On fat patients

By: Umangjot Bharaj

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

The Body Positivity Movement and Physicians

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

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

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

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

A Patient’s Experience

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

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

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

Moving Forward Together

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

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

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

Author: Umangjot Bharaj

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

Healthcare Reform in The Ford Government

By: Hasan Hawilo

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

No More LHINs?                           

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

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

Sustainable Solutions?

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

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

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

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

Author: Hasan Hawilo

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

Photo Flikr: Creative Commons, Publicly funded Healthcare in Danger

How To Stop Ebola In 4 Easy Steps

By: Zachary Weiss

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

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

Let’s get to it.

Step 1: Stabilize the DRC and surrounding area.

Democratic Republic of Congo: Map

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

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

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

Step 2: Build trust with communities.

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

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

Step 3: Stop climate change.

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

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

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

Step 4: Vaccinate, vaccinate, vaccinate.

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

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

Moving Forward

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


Author: Zach Weiss

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

Photo Credits: Wikimedia Commons

Lies and Lyme

My first exposure to ticks was 3 years ago. In the summer of 2015, I returned home from my studies at UBC to work as a tree planter with my local conservation authority. While the job was enjoyable, I will never forget the 3 days of shear torture I spent planting trees at one particular site near Sarnia, Ontario. Why was it torture, you ask? Ticks. Dozens upon dozens of ticks. Now, I’m usually the kind of person to not be bothered by bugs. Bees, spiders, even cockroaches—bring it on. But ticks? No chance in hell. Not only do they quite literally burrow into your skin to fed, they’re tiny, vampiric-looking creatures with the remarkable ability to hide in your clothes, hair, and just about everywhere else. Simply put, if you know anything about The Office (U.S.), ticks are the Toby to my Michael Scott. My absolute fear of these little summer vampires aside, there is something even more terrifying than ticks themselves: Lyme disease.

Among the dozens of diseases around the world that ticks have been shown to carry, Lyme disease is the one that poses a unique and rapidly worsening threat in North America. Lyme disease is an inflammatory infection in humans caused by Borrelia bacteria, which is found in a variety of animals including birds, mice, and deer. Ticks are the main transmission vector of Borrelia, and pick up the bacteria by biting other animals. When humans are bitten by bacteria-ridden ticks, infection occurs.

‘Bulls-eye’ rash at site of tick bite – characteristic for Lyme disease.

What makes Lyme disease particularly challenging for physicians is the difficulty of early diagnosis, with Stage 1 infection often presenting with non-specific symptoms such as fever, pain, headaches, and muscle aches. Some cases also present with a “bull’s eye” rash near the site of the tick bite (pictured on right). As Lyme disease progresses, the symptoms worsen dramatically—affecting mental health status, causing chronic fatigue, neurological symptoms like tremors and numbness, as well as even causing chest pain, heart palpitations, and shortness of breath.


The worst part? We had a vaccine for Lyme disease; LYMErix, an effective, albeit relatively expensive vaccine (at $50 USD per dose), was sold from 1998 to 2001. While shown to be over 90% effective at preventing Lyme, LYMErix was withdrawn due to a multitude of factors, most notably due to public pressure on behalf of anti-vaxxers. Their argument? The LYMErix vaccine caused widespread adverse effects, namely musculoskeletal issues like arthritis. This argument, despite little evidence in support of it, still made LYMErix one of the earliest casualties of the still-growing anti-vaccine movement.

Fast forward to today, and I had more or less forgotten about ticks and Lyme disease. That is, until I listened to a particularly interesting episode of Canadaland, a podcast tackling issues in Canadian media and politics (which I highly recommend you listen to, by the way). In this episode, a controversy about a Lyme disease cover-up was mentioned, whereby this originally-removed story in the Halifax Chronicle Herald was replaced in favour of this piece by the province’s chief medical Officer of Health, Dr. Robert Strang. While the first article argued for the existence of significant deficiencies in the Nova Scotia healthcare system in addressing Lyme, Dr. Strang argued the opposite: Lyme disease is under control and not worth worrying about.

Well, Dr. Strang, I respectfully disagree.

