07 May 2008

Nostalgia for handwriting: it's love th@ m@ters

Words are things, and a small drop of ink, falling like dew upon a thought, produces that which makes thousands, perhaps millions, think. ~ Byron

On a recent vacation, having deliberately divested myself of all digital devices, I experienced once again the pleasure of applying pen to paper and transposing the words in my head into the scrawled combinations of graphemes we call handwriting. There is no describing my satisfaction in filling a page with cursive script, nor the miracle of being able to read it back to myself, especially when about half of the content is in my own idiosyncratic shorthand. Why, then, am I writing about my little ink-stained indulgence in Google Docs, for ultimate posting to my blog?

The commanding presence of computers and their keyboards in my life has left little room for pen and pencil. It's so much easier to martial ideas and manipulate text using software. As it neatly telegraphs itself in German, "Laptop auf, Google an!" The computer facilitates the process of writing, and so much more besides. But like my attachment to printed books and paper manuscripts, the love of handwriting is still there, perhaps fostered by a childhood that knew no keyboarding — I first used a typewriter in high school, and a manual one at that. My school days were marked, and liberally spotted, by old-fashioned straight pens. I still remember the smell of the inkwell on my desk, the feel of my pen's stained cork hand-grip, and the distinctive rasping and scratching of many nibs as my classmates and I learned our ABCs.

Now my work compels me to interact with digital text and images for the better part of the day. Years of typing and mouse manipulation have wreaked predictable havoc on the tendons of my forearms. Writer's cramp was easier to deal with. At this point you are probably expecting a rant against the soulless reign of technology, but I shall have to disappoint. I actually enjoy most aspects of computing, especially the flexibility and maybe-I'll-try-that freedom of word and image processing in all its extraordinary variety. At the same time I have my fond memories of the dull pencils, nib-torn pages, smudges, leaky ballpoints, ink blots, and boo-boos of that older world of paper, not to mention the now antique art of typewriting. Underwoods really have had their day, but handwriting is indispensable it seems. Beyond the intrinsic appeal of calligraphic expression, I find it more practical for the recording of thoughts, the exchange of intimacies, note taking, appointment scheduling, grocery list making, and other obiter scripta. No electronic gadget has appealed much to me as a tool for this kind of task. And who, for instance, would feel truly comfortable emailing condolences to a friend whose parent has died? Whether a sonnet or a laundry list, a written document is a hand-produced, human thing. Writing is something handed down. It is part of our history and our most cherished invention after language itself: the perfect tool to record everything our wagging tongues could come up with, from gossip to the oracles of a god. You could say I have a nostalgia for handwriting.

As a counterpart to my computer use, I have tried for many years to order my life with a Palm handheld; but I've grown weary of fussing with it. I'm tired of flubbed Graffiti strokes and poorly aimed taps. There is the persistent mild anxiety caused by having to remember to sync or recharge the battery. I miss the old standard paper calendar books, not just for the ease of whipping them out and quickly scribbling the information I need to record in them, but also for the satisfaction of leafing through past editions, watching the history of my work life flow by as I turn the pages, reminding myself of important people, conversations, random thoughts, aperçus — all charmingly preserved on somewhat dog-eared paper.

A handheld's calendar cannot reproduce paper's tangible presence. Yes, software is efficient; screen resolution and storage are phenomenal; but my experience has been that, once past, events tend to slide inexorably into virtual oblivion. Months and years moulder into an indiscriminate bog of old data. What is lacking is the rich hermeneutical humus of varying inks or pencil types, pen pressures, private doodlings, coffee spills, annotations, underlinings, paper clip reminders, sticky attachments, crossings-out, etc. of a paper journal. Perhaps a future technology will make my complaint look petulant and uncool. I know that digital equivalents of all the above are available (well, perhaps not the coffee spills). But somehow a computer's clean, smooth surfaces act as barriers, depriving me of the all-important visual and tactile experience of paper. New developments in computer technology will doubtless bring better interfaces. When we get the optimum combination of microprocessor power and improved software, handwriting — although this time on a friendlier and ferociously sensitive digital medium — might become popular again. Who is to say where technological development will take us? It's becoming harder to follow the changes and hence to predict futures. As Wallace McLendon has written:

Ten years ago tracking technology was easier. A technology — like PDAs — flew solo, independent of other technologies, like a bird flying outside of a flock. Now technology is immersed in the flock and the flock moves as if each technology is connected. The pattern of a single technology is not as interesting or revealing as it used to be, even if we were able to extract it from the circuits and chips it shares. ... [F]uture technological innovations will be a flock of technology changes shifting and darting together over time continuous.

The demise of handwriting?

My reflections on handwriting give rise to the following questions: Has the computer led to the demise of handwriting? Is our cultural life diminished as a result? Will this loss also affect our language?

It's obvious that there has been a decline, as linguist David Crystal points out in a recent post, but "demise" is an exaggeration. Handwriting is going to be with us for some time to come. People attach great significance to handwritten documents: their "graphaesthetics" (writing style, paper choice, etc.), and what we can deduce from them about the writer's mood, personality, or status. Analyzing a writer's hand is also of vital importance to literary critics, teachers, historians, psychiatrists, forensic scientists, and the lovelorn.

There appears to be little danger to the English language from the millions of tapping fingers and thumbs out there, although anyone on the grumpy side of the Gr8 Db8 on "txting" may demur. I wrote about the phenomenon of Netspeak last October, quoting Martin Amis' very funny take on male genital insecurity and text messaging in his novel Yellow Dog:
... take my word 4 it, clint, u don't want a bloody great 2l. ... they're overr8ed! i h8 them! & what an un4tun8 effect it has on the ego: ... it's not size th@ m@ters, clint. it's love th@ m@ters.

There is no obvious connection between the loss of handwriting and the formal state of a language, as might manifest itself in such areas as vocabulary and grammar. The issues raised by the potential disappearance of handwriting seem to be more psychological and social than linguistic. The use of handwriting has indeed declined, but the language is alive and well, on our loose lips and on the web. Compared to the sinister euphemisms of Big Media, or the nerve-deadening sloganeering of corporate-speak, the lively twitter of real people is quite refreshing. Texting is often criticized, but is it really the bleak, bald, sad shorthand that some accuse it of being, masking dyslexia, poor spelling, and mental laziness? In fact, the evidence suggests the opposite. The texting system of conveying sounds and meaning goes back all the way to the origins of writing. Far from hindering literacy, texting may turn out to help it. Homo loquens at its best.

Could it also be that blogging as a technology is partially making up for the lack of a thoughtful, personalized graphic medium like the traditional diary? The popularity of blogging and other forms of individual expression online may have something to do with a certain nostalgia for paper and ink. While at present there is no substitute for the ease and comfort of typing (or even dictating) words into a computer, there will always be a place for handwriting. When the technology improves, I shall be happy to take up my stylus and handwrite my memoirs and my villanelles, even letters of condolence, onto a light, solid-state digital tablet. If writing is a labour of love, we shouldn't be too concerned about the tools employed. For it's love th@ m@ters.

04 May 2008

In floods of rancid bile o'erflows: the poetry of medicine

evoted to the mystic practice of healing, the priests of Aesculapius chanted their shamanistic verses long before scientific investigation was introduced into medicine. Over the ages poets good and bad (mostly bad) have communed with their medical muse and set down their deepest sentiments in the special language of symbol and metaphor. However halting or quirky their rhyme and metre, no matter the annihilating banality of their theme or the bottomless bathos of their bavardage, the poets of medicine have left their mark. The magic of poesy has cast its brilliant light on the unfairly neglected subjects of dissection and digestion, sanitation and elimination.

Medical librarians have been alert to these alternative interests of the physicians whose massive clinical texts accumulate on our library shelves. Whatever our own personal feelings may be regarding the poetic or other literary effusions of our patrons, we should not fail to add them to our collections. For example, Jack Coulehan, M.D., M.P.H., has recently published Primary Care (University of Iowa Press), a collection of poems written by physicians who reflect in verse on the uncertainty, pain, anger, sympathy, longing, skepticism, desperation, and love they observe in their patients and often experience themselves. Dr. Coulehan has also edited Blood and Bone: Poems by Physicians.

