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Huricane Juan
Toronto Star
  • St. Michael?s Hospital health team offers prescription for poverty

    Ten years ago, Dr. Gary Bloch examined dozens of the city’s poor on the lawn before Queen’s Park, and prescribed them money.

    Amid the political theatre, he was filling out vague provincial “special diet” forms, which — once in the hands of the patients’ caseworkers — would bump their miserly $500 monthly welfare payments by as much as $250.

    “That lit a light bulb — that we could directly intervene in poverty,” says Bloch. “That informed everything that’s come afterwards.”

    The provincial government tightened the wording on the forms a year later, requiring doctors to diagnose patients with specific diseases to qualify for the “special diet” money. Bloch and his colleagues with the newly formed Health Providers Against Poverty wound down their massive “hunger clinics.”

    They’d made their point: poverty made people sick.

    At the time, Bloch was a 30-year-old doctor, treating homeless people in city shelters and drop-in programs. Most of his patients were in terrible shape. He offers an example: a man who’d lived on the street half his life. He had diabetes, had suffered strokes and multiple head injuries, and was an alcoholic. “He was just 42, but he had the body of a 75-year-old, and his brain was veering towards dementia,” says Bloch.

    Was he to blame for his current condition? Why didn’t he get a job and cut out the booze? That’s our culture’s predominant view on both poverty and health. But Bloch understood that poverty was like smog — it insidiously causes illness.

    More at thestar.com

    Doctors launch project to address root causes of poor health

    The poorest Canadians are twice as likely to develop diabetes as the richest. They’re more likely to suffer from cardiovascular diseases, respiratory illnesses, lung cancer, depression and arthritis. As Toronto Public Health reported in April, poorer young women are more likely to get chlamydia infections.

    This is not just because of their lack of money. But it’s all the other things that come with poverty: insecure housing, unstable employment, social exclusion, food insecurity, poor education. In medical parlance, these are now called the “social determinants for health.”

    Take Bloch’s homeless patient: “He had residential school, little education, no supports,” he says. “The most I could hope for him was to have a decent meal and move him into something like a palliative care program.”

    Illnesses of poverty are hard to treat, once they’ve settled. The answer, Bloch realized, was preventing them in the first place.

    He devised a four-page pamphlet for doctors to treat poverty. It advises them to screen for poverty as they do for cancer and hypertension. But in place of medicine or lifestyle changes, his list of suggested prescriptions is applying for government subsidies and benefits.

    He delivered the pamphlets to family medical clinics across the city and spoke to doctors and nurses about poverty as a disease.

    At the same time, Bloch was working part-time at the St. Michael’s Hospital’s bustling family and community medicine department. There too, his patients are largely low-income.

    Bloch’s treatments there have included phoning the welfare office to advocate for a patient’s increased benefits and meeting Toronto Community Housing managers to demand that problems with a patient’s unit be rectified.

    When a patient lost her child-care subsidy, Bloch went straight to the city manager. “She was experiencing depression and was overwhelmed with having to take care of three children, one with a developmental delay,” he explains. “The stress would have put her at huge risk of physical health decline as well.” She got the subsidy back.

    You might think of this as social work. Bloch and his mentor Dr. Philip Berger, who ran St. Michael’s family medicine department for 13 years, say it’s an integral role of a physician.

    “Doctors have a duty to raise their voices loudly on behalf of their patients who can’t and … to hold the government accountable if their policies make patients sick,” says Berger, who now oversees the University of Toronto’s undergraduate medicine advocacy programming.

    Bloch comes from a long line of social justice doctors. His grandmother, a refugee who escaped Germany on the cusp of the Second World War, treated the poor in the townships of Port Elizabeth, South Africa. His mother’s medical practice focused on homeless youth in Vancouver. It was at Habonim Dror, socialist-Zionist summer camp, that Bloch formed his politics and penchant for activism.

    “We would read Marx and Engels,” says Bloch, now married with three children. “I came into medicine with that analysis.”

    On a whim two years ago, Bloch applied to the Ministry of Health and Long-Term Care for money to hire a health promoter within the St. Michael’s family practice clinic — someone whose job would be to help patients access money, serving all 70 doctors on staff there.

    To his amazement, the province agreed and funded the position. Health Minister Eric Hoskins said he’s watching with great interest.

    “Since then, we’ve seen an incredible explosion of programs,” Bloch says. A social worker was hired to the team. A lawyer recently arrived. A reading program was launched, which prescribes books to children at their annual checkups.

    An employment program for patients is in the works.

    “My hope is, in the medical world, this is seen as core to medical practice,” says Bloch, now 40. “I want poverty to be treated like smoking.”

    CASE STUDIES

    Patient: Brenda MacPherson, 52

    Diagnosis: Anxiety, depression, H. pylori, eating disorder, unexplained weakness in her left side, poverty.

