Canadian Medicine

A round-up of Canadian health news, from coast to coast to coast and beyond, for Friday, October 17.

"Despite their behaviour on the campaign trail, politicians cannot merely silently support the status quo" on healthcare, writes the Globe and Mail's André Picard in his latest column, "Taking on our sacred cow." Mr Picard also reports that Diane Finley is the leading candidate to become Stephen Harper's new health minister. The Canadian Press reports that Tony Clement "covets foreign affairs and international trade."

Alberta will become the first province to make private health information available to patients online, when its system launches in a few months.

E coli poisoning can lead to longterm kidney damage but not diabetes, reported researchers studying victims of the Walkerton, Ontario, water contamination problems in 2000.

Alberta has also announced it will cover the costs of hiring a midwife under the public insurance plan, beginning April 1. The bill is expected to be $4 million.

Listening to the Bee Gees' "Stayin' Alive" improved doctors and students ability maintain a 100 compression/minute rate while giving CPR, according to new research from the University of Illinois. Not only that, but humming the songs to themselves five weeks later still helped them maintain a high enough rate. "Stayin' Alive" seemed the best fit, one of the researchers told the Canadian Press, even though other songs have a similar number of beats per minute, including "Another One Bites the Dust" by Queen. "For obvious reasons, though, we thought 'Stayin' Alive' was more appropriate for the context," said Dr Elizabeth Bochewitz.

Car surfing has caused at least 58 deaths since 1990.

British doctors discovered a new dermatological condition, known as "mobile phone dermatitis."

Voting by Ontario’s physicians on a proposed contract with the provincial government ended on Wednesday, but the arguing is not nearly finished.

The deal, which was negotiated and endorsed by the senior leadership of the Ontario Medical Association (OMA), has been vehemently opposed by the Coalition of Family Physicians of Ontario (COFP) since its release last month. In a issued last week, COFP President Dr Douglas Mark urged OMA members to vote ‘no’ on the deal; he called its prospective fee increases “sub-inflationary” and denounced the OMA’s comments in presenting the deal to members as “scare tactics.”

But this week the rhetoric heated up when Dr Mark sent out another letter suggesting doctors “may consider resigning from the OMA.”

The COFP has a long history of criticizing the contracts between the OMA and the Ontario government, including the 2004 contract, which didn’t succeed, and the successful 2005 one, but in neither of those cases did Dr Mark allude to a potential exodus en masse of disgruntled doctors. “If enough physicians did this,” he , “the government would have a much harder time justifying the OMA as your official bargaining agent, since it would have few members to represent.”

As was established in a piece of 1991 legislation, the OMA is the only union for physicians permitted in the province -- thereby eliminating any room for a competing union. That law, the , required all Ontario physicians to pay dues to the OMA, which was given the authority to seize unpaid dues or remittance fees from doctors. “This last legal twist effectively gave the government very significant control over the profession, since the OMA now became dependent on government for its fiscal existence, and its funding was no longer tied to its performance and accountability as our representative body,” wrote Dr Mark. “When we consider the close fiscal relationship that the OMA has with the government, it should come as no surprise that the OMA often pushes through contracts which are advantageous to government but not necessarily to its supposed constituents, the doctors of Ontario.”

Another group, the Ontario Physicians’ Alliance (OPA), made similar accusations in a last month. “Doctors must question if the OMA is now an arm of government helping to administer the political wishes of our paymaster (also the government),” the message read. The OPA, in agreement with the COFP, decried the OMA’s status as a mandatory union; even doctors who do not belong to the OMA must pay OMA dues, under a legal clause known in Canada as the Rand formula. “The on-going and expensive public relations campaign by the OMA is irrelevant in the absence of a legitimate, voluntary and democratically valid right of the OMA to represent physicians and our ideas.”

PRIVATIZATION SUBTEXT
One important subtext of this conflict is the eternal Canadian debate about the role of the private sector in healthcare. The escalation is a result not only of the specifics of this contract, said Dr Mark’s most recent letter, but also of the OMA’s failure to advocate for political reform and loosened rules on “alternative funding”:

“The OMA's negotiating team and legal advisor have repeatedly said that given the present economic climate, this is the best deal that we can hope to get, and that there simply is no more money available. The COFP acknowledges that the government is cash-strapped, and will be even more so in the future. However, this is relevant only if the government insists on remaining as the sole payer for necessary medical services in Ontario.

“Rather than decrying the present economic situation as a crisis for healthcare funding, we can instead choose to view it as a timely opportunity to explore alternative ways of financing healthcare.”

