THIS MAN’S AIDS BREAKTHROUGH SHUNNED BY HIS OWN COUNTRY

Photography - imaging by marlis

(Update: A week after I wrote this, the Governor-General announced that Dr. Montaner had been appointed an Officer of the Order of Canada. Fancy that! http://www.gg.ca/document.aspx?id=15922&lan=eng )

Dr. Julio Montaner is hailed world-wide for his critical contribution to combatting the spread of HIV/AIDS. His aggressive treatment methods are in the forefront in Africa, in Brazil, in China and in Europe. But what does he get from Canada’s political leaders, outside his own province of British Columbia? A big, fat, collective cold shoulder.

While his landmark Treatment as Prevention strategy to stop transmission of HIV is now the cornerstone of UNAIDS’ ambitious goal to eradicate the AIDS epidemic by 2030, no province except B.C. has fully embraced it. Nor is it part of Health Canada’s approach to treatment. At the same time, despite a string of international awards that would make anyone blush, including one from, of all people,  the president of Austria,

Dr. Montaner is not even a member, officer or anything else of the Order of Canada. Austria, yes. His own country, no. It’s hard to escape a conclusion that this is the reward someone gets for speaking out against the federal government over its lack of action on AIDS and its “ideological” opposition to Vancouver’s safe-injection facility, Insite. images-4

Yet, as B.C. Health Minister Terry Lake put it last month, while announcing yet another award for Dr. Montaner, who was named to the Order of B.C. in 2010: “Nobody in Canada has made a bigger contribution to the field of HIV/AIDS research and treatment.”

I would go further than Minister Lake. Dr. Montaner may have done more than any living Canadian to save lives around the world. Although such a statement would undoubtedly make the brilliant, passionate researcher uncomfortable, it is certainly arguable.

From his modest, cluttered office among the maze of workplaces at venerable St. Paul’s Hospital in downtown Vancouver, Dr. Montaner has spearheaded treatment and programs administered to millions of Africans and others throughout the world. As a result, the impact of HIV/AIDs is slowly beginning to recede, and the dream of an AIDS-free planet is no longer mere fantasy.

Dr. Montaner is the first to point out that this has hardly been a one-man show. Many colleagues and other researchers have contributed to these advances, as well. But none perhaps with the intensity and drive of the longtime head of B.C.’s renowned Centre for Excellence in HIV/AIDS. Under his watch, employing the powerful anti-retroviral drug cocktail (HAART), originally devised by Dr. Montaner, AIDS has gone from a virtually-certain death sentence to a chronic, manageable disease.

He then went on to pioneer the game-changing Treatment as Prevention. In a recent interview, on the eve of World AIDS Day, Dr. Montaner spent most of the time celebrating the dramatic progress in the global fight against HIV/AIDS. Just this fall, UNAIDS announced its bold 90-90-90 program, with the target, as mentioned, of ending the AIDS epidemic as we know it within 15 years. Treatment as Prevention, of course, forms the core of the UN body’s stepped-up assault. DrJulioMontaner_0-1 But near the end of our conversation, Dr. Montaner began to reflect on the situation back home in Canada, where other provinces and the federal government continue to shun the proven treatment program that saves lives and reduces the spread of HIV. His mood darkened. “People are sitting around, looking the other way, because this is not a daily epidemic, or something,” he told me. “I can’t shake the feeling that is wrong. That is deeply, deeply wrong. And it tells me something about human nature that I don’t want to accept.”

In our many encounters over the years, I had never heard him sound so morose. Angry and frustrated. But never gloomy. The premise of Treatment as Prevention is simple. HAART not only halts the killer nature of the virus, it was found to reduce a patient’s viral load to such minimal levels, the danger of passing on the virus is negligible. Hence, if enough patients are treated, transmission can be stopped in its tracks.

