To What Was, What Is and What Will Be - Farewell 2015

Every year, without fail, between Christmas and New Years my mind turns to the year that was, and the year that is to come. Almost always, there is a combination of thankfulness for all that has been learned (particularly true in the most challenging years), for my family, for friendships and hope for the year that is to come. I think about the sorts of things that will move me towards my goals - personal goals, professional goals and purpose goals. I think about what has held me back, and if there is anything that can be done about those things.

In recent months I haven't been blogging as much as I would have liked - not because there has not been anything to write about (indeed there has) but rather because lack of time, leads to a kind of neglect. Indeed, there have been numerous posts began, but never finished - on work, on maternal request cesareans, on the health system, on Parent Advisory Councils and the education system and on life. Posts have been begun, stale-dated and never posted - and I have missed blogging. The space where ideas are let loose publicly - the exercise of writing, both for my own understanding and to share my ideas with others. I hope to do more blogging again in the year to come.

On the work front, I am once again, reasonably happy. Once again, I find myself working for someone who is the kind of leader I would hope to be. Someone who truly values the abilities of his staff (and understands what those abilities are), gives meaning to work, and fosters a good work climate. Once again I am engaged - and for that I am thankful. Yet, I find myself thinking that less would be far more - and so in the year to come, I am hoping to move away from a full-time schedule so that I can make more room for work outside of work - the work on the this blog, the Cesarean by Choice Awareness Network, the work I do for my husband's firm, for writing and mothering & life. Simply put, there's 24 hours in a day, and in order to find balance and perhaps do more that means more, I must adjust - I must make time and space for that work outside of work. It appears at last, that that opportunity will come to pass in the year to come.

I am incredibly thankful to be in a position where that is possible - where I will be supported to find a better balance, and I am incredibly hopeful for what that means in the year to come. I am incredibly thankful for the people and circumstances in my life that has made the year ahead possible. Indeed, looking back at 2015 - the foundation has been laid for an incredible 2016.

To 2016 - and beyond, wishing all the best - health, happiness, friendship, love, hope and success.

Election 42 - Go Vote!

I am usually a decided voter long before I enter the polls. This year I was a decided voter, until I was not. Until my preferred candidate withdrew from the race, after the nomination deadline – leaving me yet again, undecided, except for clear knowledge of who I would not vote for. I brought both my children with me – my daughter for the second time, and my son for the first time. I entered the gym of my daughter’s school and approached the table where I was directed to present my voter registration card and ID. The election worker neatly crossed my name off with a ruler and handed me a ballot. I proceeded to the box, and unfolded the ballot. I checked to ensure it was as it should be – unmarked. I then made a choice, my pencil alternating between two of the candidates before I clearly marked an X beside one. I folded my ballot again and put it into the box - narrating the process for my daughter.

Her name was still on the ballot – there was no prominent notice of her withdrawal at the polling station I attended. Momentarily, I entertained the idea of marking my “X” there despite knowing that she had withdrawn. I felt remorse and a degree of anger – after all, her reason for withdrawal was that comments she had made on facebook had been taken out-of-context and paraded about. It was not anything that she had done in the course of her work, nor in the course of her public duties – but rather her private life that had put an end to her political career. Further, it was comments made years before she was a candidate – comments that may not have even reflected her current beliefs. Comments that should have been given the same amount of deference as comments made at a dinner party.

And yet, she withdrew.

I still wanted to vote for her – for her party – in some measure because of what had happened. I wanted to vote for her, because, I believe people have a right to their personal lives – even and perhaps especially those who run for office. I wanted to vote for her, because, I believe people should be able to “live out loud” – and that their careers, their actions in public – should speak much louder than what they might have said or wrote in their private lives (including on facebook with the intended audience of friends and family). I believe that people continue to mature – that the views once held, change over time – and that what matters, truly, is a willingness to grow and learn from one’s experience. Her name was the one I wanted to mark my “X” beside – even though she withdrew.

If only she had not withdrawn. If only the party had stood behind her in some measure. If only…

Because, those who express themselves are at least willing to have their views challenged. They are at least willing to let it be known what they believe, and often why. The candidates with facebook pages are not the ones to be feared – rather, it is, the candidates who live their lives in guarded fashion who are worthy of skepticism. Those who dare not speak what they think, because of the political repercussions – for they are not willing to have their ideas challenged. Do not be fooled, guarded candidates still hold personal beliefs and opinions, but unlike those who post to facebook, they are not willing to have those beliefs challenged.

If we want a transparent government, we could start by supporting those who live their lives transparently.

Do Stand Alone Birth Centres Make Sense? Do they ensure quality care?

St. Paul's hospital in Vancouver is being redeveloped. As part of those plans, is a stand-alone birth centre that will be supported by midwives and family practitioners. It is a non-hospital facility. It is intended for low-risk births not expected to have complications.

As a non-hospital facility it will not offer epidurals. As a non-hospital facility it will likely have a high-rate of transfers to the hospital facility adjacent to it - to facilitate either pain relief or surgical delivery when necessary. It is largely conceived with the idea that births that do not involve interventions - will save money, and that the best way to avoid interventions is to remove birth from hospital facilities and have births attended by practitioners who do not view birth as being inherently in need of intervention for low-risk women.

Designing maternity care services with the view to limit the use of intervention is not going to deliver quality care to BC Women or their babies, but rather is going to increase the number of mothers who ultimately have poor experiences of care and longer term consequences as a result of that care. The harm caused by failing to intervene in a timely way when it is needed versus the harm caused by intervening too soon is an order of magnitude worse. A mother who leaves with empty arms or who will be caring for a profoundly disabled child for the rest of her life, has suffered a far greater harm than a mother who might have had a cesarean sooner had she been giving birth in a fully integrated, hospital based maternity ward.

Further it segregates care in a way that is likely to lead to lesser quality care. When family practitioners and midwives who deliver maternity services are segregated from OBGYNs it often leads to less collaboration in care - fewer opportunities to discuss their patients and develop professional relationships that benefit their patients. At it's worse, it can lead to situations where women and babies die because OBGYN's are seen as rivals rather than colleagues.

Lastly, it segregates women, new mothers from one another. It is one more way in which one mother can goad another - where how a woman gave birth is advertised merely by where she chose to give birth. It is one less thing for mothers to have in common when they meet at the neighbourhood park or coffeeshop.

If quality care is the goal, collaboration between those who provide maternity services is key. If quality care is the goal, timely care is paramount. If quality care is the goal - how maternity services are structured must be integrated, not segregated. Women should be empowered to make the choices that best meet their needs - and not coerced into making the choices that best meet the needs of the system.

What is the goal? Quality care or to save money?

Victoria's Plan for Topaz Park Deserves a Public Policy Darwin Award

This past week Victoria’s mayor and Victoria’s city council passed a motion 8 to 1 to consider establishing a designated tenting area in Topaz Park for Victoria’s homeless population. Since then, there has been a public outcry about the proposal –because a “designated temporary tenting area” by another name is a “tent city”.

At first blush, it would seem to be a quick and inexpensive fix to the problem. The homeless need shelter, a tent provides shelter and a designated tenting area has to be better than random encampments throughout the city – doesn’t it? Why not use a city park to provide land for the shelters of the homeless?

It really is rather incredible, that a problem as intractable and pervasive as homelessness has such an easy fix. After all, if the problem was as easy as a “temporary tenting area” why has it not been tried before? (Never mind that the “tent cities” that sprung up at the Cridge Center, St. Ann’s Academy, Beacon Hill Park in the past were unmitigated disasters that cost nearly a half-million in policing costs – but those were “tent cities” not formally “designated temporary tenting areas”).

After all – what could go wrong with congregating a population that has a high incidence of addiction, mental health struggles, and various other problems in a public park? What could go wrong with failing to provide showers and food and adequate washroom facilities (never mind the intensive counselling and assistance many of these people would need to actually end their struggle with homelessness)?

So will the city be on the hook when the surrounding neighbourhood finds that property crimes skyrocket? Will the city be on the hook when a child is injured by a needle discarded in an adjacent play area? What about when one of the residents of the “temporary tenting area” assaults another? After all, such problems are foreseeable – does the city not have a responsibility to ensure the health and safety of the residents of the “temporary tenting area” and the neighbourhood around it?

On further thought, not only is a “temporary tenting area” a very bad idea, it is a complete non-solution to the problem while creating a multitude of other problems – both for the homeless and for the surrounding neighbourhood. Further, if a “temporary tenting area” is established at Topaz park then, what park is next?

This idea deserves a "Public Policy Darwin Award" - for taking a serious problem and making it worse.

Sun Peaks Hit and Run Leaves Groom-to-Be in Serious Condition

There’s a bride-to-be who was less than 6 weeks away from what was supposed to be her wedding day. This time was supposed to be the start of a new life together – filled with planning and anticipation. This time was supposed to be the time when she should have been imagining the years ahead, of hoping and dreaming about their future together.

This past weekend, their dream turned into a nightmare. While at Sun Peaks, her fiancé was celebrating the upcoming nuptials with close friends. On the walk back to where he was staying, at about 3am on Sunday July 19, 2015, he was struck by a truck and sustained severe injuries.

