I did my placement in St. Paul’s Hospital, Vancouver; a hospital which specialises in treating patients with mental health and substance abuse problems. Although I was in the Haematology team, it was striking the number of our patients who were also dealing with an addiction or mental health problem. Health problems don’t stand on their own: a patient who contracts HIV from intravenous drug use can present as a haematology patient with an HIV-related lymphoma.
St. Paul’s has an Addiction team which sees roughly 23% of inpatients who are struggling with a diverse range of problems. The Emergency Department (ED) sees the highest number of people with mental health and addiction problems of any ED in the province, and a newly opened HUB next to the emergency department contains two specially equipped units to care for people with mental health and substance abuse problems before they are transitioned back to the community. The HUB also includes a Rapid Access Addictions Clinic (RAAC) where specialised teams treat people with a wide range of addiction problems.
These services have been developed in response to the opioid crisis – a public health emergency that was declared in 2016 in British Columbia (BC). Fentanyl is the drug behind soaring overdose figures. The synthetic opioid is 50-100 times more potent than morphine, and 2mg constitutes a lethal overdose. The fentanyl associated with the opioid crisis is produced in clandestine laboratories in China and is then mixed with a range of illicit street drugs to increase the high and expand profits. It is also sold alone as a cheaper alternative to heroin. Given the potency of fentanyl and the lack of quality control, unwitting users are overdosing on lethal quantities of fentanyl on a regular basis. Fentanyl or its analogues were detected in 84% of illicit overdose-related deaths in 2017. The 2018 projected figure is similar at 83%, but this is a recent crisis – the figure in 2012 was just 4%. Overdose fatalities are now the leading cause of unnatural deaths in BC. The crisis is costly to the health service, and St. Paul’s seems to be at the forefront of attempting to offer support. However, there is still a long way to go before long-term solutions are implemented.
(HUB at St. Paul’s Hospital, no date; Department, 2017; Coroners Service, 2018)
Epidemiology
With a total area of nearly 1 billion square kilometres, Canada is the second largest country in the world after Russia. Canada is also one of the least densely populated countries. Over 90% of its population of approximately 35 million reside within 100 miles of the US border. Canada is divided into ten provinces and three northern territories. The territories account for 40% of Canada’s land mass, but are sparsely populated with just 3% of Canada’s population (Government of Canada, no date; Central Intelligence Agency, 2017).
Canada first became a country on 1st July 1867, as a self-governing Dominion in the British Empire. With a starting population of about 3.5 million, Canada has grown into a population of over 35 million today and continues to grow steadily. Population growth has slowed in recent decades, as the number of deaths gradually approaches the number of births. Today, the main contributor to its 0.74% growth rate is migration rather than natural increase. With a median age of 42 years, Canada has an ageing population. The proportion of over-65s has been steadily increasing over the past 50 years due to a reducing birth rate and increasing life expectancy. Canada’s life expectancy at birth of 81.9 years now places it at 19th in the world. The pace of ageing is more rapid in Canada than in other similarly developed countries due to Canada having a relatively larger baby boom between 1946 and 1965, resulting in a bulge in Canada’s population pyramids as the baby-boomers age (see figure 1) (Government of Canada, 2015; Demography Division, 2016).
Figure 1 – Age pyramids of the population, Canada, 1961, 2011 and 2061. Source: Statistics Canada. 2010. Population Projections for Canada, Provinces and Territories, 2009 to 2036, catalogue no. 91-520, medium-growth scenario (M1)
Malignant disease is the leading cause of death in Canada, accounting for 30% of all causes of death. Heart disease and stroke follow, accounting for a further 25% of deaths. The top ten leading causes of death (see table 1) account for 75% of deaths in Canada (StatCan, 2013).
Table 1 – Top ten leading causes of death in Canada. Source: Statistics Canada, CANSIM table 102-0561.
