Tag Archives: prevention

why being canadian makes us sick

today was the annual general meeting of the canadian mental health association. our speaker was dr. paul kershaw.  from his intro:

kershaw is an academic, public speaker and media contributor. he is one of canada’s leading thinkers about care-giving and family policy, receiving two national prizes from the canadian political science association for his research.

dubbed by some an ‘evangelist professor’, kershaw uses research to be a cheer-leader and critic of canadians with the intention of inspiring substantial policy change across the country. to this end, kershaw devotes time to liaise with leaders in government, the business community, the not-for-profit sector, and the academy.

kershaw does not shy away from tough issues. on radio he has been labeled a “boomer-hater” because he speaks about intergenerational inequities between baby boomers and the generations that follow. as a proud feminist, he chides the personal and policy decisions by which many men evade their fair share of care-giving work, and fail to enjoy a fair share of the joys that come with caring. among the general public, he argues that ‘being canadian’ is making us sick, because the medical system in which we take national pride shows more of a disease fetish than an aspiration to promote health. at the university of british columbia, in the college for interdisciplinary studies, kershaw is the human early learning partnership (HELP) scholar of social care, citizenship and the determinants of health.

here are my notes from his talk:

how many children come to school ready to learn? 70%. that sounds like a good number. but what if you turn it around?

30% of children come to our schools vulnerable (don’t meet age appropriate benchmarks – e.g. not fully developed re fine and gross motor skills, playing with peers, following simple instructions, etc.)

why should that worry us?

we are most sensitive to our environments in the early years. what happens in the early years sets the tone for the rest of the life.

statistically speaking, those who are vulnerable in kindergarten tend to have more problems with teenage diabetes, mental health, coronary heart disease, elevated blood pressure, premature aging, etc.

what are the fundamental failings in canada when it comes to looking after our youngest citizens?

poverty.

poverty 1: families are strapped for time – “i’ll compromise my time in the domestic area” work-life conflict – BC has the highest rate of work life tension
poverty 2 – service poverty (lack of social services)
poverty 3 – income poverty – we have the highest rates of poverty among children

5 reasons why we fail our next generations

1 – our perceptions don’t reflect reality
2 – lack of gender equality
3 – we have other policy priorities
4 – we have a disease fetish
5 – we are a boomer centric society

1 – misperceptions

  • canadian perceptions of reality are not reflective of actual reality
  • “do you knw what share of kids reach our school system vulnerable?” 82% of BCers underestimate how vulnerable we are
  • 86% thought we’re more generous to address these problems than we are

2 – lack of gender equality

  • we are at the bottom of OECD countries re family policy and gender equality
  • gender equality and family policy go together
  • we used to be #13, now #30
  • in 2001 we had a ministry for women’s quality, now we have no ministerial representation whatsoever
  • quebec is the only place with a good family policy because they want to breed more quebecois

3 – we have other priorities

  • 45% of our budget allocated to things medical
  • social service spending has contracted
  • health care is consuming an ever growing share of the budget, mostly because the budget overall has shrunk
  • social service spending used to be 18%, then 15% just before recession, now even less – 500 dollar less per person now

4 – we have a disease fetish

  • a mismatch between how we devote our public spending and how we spend on children
  • spending increases as we get older despite the fact that it would have the most impact if it was spent on children
  • this reflects that when someone gets sick we want to be there
  • we are lousy at prevention
  • but what do we owe ourselves in this society?
  • another example: we spend millions to save the lives of preterm babies but spend nothing on things like food for 5-year-olds
  • do we want to be dominated by disease or by health?

5 – we are baby boomer centric

  • this creates intergenerational tensions
  • politicians are baby boomers, they want to spend money on what concerns their age group
  • we can tackle children’s problems in a 5-year period (different from, say, environment, which takes much longer)
  • but baby boomers are aging so that’s what they pay attention to
  • we are also worried about pensions. but we are doing well with pensions and we’re not ranking well at all when it comes to children.

what do we need to do?