The thin line between good taste and travesty is easily crossed, however, when medicine is the muse. I have taken a particular interest in those poets, whether medically trained or not, who ostentatiously occupy the other side of that significant divide. In this post I have brought together an evocative collection of my favourites.

John Keats, sweet singer of the English Romantics, studied medicine and died young. In the short time he had to compose some of the greatest poems of the English language, Keats perhaps wisely avoided the daunting task of creating odes or sonnets on the spleen or the perils of gossypiboma. Yet he was no stranger to life's vicissitudes, for he watched his brother die slowly of consumption, and himself succumbed to the same illness a few years later:

Here, where men sit and hear each other groan;
Where palsy shakes a few, sad, last grey hairs,
Where youth grows pale, and spectre-thin, and dies. (Ode to a Nightingale)
For Keats, poetry and medicine could and did share many ideological threads, among them being his theory of "negative capability." It required a certain clinical detachment and strong powers of observation honed by hours of squinting at cadaver dissections to form the basis of that world view. But despite all his concerns about etiolated youth, alone and palely loitering in unhealthy fens and drafty towers, you will find none of Keats' verse below. His negative capability did not extend to meditations on chyle or sexually transmitted diseases. Nor is William Carlos Williams's work represented. Famous for the modernist minimalism so beautifully expressed in his The Red Wheelbarrow, Williams versified little of his experience as a physician. No red gurneys haunt our modern poetic sensibility.

No, the poets here gathered are special. Some were physicians, but most were mere human beings. What brings them together is their intemperate desire to write on medical subjects, an obsession matched only by their want of taste and utter lack of talent. They have experienced the world through the gimlet eye of the surgeon, the peculiar exudations of the funeral parlour, and the horrors of the dentist's chair. They have dropped dripping literary specimens into pails and left ample swatches of gauze after sewing up thoracic cavities. It takes special courage and determination to mount the heights of Parnassus with paeans to ditches, drains, embryos, bloody scalpels, and intestinal flora. Indeed, only the most sensitive of souls could write an elegy on a dissected puppy or a smothered child.

Drawing upon this rich and redolent tradition, the writing of medical poetry continues today. Not content with the themes and visual imagery of traditional English poetry, it challenges our inner eye and nostril with a singular corpus of verse, a very human afflatus that cuts like or can be cut with a knife. As Kathleen Béres Rogers reminds us:
Indeed, one could say that modern-day medical poets and patients repeat the traditionally conceived Romantic project, expressing a “spontaneous overflow” of “powerful emotion, recollected in tranquility”: after the diagnosis, the surgery, the recovery, or the death. Yet by writing their poems, medical poets—now and then—remind us that our bodies also exist as a part of the natural world, defined by both their sublimity and materiality. (Medical poems and the Romantic rise of disciplinarity. Thesis. University of North Carolina at Chapel Hil, 2007, p. 151.)
Each year the human body excretes its own weight in bacteria. Here is an earthy subject of a sublimity and materiality perfectly fitted to the imaginative powers of the poets gathered together in this little anthology. How sad that as yet no English poets have applied themselves to this formidable reality of human existence. We are the lesser for it.

The poems and fragments assembled below, spanning a period of many centuries, are arranged thematically. Readers are encouraged to be moderate in their perusal of the collection, for too rich a diet of this poetry of medicine could require the attentions of a physician.



Two loves found refuge in my happy heart,
One for my bride, one for the healing art;
Each of my spirit claimed an equal part.

But, as my talent rose and waxed mature,
Love for my bride became more insecure,
Love for anatomy more deep and pure.

She was a subject to my eyes alone;
Not woman, forsooth, but so much flesh and bone,
Sinew, and blood, and skin, which were my own.

And I had lawful right, with foul intent,
I who for progress on this sphere was sent,
To use her body for experiment.

So in her wine I dropped consuming blight,
One moaning, shadow-haunted winter night,
And, watching, clutched my scalpel's handle tight.

Then, ere her eyes, that agony expressed,
Had closed forever, with impatient zest,
My hands were red dissecting her white breast.

Francis Saltus Saltus (1849-1889)


Sweet Dog! now cold and stiff in death,
What cruel hand enticed thee here?
Did toothsome crust of juicy bone
Allure to stretch on thy bier?

... ruthless hands of alien race
Are opening up thy quiet breast,
With prying eyes they peer within,
Explore the contents of thy chest.

Georgia Bailey Parrington (fl. 1907)


And as the anatomist, with all his band
Of rude disciples, o'er the subject hung,
And impolitely hewed his way, through bones
And muscles of the sacred human form,
Exposing barbarously to wanton gaze
The mysteries of nature, joint embraced
His kindred joint, the wounded flesh grew up,
And suddenly the injured man awoke
Among their hands, and stood arrayed complete
In immortality—forgiving scarce
The insult offered to his clay in death.

Robert Pollock (1798-1827)


In this image

Of your brain
I see each curve
In the corpus callosum,
Curlicues of gyri,
Folding of fissures,
Sinuous sulci,
Mammillary bodies,
Arcuate fasciculus,
Angular gyrus,
Tracts and nuclei,
Eyes and ears,
Tongue and phalanx.

But not even
A single syllable
Of one

Vernon Rowe. In: Angela Belli and Jack Coulehan, eds. Blood and Bone: Poems by Physicians (Iowa City: University of Iowa Press, 1998), p. 102.


Stranger! Approach this spot with gravity!
John Brown is filling his last cavity.



You have gone, old tooth,
Though hard to yield,
You have long stood alone,
Like a stub in the field.

Farewell, old tooth
That tainted my breath,
And tasted as smells
A woodpecker's nest


... her lips disclosed to view,
Those ruined arches, veiled in ebon hue,
Where love had thought to feast the ravished sight
On orient gems reflecting snowy light,
Hope, disappointed, silently retired,
Disgust triumphant came, and love expired!

When'er along the ivory disks, are seen,
The filthy footsteps of the dark gangrene;
When caries come, with stealthy pace to throw
Corrosive ink spots on those banks of snow—
Brook no delay, ye trembling, suffering Fair,
But fly for refuge to the Dentist's care.

Solyman Brown (1790-1876)



On her beautiful face there are smiles of grace
That linger in beauty serene,
And there are no pimples encircling her dimples,
As ever, as yet, I have seen.

J. Gordon Coogler (1865-1901)

Emergency Medicine


'Twas on the 8th April, on the afternoon of that day,
That the little village of Louisberg was thrown into a wild state of dismay,
And the villagers flew to the beach in a state of wild uproar,
And in a dory they found four men were cast ashore.

Then the villagers, in surprise, assembled about the dory,
And they found that the bottom of the boat was gory;
Then their hearts were seized with sudden dread,
When they discovered that two of the men were dead.

And the two survivors were exhausted from exposure, hunger, and cold,
Which caused the spectators to shudder when them they did behold ...

They were carried to a boarding-house without delay,
But those that were looking on were stricken with dismay,
When the remains of James and Angus M'Donald were found in the boat,
Likewise three pieces of flesh in a pool of blood afloat.

Angus M'Donald's right arm was missing from the elbow,
And the throat was cut in a sickening manner, which filled the villagers' hearts with woe,
Especially when they saw two pieces of flesh had been cut from each thigh,
'Twas then the kind-hearted villagers did murmur and sigh.

William McGonagall (1830-1902)



Oh, ditch of all ditches,
Death's store-house of riches,
Where wan disease slumbers mid festoons of slime!
Oh, dark foetid sewer
Where death is the brewer
And ail is the liquor he brews all the time!

Oh, hot-bed of fever,
That fatal bereaver
Whose fiery breath blights the blossom of life!
Oh, palace of miasm
Whose hall is a chasm
Where pestilence revels and poison is rife!

