Baseball’s Elbow Problem

By James Colapinto

Credit to Wikimedia Commons.

Matt Harvey

It’s August 24th, 2013, and Matt Harvey is having an off night.

Over the 2013 season, Harvey has distinguished himself as one of the best pitchers in baseball. Amid an otherwise dismal season for the New York Mets, the 24 year-old has become the brightest young hope for the team. He will finish the season with the 3rd lowest earned run average (a rough measurement of the number of runs a pitcher allows his opponents to score) in the majors. Less than three weeks ago, he pitched a “complete game shutout”–throwing an entire 9-inning game without allowing the opposing team to score a single run. Mets fans eagerly look to him as a key prospect for their team’s future. Today though, he struggles, giving up 13 hits in a 3-0 loss to the Detroit Tigers. At first, nothing seems too concerning. Interviewed after the game, he reports that he feels “pretty tired”–understandable going into the final month of Major League Baseball’s 6 month-long, 162 game season.

The next day, Harvey reports having some tightness in his forearm. A seemingly innocuous complaint on the surface, it is recognized for its seriousness by the Mets medical team. Harvey is sent for an MRI, which comes back with devastating news: his ulnar collateral ligament (UCL), a triangular bundle of connective tissue fastening the medial epicondyle of the humerus to the proximal end of the ulna, is ruptured. He will not pitch again for 18 months.

The act of overhand throwing, as primitive as it may seem, is an evolutionary innovation as unique to humans as our bipedal locomotion and massive cerebra. The anatomy of the shoulder and arm allows for the throwing of projectiles with both significant velocity and accuracy, and these anatomical features appear 2 million years ago in Homo erectus. No other primates have this capability. Chimpanzees, despite being much stronger than humans, can only manage to throw projectiles around 20 mph. Untrained humans can fairly easily reach 60 mph. The vast majority of professional baseball pitchers can throw a fastball above 90 mph, with some reaching over 100 mph. 

There are risks involved in taking the body to its physiological limits, though. Soft tissue is only so strong, and the elbow undergoes tremendous stress during the act of throwing. The violent and repetitive act of pitching often ends up exceeding the limits of the elbow. In pre-adolescent players, the stress can cause the end of the humerus to fracture. In older players, the breaking point shifts from bone to ligament: specifically, the UCL.

A few weeks after his diagnosis, Harvey underwent one of the most well known procedures in professional sports: ulnar collateral ligament reconstruction. Most know it as “Tommy John surgery”. 

Tommy John and Frank Jobe

John in 1981. Credit to Wikimedia Commons.

On July 17th, 1974, Tommy John of the Los Angeles Dodgers felt a twinge in his arm while pitching during a game. Suddenly, he was unable to throw and his fingers were tingling. The MRI had not been invented yet, but the Dodgers medical team was able to discern that John had ruptured his UCL. At the time, this diagnosis was catastrophic for a pitcher. A few years earlier, the career of legendary Dodgers pitcher Sandy Koufax ended when his UCL gave out. Without the stabilizing force of the ligament, a pitcher’s arm was rendered “dead”.

In response to John’s injury, however, one of the Dodgers’ team physicians, orthopedic surgeon Frank Jobe, proposed a new procedure to recreate the damaged ligament. Jobe would take the tendon of the palmaris longus from John’s right wrist and thread it through holes drilled into John’s left humerus and ulna into a figure-8 pattern. John agreed to the procedure. He spent the entire 1975 season rehabilitating his repaired elbow, and returned to the Dodgers in 1976.

Jobe was cautious, wanting to make sure that the surgery provided long term benefit before attempting it again. After successful surgeries on several more baseball players, as well as a javelin thrower, he became confident in the procedure, publishing his results in the Journal of Bone and Joint Surgery in 1986. Three years later, Tommy John retired after a career spanning 26 seasons. 14 of those seasons came after his UCL reconstruction. The procedure that saved his career would come to be known by his name.

Tommy John surgery has become one of the most common surgeries in sports, both professional and amateur. In 2017, 26% of active major league pitchers were reported to have gone through the procedure at some point in their life. It is well-established as a safe and effective treatment for UCL rupture, and 90-95% of those who receive the procedure return to their sport. It is not unusual to return to pre-injury performance following the procedure, and the reconstructed ligament appears to demonstrate greater durability than the original. This surgery has become so ubiquitous and successful that some parents even seek to have their athlete children receive it preemptively, thinking it will make their child throw faster. In reality, evidence suggests that the surgery reduces throwing velocity, and that preventing injury is a far more pragmatic approach.

In 2014, Frank Jobe passed away at 88 years old. He left behind a remarkable legacy. In World War II, he served as a medical supply sergeant and participated in the Battle of the Bulge. He was a clinical professor of orthopedics at University of Southern California School of Medicine and founded the Biomechanics Laboratory in Los Angeles. And of course, he innovated a medical procedure that revolutionized baseball and continues to rescue the careers of pitchers, like Matt Harvey, to this day. On his medical accomplishments, Jobe mused, “Sometimes it just makes you want to cry watching those guys go on to great things. It really does.”

Current Challenges

Today, Tommy John surgery poses a new problem. With baseball becoming increasingly competitive, rates of UCL reconstruction rose 343% from 2003 to 2014, with the highest increase in the 15-19 year old age group. All of which begs the question: could baseball, from little league through to the majors, be doing more to prevent these injuries rather than relying on an invasive reconstructive surgery that requires over a year of recovery time? While major league pitchers often have tightly controlled pitch counts (not exceeding a certain number of pitches in a game) and rest days, youth baseball leagues often do not have nearly the same restrictions, and often any rules that may be in place are ignored. Little league pitchers are pushed to pitch for longer and more frequently than is safe, and managers can be ignorant of the risks or warning signs of arm injury.

Adding to this problem is a distinct shift toward specialization in youth sports culture. An increasing number of youth athletes are focusing on a single sport from a young age, and dedicating the majority of their physical activity toward participating in and training for that sport. Many youth baseball players join “travel” teams, where they can play as many as 70 games per year for up to 8 consecutive months. This culture of playing and training as much as possible is thought to produce elite athletes, but evidence suggests that young athletes who specialize early have a greater risk of injury than unspecialized athletes, even when correcting for hours of activity per week. Specific to baseball, pitchers who pitch in more than 8 months per year are at increased risk for shoulder and elbow surgery

Increasingly, sports medicine researchers are encouraging unstructured play and participation in a variety of sports to reduce overuse injury. Unfortunately, opportunities for multisport participation appear to be decreasing. Local sports leagues are being displaced by travel teams, which typically involve more specialized players, greater time commitment, and increased financial burden. The displacement of local leagues not only decreases opportunities for youth to participate in multiple sports, but also reduces the options available to families who cannot afford a travel league. Additionally, many school districts in the United States have decreased the time dedicated toward physical education and recess, in favour of increased time in the classroom. These cuts reduce the opportunities for children to diversify their physical activity and try different sports, especially those from lower income households. In order to reverse this trend, youth sports needs a fundamental realignment of ideals, moving away from producing elite athletes for families that can afford the price, and toward creating equitable opportunities that allow children to engage with multiple different sports, regardless of financial status. Until these changes occur, though, Tommy John surgery will continue to be a familiar phrase for baseball players and fans alike.

