Food insecurity and Facebook

Things that usually clutter facebook newsfeeds: cat videos, instagram pics and party invitations. And increasingly, at least in Nunavut’s capital city, caribou carcasses.

In a startling shift away from the long-rooted Inuit custom of sharing food among families, a growing number of opportunistic northerners are instead using facebook to sell their traditional food.

 Iqaluit Sell/Swap, an open group on the popular social networking site, serves primarily as a convenient place to auction off old children’s clothes or fix-er-up cars. But lately, some members have been offering up bounty from their latest hunting trip such as caribou or arctic char – for a price.

 It’s an avarice born of desperation.

 Warmer winters have led to unpredictable and dangerous ice conditions, taking their toll on traditional hunting. For Inuit who don’t have the money to supplement the shortages with store-bought food this means long months of never-full stomachs and mental stress.
The winter of 2010/2011 was particularly hard. McGill graduate student Sara Statham, 24, wanted to find out how vulnerable the climatic changes (freeze-up came about two months later than average) would leave the impoverished neighbourhoods in Iqaluit. At the International Polar Year conference in Montreal this week, Statham presented her findings.

In addition to the strained sharing networks – which is the Inuit’s traditional way of dealing with food shortages – she discovered that 54 percent of publicly-owned households did not have enough money to buy store food and could not get country food. Previously, only 46 percent of households had reported the same.

“One week… we had no food. We only had one dried noodle pack for 4 people. We can’t live like that,” Statham recalls the mother of one young Inuit family telling her. However, Statham said she found that while environmental changes had some impact on the vulnerability of Iqaluit’s poor, there were larger socio-economic issues that were affecting food insecurity.
Food and water insecurity have been highlighted at the conference as one of the major issues facing northern communities.
Previously published on Canadian Geographic’s blog; April 27, 2012

Hospitals reuse medical devices to save cash

In a bid to save cash and reduce landfill use, New Brunswick’s largest health network has started reusing medical equipment originally meant to be trashed after first use.

The process though, is completely safe, Nancy Parker said. She is the administrative director for the surgery program at the Moncton hospital.

In the past few months, the Moncton hospital has piloted the initiative, which entered the planning stages about a year ago, she said.

“Patient safety is certainly a priority … we’re confident that every measure and precaution is being taken to lessen any risks for patients.”

The single-use medical equipment, which had been originally labelled as such by the manufacturer, is sent to certified reprocessing companies in the United States. The practice is stringently regulated by the Food and Drug Administration.

“Reprocessing” means taking all the necessary steps to ensure the device is safe and ready for another patient. This could include cleaning and sterilizing, functional testing, repackaging and relabelling. The companies are held to the same standards as the manufacturers, Parker said.

The hospital can then buy back the items at a fraction of the original cost – from 30 to 50 per cent less. When a hospital is stocking up on $5,000 ultrasound catheters, the difference can be substantial. The savings can be upward of $100,000 for a single hospital, Parks said.

An added perk, she said, is the “greening effect” of less medical waste gets tossed into landfills.

Other hospitals in the provincial Horizon Health Network will soon be jumping on board and, as far as she knows, Vitalité Health Network has also been working towards third-party reprocessing, Parks said.

Canada has no federal regulation when it comes to reprocessing single-use devices. But some provinces create their own policies. New Brunswick Health did this almost four years ago, when the department sent a bulletin to all of the hospitals in the province indicating they had a year to change their practices.

The new policy, which still stands today, states that only “non-critical” single-use devices can be reprocessed in-house. Hospitals can only reuse a device that has been cleaned at that hospital if it has not been inserted in a body. One example, Parker said, is a compression sleeve, which is fastened around an arm or leg to increase blood flow.

It is the critical and semi-critical single-use items – such as surgical saw blades or the pricey ultrasound catheter – that they must send to third parties for appropriate care.

Until there is Canada-wide regulation, New Brunswick will keep this policy, said Tracey Burkhardt, a communications officer for New Brunswick Health.

A report released in 2008 by the Canadian Agency for Drugs and Technologies in Health, stated that New Brunswick hospitals held the Canadian record for most widespread single-use item reprocessing, at 57 per cent. In comparison, the national average was just over 25 per cent, the agency stated.

Parker said she doubts that statistic still holds true today.

Reusing medical devices labelled as single-use by manufacturers is a common practice in hospitals all over the world. Most of the hospitals in Spain and Japan do it (80 per cent and 80 to 90 per cent, respectively), according to a 2010 report in the International Journal of Hygiene and Environmental Science.