Oh, wonderful sewer,
Each year brings a newer
And ghostlier charm to they cavernous deeps!
More puppies and cats,
To say nothing of rats,
And offal and filth of all manner in heaps.

Anonymous. Originally appeared in the Fayetteville North Carolinian on February 21, 1857.



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.


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.

John Armstrong (1709-1779)

Infectious Disease


Poor little Ada Queetie has departed this life,
Never to be here no more,
No more to love, no more to speak.

Poor little Ada Queetie's last sickness and death,
Destroyed my health at an unknown rate,
With my heart breaking and weeping,
I kept the fire going night after night, to keep poor little dear warm,
Poor little heart, she was sick one week
With froth in her throat,
Then 10 days and grew worse, with dropsy in her stomach,
I kept getting up nights to see how she was.

She was coming 9 years of age, when she was taken away,
By all I found out, very certain true
Poor Sissy hatched her out her egg in Chilmark,
The reason she was taken away before poor Sissy,
Her constitution was as weak as weak could be.

Her complaint that caused her death,
Was just such a complaint as poor Sissy had
Only poor Sissy's complaint ended with dropsy in her stomach.

Nancy Luce (fl. 1860s)

Internal Medicine


I always choose the plainest food
To mend viscidity of blood.
Hail! water gruel, healing power,
Of easy access to the poor;
Thy help love's confessors implore,
And doctors secretly adore:
To thee I fly, by thee dilute—
Through veins my blood doth quicker shoot;
And by swift current throws off clean
Prolific particles of spleen.

Matthew Green (1697-1737)


Gooing babies, helpless pygmies,
Who shall solve your Fate's enigmas?

from The Light-Bearer of Liberty, by J.W. Scholl (A pathetic attempt at rhyme by a very bad poet)


Between our folding lips
God slips
An embryon life, and goes;
And this becomes your rose.
We love, God makes: in our sweet mirth
God spies occasion for a birth.
Then is it his, or is it ours?
I know not—He is fond of flowers.

T.E. Brown (1830-1897)



Oh! she was a lovely girl,
So pretty and so fair,
With gentle, lovelit eyes,
And wavy, dark-brown hair.

I loved the gentle girl,
But oh! I heaved a sigh,
When first she told me she could see
Out of only one eye.

But soon I thought within myself,
I'd better save my tear and sigh,
To bestow upon some I know,
Who has more than one eye.

She is brave and intelligent,
Too she is witty and wise,
She'll accomplish more now, than many,
Who have two eyes.

Ah! you need not pity her,
She needs not your tear and sigh,
She makes good use, I tell you,
Of her one remaining eye.

Lillian E. Curtis (fl. 1870s)



Misfortune sometimes is a prize,
And is a blessing in disguise;
A man with a stout wooden leg,
Through town and country he can beg.

And when he only has one foot,
He needs to brush only one boot;
Through world he does jolly peg,
So cheerful with his wooden leg.

In mud or water he can stand
With his foot on the firm dry land,
For wet he doth not care a fig,
It never hurts his wooden leg.

No aches he has but on the toes
Of one foot, and but one gets froze;
He has many a jolly rig,
And oft enjoys his wooden leg.

James Macintyre (1827-1906). A Canadian noted for another immortal poem, Ode on the Mammoth Cheese.

Pediatrics (Psychiatry?)


Within a London hospital there lies,
Tucked in his cot,
A child with golden curls and big blue eyes.
The night is hot,
And though the windows in the long low ward
Are open wide,
No breath of air comes from the sun-baked yard
That lies outside.

A kindly nurse who sees his wistful smile,
To cheer him cries;
"The doctor says that in a little while
He'll let you rise,
And send you home again!" His eyes grow dim.
She little thinks
What since his father died home means to him—
His mother drinks!


Theirs was not the peaceful death-bed,
Where affection's silent tears,
O'er the couch of pain fast falling,
Blend with deep responsive prayers;

Nay, their death was strangely fearful!
No fond parent closed their eyes,
And no voice of pity answer'd
To their feebly moaning cries!

Mrs. Marion Albina Bigelow (fl. 1850s)

Public Health


This is the song for a soldier
To sing as he rides from home
To the fields afar where the battles are
Or over the ocean's foam:
"Whatever the dangers waiting
In the lands I have not seen,
If I do not fall—if I come back at all,
Then I will come back clean.

"I may lie in the mud of the trenches,
I may reek with blood and mire,
But I will control, by the God in my soul,
The might of my man's desire.
I will fight my foe in the open,
But my sword shall be sharp and keen
For the foe within who would lure me to sin,
And I will come back clean."

Ella Wheeler Wilcox (1850-1919)


Magnificent, too, is the system of drains,
Exceeding the far-spoken wonders of old:
So lengthen'd and vast in its branches and chains,
That labyrinths pass like a tale that is told:
The sewers gigantic, like multiplied veins,
Beneath the whole city their windings unfold,
Disgorging the source of plagues, scourges, and pains,
Which visit those cities to cleanliness cold.
Well did the ancient proverb lay down this important text,
That cleanliness for human weal to godliness is next.

Samuel Carter (fl. 1848-1851)



There are hearts—stout hearts,—that own no fear
At the whirling sword or the darting spear,—
that are ready alike to bleed in the dust,
'Neath the sabre's cut or the bayonet's thrust;
They heed not the blows that Fate may deal,
From the murderer's dirk or the soldier's steel:
But lips that laugh at the dagger of strife
Turn silent and white from the surgeon's knife.

It shines in the grasp—'tis no weapon for play,
A shudder betrays it is speeding its way;
While the quivering muscle and severing joint
Are gashed by the keen edge and probed by the point.
Dripping it comes from the cells of life,
While glazing eyes turn from the surgeon's knife.

Eliza Cook (1818-1889)


[A brigand is overpowered in the act of attempting to molest a lady and requires medical care:]

So stunned, surrounded and beset,
The surgeon struggled hard to see
His patient, or at least to get
Some signs of his proximity:
At length they opened up a way
To where a man extended, lay,
Presenting an appalling sight
Seen dimly through the chequered light...
For swelling, high amid the clothes,
The body, like a mountain rose
That scarce the head was seen;
While from below the feet protrude
(Like Satan "stretching many a rood"
So giant-like I ween.) —
And on those large and naked feet
A pair of antique spurs were placed,
Which fastened o'er the instep meet,
With many-coloured latchets graced.

[The surgeon enquires later:]

"Since when he has," (replied the nurse,)
"Been going on from bad to worse."

Samuel Carter (fl. 1848-1851)



When people's ill they comes to I,
I physics, bleeds, and sweats 'em.
Sometimes they live, sometimes they die;
What's that to I? I Letsome.


For physic and farces his equal there scarce is;
His farces are physic; his physic a farce is.

David Garrick


Coy Nature (which remain'd, though aged grown,
A beauteous virgin still, enjoy'd by none,
Nor seen unveil'd by any one),
When Harvey's violent passion she did see,
Began to tremble and to flee,
Took sanctuary, like Daphne, in a tree:
There Daphne's lover stopt, and thought it much
The very leaves of her to touch,
But Harvey, our Apollo, stopt not so,
Into the bark and root he after her did go.

Abraham Cowley (1618-1667)

In closing

And now, kind friends, what I have wrote,
I hope you will pass o'er,
And not criticize as some have done,
Hitherto herebefore.

Julia A. Moore (1847-1920) "The Sweet Singer of Michigan."

20 April 2008

Injecting doubt: the rhetoric of harm reduction and the fate of Insite

The debate over the future of Insite, the successful safe-injection and drug health centre in Vancouver's Downtown Eastside, grew more impassioned this month after the federal government's so-low-key-as-to-be-well-nigh-subsonic release of a report by a panel of experts tasked with assessing existing scientific research on the facility.

