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Remote Medicine: An Urban Medical Student’s Perspective

Posted on 02 April 2017 by Adriana Cappelletti (Meds 2018)

Last summer, I traveled to Northern Ontario with my colleague Amanda Sauvé to complete an elective in remote family medicine. After driving 1,300 kilometers and crossing many moose charging warnings, we pulled off the TransCanada highway and arrived at our destination: a town of 4,700 people in the Thunder Bay District, with fewer than two persons per square kilometer.

I had never been somewhere so remote; the next gas station was a forty-five minute drive away! I was stunned by the vast landscape of sparkling lakes and lush forestry. For the first time, I witnessed the majesty of moose and drove within meters of black bears. Despite being within my own province, this territory felt so foreign to me. It was so peaceful to be away from the hustle and bustle of urban living and to feel immersed within nature. At the same time, it felt eerily quiet and isolating. I was beginning to grasp the meaning of ‘remote’ that our peers at NOSM can appreciate.

We resided in the old nurses’ quarters adjacent to the town’s small hospital, the only hospital within a 180-kilometer radius. Three permanent family physicians and the occasional locum operate the hospital’s inpatient ward, its emergency department and the neighboring family medicine clinic. I formed my impression of health care in remote Ontario by working with these welcoming physicians, engaging with their patients and meeting with community members from a nearby First Nations reserve.

Unsurprisingly, a major barrier to accessing healthcare was geography. Back home in London, Ontario, patients can see specialists locally, and urgent CT scans and MRIs can be obtained in a flash. Conversely, in this remote town, the closest tertiary care center where these resources are available is over three hours away by car, or an hour by helicopter. We could arrange telemedicine appointments if physical examinations were not required, but otherwise, the commute to Thunder Bay was inevitable – as were the astronomical gas prices this commute entails.

Distance to amenities and associated travel costs are only two of many social determinants of health that differ up North. Employment opportunities are scarce, and small businesses struggle to survive in such low-density populations. Although housing is cheaper, it is unaffordable for many families to heat their homes comfortably in the wintertime, with temperatures dropping as low as a frigid minus forty degrees Celsius. Average monthly grocery costs are more than twice the cost in urban Ontario.1

My heart sunk at the realization that many small towns had one overpriced corner store (if any) for people to buy food, yet every town, without exception, had a liquor store. I was also deeply affected by two major public health issues in remote Northern Ontario: substance use and access to mental health services.

Regarding the former, the so-called ‘opioid epidemic’ is an inadequately addressed issue across the province, and it is particularly so in Northern Ontario. Typically, a methadone clinic provides patients with one dose per day and gradually increases the number of doses patients are allowed to take home (known as ‘carries’) as patients demonstrate that they do not divert their medicine to others. Where I worked, many patients live forty-five minutes from the methadone clinic, making daily pick-ups unfeasible for a working individual or for patients without a vehicle. As such, patients could be given a full week’s carries without undergoing the usual process of demonstrating reliability. Consequently, methadone in the area was frequently diverted, as was apparent by urine drug tests in the emergency department. Two patients have died from methadone overdose within the past couple of years at this site; in such a small population, this number is alarming.

Patients with substance use disorders or any other mental health concern have a right to reasonably accessible services under the Canada Health Act, yet patients can be forced to travel three hours or further to see a psychiatrist. The lack of mental health services is particularly apparent in the Emergency Department. For suicidal patients who are safe for discharge, it is a struggle to arrange appropriate follow up given the shortage of counseling and social work services and the distance patients may need to travel to see a family physician or psychiatrist. I remember my preceptor and I sent a teenager home with a prescription for an antidepressant and uncertain follow up, and I wondered concernedly, “Is anything going to change for her?” As for psychiatric patients who are not safe for discharge, they must be transferred to the nearest Schedule 1 facility. This means that their recovery will take place about 300 kilometers from their home and families. I can only imagine how unfamiliar that environment can feel without having a nearby support network.

Overall, in my experience, many physicians and patients up North enjoy the lifestyle and pace that the area offers. On the other hand, they often feel ignored or overlooked by government with regards to their health. Now that I have witnessed their system first hand, I feel the same way. If I felt helpless and infuriated during my brief remote medicine stint, I can only imagine how strongly that fire burns within those who live and work within that system every day. A passion to help change these circumstances has ignited within me; even though I am over a thousand kilometers away today, I have a social responsibility to keep that flame alive. I feel guilty that I cannot envision a full-time career for myself so far from where I call home. However, I can hold myself accountable by at least practicing as a locum and by advocating for technological advances and health care reform that may improve the care of these patients.

I encourage all medical students to take the initiative to plan an experience in remote medicine. Even as a pre-clerk, you can be a valuable asset to an understaffed team and underserviced patient population. Furthermore, I urge my fellow medical students in urban settings to care about the challenges faced by our peers and patients in remote settings and to join me in advocating for their health.

References
1. Source: Food Secure Canada. Paying For Nutrition: A Report on Food Costing in the North. 2016. Available from: https://foodsecurecanada.org/sites/foodsecurecanada.org/files/201609_paying_for_nutrition_fsc_report_final.pdf

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“Gaming” CaRMS: the game theory and history of resident matching

Posted on 20 January 2017 by Tina Zhou (meds2020)

Let’s face it: the sight and sound of this term is a stress-inducer for many. This charming acronym stands for Canadian Resident Matching Service and match medical students with residency programs across Canada. Each year, the participating students wait anxiously for their results, and the non-participants wait anxiously for the match statistics.

The main concern usually relates to building a competitive application. However, lurking in the back of people’s mind is the mysterious CaRMS match algorithm. To address people’s curiosity (read: stress), CaRMS has a special webpage titled “De-mystifying the Match Algorithm” that contains key words such as “Roth-Peranson algorithm”, “rank order lists” and “applicant-proposing”. But how does it really work? For a better understanding of the mechanism and history of this “globally-recognized and award-winning” algorithm, let’s take a look across the border where the algorithm was first developed.

