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

10 Traveling Tips for Global Health Electives

By: Adriana Cappelletti (Meds 2018)

1) Read up: Find out as much as you can ahead of time about the place you’re visiting.

Learn about the country’s history, current political situation, and local customs. Find out what people wear to work and around town to make sure you pack appropriate clothing. Some countries have more conservative styles. For example, where we stayed in Uganda, women almost exclusively wear skirts (usually to the knee or lower), while men wear button-down shirts and full pants, even in the heat.

2) Medical supplies: Bring your own masks, gloves and hand sanitizer. In low resource settings, you do not want to put a dent in their supply.

Also, try to snag any surgical gloves or sterile sutures you can get your hands on. You can ask surgeons, residents or scrub nurses you have worked with about any slightly expired, unopened sutures they’d be willing to donate.

3) Little Pharma: Stock up on your own mini drug supply and plan all vaccinations well in advance.

This takes up more time than you’d expect! You’ll need prescriptions for both drugs and travel vaccinations. Useful prescription drugs can include antimalarials, HIV post-exposure prophylaxis, and ciprofloxacin (or alternatively azithromycin) in case of bacterial gastroenteritis.

Travel vaccinations you might need include yellow fever, typhoid, and hepatitis A/B. Yellow fever is in limited supply in Canada and is necessary for entry to many countries in Africa and South America, so don’t leave this to the last minute. Do not expect to get travel prescriptions filled by a walk-in clinic. You can either pay $80 for an appointment at a travel clinic, or if you have a family physician, they may provide you with these prescriptions and save you eighty bucks. Over-the-counter drugs for your mini pharmaceutical kit might include polysporin, ibuprofen, acetaminophen, bismuth salicylate, PEG, and immodium.

4) Moula: Seek out any funding opportunities for global health initiatives.

If you look for it, there’s plenty of money out there to help fund your global health elective. Check out this link  for the opportunities available to students at Schulich.

5) Safe living quarters: Don’t skimp on accommodations and compromise safety for savings.

When going somewhere unfamiliar to you, it’s best to err on the side of caution and choose trusted accommodations. We connected with a Guest House owned and operated by Massachusetts General Hospital for medical trainees and staff. For $25 USD per day, we had a private bedroom and bath, 24/7 on site security, and we were walking distance from the hospital. We felt safe and at home, and we met other Global Health aficionados.

6) Expectations: Establish mutual goals with your supervisor abroad.

Either ahead of time online or in person on your first day, try to establish a sort of contract of expectations with your supervisor. Let them know what you’re hoping to get out of your elective. Find out from them what they’re expecting of you and what is actually possible at their site. This can prevent disappointment or misunderstanding on either end.

7) Dive in: Embrace the culture, food, and local language(s).

Get to know locals, either from the hospital or through your accommodations. Ask them about their lives: how did they grow up, what is medical school or residency like for them, and what do they like to do for fun in their spare time? Immerse yourself in daily living by going to market and visiting shops. Find out if there is a nearby cultural centre. When we went to the Igongo cultural centre for the Ankole district of Uganda, we learnt about how farming, construction and traditions evolved in the area.

Try traditional foods. Avoid street meat, which can be undercooked, or raw vegetables, which may be washed with unfiltered water. Learn some basics of the local language. In Western Uganda, the academic language is English, but many people speak only Runyankole, the regional dialect. Knowing simple phrases like, “How are you?” or “How was your night?” can go a long way in building patient trust. If you show interest in the country’s culture and language, people will notice and be appreciative that you are making an effort to understand their way of life.

8) Ethical tourism: Support local businesses when buying groceries or gifts and planning weekend getaways.

As a visitor to a developing country, you have the opportunity to contribute to that nation’s economy and be a responsible traveler.  When grocery shopping, hit up local markets. At supermarkets, try to buy food items manufactured within that country. If you’re planning something tourist-y (we went on safaris), book transportation and accommodations that are operated by and employ local people.

