For the record
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## Prominent Canadians lobby for drug access reform

Dr. James Orbinski, Stephen Lewis and Dr. Samantha Nutt were among more than 50 prominent Canadians urging federal Parliamentarians to vote on Dec. 1, 2009, in favour of a bill that would reform legislation aimed at supplying affordable lifesaving drugs to the developing world.

“The current law is not working,” states an open letter dated Dec. 1, 2009, World AIDS Day, and endorsed by, among others, the former international president of Médecins Sans Frontières, the former United Nations special envoy for HIV/AIDS in Africa and the founder of War Child Canada.

The private member’s bill to reform Canada’s Access to Medicine Regime, which faced second reading on Dec. 2, 2009, would streamline the approval process for the manufacture and shipping of needed drugs, advocates say.

A poll commissioned by UNICEF Canada and the Canadian HIV/AIDS Legal Network found that a majority of Canadians support the changes proposed in the bill. Reform of the regime was also supported by a petition signed by 32 000 Canadians and sponsored by the Grandmother’s Campaign, which was launched in 2006 by the Stephen Lewis Foundation to support grandmothers raising AIDS orphans in Africa.

But Bill C-393, which was introduced by New Democrat Member of Parliament Judy Wasylycia-Leis (Winnipeg North) is opposed by the Conservatives, Rx&D — Canada’s Research-based Pharmaceutical Companies and some Liberal party members of Parliament, including industry, science and technology critic Marc Garneau (Westmount–Ville-Marie).

The existing legislation is “a fast, efficient and effective tool to deliver medicines in the developing world,” states an Rx&D press release dated Oct. 19, 2009.

However, as of Dec. 1, 2009, only enough of a triple-combination HIV/AIDS drug to treat 21 000 Rwandans for one year has been shipped from Canada under the five-year-old legislation. The drugs were manufactured and shipped by the Canadian generic drug company Apotex Inc. in 2008 and 2009. President Jack Kay said the process was so lengthy and cumbersome that Apotex would not repeat its efforts under the existing law.

Canada’s legislation was heralded when introduced in 2004, a year after a World Trade Organization (WTO) decision that provided for mechanisms to speed availability of affordable generic drugs for public health emergencies and other public noncommercial use in designated countries.

But the legislation added obstacles to the effective use of the WTO decision and, as a consequence, the difficulties in arranging for the one shipment from Canada were “foreseeable,” Frederick Abbott, professor of international law at Florida State University College of Law in Tallahassee, Florida, told the Senate Banking, Trade and Commerce Committee in November 2009.

A separate private member’s bill (S-232), similar to C-393, has been introduced in the Senate and passed second reading there (*CMAJ* 2008: DOI:10.1505/cmaj.081146 and *CMAJ* 2006; DOI:10.1503/cmaj.061121.) —Ann Silversides, *CMAJ*

## Physician pool expands

Canada’s national physician pool is getting older and larger, according to the Canadian Institute for Health Information (CIHI).

A CIHI report, *Supply, Migration and Distribution of Canadian Physicians, 2008*, indicates that the number of active physicians (people with medical degrees and valid mailing addresses) increased by 8.0% over the last five years, from 60 612 in 2004 to 65 440 in 2008. That tally excludes 5809 physicians who are either in the military, semiretired, pursuing residencies, nonlicensed or requested exclusion. Including these other physicians brings the total in Canada to 71 249.

The overall physician-to-population per capita ratio grew to 195 per 100 000 in 2008, from 189 in 2004. That ratio is predicted to continue to rise as the number of new medical students increased from 8236 in 2004 to 9640 in 2007.

However, rising enrolment in medical schools is only part of the reason for the overall increase. Also contributing was a trend towards later retirement among physicians. The average age of general practitioners in Canada increased by 5.6 years, to 49.0, while the average age of specialists increased by 3.4 years, to 50.6. Meanwhile, CIHI found that 69.2% of 1667 physicians who were between the age of 70 and 74 and working in 2004 were still working in 2008, while 63% of the 643 physicians aged 75–79 in 2004 were similarly still practicing, and 47% of the 217 physicians aged 80–90 in 2004 continued to practise in 2008.

An increase in the number of Canadian-trained physicians (6.6%) and an influx of foreign-trained physicians (10.4%) also contributing to a swelling of the physician ranks.

The report also shows that Canadians are more likely to be treated by female physicians or by those trained in their own province. In 2008, women accounted for 52.1% of new general practitioners in Canada and 45.1% of new specialists. Some 66% of medical graduates are likely to still be practising within the jurisdiction in which they were trained 10 years earlier. Internationally trained physicians appear more inclined to move around the country, as only 33.8% of family physicians, and 27.9% of specialists, were working in the same place between 998 and 2008.

Over that time period, Alberta and British Columbia enjoyed a net annual gain of physicians due to interjurisdictional migration, while Newfoundland and Labrador, Quebec, Manitoba and Saskatchewan experienced net losses. — Lauren Vogel, Ottawa, Ont.