Advocates say it is safe if done properly and is good for both the environment and hospital budgets, but there is still controversy surrounding the ethics of it, the journal stated.

Previously published Aug 2, 2011; Telegraph-Journal

NB med school top of its class

It may just be a year old, but New Brunswick’s medical school already has some of the most advanced technology on the continent. Or at least they’re using it in a most advanced fashion.

As per the usual classroom setting, a professor delivers a lecture and students take notes, ask questions which the professor then tries to answer. The thing is, more than 400 kilometres separate pupil and teacher.

The school is being hosted at the University of New Brunswick’s Saint John campus, but is actually an expansion of the medical school in Halifax, and is formally called Dalhousie Medicine New Brunswick. The goal is to give New Brunswick students an opportunity to learn medicine in their own province, but without sacrificing quality of education. By using the high-definition video-conferencing equipment, students get the exact same education as their colleagues in Nova Scotia.

And now they’ve installed the equipment at four hospitals across the province so students completing their clerkship can be equally linked to their peers.

“It’s just a real tremendous improvement,” Pamela Bourque, Dalhousie Medicine New Brunswick’s program manager, said of the new installations, which took place in June. The four hospitals are located in Saint John, Fredericton, Miramichi and Moncton.

Each video-conferencing classroom is identical, with grey walls and light grey wall-hangings, medium brown tables, pleasant lighting and carpets with a grey-toned, geometric design. This way, the two parties feel more like they’re in the same room. At the front of the room are three large flat screens. During class, one displays the professor, the second the material, and the third screen shows the other students sitting in Halifax.

Sheldon Wood is going into his second year – or M2 – at the Saint John location. After next year, Wood will start his clerkship at a New Brunswick hospital, where he will be able to take advantage of the new equipment expansion. He admits that he was at first skeptical about not having the professor in front of him, but said he didn’t notice a difference. He said there is no noticeable time gap between a student asking a question in Saint John and a professor responding in Halifax – the broadcast transmission is that instantaneous.

The professor can even see the student, thanks to a table buzzer. There’s one for every two student seats, and when pressed, a camera at the front of the room swivels to point there and the student appears on the screen in front of the professor.

Representatives from other medical schools across the country have already visited Saint John to see and possibly copy the set-up. Ken Lerette is the technical operations manager at Dalhousie Medicine New Brunswick and said they’ve given tours to representatives from the University of Toronto and even Saudi Arabia.

The pilot year passed virtually flawlessly, Bourque said. She estimates that if you added up all the time that was used to fix technological problems, they probably only lost about 17 minutes of class time, over five incidents. Two impressive, futuristic central command centres in Saint John and Halifax handle all the troubleshooting and maintenance.

While similar video-conferencing equipment has been used for long-distance education, this is the most advanced system for medical education.

Previously published July 25, 2011; Telegraph-Journal

Canada lags in drug return, reuse and recycling

Drug recycling seems a more elegant solution than simply flushing pharmaceuticals down the toilet to work their way into watersheds, various flora or fauna and eventually back into the human food chain.

In fact, 38 of the United States have now accepted that rationale and adopted some manner of drug recycling or redistribution programs for the estimated 3%–7% of pharmaceutical products that go unused because patients are cured, die or, for reasons such as undesirable side effects, discontinue their medications.

The US programs vary in scope, inclusivity and restrictions. Some accept drug donations from patients or family members of the deceased. Others limit donations to health facilities. Some accept only cancer drugs while others accept all prescription drugs or all unused medications. As a general rule, though, the intent is to redistribute unused drugs to needy people who simply cannot afford them.

In Canada, by contrast, there are only a few fledgling efforts to recycle drugs and a raft of regulatory or legislative obstacles to creating such programs. But it appears that Dr. Jeff Turnbull, one of the founders of the Ottawa, Ontario-based Inner City Health Project and the president-elect of the Canadian Medical Association, has managed to sidestep the obstacles with a program for the homeless, while Nova Scotia oncologist Dr. Ronald McCormick hopes to soon establish a pilot project for recycling cancer drugs.

“There still seems to be a ludicrous waste of drugs, particularly drugs that are well-documented in terms of the safety of them,” says McCormick, medical director of the Cape Breton Cancer Centre in Sydney, Nova Scotia. “It’s crazy.”

But the fact remains that all provinces have some manner of legislation or regulation that prohibits redispensing of previously prescribed drugs, typically on the grounds of safety. In the US, some states distinguish between drugs that are donated by individuals (and thus supposedly more prone to tampering) and those donated by health facilities, practitioners, pharmaceutical firms, pharmacies or representatives of various medical facilities.

