The Pharmacare Monument

The image I have of how universal pharmacare is being added to the resources Canadians have for healthcare is a building, a specific kind of public building that can be found in most Canadian cites: a hospital. Think about a hospital in your city that was originally built sometime in the twentieth century. The original building may even be a heritage building, a monument to how health care was delivered in its era.

Adjacent to this building, and attached to it is another building, perhaps even another heritage building, but at least another edifice that is a testimony to the health services of its era, or the research conducted in that time. A particular element of these hospital structures is the way in which they are attached to each other. On occasion, the means of getting from one of these buildings to the other is an above ground passageway, often an overpass over a road. Think of the overpass between the Former Royal Victoria Hospital in Montreal and the Montreal Neurological institute. At other times, buildings are connected by a series of tunnels. Tunnels, in fact, seem to be a common feature of psychiatric hospitals. I was trying to find an image of the tunnels underneath my hospital’s former buildings and found that many older psychiatric hospitals have a series of tunnels between buildings. If that’s not a metaphor, I don’t know what is!

(Photo credit: This image of the overpass between the Royal Victoria Hospital and the Montreal Neurological Institute is from the Wilder Penfield Digital Collection of the Osler Library at McGill University.)

I am sure many healthcare providers are so familiar with these hospital images, that when I say that the new pharmacare measures being undertaken by federal and provincial governments across Canada are much like our hospitals, they will see immediately what I’m getting at. All these new pharmacare programs are add-ons. There is no vision of a whole structure being contemplated, bringing together all the stakeholders currently involved in assisting Canadians’ access to medications. There are, instead, add-ons, connected to existing plans and measures such as some Canadians’ insurance benefits, other vulnerable Canadians’ existing coverage and all Canadians’ own money. Except that, since all the money being used for all these plans is our money, we’re all going to have to deal with a series of tunnels and passageways to determine exactly how to get coverage for the latest, greatest drug our doctor has ordered. As someone who sees mostly people under 18 in Ontario where “universal” pharmacare has now been introduced for everyone under 25, I can assure you that “universal” has developed several new meanings over the past few months.

There has been tremendous progress in healthcare over the past two hundred years, and many of our older hospitals which have only gotten add-ons and not a completely new building are monuments to that progress. It is likely that, in time, the new hospital buildings that are being built will also become monuments. Unfortunately, it seems that humans struggle to build a structure, either a building or a policy, so that it can easily change and this is what is needed in healthcare. We need a new pharmacare policy that takes over from all existing drug coverage, one plan that has the same elements, no matter your age or health condition.

Wouldn’t it be great if the investment in pharmacare came with a new plan for Medicare and Canadian healthcare itself? That would be building for the future.

(This is Timmerhaus a modular building in the Netherlands built completely of sustainable materials.)

Life and Death Reporting – A Book Review

André Picard has been reporting on health and healthcare for The Globe for over thirty years. His book Matters of Life and Death: Public Health Issues in Canada is a collection of oeuvre from that period, focusing on some of the most important heath issues of that period and for Canada today. Apart from being a practicing psychiatrist, I did work for a time in health policy for the Canadian Medical Association and I haven’t quite shaken the habit. Mr. Picard’s book has become a reference for me and I am referring to it time and again when discussing or considering healthcare.

The book is organized into fourteen sections on what are arguably the most important topics in Canadian Healthcare. Picard cites fourteen areas of healthcare that deserve immediate attention because of their impact on Canadians’ health and our health care system. These are Medicare, Mental Health, Drugs, War on Drugs, Aging, End of Life, Children, Reproductive/Women’s Health, Disability/Inclusion, Indigenous Health, Cancer, Infectious Disease, Lifestyles, Social Determinants. Each topic has its own chapter and the book is very readable and understandable even if reading about health and healthcare is not easy for the reader. As someone who promotes health literacy to the sixteen year old adolescents in my practice, this is important. The short articles in each chapter are interesting and well-written. Members of my team and I used Sip on this: Like all drugs, alcohol isn’t Consequence free for a group about alcohol use in teens.