    Brenda MacPherson lost her job at a media monitoring company three-and-a-half years ago. She’d been there 30 years. She became terribly ill with depression, anxiety and grief. She says she didn’t leave her house for a year and lost 30 pounds quickly after ulcers formed in her stomach, caused by the bacteria H. pylori.

    Once her severance ran out, she went on welfare — $656 a month. She paid for groceries by Visa, racking up $9,000 in debt, which heightened her anxiety.

    At the St. Michael’s family medicine clinic on Bond St., the social worker helped MacPherson apply for welfare. The doctors filled out an application for a special diet, boosting her income by $45 a month. The income worker applied for her Canada Pension Plan payments early and also the Ontario Disability Support Program, which will almost double her monthly income.

    “This place saved my life,” says MacPherson. “I had no job, no relatives, no one.”

    Patient: Mohamed Jeylani, 49

    Diagnosis: Severe back pain; full custody of 7-year-old daughter Barike, who is intellectually disabled; and poverty.

    Mohamed Jeylani arrived in Canada in 1992 as a Somali refugee. He studied English, attended high school classes and worked low-paying jobs, washing dishes, driving cube vans and guarding apartment buildings. The pain in his back started slowly, but became unbearable about a dozen years ago, forcing him to stop work. Since then, he has had a daughter, Barike. Together, they live on his $1,100 monthly welfare cheque.

    Dr. Gary Bloch helped waive his transit costs, by writing a letter to his social worker demanding Jeylani get a monthly TTC pass (paid by the province) to attend his medical appointments. He is assembling Jeylani’s medical records to reapply for disability support payments, which would mean another $500 a month. Income security worker Karen Tomlinson has applied to Revenue Canada for Barike’s disability tax credit, and is currently completing the forms for provincial assistance for children with severe disability, which could bring in anything from $25 to $440 a month.

    “It’s just so low,” Tomlinson tells Jeylani of his current income. “When does your money run out?”

    He responds: “After two days, you are done.”

  • Gay marriage legalization in Ireland on way to resounding ?yes?

    DUBLIN—Ireland has voted resoundingly to legalize gay marriage in the world’s first national vote on the issue, leaders on both sides of the Irish referendum declared Saturday even as official ballot counting continued.

    Senior figures from the “no” campaign, who sought to prevent Ireland’s constitution from being amended to permit same-sex marriages, say the only question is how large the “yes” side’s margin of victory will be from Friday’s vote.

    “We’re the first country in the world to enshrine marriage equality in our constitution and do so by popular mandate. That makes us a beacon, a light to the rest of the world of liberty and equality. So it’s a very proud day to be Irish,” said Leo Varadkar, a Cabinet minister who came out as gay at the start of a government-led effort to amend Ireland’s conservative Catholic constitution.

    “There is going to be a very substantial majority for a yes vote. I’m not at all surprised by that to be honest with you,” said Irish Sen. Ronan Mullen, one of only a handful of politicians who campaigned for rejection.

    Political analyst Noel Whelan noted that “yes” majorities were being reported even in conservative rural districts and suggested the only question was how large the “yes” majority would be when all ballots in this predominantly Catholic nation of 4.6 million are counted.

    Varadkar, who personally watched the votes being tabulated at the County Dublin ballot centre, said the Irish capital looks to have voted around 70 per cent in favour of gay marriage, while most districts outside the capital also were reporting strong “yes” leads. He said not a single district yet had reported a “no” majority. Official results come later Saturday.

    The anti-gay marriage side credited “yes” campaigners with running a creative, compelling campaign that harnessed the power of social media to mobilize young voters, tens of thousands of whom voted for the first time Friday. They also said a “no” victory was always unlikely given that all political parties and most politicians backed the legalization of homosexual unions, just five years after parliament approved marriage-style civil partnerships for gay couples.

    Fianna Fail party leader Michael Martin, whose party is traditionally closest to the Catholic Church but like all other parties campaigned to legalize gay marriage, said it “looks like an emphatic win for the yes side.” Voters in his native Cork were being recorded by observers as more than 60 per cent yes.

    John Lyons, one of the four openly gay lawmakers in Ireland’s 166-member parliament, said he was surprised by how many older voters he met on the campaign trail who were voting yes. But he paid special credit to the mobilization of younger voters, many of whom travelled home from work or studies abroad to vote.

    “Most of the young people I canvassed with have never knocked on a door in their lives,” said Lyons, who represents northwest Dublin in parliament. “This says something about modern Ireland. Let’s never underestimate the electorate or what they think.”