Perhaps the loudest squawk came from the authors of the report's most quoted studies: "This government may already have garnered a reputation for being the most antiscience government in Canadian history." In a sharply worded article published last week on Straight.com, Thomas Kerr and Evan Wood, research scientists at the British Columbia Centre for Excellence in HIV/AIDS, accuse the federal Conservatives of politicizing science in their straight-laced and passive-aggressive approach to Insite's work with injection drug users.

Doing exactly what it was set up to do
Kerr and Wood charge the government with attempting to "cloud science" and "manufacture uncertainty." In the Tories' get-tough, war-on-drugs strategy, they aver, there is no room for sound public health strategies like harm reduction — despite the wealth of scientific evidence to support these interventions, including 22 studies by the authors which appeared in major medical journals such as the New England Journal of Medicine, the Lancet, and the British Medical Journal. This plethora of research shows that Insite is doing exactly what it was set up to do:

  • contributing to reductions in the number of people injecting in public and the number of discarded syringes on city streets,
  • helping to reduce HIV-risk behaviour and saving lives that might otherwise have been lost to fatal overdose,
  • achieving a 30% increase in the use of detoxification programs among Insite users in the year after the site opened,
  • not increasing crime or leading others to take up injection-drug use.
Moreover, Insite appears to be cost-effective and is popular among the general public. Within the strict limits imposed on it, Insite just seems to work. Undeterred by mere facts, however, Prime Minister Stephen Harper, whose strong opposition to "deviant behaviour" is well known, claims to remain unconvinced. Neither the overwhelming scientific evidence nor Insite's articulate defenders — not even the largely positive conclusions of the government's own Expert Advisory Committee — seem to have swayed this staunch defender of prudence and propriety and his loyal supporters.

The most negative finding the Committee could come up with was that Insite did not show a record of addiction prevention. However, as the Canadian Medicine blog points out in an April 14 post, "it should come as no surprise that prevention hasn't improved. Perhaps the prevention of further harm and more death should be prevention enough, and we shouldn't expect one single intervention to solve the problem of drug addiction itself. After all, this is a 'harm reduction' project we are talking about — not harm prevention." However, as is the case with global warming, no amount of compounding detail is enough to disabuse the determined believer.

Ideological warfare
Given the significant disagreement on this issue, perhaps the very term "harm reduction" is the problem, as A.I. Leshner of the American Association for the Advancement of Science suggests [1]. The imprecise application of this term and its use as a euphemism for drug legalization have "sufficiently inflamed ... drug warriors that they cannot have a rational discussion of even the underlying concept, let alone how harm-reduction strategies might be implemented." Leshner advocates the avoidance of ideological intensity. "Let's get on with studying specific strategies to protect the public health and ensure social well-being and give up this term that only gets in the way, even if it does make sense." This well-meant and seemingly pragmatic dismissal of ideology, so characteristic of certain debates within American elites, is itself highly ideological. Excellent solutions are brought forward in print, and they stay securely in print. There are still no safe injection sites anywhere in the United States.

From a Canadian perspective, Bernadette Pauly of the University of Victoria reminds us that harm reduction, however well implemented, is only a partial solution [2]. Conceived within a broader social justice context, harm reduction strategies should be part of a comprehensive approach to reducing social inequities, providing accessible health care, and improving the health of those who are street-involved. Pauly is proposing to move from print to political project. All well and good, but then we confront the by-one's-own-bootstraps catechism of the dogged Harperites and their extraordinary ability to mobilize the fear and petty prejudices of Canadians in support of their retrograde policies.

The worst part of having success is trying to find someone who is happy for you, as Bette Midler once said. Insite's harm reduction achievements are being deliberately downplayed as time runs out on the facility's exemption from federal legislation that would otherwise see operators charged under federal drug laws. The current licence expires on June 30, when Health Minister Tony Clement must decide whether to grant another exemption to the Controlled Drugs and Substances Act or amend legislation that prohibits it. Battle lines are being drawn as two law suits challenging the federal government's jurisdiction over the matter head to the British Columbia Supreme Court, and experts like Thomas Kerr demand publicly that the Minister honour the findings of his own researchers and stop injecting doubt by his disingenuous questioning of Insite's raison d'être.

The only dope worth shooting is ...

On the other side of the ideological divide, the Vancouver Police Union issued a recent statement criticizing Insite, which operates near capacity, for serving only a tiny minority. That's like denouncing underfunded and understaffed day care centres in this country for serving only a small number of Canadian children. According to the Canadian Press, Chief Superintendent Derek Ogden, the RCMP's director general of drugs and organized crime, echoed his masters by stating he would like to see further research. "I absolutely cringe when I hear people talk of a safe injection site," he said in an interview from Ottawa. How about that for informed comment. The Chief Superintendent probably also cringes at the thought of certain sexual practices, religious rituals, or undergraduate film studies courses. It's comforting to know that federal law enforcement policies are being planned based on the cringe factor. Health Canada spokespersons ran for cover and would only respond to emailed questions from the media. Predictably, they intoned the mantra that the Minister was "examining" the Expert Advisory Committee's report.

Perhaps Ottawa's balmy spring weather is distracting Mr. Clement. But the question needs to be asked. What further research is really needed, and how much more examining must he do? The money spent on this lengthy and redundant investigation (no cost figures for the Committee's efforts seem to be readily available) could probably finance the start-up of another harm reduction program in, say, Toronto or Montreal. Insite remains the only safe injection site in North America.

The strange timing of the report's appearance has not gone unnoticed. The surreptitious nature of its release late on a Friday afternoon seemed designed to minimize media coverage. The ideological reasons for the health minster's coy and constrained behaviour are obvious. As David Eaves so aptly comments on his blog, "for what must be the first time in Health Canada’s history the department is trying to bury a study that highlights how one of its programs improves healthcare outcomes to Canada’s most marginalized citizens."

Scientific arguments are insufficient in themselves

In a brilliant commentary on the ideological warfare behind the war on drugs, two Canadian sociologists take on the sententious rhetoric that labels harm reduction advocates as "legalizers" in the guise of scientists and public health professionals [3]. Because the right-wing attack comes from either the intractably convinced or cleverly hypocritical stance that abstinence, prevention, and enforcement are the only acceptable and morally legitimate solutions, harm reduction's muted stance on morals, rights and values prevents proponents from engaging criticisms of this nature in terms other than the evidence or science.The case of Insite, the authors argue, demonstrates the value of asserting human rights claims that do not rest on evidence per se. Scientific arguments are insufficient in themselves to move beyond the status quo on drugs.

They conclude, "Without commitment to 'strong rights' and the sovereignty of users, harm reduction sentiments are easily subverted to a technocratic governance agenda. Against the accusation that we are really 'legalizers' harm reduction advocates need not dispute the label but rather the suggestion that opposition to the drug war is somehow irresponsible, dishonest, or immoral. Respect for human rights moves harm reduction past the confines of a scientific project — which has not been well respected outside academic circles — toward a generative programme for replacing prohibition with policies reflecting the costs and benefits of drug use and the costs and benefits of formal intervention."

Here, surely, is the way to proceed. Palaver and posturing should not get in the way of real progress, which will be measured in terms of real lives and the difference that intelligent and compassionate social programs can make. Noam Chomsky once said, "The sign of a truly totalitarian culture is that important truths simply lack cognitive meaning and are interpretable only at the level of 'Fuck You', so they can then elicit a perfectly predictable torrent of abuse in response." Let's hope that the continuing controversy over harm reduction and safe injection sites will not sink to that level.


1. Leshner AI. By now, "harm reduction" harms both science and the public health. Clin Pharmacol Ther. 2008 Apr;83(4):513-14.

2. Pauly B. Harm reduction through a social justice lens. Int J Drug Policy. 2008 Feb;19(1):4-10.

3. Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver. Int J Drug Policy. 2008 Feb;19(1):11-16.

A PDF version of the Expert Advisory Committee's report has been created by David Eaves (www.eaves.ca) and is available here.