Medical internship in the United States was introduced in the 1900s as a form of post-graduate training. The idea gained popularity quickly for obvious reasons, but the implementation had a more troublesome history. Initially, medical students and hospitals made internship arrangements privately. An overabundance of internship positions relative to the size of graduating class each year resulted in a race among hospitals to recruit medical students as early as possible; some students received binding offers by the end of second year. Such a pre-emptive decision on the hospital’s side was risky and costly. Hospitals could potentially make a more well-informed choice if they withheld their offers until later, but they would then risk losing the brightest students to the early-acting hospitals. Consequently, everyone acts early –a classical case of Prisoner’s Dilemma.

The cost of this recruitment race was even higher for students. Many were still uncertain about their specialties of interest by the time they received an offer; signing a binding contract meant they might lose out on better options or make the wrong career decisions.

To mitigate the problem, medical schools established policies that prevented student information from being released to hospitals until a set date, forcing hospitals to make offers at the same time. This created a phenomenon of “exploding offers”. As hospitals scrambled to secure their preferred candidates, they shortened the response time for students to decide from 10 days to as short as 12 hours. Imagine if you were on a trans-Atlantic flight, you might miss your offer!

By the 1950s, it became clear that a central clearing house was urgently needed to facilitate the matching process. At first, a “priority matching” algorithm was proposed. Students and hospitals submit their preference lists for each other. In the first round of matching, those who put each other as first choices are matched and eliminated from the matching (1-1). Then, hospitals will be matched with their 2nd preferred candidates who rank the respective hospitals as first choices (2-1). In the third round, remaining students will match to their 2nd preferred hospitals who reciprocate by ranking the students as their first choice (1-2). The process goes on (2-2, 3-1, 3-2, 1-3, 2-3…). This proposal was rejected, as students would essentially be “penalized” for ranking hospitals they preferred but unlikely to secure.

Ultimately, a “deferred acceptance” algorithm was put forth. In brief, the proposing side makes offer to their most preferred candidates of the other party, who then temporarily accept the offer until they get a better deal in subsequent rounds – hence the “deferred” acceptance. Let’s demonstrate this in an example.

Assume there are four students who are trying to match to four hospitals. The students have a preference list, or “rank order list” (ROL), for the hospitals as shown:

 

Adam: Chrawna>Hammie>Vancity>Purple land

Beth: Chrawna>Purple land>Hammie>Vancity

Charlie: Vancity>Hammie>Purple land>Chrawna

Doug: Purple land>Hammie>Chrawna>Vancity

 

Similarly, hospitals rank the candidates as:

Chrawna: A>C>B>D

Hammie: B>C>D>A

Purple land: C>A>B>D

Vancity: D>B>A>C

Let’s start with the students as the proposing side. Adam and Beth both like Chrawna the best, so they both apply there. Charlie and Doug apply to Vancity and Purple land respectively. Now, since Chrawna receives two offers, it will be matched to its more preferred student Adam. Purple land and Vancity only receive one offer each and will be matched automatically. In this first stage of matching, Beth is unmatched. In stage two, she will apply to her second favourite place – Purple land. Even though Purple land is currently matched to Doug, it can still change its mind. After comparing its current match Doug to the new applicant Beth, the hospital selects Beth. At a result, Doug is now unmatched. Adam and Charlie remain matched to the hospitals from the previous stage. In the third stage, Doug will apply to the next location on his ROL, which is Hammie. Since Hammie still has not received any offer, it will happily take on Doug. Now everyone is matched and the matching process is complete.

 

Adam Beth Charlie Doug
Proposes to

Match

Chrawna

Chrawna

Chrawna

unmatched

Vancity

Vancity

Purple land

Purple land

Proposes to

Match

 

Chrawna

Purple land

Purple land

 

Vancity

 

unmatched

Proposes to

Match

 

Chrawna

 

Purple land

 

Vancity

Hammie

Hammie

Final result Chrawna Purple land Vancity Hammie

 

As a result, Adam is matched to Chrawna, Beth to Purple land, Charlie to Vancity, and Doug to Hammie.

On a cautionary note, in practice, students do not actually have to propose to hospitals repeatedly. Instead, these “stages” of matching are simulated – presumably with powerful computers at National Matching Services Inc. – with only one round of ROL submission to the central clearing house. In the context of CaRMS, each submission of ROL is equivalent to one round of iteration.

One may then wonder: does it matter which side starts the process? In the example above, the students make the “proposal” first. If one starts the process with the hospital side, there will be only one round of matching. The results are: Chrawna with Adam, Hammie with Beth, Purple land with Charlie, and Vancity with Doug. Every hospital will get their first choice, but the students will be worse off with their less preferred hospitals (just compare the results according to the students’ preferences). In general, student-proposing will lead to better or at least equally good results for students, since they essentially get their picks before the hospitals.

Is there a way to “game” the system? The simple answer is, not really. There is no incentive to put your “safer” options higher on your list just so that you are matched to at least somewhere, because you may potentially miss out on better matches. There is also technically no penalty for putting your “dream” hospital as your first choice. Even if you are rejected during the first “stage” within a submission, you can still “propose” to your other options and be accepted in later stages. As a result, the Deferred Acceptance algorithm elicits “true” preferences: students have no incentive to submit a rank order list that does not reflect their wishes.

In addition to solving the recruitment race, exploding offers, and too-risky-to-dream-big problems, this algorithm also produces so-called “stable” matches. Going back to our example, there is no pair of hospital-student such that they prefer each other to their assigned partners. Even though Hammie prefers Beth to its current match, Beth is not willing to give up Purple land for Hammie.

There have been modifications over the years to incorporate match variations such as couples matching. Nevertheless, “deferred acceptance” concept remains central to the currently used Roth-Peranson algorithm. It is used for resident matching in both US and Canada. If this post has not been re-assuring enough, the algorithm was also pivotal to Roth winning a Nobel Prize for Economics in 2012 – a truly “globally recognized and award winning” match program. Indeed, not many matchmaking solutions can be quite a match for this one and its making.

 

Resources:

De-mystifying the Match Algorithm http://www.carms.ca/en/about/blog/de-mystifying-match-algorithm/

The Match Algorithm http://www.carms.ca/en/residency/match-algorithm/

Alvin Roth “The Origins, History, and Design of the Resident Match”

Alvin Roth and Elliot Peranson “The Redesign of the Matching Market for American Physicians: Some Engineering Aspects of Economic Design.”