The bride-to-be is now sitting by her fiancé’s side in a Kamloops hospital room. Praying, pleading for his health; he is in serious condition. The bright future that laid ahead for the couple, just a few days ago – now seems incredibly uncertain. The months ahead will be focussed on recovery and healing – coping as best as possible.

The prospect of the future is made even more uncertain as the person responsible for his injuries remains at-large. The driver of the truck that struck him did not remain on the scene and has not come forward – making a tragic and heartbreaking situation an order of magnitude worse.

It is hoped that the damage will be mitigated. That he will recover as best as possible from his injuries. That the person responsible will come forward, or that information will lead to his/her identification and that he/she will be held accountable. The family has posted a $10,000 reward for information that leads to the driver responsible being held accountable.

Anyone with information is asked to call Lambert and Williams Law Corporation at 250-589-2174 – information that leads to a criminal or civil conviction of the driver will be considered for a $10,000 reward. Police are seeking anyone with information about this hit and run as well.

Pushing Back for the Best Choice - Cesarean by Choice in Canada Deserves Respect, Compassion - Not Mocking

Canadians, and Cesarean by Choice moms in particular, should be outraged at what is considered to be appropriate behaviour by research institutions and hospitals in Ontario. A website has been created - www.pushingforthebestchoice.ca - and supported by the University of Ottawa, McMaster University, the Canadian Institute for Health Research, the Canadian Health Services Policy Research Foundation, Markham Stoufville Hospital, and Queensway Carleton Hospital. It is deeply offensive and mocks patients while purporting to "Push for the Best Choice".

The content of the webpage is as follows:

Caesarean section (CS) is an efficacious option for birth, but is not without risks to mothers and their babies, including maternal mortality, infection, hemorrhage, maternal or fetal injury, increased recovery time postpartum and difficulty breastfeeding. Given these risks, it is problematic that CS birth currently accounts for more than 28% of all births in Ontario in 2010/11, which is nearly double the 15% target recommended by the World Health Organization.

I should note that vaginal birth (VB) is also an efficacious option for birth, but is not without risks to mothers and their babies, including maternal mortality, infection, hemorrhage, maternal or fetal injury, increased recovery time postpartum and difficulty in a wide variety of areas. But this article completely neglects the risks of vaginal delivery - and then proceeds to declare the prevailing rate of cesareans as problematic, while trotting out the WHO's zombie statistic that was quietly retracted in 2009 as having no evidence to support it only to be brought back to life this past year, despite having questionable evidence to support it. There is no "ideal cesarean rate" - and despite wide criticism this number continues to pervade popular media and policy circles alike.

The common perception that this large and increasing proportion of CS births is attributable to maternal requests for CS does not reflect the available evidence, particularly in a Canadian context. Maternal factors that are more likely to contribute to the increase in CS birth include increased maternal age, use of assisted reproductive technology, incidence of obesity and gestational diabetes. While these maternal factors are likely attributable to changes in sociodemographic and health status in developed countries, of particular concern are the obstetrical practice changes that have led to an increased use of technological intervention during birth. Such interventions (including increased use of labour induction, augmentation, epidural analgesia, and electronic fetal monitoring) are associated with an increased risk CS, even in cases of otherwise low-risk birth.

I agree that maternal factors (changes in the incidence of medical indications for CS) likely contribute to the higher rates that are observed in Canada. However, the article then goes on to criticize the use of technology in birth. What the article fails to consider is what happens in the absence of that technological intervention. More stillbirths (rare, but the incidence of still birth increases after 39 weeks), more neonatal asphyxia, more 3rd and 4th degree tears (and likely more pelvic organ prolapses subsequently), more PTSD as a result of extreme and uncontrolled pain... but, I guess all of that is justified to achieve a higher rate of vaginal delivery. Given the choice between many of these outcomes and undergoing a cesarean - many women would choose the cesarean and the use of technology as it best meets their needs.

Despite evidence of effective individual strategies to curb inappropriate childbirth interventions that focus on either patients, maternity care providers, or hospital policies, little is known about the cumulative effect of a multifaceted strategy to reduce CS birth.

Inappropriate by whose standard? Is it inappropriate to respect patient autonomy? Is it inappropriate to avoid the worse set of outcomes by minimizing their risk and increasing the risk of cesarean? Inappropriate to provide adequate pain relief? Little is known about the cumulative effect of a multifaceted strategy to reduce CS birth - but it is absolute foolishness to think that such a strategy is going to come without some harm. Maternity care needs to focus on what really matters, and that is not "mode of delivery" - it is healthy and happy outcomes that best meet the needs of individual mothers and babies.

As a final slap in the face, a cartoon accompanies the article (below) - a complete caricature of a doctor and a patient making a medical decision. Under the cartoon is the disturbing statistic - 10 percent of mothers (without prior cesarean) would choose it, fewer than 2 percent of mothers actually have a cesarean as a result of maternal choice.

Living a Life with Purpose: Jenn Hooper

One of the things that has been really incredible over the last few years, is meeting people (either in person or virtually, as the case may be) who are truly living their lives with purpose. Living their lives beyond themselves and taking their own experiences to help others. The sort of people who are living the kind of life that is remarkable and inspirational, the kind of life that is humanity at its best.

Jenn Hooper, Charley's mom, the founder of the Action to Improve Maternity in New Zealand is a remarkable woman (also on Facebook). As a result of lapses in care while she was pregnant and delivering Charley, her daughter was born profoundly disabled. A heartbreaking tragedy - Jenn and her family were failed by New Zealand's maternity care system and her daughter paid the price and faces a lifetime of disability. The kind of situation that is overwhelming and crushing - that destroys whatever expectations a person has about how life should be. What is remarkable is how Jenn has taken the reality of her life, as it is, with what has happened to her daughter - and through Action to Improve Maternity New Zealand has tirelessly worked so that other families might be spared the same outcome and so that other families who are failed by the system and facing the prospect of raising profoundly disabled children have the support they need.

Jenn is also an amazing mom, Charley, due to her disabilities lacks core stability. As a result, Jenn created a brace for her daughter, the "Charley Wrap" and in doing so made a product that helps other children. It is clear, that Charley is truly loved, and that Jenn does what she can to make Charley's life as best as possible, but also seeks to make the lives of others better, in whatever ways she can.

Jenn and her family - her husband, and her two younger sons - spend their winters (as they are in New Zealand, winter is June, July, August) in Bali. While they are in Bali - they employ a nanny to assist with Charley and the baby (Jenn recently gave birth to her youngest son). Once again, Jenn is seeking to help someone else. This morning Jenn made the following Facebook post:

Sulikah is Charley's much loved nanny while we are in Bali. We have known her and her family for a good few years now after meeting her as she did her normal daily job of collecting bottles and cans from the rubbish tips and bushes along the beach and roads near our rented home. She needs to collect 100 small water bottles to make 60c and 60 cans to make $1. They have nothing, and ask for nothing, but always manage smiles and love towards us and everyone they encounter.

The land their current house is on has been sold and they now have 3 weeks to get out. The landlord has already started demolishing it. Sulikah and her husband now sleep in their Warung (shop) at the front - their heads are about 3 meters from the main bypass traffic. They also don't have beds. They sleep on bamboo mats directly on the broken concrete floor.

They have worked hard in the 10 months since we were here last and have secured rent on another piece of land for 10 years. It came with the very beginning foundations of a small house, which Hasan (never having built anything before) is making into their new home. He's doing it alone because they have no money to pay for labourers.

My mission right now is to gather as much money as I can - even if that means to just keep enough materials coming in so that Hasan can keep working on it.

Please look through the pics and read the comments on each one and consider what life must be like for them. Then consider giving a little (or a lot) and help me to help secure their home and livelihood for the next decade - they so deserve it.

If possible, I'm aiming at raising a few thousand dollars. It may mean that you go without a cup of coffee next time you're at Wild Bean. It may mean a dinner of beans on toast instead of steak one night this week. Or it could mean a day's pay goes to them instead of saving for those extras this Christmas. You might consider asking at your workplaces or through your church groups - every little bit helps.

Donations can be paid into my PayPal account - jennmark@slingshot.co.nz - or directly into my NZ bank - 12-3278-0004747-00 - and I will get it changed to Rupiah.

You can't change the world, but you can change THEIR world. And God knows they need it.

Thanks for reading

Alhamdulillah

I wish Jenn the best on her mission to improve the life of Sulikah and her family. Jenn is living a life with purpose, and demonstrating that doing so can make the world a better place.

No Longer Funny, the Stereotypical CS by Choice Mom - "Baby City" book review

Recently, I was asked to review a book Baby City, written by Dr. Frieda McFadden (previous books include The Devil Wears Scrubs, Suicide Med and who blogs at www.doccartoon.blogspot.com) and Dr. Kelley Stoddard. I will admit, that I only read about 150 pages of the book – for reasons unknown to me my electronic copy became unavailable the other day, as such my comments will be limited to the portions of the book I read (but if/when I manage to find my e-copy I likely will read the rest of it). I will also admit that I tend to stay away from books/movies that include portrayals of childbirth – as I know that I am sensitive to those circumstances. It is fiction, and as such personalities and situations are exaggerated –in general , this book is in line with other medical fictions that have a comedy bend to them (ie. Popular sitcoms The Mindy Project, and Scrubs come to mind).

