Category Archives: My Blog

#endpolio

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There is nothing in medicine more elegant than a public health strategy, especially one that is well-planned and conducted efficiently. One of the best examples of such a strategy can be found in the Global Polio Eradication Strategy. The hope is that such a strategy will do for the world what a similar strategy did for Canada.
In 1953, polio peaked in Canada and, in a one year period, there were 9,000 new cases and approximately 500 deaths. The Salk vaccine was introduced in 1955 and the Sabin oral vaccine in 1962 and within 20 years of the 1953 peak, polio was under control in Canada. In 1994, Canada was declared “polio free”. In its peak years, the disease was so widespread that everyone knew a child who had developed limb paralysis because of polio. Of those who developed paralysis, 5-10% could develop paralysis of the respiratory muscles which could result in their death. It was for these people that the iron lung was developed.
Polio was a major worry for Canadian parents in the 1950’s. For many children, polio would cause fever, fatigue, vomiting, neck stiffness, headache and limb pain. I had two aunts who were pediatric nurses and I remember them speaking about the helplessness they felt nursing a child who had seemed to have a mild illness and then suddenly began to develop paralysis. My aunts have spoken about how much parents would dread whenever their child developed a fever.
When the Global Polio Eradication Strategy was initiated in 1988, there were still 350,000 cases of polio worldwide. The strategy was launched in response to a Resolution passed at the World Health Assembly. Within 20 years, thanks to 3 million volunteers worldwide, there has been so much progress toward eradicating polio that the World Health Organization believes it might be possible to eradicate polio by 2018.
The last bastion for polio is in three countries: Nigeria, Afghanistan and Pakistan. The challenges that perpetuate polio in these countries include insecurity, weak health systems and poor sanitation. It is possible for polio to migrate from these countries to other countries whose health systems are weakened by the same factors. For example, cases of polio are now being tracked in Syria.
The public health professionals and advocates involved in the efforts to eradicate polio are determined and diligent, and they will succeed. From the offices of the World Health Organization in Geneva to the grassroots volunteers around the world, there is a hopefulness in their websites and statements that is undeniable. What must be done to achieve their goal is simple: every child must be vaccinated against polio. It takes a lot of work to ensure that this is happening but many countries, and not just countries as rich as Canada, are managing this.
It is easy to understand why this can be managed. Anyone who has witnessed the suffering of a child with polio will want to prevent it. These witnesses will work to ensure that every child can be vaccinated. It is simple and elegant. You can watch the progress on social media by watching #endpolio. You can watch public health at work. You can watch the end of polio.
(Credit: This image of an iron lung is taken from the website of the Canadian Public Health Agency.)

A Lesson in Resilience

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Here in Eastern Ontario, the weather is beginning to get to me. We have had a cool, wet, rainy spring with long periods without sun and I find myself contemplating the emotional impact of poor weather, especially at a time of year when we are used to being outside, enjoying the first picnics, hikes and patio activities of the summer season. A few years ago, however, I read The Idle Traveller by Dan Kieran, a travel writer from England. I truly enjoyed this book that emphasized focusing on the journey and one of the best lessons I learned from this was not to let the weather affect your outdoor plans. This is one lesson anyone can learn from the British and I saw it in real life just last month when I visited London.
Just after I arrived, there were 3 days of sunny weather and everyone was out in the parks, sunning themselves in shorts and tank tops. Now, lest you get the impression that it was also warm, let me tell you that it was sixteen degrees centigrade out. Sixteen degrees!! I was chilly in the wind and was certainly not in shirtsleeves as many were, but it was a vivid reminder that the British do not let a little cool weather get in the way of spring.
The lesson about the weather is not the only reality check you can get from the people of Britain. In the last three months, there have been three terror attacks in England: two in London and one in Manchester. They were deadly, and frightening, and there is every reason to believe there will be another one. But no matter the level of terror alert, the parks are full of people on sunny days and everybody goes about their business as if it’s been just a regular three months. They even went to a concert with the very same artist, in the same city where two weeks earlier 22 people had been killed and many more injured. Even children had been killed or injured and still people went with their children.
The determination of the people of Britain not to let weather or terror disturb their days is evidence of their resilience, and that resilience can be cultivated. The personal qualities that are evident in resilience include a positive attitude, optimism, an ability to manage emotions and an ability to learn from setbacks.
Let’s think about some of these qualities. Positive attitude can be found in all those BBC sitcoms whose characters keep stressing “mustn’t grumble”. The entire British attitude toward weather is typical of the national optimism. Second World War posters telling citizens to “Keep Calm and Carry On” are just as popular today as they were 75 years ago. As for learning from setbacks, the Angles, Saxons, Danes and Normans were able to invade Britain but in modern times a determination to “fight on the beaches…on the landing grounds…in the fields and in the streets” has kept Britain’s enemies at bay.
Having just returned from London shortly before the attack at a Manchester concert and the attack on London Bridge, I find I have a great admiration for the extraordinary courage that manifests itself so ordinarily, as if it only what is expected. If only I could be that brave!

