Canadian Medicine

Is Paul Martin's time as finance minister in the 1990s to blame for a rise in regional inequality in infant mortality rates? That's what a new analysis of epidemiological data and government spending implies.

The study, published online on Wednesday in the journal BMC Public Health, is titled "Regional disparities in infant mortality in Canada: a reversal of egalitarian trends." The researchers -- Ling Huang, Susie Dzakpasu, and Catherine McCourt of the Public Health Agency of Canada's maternal and infant epidemiology section; as well as Dalhousie University perinatal epidemiologist Dr KS Joseph -- prefaced their work by describing the economic and political upheaval of the Canadian federal government's deficits in the 1990s.

They wrote:

"Idealistic rhetoric notwithstanding, the health care system in Canada suffered a serious fiscal crisis in the 1990s as the federal government addressed the problem of a soaring budget deficit by reducing its financial commitment to provincial health insurance plans and related social programs [6-7]. Federal transfers declined from $8.2 billion in 1992 to $6.3 billion in 1996 (then increased to $8.8 billion in 2001). Public health care expenditure declined from 74.1% of the total health care expenditure in 1992 to 70.8% in 1996 and was 70.1% in 2001 [7]. This had a profound effect on hospital and related sectors with a substantial reduction in hospital care, despite the continued pressures of population aging and population growth. Spending on hospitals and physicians which comprised 40.6% and 15.6% of health care spending, respectively, in 1987 fell to 33.6% and 14.5% of health care spending, respectively, in 1997 [6]. Social programs were similarly affected."

The man most directly responsible for the cuts, of course, was Paul Martin, who was named finance minister in Jean Chrétien's cabinet in 1994. Mr Martin's campaign for prime minister earlier this decade, as you may recall, capitalized heavily on his purportedly successful financial management of the deficit through a series of restrictive budgets and spending cuts.

But, as Dr Joseph and his epidemiology coauthors demonstrated in their new paper, Mr Martin's economic conservatism during the 1990s may have had a profound effect on the integrity of the nation's public health system as well as the economy. The paper explained:

"Correlations between infant mortality rates in 1985-89 and 2000-02 among live births [greater than or equal to] 500 g and [greater than or equal to] 1,000 g suggest that the fiscal constraints of the 1990s contributed to an increase in health disparities in Canada. These results were corroborated by a second analysis of regional disparities which showed an increasing infant mortality rate ratio between provinces/territories with the highest vs the lowest infant mortality rates."

Mr Martin is likely not the only reason for the rise in regional disparity in infant mortality rates, the authors noted. "It may... be unfair to attribute the reversal of the trends in regional disparities solely to federal fiscal policy in the 1990s."

In the end, however, Dr Joseph et al concluded that Canada's low rate of infant mortality can be attributed "substantially" to government health and social services programs designed in the 1950s and 1960s -- such as the 1967 implementation of universal medical insurance, presumably -- while "the original commitment to egalitarian goals diminished in the 1990s."

The study's analysis is fairly complex, so I'll let you examine it yourself if you're interested in delving into the data in more depth. The abstract is available and the full text is as a PDF file.

Photo: Shutterstock

A Newfoundland woman went into the hospital to pass a kidney stone and came out of it with a newborn. "When I went back to emerg, the doctor was waiting for me and he said, 'It's no kidney stone.' He said, 'You've got a baby ready to be born,'" Juanita Stead said. "I said, 'No, that can't happen'... I told him he had the wrong X-ray file." No later than six minutes after that exchange, reported the Canadian Press, out come baby Nicholas. "Honest to God, I just don't have words to explain it," said her husband. What's more, this is her second child -- and the second child whose birth caught her unawares. "People have been saying to me, same as I've been saying, 'How could you not know you was pregnant?'" she said.

