Ottawa Expertise on Display In Kazakhstan/Central Asia

January 21, 2016 2:59 pm

Downtown Astana, photo by Ken and Nyetta.

Kazakhstan is a country on the move.

Kazaks are the ancestors of the great Genghis Khan. Today, their diverse multicultural society, with its historical tribes, numerous languages and religions and their international outlook in global affairs has made it one of the most compelling countries to watch in Central Asia.

Economic growth in Kazakhstan is led almost exclusively by the coal, iron, gold and copper sectors. It is the world’s largest supplier of uranium. It has the second largest uranium,  chromium, lead, and zinc reserves, the third largest manganese deposits and one of the world’s largest copper reserves. It is a significant diamonds exporter and has one of the world’s largest reserves of petroleum and natural gas. The giant Kashagan field in the Caspian Sea has made Kazakhstan one of the world’s top oil exporters. The past decade has also seen exponential growth in its banking and financial services sector. The country is on a roll but none of this came easy. After the dissolution of the USSR in 1991, Kazakhstan experienced a difficult transition from a planned to a market economy. One of the key problems was dealing with the consequences of the fallout of 456 Soviet nuclear weapons tests held in northern Kazakhstan between the 1950’s and late 1980’s covering a geographic area larger than France. Over 1.5 million Kazakhs still suffer radiation-related illness from those tests today. Under the leadership of its first (and only) President, Nursultan Nazarbayev, Kazakhstan voluntarily rid itself of all nuclear weapons and signed the Nuclear Non-Proliferation and the Comprehensive Test Ban treaties. Nazarbayev then launched Project ATOM (Abolish Testing is our Mission) to promote nuclear disarmament and end nuclear testing resulting in the passing of the Declaration on a Nuclear-Weapon-Free World at the UN General Assembly. These efforts were supported by Canada.

Nazarbayev also devised an economic plan for the newly emerged country. A slow but gradual recovery began in the early 2000s, followed by a rise in Kazakhstan’s total trade in the second half of that decade, when it became one of the world’s top grain exporters and its mining economy started moving into overdrive. As a result, the Kazak people have seen their standard of living, incomes and quality of life improve dramatically. Nazarbayev’s free market economic reforms have made Kazakhstan Central Asia’s strongest and wealthiest economy and its capital, Astana, has become one of the most important financial centres in Central Asia.

In his sunset years, Nazarbayev is now working to secure the future for Kazakhstan and protect his legacy with Constitutional changes that embrace democratic governance models and the rule of law, all overseen by the country’s freely elected bicameral Parliament.

Some of the wealth and profits generated from Kazakhstan’s diverse economy have gone to underwrite the wonderfully extravagant capital of Astana. This city is like Dubai on steroids. To see it is to believe it. Astana has an energetic vibe and boasts an impressive skyline of buildings, ministries, museums, malls and boulevards that scream 21st century. Kazak citizens are young, educated, professional, multi- ethnic and busy. Very busy. They are true internationalists and whether it’s in the private or public sector they look to other countries to gain knowledge about how to best develop their own governance and business models. Canadian diplomats and NGO institutions from the Ottawa area are playing an important and active role in this effort.

On December 9th the Canadian Centre for International Governance Innovation (CIGI) organized the inaugural Central Asia Security Innovation in Astana in cooperation with the Kazakhstan Ministry of Foreign Affairs and the five Central Asian states (Kazakhstan, Kyrgyzstan Republic, Uzbekistan, Turkmenistan and Tajikistan) to discuss security governance challenges in five major key areas: anti-terrorism, border management, human and drug trafficking, energy and nuclear security, and transboundary water management. CIGI policy experts were on hand to provide a Canadian perspective these matters.

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Participants from CIGI, Canadian Embassy and Central Asian States at the Central Asia Security Innovation Conference in Astana Dec. 9.

The tone was set at the outset of the conference by Shawn Steil, Canada’s Ambassador to Kazakhstan, the Kyrgyz Republic and Tajikistan and Ottawa based Margaret Skok, Senior Fellow, CIGI and a former Canadian Ambassador who both observed that there was an absence of region-wide cooperation between Kazakhstan and its smaller neighbouring countries. Skok suggested these five countries work on setting aside their various enmities and try to work on a multilateral relationship that could provide them with a collective influence as a Central Asian bloc. Steil said it was his experience that “lots of dialogue, conversation and programs are the key things that build trust between states.” He also said this was easier said than done, noting that “Kazakhstan must balance the competing interests between its geographical neighbours, Russia and China, against its determination to maintain its own hard won independent foreign policy and economic relationships with the European Union, the United States and Canada.” Steil and Skok suggested Kazakhstan and the other Central Asian republics – Turkmenistan, Tajikistan, Uzbekistan and Kyrgyzstan – have a vested interest in closer regional co-operation.

Stockwell Day, Canada’s former Minister of International Trade and former Minister of Public Safety, said that the Central Asian states should work together and share information wherever possible on mutual security matters, on technical matters and on health issues. Day noted that the United States-Canada relationship was “a friendship based on respect and the ability to link arms and work together on issues and share information in areas of mutual concern in security, trade technical matters, health issues and even military.” He said that cooperation and preparation are the things that can get countries “through moments that could otherwise be disastrous” and noted that “Canada had learned from disasters within its borders and among its neighbours.”

A common theme raised by the five central Asian countries was the issue of how to prevent Central Asian citizens from joining international terrorist groups like ISIL and then returning home to cause havoc. Former Canadian Deputy Minister of Foreign Affairs and former CSIS Director Reid Morden responded to these security issues with a recommendation that Central Asian governments consider coordinating their intelligence efforts. Reid said that “intelligence today comes from across all areas whether its transportation, health, immigration, export, trade or other areas, but intelligence gathering must be based in law through an act of Parliament.” When asked about the guidelines and rules related to the collection of intelligence, Reid said that “while intrusiveness is allowed, it must be governed by the proper oversight and that there must always be a balance between security needs and the inherent rights of citizens.”

Ambassador Steil said that better communication between Central Asian states was the first step in moving forward to form a “Central Asian bloc” and that region-wide cooperation in a variety of areas including trade, border controls and the harmonization of customs regulations were good starting points. CIGI invitee and Former Ambassador of the United States to Kazakhstan (2009–2011) and Tajikistan (2003–2006) Richard Hoagland said that the kind of cooperation that could drive Central Asian prosperity would be stunted unless there was an end to “endemic and sometimes government-sanctioned” corruption. He said that the Central Asian states themselves need to understand that it is in their interest to fight corruption for their own international reputation and credibility.

Colin Robertson, a trade expert, former Canadian diplomat, CIGI fellow and Vice President of the Canadian Global Affairs Institute stressed the importance of these Central Asian nations to develop a professional civil service. He said that those involved in the military, policing and border security should be “well educated, well trained and have a high esprit de corps because these are traits that help protect countries from corruption practices.” He added that “border enforcement is important but so is trade, and it is important to expedite goods at the border and keep them moving.” Robertson said that the Central Asian countries should not see cooperating and the sharing of information as something that weakens their country, but as a strength. He noted “that sharing info builds trust and that the Central Asian countries should share info on infrastructure, roads, and pipelines.” Robertson provided numerous examples of cooperation between the American and Canadian governments in trade, commerce and border issues. He said that Canada and the United States understand the importance of dialogue and communication on many issues but they also understand that on other issues “good fences make good neighbours.” Attendees to the conference  included representatives from key ministries in Kazakhstan and the four other Central Asian governments and a large group of Central Asian university students. Two graduate students told Ottawa Life Magazine that they were impressed with the views of the Canadian participants. One said he was very impressed by the way Reid Morton explained the requirement in democracies to balance security needs with citizens’ rights and a female student said she thought Ottawa’s Margaret Skok was an outstanding moderator who “got Kazakhstan” and really seemed to understand Central Asian issues.

Moving Forward on Health Care Reform

12:04 pm

Why more money for health care is not the answer

In the Speech from the Throne and since, the new Liberal government has clearly said it is ready to re-engage with the provinces and territories on health care. This is a welcome development. For most of the past decade, the Harper government was distinctly unwilling to provide any leadership or even play a secondary role in health care reform.

The fact that the new Trudeau Liberal government is ready to work with the provinces and do so quickly is a big step forward.  But the prospect has likely raised many expectations of what new arrangements might emerge.

First, many players will be looking for more money to flow from Ottawa to the provinces. But the Harper government, even as it withdrew from active participation, committed to adequate transfers to the provinces until 2024. There may be legitimate debates about the distribution of those transfers across the provinces, and there may be some new funding called for to support new initiatives in areas such as pharmacare or mental health, but the federal money now on the table in support of the range of health care services is more or less adequate.

The health care problems we face are not the result of insufficient spending. In fact, more money may be counterproductive.

The primary focus of any new accord needs to be on the structure of the federal-provincial arrangements. The most commonly visualized instrument seems to be a return to something like the Health Accords of 2003 and 2004. Indeed, the Minister of Health referred to a promised re-engagement in these terms. What these Accords did was to identify a number of problem areas — most notably, wait times — where provinces pledged remedial actions to remedy them and Ottawa committed to increasing cash transfers to be used at the discretion of provincial governments.  