(Photo credit: This photo was found on Facebook after the attack in London in March 2017.)

One Hundred Years of Women Doctors

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Over the next ten years, various women’s medical organizations from around the world will be celebrating their centenaries. I was contemplating this while attending the Centenary of Britain’s Medical Women’s Federation last week. The American Medical Women’s Association celebrated its Centennial in 2015. The Federation of Medical Women of Canada was founded in 1924 and the Australian Medical Women’s Federation formed in 1927 even though Australia’s first medical women’s society was founded in 1896. In 2019, the international body to which all these associations belong, Medical Women’s International Association, will celebrate 100 years of operation, the oldest international medical association. Many of these organizations took as their inspiration the women’s suffrage movement – the theme colours of Britain’s Medical Women’s Federation are exactly those of Britain’s suffragette movement.

This means that there have been one hundred years of women physicians’ influence on medicine and health care. What has this meant for health and for the status of women physicians?

From the beginning of medical women’s organizing activity, women doctors have concerned themselves with the health of women and children and with advocating for opportunities for women doctors. All told, most of these women doctors’ organizations would likely believe that they have been more successful on behalf of their patients than on their own behalf.

Despite growing numbers of women in medicine, women continue to be underrepresented in the highest paid specialties, in university professorships, in clinical leadership positions and in most other medical leadership roles. This is true even in those countries in which women have formed the majority of the medical workforce for many years, such as China and Russia. The underrepresentation of women in powerful medical roles is of such concern in most first world medical women’s organizations that advancing the position of women doctors has become a primary concern for most of these organizations. “Equal pay for work of equal value” has its own meaning for women doctors!

As for health and healthcare, medical women and medical women’s organizations have championed women’s and children’s health, and especially women’s reproductive health. A look at the websites of any of the national organizations listed above will demonstrate this important work. The work of the members of Medical Women’s International Association (MWIA) has been so noteworthy that its projects have ensured that it has official working relations with the World Health Organization (W.H.O.).  MWIA also maintains Category II Status with the Economic and Social Council (ECOSOC) and is involved in the Immunization Programmes of the United Nations Children’s Fund (UNICEF). MWIA is represented in all three of the United Nation Centers, New York and Geneva by Permanent Representatives. MWIA is a Founding Member of the Council for International Organizations of Medical Sciences (CIOMS) and continues to be actively involved in that organization. MWIA also sends representatives to the European Women’s Lobby.

The projects of the various national organizations and of MWIA itself are as varied as its members. In recent years, MWIA has worked with ZONTA to distribute birthing kits to those women in poor countries who have their babies at home, often without any birth attendant – not even a neighbour. As well, one Past President, Dr. Gabrielle Caspar of Australia has collected ultrasound machines in that country to deliver to African countries. MWIA members from around the world are compiling a series of typical cases of intimate partner violence into a training manual for use around the world. The cases will cover an unprecedented example of cultural and social impact on intimate partner violence.

One hundred years ago, at the time that women around the world began to insist on a role in government by means of the vote, women doctors began to insist on a role in medicine that would allow them to have the impact on health, and especially women’s and children’s health, that was needed to improve health standards in general. These pioneering women physicians realized that healthcare must be equal for all. They fought for it then and continue to champion the same goals today.

(Note: The above photo is of the original members of MWIA in Geneva, Switzerland at the time of their founding meeting.)

My Predictable Clinical Life

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In the past week, I have started to work on an inpatient psychiatry unit for youth. It is not easy being a psychiatrist for an inpatient program, but it is interesting and more predictable than outpatient psychiatry. In an outpatient program, emergencies arrive with little notice, often disrupting one’s schedule on days when there is no room for disruption. On an inpatient unit, the emergencies are right there in front of you all the time. This is predictable unpredictability and I find this more manageable than the frenzied calls that can disrupt an entire afternoon’s clinic.

For the past week, I have arrived on the unit to calls of, “Can I speak with you now?” or “What time are you meeting with me? I have stuff to do.” With a much smaller overall caseload than outpatient psychiatry, and patients who need to be seen daily, there is an opportunity to get to know the youth I am working with so well that their needs can be more thoroughly addressed.