Healthcare system
Canada has a publicly funded ‘single-payer’ healthcare system called Medicare. A single-payer system is one in which a single entity (the government) finances healthcare, thus ensuring universal insurance coverage for all residents. In Canada, instead of the Federal Government providing a single health insurance plan, each province or territory provides health insurance to cover all residents. These local governments are responsible for the management, organisation and delivery of healthcare. Unlike in the UK, Canadian government contracts to private providers of healthcare services. These services must meet the criteria and conditions set down in the Canada Health Act to secure provincial funding. The Federal Government provides long term predictable healthcare funding to local government in line with the principles of the Act via the Canada Health Transfer payments – these are the largest major federal transfers. The primary objective of the Act is to “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” Medically necessary services provided by hospitals and physicians must be fully covered by health insurance plans. Access to services must be based on medical need and not the ability to pay. Single-payer systems decide which services they can afford to cover, and in Canada this generally excludes vision care, dental care, most prescription drugs, ambulance services and home care. Canadians pay out-of-pocket for these services and two-thirds of Canadians purchase a separate, private insurance policy to cover these costs. Local plans will provide supplemental coverage to certain groups in need of these services such as seniors and children. Direct health care services are also provided to First Nations people living on reserves, Inuit, members of the Canadian forces, prison inmates and refugees. (Department of Finance, no date; Parliament of Canada, 2012; Sarah Kliff, 2015; Government of Canada, 2016; Adamczyk, 2017)
Ethnicity, Culture & Religion
Canada is an ethnically diverse country. Over 1 in 5 Canadians are foreign-born. This group of approximately 7.5 million people are increasingly ethnoculturally diverse, with Asia now being the most frequent place of birth for foreign-born Canadians. According to the 2011 National Household Survey, almost 20% of Canadians identify as belonging to a minority group, the largest of these being South Asians (1.6 million) and Chinese (1.3 million). About two-thirds of Canadians declare their religion as Christion, with Catholics making up the largest Christion group. Nearly a quarter of Canadians declare no religious affiliation (see table 2).
Table 2 – Distribution of population in private households by religion, Canada 2011. Source: Statistics Canada, National Household Survey 2011.
In 2011, 4.3% of Canadians (1.4 million) had an Aboriginal identity. Aboriginal identity includes persons who reported being First Nations (60.8%), Métis (32.3%) or Inuit (4.2%). First Nations are the original inhabitants of Canada and include 630 distinct communities speaking roughly 60 languages. Métis means ‘mixed’ in French, and the Métis peoples have a mixed First Nations and European heritage, being descendants primarily of 18th century fur traders and First Nations in the area known as the Métis Homeland. (Statistics Canada, 2011; National Collaborating Centre for Aboriginal Health (NCCAH), 2013; Demography Division, 2016)
Although the health of the Aboriginals has been improving in recent years, these groups continue to experience considerably lower health outcomes than non-Aboriginal Canadians. The reason for this lies in the complex effects of historic colonialism and the resulting marginalisation of Aboriginals. The disparity in health is rooted in wider social determinants of health, where a persistent gap remains between Aboriginals and non-Aboriginals. For example, Aboriginals have significantly lower numbers obtaining high-school diplomas, have lower incomes and higher rates of unemployment compared to non-Aboriginals. Aboriginals suffer significantly higher rates of major health problems such as TB, HIV and type 2 diabetes. There are also higher rates of domestic violence against women, and higher rates of suicide (National Collaborating Centre for Aboriginal Health (NCCAH), 2013).
Aboriginal approaches to health are holistic and consider treating sickness as an aspect of ‘healing’. Seven routes to healing are commonly mentioned: Talking, Crying, Laughing, Dancing, Sweating, Yawning, and Yelling. Traditional healers focus on well-being as a balance of four aspects of wellness: physical (West), emotional (South), mental (North) and spiritual (East); which are sometimes represented on a medicine wheel (see figure 2) (University of Ottawa, no date; National Collaborating Centre for Aboriginal Health (NCCAH), 2013).
Personal Reflections
Medical students are treated very differently in Canada. Final year medical students work at the level of FY1s in the UK, and are fully part of the team, which also means they are expected to work long hours. Hours of work are fairly unregulated with no limits on weekly hours or shift length (24 hour shifts are commonplace), and levels of burnout among residents seem high. This came as quite a shock to me, and I soon found myself staying into the evening to make sure that my responsibilities for the day were completed, such as dictating consultations with patients. This did mean I learnt a huge amount, especially with regards to clerking and working up haematological presenting problems. As a result, my anxiety about starting work back in the UK is greatly reduced. A dominant feeling as I start my first job will be gratitude: NHS employees love a good moan, but the reality for junior doctors with the European Working Time Directive is that they have a far better deal than their Canadian counterparts, who seem to forego any idea of a work-life balance by choosing to study medicine.
Having embarked on my elective as a solo traveller, plunging into such a demanding elective alone could have caused me a great deal of stress. Luckily, I quickly found all the support I could need amongst some distant relatives who lived in Vancouver. They were delighted to learn I was visiting, and through their hospitality I became acquainted with the Jewish community of Vancouver through regular invitations to attend Shabbat dinners. Being so far from home, the warmth and familiarity of the Shabbat dinner routine relieved a lot of the stress from the working week. By the end of my stay we had become very close, and the lively dinnertime conversations were some of my best elective memories. It has reminded me that the cornerstones of Judaism change little even over thousands of miles – warmth, good food and lively conversations shared by loving Jewish families the world over mean that foreigners can always find a familiar home in an unfamiliar land.
This elective was a wonderful adventure for me and I am very grateful to the Jewish Medical Association for the bursary which helped me to afford this unforgettable experience.
Jen Young
UCL
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