The expression at the time was that the cash transfers would “buy change” necessary in the health care system. But the link between the provincial actions and the federal money was tenuous at best in 2003 — and all but absent in 2004.

So while the Accords did initiate significant flows of new money to the provinces and territories, they were not successful in spurring necessary health system reforms. They were not sufficiently specific to generate sustained efforts or sustainable change.

In fact, the extra money Ottawa provided probably did more to hinder health reform across the country than promote it. Rather than “buying change,” the extra money bought peace and serenity (at least temporarily).  Throwing additional money at problems was a lot easier than tackling structural change.

The Accords were weak because to some extent the provinces and territories have different needs and priorities.  To reach consensus on a single agreement it was necessary to be vague and general in terms of what each province and territory would do by way of reform.

A better alternative going forward might be to more directly address particular regional concerns with a distinct contract between Ottawa and each province rather than a single accord.

For a model for this we could look to the Paul Martin Liberal government’s arrangement for funding in two other areas. The first was the transfer of gas tax revenue to municipalities via the provinces for infrastructure investments. Ottawa signed one-to-one agreements with every province and territory. While the broad goals and structures were the same across all provinces, the individual contracts included variations that permitted some provinces to pursue regional goals within the national framework. A significant amount of much needed municipal infrastructure investment resulted from these agreements, and continues today.

The same general model was used by the Martin government to conclude childcare agreements with the provinces, but before they could be implemented the Harper government was elected and chose not to proceed.

This model of federal-provincial fiscal arrangements can more effectively promote health care renewal and should be considered by Minister Philpott going forward.

A set of pharmacare agreements might be concluded that would create nationally universal and portable coverage while recognizing that provinces are starting from different positions and may have different specific needs and administrative arrangements in mind. Other issues such as home care and long-term care facilities might be addressed at the same time or in a separate set of contracts.

The federal government would retain the capacity to represent national goals and interests, and the provincial governments would have flexibility to pursue their respective regional objectives within the national framework.

A stronger link between national objectives and each province’s priorities offers a better chance of sustainable health care reform.  

Maslove_alanAllan M. Maslove is an expert advisor with and a Distinguished Research Professor, School of Public Policy & Administration, Carleton University.

Why it’s time for a National Autism Strategy

January 20, 2016 11:55 am

Over a year ago, I was invited to celebrate World Autism Awareness Day on Parliament Hill.  It was attended by a dozen or more Senators from both major parties, political staffers and invited guests mostly from autism non-profit organizations.  I expected a predictable ‘feel good’ event about how far we’ve come and how far we have still to go.

But an hour later there weren’t many dry eyes in the chamber.  

It turns out, many of the politicians who decided to join the event that day had personal experiences with autism.  One Senator spoke at length of his daughter who struggles to get adequate services for his grandchild with autism, and how challenging it has been – economically, physically and emotionally — for the whole family.  He cried openly.

Another Senator spoke of a family she knows that is struggling with long wait times for essential services, such as speech or behavioural therapy.  More than one participant spoke of the difficult choice families have made to uproot and move across the country to Alberta or British Columbia where autism services are often more readily available and flexible, particularly if a family happens to have more than one child on the autism spectrum.  

Others spoke of the economic burden of pursuing private therapies – funded out of pocket (my own experience), often in the tens of thousands of dollars per year.  Many have to refinance homes or sell them altogether just to get their child with autism the basic supports they need to learn and thrive.

What became clear that day is something I’ve heard autism champion, Senator Jim Munson say before: autism doesn’t affect Liberals or Conservatives or NDPers. It’s an equal opportunity neurodevelopmental disorder that affects Canadians across the political spectrum and clear across the country.  

What was also clear that day – and from a number of reports since — is that autism families in Canada are struggling, diagnosed cases of autism are on the rise, and most provinces are not able to keep up with necessary services.

According to a recent survey from the Canadian Autism Spectrum Disorders Alliance (CASDA), almost three quarters of parents of preschoolers in Canada with autism wanted, but did not receive, early intensive behavioural intervention (IBI) for their child — one of few interventions for autism with solid peer reviewed evidence.  

A similarly troubling report, released last month from the Ontario Auditor General, reveals that in some jurisdictions in the province, there are more children waiting for autism services than receiving them, with more than 16,000 children on wait lists that continue to balloon.  

It’s not an exaggeration to say we have an autism services crisis in Canada.  So what can be done?  Plenty.  

Evidence shows proper health and educational supports for those affected by autism pay off.  Early intervention heads off more expensive and extensive supports that are needed later in life if it is not provided.  It makes economic sense, in other words, to provide autism services early.

Kids with autism are not lost causes, they are full of potential.  We are failing them.

The last federal government made a good start establishing an Autism Spectrum Disorder Working Group to bring together those working on the issues across the country to discuss key concerns and share best practices.  But much more federal support is required to make things better – now — for Canadian families.

For starters, the new Liberal government could dust off the excellent cross-party Senate report – aptly titled – Pay Now or Pay Later: Autism Families in Crisis from 2007 and get to work.  It’s number one recommendation? A comprehensive national autism strategy.  

We’ve waited almost a decade.  Now is the time for the federal government to bring together the brightest minds in the country on the issue and enact a federal strategy to give our kids with autism the services they need to survive and thrive in communities across the country.
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Kathleen O’Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University, Managing Editor of and mother of two sons, one with autism.

Five Ways We Can Reduce Suicides in Canada

January 19, 2016 11:51 am

Why a suicide prevention strategy needs to include injury prevention

Despite recent headlines, Canadian rates of suicide and attempted suicide have remained largely unchanged over the last several decades (11 per 100,000).  What has changed is that we’ve seen increasing rates of suicide in the Canadian military recently, after stable rates for decades.

With over 40,000 Canadian soldiers deployed to the mission in Afghanistan, there has been an understandable concern about mental health problems and suicides among military personnel and veterans. Both the Minister of Defense and Minister of Veterans Affairs have rightly made suicide prevention a top priority.  

The problem of suicide is not limited to the military in Canada; indigenous populations, especially in northern remote communities, have high rates of suicide.  

We need a unified approach across provincial and federal sectors to reduce suicides in the military, among veterans and civilians.  Here are five promising evidence-based strategies for suicide prevention.

1) Implement a National Deliberate Self-Harm Registry

The single most important predictor of future suicide attempts is a history of previous self-harm behavior.  It is important to develop a confidential, administrative national registry of people with self-harm behavior, similar to the national registry created in Ireland, in order to record accurate data and to target and measure our evidence-based approaches to reduce the risk of future attempts.

2) Invest in anti-suicidal psychological treatment

For patients presenting with suicide attempts, current practices and programs focus on treating the underlying mental health problem and/or addiction. Recent work is challenging this practice by showing that there is also a need for psychological interventions that directly address suicidal behavior. Two such treatments have shown to reduce suicide attempts among people with a history of self-harm behavior – cognitive behavior therapy and dialectical behavior therapy.

Both types of therapy focus on understanding the causes of suicidal thoughts, improving coping skills in managing distressing emotions and developing careful plans to reduce future attempts.  Strong investments nationally are required to increase the availability of these therapies for people with a history of self-harm behavior.

3) Reducing access to lethal means

This approach has the greatest evidence for suicide prevention worldwide. Suicide can often be an impulsive act. Access to firearms is a risk factor for suicide and is a factor in half of the completed suicides in the United States.

In the Swiss military, when access to guns was reduced, almost 80 percent of people were deterred from suicide. Although firearm related deaths are less common in Canada, 20 percent of male suicides in Canada are related to firearms.

In the UK, limiting pack sizes of Tylenol per bottle was also shown to reduce suicide.  In Canada, prescription medications, especially opioids, anti-anxiety and anti-depressant medications are common causes of both intentional and unintentional deaths.  Limiting access to large quantities of prescription and over-the-counter medications for people with a history of self-harm may reduce suicides and accidental deaths.

4) Accidental deaths and undetermined deaths need to be tracked with suicide deaths

Accidental or undetermined deaths look like suicides. We know that suicide rates around the world are widely underestimated, perhaps by as much as 30 per cent or more. This is because it is often difficult to determine the nature of the death, and specifically whether it is definitively a suicide or an accident. Often, the case can be unclear, and the coroner classifies the death as undetermined.

There is evidence to indicate that some mechanisms of suicide are more likely to lead to the undetermined classification. In fact, in the UK, injury deaths of undetermined intent are routinely included in their suicide statistics for this reason.

5) Suicide prevention strategy should include injury prevention

We have learned that individuals dying by either suicide or by accident share many similar risk factors including male sex, younger age, being unmarried, lower education and income, impulsivity, mental health problems and addictions.

Generally speaking, prevention efforts for accidental injuries and suicide are distinct. But given the shared vulnerability of these populations along with the finding that many of the accidental or undetermined deaths may in fact be misclassified suicide deaths, a more broad approach to suicide prevention must include injury prevention.

If we really want to change the rates of suicide in Canada, we need to look at areas of medicine that have been successful in reducing mortality.  For example, HIV disease prevention and cancer prevention have created national registries and invested heavily in innovative prevention programs that specifically target these deadly diseases.  We need a concerted national effort that uses evidence-based strategies to specifically target suicidal behavior.