While we have come a long way in diagnosing Lyme disease, currently available diagnostic testing is complicated and only available at a handful of centres across the country. And despite my forgetting (or conscious repression) of my nightmare-inducing tick experience, ticks—and Lyme disease—are spreading fast. In Canada, cases of Lyme disease have risen sharply from just 144 reported cases nationwide in 2009 to nearly 1000 cases in Ontario alone in 2017. And just like so many other things, we have climate change to thank for it. Rising temperatures have not only increased the range that ticks occupy, but they have also increased the developmental rate of ticks—meaning more and more adult ticks ready and able to spread Lyme disease each and every year. And while provincial and federal governments are finally waking up to the growing problem of Lyme disease, as well as with climate change, such action may be too little, too late. With the catastrophic effects of climate change predicted to start in as little as 22 years, Lyme disease has the potential to become a huge public health crisis in the years to come.

So, where does that leave us? Nowhere good. Lyme disease is a big problem that is only going to get worse, plain and simple. Tackling Lyme disease means tackling climate change—an effort yet to be seen on the scale that’s necessary. And if Nova Scotia and other jurisdictions are telling us they’ve got a handle on Lyme, not only are they lying to us, they’re lying to themselves.


Author: Zachary Weiss

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

Photo Credits: Pixabay


A Prescription for Income: The Ontario UBI Pilot Cancellation and the Impact of Poverty on Health

Case Study 101 

Imagine you’re a cancer patient. You’ve been undergoing treatment for almost a year now—a combination of radiation and chemotherapy. Finally, after months of fighting, these treatments have nearly eliminated all of the cancer from your body. With only a few more treatments, your doctors are confident you’ll be able to be declared cancer-free. Now, imagine one day you turn on the news to find that the government will no longer be paying for your cancer treatment. The government’s argument? That this kind of service is “clearly not benefitting all citizens”. Your treatments are to be suspended and you’re left with no other options.

This is ludicrous, isn’t it? Of course, no government in their right mind would halt treatment for a disease with readily accessible treatment options, right?

Enter Universal Basic Income.


What is Universal Basic Income?

Universal Basic Income (UBI), has a history that dates back to Thomas More’s Utopia in 1551, where, among other things, More argues that every person should receive guaranteed income.

The premise of UBI is simple: instead of providing citizens supplemental income and social security through an array of programs like welfare, old age security, and unemployment insurance, the government instead gives a lump sum payment every month. While various trials around the world have mostly offered UBI to citizens in lower income brackets, a nationalized UBI would, in theory, provide a basic income to all citizens regardless of their income, education, or profession. In Canada or the United States, a theoretical UBI system would provide each adult approximately $1000 monthly; not enough to fully support an unemployed individual, but enough to ensure that those with low incomes don’t struggle just to make ends meet.

Of course, UBI is not without controversy. Providing “no-strings-attached” money to all members of a society (include the wealthy) seems challenging, if not a little crazy. After all, who is going to pay for this? Won’t this just encourage laziness? Put simply, supporters of UBI argue that such a system would increase worker productivity and economic output, eliminate the administrative costs of running multiple welfare agencies, reduce healthcare spending, and reduce the stigma of receiving government support. Supporters also argue that all of these benefits, in addition to raising corporate tax rates and closing tax loopholes, would result in more than enough money to finance a full-fledged program—estimated to cost $43-billion annually in Canada.

Over the years, the idea of UBI has been tested around the world in several capacities, including ongoing projects in Scotland, Finland, and Kenya. Contrary to the belief of many skeptics, in each of these studies, researchers found the money doesn’t cause poor people to give up work. Instead, people invested in improving their own lives and the lives of their families. Things that were just out of reach—like sufficient food, quality healthcare, and education—suddenly became accessible. Although the merits of UBI continue to be debated, when coupled with other policy solutions such as a federal jobs guarantee, UBI has the potential to dramatically change the way nations address poverty.


UBI and Health 

Poverty, like cancer, is a chronic disease. The effects of poverty and cancer don’t last for months, but instead impact the lives of those affected for years, decades, and maybe even their entire lives. These diseases often don’t have one discernible trigger, and remit and relapse throughout one’s life for no apparent reason. In medicine, things like income and poverty belong to a collection of factors known as the social determinants of health (SDH). In the case of inadequate income, the stress associated with this can cause a negative ripple effect to all elements of one’s life. Poverty has been implicated as a contributing factor to poor childhood development, mental and physical health problems, and an inability to access to healthcare services. Furthermore, treatments for the health-related impacts of poverty remain elusive. UBI represents one potential solution.

