Future of health care system tops agenda as CMA Board of Directors meets

The first part of the CMA''s efforts to spark a public debate on the future of Canada''s health care system is a “visioning exercise” in which the Board of Directors will attempt to spell out the association''s views on how the system should develop. The board also discussed CMA initiatives concerning two major public-health issues — smoking and blood transfusions.     

CMA brief offers suggestions as federal commission studies country's blood-gathering system

The CMA hopes the Commission of Inquity on the Blood System, chaired by Mr. Justice Horace Krever, “will restore faith in a system that is essential for the health and safety of all Canadians.” However, the cost implications any recommendations may have for the health care system must also be taken into consideration. The CMA made several recommendations in response to the commission''s interim report.     

Family planning/contraception

It is the position of the Canadian Medical Association (CMA) that family planning advice and assistance should be readily available to all residents of Canada. This is viewed as a responsibility of practising physicians that is to be shared with other health and educational agencies. CMA has recommended the establishment of facilities in addition to physicians'' offices for the dissemination of advice on family planning. These facilities should be developed in consultation with and under the supervision of the medical profession. CMA believes induced abortion should not be an alternative to contraception as a method of responsible family planning. In the event of an unwanted pregnancy, full counselling services should be provided. Within the context of preventive medicine, CMA supports the development of educational programs in family living and the promotion of sex education in the school system by knowledgeable persons sensitive to the needs of students.     

Vehicle safety

To help reduce the number of deaths and injuries caused by vehicle accidents on Canadian roads, the CMA has for several years made recommendations on a wide range of vehicle safety standards. Since the 1960s the association has urged the provinces to enact mandatory seatbelt legislation, although it was not until 1976 that the first two provinces (Ontario and Quebec) did so. The CMA believes that the nonuse of restraint systems should be considered contributory negligence in the event of an accident producing injury to vehicle occupants. It has urged governments to approve and promote appropriate child restraint systems and to require the legislated provision of suitable and standardized tether anchorage. To increase the conspicuousness of motor vehicles the association has advocated the introduction of daytime running lights in all new vehicles. In 1965 the CMA recommended that motorcyclists wear approved helmets; indeed, it believes that there is no medical reason that would justify exemption from wearing a helmet. The CMA has also made several recommendations on safety standards for mopeds, all-terrain vehicles, minivans and light trucks and has encouraged its provincial divisions to form highway safety committees. As well as recognizing the importance of appropriate and enforced vehicle safety standards in reducing the rates of death and injury, the CMA has recommended and supported legislation aimed at decreasing the incidence of drinking and driving (Can Med Assoc J 1985; 133:806A).     

ALCOHOL AND DRIVING—Application of a Definition in a Way to Deter Offenders

Increasing speed and congestion of vehicular traffic have made the effect of alcohol on the drivers of motor vehicles a matter of growing concern. It is not possible, using the definition of drunken driving that is now prevalent in California, to establish a rule, based on a stipulated minimum concentration of blood alcohol, that will serve to indict most of the guilty yet free all the innocent. If, instead of comparing the suspected driver with the hypothetical “ordinarily prudent and cautious person” as is now done in California, we accept the more widely prevalent definition of driving under the influence which defines the offense as any appreciable diminution in skill ascribable to alcohol, then a blood alcohol concentration of 150 mg. per 100 cc. or even 100 mg. per 100 cc., could suffice for conviction.For the rule as to alcohol content of the blood to be an effective deterrent of drunken driving, all drivers—not just those involved in accidents or observed to drive erratically—would have to be subject to testing.     

Buffeted by harsh economic winds,medical schools turn a wary eye to the future

All parts of Canada''s health care system are facing fiscal pressures these days, but they are particularly great at Canada''s medical schools. However, Dr. David Hawkins of the Association of Canadian Medical Colleges is optimistic that all 16 of Canada''s medical schools will remain open, mainly because of the huge impact they have on health care in their local communities. “We don''t just turn out students — we raise the standard of health care in a whole community,” he says.     

CYTOLOGIC DETECTION OF CERVICAL CANCER—Four Years' Experience with Routine Smear Examination in Private Practice

Simplified Papanicolaou smear techniques appear to be adaptable to private clinical practice when experienced cytodetection laboratory facilities are available. A private physician''s office seems potentially an efficient, economical and practical place for detection of cervical cancer by use of the smear technique as a routine part of examination of patients.In a series here reported upon, examination of 11,207 cervical smears taken at the first examination of patients of all ages led to diagnosis of unsuspected malignant disease in 80 cases—in all instances at a stage when it should be easily curable. Cancer was not detected in examination of 6,060 smears taken later from women who had had a “negative” smear at the time of first examination, which seems to indicate that the first screening was reasonably accurate.In a few cases, early cancer was detected when smears were reported as “atypical” or “suspicious.” Such reports demand as careful follow-up as do “positive” reports.There are dangers and limitations in wide-spread clinical application of screening by this method. Care must be observed in the development of programs for its use lest the potential benefits in early detection be outweighed by the dangers from misuse.     

