrained: "To ignore scientifically-based proof of the effectiveness of harm reduction programs for sake of ideology is not only irresponsible, it is playing politics with the lives of Canadians," Dr Bennett said in a yesterday after the committee meeting ended.

But the meeting itself was far more animated than that release would have you believe.

At one point, during the Q&A with the Minister after his statement, Dr Fry challenged Mr Clement's assertion that the "science is mixed" on Insite and that there is no medical consensus in favour of its continuing existence:

Dr Hedy Fry: [...] I wonder if the Minister's researchers were peer-reviewed. Did the Minister have his report from his advisory council peer-reviewed? Yes or no?

Tony Clement: It was independent--

Dr Hedy Fry: Yes or no.

Tony Clement: [Leaning over to hear whispered advice from an aide] It was not for publication. Those people are experts--

Dr Hedy Fry: Yes or no. You haven't answered my question.

Tony Clement: You don’t want to hear my answer.

For the sake of brevity, I didn't transcribe all the times Dr Fry interrupted Mr Clement's "Well..." and "First of all..." responses with her sharp "Yes or no." I'd estimate that happened about five or six times at least before Conservative MP David Tilson asked the committee chair for a point of order, demanding Dr Fry be more respectful of the minister. Liberal health critic Robert Thibault countered that Dr Fry's refusal to accept more of Mr Clement's repetition of propaganda was perfectly acceptable.

Bloc MP Christiane Gagnon told Mr Clement she was disappointed with his position on Insite. "We doubt your sincerity and ability to help society."

Libby Davies, of the NDP, said to Mr Clement, "To have low-threshold programs [such as safe-injection sites] to draw in hard-to-reach users is critical, and I don’t understand why you don’t get that. It is something about an ideological agenda you cannot move off of. The evidence shows that harm reduction is part of the continuum [of care]. I don’t understand why you don’t intellectually understand that."

Of course, not everyone who asked Mr Clement was as hard on him as Ms Davies, Dr Fry, Ms Gagnon, Dr Bennett and others were; Steven Fletcher, a Conservative MP and the Parliamentary Secretary for Health, spent his allotted time for questions praising the minister and lobbing softball questions that had obviously been scripted by the Minister's office ahead of time. Mr Fletcher also claimed, earlier in the meeting, that his constituency office in Winnipeg was "vandalized by supporters of Insite."

The witnesses who spoke before Mr Clement painted a clear picture of Insite's benefit, with few exceptions.

Neil Boyd, a Simon Fraser professor of criminology, said, "In an ideal world we would not need a safe-injection site, but we do not live in an ideal world."

Julio Montaner, the director of BC Centre for Excellence in HIV/ADS, told the committee his research had proved that Insite reduces the transmission of HIV.

Thomas Kerr, also of the BC Centre of Excellence in HIV/AIDS, said, "A large body of research endorsed by the world’s scientific community shows Insite is saving lives and doing what it was supposed to do, and does not appear to be having any negative effects on the community. This is the only research that has passed peer review and was published in recognized medical journals," he added, in a direct shot at Colin Mangham, the author of the only anti-Insite journal article, published in the Journal of Global Drug Policy and Practice, which Dr Kerr derscibed as "simply a website operated by a well known anti-harm reduction lobby group in US, and not indexed on Medline."

One of the most dramatic moments came just as the meeting got underway, when committee chair Joy Smith, a Conservative MP from Manitoba, unexpectedly began the meeting by reading a statement from Dr Donald Hedges, who had been scheduled to speak later in the day. The letter said that Dr Hedges's office had been picketed and his patients harrassed, and that he had been advised not to attend because he was thought to be in danger. "There is no way to engage in discussion about Insite. If you do, you are villified and slandered for voicing a professional opinion of criticism against Insite," Dr Hedges's message read. "This is not science this is bullying."

This unexpected twist -- the chair reading a message from a witness out of order -- upset Ms Gagnon. "It smacks of ideology," she said. "It's not that we aren't worried [for Dr Hedges's safety], but it sounds alarmist before we hear from witnesses."