Author: James Colapinto

James Colapinto completed his B.Sc. in Developmental Biology and M.Sc. in Plant Development at the University of Toronto. He is interested in sports medicine, addiction and mental health advocacy, and classical music. He is an avid Blue Jays fan and mediocre right fielder.

Mental Illness in Ontario: Prevalence, Infrastructure, and Awareness

By Hasan Hawilo

Image credit to ewitsoe on Flickr .

October 6-12, 2019, is the Canadian Alliance on Mental Illness’s Mental Illness Awareness Week (MIAW). This week-long campaign is dedicated to raising awareness and fostering discussion around the topic of mental health. In the spirit of this initiative, it is imperative that we as medical students educate ourselves on this issue that affects our health, as well as the well-being of our friends, families, and future patients. Written by our very own Hasan Hawilo, here is an article that highlights some ideas about mental health and illness care in Ontario.

How Common Is Mental Illness in University? 

According to the World Health Organization (WHO), mental illness represents 14% of the global burden of disease. Though estimates vary, up to one-third of Canadians have their lives disrupted by the negative effects of mental illness each year. Reluctance to seek professional support is common, especially in young men. Furthermore, the lifetime likelihood of a Canadian experiencing mental illness or disorder is now estimated to be as high as one in threeUniversity students are even worse off: almost one in two were so depressed in the last twelve months that they found it difficult to function, and more than one in four report feeling that things were hopeless during the last two weeks. The number of students seeking mental health treatment continues to increase at universities across the country, and the outcry regarding long wait times to access university mental health services is nothing new in Ontario. Those seeking support from the University of Torontothe University of Western Ontariothe University of Waterloo, and McMaster University have reported that their mental health teams are understaffed, ill-equipped, and under-funded. Ultimately, these students are often referred to other mental health specialists in their community – facing the choice between paying out-of-pocket or having their mental illness go untreated. 

Lastly, when it comes to medical professionals, things aren’t any better. Medical students are at an increased risk of being diagnosed with mental illness. Up to two-thirds of physicians may rely on self-treatment as the only form of care for their mental disorder. All of these statistics, taken together, emphasize that mental illness is becoming increasingly prevalent. If you’re dealing, coping, or struggling with mental health challenges, you are not alone. Consider, as an analogy, that your brain and body operate under the same fundamental principles as an engine. When something goes wrong with your car, you don’t second-guess making an appointment with an expert in the field of automotive repairs. If you’re struggling with mental health, it only makes sense to see an expert in the field of mental health. 

This is all to say that if you think you need help, give thought to reaching out to health services in the London and Windsor communities. 

New Healthcare Infrastructure

Put simply, mental health in Canada is expensive and under-resourced. According to a 2013 report by the Mental Health Commission of Canada (MHCC), the direct annual costs of mental illness (including treatment and support services) across the country are $50 billion. Soon after the 2018 provincial elections, the Ford government announced a $1.9 billion investment in mental health funding over the next 10 years. Though this investment represents a $330-million-a-year cut from the previous government’s budget and has been criticized by health advocates in Thunder Bay as disingenuous, funding ultimately represents a step in the right direction. In January 2019, the Ford government announced $633 million in funding dedicated to the development of two new Center for Addiction and Mental Health (CAMH) buildings in Ontario, thereby introducing 235 new inpatient beds. These two additions to the Queen Street West Complex in Toronto are expected to open in 2020.

Bell Let’s Talk: Breaking Down the Stigma?

It is encouraging to note that the social perception of mental illness is not what it once was. Today, 96% of Canadians consider their mental health to be at least as important as their physical health, and 42% of Canadians have discussed mental health concerns with others. These data optimistically suggest that awareness initiatives such as American rapper Logic’s suicide hotline song are having a positive impact on people’s willingness to have frank discussions about their well-being and to seek help. However, social stigma continues to have a profound effect on the experience of mental illness in Canada; the Canadian Association of Mental Health reports that social stigma prevents 40% of Canadians affected by depression and anxiety from pursuing professional help. 

So, what impact do awareness campaigns have on the average consumer? Bell Let’s Talk Day, arguably one of thelargest and most well-known mental health awareness campaigns in the world, has been criticized for its lack of inclusive campaign advertisinglack of substantive discussion around mental health problems, and potential conflicts of interestUniversity of Windsor’s Jasmine Vido does an excellent job of highlighting the public’s ambivalent reaction to the campaign. Unfortunately, there is a lack of rigorous studies evaluating the effects of mental literacy campaigns on the public. Though promising research from other mental health initiatives, both in Canada and abroad, suggests that these mental health awareness strategies encourage patients to reach out for help, it is ultimately difficult to make meaningful and generalizable conclusions about individual campaigns. From a fiscal standpoint, since 2010, Bell’s initiative has raised over $100 million in new funding for mental health. Bell’s intentions are unquestionably profit-oriented, and its mental health campaign doubles as a spectacular marketing tactic – but so what? There are few players in the field of mental health investment. Shouldn’t a for-profit company that represents its shareholders benefit from their social good? Unlike Netflix’s original series 13 Reasons Why, which has been criticized by the Canadian Mental Health Association (CMHA) as a potentially harmful depiction of suicide, Bell Let’s Talk has garnered support from the MHCC. Until we can identify sustainable solutions that better address the complex issue of mental health stigma, Bell Let’s Talk may serve a valuable purpose.

Author: Hasan Hawilo

Hasan Hawilo completed his B.Sc. at McMaster University. He is passionate about grassroots volunteer organizations that address the social determinants of health and excited to learn more about how politics interacts with stakeholder interests to inform healthcare policy.

On fat patients

By: Umangjot Bharaj

There is significant controversy when it comes to physicians commenting on their patients’ weight and lifestyle choices. Not only is weight loss especially difficult to achieve, and even more difficult to sustain; repeatedly telling patients to loose weight often hinders weight loss. Existing in a society that constantly shames and vilifies fatness, and often treats fat people as second-class citizens, fat patients become hypersensitive about their weight and any comments about it. In this context, a physician telling a fat patient to lose weight, when done without nuance and as a cursory addition to management plans, can have a very negative impact on the patient.

The Body Positivity Movement and Physicians

Cue the body positivity movement. Body positivity is essential for the society we live in: it represents and advocates for the idea that our worth is not determined by our size or our health status, and that to discriminate, shame, and vilify people based on their size, is unacceptable. Where body positivity loses its focus, however, is if it suggests that physicians should not tell their patients to lose weight ever.

While I agree that health cannot be defined and constrained to something as simple as body size alone, and that each individual has a right to define health for themselves, I think that physicians still have a right to encourage, motivate, and influence their patients toward healthier habits. HIV patients are stigmatized, but doctors don’t stop encouraging healthy sexual practices to HIV patients. Similarly, fat stigma does not mean that excess weight does not have a correlation with bad health outcomes. Excess weight complicates pregnancies, deliveries, and surgeries in general, making them riskier, and has been linked to many conditions such as metabolic syndrome, sleep apnea, and osteoarthritis of the knees. Thus, to suggest that a physician never comment on weight as a relevant factor in causing or exacerbating a patient’s condition is too simplistic and does fat patients a disservice.