Turnbull tapped that distinction by establishing a program within the Inner City Health Project to dispense, to the homeless, unused prescription drugs donated by pharmacies or hospitals. Overstocked medical facilities donate excess supply, which is then examined by a pharmacist and approved for redistribution, Turnbull says.

MacCormick hopes to soon obtain legislative approval for a similar program. To that end, he recently established a partnership with a local community development group, New Dawn, that will seek to persuade facilities such as nursing homes to donate drugs, a pharmacy to monitor the incoming drugs and social workers to identify patients in need. Donations from private individuals will be precluded because some drugs require special care, he says.

There’s no doubt there’s a broader public benefit to such a program, says MacCormick. He and other proponents argue that recycling drugs would help to ensure that lower-income Canadians who can’t afford third party insurance have access to expensive cancer therapies. In the US, many of the programs were established as means of alleviating the cost of treating uninsured people in emergency rooms or clinics, which is essentially a moot point in Canada because drugs used in emergency departments are generally covered by Medicare. But a recycling program in Canada could help to alleviate the cost of catastrophic drug coverage programs, which most provinces now have some form of to assist people hit with extraordinary pharmaceutical bills.

Objections to recycling programs have largely been based on the argument that patient safety, and the profit margins of the pharmaceutical industry, would be compromised.

In the US, some programs prohibit donations from individuals in the interests of ensuring that the drugs have not been adulterated. Others allow individual donations but have various requirements regarding packaging, as well as various mechanisms for examining drugs after they’ve been donated. Some states allow recycled drugs to be dispensed directly to patients, while others funnel the donations to authorized pharmacies or medical facilities.

There’s been no evidence that safety has been compromised in the roughly three years that the Iowa Prescription Drug Corporation has been distributing recycled drugs to eligible medical facilities or to uninsured, underinsured or impoverished patients, says David Fries, executive director of the nonprofit corporation.

Nor does it appear that such programs constitute an enormous threat to profit margins. In Iowa, for example, roughly $US1 million worth of drugs were recycled in 2009, which would barely register on the bottom lines of Big Pharma, Fries says.

The pharmaceutical industry’s financial concerns have to be weighed against the reality that most recipients of recycled drugs wouldn’t be able to afford the drugs in the first place, Mac-Cormick notes.

He adds that the industry would also risk public approbation by opposing drug recycling programs. De facto, they’d be saying: “‘Yeah our drug works; we just don’t want anyone to have it who would get it for free.’ No one would say that, I don’t think.”

Not all firms appear opposed. Francesco Bellini, chairman of the Laval, Quebec-based pharmaceutical firm Bellus Health Inc., for example, calls it “a noble idea.”

First published Feb. 8, 2010; Canadian Medical Association Journal

To mandatory nap or not to mandatory nap

It’s safe to conclude that most people would not take issue with a requirement that they take a nap at some point during their workday. The United States Institute of Medicine even urges that a five-hour snooze should be made mandatory for all medical interns and residents who are putting in 16-hour shifts.

The Canadian Association of Interns and Residents, though, isn’t convinced of the value of mandatory naps. In fact, Executive Director Cheryl Pellerin says that if naps are added into contracts, they could interfere with a resident’s training — he or she might miss a procedure vital to a good education.

Mandatory naps are among options being bandied about in response to growing concerns that lengthy shifts for interns and residents compromises the safety of patients. While many jurisdictions are still exploring alternatives, the European Union has adopted a maximum 48-hour workweek as its solution to the problem (CMAJ 2009. DOI:1503/cmaj.109-3111).

The US Institute of Medicine waded into the debate with a recommendation that every resident or intern should be obliged to nap for five hours — at some point between 10 pm and 8 am — for every 16 hours they work. During the nap, there should be no interruptions or pages, the institute says in its report,Resident Duty Hours: Enhancing Sleep, Supervision, and Safety(http://books.nap.edu/openbook.php?record_id=12508).

While interns and residents in Europe are now limited to 48 hours of work per week, the situation in the US and Canada is less stringent. In 2003, the Accreditation Council for Graduate Medical Education capped the hours a US intern or resident could work at an average of 80 hours per week over four weeks. In Canada, while regulations vary from province to province, an intern or resident generally works no more than 60 to 80 hours per week. Only three provinces have maximum weekly hours built into their legal contracts; Manitoba’s regulations are the highest at 79 hours.