Applications and Enrolments at the Western Medical Schools: A Study of Medical Matriculants for 1964

All applicants and those who subsequently enrolled for the 1964-65 session in the Western medical schools were studied with the hope that it would encourage a national registration of applicants. Seven hundred and sixty-four applicants completed 865 applications for 288 places in four schools. Although the principal factor in selecting medical students in all Western schools is pre-medical performance, 49 “good-quality” (academically of good standing and under 30 years of age) resident applicants were not accepted in their own provincial school, and 49 places were filled with “poor-quality” students.The loss of good applicants to the Western medical schools and the 20% overlap of each school''s applicant pool with that of other schools suggests that objective standards of quality must be developed, and that a regular annual national assessment of applicants should be conducted by the Association of Canadian Medical Colleges.     

Business leaders begin to rally in support of public health care system

There appears to be growing concern among Canada''s business leaders about the future of Canada''s health care system. At a recent meeting in Montebello, Que., that was cosponsored by the CMA and several Canadian corporations, some business representatives said Canada''s publicly funded system gives them a competitive edge in an increasingly global market.     

Canada's Neglected Tropical Disease Research Network: Who's in the Core—Who's on the Periphery?

Background

This study designed and applied accessible yet systematic methods to generate baseline information about the patterns and structure of Canada''s neglected tropical disease (NTD) research network; a network that, until recently, was formed and functioned on the periphery of strategic Canadian research funding.

Methodology

Multiple methods were used to conduct this study, including: (1) a systematic bibliometric procedure to capture archival NTD publications and co-authorship data; (2) a country-level “core-periphery” network analysis to measure and map the structure of Canada''s NTD co-authorship network including its size, density, cliques, and centralization; and (3) a statistical analysis to test the correlation between the position of countries in Canada''s NTD network (“k-core measure”) and the quantity and quality of research produced.

Principal Findings

Over the past sixty years (1950–2010), Canadian researchers have contributed to 1,079 NTD publications, specializing in Leishmania, African sleeping sickness, and leprosy. Of this work, 70% of all first authors and co-authors (n = 4,145) have been Canadian. Since the 1990s, however, a network of international co-authorship activity has been emerging, with representation of researchers from 62 different countries; largely researchers from OECD countries (e.g. United States and United Kingdom) and some non-OECD countries (e.g. Brazil and Iran). Canada has a core-periphery NTD international research structure, with a densely connected group of OECD countries and some African nations, such as Uganda and Kenya. Sitting predominantly on the periphery of this research network is a cluster of 16 non-OECD nations that fall within the lowest GDP percentile of the network.

Conclusion/Significance

The publication specialties, composition, and position of NTD researchers within Canada''s NTD country network provide evidence that while Canadian researchers currently remain the overall gatekeepers of the NTD research they generate; there is opportunity to leverage existing research collaborations and help advance regions and NTD areas that are currently under-developed.     

“HIDDEN” ALCOHOLICS—Medical Implications of Undiscovered Addiction

“Hidden alcoholics”—those who drink surreptitiously to keep their addiction secret—far out-number the overt habitues of skid rows. The former rather than the latter should be considered “typical” alcoholics. Even though they have severe problems, they maintain fairly good employment stability and stability in marriage. Yet they steadily deteriorate.Often “hidden” alcoholics go to physicians because of symptoms referable to alcoholism but contrive to conceal their addiction and so make diagnosis difficult. Hence, physicians observing certain kinds of symptoms that cannot be attributed to a readily observable or demonstrable pathologic change should make searching inquiry as to the patient''s drinking habits. For not until the proper diagnosis is made in such cases can there be hope of effective treatment.     

Immunization

Vaccines have eliminated or substantially reduced the incidence in Canada of smallpox, poliomyelitis, measles, mumps, rubella, diphtheria, tetanus and pertussis. The Canadian Medical Association (CMA) advocates a single immunization schedule, complete for all age groups and diseases where immunization is indicated and available. CMA has endorsed in principle (1984), the second edition of the Guide to Immunization for Canadians compiled by the National Advisory Committee on Immunization and requested that it be disseminated to all practising physicians in Canada. CMA also firmly endorses the concept of a readily accessible nationwide method of recording immunization status. In keeping with the World Health Organization''s commitment to global control of measles, CMA (1981) supports and encourages mandatory vaccination against measles for children. The association advocates a much more aggressive and sustained public education program to promote public awareness and acceptance of immunization.     

CMA membership survey: opinions on issues facing the medical profession

A sample survey of Canadian Medical Association (CMA) members, conducted in early summer 1985 and designed to provide information to help guide the association''s activities and policies, shows that most Canadian physicians support involvement in political activities both by CMA and by indivudual physicians. A majority wishes to maintain the concept of extra/balance billing, to pursue the position that the health care system is underfunded and favours medicare premiums and hospital user fees as the preferred methods for increasing revenue.Most respondents believe that the number of doctors in Canada is about right but would prefer any reduction to be achieved by cutting medical school admissions or reducing postgraduate training positions open to graduates of foreign medical schools.Most of those members who know of CMA policies on a number of health care issues agree with them and also find them useful, but a significant proportion are not aware of their content.There is support for compulsory payment of dues by all licensed physicians to both their provincial medical association and CMA. A majority would like more information on pharmaceutical products and additional membership surveys.     