And here are the reports from the independent researchers as provided by the Vancouver Sun: http://www.canada.com/vancouversun/pdf/FinalCost-BenefitAnalysis_.pdf http://www.canada.com/vancouversun/pdf/finalEnvironmentalScan-IDU.DOC http://www.canada.com/vancouversun/pdf/boydetalfinalsis.pdf

14 April 2008

PubMed sends out a few new blooms: simplified web links

As the snow melts under the tall spruces around my house and flocks of Canada geese honk in the skies overhead like roaring twenties traffic, the blooming bottle brush trees and ocotillos of Palm Springs occupy my dreams, disquietingly alien, like science fiction flora. The Day of the Triffids meets flip-flops and Ray-Bans. On a California oldies station a snatch of the opening number from The Rocky Horror Picture Show: "And I really got hot when I saw Janette Scott / Fight a triffid that spits poison and kills." Those lurid red blooms nodding in the desert breeze seem to be searching for something. My pale raw flesh perhaps? The desert is strangely alive with growing things.

Half a continent away from the riotous brittle bushes of Tahquitz Canyon, flowers are merely in potentia here as the earth slowly thaws and scatters the snow lice in my boreal soul. But spring has come. Like my labs, I'm blowing my coat after a snarling winter. Frisking red squirrels and fisking politicians are chattering away, the sun's warmth is infectious, and my thoughts turn towards spring cleaning, perennials, and ... PubMed updates.

A recent NLM Technical Bulletin informs us that the URL parameters used to generate web links to PubMed have been simplified. I hadn't realized they were excessively complicated, but I'm all for simplicity, and I suppose eliminating the tiresome "entrez" filler in PubMed URLs is progress. I never did see the point of it. Although you'd think it would have made more sense to dump "entrez" during the past francophobic furor, when victory fries were flung in the face of l'ennemi du jour, that nation of cheese-eating surrender monkeys.

Creating Simplified Web Links to PubMed
Nothing of earth-shattering importance here, but the Bulletin's terse summary is as digestible as human flesh to a triffid and saves trawling through the user guide. It gave me some ideas about how I might use these PubMed features more frequently.

1. Simplified URL
The base URL to retrieve citations and search PubMed is http://www.ncbi.nlm.nih.gov/pubmed/. Just add the PMID. I would have liked it even better if they could have eliminated most of the alphabet soup. What prevented them from achieving a del.icio.us-like simplicity by allowing us to use http://pubmed.com? This very simple URL actually works, even with a PMID stuck on. Now that's spitting poison. Pubmed.com is resolved into an ncbi.nlm.nih.gov-type URL. But, curiously, not the new, "simplified" URL that is the subject of this announcement. If, for example, you enter


it resolves to the following:


You get to the citation, but there's that annoying surrender monkey word in the non-simplified URL. Can anyone explain why this happens?

2. Retrieve one or multiple citations

Here's something that I haven't used much. You can separate PMIDs with a comma after the base URL to retrieve citations in the default AbstractPlus HTML format:


My staff use this trick regularly to call up multiple records in order to print articles for our patrons from written requests. I can see myself using it — along with the code to change the format to text (see below) — for producing quick, painless citations.

3. Change the format
To change the format from html to text, use format=text:


I like the way this technique lets you create a quick-and-dirty citation, no matter which display you're working from. Go up to the URL, erase everything after the question mark, and enter the code "format=text." Remove the carriage returns from the resulting citation, erase the extraneous text, and you have a decently formatted citation. (It would be so nice if PubMed had a convenient button for each reference which would create a proper citation in one of the leading bibliographic formats and copy it to the clipboard for easy insertion into a document. But I'll make do with this.)
Wiswell TE. John K. Lattimer Lecture. Prepuce presence portends prevalence of potentially perilous periurethral pathogens. J Urol. 1992 Aug;148(2 Pt 2):739-42. No abstract available. PMID: 1386390 [PubMed - indexed for MEDLINE]
Of course, the easiest option is to find the reference in PubMed and select Text on the Send to pull-down menu. Send multiple references to the Clipboard first and then send to text. But make sure you're looking at the Summary display. If you send to text from the Abstract display, you're left with a fragmented citation full of blank lines, even more extraneous material to delete, and all the clicking-cutting-pasting that spells kluge.

Until we get that magic button, I'll continue to use this method for quick citations from PubMed. I know that a program like RefWorks will give me perfectly formatted citations, but all the required loading and clicking and waiting is too much effort just to produce a simple reference to insert into a blog post or an email.

4. Change the display To change the display, add the URL parameter ?report=display (where "display" is the name of the desired PubMed display format such as citation, MEDLINE, etc.).

5. Search strategy URLs:
To search PubMed, use the URL parameter ?term=search (where "search" is the actual strategy):


Note that the + sign takes the place of spaces, which are not allowed in the URL. This looks less useful. It's the rare day that my searches are so simple.

My NCBI Collections added to PubMed Send To Menu
Finally! I think everyone will appreciate this small improvement. My NCBI Collections is now available as a selection under the PubMed results Send to menu. Sending results to a Collection was previously only available from the Clipboard. Works like a charm.

11 April 2008

From critical care to comfort care: the sustaining value of humour

He who has laughter on his side has no need of proof. ~ Theodor Adorno, Minima moralia

(Plagiarized from a UPI news item)
A study by a Winnipeg researcher shows that humour can play an essential role in intensive or end-of-life care. Continuing research begun in her 2003 dissertation, Ruth Dean of the University of Manitoba Faculty of Nursing, with her colleague Joanne Major, a nurse at the Health Sciences Centre, spent hundreds of hours observing and carrying out interviews with staff, patients and families in an intensive care unit and a palliative care unit.

Their paper, published in the Journal of Clinical Nursing, demonstrates how health care staff use humour not only to reduce tension and express frustration, but to connect with patients, making them feel cared for as individuals and alleviating their embarrassment. They conclude that humour plays an essential role in promoting team relationships and adding a human dimension to the care and support of seriously ill patients and their families. "Our research suggests that nurses and other health care professionals don't need to suppress humour," Dean said in a statement.

The researchers found that staff used humour in a number of ways:
  • To cope with, and sometimes distance themselves, from difficult situations. As one person commented: "When you've had the most stressful day and you're ready to cry, sometimes it's easier to bring out humour and take it in the other direction instead of bawling on somebody's shoulder."
  • To connect with other health care professionals and provide mutual support. Shared laughter energized and nurtured a sense of community. "If you have those fun moments and that connectedness even the worst hell can happen," said one person who worked with terminally ill patients. "You sail through it as opposed to walking out really wounded."
  • To reduce tension when things don't go as well as they could do. A doctor who admitted he had been hasty suggesting that a terminally ill man give up his apartment so soon was greeted with the quip: "Shall I chart that you made a confession or that you made a mistake?"
  • To express frustration at life-prolonging measures that staff disagreed with. Staff in the intensive care unit told researchers how they paralleled what was happening to one patient by using an inflatable dinosaur called Dino and putting him through the same interventions. He became a symbol of their dissatisfaction with the situation.
  • To connect with patients and make them feel cared for as individuals. When a health care aide took a joke picture of a patient with a bubble bath helmet on his head to put him at ease, it became one of his prized possessions. He showed it to everyone who visited as evidence of the special treatment he was receiving. And when he died, it was displayed alongside important family photos.
  • To reduce patients' embarrassment with the indignity of needing help with toileting and other highly personal functions. When a patient suffered an episode of incontinence she reported that she found the nurse's matter-of-fact humour — "what goes in must come out" — made her feel less distressed.
It wasn't just the staff who used humour to alleviate difficult situations. One nurse recalled how a patient's monitor kept going off in the intensive care unit. "Don't worry, if I can hear it I'm still alive," the patient joked.

"Some people feel that humour is trivial and unprofessional in health care settings, but this study shows that it is neither," said Dr. Dean. "Despite major differences between the work of the intensive care and palliative care units, they are both areas where serious illness, high anxiety and patient and family distress are prevalent and staff are placed in emotionally demanding situations. Crises are frequent, death is close by, and emotions tend to run high."