Mandatory naps would be “kind of difficult to institute,” says Dr. Roona Sinha, past president of the Canadian Association of Interns and Residents. “What matters more is trying to make the person functional the day after.”

Shorter shifts and more rest hours after long shifts would be preferable to mandatory naps, Sinha adds.

Pellerin concurs, saying that more effective handovers of patients as shifts change would be more significant that midshift naps. An association working committee on postgraduate medical education is currently investigating the best ways to structure handovers so that the incoming physician or resident is well informed about the patient, so that fewer mistakes are made. That review is expected to be completed early this year. While most of the concern about lengthy working hours has been focused on interns and residents, some say the scope of concern must be extended to include all physicians and surgeons.

People are wary about limiting the hours worked by physicians and surgeons but it’s something that needs to be addressed, says Dr. Derek Puddester, director of the faculty wellness program at the University of Ottawa and coeditor of the Royal College of Physicians and Surgeons of Canada’s CanMEDS Physician Health Guide.

Younger physicians aren’t inclined to toil as many hours as their older counterparts, Puddester says, adding that the younger generation has been socialized to value work–life balance, so as they move up and become practising physicians, that ethic will likely be a condition of employment. As a consequence, he predicts limits on weekly work hours will be introduced within the next five to seven years for most doctors.

Cheryl Ulmer, coeditor of the Institute of Medicine report, concurs. “Doctors are human too,” she says.

But others, such as Dr. Thomas Nasca, chief executive officer for the Accrediation Council for Graduate Medical Education, says capping work hours or introducing mandatory naps for physicians and surgeons isn’t feasible. “Who’s going to take care of the patients while we’re sleeping?”

Nasca adds that the cost would be prohibitive, citing a study that indicates it would cost roughly US$80 billion per year to train the physicians that would be needed if doctors adopted the work-week standards of airline pilots (Am J Surg. 2009;197[6]:820–5). And that doesn’t take into account the notion of continuity, which is integral to effective patient care, he says.

When the Accreditation Council for Graduate Medical Education implemented an 80-hour work week limit for interns and residents in 2003, it promised a review of the guideline after five years.

The results of that review, which included a national duty hours congress, independent literature reviews and consultations with over 140 medical organizations, will be presented in February, Nasca says.

Thus far, it’s clear from the review that the number of duty hours and nap times aren’t as crucial as top-notch supervision, Nasca adds. “This is not an issue of right or wrong, it’s an issue of competing goods.”

First published Jan. 5, 2010; Canadian Medical Association Journal

No safe radiation, expert says

Daniel Rudka looks like he’s a nuclear bomb survivor. Wrinkled, milky scars flow up his arms past his neck and discolour his pockmarked face. He walks with a cane, because he can’t always trust his radiation-weakened bones to keep him upright.

But Rudka is not the victim of a nuclear bomb, accident or meltdown. In fact, he’s never even been involved with any manner of power plant mishap. He simply used to work at a plant in Port Hope, Ontario, that constructs fuel rods for nuclear reactors. But at one point, he spent three weeks scooping powdered uranium with a plastic bucket that might have been obtained from an ice machine, while wearing a T-shirt, coveralls cut off at the bicep and plastic gloves that weren’t lead-lined.

“You didn’t have to bomb me to still have the same effect,” he says.

Whether it comes from nuclear weapons or nuclear power, radiation’s effects on the human body are the same, veteran antinuclear campaigner Dr. Helen Caldicott told a Mar. 26 conference organized by Physicians for Global Survival Canada.

No radiation is safe, the 73-year-old Australian physician and author argued during a “Facing off for Social Justice in a Militarized World” session of the conference, which explored issues ranging from handling radioactive waste to the public health consequences of radiation leaks, such as those now being experienced at the Fukushima Nuclear Plant complex in the wake of the earthquake and tsunami which devastated parts of northern Japan.

Caldicott called radioactive waste one of the major unaddressed problems associated with nuclear reactors.

“There’s no container that can hold radioactive waste for more than a hundred years. Concrete cracks, plastics are no good, and iron disintegrates as it rusts,” she told the conference.

But radon is highly soluble, and once it leaks into the ecosystem, the radiation becomes bio-concentrated as it moves up through the food chain. It is also cumulative, meaning that later generations are more likely to experience the effects.

Caldicott cited Fallujah, Iraq, where it is alleged that the United States and United Kingdom used depleted uranium ammunitions during a 2004 raid, as an example of the long-term consequences. Fallujah’s recorded birth defects have become so prevalent that 80% of babies are born as cyclops, Caldicott said, adding that doctors have told women to stop having children.

