Am I my bicuspid's keeper? Canadian opinions on publicly financed dental care

In the spirit of the National Medicare Week that wasn't, it seems fitting that an article should appear discussing the results of a survey of Canadians' opinions on publicly financed dental care (1). Not only do they overwhelmingly support universal health care coverage, the vast majority of Canadians also believe dental care should be a social right, are generous as to who should have this right, and expect the government to find the necessary funds to pay for it. In fact, according to this study, which has just been published in the Canadian Journal of Public Health, 83% of Canadians think dental care should be part of Medicare, and two thirds of those think "everyone" should be included.

Contrary to this energetic expression of the people's will, the stingily funded dental care that the less fortunate are able to get in hospitals has been declining steadily in Canada from roughly 20% in the early 1980s to the current 6% of total dental expenditures. As the authors state, these cuts are a mistake, especially with mounting evidence linking oral disease to diabetes, pneumonia, cardiovascular disease and adverse pregnancy outcomes.

Oral ill health is a significant burden to the impoverished, who suffer most of the disease and experience most of the barriers to access (2,3). And the Street Health Report 2007 has found that forty per cent of the homeless are driven to extraction with dental problems. Lack of access to dental care services is an important detriment to the oral and general health of many Canadians. Not that we are an isolated case. A Surgeon General's report, Oral Health in America, called the situation in the United States a "silent epidemic" (4). It seems a simple logical step to an acknowledgement that dental care should be fully integrated into a rational health care system.

The Atlas-Shrugged types will argue vociferously that it is wrong to use taxpayers' money to provide a safety net for gingivitic ne'er-do-wells who think floss is pink and consumed in great quantities at county fairs. Pundits from corporate-funded think tanks like the Fraser Institute and Manitoba’s Frontier Centre for Public Policy will gnash their teeth in horror at such a flagrant concession to human weakness. Obviously they've never had a twanging bicuspid or a suppurating abscess they couldn't spend their way out of. One need only consider the annual expenditure by the public purse on spavined hearts and riddled livers to see that this kind of supercilious cost-accounting is all that's left of decency after the nerve has been extracted.


I pray thee, peace. I will be flesh and blood;
For there was never yet philosopher
That could endure the toothache patiently,
However they have writ the style of gods
And made a push at chance and sufferance.

Shakespeare, Much Ado About Nothing 5.1


References

1. Quiñonez CR, Locker D. Canadian opinions on publicly financed dental care. Can J Public Health. 2007 Nov-Dec;98(6):495-9.

2. Leake JL. Access and care: reports from Canadian dental education and care agencies. J Can Dent Assoc. 2005 Jul-Aug;71(7):469-71.

3. Main P, Leake J, Burman D. Oral health care in Canada--a view from the trenches. J Can Dent Assoc. 2006 May;72(4):319.

4. United States Surgeon General. Oral health in America: a report of the Surgeon General. Washington, DC: U.S. Department of Health & Human Services; 2000.

What happened to National Medicare Week?

This is National Medicare Week in Canada (November 18-24), but you would have to look very hard to find out much about the event. Ever true to their political convictions, the Canadian Health Coalition and the Canadian Centre for Policy Alternatives are celebrating the week with the publication of a new book entitled Medicare: Facts, Myths, Problems, Promise. (Duly added to my library acquisitions list for when I have a budget again.) No one else seems to have taken the trouble to mark the occasion, least of all the federal government that is charged with watching over our health. Except for the book launch, this so-called celebration week is eliciting scarcely a squeak from Canadians.

The new medicare book, of which only the preface can be previewed online, should be a worthy compilation of brave rhetoric from the usual stalwarts. It is based on contributions to a conference held last May in Regina: S.O.S. Medicare 2: Looking Forward. Among the many contributors are some imposing Canadian health care icons: Roy Romanow, Monique Begin, Tom Kent, Allan Blakeney, Stephen Lewis and Robert McMurtry. Summing up the book's raison d'être, Shirley Douglas comments: “I encourage Prime Minister Harper and CMA president Dr. Brian Day to read this book and commit to working together to fix problems rather than using the problems as an excuse to go back to the days before Medicare — when doctors could charge whatever they wanted and care was rationed on the basis of ability to pay not need.” (Douglas is the daughter of former Saskatchewan premier Tommy Douglas, who introduced universal public medicare in 1961.)

The blurb on the CCPA website does its preachy best to garner interest:

For anyone who cares about the future of Medicare, this book offers a unique source of reliable, independent information and analysis. At a time when ideologues and advocates of privatization capture much of the attention of the media and politicians, this collection is an invaluable source of information and ideas. Celebrate National Medicare Week by picking up a copy of this book today.

Frankly, the publicity could have been done better. Such drearily predictable boilerplate simply does not impress those for whom it is intended: "For anyone who cares about ... At a time when ... an invaluable source." This all may be true, but now that bringing eyes to progressive print is harder than selling sun block in Iqaluit, I am not hopeful that this latest defence of the just and the true will have much success.

