Canadian Medicine

Two months ago, we reported on a new study by a group of Quebec researchers that predicted a steep rise in climate change-related mortality.

If carbon dioxide emissions aren't drastically cut in the coming years, their study showed, global warming will begin taking its toll not just on polar bears and Antarctic icebergs, but on humans as well.

To learn more, we decided to follow-up with the Laval University physician who co-authored the study, (above), a National Public Health Institute of Quebec researcher and the head of the World Heath Organization Collaborating Centre for Environmental and Occupational Health Impact Assessment and Surveillance, who answered our questions by email.

You trained as a physician. How did you first become interested in studying the connection between health and climate change?

I have always been interested in nature and the outdoors before my medicine. So I began family practice in pristine Eastern Quebec, then changed to public health (mostly environmental health since 1984), and also got involved in environmental NGOs. Climate change issues were already discussed in those circles in the 90s, so it raised my interest for research in the area and I was involved in the first Canadian climate change assessment in 1996-1997. It has just became more important ever since.

Do you still see patients?

I don’t see patients anymore, except some risk-taking members of my family. :-)

At a time when the environment and carbon emissions controls have taken centre stage in Canadian politics, why has the medical community largely remained apolitical? There seems to be some frustration among the few physician-environmentalists in Canada about the lack of medical leadership in public on climate change.

That’s a tough question! On the health policy stage, there are plenty of other real and immediate problems that need to be addressed. I always say that most of the supporters of my work in environment health come from other sectors than health, and my fiercest competitors (for grants, program money) are my colleagues from the health sector working in infectious diseases or fighting cancer, for instance. On a more personal level, I guess many of my colleagues are too busy with their practices and when they’re off, they just want to indulge in gas-guzzling BMWs or far-away vacations! So they possibly aren’t yet ready to support a societal change that implies reducing one’s emissions drastically. But I’m a physician, not a sociologist!

Your research hasn’t been ignored exactly, but it also hasn’t really made a lot of national news. Why do you think that is?

Most of my studies were funded by the Quebec government to focus on the province, so it’s more difficult to make an impact on the national news with such a focus, even if the conclusions and results are most of the time fully transferable. But they’re very well received in the international scientific literature, at the World Health Organization and, of course, in Quebec. I was the lead author of one chapter in the coming Health and Climate Change National Assessment to be published this summer by Health Canada, so there’ll be lots of interesting material in there for journalists.

What’s your take on Liberal leader Stéphane Dion’s “Green Shift” plan? What do you think of the Conservative government’s work on the environment portfolio?

I’m not too familiar with Dion’s plan or with the respective benefits of the cap-and-trade approach versus other ones as I’m more involved in impacts and adaptation than greenhouse gas (GHG) reduction. One thing is sure though: we do need to reduce GHG in absolute terms, not reduce the intensity of an ever-increasing consumption of fossil fuels as the Harper government proposes. The amount of GHG already present in the atmosphere now will impact our climate for 150 years before stabilizing, so we’re just turning the faucet off at the same time we begin adapting. Most experts believe it’s doable to adapt to two times the current CO2 levels, but not much beyond, and we can stop the warming train around 2080 if we stop emitting now, according to the Intergovernmental Panel on Climate Change (IPCC). The former World Bank economist-in-chief Sir Nicholas Stern said the costs of inaction were immense compared to the 1% or 1.5% of the GNP that active measures to reduce GHG would cost the economy. Mr Harper accepts similar levels of impact on the economy when they are decided by greedy Wall Street subprimers, or to fight against terrorists, but apparently not when they concern the environment we live in.

Do you ever get angry letters from climate change nonbelievers?

Not so far -- maybe after this chat. :-) Anyway, an immense majority of people sense the climate is changing. It’s mostly their life habits they’re more reluctant to change.

Your research seems to indicate that unless climate change is somehow miraculously reversed in the next few years, identifying and protecting patients at high risk of heat-related mortality will be an increasingly important part of public health work. Should medical schools train students on that subject specifically? Should this become a focus of continuing medical education offered by groups like the CMA or the Canadian Association of Physicians for the Environment?

Most cities in Canada will see a doubling of their number of summer hot days in the coming decades. On top of it, we often forget that climate change is also, and maybe even more, about increased variability in climate events, with more frequent and severe extremes. This means more rain overall in some regions, more tropical-like rain, winter thawing of rivers, more hurricanes in the East, more landslides in some areas with roads and infrastructure destroyed, etc. Indirect effects on food availability and price will affect the poor. Environmental migration (some 400,000 New Orleans inhabitants never returned to their hometown since Katrina in 2005) can impact not only the migrants but the communities where they finally move. So this will require adapted and updated emergency plans, preventative measures and training of medical personnel, including at the initial university level. That’s exactly what we’re doing currently in the 2006-2012 Quebec Action Plan on Climate Change (Health component).

What should the healthcare system be doing to help protect the elderly and at-risk patients from climate change-related mortality?