The most common reason for psychiatric hospitalization for youth is to stabilize acute symptoms of psychiatric illnesses but case formulation and diagnosis and treatment plan development are becoming even more critical in youth psychiatric care. The reasons for this are embedded in the shortage of Child Psychiatrists and of youth mental health resources in general. Outpatient child psychiatry programs everywhere are stretched to the limit, to the point where the World Health Organization found that many mental health needs of youth around the world were not being addressed directly but rather through programs addressing other concerns. For example, street-involved youth often get more mental health support through housing agencies than from mental health agencies or hospital or clinic mental health programs.

Inpatient psychiatry programs and their function and purpose are not always well-understood, mostly because evidence often supports community treatment for some patients who would prefer hospitalization and hospitalization for patients who find the restrictions of psychiatric units too difficult to tolerate. This concept was summarized best by a patient I saw many years who asked me, “Dr. Beck, how come the people who want to stay in hospital can’t but the people who want to leave aren’t allowed?” When I responded, “I don’t really have a good answer for that question,” I was met with, “You don’t have any good answers.” I wish I thought that wasn’t true.

The WHO report emphasizes the need for greater collaboration between inpatient programs and the community. The social advocate in me loves the idea of working with schools, shelters, food banks and public health to develop the partnerships that will improve collaboration. The best outcomes for the clinical conditions where psychiatric hospitalization is indicated can be predicted based on social conditions. This means that those of us in who work in youth mental health must work with community partners if we are to have any success at all.

It also means that I will be diagnosing and treating conditions that go well beyond mental health into personal and social well-being. Hence, on my first day back, it was predictable that I would find myself gowned and gloved, hair covered, combing through a young person’s hair looking for nits. I can answer most questions about lice, in case anyone is interested.

How to Legalize Marijuana

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My interview on CBC’s The House had such a positive reception that I wanted to follow up with a short essay summarizing most physicians’ recommendations for legalizing marijuana. My own perspective is that of a psychiatrist whose patients are all adolescents and young adults. This means I am concerned about the short-term impact of marijuana intoxication in the young people that I see, but I am even more worried about the long-term impact of cannabis on the developing brain as well as the links between cannabis use and psychotic illnesses.

Most physicians hope that the federal government will approach the legalization of marijuana emphasizing public health concerns as the most important consideration in the drafting of legislation. There are also law enforcement and government revenue aspects of the legislation but in jurisdictions where these considerations were emphasized, health outcomes were affected. Doctors in Canada – and Canadians in general – will find that negative health outcomes will eliminate any possible benefits to legalizing and regulating marijuana.

The government’s vision is to have marijuana legally available for non-medicinal purposes by Canada Day 2018. For the implementation to fully consider the public health implications, the government can look to its experience with the legalization and regulation of tobacco and alcohol. There are lessons to be learned from this experience from a public health perspective and I hope Canadians can benefit from that experience. We can also learn from those countries and jurisdictions that have already legalized marijuana. Also, now is the time to set up an evaluation and research agenda to ensure that we continue to learn from our experience with legalizing marijuana.

Some of the main health concerns with marijuana are related to its impact on the developing brain. The brain continues to develop until age 25 and there is significant evidence that cannabis use interferes with brain development. While it would be ideal if the minimum age to purchase marijuana could be 25, Young Canadians are already using twice as much marijuana as any other age group in Canada. Young Canadians also have a higher rate of cannabis use than youth in any other G8 country. With use being this high (20% of Canadians aged 16-24), it is more realistic to focus on reducing cannabis use to the extent that is possible. The Canadian Medical Association recommends setting a national standard where minimum legal age for purchasing marijuana would be 21, but with restricted strength and purchasing limits until age 25.

As well as brain development, child psychiatrists have also noticed increased prevalence of psychotic symptoms in young people using marijuana. We notice that psychotic symptoms emerge at a younger age for those with a predisposition for these conditions who use marijuana. We also notice that cannabis use is associated with the more serious chronic symptoms of schizophrenia.

Many physicians are also concerned that that rigorous research has never been applied to whether marijuana has any medicinal value. Marijuana has been available for medicinal purposes in Canada for many years, but there are few, if any, studies confirming its efficacy. Given the health risks, is it not time to insist on research to determine whether medicinal marijuana is effective?

Finally, one of the most important public health impacts will be related to the consequences of driving while intoxicated.  One’s capacity to safely operate a motor vehicle after using marijuana can be affected for as long as 6 hours after use. There is no currently no adequate way to identify or evaluate whether a driver is under the influence of cannabis. A method to evaluate intoxication must be developed before legalization. In this regard, the experience of Colorado should inform Canadian legislators. This excellent review outlines the increase in traffic accidents and Emergency Room visits since marijuana was legalized. Traffic accidents are one concerns but there are others. Colorado legislation was focused primarily on the revenue generating aspects of marijuana legalization. The negative health outcomes should be a cautionary tale for Canadians.