## Ontario passes regulatory changes for health professionals

Legislation that will provide the Ontario Ministry of Health with the power to appoint a supervisor who can assume the regulatory duties of health professional bodies such as the College of Physicians and Surgeons of Ontario has passed third reading and needs only to be proclaimed before coming into effect.

The college had expressed concerns about the legislation (*CMAJ* 2009: DOI:10.1503/cmaj.109-3081) and sought amendments during the legislative process. Some of the amendments were adopted and “somewhat improve” what was proposed, Kathryn Clarke, the college’s senior communications coordinator, states in an email.

The college had asked that the extraordinary step of appointing a supervisor be taken only if a college had complied with requirements under Section 5 of the Regulated Health Professions Act and if the minister “is satisfied that there is a risk to patient safety.” The latter condition was not included in the amendment, though the former was, Clarke stated.

Another amendment requires that the minister give the affected college 30 days, instead of the original 14 days, notice of the intent to appoint a supervisor. As well, the affected college can, in response to the notice, make written submissions that must be included in the minister’s recommendation’s to the lieutenant-governor that a supervisor be appointed.

Overall, “the amendments fall short of what we and many other regulators” had recommended, Clarke added.

The provisions apply to all the 22 health profession regulatory bodies in the province. The legislation will also give nurse practitioners, pharmacists, physiotherapists and other health professionals the freedom to provide a wider range of services, according to a ministry press release. — Ann Silversides, *CMAJ*

## Patients on the prowl

British doctors should think twice before responding to amorous advances on social networking sites such as Facebook or MySpace, according to the United Kingdom’s Medical Defense Union.

Even polite refusals on such social networking sites are inappropriate, the association says.

“The pitfalls posed to doctors using social networking sites by inadvertently breaching confidentiality or posting unprofessional content, such as photos, have been well documented. But doctors may be less prepared for patients using sites like Facebook to ask them out on a date,” wrote Dr. Emma Cuzner, Medical Defence Union medico-legal adviser in the *MDU Journal* (*MDU Journal* 2009;25:12–3). “Some doctors have told the *MDU* they feel it would be rude not to reply, if only to politely refuse, but given that this is not a professional route of communication, any correspondence of this sort would clearly stray outside the doctor/patient relationship.”

Cuzner warned that doctors could face investigation if they crossed the line. “They have a duty to maintain the public trust in the profession at all times, in their professional and private lives and not only when at their place of work.” The organization also advised doctors to use security and privacy settings on social networking sites to prevent unsolicited propositions that may lead to liaisons. —Lauren Vogel, Ottawa, Ont.

## New Networks of Centres of Excellence announced

A University of British Columbia-led initiative to understand pediatric brain development is among three new Networks of Centres of Excellence (NCE) emerging from the latest tri-granting council/Industry Canada networks competition.

NeuroDevNet will receive $19.5 million over the next five years for a research program focused on the genetic and environmental causes of cerebral palsy, autism spectrum disorders and fetal alcohol disorders under the networks program, which is jointly run by the Canadian Institutes of Health Research, the Natural Sciences and Engineering Research Council and the Social Sciences and Humanities Research Council, along with Industry Canada.

“The network will seamlessly combine lab research — studying how the brain develops and how to fix it when it develops poorly — with the clinical situation as babies develop in utero and until three years of age,” NeuroDevNet Scientific Director Dan Goldowitz in a press release.

“We’ll bring in basic researchers to model brain development and test interventions, we’ll involve parents so they’re aware of what we’re doing, and we’ll share best practices with clinicians. The knowledge gained will provide proof of principle and contribute to discovering diagnostics and developing therapeutics. The earlier we can diagnose and intervene with the children, the bigger the effect on developmental outcome,” added Goldowitz, the senior scientist at UBC’s Centre for Molecular Medicine and Therapeutics at the Child & Family Research Institute in Vancouver, BC.

Also successful in the NCE competition (which drew 38 submissions, 10 of which were invited to make full applications) was Carbon Management Canada, which received $25 million to develop technologies to rapidly “decarbonize” fossil fuel production and use, as well as Graphics, Animation and New Media Canada, which received $23.5 million to explore new media issues such as social networking, virtual museums and e-health services. —Sabrina Doyle, Ottawa, Ont.

## Australia unveils incentive program to treat chronically ill Aboriginal patients

Australian doctors will pocket an extra A$500 a year for every chronically ill Aboriginal patient they adequately treat starting in May 2010 under a new indigenous health incentive program.

The program hopes to encourage better care for Aboriginal patients by rewarding health providers that meet treatment targets, said Minister of Indigenous Health Warren Snowdon in a press release ([www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr09-ws-ws062.htm](http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr09-ws-ws062.htm)).

General practitioners and accredited Aboriginal health service units will receive A$1000 when they sign up to participate in the incentive program. Doctors will earn A$250 for every indigenous patient they sign to their practice and an additional A$250 each time the patient renews their annual agreement.

They’ll receive another A$250 yearly for each patient treated in accordance with a target level of care, including effective follow up monitoring and treatment.

But indigenous health experts say the program will fail to deliver improved care to many Aboriginal communities, as it only extends support to health services accredited by the Royal Australian College of General Practitioners.