Ontario’s proscription of private funding for healthcare, wrote Dr Mark, is even more restrictive than those of other Canadian provinces. He continued:

“It bears noting that the only other constituency in the world with exclusive one-tier Medicare is North Korea - it does not exist anywhere else because it is economically unworkable.

“Instead of collaborating with the Ontario government on preserving an unworkable system, by agreeing to a deal that relies on underpaid labour, the COFP respectfully suggests that the OMA begin a serious dialogue with government on alternative funding. This dialogue has already begun not only in other provinces but also at the national level, with both the past and present CMA presidents publicly advocating some form of a mixed public-private system, such as those found in the 29 countries which rank ahead of Canada in terms of healthcare according to the World Health Organization.”

In a written statement to Canadian Medicine, OMA President Dr Ken Arnold said he is “disappointed” with the COFP’s response to the proposed deal:

“After conducting extensive consultations with doctors across the province, the Ontario Medical Association’s negotiations team worked hard to ensure that the deal provided members with what they asked for and we feel we reached that goal.

“As my colleagues have noted, the COFP has chosen to present a misleading analysis of the information in the agreement. While it is unfortunate that the COFP is dissatisfied with the outcome of the negotiations, the deal was unanimously endorsed by the OMA’s Board of Directors because we feel it will be beneficial to physicians and patients alike.”

Dr Arnold made no mention of the COFP’s call to physicians to consider resigning their OMA memberships, nor the COFP’s accusation that the legal framework of the OMA’s existence makes it too cozy with the government.

The results of the OMA’s vote on the proposed contract will be announced on Saturday.

A round-up of Canadian health news, from coast to coast to coast and beyond, for Thursday, October 16.

Vancouver Liberal MP Ujjal Dosanjh's near-defeat in what should have been a safe riding may have been the result of the local Chinese population's philosophical objection to Insite, the downtown safe-injection site, suggests a Globe and Mail columnist. Mr Dosanjh served as minister of health in Paul Martin's cabinet; Insite received federal funding during that period. After the dissolution of the 38th Parliament in January 2006, Conservative MP Tony Clement became health minister and later that year stopped federal funding for research conducted at Insite.

The RCMP will investigate itself after a Vancouver law firm revealed that police officers had paid for and hand-picked research that would demonstrate Insite's shortcomings.

Tony Clement, who won a Parliamentary seat in Ontario's cottage country by just 28 votes in 2006, blew his competition out of the water in this year's election, winning the same seat by nearly 11,000 votes. North Bay Nugget

The Liberal Party's health critic, Robert Thibault, all but blamed Stéphane Dion for his defeat in this week's election in his Nova Scotia riding at the hands of a Conservative candidate. "I was fortunate to win it three times, but the Green Shift was a very, very difficult sell," said Mr Thibault. "[Dion] was trying to put it through without proper debate in my mind." No word yet on who is likely to serve as the party's next health critic with Mr Thibault gone; possibilities may include former Health Minister Ujjal Dosanjh, Ken Dryden (briefly health critic in 2006), Ruby Dhalla (an Ignatieff supporter and chiropractor who was the next health critic, until Mr Dion became leader and named Mr Thibault to the position), public health critic Dr Carolyn Bennett, and Dr Hedy Fry.

Liberal candidate Dr Eric Hoskins, a humanitarian doctor and president of War Child, lost to Immigration Minister Diane Finley in the riding of Haldimand-Norfolk in Ontario.

PEI's lack of a specialized stroke care unit is dangerous, neurologist Reg Hutchings told CBC News. "If you have a heart attack, you know you are going to be treated in a very efficient coronary care unit. If you have cancer, you are going to be treated in a state-of-the-art cancer treatment centre. But if you have a stroke, may God help you."

The number of infants infected with C difficile in Regina General Hospital's neonatal intensive care unit is up to nine.

The future of the Therapeutics Initiative, an independent board based at the University of British Columbia that makes recommendations to the BC government on drug safety and coverage, will be under review at UBC on October 30 and 31. An op/ed by Dr Randall F White in the National Review of Medicine in July took the government to task for allegedly stacking a task force on the Therapeutics Initiative's value in favour of the pharmaceutical industry.

The United Nations will consider recommending that a portion of the ban on human cloning be overturned at a meeting in Paris later this month. The ban as it stands now fails to distinguish between reproductive and non-reproductive cloning, reports the Toronto Star's Stuart Laidlaw.

The latest edition of the health policy blog anthology, Health Wonk Review, is online today at Managed Care Matters. Most entries pertain to the US presidential election.