Where is the web presence? I am a passionate supporter of universal health care, but I nearly missed hearing about National Medicare Week. It's sliding by with almost as little notice as the demise of the Canadian Health Network. A quick search in Google brings the abovementioned book launch to light, but precious little else, and much of it dated. Where are the media? We have been amply informed about the deaths of two more Canadian soldiers in Afghanistan, lead paint in children's umbrellas, and the fallout from the Vancouver Airport taser nightmare; but a week devoted to the celebration of medicare seems to have been overlooked across the country. There is no mention of it in the Mop and Pail, supposedly our "national newspaper," nor have there been any of the usual supportive statements from sympathetic organizations. Even the Canadian Health Coalition's own website is curiously reticent about this week devoted to medicare, providing only a link to a PDF of the book launch blurb — no separate web page, not even the week's dates on the calendar — in short, an abysmal lack of publicity.

Contrast this with last year. To mark the 2006 National Medicare Week the Canadian Nurses Association sent an open letter to the Minister of Health, Tony Clement, in which medicare receives warm praise: "Nurses are proud to be part of a system that assures Canadians' access to health services." (Unfortunately, CNA did not choose to send another one this year. Perhaps frustration has set in. Perhaps they found out the minister doesn't care.)

In a news release marking NMW in 2006 the College & Association Of Registered Nurses of Alberta positively yodelled: “The excellence of Canada’s health system is recognized internationally and registered nurses are proud of the vital contribution they make within it.” Perhaps such semi-socialist bedizenment was too much for Alberta, because that seems to have been the last of the College's news releases, period. Its website shows no further posts for 2007.

The Catholic Health Association of Canada and the Canadian Union of Public Employees also lent their voices — with their respective emphases — to the chorus, praising medicare as "a reflection of Canadians’ desire to build a caring and compassionate society" (CHAC) and "a social right in Canada, one that speaks to our best values of fairness, pragmatism, inclusion and hope" (CUPE).

Where are those voices now? They had better start making themselves heard, because we can be sure that in Ottawa something's cooking.

Breaking the silence on cancer and sexuality

An important new book by a Winnipeg author

Anne Katz is the sexuality counsellor at CancerCare Manitoba in Winnipeg and an internationally recognized expert in the field of illness and sexuality. She is a Registered Nurse and Adjunct Professor at the University of Manitoba.

Dr. Katz has recently published a textbook that sums up the work she has been doing for five years: Breaking the silence on cancer and sexuality: a handbook for healthcare providers. A review that appeared in Home Healthcare Nurse (Volume 25(8), September 2007, p 520) calls this book "long overdue." Dr. Katz's goal is to break the silence on a topic that is all too frequently avoided, ignored, neglected, deflected, postponed, botched, bungled, or binned.

Clinicians often have trouble broaching the subject of sexuality with patients. Dr. Katz intends to change that. Her book seeks to broaden health care providers' knowledge related to sexual changes and cancer. Through a discussion of a range of cancers and how they affect the sexual lives and feelings of patients and their partners, she explains how to identify problems, initiate a discussion, share information, make appropriate referrals, and provide a well-rounded counselling experience.

Clearly written and authoritative (Dr. Katz's research is extensive, and she is the current editor of Nursing for Women's Health), this book is a valuable bench tool for clinicians. With its comprehensive strategies for addressing the most intimate issues of sexuality and cancer, it is also poignant and wise.

Highly recommended for all health sciences libraries.

---

Have a look at Dr. Katz's website: www.drannekatz.com

Katz, Anne. Breaking the silence on cancer and sexuality: a handbook for healthcare providers. Philadelphia: Oncology Nursing Society; 2007.

The Street Health Report 2007

Fifteen years ago a report on Toronto's homeless was published by Street Health, a community-based health care organization working with homeless and under-housed people in the city's downtown area. The first of its kind in North America, the 1992 report's gruesome statistics revealed a pattern of increased health risk, poor access to health care, exposure to violence, and general despair. The intervening years have been nothing short of brutal for homeless people, although the means have existed to improve their situation. While the exact number of street dwellers has been difficult to estimate, the current estimate is that about 6,500 people slept in shelters last year on any given night, a tripling of the homeless population since the early 1990s.

Released in September, Street Health Report 2007 presents the latest findings on the state of homeless adults in Toronto. The study was conducted in the winter of 2006/2007. There are few surprises. The news is terrible:

Overall, homeless people in Toronto have much poorer health than the general population. Homeless people in our survey carry an alarmingly higher burden of many serious physical and mental health conditions. Three quarters suffer from at least one chronic or ongoing physical health condition. In the past year, more than half had experienced serious depression and one in ten had attempted suicide.

The health of homeless people in Toronto has deteriorated in the past 15 years. Many serious physical health problems have become more common, and new illnesses have emerged that disproportionately affect homeless people. The most important factors impacting the health of homeless people are the result of social policy decisions that have been made by our governments in the past 15 years, particularly the cuts to social assistance and the lack of investment in new affordable social housing.

