Surviving COVID19

COVID19 is a dangerous adversary and everyone is discussing how stressful they are finding living in the age of COVID19.

There have been many excellent recommendations on how to reduce stress. Many of these recommendations have focused on stress reduction strategies like exercise.

Given my area is mental health, I would like to add to the conversations on stress by presenting a different lens.

First, let’s talk about what stress is and is not, because to tackle something one must always know what one is getting into the ring with. 

In 1936, biologist Hans Selye described a common physiological response in rats subjected to harmful factors and he named this the stress response. “The main features of the syndrome were suppression of the immune system, ulceration of the lining of the stomach and small intestine, and activation of the two … stress-response systems.”

Over the last 80 years, there has been extensive documentation of the widespread damage of stress on our body and brain.

So stress doesn’t just feel bad - it is really bad for you. Reducing stress can save your life and a sense of control is the one way cortisol and other factors provoked by stress can be reduced and the health impacts minimized.


What is crucial is that stress is not just bad things happening to you – it is bad things happening with a sense of having no control over these things.


You might be thinking: if control is crucial to managing stress, how on earth can you control a global outbreak of a virus? How can we control not only the illnesses and deaths but also the economic consequences on such a large scale. Control? It seems like a rather ludicrous word in the face of all this.

All true points. Thank you for making them.

My answer is to introduce some people whom I have known that belong to “The Greatest Generation”- those who lived through World War II. They earned their name because of their tenacity and 'can do' attitude. They did not enter the war with these attitudes but, rather, they were forged by the hardships they faced.

My father-in-law, Bill, and his twin brother were pilots in World War II. Bill’s brother died when his plane went down in Europe and he was never able to speak of him again – it was as if the grief of his loss had torn out his heart. Bill went on to get an engineering degree, marry, have children and live a life of laughter and love.

My mother-in-law, Verna, stayed home and helped in many ways the war effort. She told me stories of how they would try to get butter to make her beloved pastries, how they would save things so they could send packages to those who were fighting along with letters. The volume of letters diminished over time because many of the young men she grew up with died.


Neither of them had any ability to stop the war or save those they loved. Both were irreparably broken by the losses they sustained. Both walked into life after the war with a strong stride. They survived the war by small acts and large ones that were all acts of resistance. Bill was a man who embraced competence – taking care of his family and being the one who got things done – and Verna was loving, taking everyone under her wing. Perhaps those characteristics were their tribute to those they lost and a way to ensure that they would keep those around them safe.

Let me introduce you to Lili. She was Jewish and was sent away from her parents as a small child into hiding. She lost her parents and everyone in her family. I learned later that she had anxiety and many difficulties all her life in response to this, but what I remember about her was that she was one of the kindest people I have ever known. If the world robs you of so much through cruelty, kindness is the ultimate act of defiance.

None of them had control over global events that ended up at their door. What they did was to take control during and after in small and large ways. Ultimately, their characters are a testament to how they became known as the greatest generation, because it was not what they endured but how they endured it that defined them.

Back to COVID19. We have no control over when we will have a vaccine and this nightmare will end. However, the reality is that we have never had control over large global events and this is no different. What we do have control over is our small corner of this planet and that is where we fight. 

Much has been discussed about the courage and tenacity of my colleagues during COVID19. When I speak with them, they talk about doing what they have always done; medicine with the patient in front of them. They read voraciously about this virus, they consult others for more information, they organize their homes to have decontamination zones to keep their family safe and do many other things to manage their corner of the planet.

Many of my non-medical friends are reading and watching the news to educate themselves, they are designing new ways to get groceries safely and clean them down. They are reaching out to friends and family to inform them, check up on them and laugh with them.

When we talk about the new normal – it is the ability of each of us to have small and large acts of defiance and resistance to keep those we love safe.


We will not recover without scars. We can only hope to minimize the number we lose and comfort those who have lost people. There will be anguish: times when we wake up in the middle of the night drenched in fear. When we emerge from this - we can do so with a character forged by how we responded to COVID and how we controlled our corner of the world.

Coronavirus COVID-19: The Heroes and the Culprits

Mary Fernando, MD

Every time a patient goes to a doctor with a new illness, the story of chasing down the diagnosis is like a mystery novel with one difference: everyone works hard to make the story short with as little excitement as possible.

In medicine, no one wants a long, twisted plot line and the best stories are the boring ones where the culprit is found quickly.

This desire for a short, boring story line has done what nothing else has been able to: it has united the world because citizens of every country want the story of the new coronavirus, #COVID-19, to end before they get a starring role in the tale of a new epidemic.



On December 30, 2019, Dr Li, a 34-year-old ophthalmologist in Wuhan, posted on Weibo that he had seen 7 cases of a SARS-like virus and warned fellow doctors to wear protective clothing to avoid infection. This sensible and medically appropriate suggestion resulted in Dr Li being summoned to the Public Security Bureau four days later and he was made to sign a letter confirming he had made false statements. Before his death from Coronavirus on Feb 7, 2020, Dr. Li explained why he warned people initially despite the fact that he knew he might be punished for it: “I think a healthy society should not only have one kind of voice.”