It is however, important to accept that physicians are in a unique place to comment on the lifestyle choices of an individual. As a society, we don’t comment on people who choose to smoke, but as physicians(-to-be), it is our role to influence and motivate our patients toward healthier habits. Similarly, physicians have a responsibility toward their fat patients to talk about healthier life choices if they, in their clinical judgement, think that a patient’s weight or health is being affected by their lifestyle choices.

This is not to say that doctors have done no wrong to their fat patients. Research indicates that primary care providers do not build rapport and emotional bonds as strongly with their fat patients as they would with their non-fat patients. Another study found that physicians are more likely to prescribe more tests while spending less time with the patients themselves. There is a tendency to blame patients’ weight for all of their symptoms and in the process not recognizing other diagnoses or undertreating the other recognized diagnoses. Often, weight loss is prescribed as the treatment for all of their symptoms, even though patients would benefit from other medical interventions for their comorbid conditions.

A Patient’s Experience

One patient experience can illustrate what patients face when they go to see their doctor. This patient recounts myriad experiences of mistreatment and discrimination from health care providers: from being told that it was not possible for her to have a normal blood pressure (and having it re-taken 4 times), to being told to lose weight as a remedy for her anxiety and even her ear infection. There are even examples of doctors putting weight limits on patients they would accept: more than 250lbs and you wouldn’t be accepted by certain OBGYN. Fat patients recount experiences where doctors wouldn’t touch them, wouldn’t examine them, wouldn’t ask questions, or would refuse to order tests, refer to specialists, or write prescriptions.

These factors significantly complicate the discussion surrounding weight loss reduction. However, these are not reasons to justify that discussing weight reduction is always detrimental. Instead, they are reasons to introduce the idea of discretion and nuance in handling sensitive conversations such as those surrounding weight reduction.

In caring so deeply about our patients’ physical health, we cannot forget about their mental well-being and sanity, especially because the two are so interconnected and intertwined. For patients’ that live in a society that constantly reminds them that their weight makes them inadequate, physicians reiterating that only reinforces a vicious cycle of self-loathing, fuelling feelings of worthlessness. In patients that are battling mental health issues such as depression, anxiety, eating disorders, and substance abuse disorders, feelings of worthlessness and self-loathing can fuel into and exacerbate their mental health conditions. Perhaps most disturbing is that it discourages patients from seeking health care services at all.

Moving Forward Together

Weight loss discussions are discussions that need to happen in the context of a longitudinal relationship, or in the context where the support of a longitudinal relationship is possible. As well, these discussions require participation from the patient, and should empower and give control back to patients who likely feel disenfranchised by their inability to lose weight. There needs to be discretion as to when and how to approach the subject. This means that if a lot of times you have to ignore your patient’s weight problem because it’s not the right time or setting, then so be it. Finally, these discussions must take into account that simply prescribing patients with lifestyle changes often underestimates the influence of other contextual factors that can impact weight loss.

There is some discussion from practicing physicians about the need to reframe the conversation: instead of being preoccupied by a patient’s weight, physicians can simply encourage all patients to develop healthy lifestyle habits and behaviours. There is research to support this as well. In one study comparing the effectiveness of a weight-normative approach to a weight-inclusive approach, the latter was found to be much more effective and have better health outcomes in all domains, ranging from physical to behavioural to psychological.

Part of the challenge of being an effective physician is the art of difficult conversations. Running away from a conversation because it is difficult is neither productive nor useful to our patients. But by finding ways to have important conversations in a productive manner, we are able to better serve our (future) patients and be better physicians.  

Author: Umangjot Bharaj

Umangjot completed her Bachelor in Health Sciences from McMaster University. In recent years, she has gotten quite involved with social justice work, and has a significant interest in advocating for marginalized populations whenever possible. She loves reading and writing in her free time, and enjoys creating healthy versions of traditional recipes.
Photo Credits: Keto HC, Creative Commons 

Learning to breathe again

By: Jessica Garabon

Every so often I have to learn to breathe again…

It sounds like such a silly statement.  Breathing is something that we are innately programmed to do. But when I was asked to describe my experience with depression and generalized anxiety disorder, this was the only phrase that began to describe it. It is like learning to breathe over and over again.

My struggles with mental health have been present for most of my life. However, it wasn’t until three years ago that I could put a name to what I was experiencing – when I was diagnosed with both generalized anxiety and major depressive disorders. I had experienced many of the symptoms encompassed in these two conditions since I was a child. But because there was nothing medically “wrong” with me, I was labelled as moody, overly emotional, or disruptive. For the next several years of my life, I internalized the thoughts and feelings that I was experiencing as myself just overreacting or getting worked up over nothing. I placed an inordinate amount of blame on myself and resolved to move past these scenarios and just “be better”.

Throughout high school and university, the anxiety and emptiness that I experienced were magnified. The funny thing was, if you asked anyone in my life from my close friends to casual acquaintances, they would describe me as being incredibly happy all of the time. Sure, I knew that away from the gaze of others I would have bad days or weeks, but I would also have periods of unequivocal happiness where I couldn’t wait to see what the future would hold for me, so how could I possibly be depressed? Over time, the periods of depression and crushing anxiety began to grow longer and the moments of happiness became increasingly less frequent. Even when you need it the most, reaching out for help is an incredibly difficult feat. I found this to be especially true because I didn’t know how to define what I was experiencing yet. Was I over-reacting? Was this something that everyone goes through in university? How could I ask for help when I didn’t even know what I needed help with? With time, I finally made the decision to reach out to my doctor. Being formally diagnosed gave me a strange sense of closure. I could finally put a name to my illness. A name that made me feel even the slightest bit that my struggles were validated. I felt excited and hopeful about my future. I knew what was wrong with me and now I could go out and fix it. Like I have found time and time again, life just isn’t that simple.

When I started medical school, it was meant to be the happiest time in my life. I had worked for it for years and dreamed of it for even longer. I had always believed that my depression and anxiety were centered around my unhappiness with where I was at in life. If I could accomplish more, do better, be better then I wouldn’t have this weight hanging over me. In a one-year period I married my high school boyfriend, completed my master’s degree, and was accepted into medical school- everything I had dreamed of was finally at my fingertips. At this time, I thought that I would finally be free of the depression and anxiety that had haunted me since I was a child. I was exactly where I wanted to be in life. But as I sat there during my medical school orientation, I felt the familiar pain of not being able to breathe.

From that moment on, I fell into a depression deeper than I had ever experienced. Depression and anxiety have become colloquial terms that are thrown around to superficially talk about mental health but being suicidal isn’t something that is often spoken of. Suicide is an uncomfortable topic that is often shied away from in conversations about mental illness, but it is a very real and prevalent issue, especially within the medical community. Because of the prevalent stigma that comes along with speaking of being suicidal, I was afraid to reach out and ask for the supports that I needed. How could the girl who was always smiling and supportive, the person that classmates would go to for advice, the student body president be suicidal or suffering from depression? How could I ever be the doctor when I was also the patient?

In starting medical school, I had endeavored to keep my illness a secret. I believed that if my new peers discovered what I was hiding, the imposter syndrome that I so often experienced would be validated by all of those around me. I began to worry about how dealing with mental illness would affect my future career as a physician. But I have decided that I refuse to be part of a healthcare system where I will be stigmatized for being both a physician and patient.