I have focused on those aspects of marijuana legalization that are most important in my practice but the Canadian Medical Association prepared a detailed submission for the Government of Canada Task Force on Marijuana Legalization and Regulation. Canadian doctors and the Canadian Medical Association are extremely concerned about this legislation. Great effort has been taken to alert the federal government to the risks involved in legalizing marijuana. I mentioned earlier that I wished the legal age to purchase marijuana could be 25. I can see how unrealistic this is, given how much marijuana young Canadians use right now, when it is not legal. After the fact of negative health outcomes from legal tobacco and alcohol, Canadian governments have had to launch massive public health and education campaigns. It would be good to roll these out now, in the hope that we can avoid some of the negative health outcomes doctors know are coming.

Benjamin Franklin made what must be one of the first public health statements in America. We can remember this as marijuana legislation moves forward, even if Colorado didn’t:

“An ounce of prevention is worth a pound of cure.”

Does Ontario Have A Gun Problem?

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Adolescents have been the focus of my practice in Psychiatry for more than twenty years.  Adolescent boys have a complicated relationship with violence and anger and it is not unusual to see that erupt, especially when they are struggling with symptoms of mental illness. It almost seems as though, at some point in adolescence, men must work through what their relationship with violence will be. As they do this work, the entire course of their lives can be affected by the lethality of the weapons they have at hand. A gun is never a helpful accessory for a young man struggling to understand and cope with violent urges toward himself or others.

Why am I thinking about guns? I have just returned from Boston and early in March I spent a week in New York City for the Commission on the Status of Women. As a Canadian, I am always more cautious when walking by myself, especially at night, in American cities. This is because, as a Canadian, I believe that there are many more guns in these American cities than in Canada. Public health research has shown that guns are a health risk.

Having said this, both Boston and New York are managing gun violence while Toronto, a city where I spend much more time, has seen spikes in gun violence in 2016 and increasing gun violence in 2017. Even in Ottawa, the capital city known for its general safety, had a higher than normal number of shootings in 2016 and 2017 is showing the same worrying trend.

Canadians often smugly think that gun control manages gun violence and, while all evidence supports this, these recent trends need to be considered. These increasing numbers mostly reflect violence involving the young men under 25 I mentioned at the outset. We know that young men’s brains continue to develop into their twenties and most parents of young men certainly notice this. This is true even though, by age 21, most young men have undertaken significant responsibilities related to education and work, and often families or relationships.

During the period of late adolescence and early adulthood, young men are at higher risk of being perpetrators and victims of violence. Over many years, there has been much speculation on why this is the case. Research cites adaptive advantages from our past to the economic disparity and racial tension that is believed to fuel violence around the world.

The one factor that has kept this violence from becoming lethal has been access to a weapon, usually firearms, that immediately make an attacker much more dangerous. In fact, countries that implemented gun control saw the number of multiple murders significantly decrease. This fact alone is the number one reason to implement gun control. Gun control is the perfect example of a public health measure based on the number of deaths and injuries it prevents. With this in mind, we need to ask, is there now increased access to firearms in Ontario to account for these spikes in gun violence?

There has not yet been an analysis that allows us to answer this question. In a country with gun control, a policy that has helped maintain public safety for so long, we need to be certain that we take this increase in gun violence seriously. Experience has taught us that gun control measures can make a difference in preventing injury and death.

Those of us who are the parents of young men, or who have been young men, or have been the caregivers of young men in distress know what can happen when frustration takes over from a youth’s better nature. A young man with a gun can do much more harm with a firearm than with his fists, or a knife. We know from the crime statistics that more and more guns are aimed at others, but many of these young men also aim at themselves.

The point is that there are more victims. We often decry that police are not attuned to the mental health problems of those they arrest. However, those of us who are concerned with health need to provide some support to the police and other agents of the law with respect to the increasing number of guns in Canada. The health impact is increasing along with the crime rate. Those of us who specialize in adolescent health must begin to understand the law as it relates to our patients.

A Children’s March for Ontario

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The youth in my practice with the most complex mental health problems are those who have grown up “in care”. The expression “in care” refers to the fact that a child or youth is not living at home but rather with a foster family or in a residential care facility, usually called a “group home”. These young people are victims of assault and neglect in their families of origin, but they are also victims of a system of residential care that shuffles them around from home to home, caregiver to caregiver – a system that is no more supportive than their own family.