Homelessness is a devastating and growing problem in Toronto. There is an urgent need to take action to:

• Address the poverty and inequality that underlies homelessness

• Improve access to affordable and appropriate housing

• Improve immediate living conditions for homeless people

• Improve access to health care and support for homeless people

Quoted in a Toronto Star article, Kathy Hardill, outreach nurse and an author of the original study, says the decreased access to health care is one of the study's most shocking findings — especially given the prevalence of disease and disability among Toronto's homeless. Diabetes has increased threefold since 1992; 43 per cent have arthritis, up from 29.8 per cent; and 23 per cent have hepatitis C. In a brief news article, the CMAJ (6 Nov 2007) comments: "It paints a grim picture."

The Street Health Report concludes with an action plan consisting of realistic solutions to immediately improve the health of homeless people and to ultimately end homelessness. Among its 13 recommendations:

• Increase social assistance rates;
• Raise the minimum wage to $10 per hour immediately;
• Increase the availability of affordable housing as soon as possible.
  

The Street Health Report 2007 is available in PDF format from the Street Health website: http://www.streethealth.ca

Canadian Health Network going under

Just when I thought that the Canadian Health Network website was getting better and I was actually starting to use it for consumer health questions, I now hear that the Conservative government is shutting it down in a few months. The program will no longer be funded at the end of March 2008. The surprising news came in an Ontario Health Promotion E-Bulletin, published 8 November 2007.

For those not familiar with the CHN, here are some basics from that depressing piece of news:

The Canadian Health Network is a national, bilingual web-portal that aims to help Canadians find the information they're looking for on how to stay healthy and prevent disease. The CHN does this through a unique and extensive collaboration between the Public Health Agency of Canada, 26 major health organizations, universities, hospitals, and libraries. CHN offers links to more than 20,000 English and French Canadian web-based, quality-assessed resources; in-depth information on 25 key health topics and population groups; and a fortnightly e-newsletter. It is used currently by approximately 381,000 people per month. Usage has grown steadily since it was created in 1999, and especially rapidly in 2007, increasing by 70 per cent over 2006. Approximately 40 per cent of CHN visitors are health professionals who use CHN resources both personally and with clients; Francophones visit CHN in higher proportions than comparable sites; and 94 per cent of users recommend the site to others. Eighty per cent of the 15 million Canadians on-line use the Internet to seek health information. Add to this, the fact that CHN costs are decreasing, making the portal more cost efficient over-time. Why then would government choose to cut this program exactly when the Federal Government is experiencing a surplus?

My initial angry reaction involved some expletive-laced complaint about Prime Minister Harper's needing another tank or two for Afghanistan. But for a government in possession of a budget surplus this can't be the answer, despite the massive corporate tax cut (accompanied by a more chastely administered reduction of personal taxes) announced recently by the Minister of Finance. As the E-Bulletin asks, why are they doing this?

It is difficult to avoid interpreting the planned closure of CHN as yet another assault on the health commons by a government ideologically committed to dismantling the Canadian health care system by privatizing off bits and pieces here and there until there is nothing left but the ring of the cash register. Corporations stand to reap billions in profits from a two-tier system, and part of their "vision" is to replace publicly funded resources like the untrendy CHN with lucrative, advertisement-driven, Health 2.0-style consumer and social networking sites with queasily semi-religious names like Daily Strength, Healia, WeGoHealth, and Inspire. I have posted on my misgivings about Health 2.0 already, and that particular meme's appropriation by the new seigneurs, the foxes who have such a sincere interest in prolonging the lives of the poultry.

I'm finding it hard to imagine how the government will justify shutting down a major program like the CHN. The need for such a service was clearly expressed in the Blueprint and Tactical Plan for a Pan-Canadian Health Infostructure, published on the Health Canada website in December 2000. This report stressed the importance of public sector involvement in providing health information to the public on the web. Among the gaps identified in the developing "Infostructure" [sic] was the limited presence of the public sector in this effort. The CHN is identified as "the most notable effort in Canada" along these lines.

The Gaps
Health Information for the Public - The public sector has a limited presence in providing health information to the public in an electronic form — he most notable effort in Canada is the Canadian Health Network. The private sector on the other hand, especially US firms, have entered this market with highly capitalized ventures providing dynamic, graphic information content. The criticism leveled at these private sector initiatives is whether their health information can be trusted, especially if it is "sponsored" content. Neither the public or private sectors have integrated their electronic health information provided to citizens with other health services. In addition there is still a significant lack of information available on certain subjects or topics, for population group (e.g. Aboriginal populations) and in French.

Information for Health Service Providers - The public sector has a limited presence in providing electronic information to health providers like physicians, nurses and pharmacists. In addition, many health providers have limited ability to use computers and information technology, and thus are not strong proponents of their use in their practice. While information technology offers new opportunities to providers for improving their practices and service delivery through increased standardization, for example, the necessary support for change-management is often lacking. As a result, information technology use is not well integrated with practice. For health providers electronic information is not as extensive as paper — there is still missing information, by subject, by population group and for specific uses. There are no trusted health information standards for providers — either for content or by source.

