Canadian Medicine

Is Philippe Couillard's rather sudden about-face -- from being Quebec's health minister to becoming a partner in a private-sector health investment fund, in under two months -- in contravention of a Quebec law on transparency and ethics in lobbying?

Technically, the answer seems to be 'probably not' but that hasn't stopped the French-language Montreal dailies from insinuating that -- and worse.

Quebec law requires an ex-cabinet minister like Dr Couillard to keep secret any confidential information to which they are privy, for a period of two years after leaving office. Although he he will do so, he added:

"C'est vrai que je connais sans doute la législation et les projets gouvernementaux plus que le commun des mortels. Je les ai fait adopter!"

("It's true without a doubt I know the legislation and government initiatives better than the public. I'm the one who instituted them!")

That kind of tone, combined with Dr Couillard's central role in extending the limits on private-clinic involvement in the public healthcare system, via Bill 33, has made many Quebecers suspicious about his new job.

Bernard Drainville, the PQ's health critic, told La Presse:

"À titre de ministre, il a contribué à mettre en place un certain nombre de décisions qui favorisent l'essor du privé. Deux mois après avoir été le parrain de ces initiatives, il se place dans une situation où il va pouvoir en profiter personnellement, estime le porte-parole du Parti québécois en santé, Bernard Drainville. La décision qu'il a pris ne respecte pas l'esprit de la loi, qui est de s'assurer que quelqu'un qui a eu accès à des informations privilégiées ne s'en serve pas à des fins lucratives."

("As minister, he helped make a number of decisions that furthered the development of the private [sector]. Two months after being the sponsor of these initiatives, he's put himself in a situation where he will personally profit. His decision [to take the PCP job] doesn't respect the spirit of the law, which is to ensure that someone with access to privileged information doesn't use it to make money.")

So far, however, Dr Couillard is unshaken. He has defended himself vehemently, and even further he has that his decision to move from the head of the public health ministry to a private health investment firm should not be interpreted as a lack of confidence in the public healthcare system.

That notion, perhaps even more so than the debate about ethics in lobbying, is certain not to be dismissed so easily by the public.


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A round-up of Canadian health news, from coast to coast to coast, and beyond, for Tuesday, August 19.

At the Canadian Medical Association's annual meeting, Dr Anne Doig, a Saskatchwan family physician and professor of obstetrics and gynecology, was confirmed as the organization's president-elect. Click to read my Q&A with Dr Doig after she was nominated by the Saskatchewan Medical Association earlier this year.

You already know grapefruit can speed the absorption of some medications, including some varieties of statins. Now a team researchers led by University of Western Ontario clinical pharmacology professor David G Bailey have found that grapefruit juice, along with apple and orange juices, can have the opposite effect on other drugs, slowing the absorption into the body of an antihistamine. Their research was presented today at the National Meeting of the American Chemical Society, in Philadelphia.

West Nile virus patients typically return to normal about one year after infection, according to a study by a McMaster University pathology professor published in the Annals of Internal Medicine. []

Manitoba's regionalized healthcare administration structure isn't working, claim the opposition Progressive Conservatives. For more on recent trends in regionalization reform, read from June.

Saskatchewan's aboroginal population gets a new healthcare deal from the province and Ottawa.

You thought it wasn't possible: Newfoundland and Labrador's breast cancer hormone testing problems just got worse.

Federal Health Minister Tony Clement yesterday angered many physicians at the Canadian Medical Association (CMA) annual meeting in Montreal by not just expressing his doubts about the effectiveness of supervised injection as an element of harm reduction for drug addicts, but by going even farther and accusing Canada’s physicians of acting unethically by supporting such programs.

“I find the ethical considerations of supervised injections to be profoundly disturbing,” said Mr Clement in an address to hundreds of the nation’s most influential doctors. “Is it ethical for healthcare professionals to support the distribution of drugs that are of unknown substance, or purity, or potency -- drugs that cannot otherwise be legally prescribed?”

