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STUDENT PERSPECTIVES on TODAY'S GLOBAL HEALTH ISSUES

Vol. One | Issue One | Spring 2O11

Letter From the Editors

Dear Reader,

The Prognosis is the first undergraduate student journal at McGill that aimsto spark global health discussion among young people in Montreal. Global healthis a fairly new term that can be interpreted in many ways. We, the students in-volved in this journal, would like to provoke debate on the topic of global health,by presenting articles, opinions, and research on diverse issues related to health indifferent parts of the world.

Our inspiration for this project began in September of last year, born out ofour personal fascination with health issues and excitement over the emergence ofglobal health as a hot topic on campus. Although previously involved with theLancet Student online journal, we decided to branch out in order to create a morefocused impact among our student body. McGill University provides a great dealof opportunity to learn about global health, through various academic courses,current research, internships, and programs abroad. We, the creators, publishersand promoters of this journal, have been inspired by such opportunities and wantto encourage others to consider the intersection of social, biomedical, global, andlocal perspectives on health.

Thanks to all those who submitted articles and who helped make the journal asuccess,

The Prognosis Editorial Committee

1

Contents

Inequalities in Pre-Natal Healthcare 3

Claire Peterson

Homelessness and Tuberculosis Transmission in Urban

America 6

Katie O’Sullivan

A Crash Course on the Taiwanese Health Care System 18

Jason Tan de Bibiana

A Sobering Reality 24

Peter Shyba

Your Right to Know 29

Alexandra Markus

Do Video Games Lead to Violence? 33

Emily Erkkinen

In Cancer’s Genes 39

Pauline Helle

2

Inequalities in Pre-Natal Healthcare

Claire Peterson

Over 3.5 million infants die eachyear, almost exclusively in the devel-oping world[2]. Many initiatives toincrease children’s health have beenfunded, especially in the wake of Mil-lennium Development Goal #4, whichcalls for the mortality of children un-der 5 between 1990 and 2015 to be re-duced by two-thirds. However, even theUN admits most countries are nowhereclose to achieving this goal. Initiativesthat have been funded to eradicate chil-dren’s death have only funded the treat-ment of diseases that occur after the firstmonth of life, like pneumonia and diar-rhea, which account for 22% of children’smortality. So how will we ever reachGoal #4 when 41% of childrens deathsare being ignored[3]?

Finally, with only 5 years left tocomplete the Millennium DevelopmentGoals, 40 billion dollars has beenpledged over the 5 remaining years to aidmaternal and children’s healthcare[1].Low-cost solutions are not new knowl-edge – kangaroo care and nutrition forpremature babies, immunizations to pre-vent diseases passed in utero, the im-portance of breast-feeding and programs

to train health care workers have beenaround for decades. What’s worse isthat many countries that will receivefunding have set their own goals in termsof maternal and children’s healthcare,but I was hard-pressed to find more thana handful of countries that mention new-borns in their plans.

Imagine that you are a 28-year-oldCanadian woman who is 7 months preg-nant and that you suddenly go into la-bor. In Canada neonates of 5.5 monthgestation are viable candidates to live, soyou need not worry. Your hospital roomis equipped with all of the latest tech-nologies and the neonatal intensive careunit is right down the hall. Anythingand everything you need is right at yourfingertips and your insurance will cover alarge part of your medical expenses. Youwill be afforded the best healthcare inthe world from the most educated healthprofessionals. You are one of the luckyones, only 1% of neonatal death occursin developed countries[2].

Now let’s pretend you live inUganda, a country stricken with povertyand lacking adequate healthcare. Morelikely, you are not 28, but only a

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The Prognosis 4

teenager, which makes your pregnancymore risky. You must walk over 10 kilo-meters to reach the hospital, which isunderstaffed and overburdened, so likemany other women in rural communitiesyou will choose to have a home birth.Since you have received no prenatal careyou will likely have some sort of dis-ease, like malaria, which can be fatal toa fetus. You also may not have accessto proper nutrition, so your seemingly 7month old fetus may actually only be asdeveloped as a 6 month old fetus, leadingto a baby born of low birth weight whichis the cause of 70% of neonatal deaths.Only 1 in 5 women in developing coun-tries have access to skilled nurses andmidwives who are trained to perform es-sential newborn care[2]. Even more up-setting, your baby may be asphyxiatedbecause its lungs are still too small tobreathe on their own – easily remediedby an inexpensive bag and mask sys-tem, but even this simple interventionhas not been implemented. In Uganda,newborn deaths each year cause an esti-mated 90,000 deaths which makes 1125buses full of dead babies according tothe Uganda Newborn Study[4]. Thistragedy, like many others, is most preva-lent in Sub-Saharan Africa and South-east Asia where communities have theleast access to information and interven-tions.

Even if you don’t have a soft spotfor babies, economically speaking, new-

born complications are costly. Neonatalcomplications can result in severe disor-ders like cerebral palsy or chronic bron-chitis, not only putting an economic coston the family, but also on the commu-nity health system. When consideringthe numbers, neonatal complications af-fect over 1 million infants each year. Notonly is a family less productive, but alsovillages and even cities are less produc-tive. Finally, the social cost of neona-tal complications or death is immensefor a mother who may become depressedbecause she is outcast by her family orvillage[2]. Many women each year in de-veloping nations bear children expectingthat each child will help the family gainprosperity, but a complicated pregnancyputs families into debt. Neonatal sur-vival is proven to decrease future birthrates[2].

So why have we waited to invest untilnow? Most people believe that expen-sive high tech hospital equipment is re-quired to save infants, but a mere $5 percapita spent on neonatal care each yearcould avert 2.6 million deaths accordingto Dr. Viviana Mangiaterra, an expertin international public health. Further,even at the height of the internet, avail-able data relating to neonates is scarce;too scarce to receive policy attention[2].

More than 150 countries havepledged their support to the Millen-nium Development Goals[3] and nowthat funding has been secured its time

The Prognosis 5

countries fulfill their promises. Theknowledge to reduce neonatal deathsby over 50% is at our fingertips[2] andwe should be using it. In order to reachMillennium Development Goal #4 it isimperative that interventions to save in-fant lives are implemented.

Claire is studying Anatomy and CellBiology and International DevelopmentStudies, working towards her Bachelorof Science. Her research interests in-clude maternal and children’s health carewith a particular focus on providing in-expensive and effective neonatal survivaltools.

References

[1] Every Woman Every Child. Every Woman Every Child.Retreived fromhttp://www.everywomaneverychild.org/.

[2] Mangiaterra, Viviana.(2006). Why and How to Invest in Neonatal Health.Seminar in Fetal and Neonatal Medicine, 11.1, 37-47.

[3] United Nations. Millennium Development Goals- Child Health. Retreived fromhttp://www.un.org/millenniumgoals/childhealth.shtml.

[4] Waiswa, P. UNEST: Integrating community health workers into ma-ternal & newborn health: Implications for achieving MDG No. 4 inUganda — Healthy Newborn Network.Healthy Newborn Network. Retreivedfrom http://www.healthynewbornnetwork.org/resource/unest-integrating-community-health-workers-maternal-newborn-health-implications-achieving-m.

Homelessness and Tuberculosis Transmission

in Urban America

Katie O’Sullivan

Abstract

Among industrialized countries, the U.S has arguably struggled most with allevi-ating homelessness, ever since the issue breached the federal policy agenda in the1970s. Homelessness is associated with a diverse range of risk factors that increasean individuals vulnerability to infectious disease: poor living conditions, compro-mised mental and physical health, and risky behavior such as intravenous drug use.Within the U.S, the re-emergence of tuberculosis in the 1990s disproportionatelyaffected the homeless in urban areas. This paper critically reviews the effects ofhomelessness on tuberculosis transmission in cities across the United States. I ap-proach the peer-reviewed literature with three objectives: to determine first whatrisk factors and transmission mechanisms characterize TB cases among the ur-ban homeless, second, what methods have been used to monitor transmission, andthird, what treatment techniques have proven most effective for managing trans-mission. The literature effectively addresses these objectives through descriptivecase studies in cities throughout the U.S, though does not satisfactorily contex-tualize observed trends within broader-level social, political, and economic forces,which are together changing what it means to be homeless in urban America.Specifically, efforts to monitor and treat the new tuberculosis should account forthe new homelessin light of differential effects of treatment noncompliance, multi-drug resistant strains, concurrent infection with HIV/AIDS, and behavior on thehealth risk of these populations.

Introduction

Among curable communicable diseases,pulmonary tuberculosis (TB) is the lead-ingcause of death worldwide [7]. About

one third of the global population isinfected with the bacteria Mycrobac-terium tuberculosis, which may lie latentin a human hosts lungs for many yearsbefore progressing into an active infec-

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The Prognosis 7

tion [7]. Symptoms include coughing,chest pains, weakness, weight loss, andfever, and if left untreated, the diseasemay be lead to death. A hosts weakenedimmune system may trigger the transi-tion from latent to active TB. Once af-flicted with active TB, the host becomesinfectious and may transmit bacteria toothers via droplets from the throat andlungs expelled into the air [35]. Tubercu-losis is an ancient disease, largely reflec-tive of poverty, whose prevalence is dis-tally patterned by a multitude of social,political and economic forces [28, 29]. Inindustrialized countries, reports of TBcases have declined since the nineteenthcentury [28]. However, this trend re-versed in the 1980s when widespreadHIV infection caused the disease to re-emerge [28]. Increased migration ofpopulations from countries with highTB prevalence, development of multi-ple drug resistant strains of the bacteria,and deterioration of health care infras-tructure supporting TB control, haveall contributed to global re-emergenceof the disease [28]. In fact, the WorldHealth Organization (WHO) declaredtuberculosis a global emergency in 1983[34]. It is argued that the historicaldecline of tuberculosis is better under-stood than this re-emergence [11]. To-day, tuberculosis persists in industrial-ized countries as an important publichealth problem, with the majority ofcases occurring in poor and minority

groups, such as displaced, migrant, andcross-border populations, injection drugusers, sex workers, and the homeless [9].Homelessness is a socioeconomic phe-nomena associated with disadvantagedpopulations and ill health throughoutthe life course, and is growing in in-dustrialized nations [19]. Homelessnessis a public health problem that is in-creasing in severity, and homeless popu-lations are more susceptible to emergingand re-emerging infectious diseases suchas TB because of poor living conditionsand limited access to healthcare systems[2]. Homelessness and associated so-cial exclusion may worsen health sta-tus, while those whose health is alreadycompromised by mental or physical ill-nesses are more susceptible to homeless-ness or poor-quality housing, due to un-employment and poverty [32]. Amongthe homeless, TB rates may be twenty-times higher than general populations inthe U.S across rural and urban areas[4].In urban populations, persisting high in-cidence rates are largely due to ongoingtransmission in homeless shelters [13].