Sareen_Jitender_High resJitender Sareen is an expert advisor with, professor of psychiatry at the University of Manitoba and team leader of the Manitoba Population Mental Health Research Group.




KATZ_Cara high res photoCara Katz is a junior researcher with the Manitoba Population Mental Health Research Group and a Psychiatry resident at the University of Manitoba

What Should be Covered by our Publicly Funded Healthcare System?

January 15, 2016 9:44 am

Patients and doctors need to learn the difference between ‘need’ and ‘want.’

All across Canada provincial governments are grappling with ever growing healthcare demands in the face of shrinking resources.  Our enviable publicly funded health system is now well into a downward spiral of unenviable disrepair.  As patients are becoming more knowledgeable about their own care, and as doctors develop a wider array of options available to treat diseases, the costs are increasing.

The truth is, we can’t have it all.  Both the physicians who deliver care and the patients who receive it need to start considering the concept of limited resources in our publicly funded healthcare system.    

One of the main tenets of the Canada Health Act is that medically necessary care should be insured by public funds and that all related hospital or physician care should be paid for by the public system.  This is the soul of the cherished notion of “free” healthcare that most Canadians hold so dearly.  

But the tricky thing is that the Canada Health Act does not actually define what constitutes “medically necessary care.”  This is left up to the individual health providers to determine, on a case-by-case basis.  

At first glance it might seem easy to distinguish “medically necessary” care from optional care.  If a patient is sick, then the treatment needed to fix the problem is intuitively considered necessary – the idea being that medical needs dictate what will be provided by the public system.

And in some circumstances, determining what is “medically necessary” is easy.  Both patients and doctors could likely agree that if you have cancer, it needs medical treatment.  If you have fractures from a car accident, they need to be fixed.  

Likewise there are many other examples that most of us could agree fall into ‘optional’ care, such as laser eye surgery to remove the need for glasses or cosmetic facial surgery – wants, not needs, that don’t merit public funding.  

In between these examples, though, is a wide gray area where distinguishing need from want is not nearly so clear.  Is fixing an annoying nasal blockage a need or a want?  Is getting arthroscopy for a sore knee a need or a want?  How about a patient who wants blood tests that aren’t medically indicated, but they are just curious?

Non-essential care is by no means limited to patient demand.  There also exists a vast array of low-quality or low-impact health interventions initiated by doctors – and publicly funded.  Many of these interventions are not supported by evidence. That blood test or chest x-ray your physician ordered for you before your elective operation?  Very possibly unnecessary.  The CT scan you had for pain in your lower back? The evidence says it will not improve your outcomes.  The antibiotics you were prescribed for a persistent virus? Unnecessary and they won’t work anyway.  

Tests and treatments like these examples, and others, are not medically necessary and they are also costly to the struggling healthcare system.  In fact, unnecessary tests can expose patients to harm because of false-positive rates.  The “Choosing Wisely Canada” initiative spearheaded by the Canadian Medical Association is just beginning to explore the massive scope of unnecessary care and the impact it has on patients and the health system.

Are doctors too often offering to use public funds to investigate or treat problems that are wants versus needs and not actually medically necessary?  Are patients losing sight of the fact that no province has the funds to provide all care for all people all the time?

Our contemporary free-for-all style of healthcare, a challenge on both sides of the medical consultation room, is totally unsustainable on the public purse.

Doctors need to start openly and directly considering the concept of medical necessity when talking with patients about tests or procedures.  Patients, in turn, need to keep in mind that their healthcare is not “free,” and that many of their health-related complaints likely represent wants, rather than needs.  

Working together we can salvage what is left of public healthcare in this country, but only if both groups promptly adopt a more realistic attitude toward medical necessity.  
Rotenberg_Brian_headshotBrian Rotenberg is an expert advisor with and an Associate Professor in the Department of Otolaryngology – Head & Neck Surgery at Western University, London, Ontario.

Why Ontario Needs to do More About Doctors who Abuse Patients

January 14, 2016 11:12 am

Reforms by Ontario College of Physicians and Surgeons are a step in the right direction, but not enough.

Ontario’s College of Physicians and Surgeons receives numerous deeply concerning reports of doctors sexually abusing their patients each year despite the adoption of a “zero tolerance” approach to such abuse 20 years ago. This persistent problem has eroded public trust in doctor self-regulation. But now both the College and the province are poised to make long-overdue improvements in this area. The College recently proposed several reforms, while the government has appointed a task force to examine patient abuse.  It’s a good start, but more needs to be done.

Under the current approach, doctors often continue treating patients (subject to restrictions) while the disciplinary process drags out over several years. For example, Dr. Tariq Iqbal, who was the subject of four unrelated complaints of inappropriate pelvic and rectal exams in 2011, did not receive practice restrictions until 2014 or his final penalty (which he is appealing) until October 2015.

These delays may put additional patients at risk, particularly if the College does not adequately monitor compliance with restrictions. For example, pediatrician Dr. Eleazar Noreiga’s license was restricted after he sexually abused a patient in 2003. He was then subject to additional discipline in 2013 for flagrantly breaching restrictions that he only treat female patients with a chaperone and that he post a notice to patients. Even after other abused patients came forward, the College Discipline Committee commented that their penalty was not a “professional death sentence,” citing Dr. Noreiga’s ability to apply for reinstatement of his license.

An important concern with the current regime is that the “zero tolerance” approach only applies to the most egregious conduct. When the behaviour falls short of the requirements for mandatory revocation of license, the College has the discretion to order various penalties including reprimand, restrictions, temporary suspension or revocation of license. The College is often criticized for its lax approach to penalties in these discretionary cases. For example, only eight months after putting his mouth on a female patient’s breast, family doctor, Dr. Sastri Maharajh was permitted to resume treating male patients.

The College recently proposed the mandatory revocation of a medical license for any “sexual contact” with a patient and the discretion to order immediate revocation after a finding of misconduct, without waiting months for a penalty hearing. This has been a long time coming, but even if the government amended legislation to adopt these important changes, several gaps would remain.

First, there would be concerns with the adequacy of penalties for conduct falling short of “sexual contact.” Second, doctors subject to practice restrictions may continue to put patients at risk if the College does not properly monitor these restrictions. It is also unclear whether doctors who have displayed the poor judgement necessary to engage in sexual contact with patients have the requisite judgement to carry on professional relationships with any patients, regardless of gender.

Another concern with the current model relates to the patient’s role in the disciplinary process. The College has proposed allowing victim impact statements and enhanced privacy of witness’ medical records during the disciplinary process. Again, a good start.  However, these piecemeal changes fall short of meaningfully empowering patients.

During the disciplinary process, doctors are backed by their formidable defense organization, the Canadian Medical Protective Association, which is notorious for zealously defending its members. Taxpayers controversially bear the bulk of the nearly $200 million per year in defence costs to defend doctors against malpractice, professional discipline and even criminal charges.

Conversely, patients receive no publicly-funded representation during the disciplinary process and are treated as witnesses rather than parties to these hearings.

Although the College’s proposals represent important progress, there is more to be done. Regulatory changes must come from government, including expanding the “zero tolerance” approach and empowering the College to revoke a license without waiting for a penalty hearing. By enshrining these changes in the Regulated Health Professions Act, patients would be protected not only from abuse by physicians but the myriad of other regulated health professions in Ontario.

Provinces must also push for greater accountability of the Canadian Medical Protective Association, given the share of physician defence costs borne by taxpayers.

More broadly, regulatory bodies and the medical profession as a whole must train young doctors to respect appropriate boundaries with patients and create an environment where doctors can speak out about the inappropriate conduct of colleagues.

Lorian HardcastleLorian Hardcastle is the Associate Director of the Centre for Health Law, Policy and Ethics and an Assistant Professor in the Faculty of Law at the University of Ottawa

Putting children’s health and resiliency on the national agenda

January 12, 2016 1:48 pm

By Chris Harper

Last year, at a camp in southern New Brunswick, I met Evan. Before turning eight, he had bounced from foster home to foster home. He was sent to camp without a bathing suit or sufficient lunch. Regardless, Evan smiled constantly, excelled in school and had a striking sense of compassion. I still think about Evan all the time – what allowed him to thrive in spite of the cards he had been dealt?

Aaron Antonovsky was a medical sociologist with a similar curiosity. He worked with women who had undergone severe hardship in the past, many of whom survived the Holocaust. He found that some suffered more profoundly while others were more perseverant. He spent his life trying to figure out why. As a medical student, I learn plenty about complex management of disease once it’s started – but rarely do we learn about what keeps people well in the first place. What contributed to those women’s ability to overcome physical and psychological trauma? What keeps Evan so resilient?

Antonovsky’s research lead to what he called a “sense of coherence,” a concept just beginning to gain traction outside of academic circles in many countries. He theorizes that it is the most fundamental protective factor against disease. Based on three components, it also provides a valuable framework for how we should approach public policy making in the area of health and wellness in Canada.