Ontario cartoonist Lynn Johnston, whose newspaper comic strip For Better or For Worse has achieved international fame, designed a thank you card (left) that medical students can give to patients who submit to being reexamined for educational purposes. Inside, an Osler-inspired message reads, "We are taught that medicine is learned by the bedside, not in the classroom. Thank you for being a teacher." Ms Johnston worked as a illustrator at the medical school in the 1960s. [] "You tend to think that people have forgotten you, but then you're just warmed all over to know you still belong," she said of being asked to contribute to a McMaster project so many years later. "While pregnant with her first child," reported the Hamilton Spectator, "Johnston's obstetrician, one of the medical school's founders Dr. Murray Enkin, challenged her to create cartoons for his ceiling that his patients could read during exams. Those cartoons were published as David, We're Pregnant, which went on to sell 300,000 copies."

Canada's universal healthcare model is no guarantee of equitable medical care for the poor, said a new University of British Columbia study in PLoS ONE. "Despite public health care access, CAD [coronary artery disease] patients who reside in lower-socioeconomic neighbourhoods show increased vulnerability to non-cardiovascular chronic disease mortality, particularly in the domain of cancer. These findings prompt further research exploring mechanisms of neighbourhood effects on health, and ways they may be ameliorated," wrote the researchers. Oddly, deaths from cardiovascular disease didn't vary between people of different socioeconomic statuses [SES], but deaths from other chronic diseases -- especially cancer -- did. Very much so. "For each quintile increase in neighbourhood SES deprivation, estimated risks for non-CAD chronic disease deaths increased between 21-30%, leading to an average 2.4-fold increase between highest and lowest neighbourhood SES quintiles. Although the number of cancer deaths were small, profound effects were observed for rates of cancer mortality; estimated risks for cancer death increased 42% and 62% for each quintile decrease in neighbourhood SES family income and employment, respectively." []

Melanoma rates rose 3.1% per year between 1994 and 2004, reported American researchers in the Journal of Investigate Dermatology. "Because the incidence has gone up for both men and women of all social groups and across all levels of cancer thickness, we believe this represents a genuine increase in melanoma cases, not just a sign of better screening," lead author Dr Eleni Linos said. The research also exposed the barrier that poverty poses to early detection and treatment of melanoma.

Former Quebec Health Minister Dr Philippe Couillard was appointed Senior Fellow in Health Law at McGill University, a position affiliated with both the faculties of medicine and law. [] You can't do much better than hiring as a health law researcher the very man who was responsible for the last five years of health law in the province. This is Dr Couillard's second new gig since leaving government. In the fall, he took on a job with a healthcare-industry investment firm in Montreal.

The University of Alberta is starting a new research centre to study nanoparticles' effect on the environment, to be headed by biologist Greg Goss. "We know that history is filled with things that are produced en masse and integrated into our system," Dr Goss told the Canadian Press. "Most are non-toxic but every now and then we'll have PCBs. With nanotech, we have the first chance to actually get in on the ground floor with the new manufacturers (and ask), 'Can we be green in our approach toward integrating new materials into our lives?'"

Clioquinol, an old drug for gastrointestinal problems, may help treat neurodegenerative disorders like Alzheimer's and Parkinson's, a new study from McGill University suggested. "The danger [of publishing this research] is that you can buy a kilogram of this compound at a chemical wholesaler, but we don't want people to start experimenting on themselves," warned researcher Siegfried Hekimi. "Clioquinol can be a very toxic substance if abused, and far more research is required." []

Black women are getting shorter. Recent data hint at a reason: 51.6% of black American women from age 20 to 74 are obese.

Another year, another Norwalk virus outbreak in the Maritimes. So far, only a handful of cases have been identified in PEI, but more are suspected.

The Society of Obstetricians and Gynecologists of Canada have revised their guidelines for women who miss a dose of their hormonal contraception. [ (PDF)]

Asking an epileptic child's parents about the child's quality of life doesn't necessarily get doctors an accurate picture of reality, a new McMaster University and University of Toronto study showed. The study, published online earlier this week in Epilepsy & Behavior, demonsrated "parent perspectives alone are insufficient to measure their child’s QOL."

As the economy continues to struggle, a new study reported that Saskatchewan farmers' health is increasingly at risk because they're losing sleep over their financial problems.