For both the public and for health professionals, the official stance of the Canadian government has been that the public sector has an important role to play. Even back in 2000, at the time of the dot-com bust, it was clear that big business was poised to make huge profits in web-based health information:

The major players in this market are highly capitalized and are rapidly extending the provision of health information to include sophisticated health business transactions using the Internet and web-based technologies. Sophisticated health "portals" that provide fully integrated "one-stop" encounters for health professionals as well as the public are garnering a lot of attention. Consequently, it will be vital to engage the private sector in the development of the Infostructure.

The public sector was urged to provide leadership in responding to health information and technology needs. According to the Blueprint, government's part should be "to ensure that the information and the technology is accessible, relevant, user-friendly, supports selfcare/telecare, can be trusted and is supported by appropriate standards." The CHN's role in this was seen as fundamental to the Blueprint's authors, and they even made provisions for the participation of private sector vendors:

Canadian Health Network - the objective would be to significantly enhance the Canadian Health Network to become the trusted health information portal for the Canadian public, in both official languages. The Canadian Health Network today is primarily a directory service. It needs to evolve to a portal with a comprehensive set of services. New subject areas would be created, including dynamic news and information feeds, real-time discussion groups, live chats and expert presentations — most likely in partnership with an existing private sector vendor using a "private labeling approach." There would be an emphasis on information of relevance to Canada's Aboriginal peoples. An innovative approach could be for the CHN to co-brand with other health organizations across Canada, thereby including information on local services and how they can be accessed. Finally, the portal would link to provincial selfcare/telecare services and the physician portal.

The CHN has consistently ranked among the top five of Canadian consumer health sites. A recent article by Valeria Gallo Stampino in the JCHLA observes that the CHN has been a valuable means of finding consumer health resources in both English and French, as well as in foreign languages — although it could have done a better job. Canadian health librarians still do not have a central repository for multilingual health information resources for the public, and the impending demise of the CHN will not do anything to shorten the wait.

A 2005 Government On-Line Public Report from a pre-Conservative Health Canada describes the CHN as "a key tool for horizontal integration, collaboration and presentation of information." It mentions the results of an online survey, conducted in the spring of 2004, which revealed that "approximately 95% of users were either satisfied or very satisfied with the quality of information provided by the CHN." But that was two years ago. Apparently the government now has access to more useful information for its purposes.

The Conservatives will appeal to the concerns of some unspecified sectors that funding spent on a consumer health web resource may be better spent on "other initiatives" that would more directly influence health care quality. There will be the usual vague and patronizing assurances that the best interests of Canadians are being served by the redirection of funds to as yet unspecified areas. At the moment there is no official announcement of the demise of the Canadian Health Network on the Government of Canada website. It's unspecified as yet.

Hospital librarians and blogging: conversation or ventriloquism?

Over the past few days I have been reflecting on the recent exchange about hospital librarian participation in the great blog rolling contest. It all started with Melissa Rethlefsen's analysis of the results of the MLA’s social networking survey, according to which hospital librarians are not thronging in sufficient numbers to the blog world, nor are we sufficiently contrite, it seems, for this imprudent lack of interest.

It is generally expected that we should always believe what we read in surveys, as this makes them more interesting. What hay is there to be made from the numbers? Are we a bunch of sad sacks and schlemiels stuck in the Edsel era of librarianship, faded as the cover of a Harlequin romance? Are our work lives a permanent code blue? Are we on the losing side in the class struggle? Has the mirror crack'd from side to side?

Why are we not out with the web and floating wide, like our academic cousins? As a hospital librarian and an academic, I would like to bring my own perspective to the matter. I believe I can speak out of both sides of my mouth ... No, let's try that again. I believe I can save both my faces ... Wait a moment. That doesn't sound right either. Anyway, I'll try to speak blog from my own experience.

We don't want to go back to tomorrow, we want to go forward. (J. Danforth Quayle)

A disappointed David Rothman asked the question What do hospital librarians have against blogs? (24 Oct 2007). The Krafty Librarian explained the dearth of colleagues in the biblioblogosphere in terms of (a) time constraints, (b) insolent IT departments, and (c) the related implications for suicidality. With his usual incisiveness T. Scott summarized the issue in his comment on that post: "Hospital librarians don't feel that they have as much flexibility over their time, and they don't have as much control over the elements of IT that matter the most to them. . . . Maybe the most important difference is that many hospital librarians don't have the daily support of creative colleagues to help spur their own creativity."

Dean Giustini, in his Blog Malaise post (1 Nov 2007), wonders why there are so few bloggers emerging from the ranks of health librarians, lamenting: "We've had maybe a handful of new medical librarian bloggers in the last calendar year" (yours truly included). Pointing to a lack of scholarly literature about blogging and reflective practice in our profession, he presses a number of hot buttons:

It could be that many librarian bloggers are tired of blogging — and blogged right out. Some have abandoned the practice of daily blogging almost completely. Perhaps it didn't make sense to them to engage in all the chit-chat, or perhaps they didn't get the point or the hang of it in the first place. Other bloggers are not engaged enough in critical reflection of their blogging. . . . Blogging loses its purity and purpose when we focus on remix and pointing readers to existing content elsewhere; for heaven's sake, make some observations of the content you point to!