Gifts for your friends and family back home (or, let’s be real, for yourself) are also an opportunity to contribute to the economy. In Uganda and many other developing countries, tailors can be commissioned to make custom clothing at low cost. We bought fabrics in traditional African patterns from the market and had one-of-a-kind clothing made for $30 or less per item.

9) Emotional support: Know who you can talk to about your experience.

Global Health electives can be extremely enriching, but they can also be emotionally draining. Your clinical experience in a low resource setting might raise moral and ethical dilemmas you didn’t anticipate.

Let’s use an example: a young man gets in a bota-bota (motorcycle) accident and needs an emergent head CT. The cost isn’t covered by the government, and he and his relatives cannot afford the $200 CT that is needed to save his life. Everything is stalled while he is dying. Do you pay the $200 out of your own pocket? If you do, what happens when other patients’ families find out that the international student (you) can pay for imaging or drugs?

Don’t keep this inner turmoil to yourself. Rely on physicians with experience in Global Health. Share your thoughts with them, and have a discussion around the complexity of these situations. Back in Canada, debrief with the Office of International & Health Equity Learning (IHEL) and a physician mentor. It’s also really helpful to complete this type of elective with another medical student, for both safety reasons and to have someone who understands what you’re going through abroad and back home. For moral and ethical cases to work through in preparation for your elective, check out this link .

10) Share: Make use of the new insight you’ve gained by publishing or presenting about your elective.

You’ve had a life-changing experience! Take advantage of your unique perspective and the learning you’ve had to contribute to medical journals, blogs and conferences. You can write reflections or poems for the UWOMJ Blog or the CMAJ Humanities Blog. You can partner with your supervisor abroad to publish a case study. You can prepare a poster presentation on your experience and attend a Global Health conference in Canada or internationally.

 

Author: Andriana Capelletti

Adriana Cappelletti (Meds 2018) completed a Global Health elective in Obstetrics & Gynecology in Uganda in November 2017, alongside Rachel Loebach (Meds 2018). Adriana is pursuing a career in Family Medicine and intends to incorporate Women’s Health and Global Health within her practice. Adriana’s clinical experience in Uganda was cut short by an unfortunate physician strike, which left countless patients without care. Witnessing the repercussions of political turmoil on population health has only heightened her sense of social accountability and motivation to engage in international partnerships.
Twitter @cappelletti07.

 

 

Understanding the Health Impacts of Climate Change: Advancing the advocacy role of doctors and healthcare professionals

By: George T. Kitching

In 2009, a Lancet Commission on the health impact of climate change warned that climate change poses the greatest global health threat of the 21st century and has the potential to undermine the past 50 years of progress in global health. In June 2015, a second Lancet Commission on Climate Change, (this one focused on health policy implications), concluded that “tackling climate change could be the greatest global health opportunity of the 21st century.” In the same month, the Lancet published a joint commission with The Rockefeller Foundation entitled Safeguarding human health in the Anthropocene epoch, with the intent to create a new interdisciplinary, collaborative research field named Planetary Health.

Defining ‘Planetary Health’

There is no agreed upon definition of Planetary Health, however it was first envisioned, as the achievement of the highest attainable standard of health, wellbeing, and equity worldwide through judicious attention to the human systems-political, economic, and social-that shape the future of humanity and the Earth’s natural systems that define the safe environmental limits within which humanity can flourish. Time will tell whether this research field has staying power over the long term, however a PubMed search for ‘Planetary Health’ scientific journal articles identified 191 publications already since June 2015 regarding the topic. Much of the activity around Planetary Health has focused on defining the new field and attempting to distinguish it from Global Health and concepts of One Health and EcoHealth.