The majority of Australia’s indigenous people receive care from Aboriginal community-controlled health services units, up to 50% of which are not accredited and are therefore ineligible for the new incentive program, states the *National Aboriginal Community Controlled Health Organization Annual Report 2008-2009* ([www.nac-cho.org.au/Files/Documents/NACC-HO\_AR09_Final.pdf](http://www.nac-cho.org.au/Files/Documents/NACC-HO_AR09_Final.pdf)).

The report suggests the new incentive program, which will cost A$28 million over the next four years, will only serve to pay “mainstream” practices more for the limited service they already provide to Aboriginal communities.

Australian Medical Association data shows that Aboriginal and Torres Strait Islander peoples die up to 17 years earlier than even the most disadvantaged of other Australians ([www.ama.com.au/node/3229](http://www.ama.com.au/node/3229)).

They’re also three times as likely to have a major coronary as other Australians. — Lauren Vogel, Ottawa, Ont.

## Sepsis mortality rates remain high

While overall mortality rates are dropping in Canadian hospitals, those for sepsis are essentially unchanged since 2004, according to the Canadian Institute for Health Information (CIHI).

Roughly 47% of Canadian hospitals, excluding those in Quebec, had mortality rates below the expected national experience, compared to 36% in 2007, CIHI says in its most recent assessment of hospital standardized mortality ratios, *HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada*. The ratio compares actual (observed) deaths to expected deaths, adjusting for factors that affect in-hospital mortality, such as age, sex, length of stay and diagnosis group ([http://secure.cihi.ca/cihiweb/dispPage.jsp?cw\_page=hsmr\_results\_canada\_e](http://secure.cihi.ca/cihiweb/dispPage.jsp?cw\_page=hsmr_results_canada_e)).

But in a related report, *In Focus: a National Look at Sepsis*, CIHI said that there has been no significant improvement in either sepsis hospitalization rates or sepsis mortality rates since 2004 ([http://secure.cihi.ca/cihiweb/products/HSMR\_Sepsis2009_e.pdf](http://secure.cihi.ca/cihiweb/products/HSMR_Sepsis2009_e.pdf)).

Approximately 1400 people worldwide die of sepsis every day. CIHI estimated that 9320 patients with the disease died in Canadian hospitals in 2008. The current crude mortality rate for sepsis tops 30%, as compared with 18% for patients with stroke and 9% for people who suffered a heart attack.

In 2008–2009, approximately a quarter of all patients with sepsis were diagnosed with the condition after being admitted to hospitals. CIHI found these patients were 56% more likely to die than those patients diagnosed before their admission to hospital.

The study also found there’s a high economic cost associated with treating patients with sepsis, as they stay in hospital an average nine days longer than those admitted with other conditions. Almost half of all patients with sepsis are admitted to intensive care units.

Quebec is not included in CIHI’s study of hospital standardized mortality rates due to historical differences in the classification systems of diagnosis and intervention, says Institute Vice-President, Research and Analysis, Jennifer Zellmer (*CMAJ* 2008; DOI: 10.1503/cmaj.071784). — Lauren Vogel, Ottawa, Ont.

## US proposes stricter guidelines for university athletes who suffer concussions

In the wake of growing public and parental concern about the long-term impact of sports-related head injuries, the governing body for university sport in the United States is proposing that student-athletes be prohibited from returning to the field of play for the remainder of a game or practice if they’re rendered unconscious, “have amnesia or persistent confusion.”

The proposed National Collegiate Athletic Association (NCAA) rule, which must still be ratified by the association’s Playing Rules Oversight Panel, would also obligate teams to remove from the field of play all athletes who exhibit “signs, symptoms, or behaviours consistent with a concussion (such as unconsciousness, amnesia, headache, dizziness, confusion, or balance problems), either at rest or exertion,” until such time as they’ve been cleared by a physician ([www.ncaa.org/wps/ncaa?key=/ncaa/ncaa/ncaa+news/ncaa+news+online/2009/association-wide/safeguards+committee+acts+on+concussion-management+measures+-+ncaa+news+12-15-09](http://www.ncaa.org/wps/ncaa?key=/ncaa/ncaa/ncaa+news/ncaa+news+online/2009/association-wide/safeguards+committee+acts+on+concussion-management+measures+-+ncaa+news+12-15-09)).

The committee also urged that the NCAA convene a national summit this year to review policies regarding the medical management of concussions and examine prevention strategies.

In contrast to the NCAA proposal to stiffen its regulations governing concussions, Canada appears to lack any manner of national standards, guidelines or regulations for head injuries suffered during university sporting events.

Marg McGregor, executive-director of Canadian Interuniversity Sport, says policies regarding sports-related head injuries are the purview of members institutions. “Each of our universities have their own protocol with respect to how they manage injuries, return to game play, training and competition.” — Andrea Ozretic, Ottawa, Ont.

## Footnotes

*   Published at [www.cmaj.ca](http://www.cmaj.ca) from Dec. 1, 2009, to Dec. 24, 2009