I can hardly disagree with this, although I have reservations about the reference to blogging's "purity and purpose." (I can see the Chinese government handily making use of that expression.) I would maintain that its very lack of purity and purpose is what made blogging catch on in the first place. All the same, what we have here is a plea for more and better blogs in health sciences librarianship. I can support that.

Blogs are swiftly becoming as important to librarians professionally as the published literature, but they require some effort and the occasional bedewed brow. Blogging should come from a genuine interest in and desire to contribute; and a blog should be something more than an exchange of twaddle and a clickathon of easy links, accompanied by an expletive of glee or otherwise. "Blogging should be an extension of our critical-reflective practices," says Dean Giustini. Right on. I would add, to paraphrase Gore Vidal: Blogging is knowing who you are, what you want to say, and not giving a damn.

Ratcatcher entered the debate a few days later, disposing nicely of the "I'm-too-busy" excuse. This invidious, passive aggressive behaviour in the workplace is a defensive adaptation that points directly to an aberration in the evolution of the human brain — a malformation somewhere in the ventromedial prefrontal cortex, or possibly an undigested bit of beef, a blot of mustard, a crumb of cheese, or a fragment of an underdone potato. The pessimism of some is countered with a reminder that there has actually been an upsurge in medical librarian blogging, something Ratcatcher finds really exciting. I do too.

C'est si difficile!

Having reviewed the thoughtful discussion of my colleagues, I guess it's time to add an idea or two of my own. It's so hard to know where to start. As I began to gather my own scattered thoughts about the web reticence of hospital librarians, I was distracted by some incoming RSS feeds about contamination in the work place. Is it something in the air that makes setting up a Wordpress or Blogger account look so frightfully complicated? Are hospital librarians inhaling something else along with their scented tea? I considered the recent research on ultrafine particles from office printers and Dr. Michelle Alfa's study of the horrifying swarms of C. difficile found to be colonizing most hospital toilets (the latter research project worryingly performed in my very building.) Then I thought about Theodoric of York, who would say we're not blogging enough because we have a toad or possibly a small dwarf living in our stomachs. Not convinced, you say? I didn't find anything in UpToDate either. So I wiped my hands of it all and moved on.

What a terrible thing to have lost one's mind. Or not to have a mind at all. How true that is. (J. Danforth Quayle)

Could the ultimate explanation be found in another malaise: the sense of futility so well expressed in Dean Giustini's post? I thought back to something I read more than twenty years ago in The Listener (March 20, 1986):

The common belief that librarianship is a career is entirely mistaken. It is, like chartered accountancy, a disease which infects its victims with a morbid sense of the futility of life. In the case of accountants, the cause is obvious — it stems from being privy to the pathetic devices by which clients hope to evade the attentions of the Inland Revenue. In the case of librarians, the malaise is more mysterious in origin, but it must have something to do with working in institutions which are, in effect, cold stores for human thought. Staring at serried ranks of unread, or rarely read, books, it must be hard not to be overcome by a feeling that human life is ultimately a waste of time.

Is librarianship bad for our mental health? I'm sure that no one becomes a librarian in the conviction that life is futile, although, like accountants, we too are privy to the pathetic devices by which human beings seek to evade the inevitable: in our case, due dates, accumulating fines, and — ultimate indignity — the bill for a lost book. Consider the tedium of health libraries. All those gruesomely illustrated texts shelved in the W's, all those back issues of Gut. It is exquisite ennui, but sanity requires us to remain mute. That ours may not be the world's most exciting profession must go unmentioned, like rope in a hanged man's home. Yet how profound is our fatigue as we bang on about EBM resources to a roomful of ABH (anywhere but here) medical residents. How bored we are shuffling our 13,000 del.icio.us tags or enduring numerous PubMed arrhythmias in our literature search on Pneumonoultramicroscopicsilicovolcanoconiosis. How stale the dainties we offer at our open houses and the pointless circumlocutions of the latest strategic plan. Then, just when we have managed to free up a few hours to experiment with Utterz or hooeey, we must hurry off to a dreaded meeting, where minutes are taken and hours wasted. In these ways we have all felt deeply a morbid sense of the fatuity of things.

Stuck in a dank basement steps away from the morgue's cadaver fumes, hospital librarians can be particularly susceptible to this affliction. Why blog, when no one may be listening (certainly not the neighbours), when whatever enthusiasms or insights left in you are like a handful of feathers thrown into the Grand Canyon? Waiting for an echo: that is futility. In The Art of Preserving Health Dr. John Armstrong, whose peculiar poetic talents I have already noted in a previous post, casts his splenetic eye on the fate of the lonely librarius medicus in the cold store of human thought:

Chiefly where solitude, sad nurse of care,
To sickly musing gives the pensive mind,
There madness enters; and the dim-eyed fiend,
Sour melancholy, night and day provokes
Her own eternal wound. The sun grows pale;
A mournful visionary light o'erspreads
The cheerful face of nature: earth becomes
A dreary desert, and heaven frowns above.