My story is not special, and it is not unique. There are an endless number of people like me, who have experienced this kind of hardship and still persevere every single day. I’m still sick, and I believe that these are issues that I will continue to manage for the rest of my life. But my perspective on my illness has changed. I’ve started talking more openly about my mental health with those in my life. Normalizing my illness has given me the strength that I need to learn how to breathe again one day at a time. I’m slowly learning to trust others and that I don’t need to carry the weight of my illness all on my own. I have built the most incredible support system, and I could not be more thankful for the endless number of people that have demonstrated kindness and compassion and friendship throughout my journey. I take the medications that I need to allow my brain to function normally, and I continue to work on myself every day with the help of an incredible psychiatrist who is well-versed in physician and trainee mental health. I’m not okay today, but I know that I will be one day. I know that I have a future with love and hope and happiness. I know that my experiences with depression and anxiety will help me to be a more compassionate and empathetic doctor. I know that one day I will breathe freely again.

As I continue to move forward in my journey, there are a number of realizations that I’ve made that have contributed to my recovery. First, I have spent most of my life searching for my purpose; seeking out greater meaning in the world and the one ultimate source of happiness to light a spark inside me and show me why I’m here. This is something that I have spent years searching for but have never found because life is just not that simple. One of my closest friends has helped me to realize that life is not black or white. Good or bad. Pure or evil. Just as happiness isn’t one grand event or nothing at all. She has shown me that happiness isn’t a destination or one occurrence in life that we get to experience. Happiness, as cliché as it may sound, is a collection of tiny moments in everyday life than can bring joy and appreciation and love. These moments can be as simple as having coffee with a friend in the middle of a hectic day, spending an hour at the park with my dog, sleeping in without an alarm, or hearing the purest and most magnificent belly-laugh of my husband. Any of these moments alone are not momentous or overly significant, but together they form a life filled with purpose and meaning and value and hope.

Now, during difficult days, there is a quote that I like to remind myself of by one of my favourite authors Jamie Tworkowski:

“Your questions deserve answers, but just as much, you deserve people who will meet you in your questions. Some answers will take years. Some answers will take a lifetime. The questions often weigh so much. The good news is you don’t have to carry them on your own. This life, our healing, our recovery, it is certainly a journey. What a miracle that we don’t have to do it alone.”

Despite the difficulties and uphill battles that I still continue to face. Despite the struggle of facing a world that continues to stigmatize and cower away from my illness. Despite the beautiful and wonderful days that can be interrupted unexpectedly by a familiar sense of being unable to breathe, I am not alone. What a miracle that I don’t have to do this alone.

Author: Jessica Garabon

Jessica completed her B.Sc. in Behaviour, Cognition, and Neuroscience at the University of Windsor and her M.Sc. in Neuroscience at Western University. She is the incoming Hippocratic Council President and a proud co-founder of Proaction on Mental Health (PRO-MH). Jessica is passionate about narrative medicine and being an advocate for physician and trainee mental health. She loves travelling and coffee and is a fierce supporter of the Oxford comma.
This post was inspired by Proaction Mental Health, a new social 
movement created by Schulich medical students to tackle the stigma
of mental health, and to provide a strong supportive community among
future healthcare professionals. Follow them at @proactiononmh on
Instagram and Twitter!
Photo Credits: Breathe, Creative Commons 

Part 2: The Philosopher Emperor

By: Eric Di Gravio

Marcus Aurelius: In the Capitoline Museum

In my previous blog post, I started to describe how Marcus Aurelius thought that we should face all our struggles without complaint. But where does the strength to do this come from? Let’s continue with what Marcus thought the answer to that question was:

You have power over your mind-not outside events. Realize this, and you will find strength.

A strong person, according to Marcus, recognizes that strength comes from within. It’s in our thoughts and in how we choose to perceive the world around us. The Stoic philosophy that Marcus learned as a young adult taught him that no events which happen are in themselves evil, it’s only our perception of them that is evil. If we have the inner fortitude and belief that we will overcome whatever hardship we are facing, then that is the source of true strength. Marcus explains this well and takes it a step further when he says:

Apply this principle: not that this is a misfortune, but that to bear it nobly is good fortune.

Again, it all comes down to perception. Question yourself: Is this difficult task or unfortunate event really a bad thing, or is it simply an opportunity to make myself better? If we begin to face our problems with this in mind (which I understand is no easy feat), then we will be facing it with all the strength we can muster, and we can’t ask for much more than that.

One last passage on this topic that I found particularly powerful is the following:    

Thou sufferest this justly: for thou choosest rather to become good tomorrow than to be good today.

Medical school and being a doctor isn’t going to be easy, it was never going to be. But all the exams we write, the facts we memorize, the patients we will see and inevitably, the mistakes we will make along the way, are simply necessary steps to make us better people, and doctors of tomorrow. 

What Motivates Us

In his Meditations, Marcus spends much time discussing the purpose of his life. As he mentions over and over again, he finds the praise of others (remember that he was considered a god), the pursuit of fame, glory and wealth all as hollow things. His line of thinking is, if everything including yourself is transient, then what is the point of achieving fame and glory when people are bound to forget you eventually? As Marcus says:

What is even an eternal remembrance? A mere nothing.  What then is that about which we ought to employ our serious pains? This one thing, thoughts just, and acts social, and words which never lie, and a disposition which gladly accepts all that happens

This was not meant to be some doom and gloom statement about how we are all going to die and nothing matters. Instead, by constantly repeating statements like the ones above, Marcus was attempting to keep himself well-grounded and not to get caught up in all the extravagances that many prior, and certainly many later emperors did. He was reminding himself then, and us now, what the truly important things in life are: acting justly and for the common good, and being thankful for what life has given you. Marcus then goes a step further and says:

Have I done something for the general interest? Well then I have had my reward. Let this always be present to thy mind, and never stop doing such good.

Here again, Marcus is reiterating the fact that acting for the common good is the highest reward one can receive, even if its not appreciated at the time. Indeed, it is the very act of working for the common good that should serve as our motivation for everything we do. In other words, the most important thing is being able to go to bed each night with the satisfaction of knowing that we helped someone that day, and that that act in and of itself should be all we need to keep us satisfied and motivated.

Final Thoughts

I couldn’t help but wonder what Marcus would say if now, almost 2000 years later, I were to ask him for one piece of advice about how to be a good person and leader. But then I came across this passage in Meditations that I think answers that question pretty clearly.

Waste no more time arguing what a good man should be. Be one.

Alright then Marcus, point taken. I guess he would say that we all already have it in our hearts what it takes to be a good person and doctor, we just have to have the strength and dedication to do it.

A note on translations:

Since the Meditations are essentially Marcus’s reflections on the philosophical school of thought called Stoicism, and the vast majority of philosophical teachings at the time were written in Greek, Meditations too was written in Greek (even though Latin is the language most commonly associated with Ancient Rome). As in any work of literature originally written in ancient Greek, there are various different translations which all have the same essence, but with slightly different wording. Therefore, if you look up these quotes online or have heard/read a slightly different quote than one I have used here, note that it is simply a different translation of the same piece of work, and hopefully you can see that it captures the same meaning.