 

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Take a Hike – In Canada’s National Parks

Posted on 12 January 2017 by Vanessa DeMelo (meds2017)

Hello everyone! I hope that the holiday season had been restful and delicious for everyone. Today I’m going to write about something fun, outdoorsy, and provide information that may be more applicable for warmer weather. However, it’s fun and temperatures that I for one am looking forward to.

For now, we celebrate a brand new year. As a member of the class of 2017, one thing I had not anticipated is how much I identify with the date every time I see it written. After three and a half years of calling myself a 2017, it’s extra exciting that “The” year is finally here! First and second years, prepare yourselves for an onslaught of humans in MSB whom you have never seen before, as we walk around the VERC and lounge with an eerie poise of familiarity. I am really looking forward to being back and all the socialness that it entails, so feel free to say hello (we’re not that scary).

Now for my topic au jour – Canada’s National Parks! What are these national parks, specifically? Webster’s Dictionary (just kidding, the Canadian government website) describes them as “a country-wide system of representative natural areas of Canadian significance”, or in other language, bits of land that together represent the various natural regions of Canada. These regions include boreal forests, temperate rainforests, prairie grasslands, and more words that I bet you didn’t think that you would hear post-Grade 9 Geography. These parks are protected for public understanding, appreciation and enjoyment, and are maintained for future generations to likewise enjoy.

The park system’s origins date back to November 1885 (the year that the first appendectomy was thought to be performed), when the Canadian government designated 26 km2 of Alberta’s Sulfur Mountain to be preserved for the benefit of all Canadians. This area today is part of Banff National Park and is the Cave and Basin Hot Springs.

Pictured: A postcard by Harmon Byron showing the Government Pool at Cave and Basin, Banff National Park (produced before 1942).

The pool shown in the postcard closed in 1992 and the location has since received a multimillion dollar renovation. Interestingly, these hot springs were regarded as having healing properties and were used for thousands of years by the First Nations peoples. In 1883, they were “re-discovered” by three railway employees who were working on the construction of the first transcontinental railway through the Rocky Mountains. I highly doubt that spelunking was part of that original job description.

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Pictured: Interior pool post-renovation

Following the government’s designation in 1885, it was found that the area surrounding the original reservation was even more admirable and this led to The Rocky Mountains Park Act being passed in the House of Commons in June 1887 to establish what is now the Banff National Park, the first national park in Canada.

The history of the following development of the park system is (in my opinion) very interesting, detailed, and less fitting for a short, nothing-to-do-with-medicine blog. I found a lot of information on The Canadian Encyclopedia website and would direct you there if you are looking for more procrastination-worthy fodder!

Now, I’ve chosen (with difficulty) three National Parks to give as examples of places that you can and should visit. Many of Canada’s National Parks are also UNESCO world heritage site, which are locations listed by the United Nations Educational, Scientific and Cultural Organization as something of special cultural or physical significance. If the UN thinks they’re important, you should too!

  1. Bruce Peninsula National Park, located between Lion’s Head and Tobermory, Ontario: phenomenal camping and hiking, and only three hours away. Easily weekend-able!

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(Disclaimer: I did not take this picture)

  1. Cape Breton Highlands National Park on Cape Breton Island, Nova Scotia: it contains one-third of the world famous Cabot Trail. I was lucky enough to take a short trip here during my emergency medicine elective this fall in Sydney, Nova Scotia. Even though it was a wet day and the weather changed between drizzle, rain and snow every 500 m, the vistas were incredible and I will definitely be visiting again.

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(Disclaimer: I did take this picture)

On a less rainy day, courtesy of the internet:

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  1. Elk Island National Park, 35 km west of Edmonton, Alberta: this park hosts the densest population of ungulates (hoofed mammals) in Canada, and it is high on my list to visit this summer with my handy national park pass (what is this? Keep reading, my friends).

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I will hike, canoe and make friends with bison (interestingly, both the singular and plural form of the word. How many bison will I make friends with? It’s a mystery).

Now for the final, exciting news that you hopefully already know: To celebrate Canada’s sesquicentennial (your twenty-five cent word of the day, meaning 150th anniversary) in 2017, admission will be free to all of Canada’s National Parks, Historic Sites and Marine Conservation Areas. I feel this is all the more reason to pick somewhere where you haven’t been before, or even somewhere where you have been and would love to revisit, and make a trip of it. I’ve conveniently included a link below so that you can order your free season’s park pass!

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Happy exploring!!

http://www.commandesparcs-parksorders.ca/webapp/wcs/stores/servlet/en/parksb2c

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Views from Across the Rubicon: The Rejected Physician Services Agreement

Posted on 28 September 2016 by Adam Kovacs-Litman

crossing-rubicon

August 14, 2016 marks a turning point for the history of health care in the province of Ontario. 63.1% of Ontario Medical Association (OMA) members rejected the Liberal government’s proposed Physician Services Agreement (PSA) and in so doing voiced their vehement disagreement with the trajectory of health care in Ontario.

This is not meant as a criticism of the PSA even though it is an agreement that is certainly worthy of our criticism. It is worth recognizing the many rational reasons physicians had for voting for the proposed agreement. The Liberal Government of Ontario’s rejected PSA was beyond disastrous. It was bad for the health care system and economically untenable. It intentionally underfunded health care at a rate lower than health care growth and would have necessitated longer wait lists, clinic closures, doctor relocations to other provinces and countries, and the delisting of medically necessary services. It also would have significantly cut individual physician salaries on a progressive basis over four years after accounting for inflation. With all that said, I’m still surprised that the PSA failed to pass. The agreement was despicable in objective terms, but still managed to provide stability and predictability in its sadism. Rejecting the agreement once again puts Ontario’s doctors at the mercy of the Liberal Government, a government that has shown its willingness to engage in unilateral action, even at the expense of Ontario’s doctors, tax payers and patients. The Liberal Government will likely impose an even harsher version of the rejected PSA and pass bill 210 (the ironically named “Patients First Act”) unamended. Bill 210 is punitive in nature and cripples the ability of health practitioners to manage their own practice while grossly expanding the scope of powers of the Minister of Health.