In light of this trend of new or re-emerging tuberculosis among marginal-ized groups like the homeless, PaulFarmer (1997) calls for research in thesocial sciences to discern the mecha-nisms by which social forces affect TBtransmission, and also to identify bar-riers that prevent those with multiple-drug-resistant TB from accessing proper

The Prognosis 8

care. To contribute to Farmers call-to-action, I aim to evaluate how the so-cial process of urban homelessness hasaffected the re-emergence of tubercu-losis in the U.S from the 1980s on-wards. In order to do this, I approachthe peer-reviewed literature with threesub-objectives: to determine first whatrisk factors and transmission mecha-nisms characterize TB cases among theurban homeless, second, what methodshave been used to monitor transmission,and third, which treatment techniqueshave proven most effective for manag-ing transmission. To address these ob-jectives, I analyze research conducted incities throughout the U.S, with a specialfocus on the New York City case study,where the 1990s TB outbreak was mostprominent.

Analysis

I. Risk Factors and Mechanisms

of TB Transmission Among the

Homeless

Homelessness in the U.S stands out asan endemic social problem, with preva-lence rates between 200-500% greaterthan those in Western European coun-tries [31]. Among all developed na-tions, the highest concentration of home-less people occur in the traditionallypoorest areas of large urban settings[16]. Though structural forces suchas housing policy are crucial in shap-

ing these settings, the literature rele-vant to my aim largely focuses on thelived experience of poverty in evalu-ating risk. A study regressing struc-tural risk factors with homeless ratesin 52 U.S metropolitan areas demon-strated that poverty rates strongly af-fect homelessness, more so than fac-tors such as lack of affordable hous-ing, unemployment rates, and impact ofgovernment benefits [12]. This findingadds a new dimension to preceding lit-erature that describes homelessness asa macro-economic and housing problem[12]. In regards to poverty, character-izing the homeless became more flexi-ble with the emergence of new homeless-ness in the 1980s, as homeless status wasconferred from middle-aged, single menwith chronic drug or alcohol addictions,onto new and different groups not previ-ously identified as homeless [30, 22, 16].These groups are vulnerable to povertyand include families, women, youth, theelderly, and marginalized ethnic or mi-grant groups experiencing episodic boutsof absolute homelessness, insecure hous-ing, or inadequate housing (ibid).

In urban settings, crowded emer-gency shelters have been identified asthe primary origins for the U.S tuber-culosis epidemic in the 1990s [31]. How-ever, outside of homeless shelters it isunclear what characteristics of the urbanenvironment may foster TB outbreaks.To address broader determinants of TB

The Prognosis 9

transmission in urban environments, asystematic review examined population-based studies that attempted to quan-titatively identify risk factors for geo-graphic clustering of tuberculosis cases[10]. Prevalence of homelessness was nota statistically significant risk factor forclustering, though percent locally born,percent pulmonary TB, percent HIV-seropositive, and percent alcohol abusehad positive influences, while mean agehad a negative influence on clustering[10]. Though homelessness was not asignificant predictor of clustering, a highproportion of locally born people in anarea probably indicates a lack of mo-bility due to poverty or poor health,which may covary with other variablesinvestigated, such as alcohol abuse, HIVseropositivity, and homelessness.

The New York City Case Study

There is a large body of literature dis-cussing the tuberculosis transmissionamong homeless populations in NewYork City (NYC) in the 1990s, whencitywide TB incidence rates peaked up-wards of 3,000. However, by 2006 TBcase rates in the city were still threetimes higher than the national average[17]. Due to the quantity and method-ological quality of research in responseto this issue, NYC provides an infor-mative case study for analyzing home-lessness and TB transmission over time.The re-emergence of tuberculosis there

and throughout the world has largelybeen attributed to the AIDS epidemic.However, rises in homelessness predat-ing AIDS have also contributed to theresurgence [5], though this is unexploredin the literature. Evidence from a cross-sectional survey of high-risk homelessmen residing in a NYC shelter revealedthat total time homeless correlated posi-tively with active and latent tuberculosisinfection, and most cases of active tu-berculosis were among individuals withAIDS or AIDS-related complexes [33].This finding has important policy im-plications – if someone is more likely toacquire TB the longer they have beenhomeless, then interventions may targettreatment towards the chronically home-less, and surveillance/preventative mea-sures towards the newly homeless, aswell as those with HIV/AIDS.

Noncompliance with TB treatmentamong the homeless is associatedwith behavioral factors and pre-existinghealth conditions such as HIV/AIDS,and may lead to multiple drug re-sistance. A retrospective study re-sembling a case-control design demon-strates this by examining TB cases inan urban community hospital in NewYork City, and comparing frequency ofdrug resistant strains between home-less and non-homeless populations [27].Drug resistance was found to be sig-nificantly higher among homeless pop-ulations, and particularly among those

The Prognosis 10

with HIV/AIDS. Drug resistance wasalso significantly higher among blackpopulations (ibid). The link betweenHIV/AIDS and TB in the urban home-less is also evident in a prospective co-hort study of 224 TB patients admit-ted to a hospital in New York City in1988 [5]. Of total patients dischargedon TB treatment, 89% were lost tofollow-up and failed to complete ther-apy, and 27% of discharged patients werereadmitted within 12 months with con-firmed active TB. Noncompliance withtreatment was significantly associatedwith having AIDS or an AIDS- relatedcomplex, homelessness, and alcoholism(ibid). Because HIV infection and tuber-culosis affect subpopulations with highrates of substance abuse and homeless-ness, treatment noncompliance is a par-ticular issue.

These trends hold true in other U.Scities, even on the opposite coast. Anal-ysis of TB surveillance data on high-risk populations in San Francisco from1993 through 2005 reveals that the tim-ing of contacts with HIV positive indi-viduals and emergence of new TB casesis temporally consistent as a matter ofcause-preceding-effect. This supportsthe theory that HIV is a key factor insustaining TB transmission among thehomeless in San Francisco [23]. Self-reported health and behavioral charac-teristics of patients is another (albeitlimited) means of evaluating risk factors

for TB infection. A study assessed per-ceived health status of homeless adultswith latent TB undergoing a treatmentprogram in Los Angeles [25]. Womenwere more likely than men to self-reportworse overall and mental health status,as well as using drugs daily. Homelessadults reporting worse health were morelikely to have used injection drugs, toreport depressive symptoms and poormental health, and also to be homelessfor more than three years. This supportsthe previously discussed finding of Tor-res et al. (1990) that the chronicallyhomeless are more likely to experiencepoor health, TB, and/or HIV infection,which may be compounded by behav-ioral risk factors.

II. Methods for Monitoring Tu-

berculosis Transmission Among

the Urban Homeless

Contact investigations are monitoringmethods that aim to establish transmis-sion pathways from person-to-person,and involve having TB patients list closecontacts [18]. However, this techniquecan be difficult in homeless populationsbecause it requires patients to divulgepersonal and sensitive information. Im-proving interview skills of contact inves-tigation workers may help establish trustand make homeless TB patients morewilling to provide information, therebyincreasing the number of contacts identi-fied among homeless populations (ibid).

The Prognosis 11

In contrast to contact investigations,analyzing the genetic information ofTB infection within populations mayreveal transmission networks and sitesthat might not otherwise be discov-ered. In a recent study, Myobacteriumgenotype clusters associated with out-breaks among homeless adults in NewYork City allowed researchers to iden-tify and differentiate risk factors linkedwith particular strains of the bacteria[17]. TB cases in clusters of strainsthat have circulated in a communityover an extended period require addi-tional investigation as to whether clus-tering resulted from recent TB trans-mission, or reactivation of remote in-fection (ibid). Another study in Den-ver, Colorado used DNA fingerprintingof Myobacterium tuberculosis from pos-itive cases identified by homeless shel-ter screening, to identify cases result-ing from recent transmission. Caseswith identical DNA fingerprints clus-tered within two years served as an in-dicator for recent transmission, and re-searchers saw that the frequency of theseclusters decreased over four years, inwhich the screening program was im-plemented, indicating that early screen-ing at the shelter was effective in lim-iting TB transmission [13]. This mon-itoring method is thus capable of as-sessing treatment effectiveness in ad-dition to descriptive transmission pat-terns. In another study, DNA finger-

printing was combined with medical his-tories and interviews to identify epidemi-ological connections and clusters be-tween TB cases around the WashingtonD.C area [15]. Through these methods,over half of the cases were connected di-rectly to a large urban homeless shel-ter, or were connected by time and placepending histories of homelessness, socialnetworks, and shared boarding or tran-sitional housing (ibid). This suggeststhat mixed monitoring methods involv-ing personal interviews and contact in-vestigations, in addition to genetic anal-ysis, may prove most effective.

III. Methods for Treating Tuber-

culosis Cases Among the Urban

Homeless

The task of treating TB in homelesspopulations provides a compelling op-portunity for collaboration between di-verse public and private agencies at themunicipal level. The Centers for Dis-ease Control and Prevention (CDC) hasclearly outlined priorities for TB pre-vention and control programs to evalu-ate transmission pathways through con-tact investigation, and to treat TB pa-tients with latent or active infections[30]. However, the capacity for theseplans to address the needs of homelesspopulations has varied in practice, asdemonstrated by the following examples.

An urban homeless shelter inCharleston, South Carolina successfully

The Prognosis 12

implemented a prevention and controlplan addressing priorities highlighted bythe CDC, involving collaboration be-tween different municipal institutions[20]. The program involved screen-ing new guests to the shelter for TBwithin a week of arrival and every sixmonths from thereon, while a publichealth nurse provided preventative ther-apy at the shelter twice a week. Thisprogram had a 77% therapy completionrate for TB patients (a dramatic successin comparison to the 11% completionrate found by the aforementioned Brud-ney and Dobkin study in NYC), and theauthors attribute this success to the col-laboration between the shelter, a nursingclinic, and the local health department.