B.C.‘s full-bore employment of Treatment as Prevention, seeking out those on the margins of society and providing drugs free of charge, has slashed the rate of new HIV infections by more than 70 per cent. This in a province whose drug-riddled, impoverished Downtown Eastside area in Vancouver once had the highest HIV infection rate in the developed world. In the rest of the country, meanwhile, the number of new cases is on the rise, highlighted by an alarming increase among First Nations individuals in Saskatchewan.

As for Ottawa, its so-called national AIDS strategy has not been updated since 2004, and Dr. Montaner, for all his global tributes, can’t even get a meeting with federal Health Minister Rona Ambrose. No wonder his thoughts turned sombre. “When you think about the role model we have created for dealing with AIDS and HIV in British Columbia, it is probably one of the biggest public health successes in the history of Canada,” he said. “Yet we still don’t get the attention we should be getting. This little voice inside me keeps wondering why. Why is it that we have to work so hard for people to show their compassionate side?”

At 58, Dr. Montaner could retire from the field, content with an astonishing legacy of achievement. But his inability to make a similar mark in Canada propels him forward. “It drives me more perhaps than all the success we have had,” he said. “All the good stuff is all very nice, but it’s that dirty aspect of this business, that is so perverse, that is really what keeps me focused on going on. “Because we know how to do it,” he maintained. “We know what needs to be done. It’s right there in front of us. Yet here we have an epidemic that is out of control on the prairies, and a country that is not interested in talking about it. That is not acceptable.” Quite right.

In the meantime, at this festive time of the year, let us give thanks that we have someone as tireless and committed to the good fight as Dr. Julio Montaner. Few will be surprised to learn that he is currently planning to use the principles of Treatment as Prevention for yet new campaigns, beyond HIV/AIDS: against the growing scourge of Hepatitis C and further, against socially contagious afflictions such as smoking, obesity and addiction, itself. Will the man never slow down?

May I wish the Argentinian-born, raised and trained good doctor Montaner a very hearty Feliz Navidad.

REsised_Julio_Montaner P.S. Lest you think it’s presumptuous to suggest his induction into the Order of Canada, consider the following. For his vital efforts in the fight against HIV/AIDS, he has been showered with global recognition, including research bestowals, totaling $3.5 million. He served as president of the International AIDS Society from 2008 to 2010, and remains an elected member of its Council. In 2010, Dr. Montaner received the Albert Einstein World Award of Science for his “leadership and development of novel HIV treatment strategies with world-wide impact”. The same year he received the Prix Galien Research Award for “spearheading clinical trials that have revolutionized the management of HIV/AIDS.”

Next year, Dr. Montaner will be inducted into the Canadian Medical Hall of Fame. The lengthy list of tributes also includes that Grand Decoration of Honour for Services to Austria. “Dr. Montaner’s leadership and innovation in HIV and AIDS research has improved the lives of thousands of people in Austria and millions of people throughout the world,” explained Austrian ambassador Werner Brandstetter. If far-off Austria can find itself free to honour Dr. Montaner, why can’t Canada?

(A complete list is at the end of this lengthy Wikipedia entry on Dr. Montaner. http://en.wikipedia.org/wiki/Julio_Montaner )

THE WONDERFUL MICHELLE STEWART

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The sad, inevitable news came this weekend that Michelle Stewart, who had bravely endured so many health problems for so many years, had breathed her last. All those close to her, and there were many, knew it was coming, and Michelle knew it was coming. So the news was not a shock. But it cast a pall, nevertheless. I first knew Michelle only over the phone and through countless emails, as she endeavoured to get me information in her role as chief communications person for the health ministry. No one knew a department better than Michelle. She was special. I felt a real attachment to her. And I dare to think it was reciprocated, perhaps because, while we were two professionals doing different jobs, we knew that each of us cared passionately about the state of B.C.’s health care system. Of course, as I got to know her better after she “retired”, I realized just how much more there was to Michelle as a person, away from her job. Below, I’ve included some words of remembrance  that I posted on Facebook, an excellent piece about Michelle by Amy Smart in the Victoria Times-Colonist, a really fine tribute by Darwin Sauer who knew her very well, and the link to Michelle’s amazing blog, which, with incredible candour, recounted her struggles with eating disorders and end-stage renal failure. The blog includes heart-rending words from Michelle that she wrote to be posted after her death.