After comparing these two options, voting “for” this agreement seems maddeningly reasonable. The Ontario Government assumed that physicians would vote in alignment with their self interests and begrudgingly vote in favor of the devil they knew. What Ontario’s doctors gained by voting against the PSA is not something that is tangible. Rejecting the PSA was our profession’s confessional – it was our moral absolution. We will not be complicit in the erosion of our health care system. We are its champions and we will stand and defend it.

The word “advocacy” gets thrown around a lot in medicine and is a concept that those within the profession are perhaps overly familiar with. “Advocate” is one of the six cardinal roles that the Canadian Medical Association (CMA) identifies for physicians and “advocacy” is a deeply ingrained tradition of medicine. Physicians strive to advocate for their patients whether it’s by raising awareness for mental health, providing refugees with medical care, helping patients get access to the medications they need or just providing Ontarians with humanity and excellence in medical care. Rejecting the PSA is advocacy on a system level.

The rejection of the PSA marks a philosophical stand against the dismantling of health care that comes at great personal and professional cost. The Ontario Government likely crafted this agreement so that they could obtain the coerced consent of the medical profession and use it to legitimize further and continued cuts to health care. The language of the agreement would have made physicians responsible for increases in health care utilization, which some have compared to making firefighters financially liable for the number of fires they have to put out. This would have given the government political ammunition to blame inevitable future increases in health care expenditure on physicians. Signing the PSA would have made further advocacy considerably more difficult. It would have transformed would be advocates into hypocrites. This was an agreement that in its essence demanded silence in exchange for a slight reduction in the immediate rate of health care cuts. The Liberal Government tried to manufacture consent and it failed.

I hope that the freedom to continue to meaningfully advocate against harmful pieces of legislation is worth the heavy price that was paid. The medical profession is in an extremely precarious position and will no doubt face some trying times ahead. I hope that our rejection of the PSA is proof that we cannot be broken and that we will continue to advocate even in the face of continued propaganda and retaliatory measures.  Ontario’s doctors must serve as a check against the Ontario Liberal Government and their apparently willful destruction of our health care system.

There will come a time when we look back and reflect on the events that led to the creation of our modern health care system. In 1946, Tommy Douglas introduced the Saskatchewan Hospitalization Act, which became the model for health care across Canada. In 1984, the Canada Health Act introduced universal health care across the nation. In 1991, the OMA agreed to become a closed shop organization with mandatory membership. In 2016, the OMA rejected the Province’s Physician Services Agreement. August 14, 2016 was a day of significance.

Ontario’s doctors have crossed the Rubicon.

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#RealTalk: Cultural Facts & Perspectives that will make you a better doctor-

Posted on 21 August 2016 by Tammy Wong (Meds 2018)

The #RealTalk series allows our fellow students to share their ideas about how healthcare intertwines with their cultural and/or religious background. Check out this interview with 2nd year medical student Tammy Wong:

What is your background?

I was born and raised in Canada by Chinese immigrants from Hong Kong. My parents are Buddhist and raised me with traditional Chinese values.

What aspects of your culture differ from the stereotypical norms?

Family values: Chinese families focus largely on respecting and caring for elders and often decisions are made as a family, especially in relation to healthcare plans for patients. Furthermore, it may be hard to elicit patient wishes from the family’s wishes if they differ, but if physicians were perceived to ‘go behind/around’ the family then it would cause distrust in the system.

Food: One tradition when family members are in hospital or are ill, is that families will bring lots of cultural food to the patient so physicians should keep this in mind if there are diet restrictions for inpatients (i.e. NPO, low salt, etc).

Perspective on death and dying: Many Chinese immigrants, especially elders, are very superstitious. There is an idea that you will jinx something by saying it aloud so often patients avoid talking about death or risks with procedures. As a physician, you need to talk about these so you have to elicit it somehow from the patient. There is also a feeling of duty from remaining family members that they need to do everything that they can to ensure the patient’s survival, so a discussion about palliative care may be harder to approach but is necessary, especially if it coincides with patient wishes.

Perspective on mental health: There is usually a stigma regarding mental health among Chinese families. Many Chinese people do not really believe in the concept and think that you should just ‘get over it’. They also worry about being labelled with a mental health condition and often refuse to address it. This is something that physicians should be aware about and should try to educate to reduce the stigma.

Language barriers: Like with many other cultures, there may be a language barrier when speaking with Chinese patients. Furthermore, in Chinese culture it is common to nod or make sounds of agreement as a symbol to show that the listener is paying attention and as a form of respect. However, in contrast with Western culture, ‘nodding’ doesn’t always mean understanding and agreement; it is just to show respect and listening. Ask if they need clarification and summarize to check if patients actually are understanding.

Paternalistic view of medicine: Particularly with the elderly Chinese patients, they may be used to doctors telling them what to do and not really asking questions about their wishes or opinions because this was the format they were brought up with. Patients are also taught that doctors deserve respect and should know what is best for you. It is important to ask for patients’ wishes and values and to explain risks to help them make informed decisions, rather than just having them follow what you recommend.

Tell us a bit about Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) is still largely used by the Chinese community under the view that it can treat the body holistically and strengthen the body. Often patients will use TCM while also being treated with Western medications. In some cases, private insurance companies may require prescriptions for acupuncture, etc in order for the treatments to be covered. Without the prescription, the treatment can be very expensive and patients may need to go to ‘sketchier’ or unlicensed providers to save money which is more dangerous. Consider prescribing these treatments even if you don’t really believe in it to help out a patient pay for this, especially for a chronic disease that may not be curable with Western Medicine.

When performing a physical exam, what should be done that differs from what we are taught at school?

While there isn’t anything specific to ask about, many Chinese citizens are very modest so proper draping is very important, especially with elders. Ask if the patient would like anyone else in the room (i.e. spouse or family members) and explain what you are doing very clearly.

If you could give one piece of advice to us future doctors on providing care for your population, what would it be?

Always ask for clarification/understanding and take a bit of time to ask if there are any other issues when speaking with Chinese patients. They may not discuss their true fears or opinions until later on in the interview, especially if it is something embarrassing, sensitive or worrying to discuss. Mental health issues also fall into this category because it is often brushed under the rug. Be sure to ask and also suggest lots of supportive resources for these patients.