A round-up of Canadian health news, from coast to coast to coast and beyond, for Wednesday, October 15.

An Ontario court ruled that a doctor could not be sued by the child whose birth defects were caused by a drug he prescribed to the mother during her pregnancy. The drug, Accutane, is indicated for acne but is strictly limited from being used in pregnant patients because of the high risk of birth defects. In the case heard by the court, the father of the baby had a vasectomy, so the doctor didn't require any extra birth control methods. However, the vasectomy turned out to have failed. The ruling is noteworthy not for the judges' opinion on this specific case, but for the conclusion that a doctor owes a duty of care only to a woman and not to an unborn child.

Regina General Hospital's neonatal intensive care unit suffered a C difficile outbreak that has affected five babies.

A new recommendation to the Public Health Agency of Canada says homeless people should be given the pneumococcal vaccine, and illicit drug users should be considered for the vaccine. []

Vitamin K doesn't keep bone density at ideal levels, but it does reduce the number of fractures in postmenopausal women, reported University of Toronto researchers in PLoS Medicine.

Instead of enacting a law, Quebec plans to work collaboratively with the fashion industry to establish guidelines on models' weight and health.

South Africa's new health minister reverses the nation's government's years-old refusal to accept that HIV causes AIDS and must be treated with modern medicines.

Drinking alcohol shrinks the brain, a team of Massachusetts researchers reported in Archives of Neurology.

Three doctors from Virginia give advice on when doctors should administer biomarker tests to determine if patients are lying about their alcohol use, in order to avert untreated withdrawal symptoms. The article includes three interesting cases in which patients were found to have lied about their alcohol consumption.

Cherry-flavoured malaria drugs are as effective and as safe as the crushed-up malaria pills currently used for pediatric patients. CBC News unfortunately gets it mixed up, reporting that the sweetened drugs were better in the trial. Not so. As Reuters reports, the benefit is that the sweetened version is less likely to be rejected because of taste, as the current doses sometimes are.

On Monday I asked, "Will Tuesday's election change anything in healthcare?" Now we have our answer: nope.

Yesterday's federal election changes very little in Parliament, yielding yet another Conservative minority -- albeit a larger one, with a decimated Liberal opposition. No majority for Stephen Harper's Tories. No hope for the rumoured Liberal-NDP coalition. No change in the balance of power in Ottawa despite a total of cost of some $300 million of taxpayers' money on the whole affair, right in the middle of what all the party leaders agree is the worst global economic crisis in decades. No wonder turnout was the lowest in Canadian history.

For health policy, a second Conservative minority likely means more of the same. There's scuttlebutt that Tony Clement, who has served as health minister since the Tories came to power in 2006, may not stay in that portfolio. ("In a sense," Mr Clement told me earlier this year, "everyone who's a health minister usually has a very difficult, complex portfolio that has been the frequent graveyard of political aspirations in the past." And there's no doubt he has aspirations.) Who might replace Mr Clement if he gets moved? Leona Aglukkaq, the freshman MP in Nunavut who served as the territory's health minister until last month when she stepped down to run for the Conservatives, has been mentioned as a possible junior cabinet minister but a more experienced hand is likely required to guide Health Canada. Minister of Industry Jim Prentice's name often emerges in cabinet rumours, but he may be the one destined to replace David Emerson in Foreign Affairs.

But, really, it may not matter who becomes health minister. Stephen Harper's government has been reluctant to even speak about -- much less create new policy on -- the healthcare system. His first term began with an ambitious plan for "wait times guarantees" that he and Mr Clement touted for some time, but those guarantees haven't had much of an effect on wait times in practice. Critics pointed out that the provinces were eager to take the federal government's wait-times incentives, but simply chose to guarantee low wait times in a field in which they were already doing well; the provinces were essentially offered money for nothing, the National Review of Medicine reported last year in an article titled, "." I asked Mr Clement about this in with him earlier this year, which it seems appropriate now to excerpt:

SAM SOLOMON: Wait times are high on your agenda.

TONY CLEMENT: Yeah. I see the federal health portfolio in perhaps a fundamentally different way than some of my predecessors. We had a campaign commitment to establish, with the provinces and territories, patient wait times guarantees. That was a first year promise and we delivered it early last year.

SAM SOLOMON: But how do you know the guarantees will work?

TONY CLEMENT: Well, we don't. So my approach is to try some things out. I rail against those prophets of healthcare reform who want to change the system radically overnight. That's a very high risk enterprise. What if it doesn't work? We could in fact make things worse.