In Baltimore, Maryland a resource-intensive alternative to existing CityHealth Department TB treatment pro-grams for the homeless increased treat-ment completion rates from 11% to 33%[14]. The improvement seems modest,but is in fact three-fold. The programinvolved collaboration between a faith-based organization, an academic institu-tion, and local government. The collab-orative effort provided intensive track-ing and coaching interventions for home-less TB patients over a nine-month pe-riod. Given the modest improvementsin treatment completion relative to con-ventional programs, however, the feasi-bility of implementing such a resource-intensive treatment collaborative pro-

gram may be limited in other settings(ibid). Importantly, the authors ac-knowledge that nurses are integral indeveloping supportive relationships withhomeless patients, and in providing pri-mary care. The importance of nursesalso comes through in a cross-sectionalstudy in Los Angeles, California [26].The study assessed predictors of ther-apy completion among homeless TB pa-tients who received either a nurse case-managed program or a usual programwithout a nurse. Treatment completionwas significantly and positively associ-ated with participation in nurse case-managed program, older age, and lessillicit drug use (ibid). The nurse case-managed program also predicted sat-isfaction with treatment and greaterTB knowledge, indicating that this ap-proach to treatment may prove a viableoption among groups such as the home-less, who are transient and difficult-to-treat by conventional methods (ibid).

Other methods to monitor and con-trol tuberculosis transmission includerapid genotyping systems [6] and com-puter simulation models [4]. A simula-tion model revealed that improving ac-cess to treatment among homeless pop-ulations with active and latent TB wasmore effective in reducing TB cases anddeaths over ten years, in comparison toimprovements in the effectiveness of thetreatment programs (ibid). This sug-gests that intervention studies similar

The Prognosis 13

to those just discussed should also ad-dress the extent to which homeless pop-ulations would be able to access pro-grams under investigation, rather thanprogram effectiveness in isolation.

Discussion

The ways in which urban homelessnessaffects and is affected by re-emergenceof tuberculosis are largely influencedby national and international social,political, and economic forces, includ-ing urban housing markets, social net-works, employment trends, and govern-ment spending on social welfare pro-grams [22, 16]. These forces manifestthemselves in terms of the risk factorsand transmission mechanisms that pat-tern my preceding discussion of TB in-cidence, monitoring methods, and treat-ment methods. While homeless sheltersprovide a social safety net for those with-out secure housing, my analysis demon-strates that over the past twenty yearsthey have proven extremely importantin proliferating and sustaining activetuberculosis infection and transmissionamong homeless populations. Monitor-ing and treating these groups is ex-tremely difficult due to their transientnature and social marginalization – thatis, TB patients that are homeless aremore likely to not comply with treat-ment or surveillance efforts.

In reference to broader struc-

tural forces, framing discourse of newor re-emerging tuberculosis in termsof new homelessness could respondto McMichaels (2004) contemporaryhuman-microbe transition, brought onby widespread demographic, environ-mental, and technological change in hu-man ecology, and compounded by theimproper use of antibiotics. While de-terminants of TB emergence have re-curred throughout history, social andenvironmental changes of unprecedentedcomplexity and intensity have createdmore opportunities for emergence andre-emergence than ever before [3, 24].However, my analysis has demonstratedthat the literature does not adequatelyaddress the dynamic nature of home-lessness and its effects on tuberculosistransmission within urban U.S popu-lations. That is, the literature neglectsthe new homeless, characterized by moreepisodic rather than chronic states ofhomelessness, families, women, youth,and minority populations experienc-ing a wide range of insecure or inade-quate housing circumstances [16]. Thesehomeless populations do not fit into themodels of homelessness discussed in theliterature on urban TB transmission inthe U.S over the past twenty years. Thenew homeless tend to rely on social net-works and transitional housing ratherthan homeless shelters for housing as-sistance (ibid), and may be character-ized by a different set of risk factors for

The Prognosis 14

TB acquisition than factors such as druguse, HIV/AIDS infection, and treatmentnoncompliance, which dominate this pa-pers analysis of transmission. Differingtransmission pathways will, in turn, af-fect what TB monitoring and treatmentmethods are best suited to these popu-lations.

Conclusion

My analysis demonstrates that tuber-culosis transmission among the urbanhomeless in the U.S is characterized bypre-existing HIV/AIDS complexes, alco-hol abuse, intravenous drug use, poverty,and treatment noncompliance, and theresulting development of drug resistantstrains. Diverse methodological devel-opments to monitor and treat TB caseshave achieved varying levels of success,while mixed methods for monitoringtransmission and collaborative, nursing-based treatment programs have shownthe strongest results. However, the liter-ature overall lacks discussion of how thechanging nature of urban homelessness,

specifically the emergence of the newhomeless within the past three decades,has affected TB transmission in the U.S.This discussion would have importantimplications for evaluating which meth-ods are most appropriate to monitor andtreat particular cases. The case stud-ies explored in this paper of localizedTB outbreaks within urban Americanhomeless populations create an enrich-ing and descriptive mosaic of how TBtransmission varies with particular riskfactors. However, there is a need formore dynamic research to address howthese patterns are changing in the con-text of broader structural trends in theU.S, such as housing and social welfarepolicies, as well as economic and socialchange.

Katie is finishing her B.A Honours de-gree in Geography, and looks forwardto co-founding a small organic vegetablefarm this summer in New Mexico! Be-sides agriculture, she is interested in theimpacts of urban policy on health andenvironmental equity worldwide.

References

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[5] Brudney, K. and J. Dobkin (1991). Resurgent tuberculosis in New York City.Human immunodeficiency virus, homelessness, and the decline of tuberculosiscontrol programs.American Review of Respiratory Disease, 144(4): 745-749.

[6] Centers for Disease Control and Prevention (CDC) (2005). Tuberculosis trans-mission in a homeless shelter population–New York, 2000-2003.MMWR - Mor-bidity & Mortality Weekly Report, 54(6): 149-152.

[7] Dye, C. (2006). Global epidemiology of tuberculosis.Lancet, 367(9514): 938-940.

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[12] Ji, E. G. (2006). A study of the structural risk factors of homelessness in52 metropolitan areas in the United States.International Social Work, 49(1):107-+.

[13] Kong, P. M., J. Tapy, et al. (2002). Skin-test screening and tuberculosis trans-mission among the homeless. Emerging Infectious Diseases, 8(11): 1280-1284.

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[14] Lashley, M. (2007). A targeted testing program for tuberculosis control andprevention among Baltimore city’s homeless population.Public Health Nursing,24(1): 34-39.

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[16] Lee, B. A., K. A. Tyler, et al. (2010). The new homelessness revisited. AnnualReview of Sociology, Vol 36. Palo Alto, Annual Reviews. 36 : 501-521.

[17] Macaraig, M., T. Agerton, et al. (2006). ”Strain-specific differences in twolarge Mycobacterium tuberculosis genotype clusters in isolates collected fromhomeless patients in New York City from 2001 to 2004.” Journal of ClinicalMicrobiology, 44(8): 2890-2896.

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[20] Mayo, K., S. White, et al. (1996). ”Community collaboration: Prevention andcontrol of tuberculosis in a homeless shelter.” Public Health Nursing, 13(2):120-127.

[21] McMichael, A. J. (2004). ”Environmental and social influences on emerginginfectious diseases: past, present and future.” Philosophical Transactions ofthe Royal Society of London Series B- Biological Sciences, 359(1447): 1049-1058.

[22] Minnery, J. and E. Greenhalgh (2007). ”Approaches to homelessness policyin Europe, the United States, and Australia.” Journal of Social Issues, 63(3):641-655.

[23] Mohtashemi, M. and L. M. Kawamura (2010). ”Empirical evidence for syn-chrony in the evolution of TB cases and HIV+ contacts among the San Fran-cisco homeless.” PLoS ONE [Electronic Resource], 5(1): e8851.

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[24] Morens, D. M., G. K. Folkers, et al. (2008). ”Emerging infections: a perpetualchallenge.” Lancet Infectious Diseases, 8(11): 710-719.

[25] Nyamathi, A., J. Berg, et al. (2005). ”Predictors of perceived health status oftuberculosis-infected homeless.” Western Journal of Nursing Research, 27(7):896-910.

[26] Nyamathi, A., J. A. Stein, et al. (2007). ”Latent variable assessment of out-comes in a nurse-managed intervention to increase latent tuberculosis treat-ment completion in homeless adults.” Health Psychology, 26(1): 68-76.

[27] Pablos-Mendez, A., M. C. Raviglione, et al. (1990). ”Drug resistant tuber-culosis among the homeless in New York City.” New York State Journal ofMedicine, 90(7): 351-355.

[28] Porter, J. D. H. and K. McAdam (1994). ”The Reemergence of tuberculosis.”Annual Review of Public Health, 15 : 303-323.

[29] Rayner, D. (2000). ”Reducing the spread of tuberculosis in the homeless pop-ulation.” Br J Nurs, 9(13): 871-875.

[30] Rossi, P. H. (1990). ”The old homeless and the new homelessness in historical-perspective.” American Psychologist, 45(8): 954-959.

[31] Singer, J. (2003). ”Taking it to the streets - Homelessness, health, and healthcare in the United States.” Journal of General Internal Medicine, 18(11):964-965.

[32] Smith, S. J. (1990). ”Health status and the housing system.” Social Science& Medicine, 31(7): 753-762.

[33] Torres, R. A., S. Mani, et al. (1990). ”Human immunodeficiency virus infec-tion among homeless men in a New York City shelter. Association with My-cobacterium tuberculosis infection.” Archives of Internal Medicine, 150(10):2030-2036.

[34] WHO (1983). Plan of Action for research in the immunology of tuberculosis.Memorandum for a WHO meeting, Bulletin of the WHO, 61 : 779-785.

[35] WHO. (2010). ”Tuberculosis.” Fact Sheets, Retrieved fromhttp://www.who.int/mediacentre/factsheets/fs104/en/ index.html.

A Crash Course on the Taiwanese Health

Care System

Jason Tan de Bibiana

The Taiwanese health care systemhas famously been described as a carmanufactured domestically from partsimported from abroad [3]. For manyyears, Taiwan studied the health caresystems of other countries and con-sulted with health policy experts fromaround the world, before orchestrat-ing a dramatic transformation of itsown health care system. In 1995, Tai-wan introduced its National Health In-surance program (known as the NHI),which extended health insurance cover-age to all Taiwanese citizens and legalresidents. Taiwan designed and imple-mented a government-run, single-payersystem with universal insurance cover-age much like what we have here inCanada. However, the Taiwanese sys-tem also boasts comprehensive cover-age for prescription drugs, dental care,and traditional Chinese medicine, a co-hesive electronic health-records system,and relatively short waiting times forhealth care.