As I said before, this book has become a reference for me on Canadian Healthcare. I like to have good health policy information, to have the correct statistics and an impression of how others might be considering a health policy topic. Matters of Life and Death was accurate from these perspectives in those areas of health care where I have very good knowledge, which was always reassuring. Also, even when I don’t agree with his opinion, I can always see Mr. Picard’s point of view. This is the essence of good science journalism to me: that it stimulates dialogue and further consideration.

I feel that Matters of Life and Death is a book that every Canadian who wants to understand the problems our healthcare system should read, but I also think they would enjoy it. I will also say that the most valuable information provided was found in the Introduction. Mr. Picard compiles a list of the shortcomings of health reporting. He cites a list developed by Gary Schwitzer, a well-known American health journalist, and then develops the list further. That list is a lens against which one can evaluate journalism on healthcare, a good tool to have when you’re trying to decide whether an article is worth consideration.

(Note: I read the 2017 Douglas & McIntyre paperback edition of Matters of Life and Death: Public Health Issues in Canada.)

(My own photo)

Recovering from Child Abuse

The prevalence of child abuse in Canada is approximately 1%. This may seem not to be very high but the impact child abuse has on those affected has far reaching consequences. This is best illustrated by more statistics, so I am going to summarize these over the next few paragraphs. While you review them, I suspect that, like me, you will find yourself asking how any of these children ever recover and, when they do, you will wonder how they managed.

Thirty percent of children who are abused do not finish high school (Lansford, Miller-Johnson, Berlin, Dodge, Bates, & Petit – 2007). They are 26 times more likely to be homeless (Herman et al, 1997), 4 times more likely to be arrested as a young offender and twice as likely to be arrested as an adult (Lansford et al, ibid.). They are 3 times more likely to have an unplanned pregnancy (Irish, Kobayashi, & Delahunty, 2009). All these circumstances interfere tremendously with becoming a productive adult and so the gifts these children might have brought to the world may be lost forever.

The impact of the trauma they have suffered does result in serious mental illness in these children and youth. They are 4 times more likely to experience suicidal ideation and self-harm (Irish et al, ibid.) Not surprisingly, some studies show that as many as 100% of these children suffer from some symptoms of Posttraumatic Stress Disorder and 37-50% develop Posttraumatic Stress Disorder (Trask, Walsh, & Dilillo, 2011). They have 4 times as many contacts with mental health services as adults than the rest of the population (Spataro, Mullen, Burgess, Wells & Moss, 2004).

When I contemplate the histories of the young people that I see in the tertiary care psychiatric hospital where I work, these numbers – other than the 100% – seem low. I suspect, however, that this is because the youth we see have usually had significant mental health services even before they were seen in our programs and so those who are eventually seen in tertiary care likely have a higher prevalence of child abuse.
The young people who have been victims of child abuse also have more contact with the general medical system as 90% of them have worse health than the general population (Springer, Sheridan, Kuo & Karnes, 2007).

I am looking up these statistics for the purposes of determining to what degree mental health programs must consider their impact as they design programming for conditions beyond trauma. For example, to what degree must a program for youth with psychotic disorders allow for a history of childhood trauma? In fact, this is likely the wrong question.

The question that must be asked is: how do mental health programs ensure that the specific needs of those children and youth who are victims of child abuse get services that will also address their psychological trauma, as well as the other programs they require?

The traits that ensure that a young person can recover from the impact of child abuse, based on numerous studies examining longer term outcomes, focus on the development of resilience. You don’t have to do more than scrape the surface of the resilience literature to determine that remaining positive about one’s talents, about one’s ability to recover and about the future are the keys that unlock the development of resilience. As mental health care providers, it is our task to ensure that everyone can feel positive about themselves and their future., no matter which mental health condition they suffer from.