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Coffee is Delicious: How to Properly Order an Espresso

Posted on 05 June 2016 by Vanessa DeMelo (Meds 2017)

In the first and most important issue of business, a very happy summer to all! Though the 2017s are still slugging about clerkship, even the surgery clerks can’t help but see the sun at some point over the day. I on the other hand am about to start psychiatry and family medicine and am quite the happy duck. My bicycle is brushed off, its tires pumped up and it is ready to be back in action as the primary mode of transportation!

Back to the topic au jour. The subject of this post was solidified by an experience I just witnessed while in line at the Masonville Starbucks. Observe below:

Gentleman is next in line, steps up and places order

GENTLEMAN
An espresso, please. Long

BARISTA
Long?

GENTLEMAN
Yes, long

Barista’s puzzled look deepens

GENTLEMAN
Never mind, just an espresso

I was quite excited that I actually knew what he meant by that. The primary source of my education in this topic comes from a waiter in a café in Sliema, Malta, where he took pity on my uneducated North American self and revealed all of his coffee secrets. Let me take this opportunity to put in a plug for travelling to Malta – it is a magnificent, magical place and I had a phenomenal time there while doing a global health elective in plastic surgery (guess who gets a lot of skin cancer: older British people who retire in Malta). This is the view across the bay of Valetta, Malta’s capital city, from Sliema and the area of that very café.

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As an extremely quick bit of catch-up knowledge, espresso is coffee that is brewed with beans that are ground more finely and a smaller amount of water, which results in a more concentrated drink. It’s the base for lattes, cappuccinos, flat whites, and all other variety of coffee-based drinks that make the world a better place. Espresso bars provided a source of socialization in urban Italy, where coffee prices were controlled if it was consumed while standing at the bar.

How to order espresso:

Size: the size of the espresso refers to how much ground coffee is used to make the espresso, and can be single, double, or triple (solo, doppio, or triplo). Changing the size requires changing the basket size, and the standard shot size today is a double.

Length: the length of the espresso refers to the volume of water used with the same amount of ground coffee while brewing the espresso shot. These can be ristretto (reduced or short), normale (normal or standard), or lungo (long). To add further details, the varied shots are not necessarily the same shot made with more or less water, as this can result in the coffee being over- or under-extracted. The grind can be adjusted to reflect the extraction time required to reach the target volume — ristretto uses a finer grind, so the extraction would be finished more quickly, while lungo will take longer and can use a coarser grind.

So now to interpret the previous extraction with our new knowledge, the gentleman from before was asking for an espresso with more liquid volume in a “long” or lungo. If we were being fancy pants, we might also say that this implies a coarser blend as it takes a longer time to extract than a standard shot and we wouldn’t want his coffee to be over-extracted. Given that Starbsy doesn’t seem to be a place that takes this much into account, I wonder if they would simply have added some hot water to his espresso to make it longer had his request been properly interpreted. However, somewhere a European or pretentious hipster probably just wished me a swift death with that suggestion, so we will pretend I never pondered that thought.

As a final note for espresso consumption, Mr. Malta Coffee Man also emphasized to me that espresso must always be consumed with a glass of water. Now the pitchers of water on the counters of cafés make sense as part of the culture versus provided to hydrate tired bicyclists. I’ll give a shout out to my favourite coffee place in London, Locomotive Espresso at the corner of Colborne and Pall Mall Street. This place would own all of my line of credit funds if I happened to live closer.

v3

v1

I don’t hold it against the Starbucks barista for not knowing what our gentleman meant while working at our McDonald’s version of a café. Don’t get me wrong about Starbucks either – she holds a wonderful place in my heart for providing me with (1) caffeine and (2) a place to study where it is very unlikely that I will nap. This foray into international coffee consumption has once again brought about quite the travel itch, and all of you wonderful souls will now know how to order an espresso while off on your majestic adventures this summer! Happy traveling and great coffee to all!

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Sushi Etiquette, or Swimmy Noms

Posted on 17 April 2016 by Vanessa DeMelo

Hello once again! It is time to come back from a decently clerkship-sized writing hiatus and bring you my latest, thoroughly and refreshingly unsourced topic, how to eat sushi as would the Japanese version of Emily Post. Now, I’ll be the first to admit that some of these guidelines I in fact break without questioning (and have no fear, I’ll tell you why), but it’s comforting to know that should I ever find myself in Japan and dining with their royals, I will at least know what I should be doing. One of my dear friends from undergrad has been living in Nagoya for two years now, and her stories of corner store sushi that will knock your socks off make me feel as if this is a place I will be making a sincere effort to visit sooner or later. That, and the cherry blossoms.

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How could you not want to be sitting under trees made of pink clouds?

Source: Alyssa Craik, the expat herself

 

I’ve chosen to deliver the select pieces of advice in distinct temporal segments, so that you too might imagine you are eating a delicious sushi dinner, instead of the Campbell’s, broccoli-chicken-rice trio, or single lime popsicle you are currently consuming for dinner.

 

Step 1: The Preparation

It turns out that you’re not supposed to rub your chopsticks together to rid them of the tiny potential hemorrhage-causing splinters as if you were trying to start a campfire – it’s considered an insult to the host as you’re insinuating the chopsticks are of poor quality. You are supposed to gently graze the wooden chopsticks together instead should you notice any splinters, which I imagine sneakily and confusingly trying to do under the table as if playing a tiny xylophone. In the past, I have often opted to go full Girl Scout on the chopsticks as buccal bamboo shanks are not exactly up my alley. In truth, I’d much rather the restaurant just have reusable plastic chopsticks. Supposedly jade or gold chopsticks are a thing, and I’d accept those too.

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Allowed.

 

Step 2: The Obtaining

You should use the blunt ends of your chopsticks to take sashimi, maki, or sushi from the common plate. Supposedly, using the tapered business end of the chopsticks is somewhat akin to thoroughly dunking the half-eaten end of a baby carrot back into the ranch dressing and offering the bowl to the next minor acquaintance. A point can be made that you’re likely not on this sushiventure with relative strangers, but should end up at dinner with some combination of your boss or roommate’s grandma, you can minimize the presence of PO foreign salivary amylase exchange and consumption.

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People really seem to care about this societal faux pas.