Life has become the ideology of its own absence. (Theodor Adorno, Minima Moralia)

Sour indeed is the fate of the isolated, overworked and left behind. But, joking and poetic fromage aside, this alone cannot be the full explanation for the so-called blogging malaise, which if it exists is really a manifestation of a larger problem. Let us move away from the individual for a moment, and get serious. Many hospital librarians work for institutions that are large, impersonal, extremely complex, and decidedly unfree and undemocratic. Look at one of the comments on David Rothman's original post, which I think comes close to where I'm trying to go with this: "There are a lot of 2.0 tools that I use in my personal life, that I would LOVE to use at work, but have been essentially forbidden from even thinking about it."

Forbidden from even thinking about it. There is an Adorno-like bleakness to this kind of self-closure, the slate-clearing via negativa of manufactured assent, the always-already-erased expression of crimethink. ("In an all-embracing system conversation becomes ventriloquism." — Minima Moralia; "Life has become the ideology of its own absence." — Ibid.) I'll be accused of sophomoric philosophizing, but this, it seems to me, is where we come uncomfortably close to what really lies behind the inhibition preventing many hospital librarians from speaking out, whether among colleagues at work, in print, or in the blogosphere. I'm not talking about the common concerns over the quality of one's writing, saying something foolish (that's my specialty), not being interesting enough, or not being cool with computers.

Except for the odd overworked solo operation with only a dial-up modem, it is not really time or technology that stifles creativity. I would not entirely attribute it to the enervated state of being "blogged-out" and palely loitering in the arid interstices of Web 2.0. Nor is it merely a lack of collegial support. Blogging is not ultimately the issue at all. What is the essence of this ideology of its own absence?

Hospital librarians are often not free and do not feel free to express themselves, especially in large institutions. They must conform, both in dress and manner, to management strategies that tend to include the librarian as little more than clerical support for clinical and research priorities. As Adorno would put it, thinking no longer means any more than checking at each moment whether one can indeed think. That, at any rate, has been my experience. There are exceptions, of course. Witness the many articulate and successful hospital librarians. Yet I would maintain that the time for independent hospital libraries is over. When my library joined the University I expected, and to a great extent found, a more nurturing professional climate — and other librarians. That really helped. Academic hospital librarians benefit from faculty status and an environment congenial to intellectual expression. But it's not exactly magic. By and large we are still isolated geographically, and we miss out on that all-important daily contact with co-workers. Universities also have their own ranks of snaggle-toothed IT Orcs and querulous, distracted superiors. Much therefore depends, as T. Scott points out, on the level of support from administration. This is a point I want to explore more thoroughly.

In a state of complete powerlessness individuals perceive the time they have left to live as a brief reprieve. (Theodor Adorno, Minima Moralia)

Whether we work miles away or two doors down from the big boss, hospital librarians need to be plugged into the power mains. While there is no lack of creative ferment in most of us, if we do not have the support of administration and are denied authentic participation in the life of the organization, more than our motivation is cut off. Since the consolidation of all of Winnipeg's hospital libraries with the University of Manitoba, my co-workers and I have benefited enormously, and so have our patrons. We got connected, and not just to fantastically expanded online resources. I would say there has been a significant cultural change that has encouraged intellectual expression, experimentation in the life of the web, collaboration, and taking chances — it's like graduating from Harlequin to an Ivy League press. This year we joined our colleagues in fighting for and winning academic freedom and annual research leave for librarians in our new Collective Agreement.

University libraries face many challenges, and I welcome them. But as we remake ourselves, collegiality and participation in governance remain crucial. If these means of empowerment are denied us, creative professional work can be pursued only with great perseverance and often at odds with superiors. Without an invigorating dialogue between management and staff, the life of the workplace feels like Adorno's desolate brief reprieve. In whatever form — group projects, teaching, research, writing or webbing — the work of librarians must be nourished and sustained by a listening, caring, collaborative leadership. Otherwise people dry up and the workplace is a dreary desert. In the worst situations, when a regime becomes absolutist, secretive and petulant, people are silenced, conversation becomes ventriloquism, morale plummets, and a baleful inertia predominates. Where staff are corralled and herded into passivity they stay safely and quietly preoccupied with routine tasks. This management style may work well on an alpaca ranch, but in libraries it does little to encourage achievement or profound reflection about our work and our role in the institution.

If there is indeed a blogging malaise amongst health librarians — and I hope we will all be evidence to the contrary — we should look to our organizational culture as the cause. Librarians blog for so many reasons: to participate in the information revolution, to communicate with like-minded colleagues, to grow in the profession, or simply to dance our ringlets to the whistling wind. Libraries that foster a culture of participative governance and collegiality are already revolutionary. They get people talking, contributing, reflecting, writing, laughing. I think the blogging future is here; it's just not distributed evenly.

Those who have laughter on their side have no need of proof.

I'm finished. I just wanted to end this with a happier quote from His Bleakness.