Particularly when it comes to healthcare, past and present UBI trials have shown that UBI has the potential to dramatically reduce the health inequities that remain pervasive in our society. Alaska, home of the Alaska Permanent Fund, reports 14% decreased likelihood of low birth weight compared to other US states. In Kenya, youth experienced 24% less depressive symptoms alongside reports of feeling healthier and more hopeful. In Manitoba, an 8.5% decline in healthcare utilization and decreased hospital visits for psychiatric reasons were reported.


The Ontario UBI Pilot

Given the immense potential of UBI to address a slew of issues, in 2016 the Ontario Government under the leadership of Premier Kathleen Wynne developed a UBI pilot program. This $150-million, three-year program, which took place in a mix of urban and rural locations in the Hamilton, Thunder Bay, and Lindsay areas, enrolled 4,000 low income participants to receive a combined yearly UBI stipend of $17,000 for a single person or $24,000 for a couple, minus 50% of any yearly earned income from those actively working. This group was then compared to a control group 2,000 participants not receiving any monthly UBI payments. Overseen by researchers from St. Michael’s Hospital and McMaster University, the study was meant to investigate the impacts of UBI on those living on lower incomes with regard to food security, stress, anxiety, mental health, housing stability, and a slew of other health-related factors.


Pilot Cancellation

After less than a year of formal operations, and despite the remarkable amount of promise UBI holds, the Ford government formally announced its intentions to “wind-down” the basic income pilot project in August 2018. Asked about the cancellation of the UBI pilot, Children, Community and Social Services Minister Lisa Macleod said that the project was expensive and that “it really is a disincentive to get people back on track”.

Wait, what?

Saying that providing extra income to citizens encourages dependence on the government is akin to saying that needing treatment for cancer encourages dependence on the healthcare system. Nobody seeks cancer treatment because they wish to be there forever. People seek cancer treatment because it is their only option to becoming healthy again. Likewise, nobody relies on programs like UBI because they want to be dependent on government support. People rely on programs like UBI because it is a path to financial independence. To further counter the government’s narrative, the PC government chose to cancel this project before any meaningful data was able to be collected. Meanwhile, as previously mentioned, past UBI trials have shown that UBI empowers its recipients to find work — hardly the disincentive the Ontario government says it is.

Ultimately, this decision by the Ford government, much like their decision to once again “review” the merits of safe injection sites, (see James Payne post on SSIs) is the wrong one. The cancellation of the UBI pilot will rob the entire world of important data needed to assess the merits and implementation of UBI on a broader scale. Furthermore, this decision will further disadvantage our most vulnerable citizens. It will result in worse healthcare outcomes and it may very well cost lives. And for a government that prides itself on being “for the people”, these kinds of decisions are anything but.


Author: Zachary Weiss

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

Photo Credits: Pexels 

Natural Discovery of AAV Serotypes, Directed Evolution of AAV Serotypes, and their Importance to Gene Therapy

As we reach the end of the first month back from break, I think it’s a nice time to continue on our journey into the world of gene therapy. My last blog entry focused on why the adeno-associated virus (AAV) capsid is such an important part of gene therapy, and this time, we’ll focus on how different types of AAV capsid affect therapy efficacy and what researchers are doing to find new types of AAV capsids.

AAV was first discovered in the 1960s by groups of scientists when they found small particles riding along with adenovirus cultures. In 1982, the first AAV serotype, AAV2, was cloned. (For a more in-depth review of AAV history, click here: Birth of a New Therapeutic Platform: 47 Years of Adeno-associated Virus Biology From Virus Discovery to Licensed Gene Therapy). However, it was soon discovered that AAV2 displays natural tropism towards certain tissues. What this means is that once injected into the blood stream, AAV2 automatically moves toward specific areas of the body; in this case, the CNS and kidneys. (For more information on serotype tissue specificity, click here: Adeno-associated Virus (AAV) Guide). This specificity would prove to be a double-edged sword. On the one hand, tissue specificity reduces risks of systemically expressing genes and reduces immunogenicity; on the other hand, this means that unless new capsid types are found to target an organ system, diseases of that system would be impenetrable to gene therapy.