For the protection of elderly or at-risk patients, there are basic recommendations that are posted on most public health departments websites, but a recent study by my colleague Tom Kosatsky showed that there are several inconsistencies and contradictions throughout the world on this, and that very often we refer to the easy “Go see your doctor.” The poor doctor very often doesn’t know what to do exactly. Again, we are currently working on this: for instance, trying to evaluate the clinical significance of the interaction between some prescription drugs and heat in order to offer clinicians more robust recommendations for clinical practice.

Here’s a paradox. Air conditioning protects patients at-risk of climate change-related mortality. But the energy demands of all those air conditioners cause carbon emissions, which cause more climate change and therefore higher mortality risks for at-risk patients. What’s the solution?

The solution is in a mix of measures such as better-built homes with natural ventilation and better insulation, more shade in cities (which helps reduce the heat island effect), through various greening measures, and reducing car use through better urban design. In the end we’ll need air conditioning nonetheless for high-risk groups, though hopefully we’ll need it less often and for shorter periods. Some regions of the world are blessed with plenty of hydro power which is a very low GHG emitter, so Manitoba, Quebec and Norway (all have 97%-plus hydro) can enjoy air conditioning with less remorse...

You and your coauthors suggested in a recent paper, “,” (PDF) that Quebecers won’t enjoy reduced winter mortality rates caused by global warming, as European studies have predicted on the other side of the Atlantic, because Quebecers are already adapted to the cold and because heating prices are lower here. Unfortunately, as gas prices rise so too do heating prices across Canada. Do you think higher heating prices therefore mean higher winter mortality rates?

Actually there should be a slight reduction in winter mortality with a huge increase in summer deaths. But you’re right, higher heating prices can mean higher winter mortality rates, as is seen in several developed countries, for instance the UK. Our study showed that we’re well adapted to winter, but this is not genetic and needs maintenance on a regular basis. Some management measures can also mitigate this: After the death, some 15-20 years ago, of two Montrealers who had seen their power cut by Hydro Quebec in the midst of winter for unpaid bills, a regulation was put in place to allow any such power cuts only from April to October. Public funding for social housing is another attractive avenue for low-income groups, and Quebec is very active there too. This is primary prevention at its best!


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Role model or rotten failure?

That's what lots of Americans are asking themselves these days about Canadian healthcare.

In this year's US presidential election campaign between Democrat Barack Obama and Republican John McCain, Canada's universal healthcare system is fast becoming a central battlefield of American political discourse -- and, inevitably, of American political spin, as well.

In the United States, two opposing views of Canada's healthcare system prevail:

1) It's a bureaucratic, big-government, "socialized" disaster.

2) It's much, much better than what millions of Americans currently have, by virtue of a guarantee to access to health services to all.

Here's the problem: there's some truth in both those perspectives. And, depending on one's ideological standpoint -- #1 tends to draw Republicans; #2, Democrats -- evidence in support of one position or the other can be found in droves.

CANADIAN RUINS
The argument for the Canadian system's failure was recently made by , a Toronto-trained psychiatrist who's now a fellow at the free-market Manhattan Institute think tank, in a commentary in Investor's Business Daily under the head "."

That architect is Claude Castonguay, the early-70s health minister of Quebec and now a policy consultant, who is often referred to as the "father of Quebec medicare" for his role in designing the publicly funded healthcare insurance scheme that still exists today. Mr Castonguay was back in the news recently for his role as head of a provincial government commission that recommended several expansions of privatization in Quebec's healthcare system in a . Therein lies the "admission" that the Canadian system "lies in ruins," according to Dr Gratzer:

"We thought we could resolve the system's problems by rationing services or injecting massive amounts of new money into it," says Castonguay. But now he prescribes a radical overhaul: "We are proposing to give a greater role to the private sector so that people can exercise freedom of choice."

Castonguay advocates contracting out services to the private sector, going so far as suggesting that public hospitals rent space during off-hours to entrepreneurial doctors. He supports co-pays for patients who want to see physicians. Castonguay, the man who championed public health insurance in Canada, now urges for the legalization of private health insurance.

Dr Gratzer is right on the money (pun intended) in some respects but, when it comes to his conclusion that Mr Castonguay has renounced the philosophical basis of public healthcare, Dr Gratzer's free-market beliefs are obscuring the reality of the situation: Mr Castonguay has not "turned against his own creation," as Dr Gratzer puts it.

Instead, Mr Castonguay's position -- though radical in comparison to Canadian governments of the past -- is a more moderate one than many on the right would like to imagine. He advocates a limited expansion of the availability of private insurance; he wants doctors to have the option of running mixed public-private practices; and he has called for small annual co-pays for doctors' visits in order to make up part of the Ministry of Health and Social Services's quickly growing expenses. These are certainly major changes (most were rejected by the government, and several contravene longstanding federal legislation), but they are hardly the guilty plea that Dr Gratzer claims. Essentially, those reforms are compromises that Mr Castonguay -- along with many of his contemporaries -- sees as necessary in order to protect the integrity of the public system by creating new revenue sources.