The authors conclude that humour was very important in these stressful health care settings. "One member of staff referred to humour as the glue that holds human connections together, a statement that was clearly reinforced by our findings," said Dr. Dean. "Our research suggests that nurses and other health care professionals don't need to suppress humour. They should trust their instincts about when it is appropriate. Combined with scientific skill and compassion, humour offers a humanizing dimension in health care that is too valuable to be overlooked."


Dean RA, Major J E. From critical care to comfort care: the sustaining value of humour. J Clin Nurs. 2008 Apr;17(8):1088-95.

22 March 2008

"Flush tissue with stool": the problem of low health literacy in Canada

All Canadians must have the tools to take responsibility for their own health and the health of their loved ones. This includes access to up-to-date and accurate health-related information as well as the tools required to understand and use this information. ~ How low literacy can affect your health (Canadian Council on Learning)

Last January I wrote about a particularly atrocious example of patient information, a poop test brochure, which, among other things, advised the reader to "flush tissue with stool." Have you ever tried flushing a toilet using a stool, let alone trying to repeat the step "on the next two subsequent bowel movements?" It's not easy, let me tell you.

Every time some hapless patient is forced to struggle through the opaque vocabulary and convoluted syntax of the Coloscreen brochure published by Helena Laboratories in Beaumont, Texas, you can almost see the illiteracy ratio and mortality rate starting to rise on the charts. Whoever wielded the applicator stick that smeared this rank prose specimen into print has a lot to answer for, as has the Winnipeg health clinic that decided it was appropriate to give to patients [1]. For we have become a country of the reading challenged, where even Robert Service's unpretentious, galumphing strophes, which my Grade 4 class once recited with pleasure, are becoming artifacts of another age. For school kids hooked on Halo and Twitter, The Cremation of Sam McGee will soon be as obscure as Horace's Alcaics; although I see that someone has posted a video of McGee on YouTube. Perhaps this will become a trend: literary works preserved for the print-allergic population as YouTube presentations — bardic recitation in the digital realm. An abomination like the poop test brochure is not the kind of challenge we really want. A health brochure's business is to communicate important facts that will help guide a person to make good health decisions. How did we reach such an impasse: that we can produce neither texts that communicate nor readers who comprehend them?

A vision for a health literate Canada
This month another study is bringing bad news about Canadians' ability to read. "Low health literacy is a serious and costly problem," says a recent report from the Canadian Public Health Association. A vision for a health literate Canada was released on March 3, 2008. A CPHA Expert Panel found that a majority (more than 55%) of Canadian adults do not have the skills to understand information about their own health or to make daily health-related decisions. The low levels of health literacy in Canada are "critical" and a countrywide strategy is needed to solve the problem.

The panel's findings were drawn from a 2003 analysis of 23,000 Canadians by the Canadian Council on Learning, which offers its own take on the problem in a March 6 report on its website, How low literacy can affect your health. See also another CCL report dated February 28, 2008, Health literacy in Canada: a healthy understanding.

Videosphere vs. Graphosphere
What is the nature of this literacy problem, which is certainly not unique to Canada? It seems likely that Fahrenheit 451's flame throwers will never be required. As young people's desire to read is assiduously burned off in what Régis Debray calls the era of the videosphere, and as cultural and political discourse becomes increasingly infused by and confused with the ruminant world of the cartoon or the video game, elites will not crease their linen worrying about proletarian revolution. In a typically quirky but thought-provoking essay published in the New Left Review [2], Debray laments the loss of the graphosphere, the era of printing that made possible the Enlightenment and progressive social change. In his schema this passing age is being replaced by the era of the image, the videosphere, in which the book is knocked off its pedestal and replaced by widescreen, gridlinked digital culture. Debray offers an arresting image of the possible political consequences of the drift from the printed word to digital prattle:
A practical example: to find out what is going on one has to watch TV, and so stay at home. A bourgeois house arrest, for beneath "a man’s home is his castle" there always lurks, "every man for himself." The demobilization of the citizen begins with the physical immobilization of the spectator.
Very much like Ray Bradbury's dystopia. And today's video-capable mobile devices could act like a digital equivalent of ankle bracelets to keep our minds virtually immobilized. According to Debray, the Internet, its access devices, and the jet plane are good for internationalization, but they are lethal for progressive politics and international solidarity. They enlarge the sphere of individual relations but privatize them at the same time; they particularize even as they globalize. And it is the isolated, atomized individual who makes the ideal consumer and the credulously passive subject of the state.

A digression: lexemes and publishing extremes
Strange, then, that even as some thinkers mourn the loss of literacy and the end of solidarity, consumers at all levels of the literacy scale are buying extraordinary amounts of reading material, some of it even subversive of the ruling order. I find it difficult to reconcile the massive size of the English-language publishing industry and the continuing problem of low literacy. To illustrate, a brief note by Daniel Soar in the London Review of Books for 7 Feb 2008 cites the annual turnover of the British publishing industry as £2.8 billion. That's 900,000 books flying off British bookshop shelves every day, or one book for every nine loaves of bread sold in the UK. A lot of bread, however you look at it. In Canada book sales are healthy as well. The overall value for Canadian consumer book sales for 2006 was $1.59 billion. The Association of American Publishers reported that U.S. publishers had net sales of $25 billion in 2007. Book sales were up 3.2% over 2006, with a compound growth rate of 2.5% per year since 2002.

The average person has never been so well educated. Look at the size of an adult's working vocabulary today. According to the linguist David Crystal [3] it's 50,000 words. That represents the average adult's active vocabulary in present-day Britain. The estimate of passive vocabulary (words that can be recognized but would not be used in speech or writing) is roughly 25 per cent larger. Modern vocabularies are simply enormous. There are approximately 400,000 lexemes (actually differing words, not including various forms of the same word) in the Oxford English Dictionary which make up Modern English vocabulary. A reasonably well-educated person with a working vocabulary of about 50,000 words is thus actively employing about 12 per cent of the word stock of the language. By comparison, Shakespeare was working with a word stock of 150,000 lexemes. The size of his vocabulary is approximately 20,000 lexemes. This means that Shakespeare was using something over 13 per cent of the total word stock available to him. That total was probably much higher than his contemporaries, and it was certainly well ahead of the linguistically conservative King James Bible, which has only 8,000 lexemes. But it's extraordinary to think that the average educated working person in most English-speaking countries has a larger active vocabulary than the Bard himself. Obviously social status plays an important role here, something that Crystal does not discuss. Those buyers of books and users of dictionaries are less likely to be from the low-income strata of society.

Health literacy facts
But let's get back to the facts about health literacy. Whatever we may think of Debray's lofty theorizing and the remarkable vocabularies of the average adult, the fact remains that four out of ten Canadians still struggle with low literacy. And we have solid research to show how this affects the health of Canadians. What do we now know about the state of health literacy in this country?
  • 11.7 million working age residents of Canada (55%) are estimated to lack the minimum level of health literacy needed to effectively manage their health information needs. (CCL, 2007)

  • When seniors are added, an estimated 14.8 million may be without adequate health literacy skills. An estimated 88% of respondents 65+ fell below Level 3 on the Health Literacy Scale, which is considered the minimum level of proficiency required to meet the demands of modern day life including those posed by health information. (CCL, 2007).
  • Canadians aged 16 to 65 who rate their health as excellent or very good have the highest levels of proficiency in health literacy. People who rate their health as fair or poor have the lowest levels of proficiency. People with the lowest health literacy skills are more than three times as likely to report fair or poor health. (Outcomes from the National Symposium on Health Literacy, CPHA, 2008)
  • A recent American study examined mortality rates of a group of 3,260 adults over age 56 in four metropolitan areas and found that those with inadequate and marginal health literacy levels had a 50% higher mortality rate over a five-year period than those with adequate skills. Low health literacy was the top predictor of mortality after smoking, and was a more powerful variable than both income and years of education. (Outcomes from the National Symposium on Health Literacy, CPHA, 2008)

Dr. Irving Rootman, chair of CCL's Health and Learning Knowledge Centre and co-chair of the expert panel, provides the following grim statistics in his PowerPoint presentation: Health Literacy and Public Health [PPT]:
  • Over 800 studies have found that health-related material for patient education far exceeds the reading levels of the average adult.
  • A recent study of health information websites in Canada, the U.K. and Australia found that the content of all sites was written at a higher level than recommended by literacy organizations. The lowest level was grade 11.