Fortunately, soon after the isolation of AAV2, several other natural AAV serotypes were discovered (such as the, ‘Novel adeno-associated viruses from rhesus monkeys as vectors for human gene therapy’). These new serotypes were found to have drastically different tropisms from AAV2, which opened up new doors towards creating novel therapies that were more specific, and less immunogenic. However, as hard-working scientists go, you knew that they weren’t just going to let a couple new dozen natural serotypes be discovered. Researchers began to tinker with mixing capsids together to generate new hybrid AAVs, in the hopes of creating new capsids that combined properties that would make them even more efficient. Soon, hybrid capsids like AAV2/5 were created, combining their organ specificities and AAV2’s already well-established production efficiency.

The idea of discovering new AAVs in nature and combining them with other natural AAVs to create hybrids sounds all fun and exciting, but we must take a moment to think. What if we can create an environment that drives AAV evolution towards specific tropisms and/or improved production efficiency? What if we force AAV to adapt to certain set conditions in the lab and create new AAV serotypes that are better than those that evolved in nature? Within the past two decades, the idea of using directed evolution to create new serotypes of AAV has exploded in the field of gene therapy, and multiple methods have been described in literature to achieve this goal (here is a rather well known one: Directed evolution of adeno-associated virus yields enhanced gene delivery vectors). The basic idea of directed evolution is simple: subject AAV to a hostile environment, collect the survivors, let them grow, and repeat until the hardiest one is left. Thus, it became possible to not just find AAV in nature and hybridize them, but it became possible to speed up nature to make our own AAV serotypes.

In summary, with the discovery of new natural AAV serotypes, the hybridisation of these natural serotypes, and by incorporating the directed evolution of AAV; we have created an entire host of AAV agents that are specific to organ systems (and sometimes even to specific cells!). At the same time, it also became possible to develop new techniques that made AAV production costs much cheaper as multiple new serotypes grew much faster in culture. Next time, we will take a look at the beginning of the era of human gene therapy trials.


Author: Danning Li

Danning Li completed his BSc. majoring in Physiology at McGill University. Afterwards, he worked for two years on developing a gene replacement therapy for Canavan Disease, a rare inherited leukodystrophy, at the Horae Gene Therapy Center at the University of Massachusetts Medical School. Now a medical student at Schulich, he wants to bring attention to the interesting genetic therapies that will become available in the not so distant future.


Photo Credits: Mehmet Pinari, Creative Commons

Safe Injection Sites: Sometimes it Pays to Do the Right Thing

In this country, we too often take for granted that most sacred and coveted of human rights: the freedom to choose our own destiny.  But when we are allowed to elect our own leaders, there is an implicit responsibility invested in each of us to hold them accountable for their actions; especially when those actions are fundamentally wrong. The Ford Government’s recent decision to reconsider the “merit” of safe injection sites is the worst kind of partisan politics.  It is a move designed solely to appeal to a minority of base voters, regardless of the cost in both dollars and lives.  It is so rare that a policy is both morally just and cost effective, and yet at a time when the opioid crisis is spiraling out of control, Ontario is on the verge of reversing the few gains we have made.  If this action is allowed to continue then those dollars, and those lives we could have saved, will be on each of us.

Canadians hear a lot about this “Opioid Crisis”, yet many of us have likely never see its direct effects.  You may be asking, what is this so-called “crisis”?  Or perhaps more importantly, why should I care?  Essentially, the Opioid Crisis refers to the North America-wide (and global) problem of rapidly increasing opioid drug use and related fatalities.  The figures are staggering. Ontario alone suffers two or more overdose deaths (ODs) each day, quadruple the rate from just 25 years ago, and the numbers are continuing to climb.  On the other side of the country, BC’s rates are twice as high as those in Ontario.  Moreover, deaths due to opioid overdose are just the most visible consequence of a much larger systemic issue at play.