 

Step 3: The Flavouring

You are apparently supposed to dab bits of wasabi onto the sashimi, as opposed to mixing it into the soy sauce as if you were making a purple soup. Prepared sushi is intended to be made with the proper amount of wasabi already, necessitating no additional green fire required. As for this soup-making, I love doing this. Given that I once ate an entire ball of wasabi in one gulp on a dare (at an NYC all you can eat sushi restaurant containing mostly fraternities– I thereby classify this action as a Would Not Recommend), I considered myself a hardened and loyal soldier to the pungent sinus cleanse. I’ve even developed a certain art to ensure proper emulsification of the paste and soy sauce. So the fact that it’s a dining no-no makes me somewhat sad, and I think this might be the rule I opt to break under the table, sacrificing smoothly sanded chopsticks for the preferable oh-so-good burn.

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Just look at this leaf, so ready to be stirred right in.

 

Step 4: The Dipping

While on the topic of soy sauce, I’ve learned that you’re supposed to dip the fish-side of the sushi into the soy sauce, not the rice-side. This is done with the intention of gently flavouring the bites as opposed to eating soy-rice pudding. This one makes sense to me, but I am still figuring it out – how do you make the pieces stay together if the smaller piece is inverted? It seems as if one is advised to dip an ice cream cone in chocolate sauce with the dairy portion left to the fate of cruel, cruel torque. My breech in etiquette isn’t for a lack of trying to do otherwise, as there have been many an attempt that have resulted in the necessary rescue of the former sea dwelling creatures from a new version of salty depths.

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Yes
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No

Step 5: The Consumption

It turns out that sushi can in fact be eaten with chopsticks, nuances of which can be found outlined above, or with either of the five-digit high fivers of which you are in possession. Maybe the second option would solve my issue with gravity trumping my efforts to protein-dunk in soy sauce as opposed to rice-dunk. You are also meant to eat the sushi in one bite (NOM!), but should this not be possible, you should eat in two bites in one go-about, and not return a half-eaten piece of sushi to your plate.

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Not a chopstick in site.

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We also know who is definitely double-dipping.

 

Now, I have outlined five points (each of which I have broken on most if not all occasions) to illustrates that sushi eating customs in Canada seem to have landed somewhat by way of “Chinese” food in North America – modified, to say the least. However, sushi eaten with company or alone is great fun, an awesome chance to try food that you otherwise might not consume, and as there never seems to be enough ginger to go around in life, it has gained a near and dear place in my heart with its ready supply.

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Quoting learned doctor Chevy Priyadamkol, “mad susheries at the club”

 

Until next time,

 

The Procrastination Compilation

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Physician Burnout and the Cult of Medicine

Posted on 16 March 2016 by Adam Kovacs-Litman

I want there to be no mistake. Medicine is the most incredible profession. It intertwines a divine understanding of scientific principles with their very human application. It is one of the few professions that starts with atoms or cells and ends with people and emotions. It begins with universal laws and ends with subjective truths. Medicine is science, but it’s also poetry. Medicine exists in cosmic balance, but that balance is temperamental.

Those working within the health care profession are well aware of a phenomenon known as “physician burnout”. It is characterized by emotional exhaustion, depersonalization, cynicism and a lack of fulfillment. Studies estimate that physician burnout can affect as many as 65% of physicians. Many are surprised that such an intellectually and emotionally rich vocation can leave one drained and unfulfilled. Dr. Christina Maslach, an American psychologist and creator of the Maslach Burnout Inventory (MBI) perfectly described burnout as “an erosion of the soul”.

Maslach’s description makes a lot of sense to me because medicine is not a profession in the traditional sense. Medicine is a religion. It demands long hours and years of study – it demands sleepless nights and tireless days – in some aspects, it demands indoctrination.

We do not wear religious shawls, but we do wear white coats. We do not worship stars, crosses or crescent moons, but openly revere snakes coiled around a winged staff. Our holy text is the Hippocratic Oath and our prophets are many: Hippocrates of Kos, Galen of Pergamon, Lister of West Ham, and Koch of Clausthal are but a few. We even have modern day prophets like William Osler and Atul Gawande and false prophets like Ben Carson or Eric Hoskins.

Viewing medicine as a religion makes physician burnout easier to understand because a religion demands that life be made secondary to the divine. Medicine demands that patients always be put first and it demands that you live your life in the shadow you cast. Some have called medicine a Black Art and in some ways it is. It is perhaps the only profession that consumes the soul of the practitioner. The quest of medicine is Faustian. Many medical practitioners will pay a heavy price for the miracles they work.

I’ve read much of the literature on physician burnout and while the conclusions are accurate, they are often uninsightful. Deckard et al. (1994) correctly identify emotional exhaustion as the leading cause of burnout. Gundersen (2001) correctly concludes that certain personality profiles are more at risk of burnout. Shanafelt (2009) even claims that we can combat burnout by realigning organizational values such that patient care be given equal importance to physician well-being.

Shanafelt’s study best addresses the crux of the issue. Nothing will change unless we reorganize the value structure of medicine. Doctors burn out because they practice a toxic ideology. A man may subsist, but they cannot survive without a soul.

I believe that people really do go into medicine for noble reasons. They want to make a difference, help people… change the world, and are often willing to sacrifice themselves in the process. Unfortunately sacrificial offerings will not make the elusive “work-life balance” any easier to attain.

This is not a critique of medicine. I repeat that medicine is an incredible profession and one that I am grateful to be a part of. This is instead an invitation to examine one’s values and the values that are thrust upon us.

A man cannot sustain himself on ideology. Anyone who eats the body of Christ and nothing else will receive poor nutritional value. Surprisingly, the blood of the Lord is not rich in iron.

References

Deckard, G., Meterko, M., & Field, D. (1994). Physician burnout: an examination of personal, professional, and organizational relationships.Medical care, 745-754.

Gundersen, L. (2001). Physician burnout. Annals of Internal Medicine,135(2), 145-148.

Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). Maslach burnout inventory manual. Consulting Psychologists Press.

Shanafelt, T. D. (2009). Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA,302(12), 1338-1340.

Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., … & Oreskovich, M. R. (2012). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of internal medicine, 172(18), 1377-1385.