This process has been assisted by the launch of a new Lancet sub-journal in Planetary Health in April 2017. A scan of topics covered in the first eleven issues among others include the examination of the health co-benefits of action on climate change, and in the September issue, a focus on the health impact of pollution. A comparison between One Health (which focuses on the connections between humans, animals and their environment), EcoHealth (which values biodiversity, including all forms of life, and incorporates concepts of environmental sustainability), and Planetary Health, found commonalities between the various approaches to health, however there were differences identified between contributing sciences, core focus and core values. In particular, Planetary Health was noted to have a more anthropocentric approach to health, with greater focus on equity in human health. Planetary Health was identified to differ from Global Health through its emphasis on sustainability based on natural resources.

The Real-World Health Impact 

The development of the field of Planetary Health, with its direct focus on human health, speaks to the growing awareness of the impact of political determinants of health, mediated through the local and global environment. Air pollution and accumulating microplastics are two examples of factors that transcend national borders to contribute to global climate change and environmental degradation. The Lancet Commission on Pollution, published in October 2017, found diseases caused by pollution were responsible for an estimated 9 million premature deaths in 2015, with the greatest deaths being contributed to air pollution alone. Furthermore, these 9 million premature deaths are approximately 16% of all deaths worldwide, and three times higher than AIDS, tuberculosis and malaria deaths combined. A 2017 investigation by Orb Media found 83% of potable tap water samples, collected from locations around the world, were contaminated with microplastics. In addition, further research into human consumption of microplastics has identified other daily sources of microplastic ingestion, such as sea salt, commonly used in cooking. The impact of microplastics on human health is still unknown, however, they have been recognized as potential vectors for persistent organic pollutants.

So, what is the value of a new field such as Planetary Health? Well, it provokes the examination of climate change through a human health lens. It spurs reflection on the ways that human health is connected to the environment and affected by political, economic and social paradigms. It challenges the public and global health scientific community to engage in interdisciplinary research. AND it challenges physicians and healthcare providers to advocate on behalf of their patients, for the development of sustainable societies through aggressive climate change mitigation strategies.

Looking Forward 

In September 2015 Canada joined countries around the world in adopting the Sustainable Development Goals (SDGs) to ‘end poverty, protect the planet, and ensure prosperity for all’. While addressing climate change is recognized within the SDGs (Goal 13), it is interwoven into the meaningful attainment of every other SDG. Without addressing climate change, ending poverty (Goal 1) or ensuring health and well-being for all (Goal 3), may be transient victories, reversed rapidly for those displaced from lands no longer habitable.

In summary, definitive, lasting attainment of the targets set out in the SDGs rests upon robust and aggressive climate change mitigation. We need increased research by the global health scientific community into the health implications of climate change and its mitigation, and increased advocacy by our physicians and healthcare providers in understanding and preventing the local and global impacts of unsustainable resource use. And to achieve this, the field of Planetary Health helps to remind us all of the inseparable link between our environment and our health.

Author: George T. Kitching

George Tjensvoll Kitching is of Canadian and Norwegian ancestry, originally from Toronto. He has completed a BSc. in Biochemistry (Dalhousie University) and a MSc. in Public Health specializing in Global Health (Norwegian University of Science and Technology). George is currently studying at Western as a first-year medical student at the Schulich School of Medicine and Dentistry, at the Windsor campus. He is interested in understanding the role of healthcare providers in mitigating the health consequences of climate change.

Photo Credit: Creative Commons, Wind Turbines 

Remote Medicine: An Urban Medical Student’s Perspective

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

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

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.

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

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/

Water is Life, and We are Running Low

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/

Dominican Republic, Canadian Dental Relief International, and Hopes for the Future

People who visit the Dominican Republic think of resorts, snorkelling and beautiful beaches. They think of friendly, smiling people and shops for tourists to buy souvenirs.  When the plane touches down on the runway and you step onto the tarmac, you are greeted by a wave of warmth.  Palm trees wave hello in the light breeze. I have a different memory.  We were carting loads of dental supplies with us from Canada. I was travelling with the Canadian Dental Relief International, a group of dentists who decided to start giving back to the global community in the form of free dental care.