Toronto General Hospital's disclosure that poorly designed sinks were at fault for the spread of Pseudomonas aeruginosa, which led to the death of 12 people, has sparked a lawsuit against the hospital. University Health Network CEO Dr Bob Bell said, "It would be terrible if hospital leaders were to be gagged as to reporting risk to patients." [] Read more about the hospital's announcement last month in Canadian Medicine.

Sault Ste Marie Mayor John Rowswell will bring his complaint that "Northern Ontario residents are needlessly dying because they don’t get the same level of health care as (is) offered in the rest of the province" to federal Health Minister Leona Aglukkaq.

A UBC study published online ahead of print in the journal Sexually Transmitted Diseases proved the effectiveness of universal screening for chlamydia in a female Canadian aboriginal population in the Arctic.

In a finding contrary to what they had assumed, Quebec and Alberta researchers discovered that expert skiers and snowboarders are actually at an 88% greater risk of being severely injured on the slopes than beginners.

Breast cancer survivors who stay active are about half as likely to die of breast cancer as survivors who do not exercise regularly, reported scientists with the Alberta Cancer Board's Division of Population Health.

A University of Manitoba study to measured the effects of a program in Mysore, India, to reduce the sexual risk of female sex workers found the intervention increased condom use significantly, especially with occasional clients, and halved sexually transmitted disease prevalence. The program was intended to prevent HIV transmission, and the researchers wrote that recent HIV infections seemed to have been successfully decreased.

Children of mothers who smoked during pregnancy are more aggressive, reported a new University of Montreal study in the journal Development and Psychopathology. "The fact that we... see it [violent behaviour] in very young children is a sign that cigarette smoking is not a good thing. During pregnancy, it's not a good thing," study co-author Dr Jean Séguin told The Globe and Mail. "It affects the nervous system of the children in many ways, and this is one of them. It makes the kid harder to manage."

Two Canadians and one American co-published an essay in The Lancet arguing against the US Food and Drug Administration's administration this past fall to cease relying on the Declaration of Helsinki's medical research ethics guidelines and to instead require the less stringent ethics practices of the International Conference on Harmonization's Guideline for Good Clinical Practice. Among the ethical safeguards mandated by the Helsinki Declaration that could now potentially be done away with are rules requiring:

• Investigators to disclose funding, sponsors, and other potential conflicts of interest to both research ethics committees and study participants
• Study design to be disclosed publicly (eg, in clinical trial registries)
• Research, notably that in developing countries, to benefit and be responsive to health needs of populations in which it is done
• Restricted use of placebo controls in approval process for new drugs and in research done in developing countries
• Post-trial access to treatment
• Authors to report results accurately, and publish or make public negative findings

The authors appealed to President-elect Barack Obama to intervene. "In view of these concerns, we suggest the new US administration suspend this rule pending a review of the implications for US-sponsored research overseas. If such review confirms our concerns, the FDA should be directed to rejoin the international community in requiring that studies be done in accordance with the Declaration of Helsinki."

The Globe and Mail's Celia Milne takes a look at the dangers of transplant tourism.

Canadian musician Leslie Feist donated 100% of her band's merchandise profits from 2008 -- a total of over $200,000 -- to charities including Médecins sans frontières Canada, CARE Canada, War Child Canada, and The Salvation Army's Howard Hospital, in rural Zimbabwe, which is run by Canadian expatriate physician Paul Thistle. I wrote about Dr Thistle's work in Zimbabwe last year.

Ontario Heart and Stroke Foundation CEO Rocco Rossi will be named national director of the Liberal Party of Canada, reported The Globe and Mail.

The Canadian Medical Association is attempting to negotiate better payments for doctors to fill out third-party forms, in particular the much-maligned, lengthy Canada Pension Plan medical claims documentation, the completion of which only pays doctors $65. [CMA News]

Edmonton emergency physician Louis Francescutti would like to see Alberta implement a soft-drink tax as New York Governor David Paterson has proposed there. "We allow [patients] to be unhealthy and then when they get sick we pay for their health care," he said. "There is absolutely no incentive for anyone to go and be healthy because if you need a heart transplant, they'll give it to you for free. You can become an alcoholic and we'll fix you up." But he's not optimistic about the idea. "Would Albertans go for something like this? I don't think so. Would our politicians go for something like this? I definitely don't think so."