The book follows an OBGYN junior resident – Dr. McCoy and her colleagues at a maternity ward in a New York city hospital. One of the first “cases” Dr. McCoy and her team handle is a patient who is dubbed “The Princess”. I know that the personalities and situations are exaggerated, however, I could not help feeling really offended by the portrayal of this patient and her care. “The Princess” is a mother who has requested a primary elective caesarean delivery – or a maternal request caesarean. Sadly, every harmful stereotype about maternal request mothers is used to portray “The Princess”. “The Princess” is impeccably groomed. “The Princess” is absorbed by her iPhone and appears to be self-centred, asking for her caesarean to be performed at 37 weeks because she is itchy and fears stretch marks (note, ideally, unless there are good medical reasons for an early elective caesarean, waiting until 39 weeks reduces the risk to the infant). “The Princess” has specified how long and where she wants the caesarean to be done by drawing on her body with a sharpie. She is portrayed as controlling, and at the same time is patronised in the course of her care. Dr. McCoy is critical of the high caesarean rate that the doctor who is providing care to “The Princess” has – but admits that the patients love him. Ultimately, without talking to “The Princess” during the surgery, the doctor extends the line the patient has drawn by an inch on either side – and “The Princess” is portrayed as being completely ignorant of the change after the fact.

I found myself, having to remind myself, that this is a work of popular fiction and to cut it some slack. That portraying maternal request moms as they really are, is not really funny – and that while I take the issues of patient care and maternal request CS very seriously, that there is no obligation for others to do the same. But. But how popular media portrays childbirth and motherhood is part of the problem. How this mom was portrayed in this book is part of the problem. I was disappointed that Dr. McCoy did not make an effort to connect with this mom – to really understand her, to understand the real reasons for her medical choice and to engage in a conversation about the real risks and benefits of the choices that were being made. I was disappointed that Dr. McCoy failed to address the real risks to the baby of an early elective caesarean – namely respiratory problems, and chose to patronise the patient by offering a cream that might reduce the risk of stretch marks. I was disappointed when without so much as a word – the caesarean incision line was extended by the doctor doing the surgery.

The thing is real caesarean by choice moms, are not this stereotype. They are moms who are truly worried about 3rd and 4th degree tears, urinary and fecal incontinence. They are moms who are worried about brain injuries to their children. They are moms who have survived birth trauma. They are moms who have survived sexual assault. They are moms who are educated and reasonable and who want patient centered care where their role as medical decision makers and partners in their own care is respected. They are also moms who are stigmatized and who have an incredibly hard time finding care providers who are willing to work with them to meet their needs. They are moms who do not deserve being caricatured by a stereotype that perpetuates all of the myths about them.

The thing is, had the book taken a slightly different slant, I might have enjoyed it – it was an easy read and the kind of sitcom that I usually find enjoyable. Instead – I was left feeling like popular media will never move past the stereotype of caesarean by choice moms. That an opportunity to portray the CS mom by choice as a likeable character was once again forgone in favour of the cheap shots at who this mom is and perpetuation of all the harmful stereotypes about her; the stereotypes about CS by choice moms that make being a real CS by choice mom a really hard slog for so many women.

I appreciated the opportunity to review the book – and thank Frieda McFadden for providing me a copy to review. I wanted to like it, I just found myself unable to like it and unable to have much more than loathing for the protagonist, Dr. McCoy. The one thing, I really, truly do like about the book is that a share of the proceeds are going to a charity that supports fistula care.

Gone, but not really

I packed up my office today. Took down the degrees. Placed my text books - now ancient volumes on Economics in a cardboard uHaul box. Miscellaneous other stuff (cute kid photos and what nots took up another two boxes). All of which is now sitting in the basement. It likely will not go anywhere, anytime soon, as my new haunt does not have cubicles or offices that are assigned. Rather, employees float from place to place and have a locker that is assigned to them. It is a a departure that does not feel like a departure...I suppose because technically I am still an employee, merely on secondment with a slated return in early December - but on the same token this leaving feels far more permanent than my maternity leaves.

And yet, my leaving lacked closure. Typically when staff leave, there's a gathering in the lunchroom - a card is sent around to be signed and an envelope takes up a collection. Veggies with dip. Cupcakes. Coffee. Parting words.

My parting words were limited - to a quick, "by the way I won't be here on Monday" tacked on to the divisional "stand-up" yesterday and a rather informal e-farewell I sent this afternoon before I shut my office door for the last time. A formal email had not even gone our by the time I had left early this afternoon (Friday's are half days for me - a modified flex schedule).

A decade, and...goodbyes were foreclosed upon. The formal paperwork only just signed yesterday.

Thankful for my colleagues, who have taken the time to do informally what could not be done formally.

In everything there is tuition value - some of the most valuable lessons bruise the soul.

Compassion and Support in Short Supply for Victoria Parents Caught Off-guard

There are times when people step up to the plate to do what needs to be done to see another person through, and then there are times when people demonstrate a lack of compassion and sheer contempt for another person’s plight. Sadly, the tale of Wesley Branch, Ada Guan and baby Chloe is a tale where a young couple is thrown into parenthood without preparing themselves, where the details of their lives are put under a microscope and judged – and ultimately where people are choosing to shove another person down instead of giving that other person a hand up. What is really sad, is that the person who is likely to be harmed the most, weighs less than 10 pounds and did not ask for the circumstances into which she has been born.

Being a parent is not easy – even when a person has had the better part of 9 months to prepare for it. Giving birth is not easy – and I cannot imagine it was easy doing so on board a plane enroute to Japan (there are no epidurals at 30,000 feet). Being under the intense scrutiny of the media is not easy. Being a new mom is not easy. Being young and living in a basement suite in a city that is notoriously expensive to live in is not easy. Indeed, it is difficult to not have some sympathy for this couple and their plight.

Should Ada have known that she was pregnant? Probably. Can I understand how that would be the last thing a 23 year-old young unmarried woman of Asian descent living away from home would want to find out? Absolutely. It is not unimaginable that she was on birth control, possibly even birth control that supressed her periods and it failed – for whatever reason. It is not unimaginable that she may have dismissed her symptoms and neglected to seek medical attention. Was it the right thing to do? No. Is it understandable? Yes. Did it mean that her baby was put at risk? Yes – prenatal care has proven benefits to babies in that mothers who are aware they are pregnant can take steps to ensure a healthy pregnancy, birth and transition into motherhood, baby Chloe as a result of her mother’s lack of awareness or willingness to seek medical care was denied access to prenatal care. Further, if there had been any complications during delivery – Baby Chloe had an increased risk of death due to lack of access to appropriate medical care. Did it mean that Ada was put at risk? Yes. Having an unplanned pregnancy and birth is dangerous to mothers. What would have happened had Ada had a post-partum hemorrhage after the birth or some other complication that merited emergency medical care? Ada, as a result of being unaware of her pregnancy status, also put her own health and well-being at risk.

Both Ada and Chloe are incredibly lucky that the pregnancy and birth did not result in far more adverse outcomes for either one of them. However, both Ada and Chloe continue to be in a high-risk situation.

Ada is now a mother, with all that goes with being a mother. It was not a choice that she made after consideration of what she wants in her life, nor a choice that she has had time to prepare for but rather a choice that has been made for her –at a time when her life has been under intense scrutiny. What choices does Ada now have, under these circumstances and under what circumstances will the outcome for baby Chloe be good?

How can Ada and Wesley be empowered to focus on the best interests of their child and be supported in making the decisions that need to be made and doing the things that need to be done to ensure that baby Chloe’s needs are met?

The community response to date is chilling -people have found it in themselves to not only, not have sympathy but to have sheer contempt and judgement for this couple. Wesley Branch is unemployed and on disability. Ada Guan is a student who works part-time. They are 24 and 23 years of age. And until this past week, were living lives that are pretty typical of 24 and 23 year olds in Victoria. They had the audacity to take a trip to Japan – and to unwittingly become parents.

The community has not stepped up to the plate by doing what needs to be done to support and empower this couple at their time of need. Sadly, the couple’s GoFundMe page has raised a meagre $2,070 to date and has a $5,000 goal – a fraction of the expenses associated with new parenthood. Further, the campaign to raise funds has generated considerable backlash – and has likely left the couple feeling isolated and alienated. Perhaps, sadder still is that money is a small part of what new parents need to succeed – and that these new parents have some considerable challenges ahead. Challenges that crowd-funding is poorly equipped to handle.

Either Wesley or Ada (or both) need stable employment that can provide an adequate income to provide safe, clean housing and adequate nutrition – the living wage in Victoria for two parents working full-time to adequate provide for two kids is currently $18.93 per hour. Wesley and Ada likely need career counselling to determine the jobs that they can qualify for and to give them the tools (ie. a refined resume, training, and help with job searching and interviews) they need to get those jobs. Ideally, they would be able to find jobs that also provide extended health benefits, as many prescription drug costs & dental costs are not covered under the provincial medical services plan. Or perhaps an employer could come forward with an offer of employment to assist this young couple? Alternatively, they may need to apply for employment and income assistance.

Wesley and Ada need to get up to speed on caring for an infant. They likely need a reliable family doctor (sadly I note that none are currently accepting new patients) and would likely benefit from training in infant first aid, basic infant care and parenting information.