Given that Taiwan has learned somuch from the experience of other coun-tries, I thought it was very appropriate

that we Canadians a group of 10 stu-dents from McGill University represent-ing a variety of degrees, experiences, andcareer aspirations also had the opportu-nity to learn from the Taiwanese expe-rience. As part of an educational andcultural exchange organized by McGill‘sComparative Healthcare Systems Pro-gram, we were invited to learn aboutTaiwan‘s ongoing experience with healthcare reform and policy development.

Before we left for Taiwan last May,I was doing my best to keep up withthe health care issues close to home.My “Economics for Health Services Re-search and Policy” class discussed thelatest health care controversies makingCanadian news headlines when New-foundland and Labrador Premier DannyWilliams flew down to Florida for hiscardiac surgery [1] and Quebecs govern-ment was trying to sneak in extra feesfor health care into its updated provin-cial budget [6]. The US health reformdebate raged on and finally, US Presi-dent Barack Obama signed the PatientProtection and Affordable Care Act intolaw on March 23, 2010 [7]. A friend of

18

The Prognosis 19

mine making a documentary on the UShealth care reform debate was just ableto update her final cut to include thishistoric event.

With all this in mind, I was verykeen to get a sense of the current healthcare issues in Taiwan. I was eagerto observe what was similar and whatwas different between Canada and Tai-wan‘s health care systems and excitedto learn about the day- to-day realitiesof patients, doctors, public health pro-fessionals, policy makers, and other ac-tors within the health care system. Dur-ing our stay in Taiwan, we attended twoformal lectures given by professors fromthe top universities on the topic of thenational health care system and insur-ance program. However, I also learneda great deal about health care in Tai-wan by talking to doctors, nurses, med-ical students, and everyone else I met.

Taiwans health care system is im-pressive in many respects. It has beensuccessful in extending health insurancecoverage to 99 percent of the popula-tion [8]. Before the establishment of theNHI, 41 percent of the population wasuninsured the majority of whom werechildren and elderly persons but nowthere is universal coverage for all citi-zens and legal residents [3]. Health in-surance in Taiwan under the NHI plan iscomprehensive: medical care, preventivecare, traditional Chinese medicine, homenurse visits, prescription drugs, and den-

tal care are all covered [5]. Rememberthat in Canada, prescription drugs, den-tal care, and many other services are notcovered by most provincial health insur-ance plans. We pay for these servicesfrom our own pocket, unless we have asupplementary health insurance plan.

In Taiwan, patients have the free-dom to choose between many differenthealth care providers and facilities. Tra-ditional Chinese doctors often offer com-plementary treatments to biomedicine.Fortunately, every patient has a “SmartCard” that keeps track of their medi-cal history in an electronic record. The“Smart Card” allows each doctor to seewhat services have already been pro-vided or what drugs have already beenprescribed, and it also communicateswith the NHI to automatically processinsurance claims and pay out the doc-tors. As a result, administration costsare very low for the Taiwanese healthcare system, at approximately 2 percentof its total budget [5]. Overall, Taiwanspends roughly 6 percent of its GDP onhealth care, compared to 16 percent inthe United States [8]. And most im-portantly, the population is healthy andhappy with the system. Life expectancyat birth is 75.3 years for males and 81.2years for females [2], and public approvalratings of the NHI ranged from 60-80percent from 2001-08 [3].

Some aspects of the Taiwanesehealth care system were very differ-

The Prognosis 20

ent from what I was familiar with inCanada. In Canada, we sometimes nav-igate a system of gatekeepers and refer-rals through the health care maze. Toget an appointment with a specialist,we have to get a referral from our fam-ily doctor. In Taiwan, it is possible tobypass the gatekeepers and referrals toget an appointment directly with a spe-cialist. Furthermore, because there aremany health care providers to choosefrom and no gatekeepers, it is possibleto see a doctor almost right away. Thelong wait-times that we have come to ex-pect for health care in Canada are not afactor in Taiwan.

Instead of dealing with long wait-times like we do in Canada, patientsin Taiwan do have to pay a small feefor each health care service they re-ceive (known as a co-payment) to thehealth care provider. The co-payment isvery small and the NHI sets a ceiling sothat patients will not go bankrupt fromthe fees and waives the fees altogetherfor certain patients. In theory, the co-payments encourage patients to use lesshealth care services, or at least make pa-tients think twice about whether theyreally need to see the doctor. Accordingto the RAND health insurance study, anexperiment that randomly assigned fam-ilies to different health insurance plans,the more people have to pay for healthcare services up front, the less theywill use [4]. In Canada, although we

can just show our health insurance cardand receive medical care without anyco- payments, our long wait-times andgatekeeper system may also ration theamount of health services we consume.

As it turns out, Taiwanese people usea lot of health care services: an aver-age of 14.4 outpatient visits per capitaper year vs. 6.4 per capita per year inCanada and 129 hospital admissions per1,000 per year vs. 99 per 1,000 per yearin Canada [3]. Small co-payments donot deter most Taiwanese people fromseeking health care services when theyhave a health concern, and since there isno referral or gatekeeper system, peopleare able to see different doctors as theyplease. This leads to “doctor shopping,”a term that describes when a person con-sults with many different doctors for thesame problem. Taiwanese people mayalso end up visiting a specialist unnec-essarily and may even go to the hospitalfor a common cold.

Consequently, health care revenueshave not kept pace with expendituresand the NHI has been running a deficitsince 1998 [3]. The NHI is financedby premiums paid by the insured indi-vidual, their employer, and the govern-ment, as well as revenues from the lot-tery and a tobacco tax. Most peoplewho are employed pay 30 percent of thepremium, their employer pays 60 per-cent, and the government subsidizes theremaining 10 percent. The premium-

The Prognosis 21

shares vary such that self-employed in-dividuals pay 100 percent of the pre-mium and low-income individuals arefully subsidized by the government. Inturn, the NHI is responsible for reim-bursing health care providers for the ser-vices they perform and the patients alsocontribute the small co-payments to thehealth care providers. Since it has beenpolitically unpopular to raise the premi-ums and Taiwanese people continue touse a lot of health care services, the NHIcontinues to pay out more to the healthcare providers than it takes in from pre-miums and taxes.

To try and control costs, the NHI hasexperimented with different ways of re-imbursing health care providers. Origi-nally, health care providers were reim-bursed for each service they providedon a fee-for-service schedule without anylimit, which allowed doctors to inflatetheir salaries by prescribing more drugs,seeing more patients, and performingmore tests and procedures as fast as theycould. To curb this problem, the NHIimplemented global

budgets between 1998 and 2002for dental care, traditional Chinesemedicine, primary care, and hospitals.Each sector now has a set expendi-ture cap and is reimbursed at lowerrates for any services provided be-yond the cap, encouraging providersto stay within their set budget andstop abusing the fee-for-service scheme

[3]. Most recently, the NHI has in-troduced a diagnosis-related-group re-imbursement scheme, under which doc-tors are reimbursed a certain amountfor different types of patients accord-ing to their primary diagnosis. Thesestrategies hope to motivate health careproviders to help control costs, and alsoprovide better quality care. On the pa-tient side, surveillance of the “SmartCard” records has been used to flag thehighest users of health care services whomay be guilty of “doctor shopping.” An-other recent development is the growthof the medical tourism industry in Tai-wan, which may bring in significant rev-enue from China, the United States, andother parts of the world.

In our short visit to Taiwan, we werequick to notice aspects of the Taiwanesehealth care system that were differentfrom, similar to, or better than our ownsystem in Canada. Taiwan was verythoughtful leading up to its 1995 healthsystem reform and has benefited fromlaying the foundations of a well-designedhealth care system. However, like otheruniversal national health insurance pro-grams, the NHI is challenged to run asustainable program that also keeps doc-tors, patients, and the rest of the popu-lation happy. This unenviable responsi-bility requires ongoing troubleshooting.

The obvious conclusion that I cameto after our crash course in Taiwan isthat no health care system is perfect.

The Prognosis 22

No two health care systems are the sameeither, but there is much to be learnedfrom comparative study. Both the Tai-wanese and the Canadian health caresystems will face similar challenges inthe future and hopefully, we can con-tinue to learn from each other‘s experi-ences.

Jason Tan de Bibiana is interested inpublic health research and practice thataddresses the social determinants ofhealth, improves health care systems,

and reduces inequity. He thinks thatthere is a lot of work to be done lo-cally and globally. Jason graduated fromMcGill University with a Bachelor ofScience in physiology, geography, andsocial studies of medicine and is cur-rently based in Vancouver at the Uni-versity of British Columbia‘s School ofPopulation and Public Health, where heis pursuing a Master of Science in epi-demiology, public health, and health ser-vices research.

References

[1] Blackwell, T. (2010, February 1). DannyWilliams could have stayed in Canadafor top cardiac care, doctors say. Retrieved June 2010, from The NationalPost:http://www.nationalpost.com/news/story.html?id=2514581

[2] Central Intelligence Agency. (2010, June). Taiwan. Retrieved June 2010, fromThe World Factbook:https://www.cia.gov/library/publications/the-world-factbook/geos/tw.html

[3] Cheng, T.-M. (2003). Taiwan’s new national health insurance program: genesisand experience so far. Health Affairs , 22(3), 61-76.

[4] Folland, S., Goodman, A. C., & Stano, M. (2009). The Economics of Healthand Health Care. Prentice Hall.

[5] Lu, R. J.-F., & Hsiao, W. C. (2003). Does universal health insurance makehealth care unaffordable? Lessons from Taiwan. Heatlh Affairs, 22 (3), 77-86.

[6] Seguin, R. (2010, March 30). Quebec stirs health-care debate withproposed user fee. Retrieved June 2010, from The Globe and Mail:http://www.theglobeandmail.com/news/politics/quebec-stirs-health-care-debate-with-proposed-user-fee/article1517624/

The Prognosis 23

[7] Stolberg, S. G., & Pear, R. (2010, March 24). Obama Signs Health CareOverhaul Bill, With a Flourish. Retrieved June 2010, from The New YorkTimes:http://www.nytimes.com/2010/03/24/health/policy/24health.html

[8] Underwood, A. (2009, November 3). Health Care Abroad: Taiwan. RetrievedJune 2010, from The New York Times :http://prescriptions.blogs.nytimes.com/2009/11/03/health-care-abroad-taiwan/

A Sobering Reality: Understanding Russia’s

Alcohol Morbidity and Mortality from an

Epidemiological and Political Approach

Peter Shyba

Previously published in the McGill Daily under the title “Historical HardDrinking.”