In a Q&A following Mr Clement’s speech, CMA ethics chair Dr Bonnie Cham firmly told the Minister of Health his interpretation of medical ethics was deeply flawed. “Supporting harm reduction is not a breach of medical ethics,” she said. Her comments elicited a great deal of applause, as did comments from a public health physician, former CMA president Albert Schumacher and others.

As the session came to an end, a small group of opposition Members of Parliament assembled in the hallway.

“This guy is insulting the physicians and nurses on the frontlines,” said Carolyn Bennett, a Liberal MP and former physician. “Yet another disgusting example of ideology over science. It’s disgusting. He only talked one thing for the whole frickin’ speech!” she said. “There is a refusal to acknowledge the CMA knows more about this than he does.”

“As a physician I find Mr Clement’s remarks with regard to Insite extremely dangerous,” said fellow Liberal Hedy Fry, who’s also a former physicians. “What is most appalling to me, however, is that Mr Clement didn’t just say that his government has a moral issue with this, he then went on to lecture physicians on what is the ethical practice of medicine. Is this government going to decide to tell physicians how to practise medicine soon?”

“Sort of an irony today,” interjected Ms Wasylycia-Leis. “A lawyer chastising doctors today on ethics. Remarkable... That was a shameful performance.”

As Drs Fry and Bennett left the media scrum, Ms Wasylycia-Leis said the Liberal Party’s criticisms, though admirable, were undermined by the fact that when they were in power they didn’t increase the number of safe-injection facilities as they are now calling on the Conservative government to do.

“I think it is a bit hypocritical but at this point we need all the allies we can get,” Ms Wasylycia-Leis said. “We need to work together to stop an almost neanderthal position on the part of Tony Clement. Liberals may not be prepared to enact something and put public money towards it but at least they understand the importance of it. Tony Clement doesn’t seem to understand either, neither the importance of harm nor the importance of investing public money into it,” she said, adding that Mr Clement should feel “humiliated” and “embarrassed.”

At a press conference held by the CMA’s leadership afterwards, outgoing president Dr Brian Day said, “In rejecting harm reduction as one tool of addiction treatment, the minister is abandoning the most vulnerable members of society.”

“It is contrary to the interests of both scientific inquiry and informed public debate to categorically reject supervised injection sites,” wrote the Centre for Addiction and Mental Health’s president Dr Paul Garfinkel in an . “I regret that the Government of Canada has adopted this position.”

In addition, The Globe and Mail’s André Picard :

His comments come as the Conservatives have bombarded urban ridings in Vancouver and Toronto with ads, sent free using MPs' mailing privileges, that depict a discarded syringe and a headline that states: “Junkies and pushers don't belong near children and families. They should be in rehab or behind bars.”

The Conservative government is appealing a BC judge’s ruling that Vancouver’s safe-injection site, Insite, cannot be shuttered by the federal government.

Mr Clement has been on a roll lately when it comes to inciting anger in medical professionals. Just two weeks, at the International AIDS Conference in Mexico City, he was criticized for 'embarrassing Canada' after he spoke out against harm reduction -- during an event sponsoring a new World Health Organization document that endorses harm reduction.


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The first full day of the , here in Montreal, is drawing to a close as I type. The last few doctors are trickling out of the conference halls and stepping out into a rainstorm of biblical proportions in Montreal's downtown. Those hoping for some "retail therapy" tonight, as CMA General Council Speaker Dr Margaret Kirwan joked early this morning, will unfortunately be trudging up and down Saint Catherine Street in a downpour. (Bicycle-riding journalists, like yours truly, keep a close eye on the weather.)

So, what happened here on day one? Here are my notes on Monday's goings-on:

• 8:25am -- Outside the front door of the hotel is a big campaign sign on a lamppost, touting Conservative candidate Guy Dufort as the best choice for Westmount-Ville Marie in next month's by-election. A sign of things to come? Perhaps not: the left-wing group Canadian Doctors for Medicare stand on the sidewalk adjacent to Mr Dufort's smiling face during the day handing out pro-medicare political tracts.
  