From my Facebook page: “I’m not sure there ever was a better, more courageous, more caring, more alive person than Michelle Stewart. She was also the best communications person I ever dealt with in all my years dealing with government flacks. She was never a flack. She was smart, she was comprehensive in her knowledge, and she got you the information, with no spin or bullshit, while also articulating the health ministry’s point of view. If you are new to Michelle Stewart, who was never in the limelight, read her blog. It will astonish you. Dear Michelle, please rest in peace, and I am sure you do.”

From the Times-Colonist: http://www.timescolonist.com/news/local/blogger-michelle-stewart-s-fight-against-illness-inspired-others-1.1065871

From Darwin Sauer: http://inmemoriamofmichelle.blogspot.ca

And Michelle’s moving blog: http://bessiamabloggernow.blogspot.ca/

A MEDICAL HERO

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Dr. Garson (Gary) Romalis never sought the limelight. He was thrust into it in the most terrible way, with two serious attempts on his life. Dr. Romalis was targeted because he provided abortions to desperate women, which of course are completely legal procedures, paid for by medicare.

The first attack came within an ace of costing him his life. A sniper’s bullet fired through his kitchen’s glass doors, as he ate breakfast, tore into his left thigh, rupturing a key artery. He would have bled to death on the kitchen floor, if he had not been able to use the belt from his bathrobe as a crude tourniquet. As it was, he spent months in hospital and never recovered completely.

Six years later, he was stabbed as he walked through his clinic’s office lobby. Again, he survived.

Sadly, Dr. Romalis did not survive a serious bout with pancreatitis earlier this year, and he passed away towards the end of January at the age of 76.

My full-length obituary on this remarkable man appeared in the Globe and Mail a few weeks ago. It’s here, if you missed it.

http://www.theglobeandmail.com/news/british-columbia/garson-romalis-risked-his-life-to-perform-abortions/article17052093/?page=all

He was exceptional in so many ways, and even with all that newspaper space, there were still aspects that had to be left out.

This is from a powerful speech Dr. Romalis gave in 2008, marking the 20th anniversary of the Supreme Court of Canada’s landmark decision that removed all restrictions from abortion access in Canada.

As he began, Dr. Romalis talked about a tragic case he encountered more than 50 years ago, when he was an aspiring young obstetrician/gynecologist at the University of B.C. It’s a chilling reminder of the dark days in Canada before abortion was permitted.

“I was assigned the case of a young woman who had died of a septic abortion. She had aborted herself using slippery elm bark,” said Dr. Romalis. “I had never heard of slippery elm. A buddy and I went down to skid row, and without too much difficulty, purchased some…Slippery elm is not sterile, and frequently causes spores of the bacteria that cause gas gangrene. When it gets wet, it feels slippery, making it easier to slide slender pieces through the cervix where they absorb water, expand dilate the cervix, produce infection and induce abortion.

“The young woman in our case developed an overwhelming infection. She had multiple abscesses throughout her body, in her brain, lungs, liver and abdomen. I have never forgotten that case.”

In addition to his courage and commitment to providing services to women in the face of the violent attacks against him, what I also found laudatory about Dr. Romalis was his modesty and quiet, yet determined approach to the cause. He was not a crusader, seeking neither recognition nor headlines, quite unlike his outspoken friend, Dr. Henry Morgantaler.

But his views were just as unwavering.  After his shooting, and those of other abortion physicians, he began to advocate for a woman’s right to an abortion in a way he hadn’t before, albeit still in his typical low-key manner. He did this through selected media interviews, mentoring young doctors in the provision of abortion services, and organizing a day-long teaching symposium. All this from a doctor who loved nothing better than delivering babies. (After my obituary appeared, several friends told me they had children delivered by Dr. Romalis. He hated giving it up, because of the physical toll of his injuries.)