SECOND SITE
In another surprising twist in the fallout from Tuesday's BC Supreme Court decision, The Globe and Mail today the existence of a second safe-injection site in Vancouver. The Dr Peter Centre, an HIV/AIDS clinic, has been "quietly" running its own safe-injection program since 2002 and decided not to ask for a federal exemption to operate legally.

"Nurses working at the centre were witnessing rushed injections and a variety of health concerns," Maxine Davis, the clinic's executive director is quoted as saying. "And they decided if they knew what to do to prevent such things, why not do it?"

In fact, it seems the Dr Peter Centre was a poorly kept secret: the clinic's announces that it provides safe-injection services.

INTERNATIONAL CRITICISM
A member of the Canadian HIV/AIDS Legal Network, which has been this week in its criticism of the government's position on Insite and harm reduction, is the co-author of an in the prestigious journal The Lancet that urges the United Nations to disband the anti-harm reduction International Narcotics Control Board (INCB). The INCB has provided much of the fuel for the Conservative government's opposition of harm reduction. Ms Joanne Csete, of the Canadian HIV/AIDS Legal Network, and Daniel Wolfe, of New York's Open Society Institute, write:

Despite the political appeal of zero-tolerance policies, UN member states have recognised that measures other than prohibition are required to address massive mortality and morbidity among drug users. For example, the unanimous declaration from the first HIV/AIDS Special Session of the General Assembly in 2001 included a pledge to ensure access to sterile injection equipment for people who use drugs, which was reiterated in 2006. UN agencies have also developed guidance on HIV prevention measures, including sterile-syringe programmes, and WHO added methadone and buprenorphine to its list of essential medicines in 2005.

But some UN-supported drug-control efforts undermine recognition of the importance of HIV prevention measures for people who use drugs. The International Narcotics Control Board (INCB), a 13-member body of experts serving in their personal capacities but whose functions are paid for by the UN, for example, remains out of step with the rest of the UN on HIV and harm reduction.

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This week's medical blog anthologies are now available. Canadian Medicine's articles appear in two:

, at Parallel Universes.

, at InsureBlog.

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Ghislaine Lanctôt is out of jail, for now.

The Stukely-Sud woman (right, on the front page of Le Reflet du Lac on March 23), who had her medical licence revoked in 1997 after publishing an anti-vaccine screed called "The Medical Mafia," was being held for refusing to pay income tax since 1995 and then refusing to cooperate with the Quebec courts during proceedings this year, claiming her name was not Ghislaine Lanctôt but was rather the mathematical symbol for infinity, ∞, though she often refers to herself simply as Ghis. (She she was jailed for "refusing to endorse the fictional corporation of LANCTÔT, GHISLAINE.")

After the province issued the arrest warrant in March that led to her incarceration, I wrote the following in the National Review of Medicine:

STUKELY-SUD — Tax time is coming up fast, but one former Quebec doctor definitely won't be filing. An arrest warrant was issued early last month for Ghislaine Lanctôt, 66, for refusing to pay income tax since 1995. Ms Lanctot, who last year informed the provincial Attorney General's office she prefers to known by the name, lost her medical licence in 1997 for her anti-vaccination publication The Medical Mafia. She also refuses to use a driver's licence or health card. "Those are for the sheep," she said. "NO RELATIONSHIP PRESENTLY EXISTS BETWEEN THE LANCTOT, GHISLAINE CORPORATION AND THE HUMAN BEING, WITH A BODY, A SOUL AND A SPIRIT," was her response to the warrant. "It's a very unusual case," a government prosecutor told La Voix de l'Est.