  • Low health literacy is a barrier to effective self-management of chronic disease. A review of randomized control trial studies found that 62% of patients with lower reading skill levels were unable or unwilling to engage in self-management.

Despite the excellent work of CPHA and CCL, I'm afraid I don't have much hope that our literacy rates will greatly improve without serious social change. After all, quickly sending their own clear message about the depth of their commitment to such change, the Conservative government wasted no time in cutting nearly $20 million from adult literacy programs back in 2006. The unerringly empathetic John Baird, the minister overseeing the cut, explained at the time: "I think if we're spending $20 million and we have one out of seven folks in the country that are functionally illiterate, we've got to fix the ground floor problem and not be trying to do repair work after the fact." Funny, but I thought doing gimcrack repairs was the government's answer to most of Canada's social problems — either that or just cutting costs and programs outright, at least the type that don't get noticed at a G8 summit. One of Harper and Co.'s bright ideas for fixing the ground floor problem of health literacy has been to cut the Canadian Health Network website, which specializes in plain-language consumer health information. By the way, CHN has a good article on Canadian health literacy: Beyond words: the health-literacy connection. But you'd better look now, because whether you can read or not, it won't be available from CHN come April Fool's Day.

The role of the media
The media aren't much help either. For all their health beats, ambulance chasing, and obesity scares, by excluding or marginalizing other perspectives — notably, a more explicitly political analysis of the origins of illness — the media play a significant part in actually narrowing public debate about health, illness and medicine, and they are not helping to fix Mr. Baird's ground floor problem either. A Social Science and Medicine article [4] that looks specifically at Canadian newspapers goes on to conclude:
The absence of any discussion about social gradients in health indicates that newspapers do not find the central observation driving the population health perspective in public policy newsworthy. Even the stories that we have classified as being concerned with the social environment largely fail to discuss broad issues of the welfare state in relation to health—housing and housing policy, child development and related issues of education and child care, the social relations of work environments (as opposed to exposures to physical hazards), community design and urban infrastructure, etc. Implicit in the obsession with issues of health care is the notion that this aspect of the welfare state is singularly important to maintaining and improving human health. Debates as to whether investments in the health care sector come at the expense of investments elsewhere within the welfare state (in education, housing, income supplementation, etc.) rarely appear in Canadian newspapers. Newspapers appear to do little to advance levels of critical health literacy on broad determinants of health in Canada.
A tissue of equivocations
If we are to avoid the bourgeois house arrest of Régis Debray's isolated, passive consumers of the videosphere, we must not approach the issue of health literacy in passive isolation. It is well known that the determinants of literacy include: education, early childhood development, aging, living and working conditions, personal capacity/genetics, gender and culture [5]. These are basically the same as the social determinants of health. Literacy should be framed within an empowering paradigm that highlights opportunities and choices for people. Unfortunately, the way the media deal with the issue has been devoid of empowerment. The blatant fostering of disease-laden imagery (e.g., “stamping out the epidemic of illiteracy”) is one such counterproductive example. It is not helpful either when literacy is promoted — wittingly or unwittingly — as the predominant solution to Canada’s economic woes. What the public often gets from journalists and politicians is a tissue of equivocations.

Literacy or the lack of it should not be separated off from its social context. Nor can the solution to poor literacy be found in some bureaucratic, gimcrack program. Perhaps John Baird was right. We should stop throwing money into programs that are not truly connected to broader efforts to change the determinants of health. But he is wrong to think that anything will change without a radical program to reduce social and economic inequity in Canada.

Like the problem of homelessness in Canada, the baleful reality of illiteracy has been studied very thoroughly. As many experts familiar with the facts will admit, we have known for years what the reports are telling us over and over again. Is it any surprise, for example, to be told that "daily reading appears to be a strong determinant of health literacy?" Good heavens, Francis Bacon was saying that "reading maketh a full man" four centuries ago.

The recommendations of the most recent report are what one might expect: we need a comprehensive, coordinated, cooperative, and integrated pan-Canadian strategy on health literacy, involving all levels of government. We also need educators, bureaucrats, and health professionals who are able to communicate in plain language [6]. And, as always, more research is required. There is nothing new here. Rather than more paper, Canadians need leadership that is truly responsive to people's needs, with the political will to increase social inclusion, reduce income disparities, and uphold everyone's right to equitable health care, housing, education, and employment opportunity. As the Expert Panel conclude, "The question is: are we willing as a country to make the investment that is required to create a health literate Canada?"

Test your health literacy (from the Canadian Council on Learning website)

Can you correctly answer this example question?

Imagine your child is 11 years old and weighs 85 pounds. According to the chart below, how many 80 mg tablets of Tempra can you administer to your child in a 24-hour period and in what dosage?


1. Rootman I. Health literacy: where are the Canadian doctors? CMAJ. 2006 Sep 12;175(6):606.

2. Debray R. Socialism: a life-cycle. New Left Review. 2007 Jul-Aug;46:5-28.

3. Crystal D. The stories of English. London: Penguin; 2004.

4. Hayes M, Ross IE, Gasher M, Gutstein D, Dunn JR, Hackett RA. Telling stories: news media, health literacy and public policy in Canada. Soc Sci Med. 2007 May;64(9):1842-52.

5. Rootman I, Ronson B. Literacy and health research in Canada: where have we been and where should we go? Can J Public Health. 2005 Mar-Apr;96 Suppl 2:S62-77.

6. Stableford S, Mettger W. Plain language: a strategic response to the health literacy challenge. J Public Health Policy. 2007;28(1):71-93.

Health literacy reports
Canadian Council on Learning.

Health literacy in Canada: A healthy understanding, February 2008. This report reveals that daily reading outside of work is associated with higher health literacy scores.

Health Literacy in Canada: Initial Results from the International Adult Literacy and Skills Survey (IALSS), September 2007. Provides Canadians with a country-wide snapshot of health literacy.

Canadian Public Health Association.

A Vision for a Health Literate Canada, February 2008. The CPHA Expert Panel on Health Literacy found a majority of Canadian adults do not have the skills needed to respond to daily health information demands. Low health literacy is associated with poor health and the Panel estimates that the situation in Canada is critical.

The Ontario Health Promotion E-Bulletin of 20 March 2008 provides an excellent list of Canadian resources on health literacy.

Recent articles in mainstream media on health literacy
The Toronto Star, March 4, 2008 Alarm raised on health literacy, by Meghan Ogilvie, http://www.thestar.com/living/article/309115

CBC March 4, 2008 Canadians illiterate about health, report says, http://www.cbc.ca/health/story/2008/03/04/health-literate.html

I like to think that when I fall,
A rain-drop in Death's shoreless sea,
This shelf of books along the wall,
Beside my bed, will mourn for me.

Robert Service, Bookshelf

16 March 2008

Storm and strife as the Canadian Health Network approaches the chopping block

It is not in the storm nor in the strife
We feel benumb'd, and wish to be no more,
But in the after-silence on the shore,
When all is lost, except a little life.

Lord Byron, On hearing Lady Byron was ill

With a pair of sqawkingly incongruous dangling participles, the Canadian Health Network (CHN) has announced its own demise and its absorption by another government website:

Beginning April 1, 2008, Canadians will be able to access timely, trusted and credible public health information through a single source — the Public Health Agency of Canada’s Web site at www.publichealth.gc.ca. Accessed by over 10 million visitors a year, we invite you to bookmark this Web site as a valuable and unique source for information on healthy living, disease and injury prevention.
In their haste to liquidate this last vestige of independent, community-based health information from the government's official web presence, some faceless committee also succeeded in mutilating the English language as part of their dirty work. As if that wasn't depressing enough, there is now little doubt that the voices of nearly 4,000 Canadians who have signed a petition pleading for the CHN's preservation will be ignored. But we can still shout up a storm until the end of March, when, the Friends of CHN website informs us, Liberal Health Critic Robert Thibault will present the petition to the House of Commons, requesting that Parliament rescind the funding cut and immediately restore full, stable funding for the Canadian Health Network.