The first evening we set up temporary dental units and chairs, organized tools and supplies, and met the resident health care worker who had been providing rudimentary dental care thus far.  Over the course of only two weeks, her education had advanced in the areas of accurate anaesthetic delivery, optimal extractions methods and basic oral hygiene instructions.

We would arrive at the clinic day after day to lines of people coming from kilometers away. The people would wait at the clinic doors all day for toothache and infection relief. It was an intense and productive period of time where hundreds of patients were treated and a local health-care worker was trained.  All this was in the backdrop of beautiful, Caribbean sunsets and an armed guard to protect our sleeping quarters.  It was a country of poignant contrasts.  In hindsight, the people of the town were living in luxury compared to the depths of poverty I was to come across later on during the trip…

I remember the ride along a bumpy dirt road.  Dust created a veil in front of the surrounding landscape.  There were wide, rolling plains covered with tall green shoots.  The curious plants looked like a cross between corn stalks and bamboo.  These were sugar cane fields.  I liked it because it was exotic and because the crop stood so tall.  I imagined running through the stalks and getting lost in the maze.  There was a woody yet sweet smell in the air that was enjoyable save for the occasional intermingling of the car exhaust fumes.  The dirt road came to an end at the Batey.  This was a small village where the sugar cane workers lived.  Many of the workers were migrants from Haiti.  The men in the village spoke about their long days harvesting sugar cane.  They were friendly people but tired as well.  There were no doctors to provide care for them if they became sick. Canada, with dirt floors.  That was it.  That was the house built for a family of six.  The roof was low, too low for an adult to stand beneath without bowing their necks. There were some branches strung together outside to form a clothes line. So it went as we passed from abode to abode.  A ramshackle camp strung together with whatever buildings materials had been scavenged from wherever they had been scavenged.  There was a concrete cylinder in the center of town that housed the water supply for everyone at the Batey.  None of the shacks had running water or toilets.  They were just rooms.  Beside the water tank and in the center of town stood the single well-constructed building, which was a church.  I was struck by a sense of irony, but who was I to judge.  Whatever gets you through the day…or the life as it were…

After a tour we came to our purpose at the Batey. At the school, we presented posters and acted out skits for the children explaining the detriments of pop and candy on the teeth. I remember the kids laughing and playing games with one another. I couldn’t help but thinking that they were innocent to the truths of their poverty.  Perhaps innocence negated their poverty, at least until the point that their hunger pains began.

Looking out upon a vast field of sugar cane one was struck by the thought:  If we paid a dollar more per bag of sugar cane to help these people, would we do it?  Would the money get to them? Would their lives improve? The small act of adding a tablespoon of sugar to my tea was a silent acceptance of the servitude of men in foreign lands.  So the story goes, from the clothes we buy to the foods we eat, we are confronted with an Everest of serfdom.

I left the Batey, and the Dominican Republic with the same poignant contrast she loved to impart.  Mixed with the melancholy and overwhelming sense of powerlessness, my empathy and awareness for the difficulties of the world grew.  Balance what we take with what we give back.  You don’t have to look hard to find people in need.  As health professionals we have struggled to the top of a mountain for the privilege of a skillset that can help the world, it is our obligation to try where and when we can.

World AIDS Day

On this World AIDS Day we celebrate progress that has been made and we push to meet new goals to end the AIDS epidemic by 2030. This year the UN reached their target of treating 15 million people with HIV by 2015. In their new Fast-Track Strategy, they aim to have 90% of HIV infected individuals knowing their HIV status, 90% of those people to be receiving treatment and 90% of people being treated to have viral load suppression to the level where they are no longer infectious (the 90-90-90 goal) by 2020 and a similar 95-95-95 goal by 2030. Along with this, they are aiming to have new infections in adults down to 200 000 by 2030 and having zero discrimination is a goal throughout.
These are ambitious goals, but we have already seen proof of the amazing progress that can be made in this fight against the AIDS epidemic when world organizations come together to meet a target. We must continue with increased effort or risk back tracking as Michel Sidibé, Executive Director of UNAIDS, has stated, “We have bent the trajectory of the epidemic. Now we have five years to break it for good or risk the epidemic rebounding out of control.”
Here is Michel Sidibe’s 2015 World AIDS Day Message:
http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2015/
november/20151119_WAD2015
References:
http://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdf
For more information on the Fast-Track Strategy including materials to share on social media to show your support for the initiative: http://www.unaids.org/wad2015/