Unusual indeed. Among the many strange twists in this case, she not only refuses to own a driver's licence -- she's even designed her own licence plate. Check it out:

Je me souviens de qui je suis is also the name of Ms Lanctôt's . Be sure to take a look at this cartoon on her site about her time in Tanguay prison:
For our unilingual readers: the text at the top reads "The Tanguay prison, where Ghis is held, is invaded by rats" and Ms Lanctôt is saying "The sheep don't want to hear it, but the rats understand everything." The title of her drawing on the wall (the cartoon within the cartoon) is "The big picture." I can translate the text, but unfortunately I cannot even begin to explain what on earth the meaning is.

Yesterday morning, after a hearing at Granby courthouse, Ms Lanctôt was released from jail, Radio-Canada.

The Quebec judge, Pierre Bachand, agreed to defer the lawsuit while a similar case, against David Lindsay in Kelowna, British Columbia, who also refuses to be known by his given name, is decided. (Ms Lanctôt's includes a link to a letter from Mr Lindsay about his case.) Ms Lanctôt is now a free woman.


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Yesterday afternoon in Parliament, , Vancouver East NDP MP Libby Davies gleefully turned the knife in the government's wound inflicted by yesterday's BC Supreme Court ruling in favour of Insite, the downtown Vancouver safe-injection site.

Ms. Libby Davies (Vancouver East, NDP): Mr. Speaker, yesterday B.C.'s Supreme Court decision makes it abundantly clear that Insite, the supervised injection facility in east Vancouver, is a health facility. The ruling also makes it clear that closing Insite would be “inconsistent with the state’s interest in fostering individual and community health, and preventing death and disease”. Can the Minister of Health assure the House today that his Conservative government will abide by the court's decision and not appeal this important case?

Hon. Tony Clement (Minister of Health and Minister for the Federal Economic Development Initiative for Northern Ontario, CPC): Mr. Speaker, I am not in charge of appeals. That is the Minister of Justice. But I can say to the House that on this side of the House at least we are disappointed with the judgment. We disagree with the judgment. We are, of course, examining our options and I would say to the House that we on this side of the House care about treating drug addicts who need our help. We care about preventing people, especially our young people, from becoming drug addicts in the first place. That is our way to reduce harm in our society and we are proud of taking that message to the people of Canada.

Ms. Libby Davies (Vancouver East, NDP): Mr. Speaker, if the Minister of Health claims that he cares about people who use drugs and the issues they face, then he will respect the decision of the court. The medical, scientific and now legal conclusions just could not be any clearer. Insite is a life-saving facility and harm reduction is an essential component of Canada's drug strategy. When will the minister put aside his personal ideological position, respect the court's decision, and get to work on changing Canada's drug laws to allow access to health facilities such as Insite? When is he going to do that? He is taking too long.

Hon. Tony Clement (Minister of Health and Minister for the Federal Economic Development Initiative for Northern Ontario, CPC): Mr. Speaker, it is a bit rich for the member from the New Democratic Party to start lecturing us on ideological positions. That is its bread and butter over there, but we on this side of the House are here for public policy. We are here to help our kids and prevent them from getting on drugs in the first place. We are here to help addicts. We think the best public health is when we get addicts off the drugs, to treat them, to treat them as human beings, and to be there with the passion. That is what we believe on this side of the House.

Some hon. members: Oh, oh!

The Speaker: Order. I urge all hon. members to exercise a little more self control. We are wasting time and no one wants to waste time in question period.

At an Ottawa press conference yesterday, Mr Clement was blunt and displeased, The Canadian Press :

"We disagree with the judgment... Our government believes that the best way to deal with the health issues of drug addicts is to offer treatment and indeed to prevent people from getting on to illicit drugs in the first place... We don't consider it the best health outcome to keep people in a position where they continue to use the illicit drugs, to inject the illicit drugs."

Also, in the CP article, a member of the Vancouver Area Network of Drug Users discussed the prospect of opening more safe-injection sites, echoing Liberal MP Dr Keith Martin's sentiment: "They [health authorities and the province] would be chumps not to open another injection site. It's clearly what has shown to work. I think they can open them right now."