• 8:30am -- Pomp and circumstance as the annual meeting's General Council begins. Bagpipes (no joke: really, there were bagpipes) welcome a procession of robed figures to the large ballroom where General Council is being held. It's the CMA's executive, with outgoing president Dr Brian Day looking somewhat tired and not entirely thrilled with the costume. (Brian, if you're reading: Sorry if you actually liked the robe, but you sure didn't look like it.)
• 8:35am -- Everyone gets seated up on the stage and a physician member of the Resolutions Committee stands up to lead the assembled doctors in our national anthem. The music comes on the speaker system but it's not "Oh Canada" -- at least not at first; the opening strains feature aboriginal-sounding drumming and legato strings. As the interminably long intro to the song continues, three giant video screens facing the crowd display what I suppose are meant to be inspiring Canadian images. Trees. Rivers. Lakes. Cliffs. Mounties. Parliament. Children. Perhaps it was the fact that the coffee had run out in the lobby just outside the ballroom before the meeting began, but I wasn't impressed. (The coffee drought may have accounted for the fact that by the 8:30am starting time, only three reporters had showed.) Anyway, the song finally got around to becoming "Oh Canada" and everyone stood, etc. etc.
• 8:40am -- Dr Kirwan welcomes a long list of distinguished members and special guests. As well as guests from the World Medical Association and national medical associations from the UK, Israel, Russia and the EU, a delegation of doctors is here from Ireland and Dr Kirwan makes an attempt at levity -- in French for some reason I cannot fathom. Canadians and Irish are so much alike, she says: we both like to "avoir du fun." Oui...
  
• 8:45am -- Dr Kirwan introduces Dr Brian Day, the outgoing president, who in turn introduces Dr Robert Ouellet, the incoming president, who in turn introduces Dr Yves Bolduc, Quebec's fairly new Health Minister and this morning's guest speaker. Dr Bolduc steps to the podium and promptly spills his glass of water. He looks alarmed momentarily, then recovers. "It's just the water. Nobody's hurt." A true physician. Dr Bolduc speaks mostly in generalities about valuing physicians' input and hoping for partnerships and such. (What on earth does "...the responsibilisation of all actors..." mean, regardless of the context?) The Quebec Medical Association's president, Dr Jean-Bernard Trudeau, thanks the minister and generously offers him the medical profession's support. He'll need it, especially given the fights that his predecessor as Minister of Health, Dr Philippe Couillard, provoked with some of the province's doctors.
• 9:05am -- Eventually the first motions are read. After the first one (just a motion to start the process, basically) is moved, there are a few moments in which doctors are to vote electronically using little remote controls. In the interim, the first few bars of Chicago's excellent song "25 or 6 to 4" play, rather incongruously. (And no, it's not actually about LSD, .)
• 11:30am -- (We'll skip past the mental health discussion for now, except to say that funding for the Mental Health Commission of Canada was more than it had been initially last year.) Federal Health Minister Tony Clement's turn to speak. It's all going peachy until he comes to the topic that everyone's been wondering if he'll address here: his disagreement with the vast majority (80% or so) of Canadian doctors, and the leadership of the Canadian Medical Association, about harm reduction and supervised injection sites for drug addicts. More on this tomorrow. Suffice it to say for the moment that it wasn't pretty and Mr Clement faced harsh words from a number of doctors, including Drs Day and Ouellet, afterwards.
• 3:30pm -- After hours of talking about governance review ended abruptly and rather discordantly, the conference broke into two sessions: one on activity-based funding and the other on doctors getting politically involved. The political presentation consisted of questions being asked of Liberal MP Martha Hall Findlay, former New Brunswick Premier Bernard Lord, and NDP MP Thomas Mulcair. Some doctors complained the medical profession isn't listened to enough, others asked how much starting a parliamentary campaign costs, and another still asked how he could participate given how busy his life as an emergency physician is -- "beyond just giving money." Bernard Lord's response: "Donating money is good." Show up at local meetings and meet your MP, Mr Lord said.