What I like best about this is that it is a simple lens through which to examine programming. You examine each facet of a mental health program asking: Does this foster the development of a positive attitude toward the patient, their recovery and their future? If the answer to the question in any circumstance is “no”, then changes are needed until the answers and the approach is positive.

I do find it personally helpful to be mindful of this when I see a young person who has been the victim of child abuse. If I can focus on helping them to be positive about the future, we can usually figure out what services they need to move forward.

“Note to self: Every time you were convinced you couldn’t go on, you did.” (Anon.)

Two Books to Help You Contemplate Men’s Relationships

In the past month, I have read 2 books that I believe helped me to contemplate men’s struggles in relationships.

One of these books was a classic novel and the other was a nonfiction book on the impact books have had on an author’s life.

The novel Giovanni’s Room was written by the American author James Baldwin in 1956. It is set in Paris in the 1950’s and documents the story of a young American man’s homosexual relationship at a time when these relationships were still very much unacceptable in moral terms, even illegal in many countries. In France, however, the changes in law during the French Revolution essentially decriminalized homosexuality although there continued to be a moral prohibition until 1942.

David, the narrator in Giovanni’s Room, is torn between his love for a woman and a man. The account he gives of his internal emotional upheaval is a rare glimpse into the elements that confine men to the gender and social roles that are acceptable. That men can also be thus confined is something I have always accepted in principle, but Giovanni’s Room and David help me to understand how these limitations often keep men emotionally oppressed.

Am I Alone Here? by Peter Orner was published in 2016 and documents how Orner’s reading has shaped his various relationships. Orner’s reading serves as a stimulus to his reflections on being a son, a partner and a father. The intimacy of a gifted reader is so evident in Orner’s writing and is, for me, one of the most important elements of this book.

Orner documents his experience of books as diverse as The Golden Apples by Eudora Welty and The Burning Plane, a book of short stories by the Mexican author Juan Rulfo. Rulfo wrote two books and Orner considers both books as he contemplates that many had waited eagerly for another book, but none was written. Rulfo’s writing was considered so important as to have attracted the attention of García Márquez and Susan Sontag (not to mention Orner himself). Susan Sontag wrote this about Rulfo’s low output:

“…the point of a writer’s life is to produce a great book – that is, a book that will last – and this is what Rulfo did.” (p. 80 in Am I Alone Here?)

As I said, I read both books within the same month, one after the other. They made me feel melancholy about the way in which men can be boxed in emotionally, in a way that I have never felt as a woman. I reflected how difficult it must have been for these authors to expose publicly these intimate internal struggles, each in his own way doing what he could to break apart the box. I felt as though my own thinking about the emotional life of men was much affected by these books, but my thinking made me no less melancholy. I regret these boundaries between our emotional lives.

(Note: I read the Vintage International Paperback Edition of Giovanni’s Room, published in 2013 and the 2016 edition of Orner’s Am I Alone Here? Notes on Living To Read and Reading To Live.)

(Image from Google)

When Children Die

Like many other people from Ottawa, I have been very much affected over many years by the courage of Jonathan Pitre, who passed away on Wednesday evening. He was 17 years old and suffered from epidermolysis bullosa. There have been tributes for Jonathan from so many, including hockey players and civic leaders and journalists, as well as Moms and Dads and all the rest of us. One of the most moving tributes came from the journalist, Andrew Duffy, who has followed Jonathan’s story over many years.

Hard upon this story came the news of an accident in Saskatchewan that resulted in the death of 15 members of the Humboldt Broncos of the Saskatchewan Junior Hockey League. Most who died were under 20.

When I read through the tributes to Jonathan Pitre and his mother, or those for the Humboldt Broncos and their families, I feel so grateful that I have never had to cope with such a difficult event in my life. I wanted to write about this, but I wanted not to focus on advice on how to manage such tragedies.