Select Quotes from Meditations:

  • “And though wilt give thyself relief, if thou doest every act of thy life as if it were the last, laying aside…discontent with the portion which has been given to thee.”
  • “Short then is the time which every man lives, and small the nook of earth where he lives; and short too the longest posthumous fame”.
  • “Which of these things is beautiful because it is praised, or spoiled because it is blamed? Is such a thing as an emerald made worse than it was, if it is not praised?”
  • “The best way of avenging thyself is not to become like the wrongdoer.”
  • “Let not future things disturb thee, for thou wilt come to them, if it shall be necessary, having with thee the same reason which now thou usest for present things.”
  • “No man can escape his destiny, the next inquiry being how he may best live the time that he has to live.”
  • “Look within. Within is the fountain of good, and it will ever bubble up, if thou wilt ever dig.”
  • “Neither in thy actions be sluggish nor in thy conversation without method, nor wandering in thy thoughts…nor in life be so busy as to have no leisure.”
  •  “This too is a property of the rational soul, love of one’s neighbour, and truth and modesty.”
  • “If it is not right, do not do it: if it is not true, do not say it.”

Author: Eric  Di Gravio

Eric is a second year medical student at Western University. He also completed his BMSc in Biochemistry of Infection and Immunity here at Western. Eric is a self-proclaimed history buff but also enjoys basketball and attempting (and failing) to match his grandmother’s cooking skills.
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Photo Credit: Marcus Aurelius, Creative Commons

The Philosopher Emperor

By: Eric Di Gravio

Equestrian Statue of Marcus Aurelius, Rome

Part 1

I have always considered myself a history buff. I will admit, I still pride myself on my collection of books accumulated from childhood that fill my room. While history has always been a hobby of mine, as I got older, I found myself finding inspiration in the lives and exploits of men and women throughout history; from ancient Mesopotamia to the global conflicts that shook our world in the 20th century. Since starting medical school, I now find myself reflecting on what it means to be a ‘good doctor’ and have begun to see the stories of these same men and women in that new light. Recently, I have been on a bit of an ancient Rome/Greece binge and in doing so have come across (again) the writings of the Roman Emperor Marcus Aurelius (yes, the old emperor in Gladiator). For reasons I will endeavour to share with you, I think that we have much to learn from this once beloved emperor about how to be a good person and by extension, good doctors. But first, let us start with some background.

Importance of the Roman Empire

Ask someone to blurt out the first thing that they think of when you say “Roman Empire” and chances are it will be the Coliseum, gladiators, togas or Julius Caesar. But the Roman Empire has given us so much more than a trendy tourist hotspot, movies with Russel Crowe fighting sadistic emperors, toga parties or Caesar salad (spoiler alert, Caesar salad has nothing to do with Julius Caesar). Rome is everywhere, from the ruins left behind to the borders of our modern-day countries, even to the organization of our governments. But what can we learn from the people, places and history of 2000 years ago? While that is a question that countless classical historians have spent their lives trying to answer, what I add is this: the world of the ancient Romans that Marcus Aurelius knew was not so different from ours. Just like us today, the ancients worried about the economy, national security, religion, politics, healthcare and countless other existential crises.

Who was Marcus Aurelius?

Born in 121 AD in Spain, Marcus Aurelius was adopted by his uncle and future Roman Emperor Antoninus Pius as his son and heir to the throne. Upon becoming emperor after the death of Antoninus, Marcus devoted much time to reforming the law to be fairer for the poor and powerless, promoting free speech, stabilizing the armies and boosting the economy. For this and for his famously humble and simple personal life, Marcus is known as the last of the five “Good Emperors” and the last emperor of the “Pax Romana (Roman Peace),” stretching from the first emperor Augustus all the way to Marcus, a period of about 207 years. While there has certainly been some romanticising of this era in Roman history, there is no doubt that these years saw Rome at the height of its power in terms of economic wealth, territorial extent, military success and relative peace within its borders. After the death of Marcus, the Roman empire fell under increasingly more despotic emperors, witnessed decades of civil war and economic recession, and never truly regained the same power, influence and wealth that it had enjoyed previously. 

Marcus’ biggest claim to fame however remains his Meditations. While by day Marcus was fending off the invasion of the Germanic “barbarians” into the Roman empire, by night he was writing in a personal diary his daily thoughts and feelings. Never intended for the public eye, Meditations reflect the inner thoughts of Marcus at his most vulnerable and dark times while he reflects back on the teachings of the Stoic school of philosophy that he had learned as a young man. Preserved after the death of Marcus, this diary allows us a glimpse into the thoughts of one of the most humble and down-to-earth people to ever live, let alone be an emperor. Reading his work, you get no hint that this was written by one of the most powerful men, in one of the most powerful empires ever to set foot on the world (considering that Roman emperors were basically treated as gods on Earth). Just like many people before me, I too have found inspiration in the words of Marcus and think that there is something in them that can give us some insight into how to be good people, and by extension, good doctors.

Following then, is a collection of some of the lessons I believe we all can learn from Marcus.

On Handling the Tough Times

Even though he was an emperor, Marcus was no stranger to struggle. Death loomed heavy over his head as he witnessed both the death of many of his children, and also the eventual death of his wife. Even Marcus himself was a sickly man, (although we don’t know his exact ailment today) his seemingly impending death seemed often to be on his mind throughout Meditations. Apart from personal struggles, Marcus also had an entire empire to worry about. Early in his reign, he was fending off invasions from the Parthian Empire in his Eastern provinces. Even after a Roman victory, there was no time for rest, as very soon after there was a plague (likely smallpox) that ravaged the empire, closely followed by an invasion of Germanic “barbarians” along the northern border… and it keeps going. 

The biggest lesson I think we can learn from Marcus in this regard is best summarized by this passage in Meditations:

‘A cucumber is bitter.’ Throw it away. ‘There are briars in the road.’ Turn aside from them. This is enough. Do not add, ‘And why were such things made in the world?’

            The lesson that Marcus has captured in this passage is the fact that hardships will happen to everyone and there is no use thinking “why me?”. Marcus would say that instead of becoming upset that such things have happened, we should focus our energies on solving them and moving forward. Thoughts of “why me” or “this is such a waste of time, why do I have to do this” are in themselves “wastes of time” and don’t help solve the problem or complete the task at hand. 

But where does the strength to do this come from? Check out my next blog post to learn where Marcus thought the answer to this question laid. 

Author: Eric Di Gravio

Eric is a second year medical student at Western University. He also completed his BMSc in Biochemistry of Infection and Immunity here at Western. Eric is a self-proclaimed history buff but also enjoys basketball and attempting (and failing) to match his grandmother’s cooking skills.
Sources: 

Healthcare Reform in The Ford Government

By: Hasan Hawilo

Since the Progressive-Conservative (PC) Party of Ontario won the majority government in June 2018, Ontario physicians have been surprised with several healthcare developments. The day after assuming power, the new government announced budget cuts to OHIP+. In October 2018, frustrations with the government’s new Physician Services Agreement (PSA) proposal led the Ontario Medical Association (OMA) to engage in a two-phase binding arbitration process (yes, the same process whose updates have flooded our inboxes). The PSA is a contract negotiated by the OMA on behalf of Ontario physicians regarding compensation and funding for professional activities. However, the most recent and substantial healthcare change proposed by Ford’s government pertains to a large-scale reform. By “committing to new models of collaboration and patient care,” Premier Ford has promised to deal with hospital overcrowding and improve healthcare navigation for patients. But what can we expect of the new healthcare plan announced by the Ford Government?