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Exporting Healthcare Providers Abroad: A Short-Term, but Unsustainable Solution

Posted on 05 January 2016 by Rob Bobotsis

The Problem At Hand

In many parts of the world, poverty, discrimination, poor public infrastructure, and environmental distress have resulted in poor health outcomes[1]. To compound the problem of poor health, many countries lack sufficient healthcare providers to deal with this enormous health burden[1]. Unfortunately, resource-limited health systems, significant disease burden, and a chronic insufficiency of doctors and nurses are the reality in most low-income countries. These countries simply do not have the fiscal resources to support the expense of training and supporting crucial healthcare providers. Furthermore, many of the medical graduates from low-income countries seek opportunities in more developed areas because these other areas can provide them with the resources to do their job [2]. The World Health Organization (WHO) estimates that there is a critical shortage of 7.2 million doctors, nurses and midwives around the world, reporting that 83 countries do not even meet the minimum threshold of 23 health workers per 10,000 people[3].

Why One of Our Current Solutions is not Sustainable

Developed countries have certainly provided international medical assistance to countries in need, focusing on disease specific interventions in areas such as immunizations, maternal and child health, and HIV.2 However, the majority of the interventions thus far have not dealt with an underlying problems facing countries in need of healthcare assistance, which is the serious lack of healthcare practitioners. If a medical practitioner goes to Africa solely as a medical provider there is no doubt they will help save lives, but until the number of faculty in these countries can be increased to adequate levels, the current pattern will continue. Sub-Saharan Africa for example has no medical schools in 11 of its countries [3]. If however a medical practitioner goes as a teacher, their impact will be multiplied. The students they teach will go onto save many more lives and even become teachers themselves [3]. This would effectively help these countries help themselves in the long run.

What is Being Done to Meet This Demand

All countries need robust health care delivery systems to provide quality and accessible services. The recognition that there is a need both to improve current services and to train the next generation of in-country leaders and educators is a seemingly obvious idea, but it has taken a while to be put into practice.1 I wanted to discuss one such initiative that is addressing this lack of local healthcare providers as a root cause for poor health. In 2010, the Peace Corps and Seed Global Health (a private organization founded by a small group of faculty at the Massachusetts General Hospital), started a new dedicated doctor and nursing program.3 The program places American health professionals alongside local medical and nursing faculty counterparts in African countries to meet the teaching needs identified at each institution. In the launch year of 2012-2013, SEED Global Health placed 30 doctors and nurses at 11 training institutions in each of its three partner countries: Malawi, Tanzania and Uganda [3]. For the 2014-2015 program, 42 clinical educators are worked at 13 sites across Malawi, Tanzania, and Uganda [3].

While targeting a root cause of the healthcare crisis, one of problems with such a program is that volunteers must go overseas for a one year period, a commitment which would be difficult for physicians. They would have to leave the responsibilities of a practice or staff behind, all while facing a significant cut in their salary. The debt repayment program (up to 30,000/year) offered by SEED global health is likely attractive for more recent graduates, but not as attractive for more experienced physicians with years of teaching experience who would be the best suited to educate residents and medical students in the low-income countries they could be serving [3].
Adapting the infrastructure in the developed countries sending physicians may be a solution to this problem. If universities for example, allowed a certain number of their staff physicians to take a sabbatical year and go abroad to teach students and medical trainees in low-income countries, that would allow additional and more experienced physicians to take part.

References
1. Kerry VB, Auld S and Farmer P. An International Service Corps for Health-An Unconventional Prescription for Diplomacy. N Engl J Med. 2010; 363(13):1199-201.
2. Mullan F and Kerry VB. The Global Health Service Partnership: Teaching for the World. Acad Med. 2014;89(8):1146-8.
3. http://seedglobalhealth.org/

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Water is Life, and We are Running Low

Posted on 22 December 2015 by Sydney Todorovich

Every day you and I require at least 50 liters of fresh water in order to meet our basic needs (drinking, bathing, cooking, etc).[1] Any person anywhere in the world has this same requirement. Yet one third of the world’s population lacks access to this basic human right; they lack access to basic sanitation or clean water.[2]

Seventy percent of our world is covered in water, 2.5% of which is fresh water, and only 1% of this freshwater is easily accessible.[3] This breaks down to 0.007 percent of the world’s water being available to sustain 6.8 billion people in all facets of life.[3] Over the past one hundred years, our global water consumption has tripled, and current water demand continues to double roughly every 21 years.[4] If this trend continues, an estimated two thirds of the world’s population will have difficulty accessing safe, fresh water by 2025.[5]

This begs the question – what are we doing about it? The following offers a snapshot of a few of the projects being conducted around the world to address this problem.

Different regions face different challenges in accessing fresh water. Some areas border large bodies of salt water and have insufficient access to fresh water, while others are landlocked and see little rain, and still others have access to fresh water, but the lack of sanitation infrastructure means the water is not considered potable.

Desalination

Areas that have access to saltwater can focus their research and development on desalination projects. Large-scale desalination plants are unfeasible because of the amount of energy (and money) they require to run. However, recent advancements have made these plants more feasible for the countries that can afford them. For example, the Sorek plant in Israel (the largest desalination plant in the world) designed their plant to use larger sized pressure vessels in the reverse osmosis process in order to decrease energy consumption. This plant, which cost $500 million USD to build, pumps out 624,000,000 liters of potable water daily and is able to sell 1,000 liters for about $0.58 USD.[6] The USA is scheduled to open their own large-scale reverse osmosis desalination plant in San Diego this year.[7]

Singapore, a world leader in water processing, has been exploring the use of electrodialysis in desalination. This process removes chloride and sodium ions from water using electrical charge attraction, and would cost less than half of what revere osmosis does to produce fresh water.[8] Other methods of desalination that are being explored are forward osmosis (using a different highly concentrated solution to pull water out of saltwater)[7] and membrane biomimicry (using aquaporins in membranes to extract water).[8] Although membrane biomimicry would require significantly less energy to run, it is still not as easily scalable, it is cost prohibitive to produce, and its durability is in question.[8]

One of the bigger concerns with desalination is the salt waste that is produced, and whether putting the salt back in the ocean will negatively impact the ecosystems surrounding the plant.[7] Reports of increased salinity (from 35,000 ppm to 50,000 ppm) in the Persian Gulf surrounding the desalination plant in Saudi Arabia suggests this may be a real problem that requires addressing.[7]

Water Filtration

Every year diarrheal disease kills approximately 760,000 children under five years old.[9] The majority of these cases could be prevented by access to safe drinking water and proper sanitation.[9] Creating a cost effective, mass producible, portable, easy to use, and reliable water purification system is something that is desperately needed worldwide, especially in developing countries. Three especially interesting and innovative products that have been developed (or are in the process of being developed) to help combat this issue are the “drinkable book”, a low-cost water filter, and Slingshot.