I’ll give some references, in case some readers were hoping for advice. This is a great article from The Guardian considering one woman’s experience with the death of her child. I found that this article really helped me to contemplate how to be a comfort to someone facing this tragedy. I also found this article addressing what not to say to a parent whose child has died very helpful. The only guidance I would add to this list is: Be extra cautious about social media – it can catch people unawares, causing additional, unnecessary hurt.

I learned all I ever need to know about what it would be like for a child to die from the two women in my life from whom I have loved the most: my mother and my daughter.

My mother had two children who died very young. My oldest brother died of influenza in 1955 at age 2. This was 18 years before the World Health Organization first introduced flu vaccine recommendations for general use. A second brother died in 1956 of RhD hemolytic disease of the newborn. This is a condition that occurs when a mother who has an Rh negative blood type develops antibodies after being exposed to her child’s Rh positive blood during pregnancy. These antibodies may affect Rh positive children in subsequent pregnancies. The antibodies can cause severe illness, including death. In 1968, anti-RhD immune globulin (Rhogam) was introduced. By injecting inject mothers who were Rh negative with Rhogam, RhD hemolytic disease could be prevented. My brothers died too young to benefit from these medical discoveries.

As a child, and even as an adult, I could never completely understand my mother’s ongoing sadness over my brothers. However, in the hour after my daughter’s birth, having held her for not more than twenty minutes, I understood what every new parent also quickly understands: I could not bear it if I lost this child. I ceased to wonder about my mother’s sadness. I no longer wonder at any parent’s sadness. I know I would be inconsolable if I lost any of my children and that is what Jonathan’s mother and the families of Humboldt are going through today. Are we not all with them in spirit?

I also have one piece of advice that I can give. It is contained in this blog I wrote for The Scientific Parent. Sadly, it is one of the most popular blogs I have ever written. It provides advice on how to help children cope with difficult news. The Scientific Parent used the blog so much that they developed a graphic to go with it. I would like nothing more than for its circulation to end, but more realistically, I am glad if it is helpful.

Book Review: Summer and Vermont

One of the best parts of travelling is getting to know a new place. Yesterday was an especially cold day for April and I found myself longing for warmth and spring and vacations. I decided to write a review of books that I took on vacation to Vermont last year. So, if it’s still too cold where you are, you can read about June and Vermont, and think of summer.

In June, I travelled to Southern Vermont and, to prepare for the trip, I read two books. One was the story of someone’s journey and the other was the story about finding a place to stay.

The story of the journey was Bill McKibben’s Wandering Home: A Long Walk Across America’s Most Hopeful Landscape: Vermont’s Champlain Valley and New York’s Adirondacks. Published in 2005, McKibben walks west from his home near Middlebury, Vermont. Along the way, McKibben introduces the reader to the conservationists and farmers working to preserve the habitat and the way of life of these two disparate neighbouring regions. This journey was the opposite of my own, since I travelled through the Adirondacks to Vermont. Also, I drove, while McKibben walked through backcountry trails. Some of the trails he took were not even well-documented.
McKibben considers this landscape to be hopeful because there is so much wilderness. This journey is a reminder to the reader, who may presently be despairing about the prospects for the American wilderness, that there are not just people working to preserve it but, in fact, an organized network of people for whom this land and these places are a sacred trust. These lands around Lake Champlain, both in Vermont and New York, are enduring, with a way of life that represents the best of America and we are reminded that it will take many years, many eras, to change that. On the New York side, Adirondack Park, 6 million acres, is the largest publicly protected area on the North American continent. Like most Canadians, I am inclined to be smug about Canada’s conservation record but McKibben’s account and journey are a reminder that America still does everything bigger! (President Teddy Roosevelt set aside 194 million acres of Land for conservation. President Barack Obama protected 550 million acres. To compare, Canada has 33 million acres of land under protection.)