No More LHINs?                           

A significant transformation proposed by the Ford government is the dissolution of the province’s 14 Local Health Integration Networks (LHINs). Since April 2007, Ontario’s LHINs have been responsible for allocating and monitoring approximately $30 billion from Ontario’s Ministry of Health and Long-Term Care (MOHLTC) to fund the province’s 14 health regions. While the LHINs have promoted a community- and patient-centered approach to healthcare, they have not been without criticism. For instance, the LHINs’s $90 million annual budget has been disapproved as expensive, and their allocation process as overly-bureaucratic. Furthermore, a 2015 provincial auditor general report suggested that on average, the LHINs had successfully reached only 6 of the MOHLTC’s 15 performance targets. Perhaps more concerning is that discrepancy between the various LHINs’ performance standards could be as large as seven-fold. This concern was echoed by OMA president Dr. Nadia Alam, who expressed that the LHINs possess an “unfairness in the level of service.”

In late January, a leaked draft bill of the PC government’s Health System Efficiency Act revealed that the PC government planned to replace the LHINs, The Ontario Health Quality Council, HealthForce Ontario Marketing & Recruitment, Cancer Care Ontario, eHealth Ontario, and Trillium Gift of Life Network with a single “superagency.” Critics of the draft bill, such as former surgical oncologist and University Health Network CEO Dr. Bob Bell, argued that consolidation of these diverse organizations poses a risk to vulnerable patients whose care may no longer be prioritized. Rather than relieve concerns about the LHINs complex processes, the superagency could turn into an even bigger bureaucratic headache. Others similarly, like former Champlain LHIN director Dr. Rob Cushman, were concerned that a superagency could diminish local and regional control over healthcare.

Sustainable Solutions?

This significant overhaul of existing healthcare systems was confirmed by Health Minister Christine Elliott on February 26th, when she also announced that Health Shared Services Ontario and Health Quality Ontario would be joining the organizations amalgamated into the superagency. Some healthcare members such as Dr. Nadia Alam, Dr. Doris Grispud, CEO of the Registered Nurses Association of Ontario, and Anthony Dale, CEO of the Ontario Health Association, expressed optimism regarding this proposal. However, New Democratic Party (NDP) Leader Andrea Horwath has cautioned that privatization could be next. Furthermore, Ontario Health Coalition (OHC) executive director, Natalie Mehra, is urgently warning that the bill will not defend the public interest in healthcare. The OHC is organizing town halls across the province to protect existing healthcare and is planning a rally at Queen’s Park on April 30th.

Another of Ford’s major campaign promises involved a significant reduction in hallway medicine, a phrase he’s used extensively since election time last year. While this “emerging subspecialty of medicine” has provided a temporary answer to hospital overcrowding, Ontario’s ageing population and healthcare infrastructure shortages are contributing to capacity challenges requiring long-term solutions. Indeed, as of October 2018, alternate level of care (ALC) patients (those that no longer need hospital care, but are awaiting long-term care) accounted for approximately 16% of acute care beds. ALC has been suggested to pose challenges to both patients and hospitals. Moreover, compared to other provinces and most other developed countries, Ontario has the lowest number of acute care beds per capita, with 10% of Ontarians waiting 41 hours to be admitted to the emergency department.

Home Care Ontario (HCO), a group representing for- and non-profit home care provider agencies, looks forward to Ford’s superagency model as a welcomed opportunity to expand home-care funding. They believe homecare aligns nicely with the new budget vision and a recent government report appears to support this claim. However, given that HCO represents many for-profit companies, they also have the opportunity to capitalize on this healthcare alliance. The PC government has already provided an additional $90 million to address hallway medicine; however, critics suggest that increased integration of home care with other medical sectors will do more to improve outcomes than more bed space or increased home care funding. Innovative solutions, such as transitional spaces to address patients waiting for a new home after being discharged, and reactivation care centers to assist with patient recovery following prolonged bed rest, are areas that physicians suggest would serve as a valuable focus.

In theory, a transformation of this magnitude could integrate care delivery, address hallway medicine, and provide sustainable home care solutions to improve patient-centered healthcare experience. Whether the new provincial healthcare plan will live up to its promises and address current healthcare limitations is something that only time will tell.

Author: Hasan Hawilo

Hasan Hawilo completed his BSc at McMaster University. He is passionate about grass-roots volunteer organizations that address the social determinants of health and excited to learn more about how politics interact with stakeholder interests to inform healthcare policy.

Photo Flikr: Creative Commons, Publicly funded Healthcare in Danger

Let’s open up the conversation about death

By: Christopher Creene

I’ve been thinking about my Dad a lot recently. Another February 4th has come and gone, and this year it marked 8 years without my Dad. When asked about my parents, I find myself speaking about my Dad in present tense as if he is still with us, failing to mention that he passed away from a heart attack soon after we moved to Canada.

Why?

Don’t get me wrong – I want to talk about him. I want to share fond memories of him, and laugh about the antics he used to get up to. But over the past few years I’ve become increasingly aware of the ‘social taboo’ that exists around death. People get awkward and don’t know where to look when you talk about someone close to you dying. It makes people feel uncomfortable. So I’ve learned not to bring it up, to pretend it didn’t happen. I’ve met all kinds of wonderful people since moving to Ontario last year, but in that time I have only told one person about the death of my father. It’s with such regret that I feel I need to hold back on talking about the man who made me who I am today. He was a wonderful role model to my siblings and I, and a dearly loving husband to my mother. I have such pride in saying that he is my father.

Whilst writing this blog entry, I started to wonder how other people felt about this topic after losing someone they love. I reached out to one of my best friends, an incredible guy who I’ve known for many years now. His younger brother was tragically killed by a drunk driver 3 years ago. This is what he had to say:

“In my experience, I feel that those who aren’t your family don’t want to hear about your hardships. I think that’s mainly because it makes them feel sad, and it makes them worry that YOU could become upset, at which point they’d have to console you. Also, in general I don’t want people to pity me. I want people to do/say nice things for/about me not because they pity me, but because they respect me.”

His words perfectly describe what I’m trying to get across, and it was interesting to hear that I am not the only person who feels this way.

I’ll admit that prior to experiencing loss myself, I responded to death in a similar way. It made me uncomfortable, and I would avoid talking about it to prevent others from becoming upset. I felt that because I couldn’t relate, any words of comfort that I provided would lack authenticity. This is one of the main reasons why I felt that it was important to write this blog entry, as a way to share my personal experiences as someone who now understands, and to give advice on how I think we should be addressing the subject.

So how do you respond to someone sharing their grief with you?  How can we normalize death and open up the conversation?

The major misconception that I think needs to be cleared up is that you should avoid talking about someone’s loss because it will make them upset. Although different people grieve in different ways, my general experience has been that people want to talk about a lost loved one. By talking about that person, you keep their memory alive. The next time someone shares this personal part of their life with you, don’t shy away from the topic. Ask them ‘What was she/he like? What’s your favourite memory with them? What were his/her hobbies?’. Personally, I love talking about my Dad – it helps me keep him close.