Update, Thursday, May 29: During a briefing earlier today in front of the House of Commons Standing Committee on Health, Tony Clement announced that he will be asking Justice Minister Rob Nicholson to appeal the British Columbia Supreme Court's decision.

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Maxime Bernier's from Cabinet on Monday -- he resigned, he was fired, or he was forced to resign, depending on whom you ask -- has created a new problem for Prime Minister Stephen Harper, besides dealing with the unpleasant fallout from l'affaire "Mad Max."

Mr Harper must now decide how to round out his Cabinet.

In the interim, he has appointed David Emerson, the Minister of International Trade, to fill in for Mr Bernier as Minister of Foreign Affairs. But Mr Emerson, who defected to the Conservatives after he was elected as a Liberal in 2006, is widely considered unlikely to be able to win another election in his riding ( may be a bad sign, for instance). So there's now plenty of talk about a forthcoming Cabinet shuffle.

The Globe and Mail that the current rumours have three serious contenders for Mr Bernier's Foreign Affairs job: Mr Harper could keep David Emerson in the position until the next election, or he may consider Industry Minister Jim Prentice or Health Minister Tony Clement.

The Globe and Mail also got word of another possible scenario: Mr Clement may leave the Health Ministry to take over Mr Emerson's International Trade job, and then be moved to Foreign Affairs after the next election.

Would our Health Minister make a good Foreign Minister? According to The Globe and Mail:

Mr. Clement is perceived as both hardworking and loyal. He has also been willing to take a back seat to the Prime Minister at major announcements - a trait that could come in handy in the Foreign Affairs job.

His French is imperfect but passable. And he has had some exposure to the international stage when he dealt with the SARS crisis as Ontario health minister.

CTV News has a different take. Mr Emerson will stay on in Foreign Affairs for the moment, says, and Mr Clement may compete with Citizenship and Immigration Minister Diane Finley for a shot at International Trade.

, Human Resources Minister Monte Solberg is also under consideration for the Foreign Affairs post, so it's certainly no sure thing that Mr Clement will be moved out of Health.

No word from anyone yet, it seems, on potential replacements for the Health Minister.

I wonder if Mr Clement might be itching for a move. When he and I spoke at his office in Ottawa in January for that appeared in the National Review of Medicine in February 2008, he sounded somewhat ambivalent about his long experience as provincial and then federal Health Minister.

SAM SOLOMON: It must be tough trying to get all the different provincial health ministers on the same page -- does it ever feel like you're herding cats when you have to do intergovernmental work?

TONY CLEMENT: No, not really. You know, we're a fraternity -- which is not to say it's not a sorority as well -- but in a sense everyone who's a health minister usually has a very difficult, complex portfolio that has been the frequent graveyard of political aspirations in the past, so we have common cause and common experiences so we treat each other with a lot of mutual respect and a lot of mutual empathy, I guess is the way to put it. We always have pretty open discussions but at the end of the day we are all there for the same reason: we want better healthcare for people in Canada.

Any theories on who might be likely to replace Mr Clement if he is switched out of the Health Ministry? I have some ideas, but I'll wait for the moment to share them. (Though I will say that when I met Jim Prentice a few months back at a lecture he delivered at the Montreal Neurological Institute, I was impressed with his ability to say a lot without saying anything at all -- a trait that I imagine comes in very handy at United Nations meetings and other such foreign policy gatherings.)


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A new agreement between Nova Scotia's physicians and the provincial government has been approved by Doctors Nova Scotia's membership, the organization .

The five-year agreement, retroactive to April 1, was approved by a 71% vote.

In a news release, Doctors Nova Scotia president Dr Don Pugsley (left) said:

"This agreement is different. Rather than simply offering an across-the board fee increase, this agreement supports system change... The physicians of Nova Scotia asked us to find ways to support them in providing care that is innovative and better focused on patient needs. [...]

"This agreement will help ensure patients have access to the care they need, when they need it, whether their condition is simple or complex. This agreement also facilitates our ability to work with other health-care professionals to deliver collaborative care.