The book about finding a place was An Unlikely Vineyard: The Education of a Farmer and Her Quest for Terroir by Deirdre Heekin. This was written in 2014 and was named the Best Wine Book of 2014 by Eric Asimov in the New York Times. Heekin and her partner own a farm/vineyard in southern Vermont, a region that does not typically beckon prospective winemakers because of its harsh climate. Even though most people would acknowledge this, Heekin reminds the reader at the outset that grapes grow wild in Vermont. This is a touchstone for her along her journey.

Heekin’s book is part memoir, part manual, part history and is so well written that I actually completed it. It seemed like the best textbook on any subject I had ever read. It made me long to spend more time in Vermont getting to know more about the farmers trying to build a sustainable agriculture in this region. But then, this is a book about staying put and so, I returned home, thanks to Heekin, with a renewed interest in sustainable agriculture in my own part of the Ottawa Valley.

As I write about these books, I am reminded of another warmth – the warmth of the American people that I always meet in Vermont. They make me think I could live there. They make me realize that Canadians and Americans are not so different after all.

I was tired of the cold and I needed to think about summer, but in this winter when our leaders are contemplating a new trade deal, with rhetoric advocating protectionism, I want the warmth of our usual relationship with our American neighbours. That relationship has also proven to be sustainable, while “leaders” come and go.

Invisible and Unrepresented

In between the celebrating and resting of a long holiday weekend, I have found myself doing research on the Canadian Medical Protective Association(CMPA). On Friday, I found this tweet of the candidates for a position on the CMPA Council and was incredulous at the fact that no women were running:

(CMPA Promoted tweet)

The Canadian Medical Protective Association is a “a not-for-profit, mutual defence association which is governed by a council of physicians representing members from across Canada”. Women members, however, might well take issue with the idea that this is a representative organization when the Council, the governing body of the CMPA is comprised of 29 Council members, only 7 of whom are women.

What are the implications for women physicians when their representation on the CMPA Council is so limited? Consider this in two broad areas.

The CMPA is in the business of risk. There are negative outcomes in healthcare and in some of those outcomes, physicians might have acted differently. While some will take issue with this view, often a negative outcome cannot be accurately predicted and this is where the risk comes in.

The CMPA, in its fee structure over a number of years has taken risk into consideration. For example, the risk that a surgeon will have a successful action taken against them is higher than the risk that a psychiatrist will be in this position. Hence, surgeons pay higher CMPA fees than psychiatrists. Also, the financial awards to successful claimants is higher in Ontario than in Quebec. Therefore, Ontario physicians have higher fees than Quebec physicians.

Consider then that there is evidence that women physicians have fewer complaints against them than male physicians. This being the case, why is this not taken into consideration into the fee structure? This seems like a clear case of gender bias.

My second concern is that women physicians do practice differently than their male colleagues and yet the CMPA does not seem to have done any research into the implications of this in terms of risk. The bias against women physicians by the public, other allied health care providers and even by the profession itself is well-established. New research continues to confirm this bias and yet there is no evidence on their website that this has even been considered by the CMPA.

An organization like the CMPA cannot completely be faulted when its elected Council does not have the number of women on it that might be optimal. However, one begins to be suspicious about gender bias when there has not ever been a woman President of the CMPA. If that is not enough to have members questioning whether women physicians have a strong enough voice in CMPA, a review of their committees will show that not many women are represented here either. Surely CMPA Council has some say over the number of women on committees?

When I raised similar questions about gender bias within the educational colleges last February, the Royal College did reach out to me, although unofficially, and not with any answer that I was given permission to publish.

I will be interested to see whether the Canadian Medical Protective Association has any response. My real goal in writing this, however, is to remind women everywhere that, in organizations, professional and otherwise, there is still a need for us to demand our due from our representatives. There is still a need for us to support the work of women colleagues whose presence will eventually change organizations. This is true in all areas of work – woman are still invisible, even in those professions where we are equal in numbers.