“Pharmacare is the unfinished business of Canadian Medicare”

“Pharmacare is the unfinished business of Canadian Medicare” says a new report by Pharmacare 2020, an organization comprised of a number of prominent physicians, health policy workers, and researchers.

How did we get here? Why are prescription drugs not covered by Canadian medicare? Why don’t we need to show our health card when we go to the pharmacy? To answer these questions, we must delve into the history of Canada’s health care system.

Since the early days of medicare, many have argued that medications are a necessary part of a comprehensive coverage system. In 1945, the Federal government made the first proposal to the provinces regarding a national medical insurance system that, notably, suggested inclusion of drug coverage. In 1964, the Royal Commission on Health Services (informally known as the Hall report), recommended that the federal government assist the provinces in establishing a comprehensive, universal program for ensuring medical services (which was based on Saskatchewan’s system that was already implemented). This influential report also recommended that the plan include coverage for prescription drugs. Drug coverage was discussed at the federal level, but “was shelved because the government did not perceive sufficient public demand to make it a political win” (http://irpp.org/research-studies/study-no50/). Thus, it was not included in the 1966 Medical Care Act, a precursor of the 1984 Canada Health Act. Without federal direction, each province formed its own public drug coverage insurance plan for specific sub-populations. Most of these programs target seniors, low income families, and individuals with disabilities.

The idea of universal pharmaceutical coverage was not formally revisited at the federal level until 1997, when former Prime Minister Jean Chretien chaired the ‘National Forum on Health’. The forum identified two key problems with drug benefit plans:

  1. Having multiple bodies purchase drugs (i.e. private insurance companies, hospitals, provincial drug plans) reduced the purchasing power that could be had by a larger collective organization
  2. Seniors were under-insured for many necessary medications

Yet again, it was recommended that drugs should be included “because pharmaceuticals are medically necessary and public financing is the only reasonable way to promote universal access and to control costs.” (National Forum on Health 1997). In 2002, the Romanow commission recommended starting with federally-initiated catastrophic drug coverage. Then, incremental reforms could ultimately lead to complete drug coverage for all Canadians. This report lead to the formation of the National Pharmaceuticals Strategy in 2004. Unfortunately, funding decreased and progress was hindered due a change in the federal government in 2006.

Although not government sanctioned, a number of reports since 2002 have recommended a Universal Pharmacare Coverage program. However, a quick glance at the authors of these reports demonstrates considerable overlap. Although well written and researched, there are a limited number of groups and individuals researching potential pharmacare reforms in Canada, and even less ambassadors for it at the provincial and federal government level. However, as pointed out in the recent Pharmacare 2020 report ‘The Future of Drug Coverage in Canada’: “a July 2015 poll by the Angus Reid Institute found that 91% of Canadians support the concept of having “Pharmacare” to provide universal access to necessary medicines; 88% believe that medicines should be part of Medicare; 80% believe that a single-payer system would be more efficient; and 89% believe Pharmacare should be a joint effort involving provinces and the federal government.” Public demand for pharmacare reform is there, the research supports it, and yet there are no government initiatives and virtually no incentive for the government to do so. What should be done?

….. stay tuned for more!

 

References:

  1. Are Income-Based Public Drug Benefit Programs Fit for an Aging Population? http://irpp.org/research-studies/study-no50/
  2. Pharmacare 2020: The Future of Drug Coverage in Canada http://www.pharmacare2020.ca/
  3. 2014 Lobby Day Delegate Backgrounder https://drive.google.com/file/d/0B9cM-RadOUW2RzR5YW01UHNuZUk/view?usp=sharing