Canada Health Act 2.0: Are the Fundamental Principles Still Current, or Do They Need to be Revisited?

The Canada Health Act was passed in the run-up to the 1984 Federal Election to meet a political problem - perceived inequities in access to care due to extra-billing by physicians and hospitals. At that time, health care as a right of citizenship was still a topic of debate. Health care was for the sick, and effective interventions were few and inexpensive. The provision of health care was seen as a morally justified social cost. Today the problem is different. We are in the midst of the largest transformation in biological understanding since the invention of the microscope. New treatments are being found powerfully effective, yet costly. A new, high value added, economic sector has developed: health innovation. Health care is an unquestioned social right. Yet, although a disproportionate amount of the foundational science has come from Canada, increasingly we are unable to access the medical, economic and social benefits of a global health economy. We need a permissive, catalytic, legislative framework (CHA 2.0) that will bring together the economic strength of health innovation and the delivery of its benefits to the health and wellness of Canadians. It would espouse the following seven principles: 1. Health care and health innovation are parts of a nationally critical health economy, with a global perspective. 2. Public and private sector involvement and accountability. 3. Change and innovation mandated and rewarded. 4. Labour mobility across jurisdictions, and role mobility across professions. 5. Patient-centred care. 6. Holistic and comprehensive, based on evidence. 7. Outcome (not process) driven, and transparent in implementation.

Putting People First: Critical Reforms for Canada's Health Care System.

For over 70 years, since the Dominion Provincial Conferences at the end of the Second World War, Canadians have viewed health care as a right of citizenship. The Canada Health Act (CHA, 1984) formally entrenched the five principles that guide our current publicly operated, single payer, provincially managed system: public administration, comprehensiveness, universality, portability and accessibility. The health care system that has sprung up around the CHA has become increasingly complex, costly and strained. Our gradual descent through the rankings of major health care suggests that we are reaching the limits of what the current health care system can provide. Unfortunately, constructive political debate around this issue is often choked by intense ideological positioning. System reform is urgently needed to address the rapidly changing biological and demographic drivers of health. We do not feel that diverting ever larger flows of money into the status quo is a sustainable solution. Our nation's health and the means to advance it must be seen as assets rather than costs. We believe it is possible to meet increasing demands by expanding the supply and acknowledging the wealth of resources (scientific, human, managerial and educational) that we currently possess. In this paper we propose a cultural shift from an institution-centered system bent on cost control, to a patient-centered system that fosters a true health economy. We identify a series of interventions (some bold and others less so) to achieve a clear and evaluable goal: maximizing the well-being and debility-free life expectancy of each individual. To achieve a patient-centred system-we discuss strategies to address costs and utilization, the setting of real performance standards, the elimination of conflicts of interest and the provision of truly accessible care for all Canadians. To create a health economy, we discuss the importance of innovation, the need for a reinvigorated public health system and steps to overhaul the health care human resources environment. The goal of health care reform in Canada should be a system that is dynamic, evidence based, wealth creating and a global leader. We believe that, with leadership and vision, this goal is eminently achievable.

Navigating "Assisted Dying".

Carter is a bellwether decision, an adjudication on a narrow point of law whose implications are vast across society, and whose impact may not be realized for years. Coupled with Quebec's Act Respecting End-of-life Care it has sharply changed the legal landscape with respect to actively ending a person's life. "Medically assisted dying" will be permitted under circumstances, and through processes, which have yet to be operationally defined. This decision carries with it moral assumptions, which mean that it will be difficult to reach a unifying consensus. For some, the decision and Act reflect a modern acknowledgement of individual autonomy. For others, allowing such acts is morally unspeakable. Having opened the Pandora's Box, the question becomes one of navigating a tolerable societal path. I believe it is possible to achieve a workable solution based on the core principle that "medically assisted dying" should be a very rarely employed last option, subject to transparent ongoing review, specifically as to why it was deemed necessary. My analysis is based on 1. The societal conditions in which have fostered demand for "assisted dying", 2. Actions in other jurisdictions, 3. Carter and Quebec Bill 52, 4. Political considerations, 5. Current medical practice. Leading to a series of recommendations regarding. 1. Legislation and regulation, 2. The role of professional regulatory agencies, 3. Medical professions education and practice, 4. Public education, 5. Health care delivery and palliative care. Given the burden of public opinion, and the legal steps already taken, a process for assisted-dying is required. However, those legal and regulatory steps should only be considered a necessary and defensive first step in a two stage process. The larger goal, the second step, is to drive the improvement of care, and thus minimize assisted-dying.