Our Local Context

Here in London, a public health emergency was declared in 2016 in an attempt to combat outbreaks of HIV and hepatitis C related to IV drug use. Cutaneous infections, endocarditis, and a wide range of other potentially dangerous health conditions are all linked to the use of needle drugs.  The roots of this issue are systemic, and while the rise of illicit fentanyl and heroin are certainly major contributors, prescription painkillers are the source of addiction for many.  The role of physicians in creating this situation cannot be overlooked, nor can the actions of pharmaceutical companies like Purdue, which made false claims to doctors and patients denying the addictive nature of oxycodone, a synthetic opioid marketed by the company.

Ok, so we can all agree now that the Opioid Crisis is a big deal, and as future physicians, our profession is at least partly at fault.  So what can we do about it?  A number of measures have been proposed and implemented in the hope of lowering mortality and reducing infectious diseases related to IV drug use.  Naloxone, for example, is a drug that can temporarily reverse the respiratory-depressive effects of an opioid drug overdose; essentially, it restores life to someone who has OD’d and stopped breathing, buying more time for them to receive proper medical attention. Health care workers have begun to carry naloxone kits with increasing frequency, and these have also started to be placed in public spaces more regularly.  For example, our own Schulich Political Advocacy group recently met with London’s local municipal government officials to discuss the inclusion of a Naloxone kit at every public AED machine in the city; and in May 2018, the measure was approved and taken into effect over the summer. This represents a huge success for harm reduction in Ontario, and early data has shown that the expanded availability of naloxone has reduced mortality while sparing potential medical expenses.

Perhaps the most valuable initiative, however, has been the development of supervised injection sites (SISs).  These are facilities where IV drug users can go to use drugs under direct medical supervision.  Such sites often involve a needle exchange program in parallel, where used needles can be traded in for fresh ones.  This is designed to reduce the transmission of infection diseases, most notably HIV and hepatitis C.  These sites also act as first points of contact for providing healthcare to people who use drugs, often offering them referrals for rehabilitation, counseling, and education on infectious disease control and safe drug use.  As a relatively new concept, the effectiveness of SISs is still being evaluated, but the early data have proven very positive.

Safe-Injection Site Efficacy

A study done in Vancouver showed that with the opening of a single injection site, a 33% drop in mortality was seen from pre-SIS levels. Furthermore, there was a reduction of 40% in cutaneous infections, average length of stay in hospital fell by 67%, and ambulance calls for suspected ODs were also reduced by two thirds.  A further study of this site published in the CMAJ, found that not only was there a significant drop in mortality, but that this was done at a significant cost reduction for the healthcare system as well.  Most relevant for this effect was the decrease in HIV transmission resulting from the needle exchange program.  The cost of preventing one case of HIV was calculated to be around $20 100; which is only one tenth of the lifetime cost of an HIV patient.  When we add up all of these benefits – the reduced hospital stays, the drop in infectious disease, the prevention of overdoses – the overall result is clear: not only are we saving lives, but we are saving money while we do it!

The Ford Government now wants to evaluate the “merit” of these safe injection sites, and while they do so, they will be pausing the development of further sites.  This will cost money.  It will cost lives.  The Premier made his position on this issue quite clear during his campaign, and his actions should not be surprising. Yet his actions are nonetheless wrong. The role of the medical professional in the coming discussion will be important, and as community turns to us for answers, we must ensure that our actions and responses are measured with facts and compassion.  It is rare to find an issue with such a clear answer, and for safe injection sites, one thing at least is clear: sometimes it pays to do the right thing.


Author: James Payne

With a last name tailor-made for a future doctor, James really couldn’t have wound up anywhere but Schulich!  A London native, he did his undergrad at Queen’s, where he majored in Chemistry and Economics; the latter of which was the focus of his work for the UWOMJ journal.  James loves sports (he can catch a football better than Tom Brady), music, and, as you may come to find out, semi-colons.

Photo Credits: Marco Verch, Creative Commons 

Viral Vectors as Containers and Their Importance to Gene Therapy

By: Danning Li

Hello everyone and welcome back to the big wide world of gene replacement therapy and medicine! On our last blog post, we tackled the general idea of gene replacement therapy, which was namely to put a working copy of a gene into a patient’s body, so that the gene product could be produced permanently. This idea of course sounds incredibly simple, but considering the lack-luster implementation of gene replacement therapy in medicine today, why hasn’t this idea become widespread? Well, this blog post is going to tackle that exact question, and look at some of the challenges facing gene therapy today.  