First, Antonovsky found that whatever stresses you encounter must be comprehensible. Children, for example, must have the basic understanding that an action will often have a predictable, stable reaction. Imagine how difficult this must be when moving homes constantly or not having one at all. In 2010, 52 percent of single-mother households in Canada with children under six years of age were living in unstable housing. Just last year, by the age of seven, 7.5 per cent of children in Manitoba had been placed in some form of foster care. How can we expect children to comprehend stress when they don’t even have a home base in which to do it?

Secondly, children must have the basic tools to see challenges as inevitable yet manageable. For example, one in six Canadian children have vision problems interfering with their ability to read, yet despite our “universal” healthcare, just 14 per cent receive professional eye care before first grade. I would imagine it’s a lot easier to break the cycle of poverty when you’re able to see the blackboard.

Finally, children must be able to find things meaningful. To thrive, it’s pivotal that children have the opportunity to find satisfaction and a sense of purpose. Sadly, even that isn’t guaranteed.

Jordan River Anderson, a five-year-old aboriginal child with a rare muscular disorder, spent nearly his entire life in hospital while provincial and federal governments fought over who should pay for his at-home care, as responsibility for First Nations’ health services is often shared between jurisdictions. Jordan was denied the opportunity to make meaningful memories outside of his hospital room. This gave birth to Jordan’s Principle, which makes the reasonable request of the department first in touch with the child to cover services in the legal interim.

A strong sense of coherence – the cognitive capacity to see challenges as comprehensible, manageable and meaningful – isn’t just a fluffy sociological construct. It has been tied to evidence: better glycemic control in Type 1 diabetics and faster return-to-work following musculoskeletal injuries. In Scandinavian countries, it was found to predict the need for social assistance and unemployment benefits later in life.

Such findings present major opportunities for rethinking public policy from an “upstream” perspective – creating the foundation for good health in the first place – and pay off with a more effective use of public funding in the process. In other words, the “social determinants of health” – the multitude of non-medical factors like adequate income, stable employment and quality education that impact health – need critical attention.

So what do our policy makers and politicians need to do in real terms?

Build an effective national housing strategy so kids have a place to call home, institute comprehensive pre-school vision screening across the country so classrooms can have their full impact and cut red tape for First Nations children by committing to Jordan’s Principle.

Isn’t it time we put children’s long-term health and wellness on the national agenda?

d03d5a1d-d159-4bb6-b5f5-552b4f8fe4c2Chris Harper is a Contributor with, a medical student at the University of Toronto.

Three Things the Federal Government Can Do to Improve the Registered Disability Savings Plan

January 8, 2016 3:07 pm

Many of us in the disability community were pleasantly surprised when the Liberal party promised to create a National Disabilities Act that would safeguard disability rights, reduce systemic barriers and establish a foundation of opportunity for those affected by disability.  Canada is an outlier among developed nations for not having one – the U.S. has had theirs for 25 years – so it could not arrive soon enough.  

But the federal Conservative government did make some positive contributions of their own for the disability community during their decade in power – most notably, the Registered Disability Savings Plan (RDSP).  

The RDSP was the brainchild of non-profit organization, PLAN and was championed by the late Finance Minister, Jim Flaherty, who made it a reality in the 2007 budget.  Flaherty had first-hand experience with disability; one of his sons contracted encephalitis as an infant with lasting health consequences.  

The RDSP is Flaherty’s legacy to Canadians with disability and it remains an important and valuable program – at least in theory.  

According to a 2014 study, only about 15 percent of eligible Canadians take part in the program, meaning almost half a million eligible Canadians are losing out. With a wave of teens with autism reaching adulthood in the coming years, helping families affected by disability help themselves has never been more important.     

So what is an RDSP and what needs to be done to make it work better for Canadians?

The RDSP is a savings plan that helps parents and caretakers of those with a disability save for their loved one’s long-term financial future with some financial contributions coming directly from the government – free money, in other words.  

There are two components to the RDSP in addition to personal contributions: a federal grant and a federal bond.  The grant is based on family income and how much a family contributes privately to the RDSP.  It can equal as much as $3,500 in contributions from the government each year.  The bond is based solely on family income (those making less than $43,953) and can be as much as $1,000 in contributions from the government per year.  

Over the lifetime of an RDSP, an individual can receive as much as $70,000 from the federal grant, and if eligible, as much as $20,000 from the federal bond.  

So why are so few using the RDSP?  

In 2014, a cross-party Senate Committee undertook a study to answer this very question.  It’s time our new federal government dusted off the report and put some of the recommendations into action.

Here are three quick ways the federal government can improve the RDSP and help families affected by disability now:

1. Establish an RDSP automatically once an individual is eligible for Revenue Canada’s Disability Tax Credit.  

When I initiated my son’s RDSP, I was required to provide his Disability Tax Credit status, a Social Insurance Number, proof of age and residency in Canada.  It’s a lot of intimidating bureaucratic paperwork that could put off families who may have time, language or educational barriers.  

2.  In the meantime, raise the awareness and understanding of the RDSP program.

I regularly encounter families in the disability community who have never heard of the RDSP program or don’t know how to initiate it.  Others have told me they don’t have the money to start one – unaware they’d be eligible for free government bonds just for opening the account without requiring a penny of savings from them.

The Senate report recommends the federal government should partner directly with advocacy groups to help spread the word. This makes good sense since it’s often the front-line non-profit groups who are directly engaged with disability families and know best how to reach them and could help them with administrative hurdles.  

Another promising model is to have health practitioners work directly with their patients.  Recently, a coalition of healthcare providers, researchers and community agencies based in Ontario and Manitoba have created a Get Your Benefits! Toolkit to help healthcare workers improve the wealth – and thus the health – of their patients by helping them access income and other supports they may be entitled to. 

3. Allow other family members and friends to contribute easily to an existing RDSP

This recommendation isn’t in the Senate report, but it’s one that comes from my own experience and from others I know in the disability community.  If you have a disabled child, ‘extra money’ is not always easy to tuck away.  But birthdays and other special events are an opportunity for loved ones of the child to contribute meaningfully to their future.  

Financial institutions should work with the federal government to find an easier way for those who are not plan holders to contribute to an individual RDSP in small or significant amounts (in theory it is permitted now, but in practice, it is almost impossible in some plans).  It takes a community to raise a child after all.

The RDSP really is an excellent program and needed as much today as when it was created.  The federal government just needs to give it wings to make it fly.

O'Grady_Kathleen-high res (1)Kathleen O’Grady is the Managing Editor of, a Research Associate at the Simone de Beauvoir Institute, Concordia University, Montreal, and the mother of two sons, one with autism.

Ottawa Legal The Big Picture: Ottawa Law Firms are Amongst the Best in the World

11:51 am
Dec2015_Supreme Court_shutterstock_144649172

It is the trade of lawyers to question everything, yield nothing, and talk by the hour.

From international media coverage of gripping court cases to the dramatic portrayals of lawyers on television and film screens, we love to watch the law. As a city that is home to some of Canada’s most respected law firms and talented lawyers, Ottawa undoubtedly plays a role in generating some of this interest. Hundreds of different types of law firms have set up shop in Ottawa, ranging from long established and internationally renowned firms, to local, new and vibrant boutique practices.

Starting at the top, Ottawa is home to the Supreme Court of Canada. It formally became the court of last resort for criminal appeals in 1933 and for all other appeals in 1949. The court was established first with six judges, and increased by one additional member in 1927. In 1949 the bench reached its current composition, of nine Justices.

The Supreme Court of Canada building was built between 1939 and 1946 from plans by noted Montreal engineer and Art Deco designer Ernest Cormier who included two candelabrum-style fluted metal lamp standards at the entrance, marble walls and floors in the grand interior lobby that contrasted with the châteaustyled roof. In 2000, it was named by the Royal Architectural Institute of Canada as one of the top 500 buildings produced in Canada during the last millennium.

The building also contains two court rooms used by both the Federal Court of Canada and the Federal Court of Appeal. The Canadian court system is pyramidal, with a broad base being formed by the provincial or territorial governments. At the next level are the provinces’ and territories’ superior courts, where judges are appointed by the federal government. Judgments from the superior courts may be appealed to a still higher level, the provincial or territorial courts of  appeal. Several federal courts exist in Ottawa (and across Canada) including: the Tax Court of Canada, the Federal Court, the Federal Court of Appeal, and the Court Martial Appeal Court of Canada. Unlike the provincial superior courts, which exercise inherent or general jurisdiction, the federal courts’ jurisdiction is limited by statute. In all, there are over 1,000 federally appointed judges at various levels across Canada, many from the national capital region.

Each year, the Supreme Court hires 27 recent graduates from across Canada to work as law clerks providing aspiring lawyers with a privileged opportunity to work with Canada’s top legal minds in the nation’s capital.

The Ontario provincial courts and Ottawa courthouse are located the heart of Ottawa at 161 Elgin St. It is not unusual to witness a flurry of media activity around these buildings, as reporters cover high-profile Canadian cases. When political figures find themselves in court, they often turn to Ottawa lawyers to defend them.

Many of Ottawa’s most reputable law firms – Osler’s, Gowlings, Nelligan O’Brien Payne, May & Konyer, and Soloway Wright, are located in close proximity to the courthouse on Elgin street, some of them in heritage buildings, others in modern towers. These firms specialize in a range of areas, from criminal law to business law to estate law. With over 100 law firms dispersed throughout the city, if you need a lawyer, you’re all set.