Assuming Wesley and Ada find adequate employment, they will need reliable, safe childcare. Finding childcare in Victoria is notoriously difficult with spaces for infants being the most difficult to find. Many parents get on waitlists months in advance of their due date in order to have a space available when they need it. Worse yet, childcare in Victoria tends to be notoriously expensive with many infant spaces costing more than $1,000 per month. Again, Ada and Wesley would be wise to look into the BC Child Care Subsidy to mitigate this expense.

Wesley and Ada need adequate housing – they are currently living in a basement suite in Fernwood and might find that it is inadequate for the needs of a family of 3. Most 2 bedroom units in Victoria rent for more than $1000. Wesley and Ada would be wise to contact BC Housing to apply for a subsidized unit to move into.

Wesley and Ada likely need a range of baby goods including a safe crib, a stroller, a car seat (what I’ve just listed often tallies to more than $1,000 alone), clothing, bedding, diapers, formula (or alternatively a breast pump and nursing bras and clothing and bottles if Ada is to continue working), baby toys, etc., etc., etc. As a parent with small children, I can attest that the list of needs for an infant is nothing short of staggering. Some items may be purchased used and that can save some money or better yet, some items might be donated.

Lastly, Wesley and Ada need a communities of of support like those at the Young Parents Support Network and Parent Support BC and Ada needs to find other moms who can help her figure out motherhood for herself and she might also benefit from the baby and toddler groups offered by Mothering Touch or other local drop-in play groups. I would also encourage Ada and Wesley to check out and access Strong Start .

The decisions in the days, weeks, months and years to come are not easy choices and will require guidance, maturity and hard work – a complete departure from the lifestyle they once knew just a few short weeks ago. While their fundraising campaign drew a considerable amount of backlash as the amount originally asked for was thought extravagant, the reality is that this couple is going to need a lot of support going forward. Ideally, the community would step-up to the plate and offer a hand-up to young parents – the kind of support that helps to ensure that their kid does not suffer as a result of being born into the wrong circumstance.

This couple deserves a second chance and a hand-up – or at the very least their baby does not deserve to bear the consequences for the poor judgement and past decisions of its parents. The very least we can do is step-up for the sake of children and we could start by stepping up for the sake of this child. For the sake of baby Chloe, I am hoping that her parents are empowered and enabled to do what is in her best interests.

A System that Fails to Care, Will Fail When it Matters Most

Hospitals, doctors, nurses - the entirety of the health system is under incredible strain. Back when I started working as a health economist in 2004/05, an "ideal" occupancy rate for a hospital was seen to be 85 percent. This was a level that was thought to be the sweet spot of providing quality care, a level that allowed for surges in demand to happen and would minimize the number of elective procedures that might need to be cancelled due to a lack of capacity. Even back in 2004/05 occupancy rates often ran above 85 percent - but rarely did occupancy rates exceed 100 percent. Fast forward a decade, and the hospital occupancy statistics in British Columbia are nothing short of disturbing. For many hospitals in British Columbia an occupancy rate less than 100 percent would be a dream. Many hospitals are running over-capacity - and significantly so. Numbers well above a 100 percent in British Columbia are no longer rare.

What does an occupancy over 100 percent mean for patients? It means stays in the Emergency Room that do not last hours, but rather last days and might last the entirety of the care encounter. It means elective surgeries being cancelled or deferred as there is simply no bed to admit a patient to. It means discharging patients without adequately considering what will happen after the discharge. When care capacity is stretched too thin in hospitals - it means quality care, the care that patients deserve and trust that they will receive does not happen. When care capacity is stretched too thin - it means those who work in the system, the doctors, the nurses, the porters, the technicians, the care aides (really everyone), are also put under incredible strain and the risks of error and burn out dramatically increase. Ultimately, when a system tries to do too much with too little - it loses the humanity it needs to delivery quality care and to perform well.

It is heartbreaking to read Mrs. Brenan's tale of care in the Manitoba health system. Mrs. Brenan spent the entirety (4 days) of her care encounter in the Emergency Department of the Grace Hospital, she collapsed on her front doorstep and died of a blood clot that moved to her lungs. Others have been discharged to cabs, only to freeze to death on their porches.

Is the hand-off of care of patients to taxi drivers appropriate - is a taxi service adequately prepared, trained or compensated to handle what needs to be done? Is it the act of a "caring" system or is it what a system stretched beyond capacity does to save a few dollars?

It is easy to reduce the transportation from hospital to home as just being transportation. However, patients are not packages to be couriered from one place to another - and the mere reality of being a patient in an overburdened system is that what is adequate for "an average person, a non-patient" may be entirely inadequate for a patient who has been discharged. The reality is that many patients who are discharged from hospital, are not "non-patients" but rather are still patients who are merely going from one place of care (the hospital) to another place of care (home). As such, the standard of care for transportation from one place of care to another place of care is different from what should be expected from a taxi - the taxi standard of care is a failure, as demonstrated by the experience of Mrs. Brenen and others. I would argue that if "the system" is going to discharge people before they are "non-patients" and treat patient residences as extensions of the healthcare system, that transportation from one place of care to another place of care is also part of the system.

Quality care demands that the reality of patients is considered and that their needs are met. Discharge to taxi is a failure to provide quality care - a failure that needs to be remedied, and a failure that likely results from a system that is simply too lean to care.

Are All Improvements in Health Worth the Same? (Yes AND No)

There’s a well-known concept in economics – diminishing marginal returns – that basically states that ever increasing investments lead to ever reducing improvements. What this means is that the first dollars spent buys far more value than the last dollars, or marginal dollars spent. To think about this concept, think about a worker who is paid an hourly wage for each hour he or she works. The first hour the worker is most productive (they’re well rested, mentally ready) but as each hour passes the worker gets less productive – and ironically the hours for which the worker is paid the most, overtime hours, are likely to be his or her least productive hours.

In healthcare, this concept is clearly at work. The first dollars spent are spent on the basics: things like vaccination, clean water, basic health literacy, primary care and maternity care. These things consume a relatively small share of the healthcare budget, but produce relatively large improvements in both the quality and quantity of health that is realized. The next health dollars are spent on things that cure acute (time limited) conditions and restore health. The next health dollars are spent on addressing the needs of chronic conditions. Finally, the last dollars spent, are spent on End-of-Life care – it is well known that the dollars spent in the final years of life buy little in the way of quantity or quality of life. Each marginal dollar spent in healthcare buys an ever shrinking amount of quality or quantity of life. Yet the costs of these very marginal improvements can be very large indeed.

There’s also a parallel concept in economics, where the less of a good a person has, the more he or she is willing to pay to get more of that good. The more of a good a person has, the less he or she is willing to pay to get more of that good.

Again, this concept is readily applied in the healthcare context. If you have a high quality of life, or a long life-expectancy, you would be hesitant to pay a large amount of money to realize a relatively small increase in either quality of life or additional life expectancy. As a 25 year-old with an expected remaining life expectancy of 55 years, you would likely not be willing to pay a lot to increase that expectancy to 55 years and 1 month. Nor would you be likely to pay a lot to increase your general level of well-being from feeling very good to feeling as good as you possibly could (if life quality were measured on a scale from 0 (dead) to 100 (the best health possible) going from 90 to 95 simply might not be worth the cost of doing so). This is likely the perspective of the average taxpayer – they have a fair amount of life expectancy on average and experience a relatively high level of quality of life.

This changes dramatically when a person is faced with having very little life expectancy left and very little quality of life left – then the amount that person is willing to pay to realize even modest improvements in health is considerably greater than the person with a lot of time left and a high quality of life. A person with a month left to live might be willing to pay dearly to extend that to two months and a person who is suffering with a low quality of life would be willing to pay to have that quality enhanced even modestly (perhaps even to the point of merely relieving pain). This is the perspective of the vast majority of patients of the healthcare system – they struggle with limited life expectancies and compromised qualities of life.

Using this framework – it becomes incredibly clear that there is a conflict between what taxpayers view as being value for health dollars spent and what patients are likely to view as being value for health dollars spent. To whom does the system owe its allegiance? Is it to taxpayers or is it to patients?

It becomes incredibly clear, that in a single payer system – the allegiance is to taxpayers and that all improvements in health are worth the same (a month that accrues to person A is worth the same as a month that accrues to person B). From that perspective the goal is to buy the most health possible (quality and quantity of life) for the dollars available. From that perspective there is a large amount of money that is spent on care that is viewed as being of dubious value for the money spent. There is hesitation to spend public money on care that will result in very marginal gains and the money that is spent on that care is seen to jeopardize the financial sustainability of the system. When thinking about this kind of care – think about the cost of drugs for rare disorders that run as high as half a million per year. When thinking about this kind of care, think about all the money that is spent in the final year of life, relative to all the money that was spent in the lifetime before. Think about expensive drugs that may buy a month or three months of life at an incredibly tremendous cost. There is a tremendous incentive to develop guidelines and to limit care that is publically funded to only the care that meets the taxpayer’s perception of being good value for money. It is seen as being critical to the financial sustainability of the system as a whole.

It also becomes incredibly clear that in a single payer system an allegiance to the taxpayer, harms patients by depriving them of access to care that they see as costing less than the value of that care to them. From the perspective of patients all improvements in health are most certainly not worth the same. If $30,000 is the cost of an additional month of life, is it right to deny a person access to that month of life if they are willing to pay for it from their own resources? Is it ethical? What about care that is not the cheapest care but seen as best meeting the needs of the patient from the patient’s perspective – is it ethical to deny access to that care? Should patients forego care that meets their needs in order for taxpayers generally to benefit? Further, what about the adoption of new technologies – is it fair to stymy innovation because (at least initially) it fails to deliver adequate value from the taxpayer’s perspective but is seen as having value from the perspective of at least some patients?