The Drinkable Book™ is literally a book filled with paper that contains nanoparticles of silver and copper.[10] As the water is being filtered through the paper, the bacteria absorb the silver and copper, causing them to die. This paper has been tested both in the lab and in the field (including water that had raw sewage dumped into it), and the paper removed greater than 99% of the bacteria within the water. [10] Each page has instructions printed on it directing the person how to use the filter properly. One page from this drinkable book can filter approximately 100 liters of water, and one book could filter enough water to last a person four years. [10] The only drawback to this book is that it has not yet been tested on viruses nor protozoa. [10]

Askwar Hilonga is a rural Tanzanian native who studied abroad to achieve a PhD in nanotechnology. He hoped that his education would enable him to create a water filtration device that would help supply clean drinking water to the 70% of Tanzanian households who do not have it.[11] Still in its early stages, the filter shows a lot of promise. It is a sand based filter, and although sand can remove debris and bacteria from the water, Dr. Hilonga added specific nano materials to the filter in order to remove chemical and heavy metal contaminants as well.[11] He recently won a prize of $38,348 USD from the UK’s Royal Academy of Engineering for his innovation. Dr. Hilonga estimates that the price per unit will be considerably less that the initial $130 USD now that he can buy materials in bulk to create the filters. For those families who cannot afford their own filter, Dr. Hilonga has created water stations where people can buy the clean water at an affordable price.[11]

Slingshot is the creation of inventor Dean Kamen, better known for his invention of the Segway. Slingshot is a machine that produces potable water from practically any source through vapour compression distillation and requires no filters to function.[12] Its power can come from electricity if available, from a diesel generator (found at many remote hospitals), or in very remote areas it can use a Sterling engine, which is fueled by any combustible source.[13] When designing Slingshot, Mr. Kamen wanted it to be able to run for 5 years without maintenance, use less than a kilowatt of power (less than a hair dryer), generate 1000 liters of clean water per day, and require no pipelines, pre-treatment or consumable materials for the filtration.[13,14] Mr. Kamen has finished his creation, and has created a documentary about it, so we will just have to wait and see if this machine works as well as its creator hoped it would.

Making Water From Thin Air

What if there was a billboard that could use humidity to create clean drinking water? Sounds crazy. It exists. In Peru, the University of Engineering and Technology (UTEC) designed a billboard that can condense water from humidity. This billboard is located in one of the driest places on earth – Lima, Peru. Lima receives practically no rainfall even though it experiences average relative humidity of 83.9%.[15] Lima’s population is approximately 7.5 million, 700,000 of which do not have access to clean drinking water. [16] In response to this need UTEC created the billboard, which harbours five condensers that act to cool the air and thus create liquid water. The water is subject to reverse-osmosis purification before it can be stored in the 20L storage container at the base of the billboard. It is capable of producing 96 liters of water per day for local residents. And although the billboard cost a mere $1200 USD to build, it has the ability to offset the construction and energy costs through advertising on the billboard itself. Whether more will be created, or whether the design will be available for sale to other countries or industries is yet to be seen.[16]

References

1. Gleick P.H. (1996). Basic water requirements for human activities: Meeting basic needs. Water international, 21; 83-92.

2. USAID. (2015). Water and sanitation. Retrieved from: www.usaid.gov/what-we-do/water-and-sanitation

3. National Geographic. (2015). A clean water crisis. Retrieved from: environment.nationalgeographic.com/environment/freshwater/freshwater-crisis/

4. Chakravorti, B. (2015). Is clean water the new oil? Retrieved from: fletcher.tufts.edu/MIB/Ten-Questions/Q6-Is-clean-water-the-new-oil

5. Scanlon, J., Cassar, A., & Nemes, N. (2004) Water as a human right? IUCN Environmental Policy and Law Paper No. 51

6. MIT Technology Review. (2015). Megascale Desalination: The world’s largest and cheapest reverse-osmosis desalination plant is up and running in Israel. Retrieved from: www.technologyreview.com/featuredstory/534996/megascale-desalination/

7. Belton, P. (2015). Can making seawater drinkable quench the world’s thirst? BBC Business. Retrieved from: www.bbc.com/news/business-34478052

8. McKeag, T. (2014). Do tilapia and mangroves hold secrets to desalination? Retrieved from: www.greenbiz.com/blog/2014/09/03/desalination-how-nature-can-guide-us-water-fit-drink

9. The World Health Organization. (2013). Diarrhoeal disease. Fact sheet No330. Retrieved from: www.who.int/mediacentre/factsheets/fs330/en/

10. Webb, J. (2015). Bug-killing book pages clean murky drinking water. BBC Science. Retrieved from: www.bbc.com/news/science-environment-33954763

11. BBC. (2015). Tanzanian low-cost water filter wins innovation prize. Retrieved from: www.bbc.com/news/world-africa-32973591

12. Melanson, D. (2008). Dean Kamen aims to clean water, generate electricity with Slingshot machine. Retrieved from: www.engadget.com/2008/04/23/dean-kamen-aims-to-clean-water-generate-electricity-with-slings/

13. Science http://science.howstuffworks.com/environmental/green-tech/remediation/slingshot-water-purifier3.htm

14. Kamen, D. (2010). What’s behind my curtain? TEDMED 2010. Retrieved from: www.tedmed.com/talks/show?id=6994

15. Wikipedia. (2015). Lima. Retrieved from: en.wikipedia.org/wiki/Lima#Climate

16. Smith-Strickland, K. (2013). A billboard that condenses water from humidity. Popular Mechanics. Retrieved from: www.popularmechanics.com/science/green-tech/a8875/a-billboard-that-condenses-water-from-humidity-15393050/

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