Ottawa is also a prime destination for law students as we have the largest law school in Canada. The University of Ottawa’s common and civil law programs accept close to 400 students every year. The Supreme Court hires 27 graduates from across Canada to work as law clerks providing aspiring lawyers with a privileged opportunity to work with Canada’s top legal minds.

Ottawa’s legal reputation today is a far cry from our roots as a rowdy, bawdy sawmill and lumber town.

Pre-Confederation, Bytown (as Ottawa was called then), was a scarcely populated lumber town that often erupted with violence and debauchery. Brawling was common. Lt. John By, responsible for the supervision of the construction of the Rideau Canal, was forced to reassign several canal workers to work as street patrollers. However, they had little influence or power. In 1842, fresh out of law school, 18-year-old, John Scott placed an advertisement in Ottawa’s then newspaper, the Bytown Gazette. Scott would later become Bytown’s first official mayor. That same year, Bytown’s first courthouse and jail were built by architect Thomas McKay. In 1841, citizens had voted in favour of the construction of the courthouse and jail, in an effort to reduce violence and crime. Though the original courthouse and jail burnt down, the structure was rebuilt in 1871 and still stands today at the corner of Nicholas St. and Daly St.

As the legal system developed in Bytown, so did the town itself. In 1855, its name changed to Ottawa, and it officially became known as a city. In1857, it was chosen by Queen Victoria to be the capital. By 1867, Canada had officially become a country, and the British North America Act of 1867 called for the creation of a federal Supreme Court. On April 8, 1875, the bill proposing the creation of this court was officially given royal assent, and law firms such as Henderson McVeity, established in Ottawa in 1887, began opening their doors for business in the nation’s capital.

In 1857, it (Ottawa) was chosen by Queen Victoria to be the capital of the provinces of Canada. By 1867, Canada had officially become a country, and the British North America Act of 1867 called for the creation of a federal Supreme Court.

Today, Henderson McVeity is known as Gowling Lafleur Henderson LLP (Gowlings) and is the second largest law firm in Canada with offices in Beijing, Moscow and London. Its Moscow office was one of the first Western law firms on the scene in post-Soviet Russia and the firm sent a young talented lawyer named Monique Couture to lead the charge in what was then the wild west of new Russia. Her work there is still paying dividends for the firm’s reputation today.

There are several Ottawa firms with an international presence. Cassidy Levy Kent’s main offices are located in Ottawa and Washington, Blake Cassels and Graydon has offices in Ottawa, Vancouver, New York, Chicago and London, and Osler has headquarters in both Ottawa and New York City, just to name a few. Osler has been in the business of law since 1862, when Bath Osler began to practice law in Dundas, Ontario (70 km west of Toronto). By the age of 23, Osler had opened two law offices (Dundas and Hamilton) and started his own venture in what would become one of North America’s  first commuter railways. In 1882, Osler moved his practice to Toronto, the provincial capital and at the time Canada’s second most important city for business, after Montreal. Within a decade, the enterprise grew to become one of the top three law firms in Canada and it would eventually set up shop in Ottawa. Almost from the start, the firm’s clients included many of the country’s largest companies and others that would grow to become leaders in key emerging industries including railways, banking and insurance, manufacturing and natural resources. As the firm prospered, it attracted international companies seeking opportunities in Canada. Osler’s has been ahead of the game in promoting women in a sector that was far too long known for having a glass ceiling for women. In 1968, Osler became the first large corporate law firm in Canada to admit a woman as a partner, Bertha Wilson, who went on to become the first female Justice appointed to the Supreme Court of Canada.

Other firms in Ottawa have had similar success while remaining true to their Ottawa roots. Nelligan O’Brien Payne LLP was founded in the capital in 1963 and the mid-sized general practice firm has kept Ottawa as a home base, with an additional presence in Alexandria, Kingston and Vankleek Hill. The firm and its lawyers have an exceptional and decades long record as active participants in the community, and support a wide variety of volunteer and locally based activities including the Terry Fox Run, the United Way campaign, the Ronald McDonald House Ski Day, and various other fundraising activities throughout the year. They also support numerous community events through sponsorships or donations and host the annual Lawyers Play where the musical and dramatic talents of their lawyers are put on display at the Great Canadian Theatre Company.

Nelligan has received an A+ rating from Ottawa’s Better Business Bureau. Real estate and business law firm Soloway Wright, established in Ottawa in 1945, prides itself on being a community-based firm, with locations in both Ottawa and Kingston. The firm is centered on community involvement, and has been recognized for its philanthropic efforts.

Though some of the city’s historical firms have been growing since Confederation-era Canada, others in Ottawa have only just recently opened but are prospering. LaBarge Weinstein LLP, opened in 1997, specializes in knowledge-based and technology companies, while the 20-year-old firm, Sicotte Guilbault LLP, is another growing vibrant general practice firm. From global to local, from old to new, Ottawa’s range of law firms suggests that the national capital region has become a hub for both experienced lawyers and aspiring ones.

Five Things You Might Not Know About Food Insecurity in Canada.

January 7, 2016 10:30 am

For many Canadians, food plays a central role in the holiday festivities. But for those experiencing food insecurity, a bountiful feast will not be in the cards this year. Over 4 million Canadians, including 1.15 million children experience some level of food insecurity.

Food insecurity, also known as ‘food poverty,’ can cause significant anxiety over diminishing household food supplies and result in individuals modifying their eating patterns — adults skipping meals so children can eat or sacrificing quality food choices for cheaper, less healthy options, for example.  Food insecurity also often results in physical hunger pangs, fatigue and lack of concentration and productivity at school, work or play.  

Then there are the social impacts of food insecurity that most of us wouldn’t consider, such as not being able to invite friends and family to dinner or being unable to afford to meet people for coffee.  Food poverty can also create stress and conflict in family relationships and meals are often not a happy gathering opportunity.  

Here are five things Canadians need to know about food insecurity:

1) Food insecurity significantly affects health

Evidence shows that among children, food insecurity is associated with poorer physical and mental health outcomes, including the development of a variety of long-term chronic health conditions such as asthma and depression.

For adults, research shows that food insecurity is independently associated with increased nutritional vulnerability, poor self-rated health, poor mental, physical and oral health and multiple chronic health conditions including diabetes, hypertension, heart disease, depression, epilepsy and fibromyalgia. Studies also show that food insecurity impacts a person’s ability to provide self-care and manage chronic health conditions.

Evidence also shows the health impact of food insecurity exists on a gradient – meaning adults in more severely food-insecure households are more likely to report chronic health conditions as well as receive diagnoses of multiple health conditions.

2) Household food insecurity is a strong predictor of healthcare utilization and costs

A study in Ontario found that among adults, total healthcare costs — including inpatient hospital care, emergency department visits, physician services, same-day surgeries and home care services – increase significantly with the level of household food insecurity.

In other words, food insecurity costs us all through increased healthcare use.  Compared with adults in food-secure households, annual healthcare costs were, on average 16 percent (or $235) higher for adults in households with marginal food insecurity, 32 percent (or $455) higher among those with moderate food insecurity and 76 percent (or $1092) higher among those with severe food insecurity.

3) Food bank use is a poor indicator of food insecurity  

Food Banks Canada recently estimated food bank use for a twelve month period at 1.7 million people, yet the number of food insecure individuals living in Canada is more than double this estimate. The main reason for this discrepancy is that most people struggling to afford the food they need do not turn to charities for help. The evidence suggests that using food banks is a last resort. Because food banks rely on donated food, both the amount and type of food available for distribution is limited, and agencies are unable to provide for everyone in need.

4) An adequate and secure level of household income is strongly linked to food security

It is perhaps surprising, but households reliant on wages and salaries make up the majority of food insecure households in Canada at 62 percent. Households whose main source of income was either pensions or dividends and interest had the lowest rate of food insecurity in 2012 at seven percent — compared to 11 percent for people in the workforce and 70 percent for people on social assistance (i.e., welfare and disability support programs). Researchers suggest the low rate of food insecurity among Canadian seniors reflects the protective effects of our public pension system.

5) Relatively modest increases in income have been found to lessen food insecurity among low-income families

Studies have shown that improved incomes and changes in employment can reduce food insecurity. An example of this can be found in Newfoundland and Labrador where evidence shows that from 2007 to 2012 the rate of food insecurity among households living on social assistance in this province fell from a staggering 60 percent to 34 percent. During this time period, the Newfoundland government made several changes to improve the circumstances of people living on social assistance, including increasing benefit levels and indexing them to inflation (until 2012). 

Let’s not let another year go by without addressing food insecurity in Canada.  In a country as rich as ours, there’s no reason anyone should go hungry. 

 Shimmin_Carolyn_HIGH RESCarolyn Shimmin is a Knowledge Translation Coordinator with and the George and Fay Yee Centre for Healthcare Innovation.






tarasuk aug 11 2015Valerie Tarasuk is a Professor in the Department of Nutritional Sciences and Dalla Lana School of Public Health at the University of Toronto and Principal Investigator of PROOF, a research program funded by the Canadian Institutes of Health Research to identify policy interventions to reduce food insecurity in Canada.