If Vodka cost a dollar fifty a dol-lar fifty for half a litre, how much of itwould you drink? In Russia, where theprice of Vodka averages between $1.50and $3.00, the answer is simple: a lot [2].Each year an average of 19,000 Russiansdie from alcohol poisoning and hundredsof thousands of others suffer the ill con-sequences of excess alcohol consumption– cirrhosis of the liver, heart disease, in-creased risk of cancer, type-twodiabetes,impaired mental development, and roadaccidents [1].

Between 2.5 and 20 million Russiansare estimated to be alcoholics, contribut-ing to the ten year gap in the life ex-pectancy between genders (with men dy-ing earlier than women), the highest ofsuch gaps in the world [1][3]. The en-demic effects of alcoholism are seen notjust in Russia, but also among the wholeblock of former Soviet countries. Whilethe rest of the developed world has pro-

gressed in terms of life expectancy, for-mer Soviet Union countries have largelylagged behind.

New measures implemented by Rus-sian president Dmitry Medvedev lastwinter that set a minimum price ofvodka at $3.00 per pint (around half alitre) are meant to offset the detrimentaleffects that alcohol has, not only on theinternational image of Russia but also onits economic stability [4]. According toa Time Magazine poll, an estimated $8billion from the Russian economy is lostper year due to drinking. This is due inpart to the roughly 25 per cent of Rus-sians who admit to drinking before work,while another 20 per cent drink duringwork itself [5]. While its too early to tellnow if the measures have been effective,one can presume that the laws, meantto deter the poorest of Russians fromimbibing too frequently will in fact back-fire. Russians will continue to drink, and

24

The Prognosis 25

those who can’t afford the $3 minimummay turn to illegal vodkas.

Bloomberg Business estimated thatthe black market accounts for 1.2 bil-lion litres of alcohol consumption in Rus-sia, half of the countries yearly average[6]. This bootlegged vodka accounts forabout 127.6 billion rubles (around US$400 million) annually [6]. This blackmarket Vodka comes in two differentforms. The first is alcohol that is madein factories “off book”, whereby factoryworkers manufacture extra vodka to sellfor profits above their usually low wages.The second and more dangerous formis vodka that isn’t actually vodka atall, but rather chemicals like householdcleaning product or medicines mixedwith water. In 2004 the Yekaterinburgdistrict of Russia suffered three deathsand dozens of hospitalizations when res-idents drank disinfectants passed off asalcohol [11].

Perhaps the most interesting facetof this problem is the seeming para-dox it presents to the liberal-mindedinternational development community.Hobbess statement of life being “nastyand brutish and short,” is true for manyRussian men, whose life expectancy foris roughly sixty years old [3]. This state-ment has become an indelible call toarms for demographers and social sci-entists as a community, who constantlychallenge this statement and implementpolicies with the primary intention of

increasing life expectancy and disprov-ing the verisimilitude of Hobbes’s fa-mous claim. Logic follows that since lib-eral democracies have seen a dramaticincrease in life expectancy and qual-ity of life, then development strategiesthat encourage liberalization (econom-ically, politically and socially) will, inturn, increase life expectancy, health,and wealth.

Why then, was life expectancy at oneof its highest points in Russia in the1960s [3], arguably at the peak of theUSSR? Why then is the gap in maleand female health outcomes continuingto widen even though Russia is becom-ing relatively more liberal? The answermay lie in the bottom of the vodka bot-tle.

There are few things more stereo-typically Russian than vodka, and thedrink holds a fervent national signifi-cance. In 1977, Poland filed a claim toan international trade court that its na-tion was in fact the inventor of vodkaand as such, was the only country withthe right to market the drink [7]. If theclaim had been accepted, Russia wouldhave been forced to market their vodkaas “bread wine,” an idea that didnt sitwell with the USSR. This claim igniteda fierce battle between the two coun-tries, with Russian“scholars” claimingthe drink was first brewed in Moscowin 1440. In an era of intense domina-tion by the Soviet superpowers, Poland

The Prognosis 26

was unable to present the facts fairly; ac-cording to research done by Vice Mag-azine, it was in fact it was very likelyPoland that first brewed vodka, techni-cally giving them the exclusive right tomarket the drink[7]. The outcome ofthis battle would prove to be economi-cally significant to the Russians. Vodkais now the one of the worlds most pop-ular spirits, with annual sales in the bil-lions of dollars. Sales of top-shelf brandslike Grey Goose have risen particularlyquickly, (the French-made Grey Goosewas sold for $2.3 billion in 2002, thelargest brand takeover in world history[8]).

In the Soviet Union, alcoholism wastouted as a “relic of capitalism,”[9]where it was presumed that men wereled to drink because of the exploitive na-ture of factory work. The belief was thatthrough communism, alcoholism wouldeventually fade away. But the Sovietsdidnt do their homework. Alcoholismhas been an issue in Russia since about986 AD, when Muslim Bulgars encour-aged Grand Prince Vladimir I to adoptIslam in that year. He declared: “Drink-ing is the joy of the Rus. We cannot existwithout that pleasure.[9]”

Thousands of years (and many hang-overs) later, Nicholas II, the last Tsarof Russia, ordered a countrywide pro-hibition during the First World War[8]. Already on the brink of revolt, theTsar’s decision further loosened his ten-

uous grip on power. In 1985, Gorbachevdid the same as a part of Glasnost andPerestroika. Between 1955 and 1984, al-cohol consumption had increased 250%in Russia [10], and Gorbachev decided todo something about it. He ordered lim-ited hours on liquor stores and decreasedthe amount of alcohol restaurants couldserve to patrons. Many began to drinkcologne and rubbing alcohol with dev-astating health consequences [11]. Sixyears after that prohibition, the USSRwas no more. Alcohol consumptionseems to be a frequent and importantaspect of Russian history and culture.

This history of alcoholism may giveus some answer to the question of Rus-sias poor life expectancy. Those dwellingin the former Soviet Union have histor-ically been prone to alcoholism, in part,because there have been few occasions inhistory when these countries have beenethnically and nationally determined. Itwould seem that without autonomousleadership, these countries fall victim toa sense of pervasive helplessness, whichin turn leads to a dependence on al-cohol to escape. Their alcoholism isa somatization of their political repres-sion. Similar to the condition known asNervos[12], described by medical anthro-pologist Nancy Scheper-Hughes, Rus-sian alcoholism is likely more politicalthan biological or cultural in its epidemi-ology. In viewing the issue of alcoholismas a political issue rather than a biolog-

The Prognosis 27

ical one, it becomes less pervasive.Even now, under what is called

“democracy,” Ukrainians, Russians, Be-larusians, and other former Soviet blocdwellers live under intensely paternalis-tic governments. Russian people specif-ically rely on their government to setrules regarding consumption. Thereare few rehabilitation centres, supportgroups, or government policies to helpwith prevention. The Russian govern-ment, now officially a “democracy,” re-fuses to let go of Soviet style-paternalismwhen it comes to the health outcomes ofits people. By extension, the strangle-hold that Russia still has on its formersatellites prevents them from truly lib-eralizing healthcare.

Ukrainians are now just starting to

get their footing as a free country. TheOrange Revolution signaling Ukraine’sdesire to end Russian dependence andjoin the European Union may be the ex-act freedom the Ukrainian people desire.Maybe then, once wealth can be createdand the Russians lose their dominanceover the region, the former Soviets havea reason to stay alive, and sober.

Peter Shyba is a second year McGillstudent studying International Devlop-ment and the Social Study of Medicine,and is currently a visiting student at theUniversity of Calgary. His interest liesin the History of Medicine in developingcountries, especially former communistnations.

References

[1] Kamenev, Marina. (2009). Russia’s Artisanal Moonshine Boom. Time Maga-zine Retreived online.

[2] Suddath, Claire.(2010) Russians and Vodka. Time Magazine Retreived online.

[3] Http://gapminder.org. Retreived February 2nd 2011.

[4] Barry, Ellen. (2010)In Russia, a New Year and a New Price for Vodka. NewYork Times.

[5] Moody, John, James O. Jackson, and Nancy Traver. (1985) Soviet UnionFighting the Battle of the Bottle. Time Magazine Retreived online.

[6] Ermakova, Maria, and Andrew Cleary. (2009). Russian Blitz on BootleggedVodka May Be Boon for Synergy Sales. Bloomberg Business Retreived online.

The Prognosis 28

[7] www.vbs.tv/watch/the-vice-guide-to-travel/wodka-wars. Retreived February2nd 2011.

[8] Prial, Frank J. (2005). The Seller of the Goose That Laid a Golden Egg. NewYork Times.

[9] Blocker, Jack S., David M. Fahey, and Ian R. Tyrrell. (2003). Alcohol andTemperance in Modern History: an International Encyclopedia. Santa Bar-bara, CA: ABC-CLIO. Print.

[10] Veni, Vidi, Vodka.(1989). The Economist (US).

[11] http://www.inform.kz/eng/article/2089456 Accessed February 2nd 2011.

[12] Scheper-Hughes, Nancy.(1992). Death without Weeping: the Violence of Ev-eryday Life in Brazil. Berkeley: University of California.

Your Right to Know

Alexandra Markus

When I started volunteering at St.Mary’s Hospital two years ago, I wasplaced in the outpatient department.Most of my job involved sorting andstamping charts, and delivering them todifferent departments of the hospital. Intraining, the secretaries couldn’t empha-size enough that I must never let a pa-tient see their own chart. Failure tocomply with this strict regulation wouldresult in immediate expulsion from thevolunteer program. On one occasionwhen I was walking past the waiting areato deliver a chart, a patient asked me ifshe could see her chart. Everyone wasappalled, as if asking such a questionwere as egregious as me picking up herchart and reading it aloud. I apologizedand said that it is against hospital pol-icy.

Six months later, I was “promoted”to the Medical Day Center, where thereis much more patient contact. At first,like in the Outpatient Department, thecharts were all gathered in numerical or-der on a trolley behind the secretary’sdesk. Whenever a physician needed achart, he would get it himself and thenput it back. At the end of the day,

sometimes, I would be in charge of push-ing the trolley to Medical Records. Butthings were soon to change.

I fondly remember about a year ago,after six months in the Medical Day Cen-tre, a kindly woman in a volunteer uni-form dropped by the Medical Day Cen-tre. She passed around a few pens withpapers that rolled out detailing every-thing patients need to know about theirrights. She said she was from the newPatient Advocacy Team. There werenumbers patients could call if they felttheir rights were being compromised,and a statement that said: “Every pa-tient is allowed access to their medicalrecords. If you would like to see yourchart, drop by medical records or callthis number to make an appointment.”This was a pivotal moment in my expe-rience as a volunteer; the peripateia thatprecipitated a revolution in how patientcare and confidentiality of records wasviewed. Or so I thought.