Nevertheless, Dr Gratzer's rhetoric has proved effective -- at least online. Dr Gratzer's message has spread like wildfire on the blogosphere, spawning headlines such as:

There's plenty . (A lesson from my travels in the World Wide Web: partisan blogs, left and right alike, are usually little more than echo chambers.) It's no coincidence that my interview with Mr Castonguay, published on this blog not long after his infamous report was made public, has suddenly become the most popular article on our site over the last few weeks.

At a time when universal healthcare seems increasingly plausible in the United States, Dr Gratzer is saying, Americans should keep in mind Mr Castonguay's "road to Damascus" conversion:

However the candidates choose to proceed, Americans should know that one of the founding fathers of Canada's government-run health care system has turned against his own creation. If Claude Castonguay is abandoning ship, why should Americans bother climbing on board?

This kind of message -- inaccurate but widely influential -- is sure to proliferate in the US as the election draws nearer.

"THE MAPLE LEAF MODEL"
Meanwhile, while partisan sniping continues unabated in the media, American physicians are preparing for what many see as Senator Obama's sure victory in the November election.

Senator Obama's cautious campaign is not recommending a single-payer system at the moment, though he's spoken favourably of the idea in the past; the is to negotiate with the insurance industry to achieve what would amount to universal care.

The times they are a-changin': universal healthcare is not a prospect that frightens American doctors any longer: a majority -- 59% -- now favour a national health insurance plan that would guarantee universal coverage, according to the published in the Annals of Internal Medicine in March.

Accordingly, elements of the American medical profession are trying to wrap their minds around what such a change might mean. In an , Lea Cearnal writes:

With political momentum seeming to build toward some sort of system that will extend health coverage to everyone, doctors in the US might be expected to be curious about how it might affect them. Though what form such “reform” might take is anyone's guess, emergency physicians in the US have a universal coverage model close by that might offer some comparisons and contrasts.

Everyone in Canada is covered by health insurance, paid for by the government, or more properly, the federal, provincial and territorial governments jointly. But what effect does the system of reimbursement have on clinical practices, diagnostics, pay, work frustrations and other areas?

The answer—based on interviews with several prominent doctors familiar with emergency medicine on both sides of the border—seems to be: not so much.

The articles goes on to explore the effects of government-run insurance and universal coverage on a number of issues: salary, wait times, billing hassles, clinical care, the state of primary care and health promotion, and more.

It's worth a read, if only because learning how our neighbours to the south see us -- and you may be surprised at how positive the article is -- is edifying about how we choose to see ourselves.


Photo: A maple leaf from British Columbia damaged by air pollution,

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In an article on page A1 of today's National Post (""), Dr Louis Francescutti takes Canadian governments to task for failing to protect children and teens from ATV injuries:

"If we were to view injuries similarly to how we view other diseases, then we would do something about it. But, unfortunately, politicians and Canadians have this fatalistic attitude: 'It was an accident, a freak accident, time is up, ticket's up, wrong place at the wrong time...'

"There are thousands of these [incidents] that go on across the country on an hourly basis. It's insane that we just sit back and claim that we're civilized; that there's no public uproar."

Dr Francescutti, a University of Alberta epidemiologist who specializes in injury control (here's ), would like to see a national strategy to protect youths from ATV-related injuries and deaths.

The threat is surprisingly large: according to a 2006 (PDF), an average of 400 Canadian kids 14 and under were hospitalized per year between 1994 and 2000 as a result of ATV injuries. The growing trend among Alberta teens of drunk ATV-driving doesn't help matters, says Dr Francescutti. "There is a minority of knuckleheads out there whose idea of a good time is letting the wind blow through your hair while you're liquored on a Friday night. That's a pattern we usually see here on a Friday night. People doing stupid things and paying the consequences."

Some provinces have made an effort to prevent youth injuries by requiring ATV drivers to be of a minimum age -- 16 , for example; you can check other provinces' laws (PDF) -- but others appear to be moving in the opposite direction (although, granted, that photo above is a bit of an exaggeration).

Take Nova Scotia, for instance. In the National Review of Medicine's July issue, I reported the :

ATVs-for-kids scheme galls MDs
HALIFAX — Spending $230,000 on all-terrain vehicles for kids was, in retrospect, "not the appropriate thing to do," admitted Nova Scotia Premier Rodney MacDonald. Complaints poured in about the Ministry of Health Promotion project not just from taxpayers but from concerned physicians as well. The ATVs were purchased for "safety programs" for kids 6 to 15, and to study the health benefits of ATV riding. Doctors Nova Scotia and officials at the IWK Health Centre say children under 16 shouldn't use ATVs.

Sometimes "health promotion" policy isn't all it's cracked up to be, I guess.

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