Health reporter Charlie Fidelman lists some of the things patients should not bring to the emergency room with them: dirty diapers, live scorpions, bloody tissues and sex toys (assuming they're not stuck somewhere).

Diabetic patients performed significantly worse than non-diabetics on a series of brain-function tests, a new University of Alberta study found. [ (PDF)]

Merck has, as promised, finally submitted its request to the US Food and Drug Administration to approve its human papillomavirus (HPV) vaccine Gardasil for use in boys. Recently, we analyzed some of the recent research on the vaccine in boys. [Canadian Medicine]

The oldest person in the world, Maria de Jesus, of Portugal, died at the age of 115. Born in 1893, Ms de Jesus didn't attend school, was illiterate, had six children, and never "fell ill, nor took any medication," her daughter said.

Schering Plough researchers have created a new, artificial binding molecule to treat blood poisoning and overdoses and eliminate anesthetic medications from the bloodstream.

US President-elect Barack Obama offered the job of Surgeon General to neurosurgeon and CNN reporter Sanjay Gupta. No word yet on whether Dr Gupta plans to accept. The Post's Ben Pershing teased, "He narrowly beat out Dr. Phil for the post. (The joke was just sitting there, waiting for someone to make it.)" In an interview last year with the Canadian news magazine the National Review of Medicine Dr Gupta said he hoped some form of universal healthcare would be implemented. "There are a lot of pluses to Canada's healthcare system. The biggest plus -- besides the fact that people have healthcare insurance -- is that there's a certain amount of psychological well-being, feeling safe just from knowing that you're going to be taken care of if something bad happens to you. Unfortunately, in the US people don't have that." Asked if he would consider entering politics, he said, "I don't know if I'd ever want to run for electoral office, but I can see myself one day in a position where I can do something with health policy. I've always been interested in health policy. I think the way we take care of other people is a reflection of our society."

Dr Raj Sherman (right), a rookie representative in Alberta's legislature after putting in years as an emergency physician, was voted the sexiest male member of the Alberta government. "Geez, they all think I'm just a hunk of meat," he told the Edmonton Journal. "My doctor colleagues are all going to say, 'What are you doing over at the legislature?'" Dr Sherman added that he's not hitched. "Single dads need all the help they can get." Health Minister Ron Liepert was voted the rudest member of the legislature.

New Brunswick Health Minister Michael Murphy plans to introduce legislation this year to allow private health clinics to do business in the province. "Publicly-funded health care is going to prevail, but that doesn't mean that every piece of equipment will be owned by the public nor every particular person treating you will be employed by the public sector," he told CBC News.

The inquiry into last year's deadly listeriosis outbreak still has no lead investigator, as the clock counts down to the March 15 reporting deadline promised by the government. Maclean's columnist Paul Wells couldn't contain his outrage at reading the story. He called the government's failure to move ahead with an investigation evidence of our lack of a coherent government, proof that we are a "failing state." "Canada," wrote Mr Wells, "has become a more genteel Somalia."

The looming Obama-led movement to reform the health insurance industry in the United States could drain doctors away from Canada, according to Dr Fred Ralston, the chair of the American College of Physicians's Health and Public Policy Committee. If the US expands government-run health insurance, the demand for primary care physicians will rise. Therefore, incentives could potentially be implemented to lure GPs south of the border. "If you don't make parallel moves, that could really cause problems," Dr Ralston told the National Post. "That's something that could definitely impact on our resources," College of Family Physicians of Canada President Dr Sarah Kredentser said.

McMaster researchers announced the discovery of a method to distinguish between "good" and "bad" -- or cancerous -- stem cells.

New data from the Alzheimer Society of Canada projected a doubling of the Canadian prevalence of dementia within the next 25 years.