  • we need to think about health promotion differently. we need to address time, service and income poverty. improve parental leave system. why 40-45 hours a week for both parents? typical canadian works 300 more hours than the typical dutch person; netherlands and scandinavians do much more for children
  • need to increase welfare by 50%, and need to think about tax policies for the working poor
  • service poverty – need access to monthly parenting support and health check in. too spotty right now.
  • after kids are 18 months, needearly learning and care services. THAT is a major health promotion policy.

this is not inexpensive, a good 3 billion dollars a year. where to find the money?

1 – we HAVE found an extra bunch of money before, for increased health services
2 – if you’re patient, prevention early on has HUGE economic payback once they hit the labour market. we can predict the quality of our labour supply. with increased child health, we can increase economic growth by 25% – enough to pay down entire debt before these kids reach retirement

frozen pea friday: researching tamoxifen

a tamoxifen pilltoday is frozen pea friday, and as usual, i’m writing about cancer.

a friend of mine who just underwent a mastectomy and will most likely get the recommendation to take tamoxifen in the near future was asking some of her friends to do a bit of research for her (remember, sifting through tons of information can be a heavy burden for someone with cancer). so i decided to do that here. when i looked for information i tried to take into account that we are looking for information for someone who is not postmenopausal, which makes it a bit tricky because most material seems to concentrate on older women.

first of all, let’s remember this: research has shown that not all breast cancer web sites contain correct information. i think i have a relatively good nose for reliable information but let’s take all of this with a big grain of salt, shall we?

what is tamoxifen?
tamoxifen, or nolvadex®, is a drug that interferes with the activity of estrogen, a female hormone. (see this article at women to women for a discussion of the connection between estrogen and breast cancer). tamoxifen has been used for more than 30 years to treat breast cancer. the known, serious side effects of tamoxifen are blood clots, strokes, uterine cancer, and cataracts. other side effects include menopause-like symptoms. the results of the breast cancer prevention trial (BCPT) showed a reduction in diagnoses of invasive breast cancer among women who took tamoxifen for 5 years.

a good overview of tamoxifen is on a site i had never seen before, organized wisdom. it is a human-powered health search service. their guides and physician reviewers create WisdomCards to help people find the best health information, products and services on the web. i’m not sure what their background is (are they big pharma driven?) but i found their summary on tamoxifen helpful, particularly the indications and contra-indications of tamoxifen.

tamoxifen, goserelin, chemotherapy and ovarian ablation
ovarian ablation [i.e. removing the ovaries, because of their hormone production] with goserelin is equivalent to CMF [cyclophosphamide, methotrexate fluorouracil – a chemotherapy treatment] without tamoxifen, and goserelin plus tamoxifen is more effective than CMF without tamoxifen. if one has a premenopausal patient with ER-positive, lymph node-positive breast cancer, goserelin plus tamoxifen is a good alternative to treating her with intravenous CMF without tamoxifen while achieving the same results.

what happens after the first five years of tamoxifen?

the received wisdom seems to be that tamoxifen is fine for preventing the recurrence of breast cancer for the first five years. what happens after that seems to be a a thing of debate.

1. take letrozole
currently, women whose tumors were fueled by the hormone estrogen can take the drug tamoxifen after undergoing surgery, radiation and chemotherapy to reduce their risk of a recurrence. but tamoxifen only helps for five years. after that, it may be dangerous.

a recent study in conducted in canada reveals that breast cancer patients treated with the drug femara® (letrozole) several years after completing treatment with tamoxifen (nolvadex®) have a reduced risk of a recurrence. these findings were published in the journal of clinical oncology.

supposedly, letrozole is very similar to anmidex, a drug that my twitter friend susan reynolds – the original princess of the frozen pea – is planning on taking after her 5-year run with tamoxifen.

how similar different drugs really are is up for question, as this article in the obstetrical and gynecological survey shows. i certainly remember from my work with people with chronic pain that the minutest changes in medication can have a significant effect.