Although the International Atomic Energy Agency promotes nuclear reactors as a clean, green and safe solution to the ever-increasing global need for electricity, exalting nuclear reactors, while condemning nuclear weapons is hypocritical, Caldicott added. “They say: ‘You can have a nuclear reactor but you mustn’t build a bomb. We’ve got all the bombs and you can’t have them. But here’s a bomb factory’.”

Caldicott argued that government should take the money spent on nuclear power — $12 billion to $15 billion per reactor — and use it to refit all homes and buildings with solar panels.

Dr. Michael Dworkind, president of Physicians for Global Survival Canada, echoed the call for the elimination of both nuclear reactors and nuclear weapons, saying it would be “the ultimate in preventive medicine.”

The health consequences of radiation poisoning, which have long been demonstrated, can include hair loss, recurring infections, anemia, weight loss and cancer.

Rudka, who worked at the Port Hope plant, then called Zircatec, from 1993 to 1995, says he still periodically vomits in the mornings as his body goes through “stages of decay.”

His is a classic case of the consequences of exposure to radiation and another example of why “nuclear is not the answer,” Caldicott said.

First published April 4, 2011; Canadian Medical Association Journal

One-stop shopping for international medical graduates

International medical graduates will be entitled to apply for a medical licence simultaneously in all provinces under a new national electronic application process that will come into effect in 2012.

The initiative will further streamline and simplify the foreign credentialing process by building on a central electronic repository that was established a few years ago to house information from international medical graduates (IMGs) seeking to work in Canada.

In addition to all but eliminating paper-caused confusion, it will be a “one-stop shop” for IMGs, says Dr. Ian Bowmer, executive director of the Medical Council of Canada. As the application will be online, “it will be more transparent and everybody will know what is required. You won’t have to go to 13 different websites to find out.”

The Medical Council of Canada-and the Federation of Medical Regulatory Authorities of Canada-led initiative is being undertaken with the aid of a $2.8 million contribution from Human Resources and Skills Development Canada’s Foreign Credential Recognition Program.

Currently, physicians must complete a different application for each province or territory to obtain a licence to practise within that jurisdiction. But once this national process comes into effect in late 2012, the same form will be used to apply to multiple regulatory authorities.

License applications to a province will include online access to an applicant’s resumés, which will be housed in the Medical Council of Canada’s Physician Credentials Repository.

An application will also include information about examinations and certifications required by a particular provincial licensing body, so IMGs can readily determine whether applications contain all the requisite components.

The new process will not replace the Medical Council of Canada evaluating exam or two-part qualifying exam needed to obtain a licentiate from the council — a prerequisite for Canadian licensure — and each province and territory will still control its own requirements for awarding full certification.

Nor will it reduce the significant expenses that IMGs incur to become licensed. For example, taking the evaluative exam alone costs $1500.

“The savings for IMGs coming to Canada will be through more simplicity, more understanding of the system,” says Dr. Bill Lowe, president of the Federation of Medical Regulatory Authorities of Canada.

Lowe adds that it’s hoped over the course of the coming two and a half years, regulatory authorities from each of the provinces and territories will be able to collaboratively produce a pan-Canadian application process for medical licensure which will satisfy all the licensing bodies.

But while some internationally-trained physicians say that creating a simpler application process would be “great,” they suggest that the monies might be better spent on creating more positions for IMGs. An IMG has fewer opportunities to become an intern or get a job because most positions are set aside for graduates of Canadian medical schools, says Dr. Monica Herrera, president of the Association of International Medical Doctors of British Columbia.

“Right now, it doesn’t matter how much you try, doesn’t matter if you pass everything, you may not get it at the end,” says Herrera, who was born in Chile and practised many years in Colombia before immigrating to Canada in 2003.

While the initial goal of the initiative is to simplify the application process for internationally-trained physicians, Lowe says the long-term objective is to make it easier for physicians to obtain their licences in other provinces and territories.

When the Federation of Medical Regulatory Authorities of Canada and its members became aware that some sections of a soon-to-be-finalized agreement on interprovincial trade would enable licensed physicians to relocate in other provinces or territories without further examination or assessment, they realized they needed a consensus on qualifications for pan-Canadian medical licensure, Lowe explains.

Another added benefit is that the Medical Council of Canada’s credential repository will eliminate the need to repeatedly supply original documents, Lowe says, recalling the case of one doctor who had to bring in his coffee table to Nova Scotia authorities to verify his medical certificate because he’d laminated the document to its surface.

First published Sept. 13, 2010; Canadian Medical Association Journal