Much more fluid in its syntax was the succinct form letter I received from Tony Clement, the Minister of Health, with its admission that the decision to "terminate" the Canadian Health Network was "difficult, and was by no means arrived at without thoughtful consideration." But, as always, there are "other equally important health priorities that require government funding." Yes, like the one billion dollars a year that our military adventure in Afghanistan is costing us and the frightful, ongoing costs of caring for all the Canadian wounded, of whom we hear remarkably little in the media. The Minister likes the idea of providing health information through "a single, consolidated website." Somehow that is supposed to ensure that "more Canadians will have access to quality and trusted health information." I would very much like to know how dumping the CHN is going to provide more people with information.

And as the Social Justice Librarian justly pointed out in a recent post, "it’s one thing to take away a really great consumer health resource. It’s another to take it away and leave a pointer referring people to another resource that is virtually useless for the same type of information seeking!" A query of both the Public Health Agency of Canada and the Health Canada websites provided no comprehensible results to a question she and a student posed concerning the relationship between abortion and breast cancer. By contrast, when CHN and MedlinePlus were consulted, they offered reliable, consumer-friendly information when searched with the same key words.

The quality of that service does not seem to have been of great concern to my MP, James Bezan (Selkirk-Interlake). In his response to my complaint about the axing of CHN he pleaded lack of funds. "The Conservative Government has had to make decisions as a result of cuts to spending made in the previous government's ... budgets." That's it. Blame it on the Liberals. Mr. Bezan assures me that "moving from three sites to two will result in saving $7 million per year" — enough to keep the Afghanistan "mission" going for about two days. I am to "rest assured that PHAC will work with CHN in the transfer of information ... wherever possible." The last two weasel words, of course, mean that exactly nothing is promised.

Nothing in Mr. Bezan's letter makes me feel rested or assured. In closing he respectfully counsels me once again to "rest assured that Canadians will continue to have access to the important healthcare information they need." The importance and the need, we can all rest assured, will be determined solely by our wise leaders in Ottawa, whose "thoughtful consideration" has burdened the country with an $18-billion defence budget, the highest level of military spending in inflation-adjusted dollars since the Second World War.

Even if you're feeling benumbed, please sign the Save the CHN petition and write to the Minister of Health and your Member of Parliament.
Augustus was sensible that mankind is governed by names; nor was he deceived in his expectation, that the senate and people would submit to slavery, provided they were respectfully assured that they still enjoyed their ancient freedom.

Edward Gibbon, The decline and fall of the Roman empire, Chapt. 3.

10 March 2008

Oh Brother: the Ontario health minister joins the Soggy Bottom Boys

... nearly blowed us into shivers and smithers. ~ Charles Dickens, Our Mutual Friend, Bk. 4, Chapt. 13

Ontario's health minister, George Smitherman, was singing his own version of Man of Constant Sorrow last month. He made a bad mess worse when he responded to criticism of the treatment of the elderly in the province's nursing homes by blurting out that he was prepared to don an adult diaper — and use it — to justify his government's policies. Not surprisingly, this singular outburst didn't sit well with an outraged public. Advocates for the improvement of personal care homes have complained for years that standards are poor, that homes are understaffed, and that private companies such as Extendicare endanger patients by pressuring their employees to cut costs.

The Ontario Association of Non-Profit Homes and Services for Seniors says seniors in nursing homes should be getting at least three hours of personal care; it says the average in the province is now about 2.5 hours a day. The Canadian Union of Public Employees (CUPE), which represents many nursing home workers, says the standard should be 3.5 hours. Many studies have shown that without proper staffing and adequate standards the quality of care plummets. Front-line nursing home staff in Ontario report that residents are sitting in deplorable conditions. Incontinence products are often kept under lock and key, and many homes are directing staff to change residents only when the product is 75% soiled.

On February 27, two long-term care workers used four bottles of water to fill an adult diaper at a CUPE press conference in Toronto. They wanted to show how much urine had to be in a diaper before care aides were allowed to change it under current legislation. With stunning insensitivity Smitherman said in response that he was ready to test out an adult diaper to show criticism was unfounded. “I’ve got one of these incontinence products — albeit a new one, not the ones that tend to appear at committee — on my desk and I’m really giving this matter very serious contemplation,” Smitherman said. It wasn't only critics of the Liberal government who were angry. There were loud calls for the minister's resignation, even within his own caucus.

Wags and cynics sharpened their quills. March 1st's National Post published an imaginary Smitherman diary entry, with entries like this:

Major confession, diary. I tried out an incontinence diaper today. It was so ... freeing. I had three large coffees ... and then I sat through a three-hour meeting with a bunch of bureaucrats. No pee breaks! It was so much more efficient. Made a bit of a stumble at lunch, though, by having the side dish of asparagus. Won't make that mistake again! I think this will really help in my discussion with the nurses' union. Five hours seems to be the limit before things get a little soggy. I think I'll publicly float the idea tomorrow. Right after I shoot up an eight-ball of smack to get a better feel for drug addiction.
Of course, an apology followed immediately. "I wasn't trivializing the matter," Smitherman said. "I take it really, really seriously." Not surprisingly, the minister couldn't be reached for comment afterwards; but his "diary" entry gives us some insight into why:
After I came in from my night on the streets yesterday morning, Dalton [Premier Dalton McGuinty] called and ordered me to apologize for the diaper "stunt." I explained that I only thought it would gain a better understanding of the issue, but he wouldn't listen. "Also, George," he said, "please tell me you weren't wearing one in my office the other day. Because I thought it smelled like asparagus, if you catch my drift." I told him my cellphone was cutting out and I hung up.
Sam Solomon, writing in his blog Canadian Medicine, adds that this isn't the first time that "Furious George" has run off at the mouth:
Speaking about new building plans suggested by some hospital boards in Ontario, Mr Smitherman dismissively referred to the expensive proposed upgraded facilities as "Taj Ma-hospitals."

His most famous outburst was featured on Stephen Colbert's American parody politics talk show in 2005. Talking to none other than an assemblage of the Ontario Association of Optometrists, Mr Smitherman called optometrists "a bunch of terrorists, and I don't negotiate with terrorists." "Bravo, sir," Mr Colbert said. "Optometrists are a menace. You have to be careful with a group that gets their kicks blowing air into our eyeballs."
Smitherman’s bizarre antics were dismissed by Sid Ryan, president of CUPE's Ontario chapter, who said the minister completely missed the point. The problem isn’t the products, but the cruel reality that residents in long-term care facilities are forced to wear soiled diapers through the night and sometimes up until noon the next day. “If the minister wants to play silly games, well then, let him put on a diaper and sleep in it all night long and come into the legislature and wear it up until 12 o’clock,” Ryan told the Canadian Press.

Could the problems so clumsily dealt with by Ontario's health minister be related to the fact that in Ontario 60% of all publicly funded long-term care beds are in for-profit institutions, as compared with 15% in Manitoba [1]? There is ample research to show that public investment in not-for-profit, rather than for-profit, delivery of long-term care results in more staffing and improved care outcomes for residents [1,2]. Instead of experimenting with adult diapers, perhaps Mr. Smitherman should try absorbing some of these important statistics. There are a lot of excellent health libraries within throwing distance of the Ontario legislature.


1. McGrail KM, McGregor MJ, Cohen M, Tate RB, Ronald LA. For-profit versus not-for-profit delivery of long-term care. CMAJ. 2007 Jan 2;176(1):57-8.

2. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, Ronald L, Cvitkovich Y, Beck M. Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter? CMAJ. 2005 Mar 1;172(5):645-9.