Equally clear is that a purely private system would also fail to perform as it would fail to deliver care that is seen as being of good value from the taxpayer’s perspective simply because some patients may be unable to pay for it.

Perhaps this is the theoretical underpinning of how hybrid systems in most advanced OECD countries out-perform both single payer systems (Canada) and largely private systems (US). A hybrid might go a long way to resolving what is otherwise an unresolvable conflict between what patients view as being value for money and what taxpayers view as being value for money.

An Open Letter to Dr. Marleen Temmerman

Dear Dr. Marleen Temmerman;

I have a lot of respect for your organization and the work that it does to advance health outcomes, particularly in the regions that profoundly suffer due to a lack of resources that are commonly taken for granted in countries with advanced economies and an abundance of resources. The risks and benefits of individual choices in those countries that struggle with a lack of resources are vastly different from the risks and benefits of choices in countries with an abundance of resources. This is particularly true when it comes to both breastfeeding and childbirth.

The WHO is absolutely correct to promote breastfeeding in countries where the lack of access to clean water and refrigeration and the costs of formula means that young children will pay a dear price for formula use that is not necessary. Similarly, promoting caesareans in countries that lack access to antibiotics, reliable power, and an absolute shortage of resources for healthcare – would be irresponsible and would cause suffering to both women and children in those countries.

However, applying the same logic to women in very different circumstances (women in resource rich countries) – does those women an incredible disservice, and indeed may harm their health and well-being and that of their children. Those women are making very different choices with respect to both infant feeding and childbirth. Those women face a different set of risks and benefits – for a myriad of economic and social reasons. Telling those women that they should make the same choices as their counter-parts in third world countries is as sensible as combating world hunger by demanding children in first world countries “clean their plates”. It causes a whole other set of problems while doing nothing for those who suffer with malnutrition in resource scarce countries.

That is what the WHO has done with its latest statement on caesarean sections. It has effectively told women and healthcare providers in resource rich countries that they should focus on avoiding caesarean sections because caesarean sections are risky in resource scarce countries.

In doing so it has lost sight of the ultimate objective: the best health outcomes possible for all women and their babies and has substituted it with an ideologically driven objective – vaginal births whenever possible regardless of the impact on women and their babies. It has breathed life back into a statistic that has been used to deny access to caesareans by those who choose them – by deeming the need to bring down the caesarean rate in all countries as some kind of laudable goal when it is not.

Worse, it harms the health and well-being of women and their babies by depriving them of accurate information with respect to the choices they must make and supporting them in their rights to make those choices. It fans the flames of misogyny and denies women their basic rights: the right to informed consent (or refusal), the right to make medical decisions, and, the right to timely access to quality care.

Do you think that being told, “you cannot choose what is done to your body” does not have negative impacts on the health and well-being of women? Does the mental health of women not matter? How can their suffering be justified?

Let me be frank with you Dr. Temmerman – the rights of women and the health and well-being of women cannot be advanced in one part of the world by harming the rights of women and the health and well-being of women in another part of the world. The disparities and realities of women in different parts of the world are not ameliorated by pretending that one size fits all policy solves the problem. The focus needs to be on supporting rights and working towards the best outcomes in the context in which women live – and improving that context where it needs to be improved.

There is much work to be done, Dr. Temmerman – and fanning the flames of misogyny in resource rich countries will not do anything to ameliorate the plight of those in resource scarce countries. So rather than making global pronouncements on caesareans, why not reconnect with the purpose of the WHO and focus efforts on the myriad of ways the health and well-being of women in resource scarce countries can be improved? Why not work to highlight how great the disparities in health outcomes are and how different the context in which women make choices are, and then work to ameliorate those? Why not focus on what matters, instead of wasting time on the things that really do not matter?

Sincerely,

Janice Williams

First, Know Yourself

I have spent a lot of time thinking about work in the past 8 months - about what I needed to work a life I can live, about what I wanted to be "when I grow up". It has been a difficult process - one that has made conversations about what I plan on doing with myself difficult ("I'm still thinking about that" seeming like a wholly inadequate, albeit very honest, answer) and as a result, I have been stuck in a bit of a transactional rut, work-wise. That rut where I do my job and I do it adequately but where work is not a source of incredible satisfaction in my life. That rut, that's actually very stressful for me (because of who I am) - where I really did not know what I wanted, or at least had no concrete ideas on how I would get there. That rut that even made doing an adequate job of my resume difficult if not impossible. That rut that made it next to impossible to plan or work towards something without some more concrete kind of idea about what that something is. That rut that is wholly unproductive and uninspired. That rut where I worried that the activities that actually were bringing me a great deal of satisfaction and enabling me to cope would result in either discipline or termination. I had some ideas that I wanted to align who I was, with what I do; I wanted to be fully present in my work and I wanted some larger things to work towards - but those ideas had not crystallized in a way that I could effectively communicate to others - others I would need to bring onboard with any plans.

I needed to know myself, I needed to reflect on the conditions that would drive a productive and satisfying work life for me and I needed to go about finding or creating those conditions.

I know I do not want to live a life of leisure - having the day at my command would not be enough. I need my days to not only be under my own control, but I also need them to be productive. I also know that being an economist is part of who I am - not practicing economics, remains unfathomable, it needs to be part of what I do. Equally, I know I am a writer - writing needs to be a part of what I do. Further, I know I need variety and I need to be creative in the work I do. I like work that I have not done before - I like applying my skills in new areas and perpetually growing the things I know about. I particularly like developing ideas and fostering communities - I like engaging others, "I think out loud" and thrive on respectful discussion. I find hierarchy soul crushing - the relationships with my supervisors or those I work with or for need to be collegial and constructive - I need to work in an environment where there are ideas about what needs to be accomplished (and ideally where I have helped to shape what those things are) - but where I am largely left to explore how that is to be done. I need to be able to be innovative. I need deadlines - but little else, the less structure, the better. Work needs to reflect and be a part of who I am. That is now the direction I am going in.

In the last week, I have been able to do what I could not in the months before. I have been able to articulate what I want to be "when I grow up" - I have found the drive that has been absent for many years, and am making not just steps but strides in my life. To paraphrase an old song - life these last few months has not given me much of what I thought I wanted, but it has given me what I truly needed. Life finds a way - a way of slowly teaching a person that they can not change who they are, that sometimes even changing where you are is beyond your control, but that there is almost always a way forward.

Life in the next few months will be busy - busy preparing for the transition. Busy making plans. Busy getting things done. I'm a pretty happy person at this moment (despite what is a daunting workload in the months to come) - and am hopeful that if I just focus on doing good work, that the money will follow (after all, there are obligations to meet).

At this moment, I also have an incredible amount of gratitude - for those who have made where I am at now possible. You know who you are, and thanks.

Sewing a Parachute

Since Friday, I have been sewing a parachute. Crafting an exit strategy with fervent energy - an exit strategy not just out of the ministry, but out of government entirely. I am on the brink of leaving the organization - because, my work and who I am often seem in conflict; because my strengths go unused; because I don't feel like I can be who I am; I don't feel like I can bring and apply my passion to my work; I don't feel like I can shape my work; I don't feel like I can explore ideas; I don't feel like I can be innovative. I feel frustrated; I feel anxious and stressed (and half-wonder, could this blog ever get me fired?); I feel like I cannot be innovative; I feel like I can not "Think Big" at work; I feel like I am not in control of the work I do, how I do it or what becomes of it; at the very least I feel misunderstood.

And yet - when I think about what I am passionate about - when I think about what is needed, I can not help but think that my organization needs me, needs people like me to get past the hard bits to a place where they can be at work and be who they are and bring everything to the table because nothing less than everything will do.

I am passionate about a healthcare system that works for the people it serves.

I am passionate about being engaged and heartbroken at the disengagement prevalent in the organization at this time.

I am passionate about truly good policy.

I am passionate about writing - and good writing in particular.

I am passionate about thinking big.

I am passionate about building bridges.

I am passionate about learning.

I am passionate about transparency.

I am passionate about engaging people in a discussion of ideas and true collaboration.

I am passionate about evidence informed decisions making.

I desperately want the work I have done outside of work, to match the work I do at work.

I want to work a life worth living - where I am productive because work is not work, but a part of who I am.

Yet, I am sewing a parachute...while part of me yet still, hopes I won't need it.

From Here to There

We have an engagement problem at work. It is well known. The last workplace environment survey (WES) results demonstrated our division had sunk to the lowest scoring work unit in the entirety of the Ministry. At one time, it had one of the highest scores. The impact is acutely felt. As such, I had some hope when the Deputy Minister put out a call for expressions of interest to co-chair an employee engagement forum, there was just one catch: subject to supervisor approval.

I am not a person who believes that any problem can be solved by denying that it exists in the first place. Further, my door has been open and I have had an open ear to my colleagues. I have also written a book review in our divisional newsletter on a book that seems 'on-track' for solving these kinds of problems (Dan Pontefract's Flat Army: Creating a Connected and Engaged Organization). I have given voice to the concerns I have heard at meetings. I have also undertaken a project that resulted in art being hung in the halls - halls that had been barren for a decade. I want work to be a better place, I truly do - so I figured I should throw my hat in the ring.