Cancer study 23 decades too late

1Advice to the feeble, feckless and stout from an eighteenth-century doctor of physick

Millions of cancer deaths in industrialized countries could be avoided if the public paid more attention to diet, exercise and weight. That is the conclusion of the newly released study, Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective, which made headlines in many countries. The Globe and Mail shouted "Poor diet ratchets up cancer risk." The Winnipeg Free Press weighed in: "Study isolates cancer causes: weight, red meat, booze increase risk." The Economist noted: "To avoid the big C, stay small," adding in its usual wry manner that when it comes to cancer risks "many a mickle makes a muckle, and in total they add up to something significant."

The research took six years. Nine research institutes participated. More than half a million publications were examined — finally whittled down to 7,000 relevant ones. The crushing conclusion: there are close links between lifestyle and cancer, red meat is bad, fat is poison, drink worse, and everyone should stay as slim as possible "without being underweight" — good they threw that in, or all the work being done to get anorexics off fashion runways will have been in vain. These results should bring much rejoicing to those who would prefer to see the lower classes return to their proper lifestyle of heavy labour, weak beer, and gruel.

Exhausted and understandably distracted after reading hundreds of thousands of research papers, the study's authors did not realize that their scientific conclusions had been anticipated 250 years ago by the Scottish physician and poetaster extraordinaire, John Armstrong (1709-1779). In his long and industrious career Dr. Armstrong distinguished himself as physician to the British Army in Germany, as well as being a man of considerable literary ambition. In 1737 he published A Synopsis of the History and Cure of the Venereal Disease, immediately followed by a mildly salacious first book of poems entitled The Oeconomy of Love, which, though said to have been designed as merely a burlesque upon certain didactic writers, was, it has been recorded, justly condemned for its warm and alluring pictures and its tendency to inflame the passions of youth. Indeed, Dr. Armstrong's admiration of Milton was passionate beyond all natural bounds. Inspired by the blind bard, he could not resist the urge to express himself on paper just as he did on biliary dyspepsia and carbuncles, thereby adding fresh uneasiness to his patients' normal misgivings by indulging himself in the arts of poesy. In his free moments, when he was not sawing off arms or sewing up sabre wounds, he would write epic stanzas on peristalsis and purging.

John Armstrong's defining work, The Art of Preserving Health, was published in 1744 to much acclaim. This didactic poem in blank verse, extending through four books, has enriched our literary heritage with its peerless lyrical analysis of the healthy conduct of creaturely life, comessation, and the gastrointestinal system, all under the guidance of the meat-eschewing muse Hygeia. With every stroke of Armstrong's precocious quill the vast apparatus of Miltonic metre and metaphysics is brought to bear on phlegm and flatulence, black bile and swelling blood, with results that can gratify the seeker of salubrity and connoisseur of unique literary phenomena. At least so says Bruce Boehrer in a pithy review of Armstrong's work in the Milton Quarterly. As a critic of his day wrote of this eighteenth-century practitioner in viscera and verse: "He thinks boldly, feels strongly, and therefore expresses himself poetically. When the subject sinks, his style sinks with it." (Source: Significant Scots on the ElectricScotland website.)

Now, as a hospital librarian I am interested in John Armstrong's influence on modern science, not the quality of his iambic pentameter. Through my own research in standard library resources, I have discovered remarkable parallels between the health prescriptions of Scotland's medical versemaker and those of today's expert team of cancer researchers. In fact, their monumental study, the most comprehensive of its kind ever undertaken, showing that diet, lack of exercise, and body weight appear critical in causing many cases — perhaps up to one-third — of all cancers, is, I say, but a lengthy commentary on Dr. Armstrong's own work. Little did this intrepid band of scientists realize that their conclusions are a mere reprise of the discoveries made by this unassuming man of medicine. Moreover, his extraordinary prescience and irrepressible prognosticatory skills are limned in the noble cadences of heroic blank verse, a welcome change from the arid and monotonous prose of contemporary science.

In the following I shall demonstrate conclusively the truth of this assertion. Let us begin with an excerpt from Book II of The Art of Preserving Health, through which stream forcefully Dr. Armstrong's enunciations on diet and the dire risk of excess fat, "the gummy nutriment":

The languid stomach curses e'en the pure
Delicious fat, and all the race of oil:
For more the oily aliments relax
Its feeble tone; and with the eager lymph
(Fond to incorporate with all it meets)
Coyly they mix, and shun with slipp'ry wiles
The woo'd embrace. Th'irresoluble oil,
So gentle late and blandishing, in floods
Of rancid bile o'erflows: what tumults hence,
What horrors rise, were nauseous to relate.
Choose leaner viands, ye whose jovial make
Too fast the gummy nutriment imbibes. (The Art of Preserving Health, Bk. II)

Although the poet's advice to those of "jovial make" (i.e, the obese) is perceptibly tinged with gloomy pleasure at their sufferings, he rightly makes his case for avoiding fatty foods. His opinions on the "oily aliments" are quite vehement, with dire predictions of "tumults" and "horrors" when the "rancid bile o'erflows." How does this compare with our current knowledge? Armed with years of diligent research, the authors of our imposing cancer study can do little more than repeat Dr. Armstong's recommendation to "choose leaner viands" in order to stay lean.