Patents Associated with High-Cost Drugs in Australia

Australia, like most countries, faces high and rapidly-rising drug costs. There are longstanding concerns about pharmaceutical companies inappropriately extending their monopoly position by “evergreening” blockbuster drugs, through misuse of the patent system. There is, however, very little empirical information about this behaviour. We fill the gap by analysing all of the patents associated with 15 of the costliest drugs in Australia over the last 20 years. Specifically, we search the patent register to identify all the granted patents that cover the active pharmaceutical ingredient of the high-cost drugs. Then, we classify the patents by type, and identify their owners. We find a mean of 49 patents associated with each drug. Three-quarters of these patents are owned by companies other than the drug''s originator. Surprisingly, the majority of all patents are owned by companies that do not have a record of developing top-selling drugs. Our findings show that a multitude of players seek monopoly control over innovations to blockbuster drugs. Consequently, attempts to control drug costs by mitigating misuse of the patent system are likely to miss the mark if they focus only on the patenting activities of originators.     

A Qualitative Study of Alcohol,Health and Identities among UK Adults in Later Life

Increasing alcohol consumption among older individuals is a public health concern. Lay understandings of health risks and stigma around alcohol problems may explain why public health messages have not reduced rates of heavy drinking in this sector. A qualitative study aimed to elucidate older people''s reasoning about drinking in later life and how this interacted with health concerns, in order to inform future, targeted, prevention in this group. In 2010 a diverse sample of older adults in North East England (ages 50–95) participated in interviews (n = 24, 12 male, 12 female) and three focus groups (participants n = 27, 6 male, 21 female). Data were analysed using grounded theory and discursive psychology methods. When talking about alcohol use older people oriented strongly towards opposed identities of normal or problematic drinker, defined by propriety rather than health considerations. Each of these identities could be applied in older people''s accounts of either moderate or heavy drinking. Older adults portrayed drinking less alcohol as an appropriate response if one experienced impaired health. However continued heavy drinking was also presented as normal behaviour for someone experiencing relative wellbeing in later life, or if ill health was construed as unrelated to alcohol consumption. Older people displayed scepticism about health advice on alcohol when avoiding stigmatised identity as a drinker. Drinking patterns did not appear to be strongly defined by gender, although some gendered expectations of drinking were described. Identities offer a useful theoretical concept to explain the rises in heavy drinking among older populations, and can inform preventive approaches to tackle this. Interventions should engage and foster positive identities to sustain healthier drinking and encourage at the community level the identification of heavy drinking as neither healthy nor synonymous with dependence. Future research should test and assess such approaches.     

Intention Understanding in Autism

When we observe a motor act (e.g. grasping a cup) done by another individual, we extract, according to how the motor act is performed and its context, two types of information: the goal (grasping) and the intention underlying it (e.g. grasping for drinking). Here we examined whether children with autistic spectrum disorder (ASD) are able to understand these two aspects of motor acts. Two experiments were carried out. In the first, one group of high-functioning children with ASD and one of typically developing (TD) children were presented with pictures showing hand-object interactions and asked what the individual was doing and why. In half of the “why” trials the observed grip was congruent with the function of the object (“why-use” trials), in the other half it corresponded to the grip typically used to move that object (“why-place” trials). The results showed that children with ASD have no difficulties in reporting the goals of individual motor acts. In contrast they made several errors in the why task with all errors occurring in the “why-place” trials. In the second experiment the same two groups of children saw pictures showing a hand-grip congruent with the object use, but within a context suggesting either the use of the object or its placement into a container. Here children with ASD performed as TD children, correctly indicating the agent''s intention. In conclusion, our data show that understanding others'' intentions can occur in two ways: by relying on motor information derived from the hand-object interaction, and by using functional information derived from the object''s standard use. Children with ASD have no deficit in the second type of understanding, while they have difficulties in understanding others'' intentions when they have to rely exclusively on motor cues.     

Coumarin Therapy and Platelet Aggregation

Platelet aggregation has been related to blood coagulation studies in patients on nicoumalone, a coumarin anticoagulant. Aggregation studies were performed by means of Chandler''s tube and the adenosine diphosphate (A.D.P.)-induced optical density method. Platelet aggregation in Chandler''s tube has been shown to be quite different from A.D.P. aggregation and to be dependent on the “intrinsic” (blood) clotting system. When the intrinsic system was depressed by coumarin anticoagulant, aggregation was delayed in Chandler''s tube, but patients with a predominantly “extrinsic” (tissue) system defect gave normal results even when their prothrombin time was excessively prolonged. In contrast there was an increased response to A.D.P. in the anticoagulated patients.The study emphasizes the different mechanisms of platelet aggregation, which we have referred to as coagulation-induced and A.D.P.-induced aggregation. It also shows the limitations of routine control of oral anticoagulants by prothrombin time alone, as the coagulation-induced platelet aggregation appears to be quantitatively related to the overall level of clotting factors in the intrinsic system and independent of the extrinsic system.