Things started changing slowly butsurely in the Medical Day Centre -though I was unsure whether it wasmerely from an increase in awarenessdue to this newly implemented Patients

29

The Prognosis 30

Committee or from new regulations re-garding medical records altogether. The“chart trolley” got smaller and smaller,and charts started appearing on thesmall rolling tables next to the patients’beds, next to their lunch trays. Theywere free to peruse them at their leisurewhile waiting for the doctors to come.

Recently, after a conversation with arepresentative from St. Mary’s Depart-ment of Medical Records, I found theanswer. According to her, the observedtrend did not reflect a change in rules,as they had always been the same: “Ifa patient ever wants to see their chart,they are supposed to make a written re-quest to medical records. They’ll set upan appointment to view the chart. Thewaiting room environment of the Out-patient Department, for example, is thereason why patients are not allowed ac-cess to their charts, as, unlike in theMedical Day Centre, it is not supervisedby nurses and there is a risk that they oran accompanying relative will walk outwith it. The charts are the property ofSt. Mary’s, so they must remain here atall times.”

This rule was evidently put in placeto ensure absolute confidentiality, some-thing that is taken very seriously at theMUHC. According to the representativeat St. Mary’s Medical Records, “No-body is allowed to view your file withoutyour written consent, so letting patientssee their charts whenever they want also

adds a small risk of the patient acciden-tally leaving the chart behind for otherpeople to look at.”

Even doctors are not allowed to viewa patient’s chart without the patient’swritten consent. Meaning, any doc-tor in the hospital who is not follow-ing a particular patient is not allowedto see their chart with only one ex-ception: If an emergency warrants im-mediate action, the doctors taking careof the situation are allowed to see thecharts under the clause of either “in-ferred” or “forced” consent [1]. The for-mer means that it is assumed that thepatient would allow the doctor to seehis or her chart if this patient were oldenough, conscious enough, in less acutecondition, or of sound enough mind tomake the decision; and the latter meansthat the patient would be a menace tosociety if consent is not forced (Hunterv. Mann[1974]).

Confidentiality is absolutely crucialfor any medical system to work, as,“if clinicians were not required to keepconfidence, people would be reluctantto provide them with personal informa-tion about their physical and mentalhealth. In the case of psychiatric pa-tients, a proportion of whom might alsobe dangerous.[1]”

Anyone with statutory right of accessis allowed to see his or her personal data[1]. In Quebec, this refers to anyone whois 14 years of age or older and is not a

The Prognosis 31

ward of the state. The Quebec Healthand Social Service Ministry states thatyou are also allowed to request a hardcopy of your chart free of charge, pro-vided you have the proper identification(your RAMQ Health Insurance Card).

The year 2011 marks a pivotal yearfor medical recordkeeping in Quebec.Starting this year, paper medical recordsare going to be transferred to an elec-tronic database [2]. This initiative,already commonplace in Europe andstrongly pushed by both the Bush andObama administrations in the US, hopesto reduce the cost and environmental im-pact associated with the collection andmaintenance of paper records. CTs,MRIs, and X-rays, among other test re-sults, are already in an online databaseat all McGill affiliated hospitals, so itseems perfectly logical for the rest of pa-tients’ charts to follow suit. However,such a large-scale change seldom comeswithout its opponents. Many peoplefear that placing medical records onlinewould render them susceptible to hack-ers and other intelligentsia. The QuebecMinistry of Health and Social Serviceaddresses and refutes this point, claim-ing it is not a legitimate worry as all in-formation would be stored under tightsecurity, and will be backed up in sucha way that in the very unlikely event ofhacking or system breakdown, an accu-rate copy of the records before their van-dalism or breakdown would still be ac-

cessible [2]. Moreover, Dr. Brian Jacobsfrom the Childrens National MedicalCentre in Washington, D.C., claims thatthe benefits of storing medical recordselectronically far outweigh the risks. Heraises a valid point in stating “the rootof most medical errors is miscommuni-cation. With electronic records, we canprevent that.” For instance, anyone whoknows a pharmacist knows that it’s def-initely not a myth that a large propor-tion of doctors have illegible handwrit-ing. With the new electronic system,prescription errors due to bad handwrit-ing would be a thing of the past, and testresults can be accessed quickly and eas-ily by any practitioner who needs them[3].

The Quebec Electronic HealthRecords (EHR) website states that au-thorized health professionals who haveat least limited access to your chart in-cludes doctors, nurses, microbiologists,medical archivists and pharmacists, aslong as they are personally responsiblefor your care. The government hopesto expand the list of “authorized per-sonnel” to dentists, nursing assistants,podiatrists, optometrists and midwives.Another new development starting in2011 is the restriction of your employer,insurance company, or person from seek-ing to have you sign a contract thatrequires a health assessment or to re-quest even a partial copy of your EHR.This is for the purpose of alleviating any

The Prognosis 32

burden, financial or otherwise, that dis-closure might cause. So if any employerrequests access to your medical records,you are required by law to refuse themaccess without penalty[2].

For more information about yourrights to your medical records, consulthttp://www.dossierdesante.gouv.qc.ca.Alexandra Markus is a U1 studentcurrently majoring in Physiology and

double-minoring in Drama and Theatreand Social Studies of Medicine. Globalhealth has always been a passion of hers,primarily thinking up creative yet practi-cal ways of lessening the health burden indeveloping countries. This summer, shewill be going to Peru with Patch Adamset al. to clown around, paint murals, andof course, run a clinic.

References

[1] Dolan, Bridget. (2004). Medical records: Disclosing confidential clinical infor-mation. The Psychiatrist, 28, 53-56. doi: 10.1192/pb.28.2.53. Retrieved Feb18, 2011 from http://pb.rcpsych.org/cgi/content/full/28/2/53.

[2] Ministere de Sante et de Services sociaux du Quebec. (2011). Dossier deSante: Pour mieux prendre soin de vous. Retrieved Feb. 18, 2011 fromhttp://www.dossierdesante.gouv.qc.ca

[3] Silberner, J. (2009, March 29). Electronic Medical Records ACharged Debate. National Public Radio. Retrieved Feb. 18, 2011 fromhttp://www.npr.org/templates/story/story.php?storyId=102481028.

Do Video Games Lead to Violence?

Emily Erkkinen

There is a world where “points” be-come synonymous with “kills”, wherethese points are ones sole source ofveneration, and existence atrophies intoan unremitting cycle of kill, be killed,and repeat. This world is the virtualreality of violent videogames (VVGs).Thus begs the question: are videogamessimply innocuous child games, or arethey enactors of desensitization and cre-ators of criminals? Gentile and An-derson (2003) in their article “ViolentVideo Games: The Newest Media Vio-lence Hazard,” allege that videogamespromote violence. They attest thatVVGs are inherently comprised of learn-ing mechanisms that ingrain violent ten-dencies, including acting out completebehavioral sequences, active participa-tion, repetition, reward systems, per-vasive violent themes, and first per-son identification with a violent char-acter. Specifically, they enumerate re-sults such as decreasing prosocial be-havior, and increasing blood pressure,aggressive thoughts, hostility, anxiety,frustration, and aggressive behavior. Ol-son(2004), in contrast, claims in her arti-cle “Media Violence Research and Youth

Violence Data: Why Do They Conflict?”that videogames are benign.

She exposes serious flaws in VVG re-search tests, such as inadequate sam-ple quality, the inaccuracy of artifi-cial tests, inappropriate combinationof tests in meta-analyses, and varyingmeasurements of the abstract conceptsof “aggression” and “violence.” Shestates that without testing for violentpeople “selecting into” playing violentvideogames, the studies results are notproven to be of significance.

With all the uproar about the neg-ative effects of violence in the me-dia, more researchers and policy makersshould turn their focus to videogames,a growing industry whose revenue hasnow surpassed that of music and movies.As current research has shown, violentvideogame content, design, and addic-tive qualities predispose gamers to sub-sequent violent behavior. As videogameusage rises, researchers should elucidatethe detrimental effects that videogamescould pose to our society, so thatmeasures to offset the potential conse-quences can be taken.

Naturally, an observer forms violent

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The Prognosis 34

thoughts when exposed to violent im-ages [1]. A person who has just heardviolent discourse or observed violent be-havior is more apt to speak or act ag-gressively because the response is moreaccessible in his or her mind. There-fore, the content of VVGs has the po-tential to produce negative effects. Var-ious cross sectional studies [3], longitudi-nal studies [2], and meta-analyses[1] in-dicate that VVG content augments ag-gressive behavior, aggressive cognition,aggressive affect, physiological arousal,aggressive emotions, and/or desensiti-zation. This augmentation exacerbatessubsequent violent behaviors. Despiteconservative statistical procedures [1],critics snub these studies by selectivelyexamining evidence, restricting their fo-cus to negligible flaws, and overlookingcognitive learning theory [9]. For ex-ample, they harp on the debate of “se-lection” versus “causation” [12] but for-get that selection and causation are notmutually exclusive [14]. A longitudinalstudy controlling for initial violence stillfound that exposure to videogames withviolent content predicted later aggres-sion [2]. Cross-cultural studies [1][2][7]further show that effects are causal innature. For example, in Gentile’s (2009)study, the United States, Japan, andSingapore all demonstrated similar ef-fects from VVG exposure, even thoughthe Eastern countries have a less crime-ridden culture.

These studies are pertinent becausetoday 90% of American children playvideogames at home [1], and 99% ofboys and 96% of girls say they playvideogames. Even people living at a lowSES are exposed to VVGs [7]. The poorare already especially prone to develop-ing mental illness. Since VVG contentaffects diverse groups, it can accumulateas yet another risk factor for already dis-advantaged groups [11].

Although the short-term conse-quences of VVG exposure (such as phys-iological arousal and aggressive scriptpriming) are well-known [1], critics as-sert that there will be only negligi-ble long-term consequences, but con-sequences nonetheless [12]. On thecontrary, VVG design enhances a pe-jorative learning process, deeply em-bedding violence into ones personal-ity. Well-studied and widely-acceptedmechanisms of learning that are presentin videogames include active participa-tion, repetition, and reward systems.Since VVGs are inherently interactive,a player is both a witness and an en-actor of violence [2]. Frequently, VVGdesign necessitates that the gamer inde-fatigably decide to engage in harmful be-havior to earn a reward, perpetuating acycle of learning and reinforcement [7].Moreover, “problems” encountered fre-quently offer only one solution: to actviolently. This further reinforces the for-mation of a violent personality. Once

The Prognosis 35

these learning systems are in place, long-term changes in personality will presum-ably ensue. Longitudinal studies illus-trate this by controlling for a person’sinitial aggressive personality levels. Testsubjects who habitually play VVGs, re-gardless of their initial violent person-ality levels, experience intensified subse-quent violent behavior [2].