Simon Fraser health professor Robert Hogg discussed the new Canadian Observational Cohort, the first national effort to comprehensively evaluate the Canadian experience with anti-retroviral therapy for HIV/AIDS.

More than half of patients with REM sleep disorders will develop a neurodegenerative disease within 12 years, a McGill University study found. []

Here's an ethical conundrum for you. A joint Indian and American team of researchers found that while giving breastfeeding HIV-positive mothers daily doses of nevirapine reduces the likelihood of HIV transmission to the infant, giving the drug also raises the chances that the transmissions that do occur will be drug-resistant strains of HIV. "[T]he value of preventing HIV infection in a large number of infants should be considered alongside the high risk of resistance associated with extended NVP prophylaxis," the authors wrote in an ominous-sounding wording, before going on to reassure readers that "Given the high mortality associated with pediatric HIV infection in the first year of life, the complexities of early infant diagnosis, and limited resources for initiating HAART in infants in settings where breastfeeding itself is critical for survival, the primary goal should be to prevent peripartum and breast-milk transmission with infant antiretroviral prophylaxis. As other prevention options become available, this increased risk could be revisited."

Two American lawyers who specialize in defending pharma companies complained that Canada's judges grant too many class action suits. "[W]e were startled by what we heard about Canadian class action law at the ACI conference in New York City last month. One speaker said that, to date, no Canadian court has ever denied a motion to certify a class in a drug or device case."

Alberta is fast-tracking foreign-trained physicians to become paramedics here, offering them a six-month-long training program instead of the regular two-year one. It's the first such initiative in Canada. "This is a wonderful opportunity for me," Bangladeshi émigré Dr Omor Bhuiyan told the Edmonton Journal. "I thought the emergency medical system was a good system and I thought that would satisfy my ego as a doctor."

The registrar of the College of Physicians and Surgeons of Alberta has endorsed the provincial government's plan to expand paramedics' scope of practice by allowing them to decide whether patients need to be hospitalized or not. "The idea is right in that there is a small proportion of patients who are going to emergency departments -- in Calgary in particular -- because they can't get in to see a family doctor," Dr Trevor Theman told the Calgary Sun. "If paramedics can help those patients get care in some other way and take the burden off the emergency department, then that's a good thing."

Monique Bégin, the Liberal health minister who co-wrote the Canada Health Act of 1984, now wants to retract some of her past paeans to Canada as a social-democratic paradise. Inequality in housing and education has led to major negative health consequences for Canadians, she told Canwest. “Canada’s the least bad of the Americas, but it’s not Sweden by a long shot,” she said.

Governor General Michaëlle Jean kept busy over the holidays, naming 60 new appointments to the Order of Canada. Governor General news release The health sector was very well represented, with honourees including Dr Paul Garfinkel, the president/CEO of Toronto's Centre for Addiction and Mental Health , as well as Canadian Mental Health Commissioner Michael Kirby ; Windsor, Ontario, neuropsychologist and professor Byron Rourke ; cardiac surgeon Arvind Koshal ; Winnipeg radiology researcher and professor Ian C. P. Smith, who heads the National Research Council's Institute for Biodiagnostics ; Ontario patient safety chief Dr Michael Baker [ ; Ontario Hospital Association governor David A. Brown; Max Cynader, the director of UBC's Brain Research Centre; retired BC physician, coroner and Lyme disease activist LaVernre Kindree ; Dr John F. Lewis, of Newfoundland; UBC pediatric rheumatologist Ross Petty; Donald Storch, the former chair of the Canadian branch of the Victorian Order of Nurses ; Montreal cardiology researcher Dr Pierre Théroux; and former International Liver Transplantation Society president Dr Bill Wall, of London, Ontario.

We know that smoking is bad for you. We know that second-hand smoke is bad, too. But now third-hand smoke is here. Third-hand smoke is defined as the contaminants and toxins that stick to hair and clothes and can be spread to places where no one has been smoking. Most smokers, however, don't believe that third-hand smoke is harmful.

Dr Arya Sharma's predictions for obesity medicine in 2009. []

Dr Liana's medicine-themed road-trip game.