Why Canada Needs a National Plan to Address Dementia and Alzheimer’s

December 22, 2015 10:47 am

One of the biggest threats to quality of life and health in ageing is the loss of cognitive abilities and functional autonomy that are associated with dementia, including Alzheimer’s disease. The projections of the number of Canadians living with dementia are staggering, with over 750,000 individuals affected today, an attendant doubling by 2030 – and with health care costs of $293B by 2040.

In September 2015, the Canadian Academy of Health Sciences (CAHS) held a Forum on dementia in Canada. This brought together social scientists, biomedical and health services researchers, healthcare practitioners and technology experts to review current knowledge about prevention and care of dementia with the goal of advancing solutions.

The overarching message of the Forum was that while we have seen many successful pilot projects across the country, there is no mechanism to ensure that these best practices and evidence are scaled up so that all communities in Canada benefit.

So what should be done?  Canada needs a national action plan to address dementia and Alzheimer’s.  And we need one soon.  Here’s why.

Drugs are not presently the answer, and imminent pharmaceutical solutions seem unlikely with more than 200 drug development failures in the last 30 years.

Prevention is promising but challenging.  The recently reported FINGER study shows that dietary counselling, exercise training, blood pressure control and cognitive training achieved significant benefits in cognition and well-being.  Unfortunately there is no clear way to scale-up these important findings for the population as a whole.

Then there’s quality of life, mobilization and sustaining a safe environment which are also critical for people already living with dementia in their homes and community settings.  There are promising solutions, ranging from age friendly community design to technology – much that Canada could learn from.

Dementia-friendly communities and optimizing built environments are being explored internationally enhance accessibility, way-finding and engagement in community life. Those affected with dementia may also stay in their homes longer, through “smart” technologies that prompt tasks and collect data that can be relayed to family and healthcare providers. Robotics, too, may support an individual’s cognitive strength while futuristic self-driving cars come ever closer to implementation.

In other words, there’s no magic bullet.  What we need is a multi-faceted approach that requires real leadership and adequate resourcing for implementation.

There are some key challenges across the country that need addressing for starters.  Accessibility to assessment, diagnosis, treatment and comprehensive continuity of care is a major challenge in all jurisdictions across the country. Quebec offers a promising model with the family doctor at the center of an interdisciplinary team, coordinating care and supporting affected individuals and their families through their disease course.

Homecare needs national attention too.  The type of home support available across Canada varies widely, with limited provision being the common feature. The truth is family and friends of persons with dementia provide most of the care and the healthcare system tends to be reactive rather than guiding or integrating care.

We can address this with a national focus.  There are noteworthy programs that have been developed within provincial boundaries but which have not yet spread to other jurisdictions.

In Saskatchewan, for example, researchers and clinicians have created a “one stop shop” dementia intervention clinic using telehealth, allowing more care to be provided in the home community, making it easier for those living in rural areas – a major challenge in Canada.

A national plan also needs to address the later stages of living with dementia. Right now we are highly dependent on residential care settings where there are significant challenges across the country in providing consistent quality of care, quality of life and quality end-of-life care.

We can no longer hope for simple solutions or a miracle drug to cure our dementia problem in this country (if we ever could).  And the status quo simply won’t hold.  What we need is a strategic action plan for the country that facilitates prevention strategies, advances systems of care delivery, re-shapes our living and built environments and mobilizes technology so that all Canadians with dementia – regardless of who they are or where they live – are supported in their communities as long as possible, and when that is no longer possible, receive exemplary quality care.

We’ve known about the rising rates of dementia – and the catastrophic costs to the healthcare system ­– for years.  What we need now is a multi-faceted action plan with government, the private sector, and the community at large coming together.

Feldman-Howard-MEDI 06Howard Feldman is an advisor with and Professor of Neurology, Faculty of Medicine, University of British Columbia. 






ESTABROOKS_Carole-resized (1335x2000)Carole Estabrooks is Professor & Canada Research Chair, Faculty of Nursing, and University of Alberta.

Canadians Should Modernize not Privatize Medicare

December 21, 2015 11:27 am

National Medicare Week has just passed, buoyed with optimism as a fresh-faced government takes the reins in Ottawa – elected partly on a promise of renewed federal leadership on health care.  Yet these “sunny ways” are overcast by recent developments at the provincial level that entrench and legitimize two-tier care.

Saskatchewan has just enacted a licensing regime for private MRI clinics, allowing those who can afford the fees – which may range into the thousands of dollars – to speed along their diagnosis and return to the public system for treatment.  Quebec has just passed legislation that will allow private clinics to extra-bill for “accessory fees” accompanying medically necessary care – for things like bandages and anesthetics.

Once upon a time, these moves would have been roundly condemned as violating the Canada Health Act’s principles of universality and accessibility.  These days, two-tier care and extra-billing are sold to the public as strategies for saving medicare.

Under Saskatchewan’s new legislation, private MRI clinics are required to provide a kind of two-for-one deal: for every MRI sold privately, a second MRI must be provided to a patient on the public wait list, at no charge to the patient or the public insurer.  Quebec’s legislation is touted as reining in a practice of extra-billing that had already grown widespread.

Underlying both reforms is a quiet resignation to the idea that two-tier health care is inevitable.

This sense of resignation is understandable, coming as it does on the heels of a decade-long void in federal leadership on health care.  Throughout the Harper government’s time in office, the Canada Health Act went substantially unenforced as private clinics popped up across the country.  Even in its reduced role as a cheque-writer, the federal government took steps that undermined national unity around health care, switching the Canada Health Transfer to a strict per capita formula, which takes no account of a province’s income level or health care needs.

If Canadians hope to reverse this trend, we cannot simply wage a rearguard battle for the enforcement of the Canada Health Act, as it was enacted in 1984.  Even if properly enforced, the Act protects universal access only for medically necessary hospital and physician services.  This is not the blueprint of a 21st century public health care system.

We desperately need universal coverage for a full array of health care goods and services – pharmaceuticals, mental health services, home care and out-of-hospital diagnostics.

Canada is unique among OECD countries in the paucity of what it covers on a universal basis despite falling in the top quartile of countries in levels of per capita health spending.  Far from being our savior, the Canada Health Act in its current incarnation is partly to blame – not because of its restrictions on queue-jumping and private payment but because it doesn’t protect important modern needs, like access to prescription drugs.

There are limits on what a public health system can provide, of course – particularly as many provinces now spend nearly half of their budgets on health care.  But fairness requires that these limits be drawn on reasoned basis, targeting public coverage at the most effective treatments.

Under our current system, surgical removal of a bunion falls under universal coverage, while self-administered but lifesaving insulin shots for diabetics do not. A modernized Canada Health Act would hold the provinces accountable for reasonable rationing decisions across the full spectrum of medically necessary care.

Instead of modernizing medicare, Saskatchewan and Quebec are looking to further privatize it.  Experience to date suggests that allowing two-tier care will not alleviate wait times in the public system.  Alberta has reversed course on its experiment with private-pay MRIs after the province’s wait times surged to some of the highest levels in the country.

The current wisdom is that long wait times are better addressed by reducing unnecessary tests.  A 2013 study of two hospitals (one in Alberta, one in Ontario) found that more than half of lower-back MRIs ordered were unnecessary.

Skirmishes over privatization have to be fought, but they should not distract us from the bigger challenge of creating a modern and publicly accountable health system — one that provides people the care they need, while avoiding unnecessary care.  Achieving that will make National Medicare Week a true cause for celebration.


Colleen M. Flood.

Bryan Thomas is a Research Associate and Colleen M. Flood is a Professor, Centre for Health Law, Policy and Ethics, University of Ottawa.  Colleen is also an expert advisor with

Shaw Creating Turbulence in Canadian Telecom by Acquiring Wind Mobile Corp.

December 17, 2015 4:23 pm

What Happened?

Shaw Communications Inc. announces a $1.6 billion (Enterprise Value) acquisition of Wind Mobile Corp., a privately held wireless carrier with subscribers and infrastructure in Ontario, Alberta & British Columbia. Wind has earned expected revenue of $485 million in 2015, implying Shaw is paying a multiple of 3.3x estimated revenue. With this purchase, Shaw acquires 924,000 wireless subscribers making it the fourth largest Canadian telecom carrier.

Brace for Impact

This acquisition allows Shaw to diversify its product portfolio adding wireless into its bundle (Already including WiFi internet, fibre broadband, and cable). Shaw previously owned wireless spectrum acquired from the Canadian government in the 2008 wireless spectrum auction for $189.5 million. Rather than building out a Wireless business at that time, Shaw decided to dispose the asset, selling the spectrum to Rogers for an estimated $350 million ($250 million to secure the option and $100 million to execute) yielding a holding period return of 85%.