As such I was greatly disappointed when my supervisor came into my office on Friday to tell me that she was withholding approval of my application to Co-chair the forum. Not so much because she wanted to, but rather because the Executive Director felt there might be workload issues, and more tellingly that "I may express negative opinions with respect to the situation in our division". I wish I could say that it was completely unexpected, but it really wasn't as the executive director has demonstrated that she is far more concerned with how things look, than with how things are. Yet another indication of where the culture of my workplace is at - and how unlikely it is to change anytime soon.

This is the painful part - the part where the relationship has been long-dead, the part where whatever bits I once loved have long since withered, the part where it is clear there is not going to be some miraculous turn around. This is the part where I have to take into account my strengths and the work I could be doing instead. This is the part where I must dig deep - think hard, and hope that in 25 years I will look back and know I made the right choices even though they were hard and uncomfortable and risky.

The Modern Day Malthusian Catastrophe: Healthcare Sustainability

The foundation of most healthcare expenditure projections is that the patterns observed in the recent past will continue into the foreseeable future. Patterns of health care use remain the same. Patterns of disease remain the same. Patterns of health care delivery remain the same. More sophisticated models incorporate some change, but again, it is based on the assumption that the rate of change in the future will be the same as the average rate of change in the past. In short, most projections (at least those beyond the next five years) will be almost comically incorrect. They paint a Malthusian Catastrophe in the making - where access to healthcare is limited and costs associated with providing healthcare are astronomical.

These projections paint a picture of a health system that is wholly unsustainable - a picture where the vast majority of public resources are gobbled up by an ever more hungry healthcare system. Gobbled up by providers demanding ever more pay. Gobbled up by patients demanding ever more marginal and incremental increases in longevity or quality of life that come at an ever increasing costs. Note - in the story that is currently told about healthcare and its future, both patients and providers are villains.

In these projections - the future is some ominous place where things go from bad to worse. In these projections, waitlists grow and costs increase.

However, it should be noted that in these projections, the critical assumption is that the status quo will prevail.

Given that the projections are likely painfully correct if the status quo does prevail, the challenge is in developing and fostering a system that embraces change and innovation, rather than stagnation. If a system sees change as a threat rather than an opportunity - the Malthusian Catastrophe becomes more likely. If the system embraces change and the idea that it is possible that more can be done with the resources available, or that the capacity to pay for more can be expanded, then the Malthusian Catastrophe is averted.

The way our system is structured, it has assumed that the way healthcare has been delivered in the past (physicians and hospitals), and the way it has been demanded in the past is the way it should be and will be delivered in the future. It has limited capacity to embrace change and innovation. It ignores the patient and their role, at its own peril.

It is poorly structured to adopt practices that move healthcare from being delivered by doctors and in hospitals - in part because there are large cost-shifting realities. Our system covers almost all medically necessary services provided by physicians or those services provided in hospitals, but little coverage is provided for dentistry, pharmaceuticals, or other practitioners. As such, even if a pharmaceutical becomes the more effective treatment modality, there is an incentive for patients to choose the less effective or efficient modality simply because doing so is free, whereas the alternative might incur potentially large out-of-pocket expenses. Pursuing the "better level of care" - with things that often turn out to be preventative or prophylactic but incur out-of-pocket expenses becomes the domain of those with the resources to do so - and the gap in health status between the top 5 percent and the bottom 5 percent widens. This speaks to the need for the system to be far more comprehensive in its view of what is, or is not "healthcare" that is to be covered or subsidized.

It also speaks to the unspoken trade off between equality and equity that has been made. Everyone is equal - meaning all those with bad hips are served equally badly, while all those with heart attacks or cancer are served equally well. As a result, the level of satisfaction with the system largely depends on whether or not you happen to have your specific needs met adequalty and that largely depends on what those needs are and whether or not they have been deemed worthy of adequate resources. A poor man who happens to need pharmaceuticals is just as screwed as the well-to-do in need of a new hip - neither has their needs met and might be better served by a system that would cover the pharmaceuticals of the poor man and permit the rich man to spend his own money to get access to a new hip.

The Invisible Hand of Things Done Well

Choosing the right goal is perhaps the most important thing an organization or individual can do. It will guide what is done or not done. It will illuminate the path to incredible success, or will lead down a rabbit hole of misery where the difference between what is, and what is possible grows instead of diminishes.

When it comes to healthcare, it must be wondered, “Do most of our problems stem from a relentless focus on the wrong goal?” In healthcare in Canada there has been a relentless focus on the dollars spent – all the while, the dollars spent grow and the outcomes do not get appreciably better. All the while, longer wait lists. All the while more disability and suffering seems apparent. All the while, the difference between where we want to be and where we are seems an ever increasing chasm. All the while, our rankings in international reports on the healthcare systems continue to drop – going from being a lead system, to being mediocre, to, now almost last place.

Providers in the system do not seem overly pleased, nor for that matter do patients – further, successive governments are repeatedly chastised for failing to perform. Nobody is happy – and yet despite our obsession with the healthcare system and its costs, nothing seems to get better and many things seem to get worse.

It is depressing and frustrating – how is it a country with so much can perform so poorly when it comes to healthcare? How could we have lost so much ground in comparison to other countries?

The thing is that when things are done well – a simply incredible thing happens, almost always what is possible aligns with what is, and the cost of doing it is minimized. If something can be done better, for less – better for less happens. By focussing on doing better, on better meeting the needs – and then focussing on doing so more efficiently, a kind of evolution happens. It happens in cars. It happens in computers. It happens in almost everything – so why does it not happen in healthcare in Canada?

The answer is quite simple, the pursuit of “better” was consumed by the pursuit of “cheaper”. Imagine if a company failed to invest in making its products better. Failed to spend the money now, to reap benefits later – focussed on the short-term, on maximizing profits for shareholders. It would not be long before that company would fail, before competitors would simply outperform. Likewise, in healthcare – for far too many years there has been a relentless focus on doing things cheaper. Steady increases in the budget have seemed extravagant, but the truth is they obscure the demands of keeping pace with a growing and aging population. The focus has not been on doing “better” for quite some time, and looking forward at budget increases of less than 3 percent in the years to come, it is unimaginable that there will be a shift in focus to doing things “better” for quite some time. “Better” costs money – at least initially, and that is not something that the system seems willing to invest at this time – by focussing on being lean it is growing ever fatter.

Imagine for a moment, if “better” became the focus instead of the dollars spent. If the focus shifted to the things that really mattered, things like minimizing suffering, minimizing the impact of disability, minimizing death, and maximizing patient satisfaction. To solving the very real problems faced by patients. Further, what would happen if the way things were done shifted – from top down to bottom up? What if we harnessed the knowledge of those who do things, to do those things better? What if we smashed the healthcare hierarchy and fostered an eco-system instead?

Would the invisible hand of things done well happen in healthcare – could we have healthcare that is both better AND cheaper?

Focussing on Physician Compensation is Dysfunctional

There are a large number of economists (and others), that simply believe that the reason healthcare is so expensive, is that doctors and nurses simply make too much money and need to be paid less for the services that they perform.

Not surprisingly, those who believe this are not incredibly popular with either physicians or nurses.

After all – telling people, professionals who have dedicated their lives to the industry, and are the suppliers of the vast majority of healthcare services, that they make too much money sends some very disengaging and negative messages. It sends the message that the work done is not valued. It sends the message that the suppliers of healthcare, themselves, personally, are responsible for the high-cost of healthcare and are responsible for the lack of financial sustainability of the system. It sends the message that the suppliers of healthcare (physicians and nurses) lack integrity and are out to fleece the public. It is a direct and very personal attack.

Worse than that, it likely works against the very things the healthcare system really does need – workforce engagement and innovation. It works against aligning the interests of those supplying healthcare with the interests of those in need of healthcare – the users of the healthcare system. It distracts from focussing on the things that really do matter and solving those problems collaboratively.

The things that really do matter are supplying enough healthcare services of a high-quality so that there is little or no unmet need (unnecessary disability, death and suffering) while constraining public expenditures to a financially sustainable level. That is the problem that needs the focus, adequately meeting the health needs of the population. That is the problem that needs to be solved – and solving it will require collaboration – and innovation. It will require physicians and nurses and patients and governments to shift their thinking away from the 1,000s of things that are essentially “red herrings”, things like physician compensation to the things that are actually worth focussing on.

Should the public care if a physician earns $1.5M per year or should they care that as a result of that $1.5 Million as much “health” as possible was bought. Which is a better investment? Paying 20 doctors each a $75,000 a year salary or one doctor $1.5M? It depends, are the doctors equivalent in skill or in productivity? Are the services provided to those who would benefit the most from the services? If the $1.5M doctor has innovated and delivers more health than the 20 other doctors combined, she or he might represent excellent value for money. The cost of a unit of health bought from the expensive doctor might be less than the cost of a unit of health bought from the group of 20 other doctors. Further, the “out-of-public-pocket” cost of Dr. A might be significantly less, as he would face a high rate of taxation on the income they earn.