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Two pro-medicare physician associations yesterday complained of the alleged privatization agenda of the Canadian Medical Association (CMA) as the first day of the Canadian Medical Association's 2008 annual meeting got underway in Montreal.

The two groups, Canadian Doctors for Medicare and Médecins québeécois pour le régime public, issued a to demand "equity and quality rather than promoting private insurance and the creation of markets for buying and selling health care."

"There are problems in the healthcare system but dismantling the public system is a mistake," Dr Danielle Martin, the president of Canadian Doctors for Medicare, told reporters at a news conference held at a hotel a block away from the CMA meeting venue. (Dr Martin also authored an in today's Montreal Gazette.)

Much of the news conference focused on a hospital funding method called activity-based funding (ABF), sometimes also called patient-based or service-based funding. Canadian Doctors for Medicare released an (PDF), saying it may lead to increased costs and increased wait times -- despite promises to the contrary by its proponents, who include outgoing CMA president Dr Brian Day. "Activity-based funding hasn't succeeded in other countries," said Dr Simon Turcotte, a resident member of Canadian Doctors for Medicare. Dr Martin explained that ABF could be used as a guise for introducing more market-based systems into the healthcare sector, potentially being paired with private for-profit models of medical clinics as has been the case in the United Kingdom.

Dr Brian Day told Canadian Medicine before the CMA's annual meeting began that he will put forward a resolution urging the CMA's membership to endorse the adoption of ABF across Canada.

The physicians also announced the release of a document called the , which argues that health costs are not "spiraling out of control" -- a notion that has recently been espoused by proponents of increased privatization, such as Quebec healthcare expert Claude Castonguay and the governments of British Columbia and Quebec, among others.

The doctors' opposition to the CMA's policies continued on Monday; members of Canadian Doctors for Medicare were handing out pamphlets at a booth at the annual meeting.*

Other left-wing groups have added their voices to the din surrounding the CMA meeting as well, including the and CUPE, which is leading a campaign to send messages to Health Minister Tony Clement to push him to stop further privatization in the healthcare system.


*Correction: The original version of this article stated incorrectly that Canadian Doctors for Medicare was distributing pamphlets on the street outside the hotel. In fact, their pamphlets were being given out by someone else. We apologize for the error.

A round-up of Canadian health news, from coast to coast to coast, and beyond, for Monday, August 18.

Dr Philippe Couillard, the neurosurgeon who recently resigned from his post as the health minister of Quebec, has signed on with a private investment firm, Persistence Capital Partners. The firm, which recently acquired the private Montreal healthcare firm Medisys, is launching "Canada's first private equity fund dedicated to healthcare." [] [La Presse]

The College of Physicians and Surgeons of Ontario (CPSO) has drafted a warning to the province's physicians warning that changes to the Ontario human rights commission could force doctors to set aside their personal or religious opinions about certain types of treatment. Several religious physicians, however, have attacked the CPSO's document instead of the province's reforms that it is designed to respond to.

Canadian basketball superstar Steve Nash versus the government of Ontario, on the question of funding for enzyme replacement therapy funding for a disease called Hunter Syndrome, which afflicts six people in Ontario. []

An excerpt from International AIDS Society president and Vancouver-based AIDS researcher Dr Julio Montaner's "controversial" closing speech at this month's International AIDS conference in Mexico City, courtesy of The Globe and Mail: "Let's be perfectly clear: Failure to enact a comprehensive, sustained and multipronged attack on the pandemic represents a crime - a crime against those infected, those affected, and those susceptible. Indeed, it represents a crime against humanity."

Pathological gamblers sue Loto Quebec. []