“It won’t solve all of our health-care issues, but it’s a step in the right direction. It will strengthen our ability to deliver the highest quality patient care - a high priority for our members.”

Doctors Nova Scotia announced that the new agreement, which will be in effect until March 31, 2013, includes:

• a focus on encouraging doctors to provide a broad spectrum of care to their patients;

• new funding to help retain rural specialists;

• funding to support collaborative care with other health-care providers;

• more funding to support general practitioners who provide comprehensive care, chronic disease management and in-hospital care; and

• funds to address unforeseen issues that may arise throughout the life of the agreement.

This new contract follows the provincial government's new strategy that was released in January as a report called the , or PHSOR for short. (Strangely, it's pronounced 'fa-ZORE' by those in the know. Really.)

You can read more about that strategy in from the National Review of Medicine's February 2008 issue. In our article, Dr Pugsley endorsed the review, saying, "Certainly we believe it's past time for change and modernization of the healthcare system in Nova Scotia."

Today's approval of the new agreement with the government, he says, is another step in that direction.


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The uncertainty is over.

Insite, the (pictured right) and the subject of a great deal controversy across Canada, cannot be cancelled by the Conservative federal government, a number of news outlets reported today. The government had been equivocating about granting Insite another exemption from federal drug statutes.

And that's not all: by BC Supreme Court justice Ian Pitfield also found sections of Canadian federal drug law, the Controlled Drugs and Substances Act, to be unconstitutional, for violating drug users' rights under , which reads: "Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice."

In his strongly worded , Justice Pitfield writes:

"Society cannot condone addiction, but in the face of its presence it cannot fail to manage it... While there is nothing to be said in favour of the injection of controlled substances that leads to addiction, there is much to be said against denying addicts health care services that will ameliorate the effects of their condition. Society does that for other substances such as alcohol and tobacco. While those are not prohibited substances, society neither condemns the individual who chose to drink or smoke to excess, nor deprives that individual of a range of health care services. Management of the harm in those cases is accepted as a community responsibility. I cannot see any rational or logical reason why the approach should be different when dealing with the addiction to narcotics, an aspect of which is that the substance that resulted in the addiction in the first place will invariably be ingested in the short-term, and possibly in the long-term, because of the very nature of the illness. Simply stated, I cannot agree with the Canada’s submission that an addict must feed his addiction in an unsafe environment when a safe environment that may lead to rehabilitation is the alternative."

This decision in favour of drug addict litigants Shelly Tomic and Dean Edward Wilson and the Portland Hotel Society, which operates Insite, was not -- to put it mildly -- the result that the federal government had been hoping for. To be told that not only is it illegal to decide the future of the divisive project, but in addition that the laws governing drug enforcement must be revised, flies in the face of the government's longstanding position. Justice Pitfield has now given the government until June 30, 2009 to bring the relevant laws in line with his decision.

Since it came to power, the Harper government has been accused of hostility towards Insite and other harm reduction programs. In an in the September 15, 2007 issue of the National Review of Medicine, I examined the feds' reluctance to provide longterm extensions to the clinic's licence to operate. (Physicians from the BC Centre for Excellence in HIV/AIDS wrote an about the issue.) "The current federal government has philosophical objections to harm reduction initiatives. They're trying to obscure the evidence by saying the research on Insite is not clear," said Dr Stephen Hwang, of Toronto's Centre for Research on Inner City Health, who rallied over 130 scientists and physicians to sign a petition opposing the government's stance on harm reduction. Dr Keith Martin, a former addictions physician who now sits as a Member of Parliament in the Liberal caucus, told me he left the now-defunct Reform Party because of the ideological and unscientific approach to addictions and the law taken by his colleague at the time, Stephen Harper. Dr Martin told me to read an essay Mr Harper wrote about the Left called "" from Report magazine in 2003 for an example. One passage from that essay reads:

"This descent into nihilism... leads to silliness such as moral neutrality on the use of marijuana or harder drugs mixed with its random moral crusades on tobacco. It explains the lack of moral censure on personal foibles of all kinds, extenuating even criminal behaviour with moral outrage at bourgeois society, which is then tangentially blamed for deviant behaviour."