Treatment of AIDS-associated Kaposi's sarcoma in Zimbabwe: results of a randomized quality of life focused clinical trial.

Kaposi's sarcoma is currently the most common tumor in Zimbabwe. The purpose of our study is to compare the effectiveness of supportive care vs. 3 intervention approaches, namely oral Etoposide, a 3-drug combination, and radiotherapy using quality of life (QOL) as the primary measure of success. In addition, our study was to determine whether a disease-specific module has greater sensitivity to group differences than a generic QOL questionnaire and to determine the most pragmatic approach to treating epidemic Kaposi's sarcoma (EKS) in Zimbabwe. Histologically confirmed HIV-positive patients with Kaposi's sarcoma were randomized to receive supportive care only or supportive care plus either radiotherapy, oral Etoposide or a 3-drug combination consisting of actinomycin-D, vincristine and bleomycin. No patient received antiretroviral therapy. The primary outcome was QOL measured by the functional living index-cancer (FLI-C) and supplemented by the Kaposi's sarcoma module (KSM). From 1994-1999, 495 EKS patients were accrued, and 470 were evaluable. Of these, 433 are known to be dead, 26 are lost to follow-up and 11 are still alive. The group treated with oral Etoposide had a significantly better QOL than the radiotherapy group for the total FLI-C score (adjusted mean plus standard error at 3-months 89 +/- 3 vs. 76 +/- 3; p = 0.004) and for the hardship (11 +/- 0.4 vs. 9 +/- 0.4; p = 0.001); social (10 +/- 0.4 vs. 8 +/- 0.4; p = 0.001) and nausea (9 +/- 0.4 vs. 8 +/- 0.4; p = 0.002) subscales. In addition, on the physical and psychological subscales, the Etoposide group had a significantly better QOL than the other 3 treatment groups (p < 0.04). The 3-drug combination, supportive care and radiotherapy groups did not differ significantly from each other with respect to the total FLI-C score or its subscales. There were no group differences with respect to survival. Oral Etoposide therapy resulted in better total FLI-C QOL score than radiotherapy. As well, Etoposide resulted in better physical and psychological subscale scores than radiotherapy, 3-drugs and supportive care. Thus, funds permitting, oral Etoposide is a pragmatic approach to treating EKS in an environment where antiretroviral drugs are not universally available. The study underscores the value of undertaking studies in areas of disease prevalence and the necessity of selecting appropriate outcome measures.

Un modelo regulador para el cáncer: la evidencia y las estrategias a seguir / Regulator model for cancer: evidence and strategies to follow

¿Qué es el cáncer? ¿Cómo podemos prevenirlo? ¿Cómo podemos minimizar su morbilidad y mortalidad?. Nuestro acercamiento a estas preguntas depende de como nosotros conceptualizamos el cáncer. Por más de cien años, nosotros pensamos que las células tumorales están irreversiblemente fuera de control, matando inevitablemente al huésped a menos de que fueran totalmente erradicadas. Desde 1970, los Estados Unidos de Norteamérica declararon la guerra contra el cáncer. Como una real guerra, la posibilidad de batir el cáncer dependerá del poder de nuestro armamentario químico. La premisa central de este modelo asesino es: es necesario luchar nás para matar más, siendo la completa desaparición del tumor la única posibilidad de lograr la cura. Regímenes con intensificación de dosis son usados para matar la última célula. Pero hoy en día, nosotros sabemos que aunque tenemos poderosas armas, nosotros perderemos la guerra en la mayoría de nuestros pacientes. Es tiempo de parar la guerra y cambiar el paradigma del cáncer. Nosotros necesitamos comprender que el cáncer es un proceso dinámico, la consecuencia clínica de los sistemas regulatorios normales parcialmente fuera de control. Este proceso está caracterizado por un desequilibrio regulatorio y este desequilibrio es potencialmente reversible. Esto significa que la cura funcional no requiere una remisión completa. Además, las estrategias asesinas pueden ser contraproducentes. Nuevas tendencias en el diagnóstico y tratamiento y sus resultados dependerán de este nuevo modelo regulatorio. El modelo regulatorio cambia la manera aunque nosotros investigamos, prevenimos y tratamos el cáncer. Le atrae la próxima gran aventura en oncología.