Of course, sometimes I do get upset when talking about him. But that doesn’t mean that you should avoid bringing it up! In writing about the death of a close friend, Alfred Lord Tennyson wrote “’tis better to have loved and lost than never to have loved at all”. When someone dies, the family and friends left behind don’t want to just pretend that person never existed. We want to talk about the music they liked and the jokes they used to make. We want to talk about precious memories and laughs we shared. But I’ve found it difficult to do so because over the years I’ve been met with discomfort and avoidance when I bring it up. I’m asking you, the reader, to help open up the conversation. By talking about them we can keep them as a part of our daily lives, even if they’re not physically with us anymore.

I’ll finish with a quote that someone shared with me when my Dad died. It means a great deal to me and it sums up my message wonderfully:

They say a man dies twice. Once when he stops breathing and the second, a bit later on, when somebody mentions his name for the last time.”

Author: Christopher Creene


Christopher grew up in Bristol, England, and moved to Canada when he was 15. He completed a BSc. in Microbiology & Immunology at Dalhousie University, and subsequently spent a year working at the QEII Health Sciences Centre as a phlebotomist. He is now on his way to completing his first year of medical school at Schulich. He is passionate about running, music, and the environment.

Photo Credits: Flikr, Creative Commons

How To Stop Ebola In 4 Easy Steps

By: Zachary Weiss


Ebola is in the news again. And this time, things are different. Very different. The Central African nation of the Democratic Republic of the Congo (DRC) is at the epicentre of what is now the second-largest Ebola epidemic in history. Though still a far-cry from the 11,000 deaths during the West African Ebola outbreak from 2014-2016, this current epidemic has already resulted in over 420 cases and 240 deaths. To make matters worse, numerous setbacks have caused officials to admit they are struggling to maintain control of the situation, and projections estimate the current epidemic could persist well into 2019.

So, what are we doing about this most recent outbreak? Not enough. What can we do to stop something like this from ever happening again? A whole lot. And lastly, why should you care? Because millions of lives are at stake.

Let’s get to it.

Step 1: Stabilize the DRC and surrounding area.

Democratic Republic of Congo: Map

The DRC is at war. Since 2014, fighting has been ongoing between rebel and militia groups in the cities of North Kivu, a province of the DRC along the border of Uganda, Rwanda, and South Sudan. This area is no stranger to traumatic events, with war, outbreaks, and atrocities dating back to the Rwandan genocide of 1994. This history, along with over 4 million displaced persons, has created a perfect storm for Ebola to exploit.

With the rebel groups now targeting civilians, abducting children, and targeting aid workers, the situation is growing more grave by the day. This conflict has significantly impaired the WHO’s and other agencies’ ability to operate in the area and respond to the outbreak, even leading the WHO to temporality halt its response in Beni, the city at the centre of the current outbreak. Security concerns have even prompted the Trump administration to withdraw all CDC officials from the affected area, leading to further deficits in the ability to respond effectively to the growing crisis.

Though this may be the first time Ebola has entered a war zone, outbreaks in highly unstable regions are nothing new. If we are ever to stop this outbreak and prevent future outbreaks from occurring, stability is key. I’m not going to pretend I know how to solve this issue, but I can certainly offer some suggestions. To stabilize the area, tens of thousands of more UN Peacekeepers in addition to the over 15,000 already present will be needed. More aid will need to start flowing in. Roads to move that aid will need to be built. International observers and election specialists will need to supervise the upcoming elections. The DRC’s immense wealth of natural resources will need to be mobilized for the DRC, and not the West. Land will need to be redistributed to its rightful owners. Hundreds of millions of dollars will be required. And this is just step 1.

Step 2: Build trust with communities.

One of the biggest challenges to fighting Ebola (or any other disease, for that matter), is building trust in the communities affected. In the DRC, many civilians still refuse to believe in the existence of Ebola, and see the global response as nothing more than attempt to test new medications on Africans. Even among local healthcare workers, knowledge about Ebola remains abysmal. And all of this is understandable; in a region that has been under constant threat of attack by armed groups for over 20 years, distrust is rampant.

So how do we change this narrative? By asking a lot of questions. Learning from its huge missteps during the last Ebola outbreak, the WHO has recruited sociologists and anthropologists in the DRC to help the agency better understand the region. By further elucidating the root of the conflict in the region, the importance of local burial practices, and the local perceptions of the global response, the agency hopes to break down barriers and build trust with people of the DRC. It’s not enough. But it sure is a great start.

Step 3: Stop climate change.

The Bonobo, endemic to the Democratic Republic of Congo is a disappearing population mainly due to deforestation.

PSA: The climate is changing, and fast. Now, without debating the undeniable, irrefutable, and truly terrifying reality of climate change, I’m sure you’re wondering—how does climate change have anything to do with Ebola?

The most well understood link between climate and disease can be seen through the spread of disease vectors like mosquitos and ticks. As I wrote about in my last piece, warming temperatures have resulted in an expanded range and an increased development rate of ticks, resulting in a huge rise in the incidence of Lyme disease over the last decade. In the case of Ebola, however, another interaction between climate and disease is taking place. In the DRC and surrounding nations, humans and animals are increasingly forced to compete for dwindling resources. As humans and animals, particularly primates and bats—the main animal vectors for Ebola—get closer together, the chance of Ebola spreading to humans dramatically increases. This can be stopped, however, through the painless act of reducing carbon emissions, developing tighter controls and management on food and water resources, and reversing deforestation as a method of carbon sequestration. In particular for the DRC, huge investment in rural access to clean water, sanitation, and healthcare will go a long way to reducing current migration to urban centres, and stop Ebola from migrating to these areas, too. I digress.

Step 4: Vaccinate, vaccinate, vaccinate.

This article has been very dark. So, I think it’s about time to talk about what may be the one and only bright spot of the current Ebola epidemic: we have a new, effective, and Canadian-made Ebola vaccine. rVSV-ZEBOV, a still-experimental vaccine developed at the National Microbiology Laboratory in Winnipeg, Manitoba, is currently being deployed to combat Ebola in the DRC. While human trials of the drug have been limited to past outbreaks scenarios with limited data and controls, early results suggest the vaccine could be close to 100% effective at stopping Ebola. With the help of a public-private partnership with the pharmaceutical giant Merck, this vaccine is now being used in the DRC through a process called “ring vaccination”, whereby officials vaccinate all those who may have come in contact with an Ebola patient. Another point of hope: vaccine acceptance in the region is (surprisingly) very high, with a recent survey finding 82% willingness to accept the vaccine. Now, Merck is stockpiling this vaccine, and is said to have hundreds of thousands of doses ready for combating this outbreak and the next one. If all of this is true, and if the vaccine is used appropriately, we may now have the capability of wiping Ebola off map—something that would have led to thunderous laughter amongst infectious disease specialists even 5 years ago.

Now, if at this point you haven’t notice the rampant sarcasm in this piece, let me confess: stopping Ebola is really, really hard. That’s the reason why Ebola pops up in similar outbreaks every couple of years, and that’s why it likely will again and again for the foreseeable future.