“I didn’t sign on for danger pay. I didn’t think I would be on the front line in a war zone,” he told reporters. “These are acts of terrorism designed to frighten doctors into stopping performing abortions and they threaten the health of women.”

Of course, there was more to Gary Romalis than his heroism as a doctor. His good friend, veteran Vancouver lawyer Howard Shapray, cites his extreme loyalty, away from the stethoscope, to those around him. Shapray recounts his ongoing relationship with a former psychiatrist he knew well, who was later diagnosed with acute schizophrenia, ending up on the city’s bleak Downtown Eastside.  Dr. Romalis made a point of lunching with him almost every Saturday.

And when he switched from his long-time barber to a more conveniently-located hair trimmer, Dr. Romalis went to his old barber, apologized for making the change and gave him a bottle of Scotch. “Things like that were the measure of a guy,” Shapray says. “He was a man of complete integrity. He always wanted to do the right thing.”

Nor was Dr. Romalis without an irreverent sense of humour. Two years after the shooting, the Globe and Mail’s Robert Matas asked him what cautionary advice he provides for other abortion providers who might feel at risk: He replied: “I tell them to buy a bathrobe with a belt.”

Throughout his career, Dr. Romalis consistently stressed that an abortion – safe, legal, and relatively quick – can rescue a woman from the most stressful situation of her life. One day, after speaking to a class of UBC medical students, a student approached him, as he prepared to leave. She told him: “Dr. Romalis, you won’t remember me, but you did an abortion on me in 1992. I am a second-year medical student now. If it weren’t for you, I wouldn’t be here now.”

Garson Romalis, Braveheart, RIP.

 

 

TOP 10 LIST OF GOOD DEEDS BY BC GOVERNMENT

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Happy New Year, Premier Clark, wherever you are!

On such a bright, sunny, wintry morning, it’s hard to cast ill-will towards anyone. So, in the spirit of rare, Mickle positive thinking, here is my Top Ten list of good things done by the provincial government since May, when 44 per cent of the voters decided they should rule over us for the next four years. I’m sure I will recover soon and produce a more customary list of Top Ten baddies by the same Gang of Forty.

Anyway, here goes. Peace.

  1. After cynically accusing Vancouver Mayor Gregor Robertson of “playing politics” over the very real mental health crisis in the city, Health Minster Terry Lake came to his senses and announced some worthy, initial steps towards making a difference. These included a new psychiatric assessment and stabilization unit at St. Paul’s, plus funding for more, badly-needed outreach workers in the troubled Downtown Eastside. The Health Minister must know, however, that this “action plan” is hardly enough, so it’s also welcome news that a multi-pronged committee has been struck to map out more long-term solutions.

2. Kudos again to the ex-vet from Kamloops for standing up to Federal Health Minister Rona Ambrose, after her ideologically-driven, mean-spirited decision to cut off access to heroin for fragile patients enrolled in a special, harm reduction study. “We have to think outside the box sometimes,” Lake observed. “I know the thought of using heroin as a treatment is scary for people, but I think we have to take the emotions out of it and let science inform the discussion.” Well said.

3.  The recent five-year, exceedingly-modest, tentative agreements covering about 25 per cent of the provincial government’s public sector work force are astounding, and the first of their kind in B.C., a province once renowned for labour militancy. Union leaders decided the tiny wage increases were a worthwhile trade-off for the security of no reductions in pension and benefits until at least 2019. Whatever one thinks of the contracts, no one forced the unions to sign them, so it’s a big win for a government obsessed with its bottom line. And they weren’t even mean about it.

4. Okay, obviously no one knows how long the Clark government will continue to oppose the Enbridge pipeline. But, as of this moment, a bitumen conduit through B.C. and thence by super tanker through B.C. coastal waters to Asia is a non-starter for a premier who opens and closes cabinet meetings with incense and soothing chants of the mystical word ‘El-En-Gee’. Quoth Environment Minister Mary Polak, after the National Energy Board’s non-surprising “green” light for the proposed pipeline: “We are not yet in in the position to consider support for any heavy oil pipeline in B.C.” You hear that, Mr. Harper? No amount of googly eyes at Christy Clark is going to change that.