Since videogames are highly interac-tive and take place from a first-personperspective, the gamer is inclined to be-come attached to his or her charactersrole in the virtual world [2]. Symbolicinteraction theory hypothesizes that aperson develops personal meaning by en-gaging in social interaction. This mayspan into situations of virtual interac-tion as well. Videogames can become asort of virtual social world to the gamer.Since identities held by an individual in-fluence one another because of the indi-viduals network embeddedness, behav-ior learned in a virtual social context willbleed into real world social identities. Ifa gamer becomes deeply committed tohis or her role as a violent videogamecharacter, his or her violent identity willpermeate his or her non-virtual percep-tions and reactions [16].

While many studies have real-lifemeasurements of violent or prosocialaugmentation, such as willingness to as-sist a harassed woman [8], critics pur-port that ambiguous definitions of “ag-gression”, “violence”, and “prosocial”

undermine the findings of such stud-ies [12]. Regardless, if a person islabeled as “violent” they will still bepushed into further deviance [10]. More-over, videogames prevent social ties frombeing formed when played in excess,thereby removing salubrious social sup-port systems [13]. On average, Ameri-can boys play 16-18 hours of videogamesa week [2]. In addition to contentand construct, time allotted to playingvideogames can have detrimental effectson personality formation by detractingfrom time spent engaging in more proso-cial activities. Addiction to videogamesdetracts from interaction with others,thereby impeding the formation and de-velopment of one’s social identity. Ad-diction becomes a form of isolation fromsocial circles, decreasing the amount ofrole sets formed. The less role setsformed, the more likely a person is tohave a psychological disturbance, suchas aggressive personality [1][16]. Fur-thermore, labeling a person as “aggres-sive” will have negative repercussions forhis or her social networking and self-esteem, according to modified labelingtheory. These consequences predisposethe individual to further deviation fromsocietal norms, thus enhancing violentbehavior. The deviance becomes inter-nalized [10]. Correlation has alreadybeen demonstrated between time spentplaying videogames and poor school per-formance and social skills [2]. Since pro-

The Prognosis 36

ductivity is more socially esteemed thanstigmatized videogames, a person lack-ing these socially venerated skills mayfall further into the cracks of social de-viance [4][16].

VVGs have negative consequencesfor social behavior through their con-tent, design, and addictive qualities.Psychological research on VVGs bene-fits from utilizing sociological conceptsto further elucidate how, when, and whyVVGs impact the gamer, specifically byanalyzing social interaction and label-ing theories, social support systems, andthe discrepant impacts across differen-tially vulnerable groups of people. Forexample, by studying VVGs differentialaffects on at risk populations (such aschildren and the poor), researchers maybetter be able to explain the magnitudeof their results and incite institutionalchange [1][8]. To further gain public sup-port, research should eliminate commonexperimental design flaws by lengthen-ing the time period of longitudinal stud-ies [2][1][3], using larger sample sizes

[2][1], and construing a common defi-nition for “violence” to make separatestudies more comparable [1].

Once someone’s deviance (eg. vio-lent behavior) is affirmed through an-others reaction, the deviance can cas-cade into a self-fulfilling prophecy be-cause of stigmatizations consequences,such as losing social ties [5]. Lack of so-cial support is an integral factor in thepathway to violence, and is especiallypotent when there are other stress fac-tors in operation, such as low SES [15].The effects VVGs have on individualscould be reduced by reducing the stigmathat comes with struggling with socialskills, playing “nerdy” videogames, andperhaps acting violently [17]. Althoughremedying stigma is difficult since itis so deeply embedded in society, pub-lic information campaigns could increasecommunity understanding of the rea-sons for the consequences of VVGs, andthereby diminish social support loss forthe gamer [18].

References

[1] Anderson, C. A., Bushman, B. J., Ihori, N., Rothstein, H. R., Sakamoto, A.,Saleem, M., ... & Swing, E. L. (2010). Violent Video Game Effects on Aggres-sion, Empathy, and Prosocial Behavior in Eastern and Western Countries: AMeta-Analytic Review.Psychological Bulletin, 136(2), 151-173.

[2] Anderson, C. A., Gentile, D. A., Ihoiri, N., Kobayashi, K., Naito, M.,Sakamoto, A., ... & Yukawa, S. (2008). Longitudinal Effects of Violent Video

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Games on Aggression in Japan and the United States. Pediatrics, 122(5),e1067-e1072.

[3] Bluemke, M., Friedrich, M., & Zumbach, J. (2010). The Influence of Violentand Nonviolent Computer Games on Implicit Measures of Aggressiveness. Ag-gressive Behavior, 36, 1-13.

[4] Diller, L. H. (1996). The Run on Ritalin. The Hastings Center Report, 26(2),12-18.

[5] Frese, F. J., & Davis, W. W. (1997). The Consumer-Survivor Movement, Re-covery, and Consumer Professionals. In J. D. McLeod & E. R. Wright (Eds.),The Sociology of Mental Illness: A Comprehensive Reader (pp. 805-808). NewYork, NY: Oxford University Press.

[6] Gentile, D. A., Anderson, C. A., Bushman, B. J., Huesmann, L. R., Ihori, N.,Khoo, A., . . . & Yukawa, S. (2009). The Effects of Prosocial Video Games onProsocial Behaviors: International Evidence from Correlational, Longitudinal,and Experimental Studies.Personality and Social Psychology Bulletin, 35(6)752-763.

[7] Gentile, D. A., & Anderson, C. A. (2003). Violent Video Games: The NewestMedia Violence Hazard. In B. Slife (Ed.), Taking Sides: Clashing Views onPsychological Issues (14th ed.) (pp. 300-308). Dubuque, IA: McGraw Hill.

[8] Greitemeyer, T., & Osswald, S. (2010). Effects of Prosocial Video Games onProsocial Behavior. Journal of Personality and Social Psychology, 98(2) 211-221.

[9] Huesmann, L. R. (2010). Nailing the Coffin Shut on Doubts That ViolentVideo Games Stimulate Aggression: Comment on Anderson et al. Psycholog-ical Bulletin, 136(2) 179-181.

[10] Link, B. G., Cullen, F. T., Struening, E., Shrout, P. E., & Dohrenwend, B.P. (1989). A Modified Labeling Theory Approach to Mental Disorders: AnEmpirical Assessment. In J. D. McLeod & E. R Wright (Eds.), The Sociologyof Mental Illness: A Comprehensive Reader (pp. 433-459). New York, NY:Oxford University Press.

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[11] Miech, R. A., Caspi, A., Moffitt, T. E., Entner Wright, B. R., & Silva, P. A.(1999). Low socioeconomic status and mental disorders: A longitudinal studyof selection and causation during young adulthood. In J. D. McLeod & E. R.Wright (Eds.), The Sociology of Mental Illness: A Comprehensive Reader (pp.294-315). New York, NY: Oxford University Press.

[12] Olson, C. K. (2004). Media Violence Research and Youth Violence Data: WhyDo They Conflict? In B. Slife (Ed.), Taking Sides: Clashing Views on Psy-chological Issues(14th ed.) (pp. 309-316). Dubuque, IA: McGraw Hill.

[13] Pearlin, L. I. (1989). The sociological study of stress. In J. D. McLeod & E.R. Wright (Eds.), The Sociology of Mental Illness: A Comprehensive Reader(pp. 170-188). New York, NY: Oxford University Press.

[14] Simon, R. W. (2002). Revisiting the Relationships among Gender, MaritalStatus, and Mental Health. In J. D. McLeod & E. R. Wright (Eds.), TheSociology of Mental Illness: A Comprehensive Reader (pp. 249-272). NewYork, NY: Oxford University Press.

[15] Silver, E., & Teasdale, B. (2005). Mental Disorder and Violence: An Exam-ination of Stressful Life Events and Social Support. In J. D. McLeod & E.R. Wright (Eds.), The Sociology of Mental Illness: A Comprehensive Reader(pp. 753-775). New York, NY: Oxford University Press.

[16] Thoits, P. A. (1983). Multiple Identities and Psychological Well-Being: AReformulation and Test of the Social Isolation Hypothesis. In J. D. McLeod& E. R. Wright (Eds.), The Sociology of Mental Illness: A ComprehensiveReader (pp. 189-206). New York, NY: Oxford University Press.

[17] Tsao, C. I. P., Tummala, A., & Roberts, L. W. (2008). Stigma in MentalHealth Care.Academic Psychiatry, 32(2) 70.

[18] The World Health Report. (2001). Mental Health: New Understanding, NewHope. Geneva, Switzerland: World Health Organization.

In Cancer’s Genes

Pauline Helle, Co-President of Think Pink McGill

Recent and even controversial findings give an astonishing glimpse into

the future of research, prevention and potential cure for breast cancer

Professor Anne-Lise Børresen-Dale, Head of Department of Genetics at the Insti-tute of Cancer Research at the Norwegian Radium Hospital, specializes in molecularoncology of breast and ovarian cancer. She has served as Member of the Board ofDirectors in the American Association for Cancer Research (AACR), as Presidentof the European Association of Cancer Research (EACR) and as Member of theBoard, the European Cancer Organization (ECCO). Her publications include over350 scientific papers and 30 chapters in books and invited reviews.

Professor Børresen-Dale is a pioneer in gene-based cancer treatment. By decodingthe genetic material of a patient’ s tumor, researchers can determine the tumor’s“Achilles’ heel,” its weak point, and thus the optimal treatment. This approachis known as “ personalized treatment” and may eventually lead to “personalizedprevention,” whereby researchers are able to foresee genetic dispositions towardsparticular diseases and prevent them from occuring. Hand in hand with her ge-netic research work, Professor Børresen-Dale works as an avid advocate for thedevelopment of translational sciences. Translational science refers to the conceptof converting results from basic research into applied research and product devel-opment, also described as translating bench science into bedside clinical practice.With personalized treatment potentially redefining our approach and experience inbreast cancer research, we asked Pr. Børresen-Dale ten questions about the futureof breast cancer.

Think Pink:What is the financial costof codifying a patients genes in 2010 andcan it be standardized?

Pr. Børresen-Dale: Today, if weput this into the clinics it would be too

expensive to be a standardized proce-dure. Partly because we currently arenot able to reduce the time in finding theAchilles’ heel which could lead us to thebest treatment. This process is costly if

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The Prognosis 40

we are going to do full mapping and se-quencing of each cancer gene. Today, thecost is close to 20,000 dollars, but that isnot all that is needed. What must followis an extensive interpretation of the dataand we do not yet know the best way ofdoing that.