To start off, the main problem in gene replacement therapy is that the human body really hates taking in undigested DNA (if anyone wants to read about extracellular DNA in the body, here’s a good paper: The Origin and Properties of Extracellular DNA: From PAMP to DAMP). So, automatically, the idea of oral gene therapy pills is difficult to implement, since stomach acid and digestive enzymes would rapidly degrade incoming DNA into individual base pairs or base pair components. At the same time, injecting DNA directly into the blood stream or local tissue would meet a different problem; the immune system, which would rapidly detect the foreign DNA and then degrade it into all of its components (click here to see how the innate immune system detects DNA). Therefore, this leaves scientists and physicians with a problem, how can we create a therapy that can sneak past the immune system to deliver our uncompromised DNA to our target tissue?

Infective Solutions: The Virus

First thought: viruses, a common solution to a scientist’s dilemma. By the 1970s, it was already known that viruses are natural agents at injecting their genetic information into host cells for viral reproduction purposes. The goal then became to find a good viral candidate that could somehow be used as a gene delivery system to the human body. To be considered a good candidate, the virus must meet several criteria: it must be able to deliver the genetic information efficiently, it must be minimally immunogenic, it must be non-replicative, and it should have a low risk of insertion into the host genome (this article is a good summary of viral vectors for gene therapy).

The process to meet these goals requires the original viral DNA to be removed, and only the viral capsid to be used. Without going into a lot of details, since the virus has been rendered non-replicative, the production of the viruses would have to be split into multiple parts; this means that the DNA plasmid of our target gene would be given alongside our packaged plasmid expressing the viral capsid protein using a co-transfection protocol (triple transfection is the newer technique and has much better yield than double transfection). However, the question remains, just what kind of virus should be used? After all, there are so many types of viruses to choose from! For now, we will focus on 3 types of viruses that are of interest: retroviruses, adenoviruses, and adeno-associated viruses.

A) Retrovirus

As medical students, we have all heard of retroviruses, with HIV being the most widely known member of the retroviral family. For gene therapy purposes, lentivirus, a subtype of retrovirus, is used instead of a standard retrovirus, since a lentivirus can infect non-dividing cells. The good and bad thing about a lentivirus is that it will insert its own genome into the host genome-this is great because once the insertion occurs, the cell will have the DNA forever (no backsies)-but on the negative side, inserting DNA into random places within the human body will disrupt normal gene function and could lead to cancer. This was unfortunately shown when children given an experimental gene therapy to cure X-linked SCID-XI syndrome developed leukemia due to random insertion inducing mutagenesis (they were cured of their SCID-XI syndrome though, so mission success with unfortunate side-effect?).

B) Adenovirus

Our second virus of interest is the adenovirus, a virus responsible for many infections in the respiratory tract, among others. This early candidate for gene therapy however, had the tendency to spread throughout the body and become immunogenic. This was shown sadly in 1999, when Jesse Gelsinger died due to an immune reaction to adenovirus in a trial to cure ornithine transcaramylase, a metabolic disease that affects ammonia elimination,.

C) Adeno-associated Virus (AAV)

Finally, we arrive at our last viral candidate, the adeno-associated virus or AAV. The name is pretty straight forward, AAV depends on adenoviruses to reproduce (it’s like a virus of a virus). In fact, when AAV was first visualized under electron microscopy, scientists weren’t quite sure what it was due to its small physical size. Since AAVs are naturally non-replicative, they are minimally immunogenic, and there are no diseases that are known to be caused by AAV. The major limit of AAV usage however is their small size, since only about 2.5kb worth of DNA can be delivered with one virus, which significant limits the amount of treatable diseases with this strategy, since human genes are quite large in base pairs. However, since safety is the major concern of viral gene delivery, much of the focus on gene replacement therapy has focused on developing good recombinant AAV (rAAV) platforms because of their high safety features.