Shaw is paying 3.3x revenue and 24.6x EBITDA for WIND which appears to be a steep price. Comparable EBITDA multiples for Canadian wireless companies range from 6.0x – 8.1x. However, revenue multiples are in line with Canadian wireless peers trading at 2.8x – 3.1x revenue. The exit multiple of 3.3x implies a premium of between 4% – 17% to secure controlling interest from the private equity consortium of West Face Capital, Tannenbaum Partners, and Globallive Capital, former Wind Founder Tony Lacavera’s investment fund. This deal is likely synergy rich since Shaw has access to Wind’s subscribers, infrastructure, and distribution network of storefronts. It likely also factors in Wind’s current trajectory to grow its subscriber base and ARPU, as subscribers have grown from 800k to 924k and ARPU from an estimated $31 to $43.74. Shaw will likely increase Wind’s monthly average revenue per user up to a figure in line with peers of $61 as the LTE network comes online by 2017.

The incremental EBITDA of $65 million will likely increase, assuming Shaw plans to decrease operating costs with their additional scale, normalizing margins upwards from 13% to 30%. One way this can occur is with better purchasing terms with handset suppliers. For the past year, Shaw’s share price has been a laggard relative to its peers. Year-to-date its share price has fallen 13.97%, compared to the broader S&PTSX composite down 10%. The risk of cord cutting (consumers cancelling their cable subscription to use more internet and mobile services to satisfy their specified utility) applies a greater degree to a firm like Shaw, whose revenue is predominantly cable generated and threatened by the increasing adoption of IPTV. This deal could be the stimulus investors are looking for to regain excitement about Shaw. Shaw insists that it will maintain its investment grade status with the ratings agencies (currently BBB- which is the lower limit for investment grade), and has $398 million of cash on its balance sheet (as of August 31st their last reported quarterly statement) an insufficient standalone amount. The company has secured bridge financing from a consortium of Canadian banks and is not ruling out issuing preferred stock or additional equity either to finance this purchase. This does present some dilution risk to current equity holders. However, this cannot be confirmed until further details are disclosed upon the transaction close.

Calm After the Storm?

This will likely apply some pricing pressure on the incumbent carriers BCE, Rogers, and TELUS, but likely not a material downward shift. TELUS may experience a higher Churn as a result in Western Canada as Shaw will offer a stronger product in this region, in which TELUS has a threatening presence. It is reasonable to speculate that Wind’s ARPUs will rise as Shaw continues to fulfill Wind’s current transition from 3G to an LTE network to offer a competitive suite of voice and data services to Canadians. Shaw CEO, Brad Shaw indicated this in an interview with the Globe and Mail.

As the quality of the wireless service offering improves, Shaw will likely charge a price in line with what their competitors offer (noting a possible discount), but employ a similar price differentiation strategy such as bundling with their current cable and WiFi customers. Shaw possesses scale, is a proven network operator, and has access to financial capital that WIND does not which is necessary to compete in this capital-intensive industry. (Wind did recently raise financing at below high yield rates, this is not the norm, and was likely done to recapitalize and make the firm more attractive for acquisition)

Shaw has all the ingredients of being a fourth incumbent and a welcome addition to the Canadian Telco Oligopoly. Shareholders rejoice while consumers prepare for the same old song and dance.


David A. Pickett is a former equity research associate from a large Canadian Broker Dealer and has over four years of telecommunications experience in both sales and analytical capacities. He studied his MBA at McMaster University with a focus in Finance and Business Valuation and his interests include history, business, baseball, and board games.

The Planet is Dying of Consumption and Only Citizens can Halt the Process

December 15, 2015 10:03 am

At the 2015 Paris Climate Conference, COP21, the focus has been on promises countries make to reduce their greenhouse gas (GHG) emissions. These macro level commitments are always made with varying degrees of sincerity because few political leaders will be willing to cause real or even perceived damage to their economies.

In other words, it may be unrealistic to expect the bold and courageous political leadership necessary to address the magnitude of the climate problem.

Although Canada’s reputation as an environmental laggard evolved while the Harper government was in power, it should not be forgotten that the Chretien government’s support of the Kyoto Accord was mainly symbolic. Even the most cursory research would reveal that Canada worked to weaken parts of the final Kyoto Protocol through market-based, flexibility mechanisms that reduced Canada’s responsibilities to combat climate change.

For instance, Canada favoured Joint Implementation and Clean Development Mechanisms which allow one country to fund and receive credit for emission-reduction in another country. These devices, embraced by other countries including Japan, the U.S. and Australia contributed to a watering down of national targets to make them palatable to economic interests.  

Regardless how determined the current Liberal government may be to tackle climate change, there are powerful political and economic forces it has to contend with.

That is why if the warming of this planet is to be slowed — if not halted — it will not come about by government fiat, nor should it. Governments are reluctant to impose unpopular measures and the corporate sector will resist attempts to curtail our freedom to consume. This is the elephant in the room: the planet is dying of consumption, a fact that was recognized four decades ago.  

So what’s the solution? The impetus must come from citizens. Their overwhelming support will stiffen the spines of political leaders.

It will require nothing less than a popular uprising, especially in the industrialized world, to convey the message that tackling climate change is urgent. And Canadians must express their willingness to swallow the bitter medicine necessary to solve the problem. For a start, we need to be less wasteful — we throw out more garbage per capita than people in any other developed country.  We also throw away half our food, but on this matter, we are not alone.

People in industrialized countries enjoy an unsustainable lifestyle that swallows up the bulk of the world’s resources. With about five percent of the world’s population, Canada and the U.S. consume 32 percent of its resources. If the rest of the world caught up with us, it would be catastrophic.

It’s easy to ignore the impact of individual actions on the environment.  Whether it is using energy for our mobile devices – the smart phones that never leave our sides – or the proliferation of two-storey inflatable Santa Clauses (or their seasonal equivalent) that adorn more and more lawns, few of us even think of the consequences of our spending habits. Consumption must be addressed.

COP21 was an opportunity for citizens to inform governments that they are ready to make painful choices. But we, at the grassroots level, must drive the process otherwise governments will continue to meet and sign accords with lots of wiggle room and it will all be for show.

If our new federal government truly believes in hope and change, it will come up with more robust means to reduce greenhouse gas emissions.  Prime Minister Trudeau has announced to the world that Canada is back and if that means we’re back to a wishy-washy approach to environmental solutions, the hopes that are riding on his shoulders will soon evaporate.

Barrie,Doreen_PoliSci_Sep2015Doreen Barrie is an Adjunct Assistant Professor of Political Science at the University of Calgary.

It’s Time to End Canada’s Opioid Epidemic – An Open Letter to Canada’s New Minister of Health

November 30, 2015 11:18 am

Dear Minister Philpott,

Congratulations on your appointment as Minister of Health. As an experienced physician, you bring valuable perspective to the post. While there are many contentious matters before you, including a new health accord, physician-assisted dying and marijuana legalization, few could be more pressing than the prescription opioid epidemic, an issue all but ignored by your predecessors. This is the greatest drug safety crisis Canada has ever faced.

When you returned to Canada in 1998 after nearly a decade of practice in Africa, you witnessed the seeds of this epidemic being sown, with strong painkillers like OxyContin prescribed liberally for chronic back pain, arthritis and fibromyalgia. You heard experts say these drugs worked well for chronic pain, that the risk of addiction was low, and that doctors who resisted prescribing them were “opiophobic.” Perhaps you even began prescribing opioids for chronic pain, as did I and thousands of our colleagues, unaware that what we had been told was untrue.

It’s clear now that we were objects in an elaborate marketing effort. Cloaked as it was in the virtues of compassion and beneficence, it was a remarkable success – until, that is, we consider our patients. Today, doctors’ offices are inundated with people who have been harmed more than helped by these drugs. Thousands more are dead. No demographic has been spared. And yet the marketing continues, with pain specialists and advocacy groups opposing moves to curtail opioid prescribing, their efforts financed by the very companies that make these drugs. These forces, coupled with the societal expectation that pain be medicated, threaten every community in this country.

Dr_Jane_Philpott (1)

Canada’s new Health Minister Jane Philpott.

An estimated 10,000 to 20,000 Canadians have died from opioids since 1995, and an untold number now suffer from addiction. The federal government must take the lead in dealing with this crisis, rather than offloading responsibility to the provinces. I propose several concrete measures to that end. Some are squarely within your purview; others will require provincial cooperation.

We must quantify the toll of the epidemic. In the United States, more than 16,000 people die of opioids each year; remarkably, there are no corresponding data for Canada. We can’t fix what we don’t even measure. The Public Health Agency of Canada should work with provinces to develop mechanisms to quantify opioid-related deaths. These data should be public.

Prescription monitoring programs should connect pharmacies in real time, in part to identify the small but important subset of patients seeking prescriptions for misuse or resale. These systems can also identify physicians whose prescribing falls afoul of good practice or, in some instances, the law. In an era when teens on different continents play video games in real time, it’s absurd that pharmacies in the same town operate in isolation.

Some measures involve specific drugs. Eliminate nonprescription codeine products from Canadian pharmacies. These are poor analgesics prone to abuse at high doses, resulting in deaths from acetaminophen and ASA toxicity. Revoke approval for “generic OxyContin” tablets, which are easily crushed and disproportionately benefit the dealers who sell them. The popular painkiller tramadol is increasingly abused and should be reclassified as a controlled substance, as its pharmacology demands and as Health Canada contemplated in 2007 before being lobbied by Purdue Pharma. Finally, treatment with fentanyl – an especially dangerous drug – should be restricted to patients willing to return used patches for new ones.