In late 2016, the Government of Ontario undertook to improve the lot of these youth. On the usual road, paved with the usual good intentions, the Government introduced Bill 89: An Act to Enact the Child, Youth and Family Services Act, 2016, to amend and repeal the Child and Family Services Act and to make related amendments to other acts. In many respects, the young people in this province who are living in care played a large role in ensuring that such an act is even before the Ontario legislature.

In November 2011, with the support of the Provincial Advocate for Children and Youth of Ontario, youth volunteers from across Ontario convened the Youth Leaving Care Hearings at Queen’s Park in Toronto. This was the first time youth had organized public hearings at Queen’s Park. The reason for the hearings was to address the concerns of the over 8,000 children and youth who are Crown Wards in Ontario – children and youth whose guardian is the Crown, through the Children’s Aid Societies in Ontario. There is a Report on the Hearings, My Real Life Book, and You tube videos. These will help you to understand how many youth live in care in Ontario and how they feel about this experience. I felt very honoured to be one of the adult contributors to the hearings. I remember an interview after my presentation and how emotional I felt during the interview. I had met three youth I had cared for at the hearings and I was so glad to see them doing well after everything they had gone through.

After the hearings, the youth continued to be involved. They participated in the inquests for Jeffrey Baldwin and for Katelynn Sampson, two children who died at the hands of their caregivers while living as wards, even though both these experiences must have been extraordinarily difficult personally. Their work and participation and enthusiasm finally convinced the Government that it had to act to change the existing Child and Family Services Act to better serve the children and youth it was meant to help.

The best part of Bill 89 are the principles it sets out as guidelines:

“The Government of Ontario is committed to the following principles:

Services provided to children and families should be child-centred.

Children and families have better outcomes when services build on their strengths.  Prevention services, early intervention services and community support services build on a family’s strengths and are invaluable in reducing the need for more disruptive services and interventions.

Services provided to children and families should respect their diversity and the principle of inclusion, consistent with the Human Rights Code and the Canadian Charter of Rights and Freedoms.

Systemic racism and the barriers it creates for children and families receiving services must continue to be addressed. All children should have the opportunity to meet their full potential.  Awareness of systemic biases and racism and the need to address these barriers should inform the delivery of all services for children and families.

Services to children and families should, wherever possible, help maintain connections to their communities.”

The worst part of Bill 89 is that, in fact, it may not, in fact, adhere to these principles and it is not at all clear in the text what the measures are to ensure that Children’s Aid Societies and group homes or foster parents will comply with the new measures of the act. Legislation is always complex, and difficult for people to understand. I am very well-educated – 11 years of postsecondary education – and I have trouble completely understanding the bill. Can you imagine how difficult it is for those who have not yet completed their education to understand it? Youth in care in Ontario have worked for many years to bring changes to the Child and Family Services Act. They made submissions to hearings and inquests, telling their stories of being cut off from their families, from those who loved them and from services that would have helped them heal. They told these stories even when it brought back horrible memories of what happened to them. They told these stories even if their mental health deteriorated.

They are, in fact, getting ready to do this again. Bill 89 is now in Committee and the Youth in Ontario want it to meet their needs. There are over 8,000 Crown Wards in Ontario, but there are almost 20,000 living in Children’s Aid Society Care. These are Ontario’s children – literally.

This Act – in fact, every legislative act – needs to be accessible. In simple language, citizens must be able to understand what an Act is saying to ensure that it does what it means to do. No one is blaming the legislators – the lofty goals and language set out in Bill 89 make it clear that the intent is to improve the situation for Children and Youth and Families in Ontario who need support. If the Act is made understandable for the Youth who have worked to get Bill 89 onto the legislative agenda, they will know whether it can be effective.

The Government has also made it clear that these changes are needed quickly and so, as is often their habit, the Committee process is being truncated. This is not fair to the youth who have been working for these changes. Until every submission is heard, from every youth who wants or needs to provide their input, the Committee process should not stop.

Our Voice, Our Turn, My Real Life Book, and the inquests for Jeffrey Baldwin and Katelyn Sampson showed us that the current Child and Family Services Act silenced children and youth and allowed their suffering, even their deaths, to be institutionalized. Let us honour these young people and their heroic actions to make Ontario a better place to grow up. Let us urge the Government to wait, and make Bill 89 as effective as it can be. Let’s match their courage with our own.

(Note: The Children’s March refers to incidents in Birmingham Alabama in 1963 when African American children left school to march downtown to meet the Mayor and speak about their experience of segregation. They were arrested, sprayed with hoses, but kept on marching, causing legislators, and especially President John F. Kennedy, to finally move forward on Civil Rights legislation. Photo is from a Biography documentary.)