Justice Pitfield puts that argument to shame in his decision:

"While it is popular to say that addiction is the result of choice and the pursuit of a liberty interest that should not be afforded Charter protection, an understanding of the nature and circumstances which result in addiction, as I have discussed elsewhere in these reasons, must lead to the opposite conclusion."

Insite's supporters are rejoicing today after hearing the news of the decision. CBC News published a from people involved in the case this morning:

“It's a major victory, really — a judge for the first time in Canada has said that this project is about health care so the Controlled Substance and Drugs Act does not apply to it, so that is a major victory." - Mark Townsend, Portland Hotel Society director

"This decision is a huge victory for people in our community, for people who are marginalized in the community, who are struggling day by day to survive, and this decision is the foundation on which I think we can build on." - NDP MLA Jenny Kwan (Vancouver-Mount Pleasant)

"The court ... affirmed the right of people with serious addictions to access the health care they need to deal with the addictions and the coincidental health affects of those addictions." - Monique Pongracic-Speier, the lawyer who represented the Portland Hotel Society, Mr Wilson and Ms Tomic.

The Vancouver Sun's Ian Mulgrew Justice Pitfield's decision "courageous."

It's unclear at this point to what extent the recent federally commissioned review of Insite played in Justice Pitfield's decision. That review, which I wrote about when it was released on April 14, was largely positive; it would be an ironic twist if the government's own study proved instrumental to the defeat of its argument in court.

It also remains unclear how this decision will affect the potential development of other harm reduction programs, including more safe-injection sites and projects like the (NAOMI), which Dr Martin has been touting for expansion recently. In an email to me on Monday, he said, "I am still fighting to keep Insite open and expand this program and NAOMI into other jurisdictions such as Victoria, Toronto and Winnipeg."

It will be very intersting to see what happens tomorrow morning during a briefing scheduled at the House of Commons Standing Commitee on Health, where Health Minister Tony Clement is alongside a group of researchers mostly sympathetic to harm reduction, including Julio Montaner and Thomas Kerr from the BC Centre of Excellence on HIV/AIDS. The meeting begins at 10am Eastern time. You can watch it on ParlVu.


Update, Thursday, May 29: During a briefing earlier today in front of the House of Commons Standing Committee on Health, Tony Clement announced that he will be asking Justice Minister Rob Nicholson to appeal the British Columbia Supreme Court's decision.


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"Patients may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive," writes Dr Michael W Kahn (pictured here) in an NEJM published early this month.

The crux of his argument is that professors "may or may not be able to teach students or residents to be curious about the world, to see things through the patient's eyes, or to tolerate suffering." But they can teach students to "shake a patient's hand, sit down during a conversation, and pay attention."

By the same token, patients don't care if their physician has read medical literary classics or written reflection pieces which many schools believe will sow the seeds of maturity and sensitivity in their students; they only care when their physician doesn't smile or pays too much attention to her laptop.

As a solution Dr Kahn has deliberately emulated Dr Peter Pronovost and the he developed to help stabilize patients in the ICU. (I wrote about in NRM.) If doctors use a checklist, Dr Kahn believes there's a greater chance patients will leave satisfied. Here's his list for a first meeting with a hospitalized patient:

1. Ask permission to enter the room; wait for an answer.

2. Introduce yourself, showing ID badge.

3. Shake hands (wear glove if needed).

4. Sit down. Smile if appropriate.

5. Briefly explain your role on the team.

6. Ask the patient how he or she is feeling about being in the hospital.

After reading this list one can only wonder whether Dr Kahn isn't being a little tongue in cheek. Are physicians that hopeless when it comes to face-to-face interactions? What do you think about his approach? Will it work, or is it wonky? Leave some comments and let us know.