SAM SOLOMON: When will we know if it's working?

TONY CLEMENT: I think it's going to take a couple of years.

SAM SOLOMON: And how much money are we going to throw at it before we know?

TONY CLEMENT: We've committed over $600 million from the last budget. But my point is — look, the idea is worthwhile. It's a new idea for Canada, but it's not a new idea in the world. In fact, many countries have gone past their first generation of wait times guarantees. In Sweden, for instance, they went from a flat 90-day guarantee, every procedure available within 90 days, and bumped it down to 60 days. We're still at the earlier stage, but we can learn from that.

SAM SOLOMON: One of the loudest criticisms against the guarantees is that the provinces are just picking the easiest targets to meet.

TONY CLEMENT: Yeah, the low-hanging fruit.

SAM SOLOMON: Do you think it's a problem?

TONY CLEMENT: I don't think so. The provinces were saying, 'You know what, we are doing so well all we need is to shave off a week here or a few days there and we can say for every single person in the system this guarantee is there so you will get the care you need.' Whether it's in cataracts or joint replacements or cardiac, access to diagnostics, for cancer, I think that's actually the right way to approach it rather than empty, half-baked promises that don't help anyone.

SAM SOLOMON: But doesn't that mean we're not actually guaranteeing a reduction in wait times but rather guaranteeing to maintain the status quo? Or even making things worse — in one case, radiation oncology, the benchmark ended up being longer than the one set by the radiation oncologists themselves.

TONY CLEMENT: You're going to get folks, specialists, that they think it should be 90 days rather than 60 or 60 rather than 90. That's a healthy clinical dialogue to have. The way other countries have approached this is entirely different. They've set a flat guarantee across the whole system. Maybe at some point we'll be ready for that — we're not right now.

SAM SOLOMON: Wouldn't it be easier to have one federal set of wait times guarantees?

TONY CLEMENT: Here's the advantage and the disadvantage of the Canadian healthcare system: everybody wrings their hands because you've got 14 systems, you've got 13 provinces and territories and the federal government. 'Gosh, wouldn't it be easier, wouldn't it better if we had one system, run at the federal level?' That's like wishing the sky were purple.

SAM SOLOMON: Do you wish the sky were purple?

TONY CLEMENT: No, I like to wish for things that are realistic. That isn't the way the country was put together, so stop pining over something that will never happen.

Although Mr Clement and Mr Harper had reputations as private-healthcare zealots before they arrived in Ottawa, neither has even mentioned the possibility of a legislative reform. Their tenure hasn't been entirely impotent, however. In the October issue of Parkhurst Exchange, I reported:

Across the country, in the past two and a half years of Conservative minority government, Canadians have experienced the fastest rise of uninsured health costs since the drafting of the Canada Health Act; average out-of-pocket health expenses grew about 2.5 times faster since Stephen Harper's election than they did in the previous 22 years. (1)

The Liberals and New Democrats attempted to get healthcare some airtime during this year's campaign, speaking about catastrophic drug coverage plans, national pharmacare and remedying the shortage of doctors and nurses across the country. Tony Clement sounded open to discussing a national pharmacare program -- especially after the most recent Council of the Federation meetings, where the provinces pushed the idea -- so it's possible there may be some progress on that front within the next few years.

Frustrated at the lack of attention healthcare received during the election campaign, the Canadian Medical Association (CMA) has pledged it will do its best to keep healthcare reform front and centre in the new minority government. My interview with CMA President Robert Ouellet about what the election results mean for doctors and patients will appear in the next issue of Parkhurst Exchange.

(1) Osberg L, Sharpe A. (PDF). GPI Atlantic 2008.

Taking the measure of the 40th Parliament

Conservative and Conservative-aligned independent seats: 145
Seats needed to form a majority: 155
Number of Quebec seats Conservatives were projected to win, one week before the election call: 30
Number of Quebec seats Conservatives actually won: 10
Number of seats won by Conservatives in downtown Montreal and Toronto: 0

Liberal + NDP combined popular vote, as a percentage of Conservative popular vote: 118%
Liberal + NDP combined seats, as a percentage of Conservative seats: 79%
Bloc Québécois popular vote share: 9.97%
Bloc Québécois seats: 50
Green Party popular vote share: 6.8%
Green Party seats: 0

Number of physicians who ran for Parliament: 12
Number elected: 4
Proportion of those who were Liberal incumbents: 100%

Number of sentences in Conservative platform devoted to healthcare system policy: 1
Number of sentences devoted to cell phone text messaging charges: 3

A round-up of Canadian health news, from coast to coast to coast and beyond, for Tuesday, October 14.