For it all comes down to the stomach, Dr. Armstrong would say. In the following excerpt, in which the poet can no longer hold back, but must urgently find relief in calling upon his gastric muse in this churning paean to intestinal integrity, he warns uncompromisingly of the terrifying consequences of vile viands and ill-chosen nutriments:

Half subtilis'd to chyle, the liquid food
Readiest obeys th'assimilating powers;
And soon the tender vegetable mass
Relents . . . .
The stomach, urged beyond its active tone,
Hardly to nutrimental chyle subdues
The softest food: unfinished and depraved,
The chyle, in all its future wand'rings, owns
Its turbid fountain; not by purer streams
So to be cleared, but foulness will remain. (Ibid., Bk. II)

Foulness, indeed, is all that remains. On the matter of drink, while as suspicious of "the colliquation of soft joys" as our international team of experts, Dr. Armstrong occasionally qualifies his lofty disapproval of bacchanalian imbibing, even expostulating at one point on "that divinest gift, / The gay, serene, good-natured Burgundy." In an eruption of ascetic rigour that goes far beyond even the stern admonishments of their predecessor, our cancer and lifestyle experts condescend to allow as permissible only a miniscule amount of alcohol — and that reluctantly — with long-suffering women cruelly restricted to a single drink per day.

On exercise, Dr. Armstrong is uncannily contemporary in his views. Lauding those "whose blood / Impetuous rages through the turgid veins," he regards with abhorrence "pale and bloated sloth," which must needs bring on the unhappy superflux of "rancid byle." Exercise contributes to the augmentation of good digestion and is the best remedy for constipation, "the stubborn aliment." Recommending the avoidance of "the full repast," our physician-poet advocates sufficient daily activity to stimulate the alimentary tract:

. . . His daily labour thaws,
To friendly chyle, the most rebellious mass
That salt can harden, or the smoke of years;
Nor does his gorge the luscious bacon rue . . .

Washing is acceptable, in moderation: "The warm ablution just enough to keep / The body sacred from indecent soil." Those brave enough to wash in cold weather are deserving of special notice:

Against the rigours of a damp cold heaven
To fortify their bodies, some frequent
The gelid cistern; and, where naught forbids,
I praise their dauntless heart. (Ibid., Bk. III)

While his suggestions for physical exercise are innocent of Bowflex brochures and Pilates publicity (in fact, they are more reminiscent of the pastimes of the fallen angels in Milton's Pandemonium), Dr. Armstrong, it can be said with confidence, profoundly understood physical activity's role in the maintenance of good health, even to the point of foreseeing the advent of the sweat shirt. Not a few contemporaries, however, were critical of his excessive trust in "vacant fancy,"and his enthusiastic endorsement of frolicking in "naked stubble" must have troubled concerned parents and clergy:

Whate'er you study, in whate'er you sweat,
Indulge your taste. Some love the manly foils;
The tennis some, and some the graceful dance.
Others more hardy, range the purple heath,
Or naked stubble; where from field to field
The sounding coveys* urge their labouring flight; * partridges
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
He chuses best, whose labour entertains
His vacant fancy most. (Ibid., Bk. III)

Special derision is reserved for feather beds ("the blandishments of down"), which are fit only for "the lean projector, of dry brain and springy nerves" (the information specialist?) and "the buried bacchanal" (the drunkard), exhaling his surfeit "in prolixer dreams." For those who would wean themselves from sloth, it were best to extend the limbs upon "the hard mattress or elastic couch."

So much for the feeble and the feckless. What, then, of the stout — those "of jovial make?" We have already seen Dr. Armstrong's withering disapprobation of "the languid stomach." Towards the adipose and pinguitudinous he is implacable, relentless and remorseless. In short, he is not one to suffer fools lightly. Though long dead, truly he is a man of our time:

. . .But ye of softer clay,
Infirm and delicate! and ye who waste
With pale and bloated sloth, the tedious day!
Avoid the stubborn aliment, avoid
The full repast . . .

Gluttony, and the obesity that results, is a sin utterly Mephistophelian in its bestial depravity and degradation. For those unable to avoid "the pure delicious fat, and all the race of oil" special horrors are reserved, including severe periodontal disease. The doctor counsels: "let sagacious age / Grow wiser, lesson'd by the dropping teeth."

Could any now disagree that a close reading of John Armstrong's complete opus is the foundation for any future research on cancer and lifestyle? His foresight is prodigious, his diagnosis accurate, his prescription astute. It is nothing short of astonishing how, alone with his muse and unassisted by teams of trained assistants and years of accumulated data, an obscure, eighteenth-century doctor of physick, toiling amongst amputated limbs, bleeding bowls and unwashed lancets, should have anticipated so accurately the results of a heavily funded, internationally backed research project of the 21st century. Twenty-three decades after his death, Dr. Armstrong's disrelish for the slightest human weakness and uncompromising scorn for fat in all its forms seems completely up to date. Much like the authors of Food, Nutrition, Physical Activity, and the Prevention of Cancer, he had, as James Beattie wrote to his friend and biographer William Forbes, "a rooted aversion against the whole human Race, except a few Friends, which it seems are dead."