To conclude, I hope this post provided you a brief understanding of some of the current challenges in delivering gene replacement therapy in medicine and next time, our topic will be on the different types of rAAV vectors (delivery gene mechanisms), and how the choice of this rAAV subtype (there are a lot) is important for therapy development.

Author: Danning Li

Danning Li completed his BSc. majoring in Physiology at McGill University. Afterwards, he worked for two years on developing a gene replacement therapy for Canavan Disease, a rare inherited leukodystrophy, at the Horae Gene Therapy Center at the University of Massachusetts Medical School. Now a medical student at Schulich, he wants to bring attention to the interesting genetic therapies that will become available in the not so distant future.

Photo Credits: Creative Commons, Capsid

What is Gene Therapy?

By: Danning Li

On December 19th, 2017, Leber’s congenital amaurosis, an inherited disease that causes severe vision loss and blindness in children met its match in the form of voretigene neparvovec (AAV2-hRPE65v2, or Luxturna for ease of pronunciation), the first gene replacement therapy approved by the FDA for sale in the United States. The previous sentence might contain some words that are not part of the current medical curriculum, but they will become an increasingly important part of our future practice as technology develops. Already, the rate of approval for these novel therapies is ramping up. Last year, the FDA approved three new genetic therapies for public sale (for those interested, the FDA news releases are here in chronological order Kymriah, Yescarta, and finally Luxturna). So, for today’s blog entry, with the possible dawn of the genetic therapy age upon us, let us focus on just what a “gene replacement therapy” is, and why it is such a big deal.

Gene Replacement Therapy 

Gene replacement therapy, as its component words suggest, is a treatment that aims to provide a replacement copy of a gene to a patient’s body. It doesn’t matter if the patient doesn’t have this gene, protein or enzyme, or even if the patient has a mutant, non-functional or less-functional version of the enzyme; gene therapy seeks to rectify this issue. The goal of this therapy is for the replacement artificial gene copy to produce a functional enzyme or enzyme subunit that the patient’s own body needs, and can use effectively.

Now, some might be wondering why we don’t just supply the missing enzyme instead, after all, Enzyme Replacement Therapies (ERTs) are well-established treatments for several diseases already. However, the answer to this question is simple: economics. Remember how enzymes are constantly made and broken down in the body naturally? Well, this applies to inherited diseases too since the patient would break down the injected replacement enzymes overtime, and the effects would wear off. Since the replaced enzymes are made in a lab and have to be reinjected into the patient regularly, we would have to constantly produce the purified enzymes and the patient would be on the hook for the rest of their life. This might not sound like such a bad problem, a lot of medications are like this already, right? Unfortunately, it turns out treating someone for decades with regular ERTs cost around USD $9-10 million or more. Insurance companies and OHIP won’t be very happy if a lot of patients started lining up for therapies with these kind of price tags attached.

Looking Towards the Future

Naturally, when faced with such a tantalizingly difficult problem, scientists and physicians thought up a ridiculously simple solution in the 1960s. If making these enzymes outside of the body and then injecting it into the patient is too costly, why don’t we just give the patient’s body the genetic information it needs to make the missing enzymes inherantly? After all, the most efficient enzyme production facility is a living, breathing body that converts regular nutrients into precious enzymes. Even better, if we were lucky enough, and the inserted DNA managed to stick around inside the body somehow, we would have just cured the disease completely, improved the patient’s quality of life, and opened up a completely new world in science. Thus, the idea for gene replacement therapy was born, and brilliant minds around the world would spend the next half a century trying to make this ridiculously simple idea, a reality.

Author: Danning Li


Danning Li completed his BSc. majoring in Physiology at McGill University. Afterwards, he worked for two years on developing a gene replacement therapy for Canavan Disease, a rare inherited leukodystrophy, at the Horae Gene Therapy Center at the University of Massachusetts Medical School. Now a medical student at Schulich, he wants to bring attention to the interesting genetic therapies that will become available in the not so distant future.

Photo Credits: Creative Commons, Gene Therapy Infographic

Title: Cost and Effect: Do We Over-Regulate Drug Development?