Unfortunately, the way the system is currently structured, there is no incentive to maximize the amount of health (or conversely minimize the pain and suffering) that is bought with the money available. The price of procedures is standard – the fee for an office visit is the same regardless and there is no price flexibility to account for circumstances of either the physician or the patient. As a result a variety of worrying problems emerge. There are physicians who would like to be working – who might even consider working for less than the standard fee who are barred from doing so and go unemployed. There are patients in need of health services who have unmet needs – patients who might be willing to pay above the standard amount to get access to care - but they too are barred from doing so. There are no market mechanisms to assist in matching the supply of health services with the demand for health services.

Further, there is little incentive to go above and beyond or to provide services that truly meet the needs of the patients served. There is little incentive to provide enhanced services (aside from some personal motivation to do so) – services that set one provider apart from another or might even avoid the use of health services. Technically speaking, the provider who minimizes the use of health services by their patients, does so at the expense of their own income. Technically speaking, the provider who makes his office nicer, also does so at the expense of their own income. Technically speaking, the things that most enhance health for some individuals, might not even be health services – but might be problem solving (ie. Finding adequate housing).

Which speaks to the really, really big problem. The focus is not on maximizing health, or minimizing suffering. It’s about making the providers technicians rather than leaders and the patients throughputs rather than partners in health. The system is hierarchical not collaborative – it is resistant to change, and focussed on the wrong things.

Mrs. Sophie Gregoire-Trudeau Shared a Story with Me, So I Shared a Story with Her

Dear Mrs. Sophie Gregoire-Trudeau–

You sent me an email and shared with me a story about helping a new Canadian mother through a difficult birth – but how she was happy that her baby was going to be a Canadian. That you loved this story because it reminds you to “cherish your identity as a Canadian,” and “how lucky we are to live in a beautiful country, and share it with such generous and caring people.”

Can I share a story with you?

Let me share with you the story I’ve heard time and time again about new mothers giving birth to Canadians in Canada and being left with substantial medical bills. Let me share with you the story about new mothers giving birth at home or in hotel rooms out of fear of the substantial medical bills a hospital birth will leave them with. Let me share with you the story of those mothers enduring substantial pain because they fear the cost of an epidural. Let me share with you the story of mothers foregoing prenatal care because of its cost. Let me share with you the story about how we neglect the prenatal and birthing care needs of those women. Let me share with you the story of how these women and their infants face a 7 fold increase in infant and maternal complications, including death.

Who are these women who are uninsured? These women are the wives and partners of Canadians who are waiting for their permanent residency to be approved so that they can be eligible for Canadian health insurance. These women are refugees. These women are temporary workers and visitors to Canada whose visas have expired. Some of these women are future Canadians. These women are mothers to Canadians – Canadian babies who are denied free access to care they need while in utero and during birth because their Canadian parent happens to be their father instead of their mother or because their mother is newly arrived in our country. These are Canadians whose parents face substantial medical bills due to their births, bills that might have deep impact on their family’s ability to provide during their early years.

I hate this story, this story that I’ve heard time and time again. I hate that it reminds me of how we currently deny access to the best possible beginning to the most vulnerable Canadians – newborn babies. I hate that it demonstrates a lack of compassion, a lack of caring and a lack of generosity. Your email asked me for a donation to the Liberal Party – in support of its bid to become the next governing party.

I want to see a government elected that shares progressive values. I want to see a government that cares for the most vulnerable citizens – newborn babies. I want to live in a county where all mothers can put the best interests of their children first without fearing the financial repercussions of accessing appropriate medical care during pregnancy and childbirth. Will the Liberal Party of Canada do that? Will they commit to providing free access to medical care for all pregnant and birthing mothers in Canada, even those who are uninsured? Will they step up to the plate and demonstrate leadership, caring and compassion on this issue?

Before I consider donating, I’d like to know the Liberal Party of Canada’s position on this issue and what steps it plans on taking should it be elected to ensure the health and well-being of all new born Canadians and their mothers.

Sincerely,

Janice Williams

Background Stories and Information:

http://thetyee.ca/News/2014/03/21/Uninsured-Moms/

http://www.cbc.ca/news/canada/british-columbia/red-tape-leaves-expectant-b-c-mom-with-no-medicare-1.2638068

http://www.ncmn.ca/Resources/Documents/Plenary%20_1%20-%20CTAC%20Paul%20Caulford%20Sept%2026%202013.pdf

http://www.citynews.ca/2013/02/16/hamilton-mans-fight-for-maternity-care-for-wife-exposes-gap-in-canadian-system/

Transformative Change: The Carter Decision

This past week the Supreme Court of Canada unanimously decided that the provisions of the Criminal Code that prohibited assisted suicide were unconstitutional and should be struck, giving the federal government and the provinces a year to enact legislation with respect to assisted death. The impact of this decision should not be underestimated - as much of what was articulated has implications for not just how people approach death, but also for the healthcare system, the legal system, and cases that have yet to be decided in the years to come. Make no mistake, the Carter decision is a profound decision that is a landmark of profound changes in the years ahead.

The legislation and regulations that provinces and the federal government develop to govern assisted death will determine who is permitted to assist in a death, the circumstances that must be met, and whether or not it is to be publicly funded as an insured service. The only requirement is that whatever legislation and regulations that are developed conform to the requirements of the constitution, or risk being struck down in the course of time.

It is difficult to predict how accessible or how popular assisted death will be - however, it is not difficult to predict that the removal of the ban on assisted death is a big shift in the landscape, and will likely be a transformative change in and of itself, and might be the start of a set of substantial and transformative changes. The decision was an affirmation of patient autonomy - an affirmation of a competent, adult individual's right to decide what happens with their body and to make medical decisions for themselves, even when the consequence of those decisions is certain death. To endure the suffering associated with many devastating diseases and the end of life will no longer be an obligation thrust upon victims, but rather a choice that is made by the individual after consideration of their own needs and circumstances. It is a shift away from a kind of paternalism towards individual autonomy, towards respect for what is an incredibly personal experience.

It is also a shift towards a more sustainable health system (as of this week all forecasts of demand for health resource use should be considered obsolete). Upwards of 25 percent of all health expenditures are made within the final 12 months of life - the provision of palliative care services, residential care services, and home care services have been widely acknowledged to face considerable challenges in the years ahead. The availability of assisted death will alleviate demand and reduce the amount of resources spent on the final months of life. Those electing assisted death, may enable those electing to endure better access to palliative care and other resources. Further, those electing assisted death might be able to choose between spending their wealth on longterm care or preserving it for their estate. However, given the strong incentives that both the government (as sole provider of health services) and perhaps individual's own family's may have in encouraging assisted death - it will be of tantamount importance to enshrine protections against being coerced into accessing assisted death services. Indeed, assisted death will not only be a new area of medical practice, but also a new area of legal practice.

Further, there are profound implications for future litigation concerning the health system. Specifically, the litigation that is currently underway in the Cambie case in British Columbia. If it is unconstitutional for there to be an outright ban on assisted death, how is it constitutional for there to be an outright ban on privately purchasing access to health services that enhance quality of life? If failing to provide access to death, infringes upon security of person and an individual's right to autonomy - then surely relegating people to waitlists or denying access to health services altogether must also be an infringement on Charter Rights. It would be sadly ironic, if assisted death is determined to be a "medically necessary" health service and insured by the provinces, that those who have fought hard for the right to die with dignity might suffer the indignity and the frustration of that right by finding themselves imprisoned by the shortcomings of the healthcare system.

Her Name Was Veronika

Maybe it was an accident.

Maybe she went to the bridge to think, to reflect – and while she was there, maybe she started to fall asleep, having been sleep deprived for a little too long, maybe she just nodded off; falling to the waters below – not intending to be there.

Or maybe there were other reasons, and one thing led to another, which led to her being in the frigid waters with her seven-month-old son. That led to her death, and his clinging to a life that has only just begun – his father keeping vigil while grieving her death.

The Coroner’s office is investigating.

The question that needs to be answered is: What needed to happen, that did not happen? What needed to happen, that would have led to some other reality? The reality in which a boy has his mother, a father has his wife, and they get through the now – the incredibly exhausting present of having a very small child. The different reality where a small child is not fighting for a life that has only just begun – a life that now will bear no resemblance to what could have and should have been.

What needed to happen, that did not happen?

Would a solid night's sleep and a shower have made a difference?

Would less judgement about whatever choices had been made, made a difference?

Would simply knowing who to call, and where to go have changed the outcome?

This is an unnecessary and tragic loss of life – and should renew the call for Canada to do better. Over a year ago, Kirsten Patrick, then deputy editor of the Canadian Medical Association Journal pointed out that in other countries maternal deaths are analyzed on a case by case basis to identify contributing factors, and that such an approach does not happen in Canada.

Will this mother’s death serve the only purpose it can? Will it be looked at and analyzed – to determine what needed to happen that did not happen, to determine how we could possibly do better?

Will this baby, and this father – who now have suffered her loss be adequately supported going forward?

Are we doing enough right now? Really?

Moms matter. This mom mattered. Her loss is tragic, regardless of the underlying cause.

BC Provincial Policy Intended to Ensure Quality Care Likely to Erode Quality in BC

There’s a pretty big policy change on the horizon of the healthcare system in British Columbia. One that most patients are probably not remotely aware of, that is likely to have sizeable, and foreseeable, albeit unintended consequences that might well result in achieving the opposite of what was intended. One that might make our already access strained system, even more painful, one in which both patients and the providers being impacted may not have been adequately consulted, and one that is likely not as evidence driven as it should be.