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5. Social housing remains a plus for the Liberals, with Mr. Mover and Shaker, Rich Coleman, seemingly still fired by determination to fund living space for “the poor”. As such, he has one of the strangest cabinet portfolios in the history of Canadian politics: Natural Gas Development and Housing. Thousands of new units of subsidized housing have been financed and built under Mr. Coleman’s caring watch, many in the Downtown Eastside and vicinity. Here’s a recap of what was done on the file in 2013. Of course, it’s never enough, but there is no sign of the pace slowing down in the year ahead.

6. Thank you, Christy Clark government, for finally agreeing to cough up the dough for a seismic upgrade of Vancouver’s historic Strathcona elementary school, more than 80 years after my mother dodged death by attending the earthquake-prone house of learning.

7.Um….

8. Er…..

9. Let me see….Anyone?

10. Oh well, there’s always next year….

(Suggestions welcomed to aid my trouble-ing mind.)

A WIN FOR THE GOOD GUYS

On a believe-it-or-not week when Canadians clamoured to listen live to our sedate chamber of relatively sober second thought and heard more than senatorial snores, some good news from Victoria managed to trickle through the crashing, rhetorical waves of the Poor Me Trio. Or, as The Current referred to them on Friday: “Messrs. Brazeau, Duffy and Wallin.” I guess that really makes Ms. Wallin one of the boys…. Anyway, the positive news was the long overdue restoration of government funding to an acclaimed institution that had friends and supporters everywhere, except in high places. Read all about it:

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It’s too bad that British Columbia’s most valuable guardian of the efficacy of new prescription drugs wasn’t called something grabby, like On Your Side or WatchdogBC. That might have slowed or even forced a halt to the seemingly methodical quest by the Liberal government to weaken its role and smooth the path of drugs to the province’s PharmaCare program.

As it was, the public found it hard to rally behind a review panel with the unhelpful title of Therapeutics Initiative. What the heck was that? No matter that its cautious approach to greenlighting drugs had saved hundreds of millions of dollars and many lives over the year, plus contributing to B.C. spending less per capita on prescription drugs than any other province in the country. Whenever the Therapeutics Initiative (TI) was raised as an issue, eyes of the public and editors would mostly glaze over, waiting for a return to pipelines or ferries or the miracle drug LNG, something that fit easily into an understandable headline.

But ‘big pharma’ certainly knew what it was, as did public interest advocates across North America, loathing and loving the Therapeutics Initiative in equal measure.

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The TI is a group of independent, research-minded faculty members at UBC’s School of Medicine. Since 1994, they have had the task of scrutinizing the cost and health benefits of new, often-expensive drugs promoted by brand-name pharmaceutical companies and assessing whether they should be covered by PharmaCare. Much to the annoyance of the drug companies, the TI regularly took its time. There was no rush to judgement. Nor was the TI shy about questioning, when warranted, the purported value of the latest ‘breakthrough’ drug. Their caution led to far less use in B.C. of several drugs that were subsequently withdrawn from the North American market after causing numerous deadly side-effects elsewhere.

In 2008, however, as large political donations from the pharmaceutical industry piled up, the ruling Liberals began to take aim at the Therapeutics Initiative. Following the recommendations of a faux task force with strong drug company representation, the TI’s funding was slashed by nearly 50 per cent, while more and more drugs were referred to the Common Drug Review in Ottawa. Those in the health ministry who understood the agency’s worth were silenced.

In vain was the TI’s rigorous work also championed by advocates ranging from former editors of the prestigious New England Journal of Medicine to members of the U.S. drug safety committee to Conservative MP Terence Young, whose 15-year old Imagedaughter died from an adverse drug reaction. “People on the Therapeutics Initiative work only on the evidence. They hurt drug sales,” Young told me during an impassioned plea for full funding to be restored. “They embarrass governments. They are a Canadian jewel.”