By: James Payne

On one of my very first tests in medical school, I was asked which branch of government was responsible for approving new drugs in Canada, and I’m ashamed to say the question gave me pause.  One frequently hears about the actions of the FDA in the US; but is there even a comparable body in this country?  Of course, I’m being glib.  The Health Products and Food Branch of Health Canada (totally didn’t have to look that up) does indeed regulate which drugs are available for patients. So, we can all sleep safe tonight knowing we’re protected from the profit-hungry machinations of Big Pharma; but should we?

Government regulations are designed to keep us safe, and it’s not hard to see why they’re so important.  One needs only to recall the failure of the authorities to protect young mothers and their children from thalidomide in the early 1960’s.  Even after the drug was withdrawn from markets all around the world due to the terrible effects on fetal development, thalidomide was still legally sold in this country. Ironically, it was a Canadian physician, Dr. Frances Kelsey, who blocked approval of the drug in the United States even while up against enormous pressure; and so spared that country from suffering the same fate of her own.  In 1962, Health Minister J.W. Monteith specifically cited the thalidomide tragedy when pushing for a new bill with stricter regulations on drug development in Parliament.

Drugs are among the most important discoveries in the history of science.  How many lives have been saved by antibiotics?  By chemotherapeutics?  By the almighty beta-blocker!? But these drugs can also pose a danger to us all as well.  They are designed to change things within our bodies; yet our bodies are so complex that sometimes they may change the wrong things.  This is why thorough and extensive drug testing is so important to protect both patients’ safety, and their confidence in the healthcare system.  Regulation is essential.  But have we recently gone too far?

Big Pharma and Drug Development

People often look with contempt at big pharmaceutical companies.  Yet, we should also remember that these companies are responsible for many major drug breakthroughs over the past century.  They’re in the business of making money, but saving lives is a happy side effect.  I don’t expect you to feel sorry for Pfizer or Novartis or Roche, but I will ask you to consider that when they don’t make money, they don’t make drugs. Their bottom lines can be very much our problem.

Regulations on drug development increase drug costs (okay, fair enough; as we have discussed above, regulations are important!).  But the question of the day is: Do we over-regulate?  Over the past decades, evidence standards for drug efficacy and safety have steadily risen, and thus so have the costs of development.  Yes, this has likely prevented injury and even death from dangerous drugs (which cannot be undervalued); but if there is a steadfast rule of economics, it is that when firms pay more, we pay more.  Fifty years ago, the cost of developing a new drug was approximately $250 million USD (adjusting for inflation).  Today, it may be as high as $5 billion.

These prices are astonishing, so it’s not hard to imagine some valuable areas of research being dismissed as unprofitable, especially for diseases more prevalent in the developing world. Of course, there is a strong argument to be made that regulations help drug companies to an extent; getting to claim an FDA stamp of approval can be used as justification to charge more per pill, and skyrocketing drug costs are not solely a function of increased regulation. However, stringent regulations may be costing us even more than mere dollars and cents.

Understanding the Process

As standards rise, so does time of development.  The time required to take a new drug from discovery to distribution has increased steadily since the 1960’s; currently, the average ‘bench to beside’ period for a new drug is 14 years.  Let us consider the implications of this delay: drugs limit mortality and morbidity.  Therefore, does increasing the time required to produce a new drug lead, in the interim, to increased death?  Basic logic suggests that it does, and some studies have estimated the numbers to be in the hundreds of thousands.

Moving forward, should the drug approval process become a simple matter of guessing whether it will kill or save more people?  Of course not.  Medicine is more than arithmetic; public confidence and peace of mind depend on the knowledge that what doctors prescribe is safe.  But can we reduce those regulations without seriously undermining the efficacy of authorities like the FDA?  Several ideas have been proposed, and I encourage you to read some of them here.

To leave some food for thought: are we so preoccupied with making sure our medications don’t kill us, that we allow diseases to do just that?  Is one worse than the other?  These are difficult questions.  But it may be time to ask ourselves: when it comes to regulating drugs, what is the cost, and what is the effect?

Author: James Payne

With a last name tailor-made for a future doctor, James really couldn’t have wound up anywhere but Schulich!  A London native, he did his undergrad at Queen’s, where he majored in Chemistry and Economics; the latter of which was the focus of his work for the UWOMJ journal.  James loves sports (he can catch a football better than Tom Brady), music, and, as you may come to find out, semi-colons.