Think Pink: Do you think this tech-nology will be something my generationcould benefit from within our lifetime?

Pr. Børresen-Dale: I definitely thinkso because the technology is moving sofast. The informatics, how you handlethe data, is escalating. We get moreand more sophisticated tools helping usto really see the structures in the data,revealing information which we haven’tthought about at all. Then we may beable to identify the Achilles’ heel in thatparticular tumor. The cost of sequenc-ing a genome is moving down to 10,000dollars and the aim is to get it down to1,000 dollars within the next five years.As it is today we are still struggling tofind the Achilles’ heel in each patient. Sofor the time being what we need to dois molecularly characterize as many tu-mors as possible with good clinical anno-tations that we can use for further mod-eling.

Think Pink:Do you see this technologyultimately leading to more of a preven-tive than a curative approach?

Pr. Børresen-Dale: That is wherewe need to go to be able to effectivelycombat cancer. Indeed we need to do

more to prevent it. We have for sometime been talking about more person-alized treatment, but we also have todare to start talking about personal-

ized prevention. It’s not good foreveryone to eat carrots everyday. Youneed to know “who is at risk for what?”This is ultimately the goal, but I thinkit comes together with knowing moreabout the cancer itself and what trig-gered that cancer in that particular pa-tient. . We should not limit our re-search to the tumor but go on to ac-quire knowledge about the genotype ofeach patient and the patient’s lifestyleand environmental exposure and ask thequestion: What kind of cancer did thewoman with that genotype and that en-vironmental exposure develop? This ispart of a whole system of biology, andwhen you can decipher that for each in-dividual, you may be able to predict thetype of cancer that a particular womanmight develop. At this point, you canstart individualized prevention.

Think Pink: Do you have other per-sonal goals?

Pr. Børresen-Dale: One of mydreams is to do an image type of analy-sis, without involving any invasive sam-pling, where you capture the status ofall the molecular components and thenget a high digitalized image that showsthe structure. When you see a particu-lar image, it will identify a specific type

The Prognosis 41

of tumor and the precise nature of itsAchilles’ heel. This will immediatelytell you how to treat that patient. Itmay look like science fiction, but I reallydo think it is possible in the not too dis-tant future.

Think Pink: Are there any warningsigns that one may develop breast can-cer or other cancers?

Pr. Børresen-Dale: I think the firstthing to look for is the family history. Ifyou have a close relative that had lungcancer and smoked, don’t smoke! Phys-ical activity prevents a lot of diseasesincluding breast cancer so exercise andstay slim. Some infections may stimu-late certain cells to grow, possibly occulttumor cells, and thus become a risk fac-tor for developing cancer. The samecan be said for surgery, which may alsostimulate cell growth so avoid unneces-sary operations. There are also reportsthat the healing process after injuries,for example in knees, may stimulate tu-mor cell growth. So I think we need tobroaden our scope and to start lookingat other diseases like diabetes, rheuma-tism and other autoimmune diseases todetermine how they affect one’s systemand how that system affects the risk ofcancer. Such studies are starting to takeplace. We see that similar genes maybe involved in several different diseases,with the same genes affording protection

against one type of disease but indicat-ing susceptibility for another. It can goboth ways. Again, we need to be muchmore open-minded when looking at thesimilarities between different diseases.As previously mentioned, we need toconsider diseases at a systems biologylevel.

Think Pink: The question of naturevs. nurture (genetics vs. lifestyle) re-mains an issue with breast cancer andcancer in general. Now we hear aboutanti-cancer food or that severe depres-sion or anguish can trigger breast canceris there any truth in all this?

Pr. Børresen-Dale: It’s never onlyenvironment; it’s never only genetics.It’s a gene environment interac-

tion all the time. The younger youget the cancer the more likely it is thatthe genetics play a major role and theolder you are it’s more likely that the en-vironmental factors are stronger. Takestress for example. Stress causes you tostart to hyperventilate, you get anaer-obic metabolism, and you get a lot ofbi-products which may harm your DNA.If you have a very good repair capacityit doesn’t matter. Then again, for somepeople stress is more dangerous thanothers; but for the time being we don’tknow who is and who isn’t at greaterrisk. Similarly, I think nutrition may beprotective for some people but not for

The Prognosis 42

all.

Until recently, it has been a big prob-lem for epidemiology research aiming atfinding risk factors for breast cancer thatwe have been looking at breast canceras one single disease. We clearly knowtoday that it isn’t. The risks for the dif-ferent groups are probably very differ-ent. If you look at smoking for example,it is quite interesting that some women,who carry mutation in the BRCA1 gene,have a reduced risk for breast cancer ifthey smoke! So their smoking works theother way around for the risk of breastcancer, probably by lowering the hor-mone level. But no one talks about thatbecause smoking is bad, and of coursesmoking presents risks for many otherdiseases. Quitting smoking will alwaysbe beneficial for one’s health; however,what is interesting to me is that it’s notabout smoking per se, but what smok-ing does to your body to reduce the riskfor cancer in these individuals. That iswhat’s important. It may lower yourestrogen level and that again protectsyou if you have a high risk of developingcancer. We must rethink for the indi-

vidual. But it’s hard for a governmentto promote strategies that must vary forindividual to individual and to be ableto say, “this is good for this group andwill work for them, but not for this othergroup that needs different advice.” Thisproblem gets even more difficult whendealing with a heterogeneous popula-

tion.

Think Pink: What is the upcomingmain challenge for breast cancer re-search from a genetics point of view?

Pr. Børresen-Dale: I would say thatbreast cancer is actually a success story.If you are diagnosed with breast can-cer in Norway today, you have almost a90% chance of being alive after 5 years,which is extremely good. On the otherhand, we know that we do “over-treat”and that some individuals suffer severelong-term side effects as a result of treat-ment. The challenge is to identify thosethat need the heaviest treatment andthose who can receive less and still sur-vive. We have not really started to treatin a personalized manner yet. We donot dare NOT to treat. The treatmentitself contains carcinogenic substances,and may cause development of a secondcancer, so avoiding that is the biggestchallenge. It has been estimated that by2015, every 4th or 5th patient diagnosedwith cancer will actually be a previouscancer patient having developed a sec-ond cancer as a result of the exposurefrom the treatment of the first cancer.If blood tests existed that could alert usto the presence of cancer formations atan early stage, and if there were teststhat could monitor the efficacy of thetherapy, I think we could prevent muchof the over-treatment. We are not there

The Prognosis 43

yet, but we are working hard on thisconcept.

Think Pink: What are the goals fortranslational science in breast cancer re-search and for patients?

Pr. Børresen-Dale: Women are notmice so we need to do research involv-ing women. We, the scientists, needto be able to follow the patients in or-der to produce new drugs and, by usingthem in early experimental trials, de-termine if the treatment is beneficial.So, a very close and good collaborationwith the clinicians and with the patientsis needed. We must explain what weare doing to the patients and give themthe necessary knowledge so that theycan make informed decisions on furthertreatment. We must work hard to edu-cate the public. Lay groups could helpin reaching out and that is why your(Think Pink) request was so interestingto me, because indeed you have to startwith educating the young ones. Theyhave to get the knowledge before it istoo late. Many of the patients partici-pating in research projects say “I don’tdo this for myself; I do it for my daugh-ters.” So the daughters should be aware;they should know what we are doing. Inreturn they can be supportive. We needyoung advocates for our cause. We needto demystify cancer. People are livinglonger and at the rate of one in four

contracting cancer in his or her lifetimewe know that virtually every family willhave to face this disease in some way.

The hope is not to have to notwait 10 years for the FDA to approvenew promising treatments. We want toshorten the time between acquisition ofnew knowledge and possible new treat-ment. We need to dare to fail and goback again. Part of translational scienceand research is to be able to go backand forth between bench [science] andpatient.

Think Pink: What are some of thebarriers of translational sciences cul-tural, linguistic?

Pr. Børresen-Dale: One of the chal-lenges is the internalization of the ideaof translational sciences and being openabout what you know. Some competi-tion is always good, but sharing dataand knowledge will enhance the fieldfaster. You may experience having yourideas stolen by a competitor, but thatmight occur two or three times in alifetime. The risk and personal harmis nothing compared to what you getback from being open! That is one ofthe things I really hope to see happena more open sphere of dialogue, es-pecially between the different profes-sionals, the basic researchers, the clin-ical staff, the clinical scientists and, ofcourse, the patients. If we could get this

The Prognosis 44

rotation of feedback and of knowledge

spinning, we would be much better

informed much faster.

Once, while working with a teamat the Yale University, I experienceda challenging situation. There was awhole group of experts, including epi-demiologists, oncologists, pathologists,radiation oncologists, molecular biolo-gists and geneticists. Each had differentinformation at hand with respect to thepatient’s genotype, exposure, family his-tory, the size of the tumor, etc. Theydiscussed how to best treat the patientbased on all this information. After go-ing through all the data and the possibleoptions for the patient for a personalizedtreatment, a final question was asked:“what kind of insurance does she have?”Many of the treatment options that hadbeen proposed had to be abandoned be-

cause of insufficient medical coverage!!!This is unfair!! Medical improvementsfor the patients are slowed down by non-medical factors.

Think Pink: Do you have any advicefor women between 18 and 25?

Pr. Børresen-Dale: If you shouldbe presented with a cancer diagnosis,be positive. I am certain that havinga positive attitude during treatment af-fects how you experience it and fightit. Don’t feel guilt, thinking “I shouldhave” and “I shouldn’t have.” We stilldon’t always know why cancer happens.I hope that one day we will be able togive that diagnosis, so the patient canget that relief, that answer. But today,we don’t know.

Despite all the advances made in recent years and her promising research, Prof.Børresen-Dale does not hesitate in stating that, “ we should not be nave and thinkwe will eradicate breast cancer or cancer from the human population. Cancercomes from our genes. If we stop our genes from changing and developing, we arestopping evolution.” On a brighter note, she adds that the next step is rather tochange the outlook. “We hope to change how we will live with cancer. By 2015,25% of the population will be affected by cancer at one point in their lives. Wemust learn not to die of cancer but how to live with it. The hope is to minimizethe pain and suffering around cancer.”

Think Pink is a student-run McGill club dedicated to raising breast cancerawareness and fundraising for the Quebec Breast Cancer Foundation (QBCF). Formore information visit http://thinkpinkmcgill.ca/.