Moving Forward

The point of this article is not to belittle the courageous efforts of the many who work on the front lines each and every day to control this outbreak. The point of this article is also not to make light of the fundamental structural issues in the way of preventing future Ebola outbreaks. Rather, the point of this article is to demonstrate that fighting Ebola is not a unique challenge. There are tangible, well understood solutions to each of the steps I’ve outlined above. Sure, many of these solutions will take Herculean efforts not seen since WWII. And yes, many of these solutions will take tremendous time, money, and effort. But, at the end of the day, this is a fight worth fighting. Ebola is not simply a virus or disease. Ebola is symptom of a much greater, widespread, and truly sad reality. It is a symptom of how we have forgotten how to work together to solve global problems. It is a symptom of a global healthcare and economic system that favours some nations (the West) over others. None of these solutions are out of reach, technically speaking. But politically and practically speaking, things are different. And I’m not naive to this. But I am hopeful. And maybe one day, you’ll be hopeful too. Because if we can’t even have hope for a solution, we certainly can’t even begin to solve the problem.

 

Author: Zach Weiss

Zach Weiss completed his B.Sc. in Microbiology & Immunology at UBC in Vancouver. Over the years, Zach has become increasingly fascinated with the world of politics and policy, and has spent way more hours listening to political podcasts than he’s willing to admit. As a first-year medical student at Schulich, He’s particularly interested in merging his interest in politics and policy with his growing medical knowledge to advocate for and bring awareness to issues that are often overlooked.

Photo Credits: Wikimedia Commons

Screaming without a Sound: Sex Trafficking in Ontario

Human-trafficking is essentially a form of slavery. It entails the movement of individuals against their will, and exploitation of their rights for profit through various services such as labour, or in this particular case: sexual services.

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Victoria sobbed in fear as she felt exhaustion overtake her once again. When her eyes closed: they would come again. Sounds. Smells. Tastes. Touches. This dark room had no place to hide. Even in sleep she could not find rest. Where could she run? They would find her again.

There was no escape.

Victoria was a victim of domestic abuse when she was but a child. Her drunken father beat and killed her mother leaving her alone. What followed next was a whirlwind of neighbours, police, and social workers. Having gone through child protective services, she was placed into a new family. And that was where her story should have ended. Instead, her foster father pimped her out to his friends, and eventually other men who would put down money. She was ten.

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Jacob clutched the few dollars he had, and ran back to his boyfriend. He was always running. Running at school. Running on the track team. Running away from his family… But with his new boyfriend, he didn’t have to run anymore. He could trust him.

The money wasn’t enough? Black eye. A couple dollars? Broken rib. How many people did he service? Coughing up blood. It was finally enough. A smile, all that Jacob wanted.

Restart again.

Jacob ran away from home when he came out to his family. His parents being very traditional refused to have a son who was LGBT, and he ended up wandering the streets of a large Ontario city. Very soon he fell into a group of fellow street teens who showed him how to survive. One of them took a liking to him, sharing food, advice, a bed. Then the drugs happened. Jacob couldn’t pay up, and his boyfriend beat him. Jacob loved him. He wanted it to go back to the way it was before. So he started selling himself out to pay his debts. He was 19.

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 Jasmine clutched the edge of the sink and looked at herself in the mirror. She was beautiful once. Her father loved her and called her his princess. Her mother found the best clothes for her and dressed her up like a doll. But then the war happened.

The handsome man that met her in town came from Canada he said. She was very kind and gentle he said. He had children at home and would love to have her come and take care of them. She accepted. She was trapped.

The door opened. Another client. Smile he said. The men like it better when she is happy he said. You belong to me. He said.

Jasmine came from a war torn country. In that instability, a trafficker promised her legitimate work in Canada with promises of citizenship. Upon entering the country, her passport was stolen and she was sold to the next bidder. She was told that she needed to pay back her handler for fees, and that if she went to police she would be deported. She was 24.

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Disclaimer: All the vignettes you just read are not real individuals. Rather, they are a culmination of many real people who have been in these situations or are currently in these situations. They have names. They have stories. They could have been you.

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Human trafficking is one of the most underreported crimes in Canada. The latest report from Stats Canada (2009-2016), states that there were 1220 confirmed reports of human trafficking. Over 723 (65.8%) of these cases were in Ontario, of which 48 were in Windsor, 46 in London, and 272 in Toronto. As of September 2018, We Fight, an anti-human trafficking project in Windsor stated they have 80 open cases. Keep in mind, that this is a gross underestimate of the problem since these are the cases that were confirmed by law enforcement. Due to the nature of all illegal activity, it is extremely hard to have proper estimates of the extent of this problem. In 2013, the US Department of State released their annual report on human trafficking stating that for the 40,000 worldwide confirmed victims the previous year, it was estimated that there were still 27 million people being trafficked worldwide which were unreported. According to the Canadian Department of Justice, net revenues for trafficking on a worldwide basis account for about 32 billion dollars: an exceptionally lucrative business for organized crime and gangs.

There is no one profile of trafficked victims. Like the above stories, they come from all backgrounds and histories. However, statistically, most victims are young girls and women, starting from an age as early as 12, if not younger. In a 2013 report from the Canadian Women’s Foundation, many victims of sex-trafficking came from low socioeconomic backgrounds, homelessness, discrimination and/or childhood trauma. It should also be noted that nearly 50% of women who are trafficked in Canada belong to indigenous populations, which is absolutely horrific considering the fact that indigenous women only make up 4% of the population of women in Canada. The RCMP reports that many of these people are sold, bought, and moved against their will and forced to perform sexual acts in: “hotels/private residences and in adult entertainment establishments”.

So now comes the inevitable question? What can I do about it? As future or current physicians, we are among the frontline personnel to have contact with victims of trafficking. Studies suggest that almost 28% of victims of trafficking will eventually get into contact with healthcare workers during their imprisonment. This is a very large window of opportunity on a healthcare standpoint for early recognition and intervention. The more knowledge we have on this topic, the better our chances at identifying high-risk situations and responding to them effectively. If we, as physicians are aware to the extent of the problem and the signs of this issue, people like Victoria, Jacob, and Jasmine might stand a chance.

Below are pertinent signs of trafficking. For more information on who to contact, the end of the report from the Ontario Ministry of Children, Community and Social Services has a map in which you can enter your city and have agencies listed.

What to Look For (from the London Anti-Human Trafficking Committee):

People who are being trafficked may:
- Speak neither English nor French, or may not speak on their own behalf
- May be accompanied by someone who is controlling them
- Originate from foreign countries or from another city/province within Canada
- Be unaware of local surroundings although they have been in the area for a while;
- Show evidence of control, intimidation or abnormal psychological fear;
- Not be able to move or leave job;
- Have bruises or show other signs of abuse;
- Show signs of malnourishment;
- Be frequently accompanied or moved by their trafficker.

Map of Resources from the ON Ministry of Children, Community, & Social Services

 

Author: Phong Nguyen

Phong Nguyen completed his BSc.[H] in Biology at the University of Windsor. Following graduation, he worked in the US with social work non-profits providing assistance to vulnerable populations: in particular, youth experiencing homelessness and in crisis. Now at Schulich, he hopes to pursue work related to advocacy, social inequities, and field medicine.

 

 

Picture Credits: Englin Akyurt