  • ?The rich do better?: ethics and Eugene Melnyk?s new liver

    It should shock no one that in the matter of access to health care, even to the organs in other people’s bodies, the wealthy and well-connected, such as Ottawa Senators’ owner Eugene Melnyk, are different from the rest of us.

    “The rich do better,” Dr. Arthur Caplan, head of bioethics at New York University Langone Medical Center, told the Star. “I don’t know that that’s a headline, but it’s nonetheless true.”

    Caplan co-wrote an article on Forbes.com last week that said publicity campaigns for donor organs, such as that successfully mounted by Melnyk for a liver, create “a double standard” under which those with name recognition have an advantage over those with fewer resources and less profile.

    After a plea last week by the Senators on Melnyk’s behalf, more than 500 potential donors volunteered. Doctors with the University Health Network’s multi-organ transplant team selected one from 12 potential candidates and a plea last week this week on the 55-year-old Melnyk.

    More than 20 of those not selected to donate to Melnyk have said they would continue in the process to donate to others in need, said Dr. David Grant, leader of the surgical transplant team. “Many lives will be saved as a result of this appeal.”

    Both Melnyk and the anonymous donor were in stable condition and recovering. The donor, who wished to remain anonymous to the public and to Melnyk, told Dr. Grant that part of the motivation was a desire to help the owner bring the Stanley Cup “home to the Ottawa Senators.”

    Despite Dr. Grant’s belief that others awaiting transplants will benefit from the public appeal, experts agree there’s something unsettling about the speed at which Melnyk was treated and his ability to raise options less famous people couldn’t hope to match.

    The intriguing aspect, said Dr. Udo Schuklenk, Ontario Research Chair in Bioethics at Queen’s University, is less that Melnyk used all tools at his disposal to save his life – who wouldn’t? – but that there were “apparently hundreds of people willing to donate organs for him, but not for others.”

    Even so, he said, there is nothing unjust because “when you take the emotions out of it, you ask yourself, given what this guy has done, is any other patient any worse off? The answer is no.”

    Melnyk had been suffering end-stage liver failure from an undisclosed disease. He was put on the waiting list for a liver from a cadaver. Due to his rare blood type, the odds of that happening were slight. That meant finding a living donor.

    After unsuccessfully seeking a match from family and friends, he went public through the Senators. The response was remarkable.

    Schuklenk said a case can be made that those still waiting for transplants will be better off as a result.

    Melnyk is off the waiting list. Prospective donors who came forward for him might still donate to others. The awareness created by high-profile stories such as his will likely bump those signing organ-donor cards. And the Senators say that promoting organ donation will be an ongoing initiative.

    Better still, the publicity might prompt the system to be changed, he said, from one in which citizens have to opt in to donate organs to one in which consent is presumed unless they opt out.

    Usually, he said, people don’t sign up “because we’re too lazy, not because we have any objections to it.”

    There are about 1,500 waiting for a heart, kidney or liver in Ontario. One in three people die waiting for an organ.

    For his part, Caplan said each transplant centre holds considerable authority to determine what donors and recipients they will treat.

    “Maybe more regulation is needed,” he said. Few would balk at a parent donating a kidney to a child. But “if you want to donate your liver to me, that gets to be a little different. Because, ‘why me’?

    “There might be others who are needier or would do better with it. I think we could use an examination of that issue.”

    An obvious concern is whether money or other considerations are changing hands, he said. Or whether a recipient might be vulnerable later to extortion.

    There are also two lives at risk in such a procedure, he said, and there are questions to be asked of a donor.

    “Are they doing it for the right reasons? Are they rational? Are they overcome in this case by being a fan?

    “If you say, ‘I’m a really loyal Senators’ fan,’ maybe that’s not good. Maybe you want to have other reasons.”

    If the Melnyk case proves troubling to Canadians, it should be possible to find better arrangements, Caplan said.

    “You could set up a system whereby people who need donors register their name and remain relatively anonymous, if you were trying to balance the playing field. You could set it up so that the only way you could get an organ is going through the system” and playing by the same rules as everyone else.

    Caplan had another question.

    “Who’s paying for all this?”

    It’s nice that a donor stepped up for Melnyk, he said, but they didn’t for others with rare blood types also needing livers. “If we’re all going to pay for it, how does that sort out relative to fairness?”

    It was not the only money question to arise.

    As the Ottawa Citizen reported, Melnyk is a Canadian citizen but a permanent resident of Barbados. The Ontario Health Insurance Plan requires patients to make their primary residence in Ontario and spend at least 153 days in the province in any 12-month period to maintain coverage.

    Neither the team nor the hospital would comment on coverage issues. The Citizen reported that non-residents in urgent need of life-saving treatment could receive transplants and those without coverage could be billed directly.

    As Dr. Caplan observed, the rich do better.

Arts & Letters
Trudy
Sunday, 12 August 2007