2. stick with tamoxifen
7,154 women at high risk for breast cancer were randomized to 5 years of daily tamoxifen or placebo. (such a placebo-controlled trial couldn’t be undertaken today for ethical reasons because tamoxifen is now approved as a breast cancer chemopreventive agent).

the primary end point was the incidence of breast cancer, which at 10 years was 3.9% in the tamoxifen arm and 5.5% with placebo, for a highly significant 29% relative risk reduction. this result included a 38% reduction in ductal carcinoma in situ and a 27% decrease in invasive breast cancers.

there were 87 estrogen receptor-positive invasive breast cancers in the tamoxifen group and 129 in controls, for a 34% relative risk reduction. tamoxifen had no effect on the rate of estrogen receptor-negative tumors.

tamoxifen prevented tumors of all grades. importantly, the risk reduction was as great in year 10 as in year 1.

drawbacks of tamoxifen and possible alternatives

long experience with tamoxifen, has shown that it does have drawbacks. the drug is considered to exhibit mixed effects, being antiestrogenic in breast tissue but estrogenic in the endometrium, bones, and liver; and a significant increase in the incidence of endometrial cancer has been consistently seen with its use. tamoxifen is also associated with a significant increase in thromboembolic events, with pulmonary embolism being a particular concern. the related but more selective estrogen receptor modulator (SERM) raloxifene, as well as other SERMs such as toremifene, have also been undergoing evaluation as potentially safer alternatives to tamoxifen.

a relatively recent article (october 2006) at the fabulous resource breast cancer research site states that

placebo controlled trials in over 25,000 women showed that tamoxifen reduced breast cancer risk by about 40% and osteoporotic fracture risk by about 32%. similarly placebo controlled trials in nearly 18,000 women showed that raloxifene reduced breast cancer risk by 44-72% and osteoporotic fractures risk by 30-50%. a direct comparison of tamoxifen with raloxifene showed similar risk reduction for breast cancer and osteoporotic fractures with less toxicity for raloxifene.

other alternatives come from complimentary medicine. that’s a whole difference bowl of wax. perhaps we’ll post about that some other friday.

(image by linda bowman)

8 points on emergency preparedness for winter depression

the days are getting shorter. it’s raining. cold creeps in.

for some people, yet another bout of winter depression, or SAD (seasonal affective disorder) is just around the corner.

chronic and recurring conditions – and for many people, depression falls under those categories – are manageable. we can learn from them: each time they happen, we can take note so that we can improve next time around.

it’s a little like emergency response. think about how hard places like japan used to be hit by earthquakes. yet today tokyo, for example, has a whole system of confidently building skyscrapers. it stands on shaky ground, just like people with mental illness often feel they stand on shaky ground, but with patience, experience and ingenuity, that didn’t prevent it from becoming one of the most vibrant, successful cities.

here are some ways to prepare for the depression emergency that my clients and i have found useful:

  1. make your mental health a priority. take an hour or so to think about what that means for you. if mental health is a big issue for you, you might have to make it priority number one – before work, before relationships. definitely before TV, computer use and whatever other “escape” activities you engage in.
  2. devise a ruse to get yourself outdoors for at least 30 minutes each day, during the daytime.
  3. don’t draw the curtains! drawing the curtains, together with the next point, not answering the phone, is perhaps one of the most typical activities of people in depression.it seems like a small thing but doing this helps in many ways. it keeps you connected with the world and with light, on a very physical level. when it feels like you don’t have the emotional connection, at least you can have the physical connection.
  4. answer your phone, for the reasons mentioned in 3. and 5.
  5. make sure to interact with people on a daily basis. talk and listen. the isolation that creeps in around depression is similar to the false protection our muscles try to give us after an injury. when you’re right in the depression, a lot of the things people say will irritate and bore you.however, if you can tell yourself before it gets too bad that staying connected will ultimately help you, you may not even fall that low, and you might just be able to stand the discomfort of these seemingly irritating interactions.
  6. make sure you have a trusted person from whom you can expect the understanding that you might not be able to get from others at this time. a friend, a spiritual director, a counsellor, a doctor.
  7. if you have a trusted mental health professional, make sure you stay in touch with her or him and do your best to follow any plans you’ve laid out together. this is probably not the time to experiment.
  8. most importantly, listen to yourself. what does your body need? what does your soul need? again, if you get yourself to train your inner ear now, you’ll have an easier time picking up on the messages should the numbness of depression set in more fully.

what are some ways that help you prepare for and live through the emergency of depression?