People with opioid addiction need more support and less marginalization. They require greater access to addiction specialists and medications like buprenorphine, along with supervised injection sites for those who choose this path. These save lives, as does the antidote naloxone, which should be freely available to anyone who wants it. Health Canada’s review of naloxone, inexcusably glacial, must be accelerated.

Finally, the government should introduce legislation akin to America’s “Sunshine Act”, illuminating the financial relationships between pharmaceutical companies and doctors, specialty organizations and advocacy groups. The money here flows in one direction only, its sole purpose to increase drug sales. This initiative, sure to be opposed, will necessitate provincial cooperation.

Some of these suggestions are more easily implemented than others, but all warrant your consideration. With more than a hundred Canadians dying every month, there is no time to waste.

Juurlink_David_HIGH RESDavid Juurlink MD, PhD is a Professor and Head at the Division of Clinical Pharmacology, University of Toronto. You can find him on Twitter at @davidjuurlink.

Dear Health Minister Philpott — We Need Leadership In Medicare Restored

November 19, 2015 11:00 am
Dr_Jane_Philpott (1)

Dear Minister Philpott,

It is fantastic news that as a family doctor you are our next federal health minister.  You will know very well that our healthcare system shows its age.  Born in the middle of the 20th century, its primary focus on doctors and hospitals is outmoded as technology shifts and our health needs change.  But forging change in Canadian heath care has proved an extraordinary challenge.   

In the past, the stickiness of the status quo means that even if new federal dollars for healthcare are transferred to the provinces, they will be spent mostly on increased fees for physicians and hospitals. You will also know too well from history that real change won’t happen by providing more federal money with unconditional transfers.  

Real change will require helping provinces to shift the focus of our health system away from those who are relatively well resourced to new areas of care, such as essential pharmaceuticals and homecare.

So what should you do?  

First, and most importantly, you should accept and endorse a shared responsibility for healthcare in the federation.  

The Harper decade was a dark one for healthcare leadership.  His mantra was that all healthcare decision-making was a matter for the provinces.  It has since become a common refrain for media pundits to claim healthcare is a matter of exclusive provincial jurisdiction although our Constitution clearly provides it is a matter of shared jurisdiction.

Federal leadership in healthcare does not mean dictating to the provinces what to do or how to do it, but it does mean bringing provincial leaders together in the spirit of cooperation and under shared initiatives with specific targets, goals and money attached.  

There are two areas that could most benefit from critically needed federal-provincial shared leadership: pharmaceutical drugs and long-term care/homecare.    

We are the only developed country with a universal health system not to insure its citizens for prescription drugs.  This means too many Canadians are going broke to afford their essential medicines or forgoing them altogether, and costing Canadians far more in acute health services in the long run.  

But apart from the access problem, we also have a cost problem – we spend a lot on medicines.  Indeed, the OECD has just issued a report showing Canadians are (still) paying some of the highest prices for pharmaceutical drugs in the world.  

We are in this situation because we rely on multiple (and largely unregulated) private insurers with most government plans covering the poor and very old.  Neither have been strong bargainers on our behalf with pharmaceutical companies.

So how do we shake up the status quo? We need universal drug insurance covering all Canadians.  We can’t go on with a medicare that doesn’t cover essential drugs like insulin or cancer medications, for example.  

It is a false economy to think the expansion of public money is a luxury we can’t afford when, overall, if we had universal drug insurance we would have better control of total (public and private) spending than we presently do — and the ability to negotiate better prices for drugs.   

To get there we could follow in the footsteps of Australia.  In the 1940s, Australians changed their constitution so the federal government assumed jurisdiction over pharmaceuticals. An appropriate first reaction might be that a constitutional change in Canada has a snowball’s chance in hell, but it may be easier than you think.  Canadian provinces once agreed voluntarily to just this kind of arrangement for pharmaceuticals during the last Liberal administration.  Don’t say no this time.  

Another option might be to amend the Canada Health Act to tie fiscal health transfers to provinces on the condition they provide some form of insurance for important prescription drugs.  How they do this would be their decision, but leadership from the federal government would go a long way in making critical medicines accessible to all Canadians.  

Finally, Canada needs real change in homecare and long-term care.  Prime Minister Trudeau already promised $3 billion dedicated to homecare, but please make sure the provinces are required to use this money to get people more needed homecare and long-term care rather than being used to maintain the status quo.

New money must drive real systematic reform.  

You need to lead and explore with the provinces new ideas like possible universal long-term care insurance (similar to CPP) or other innovative financing strategies that maximize individual autonomy and choice.  One idea could be personal support budgets which are popular in Europe and allow those in need a source of funds to buy homecare and other supports in the community rather than being forced into (costly) public institutions.

Minister Philpott, we need new models of thinking about how we provide essential medicines and health services to Canadians. The same-old-same-old thinking will no longer do.

Flood_ColleenColleen M. Flood is a Professor, Director of the Centre for Health Law, Policy & Ethics, and a University of Ottawa Research Chair in Health Law & Policy.

Why Police Fear Evidence-Based Research

November 12, 2015 11:21 am

While almost every sector of society in the 21st century recognizes the importance of evidence-based decision making, police organizations are caught up in outdated policing approaches that are devoid of empirical evidence.  The major reason police are so resistant to the new regulations on carding announced by the provincial government is the fear that they will be subject to increased scrutiny.  

In short, it’s not carding that they fear but evaluation and evidence-based policies that will be able to measure their effectiveness.  Jeff McGuire, president of the Ontario Association of Chiefs of Police, argues that the new carding regulations will strain ties with the community and lead to an increase in complaints against the police. This is as devoid of empirical evidence as the misguided argument that carding helps police solve crime.

So why do police fear evidence-based approaches to policing?  First, police organizations in the past have functioned with relatively little outside scrutiny as to how they conduct their operations.  This independence has helped them avoid being evaluated and criticized for the way they police the community. For example, it’s a well known fact among academics that police organizations are very wary of letting researchers carry out empirical research on how they police.  This resistance is one of the major reasons there have been so few studies that look at police use of force, racial profiling, carding, police community relations and race relations, to name just a few.

Second, police organizations are generally very conservative and are more interested in preserving the status quo than making major changes to how they police.  This abhorrence to change comes from the fact that many police chiefs came up through the rank and file where compliance and conformity is rewarded and innovation and creativity is discouraged.  Staying the course is easier than adopting new methods of policing and it’s so ingrained in the police culture that any change is actively discouraged.

Third, police leaders are afraid that evidence-based research that reveals flaws in the way they police may lead to them being fired or removed from their jobs.  As a result police agencies see empirical research as a potential threat to their occupation.  This is particularly true for police leaders who have no formal education or understanding of the role that research can play in improving their organization’s overall effectiveness in policing.  Many police chiefs still have stereotypical ideas about crime, punishment and criminality that bear no actual resemblance to research evidence in the 21st century.  Some police officers still see themselves and society gridlocked in an ‘us versus them’ dichotomy when dealing with the public.

Fourth, many police organizations are ignorant of the value that evidence-based research can play when it comes to improving their relations with the public and in reducing crime.  Carding is a good example.  While some police chiefs claim that the new carding regulations will negatively affect their relationship with the community they completely overlook the enormous harm that carding has caused in the discriminatory manner in which it has been used by police to bully, intimidate and label minorities.  Police have repeatedly ignored the fact that carding is a violation of the Canadian Charter of Rights and Freedoms and that it is a non-transparent form of surveillance that records and retains data on non-convicted people.  It has absolutely no place in a civil and democratic country that is governed by the rule of law.

Before stepping down as the Chairperson of the Toronto Police Services Board, Alok Mukherjee outlined a new model of policing for the City of Toronto.  His policing model was not based on antiquated concepts and ideas that are 40 years out of date but rather on solid empirical evidence about policing in the 21st Century.  Most people are not aware that less than 20 per cent of a police officers time actually deals with law enforcement related activities.  In fact, studies show that police officers spend 80 per cent of their time filling out reports, facilitating traffic at construction sites, responding to noisy parties and helping mediate neighborhood disputes.  Does it make sense that we should be paying a police officer $80,000 a year for these duties when they could for a fraction of the cost be transferred to bylaw officers or other people to perform these tasks?  In the nation’s capital the Ottawa Police Service is responsible for enforcing the rules governing bicycles.  Is this a productive and cost-effective utilization of their time?  The fact is that if more people were aware of what police do with their time some people might actually start questioning the costs of policing in their neighborhoods.

Under the Canadian constitution it’s not the role of the police to make laws in society and police chiefs and police associations should not be accorded any special status, privileges, treatment or influence in directing government policy in Ontario that is not equally afforded to the average citizen.  The fact is that police organizations must change the way they police citizens in this province by adopting innovative policing measures in the 21st Century that are evidence-based, progressive and cost-effective.  Citizens should expect and demand nothing less.

The views expressed are those of the author in his personal capacity and they do not necessarily represent the position of Carleton University.

Darryl T Davies is an Instructor in criminology and criminal justice with the Department of Sociology and Anthropology at Carleton University.

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