A group of activists is suing the federal government for attempting to regulate natural health products, which they claim are "ultra safe." Among the plaintiffs is a group called Freedom of Choice in Health Care Inc, a group founded by a naturopath named David Rowland, who is running under the Republican Party of Canada banner against Health Minister Tony Clement in today's federal election. []

Saskatchewan-based healthcare analyst Steven Lewis wrote quite a funny (and very long) imagined discussion between the five major political party leaders. It begins, "As usual, health care is front and center in this election. [Leaders look at each other quizzically, and leaf furiously through their briefing books.] Medicare is in crisis. The system hangs in the balance. What will you do as Prime Minister to strengthen this icon of Canadian identity?"

Health Canada recently approved a new preservative that could prevent the growth of listeria. Maple Leaf, the food company at the centre of the recent listeriosis outbreak in Canada, said it is examining the new preservative.

Alberta's legislature is back in session as of today. Health Minister Ron Liepert will introduce legislation to reform the provincial drug and long-term care plans.

A member of the Order of Canada has begun a legal challenge asking for Dr Henry Morgentaler's Order of Canada award to be rescinded.

The New York Times reported on the attacks against Toronto Liberal candidate Dr Carolyn Bennett's supporters. “In some ways, I don’t think this has anything to do with me," Dr Bennett told the Times. "It’s an unwell person or group of people who are doing this and not caring about the consequences. All of a sudden the family doctor in me bubbles up and I ask, What’s wrong with these people?”

A new book by Toronto researcher and physician , Unlearning: Incomplete musings on the game of life and the illusions that keep us playing, is available for free download or as an inexepensive paperback. An excerpt of the book is available from the Longwoods blog, where Dr Jadad writes: "I just published my first non-medical book, entitled 'Unlearning', which I am using to explore the impact of combining online publishing, social networking and the notion of Freeconomics [sic]."

Grand Rounds is hosted by Notes of an Anesthesioboist.

If you cut through the rhetoric and the interminable photo-ops and media-availabilities, the unhappy truth of the matter is that when it comes to prospects for real healthcare reform, Tuesday's election offers little reason for optimism.

One of the media narratives throughout this campaign has been the absence of debate on health policy. University of Toronto policy analyst and physician Michael Rachlis bemoaned the apparent lack of concern about healthcare issues in a in the Toronto Star last week. "Canadians are justly proud of their health system but this election campaign does not mirror their concerns," he wrote, indicting all five parties for what he sees as unclear and insufficient plans to remedy our healthcare system's problems. (Referring to a Canadian "healthcare system" may in fact be part of politicians' failure to address the problems, he writes, given that healthcare delivery is, for a majority of citizens, a provincial jurisdiction.) Voters in this year's election, Dr Rachlis concludes with an unmistakable disappointment, "will have to look long and hard to identify a party that champions their vision of medicare."

In the same vein, the Canadian Medical Association (CMA) issued a press release last week under the surprisingly direct heading "" (PDF).

Doctors, nurses and the average Canadian all know that the healthcare sector needs far more than just the analgesia and palliative care it has been receiving for a number of years now. But politicians' solutions have been either consistently unrealistic -- proposals to train many more physicians and nurses than we currently do without addressing the underlying education, remuneration and delivery problems, for instance -- or chronically absent. Health policy hasn't become the serious campaign issue it deserves to be, but there are undeniably some differences -- albeit not immense ones -- in the various political parties' approaches. So as a doctor, a nurse, a hospital admin, or as patient, how should you decide whom to vote for on Tuesday?

The CMA's "" (PDF) may provide a place to start. At a very manageable nine pages, the document includes an introduction by President Robert Ouellet and summaries of responses to questions about the six most important health policy issues posed by the CMA to each party. (The section reserved for the Conservatives' answers consists of one page almost entirely blank but for a terse note in the centre: "The Conservative Party of Canada declined to respond.")

To read more about each party's healthcare platform, follow these links:

Conservative Party

of the "Conservative record in fighting disease and promoting health for all Canadians" over the past two and a half years

Liberal Party
(PDF)

New Democratic Party
(PDF)

Green Party
(PDF)

Bloc Québécois
(PDF, English)

Whomever you decide to vote for -- whether it's one of the five parties above or one of the many other parties running candidates in some ridings -- don't forget to cast your ballot. For information on where to vote and what type of identification you need to bring with you, consult .

Photo: Detail from (PDF), Elections Canada