In the wake of a health-system scandal in 2011 involving 4 radiologists in British Columbia, where 12 British Columbians had their treatment delayed or were misdiagnosed and three of those patients died, where thousands of diagnostic images were suspect, British Columbia sought to improve the system by which doctors are licensed, credentialed and given privileges in order to safeguard patients. The policy response included the Provincial Privileging Standards Project an overview of which can be found here. With a blog about the project being established here. The stated goal of the Provincial Privileging Project was to create discipline specific privileging dictionaries along with criteria required to apply for and maintain those privileges for all medical staff disciplines in the province. Not a goal I'd choose for a major policy project, but it is certainly attainable.

The dictionaries would establish the set of procedures and activities a doctor would be permitted to perform based on that physician’s credentials (degrees and post-graduate training already completed), currency (the level of current experience the practitioner has in the activity), and context (the ability of the facility in which the doctor practices to support the procedures and activities). My understanding of how the dictionaries have been developed is that 28 expert “panels” have been established for each specialty with each panel consisting of two or more senior practitioners in each specialty who have delineated all of the activities undertaken in each specialty and have established “core activities” and “non-core activities” for each specialty along with the amount of recent experience in the procedures and in general practice that the expert panel felt would be required to maintain competence in undertaking the services. The physician would be required to request and demonstrate that they meet the qualifications to acquire privileges, and if they were lacking in any area there would need to be a “conversation” about it.

Providers have publicly voiced concern over the pending policy change as illustrated by a recent article in the BC Medical Journal. Provider’s are concerned that the currency standards that have been established have not been shown to demonstrate competency or procedural safety based on sound evidence and that the new dictionaries will ultimately lead to a loss of access to medical services.

In response to the criticism raised the champions of the project replied in a subsequent article . The reply to the concern expressed is that providers are being unjustifiably fearful of the policy change, that failure to meet a standard in the dictionary will merely merit a “collegial” discussion, that they understand that there is a difference between currency and competency and that there was wide consultation with 56 expert panels being established along with collaboration with administrators, and that they recognize that the dictionaries will need to be updated on an ongoing basis.

This policy change is fueled by the best of intentions (to safeguard patients) – however, patients and providers are right to question whether or not the policy will safeguard patients (at all) and to consider the full impact the policy may have on the healthcare system. Was consultation broad enough? Are the standards evidence based or are they arbitrary? What will happen to access to medical services as a result? What is the cost of this new tool and its maintenance and are there other policy tools that are likely to be more effective and less costly? And perhaps most importantly, will quality of care that patients receive actually improve?

Disturbingly, it appears that patients have not been included in the development of this policy. Disturbingly, it appears that including a few members of the specialties involved is considered “broad consultation”. Disturbingly, it appears that the standards that have been set are arbitrary in that every practice and procedure is to be included in the dictionary, whether or not there is clear evidence that volume of service delivery or experience has any clear link to quality or safety. Disturbingly it appears as though concerns with the policy are being brushed off as merely fearing change.

This policy will not improve transparency or shared decision making between patients and care providers. This policy will not improve the recourse patients have when they experience medical error. This policy will not encourage innovation in the delivery of medical services. This policy will not identify providers that have patients that experience qualitatively or quantitatively bad care – it will not monitor clinical performance. By and large this policy appears as though it likely will reduce the number of providers that are available to provide services to the public and will increase the amount of bureaucracy in the system. It appears that patients might well be told they can’t have access to a medical service at all, rather than have access to the service provided by someone who is overwhelmingly likely to be able to provide the service safely.

Quality care and public confidence is critical to the system, but we’d be foolish to think that the “Provincial Privileging Program” is going to effectively advance quality in the British Columbia healthcare system. Policies that are implemented with patient safety and patient confidence being the goal should be robust and subject to scrutiny by providers and patients. Knee-jerk responses to critical lapses in the provision of quality care should be avoided as they may be very expensive responses that fail to meet the goals that matter. If you think access to care in British Columbia is bad now, just wait, things could get substantially worse.

The Great Tale of How I met Mr. W - But is it Prize Winning?

I submitted the tale of how I met my husband to a contest with the Vancouver Observer and it made it to the top 5 - it'd be fun if it won - so I'd like to ask my readers to check it out and vote at the following link on Facebook.

Little in the Canadian Healthcare System Fosters Patient Centred Care

To be blunt, there is little about the Canadian healthcare system and how it works that fosters and encourages patient centred care, and there is much about it that stymies efforts to develop and deliver truly patient (or family) centered care. Much of how the system works is even in direct conflict with improving health outcomes. As a result, we have a system that is relatively expensive, while performing poorly particularly with respect to measures of access to healthcare services.

This might seem to be a harsh criticism of a system that is held in high regard by many Canadians (many of whom are actually non-users of the system, and so may hold beliefs about it that are in stark contrast to the realities faced by actual patients). However, there are a number of critical ways in which the system hinders the development and delivery of patient centred care.

A patient centred system would be accountable to patients for the services that are delivered. The reality is that there is little meaningful accountability. Currently, the only avenue for patients to be compensated for harm caused by the medical system (either by medical error or negligence) is to pursue a medical malpractice claim. Sadly, doing so is often a tale of David and Goliath, where the harm caused by the error or negligence must be very significant and the evidence exceptionally clear in order to merit the substantial resources needed to pursue the claim. In part this is because of a medical protective association that seeks to aggressively defend every claim that is made, and as a result many meritorious claims are never pursued and many patients never receive compensation for the harm that they have suffered. Absent compensation for harm caused, the other avenues for accountability include the Patient Care Quality Offices, the Colleges of Physicians and Surgeons across the country, the media and patient advocacy groups. Sadly, as a result of their limited powers to remedy the harms caused, many patients with poor experiences never have their voices heard as the cost of doing so simply exceeds the expected benefits. In the Canadian system patients are not even routinely surveyed about their experiences of care and outcomes. As a result, there is likely a large under reporting of poor experiences of care or outcomes. A no-fault compensation system similar to what exists in New Zealand would be a meaningful step in the direction of patient centeredness.

A patient centred system would reward care that meets the needs of patients and penalize care that fails to meet the needs of patients. The reality is that the doctor who makes a patient make 3 appointments (one for each issue needing to be addressed) gets paid more than the doctor who accommodates a patient’s need to have your appointments consolidated or who spends a bit more time with a patient to ensure questions are adequately answered, or who provides access to information before the appointment so that the patient can come prepared. The reality is the doctor who forces his or her patients to come into the office has an advantage over the one who is open to being available via email or phone to address minor concerns. The reality is that there is no incentive for a doctor to go above and beyond – because at the end of the day they will be paid exactly the same (or worse) as their colleague who does the bare minimum. Further, given the relative scarcity of doctors, patients who are dissatisfied with their care are often trapped between a rock and a hard place, where the choice is a doctor with whom they are dissatisfied with or no doctor at all. There is no reason for doctors to actually care about whether or not their patients are happy (except for the intrinsic desire to deliver good service) or to solicit feedback from patients about the care that was received. There is no reason for doctors to be innovative in order to set themselves apart from their competition. At the end of the day the doctor who delivers the most services (regardless of the quality of services delivered) takes home the fattest paycheque. There might even be a disincentive to actually improve the health of patients, as healthy patients do not see doctors and absent service use, there is no pay. Further, many doctors are in a conflict between serving the interests of their patients and serving the interests of the broader healthcare system.

A patient centred system would be transparent. Medical records in this country are often held for ransom (it is not uncommon for doctors’ offices to charge fees to patients if and when they change doctors to transfer the file to the new care provider). Test results and referral letters are rarely communicated or shared directly with patients absent an office visit. Few patients have care and control of their medical information. In order to gain access to information about our bodies, a referral for tests or imaging is needed. Data about the system is often hoarded and the metrics that are publically available are carefully scrutinized to limit the amount of potential political fallout that might result from their publication. Patients are largely kept in the dark about things that critically impact their lives such as hospital policies and practices or even the expected amount of time that they will wait before gaining access to the care that they need.

A patient centred system would be truly comprehensive and co-ordinated. A lot has changed since medicare started – including the options for treatment of many conditions. Pharmacological care, dental care and optometric care are all excluded from the publicly funded system. Not to mention many para-medical services including those provided by psychologists, massage therapists, physiotherapists, chiropractors, nutritionists, and others. Further there is limited communication between different care providers and navigating the system as a whole is often a daunting task for patients.

A patient centred system would respect patient choice and patient autonomy and recognize that different people value different things. There remains a culture of paternalism in medical care. As an example the approach to maternal request caesarean in Canada – where many Canadian women have difficulty accessing the care they desire. As another example, the prohibition against the purchase of medically necessary care means that the supply of care and access to care is regulated regardless of patient preferences.

There is considerable reason to believe that a system (similar to that in many European countries) that allowed for privately funded medically necessary healthcare services in addition to more comprehensive publicly funded healthcare services would be more patient centred than the current system.

However, absent significant changes and considerable courage on the policy front – patient centred care in Canada will happen in spite of the system because of those driven by a higher purpose to make the lives of others better rather than because of it.