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Last week, the US Federal Aviation Administration (FAA) barred pilots and air-traffic controllers from taking the powerful smoking cessation drug varenicline (called Chantix in the US, Champix in Canada).

The move was sparked by a from the Institute for Safe Medication Practices (ISMP) warning against operating nuclear reactors, high-rise construction cranes, trains, planes or any heavy machinery while taking the drug. Any lapse in alertness or motor control brought on by the med could lead to "massive, serious injury," it suggests.

reports have linked the drug to increased incidence of suicide and psychosis, and the ISMP's recommendations pull no punches either. The warning, it says, arises from the drug's ties to numerous reports of "sudden loss of consciousness, seizures, muscle spasms, vision disturbances, hallucinations, paranoia and psychosis."

"If we're going to err, we're going to err on the side of caution," FAA spokesman Les Dorr told of the decision to stop pilots and air-traffic controllers from taking the drug.

Two of Canada's leading smoking-cessation experts sounded off in about the drug's efficacy and dangers. "We should be careful about who we give this treatment to," said Dr Andrew Pipe, a cardiologist at the University of Ottawa's Heart Institute. But both he and Dr Peter Selby, the clinical director of the addictions program at the Centre for Addiction and Mental Health in Toronto, agreed that patients must be reminded that the side effects are "short-term discomforts versus the longterm gain of being smoke-free."

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Climate change isn't just threatening polar bears anymore -- Quebec residents will face more and more deaths by global warming during warmer and warmer summers in the coming decades, a team of Laval University researchers reported last week in the International Journal of Health Geographics.

By the year 2080, (PDF) found, Quebecers can expect to see between an 8% to 15% rise in mortality in the summer months, which translates to a total of up to 540 extra deaths per summer in Montreal alone compared to the 1981-1999 average, which the study uses as the baseline. Even a more conservative model of carbon dioxide emissions predicts 310 extra deaths. (In 2005, Dr Gosselin and other Canadian officials a United Nations conference in Montreal that climate change could conceivably kill 150,000 people a year worldwide.)

In the figure above, you can see the huge rise in summer mortality in Montreal predicted by the study.

Similar studies conducted in the United Kingdom have shown similar results for summer mortality, but the European data shows an overall yearly drop in mortality because of warmer winters. But this new study -- titled "The potential impact of climate change on annual and seasonal mortality for three cities in Quebec, Canada," by physician Pierre Gosselin, who heads the World Health Organization Collaborating Centre for Environmental and Occupational Health Impact Assessment and Surveillance, and researchers Diane Bélanger and Bernard Doyon -- found no such winter benefit, as you can see in the figure. Why? Because Quebecers are used to the cold already, so a giant snow storm or a weeks-long freeze doesn't have the same dangerous effect in Quebec as it does in more temperate regions, like the UK. The study explains:

"Over the years, Quebecers have developed various strategies to acclimatize to the cold. The Act respecting the conservation of energy in buildings (1983), aiming to ensure a minimum performance of the thermal insulation of walls and ceilings, is one example. Furthermore, natural resources ensure heating at a relatively low cost, and even among the most advantageous, compared to several industrialized countries including the United Kingdom."

American studies have shown similar results, the authors say, which proves that different regions and different circumstances will see vastly different mortality effects as a result of global warming.

The study is an extension to the three researchers' previous work, (PDF; French only) in December 2006 by the National Public Health Institute of Quebec, which established the validity of the particular statistical model used in their new work.

The conclusion then was the same as the conclusion now: if carbon dioxide emissions aren't drastically cut in the coming years, global warming will begin taking its toll not just on polar bears and Antarctic icebergs, but on humans in first-world nations as well.


Figure: "The potential impact of climate change on annual and seasonal mortality for three cities in Quebec, Canada," Bernard Doyon, Diane Bélanger, Pierre Gosselin, International Journal of Health Geographics 2008, 7:23. (PDF)

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