Not only did these pleas fall flat, the situation got worse. Just over a year ago, the TI’s remaining annual funding of $550,000 was cut off completely. The government blamed an alleged privacy breach among its health research staff and a resulting freeze on distribution of data. That left the TI, which was not involved in the case at all, with almost nothing to do. Many saw this as a convenient excuse for the Libs to kill off an operation that was far too independent for their liking. Neither Premier Clark nor Health Minister Terry Lake did much to counter that view.

This time, however, the mainstream media began to weigh in. CKNW talk show host Bill Good took the issue on. The Vancouver Sun’s Lori Culbert did some fine, investigative work. Among other things, she disclosed that pharmacies and drug companies donated nearly $600,000 to the B.C.  Liberals over the past eight years, 14 times the relative pittance they doled out to the NDP. The Sun even wrote a hard-hitting editorial, urging the Liberals “to step up, reverse their decision, and pledge their continued support for a group that has more than proved its worth to every British Columbian.”

Finally, with the departure of Gordon Campbell-appointee Graham Whitmarsh as deputy health minister and the fine Stephen Brown in his place, the government listened. Health Minister Terry Lake announced this week that the Therapeutics Initiative would be resuming its valuable work. The $550,00 was back in place.

Sometimes the good guys win. Even in politics.

A VICTORY FOR PUBLIC HEALTH

It has never ceased to astound me that so many health care workers refuse to get an annual flu shot. We’re not talking about that small, cranky minority of Canadians who dispute all vaccinations, including those for their young children. These are individuals on the frontlines of caring for vulnerable patients, and every year, upwards of 50 per cent of them simply decline to be vaccinated against influenza. Some wear a mask instead, but not many.

In vain have public health officials, hospitals and long-term care facilities rolled out education campaign after education campaign, stressing the value of flu shots in preventing the spread of a potentially serious, even fatal, condition to those they care for. Vaccination percentages in health care settings remain stubbornly low.

Reasons vary, but mostly they boil down to protecting the right to decide what goes into one’s body, and questioning whether vaccinations do much good. Indeed, the effectiveness of flu shots is relatively low, compared with vaccinations against other diseases. But public health officials are unanimous that they still offer the best protection there is against the spread of influenza. Having a flu shot provides more protection than not having one. Yet, vast numbers of health care workers continued to go unshot.

Finally, B.C.’s Provincial Health Officer Dr. Perry Kendall and others in the field decided something more had to be done. Last year, they unveiled a policy that mandated  all health care workers in contact with patients to be vaccinated against influenza, wear a mask, or face the possibility of discipline. This province-wide dictate was the first of its kind in Canada.

Not surprisingly, health care workers and their unions strongly opposed the get-tough measure, prompting the province to withdraw the proposed policy and institute, temporarily, a more collaborative approach. Meanwhile, the matter of mandatory flu shots or mask wearing went to arbitration.

Today, following 15 days of hearings, involving international and Canadian public health experts on both sides, including the renowned Dr. Allison McGeer, director of infection control at Toronto’s Mount Sinai Hospital and advisor to the World Health Organization, we have a verdict. In a comprehensive, 115-page judgment, Robert Diebolt, law professor emeritus at UBC, ruled that, given all the evidence, the policy of compulsory immunization or mask,  while not perfect, was reasonable.

He wrote: “It is indisputable that influenza can be a serious, even fatal, disease. Immunization also indisputably provides a measure of protection to health care workers and I have found that their immunization reduces influenza transmission to patients. I have also concluded that there is some evidence to support the masking component of the Policy. In short, there is a real and serious patient safety issue and the Policy is a helpful program to reduce patient risk.”

This is a victory on many fronts: for patients, for common sense and for sound public health. I hope those reluctant health care workers now get the point!

Rather than accept my word for it, however, here is Professor Diebolt’s ruling, in its entirety. Happy reading.

http://www.scribd.com/doc/178741720/Diebolt-Award-23Oct-13-pdf