Like the Chinese government who tried to put a lid on information about COVID-19, we have had many others who have tried to do the same for political and financial reasons. There’s nothing wrong with trying to protect businesses, however, there is a great deal wrong with stifling information. The only thing that protects people and saves lives is the truth: if certain activities or places are unsafe, people should know this.

Through the evolution of this disease, there have been many kinds of voices speaking out and, just like in any mystery novel, each new crises reveals a great deal about the character of those involved.

There are some people who want everyone to stay calm – as if one smidgeon of worry will muck up their world. They came out in force at the beginning of this epidemic grabbing every straw they could to dampen down concern. I’m a huge fan of calmness but not when it is coupled with misinformation such as: this is only spread by animals, only spread by people who are symptomatic, the virus doesn’t live on surfaces for days and it is no more lethal than the flu.

Not one of those statements is true and people cannot protect themselves if they don’t know the truth. 


While some grasp at anything to calm people down, others have done the opposite and developed theories to fan all sorts of flames and even to start fires on their own. One theory floated around that this new virus was developed in a lab to destabilize the world. Right on the heels of this is another, very malignant theory that this is a virus that largely infects people of Chinese origin and that they are responsible for the spread of this. This has resulted in racist attacks on people around the globe.

There is another set of characters that have been emerging and speaking loudly: those who take a great deal of reassurance if they know things and even more reassurance if they know everything. Now this person who knows everything is a purely fictional character who has never existed but this doesn’t stop some people from emulating them. If this person who believes they have all the information has a large pulpit, they can spread information that is inaccurate and possibly dangerous.


Who is the biggest, baddest, scariest culprit in the saga of #COVID-19?
 Misinformation, spread by people whose need for calm, chaos or personal brilliance blinds them to the new facts emerging about this virus daily.

Some of those new facts are reassuring, some are worrisome and not one of us knows them all because it is an evolving story. For example, there has been some evidence that gastrointestinal symptoms such as nausea and diarrhea may precede respiratory symptoms during infection with this new coronavirus– this is crucial information that could lead people to seek medical attention earlier and therefore limit spread of the disease. Since we know that people without symptoms can spread the disease – unlike with SARS – we can’t assume we haven’t been exposed because no one around us was ill. 


Just like in any mystery novel, we should remain suspicious of all the characters - any one of them could spread misinformation – often not from malice but because their character compels them to engage in certain behaviours that increase misinformation. Bottom line – the only thing that will keep you and those you care about safe is information on how to avoid getting infected with coronavirus.

The heroes of this story? The first hero was Dr. Li  because he had a simple mission: to inform those around him with whatever information he had to keep them safe.

Inspired by the heroes in this coronavirus story, I recently told my children who were traveling with me that – given the fact that this disease can be spread by people who have no symptoms and the virus can live on surfaces for days – they could stay safer if they assume their hands are infected and not touch their face and food without disinfecting them first. This simple set of instructions was the best way I could summarize this disease to the people I care about the most in this world. I also keep telling them that we are in the midst of learning about this disease so I’ll keep them updated. My children must have confidence in me because they grin every time I say this.

➲ As of the 7^th of March, 2020, the World Health Organization reported that the number of confirmed cases of COVID19 has surpassed 100K. The doubling time of this disease appears to be around 7 days but the numbers, just like this disease, are fast moving. A peek at that study along with with data used gives an idea of why we need to take a deep breath and keep learning.

Another World: Writing a Mystery Book

I wrote a new book. Except it’s not new anymore. I wrote it 2 years ago. Edited. Reedited. and yes, did that multiple times. Sent it to an editor and then another. Reedited.

Now it sits in my computer and I have a problem.

It’s not the book that’s the problem: it is the mystery novel that wanted to write.

The main character was written as a rebellion against the need to have a woman detective who is either a drunk or who sleeps around because she’s deeply damaged. Because, you know, that makes her interesting. I wrote her as someone who has lived a life with troubles – because that’s what life brings - but is like the women I know and love. They may be damaged by life but are not busy damaging others in their life. Women who I’ve looked up to. Women who make me laugh. Women who force me to think.

I wrote the things I have learned from friends, patients and my own life. There’s domestic violence to racial profiling of Muslims. I tried to write it as others had lived it. I told the stories that I have heard - the ones that had made me hold my breath in fear of missing a word.

I’m on my final edit. The problem is me.

During the writing and editing, my dearest friend was ill and then died. My father was ill and then died. My mother is now ill. All this has required time and energy to help during their illness. Time to deal with the loss.

Here is the crux of the problem: when I write I do little else. I enter this world and disappear for hours on end. I live it, breathe it and reality pales in the face of the world I’ve created.

Now, my reality has jagged edges, and cuts into this world. Sawing into it until it disappears like morning mist in sunlight. When it’s gone, I can’t get it back.

My ability to concentrate - to enter other worlds - was how I’ve done everything of value. It was as natural as breathing. It’s how I studied medicine, how I spent long hours with patients and trained, it’s how I parented by disappearing in the world of my children.

All the best things in my life were dependent on not having a reality so jagged that it sawed through every thought.

So, my book and I are now on separate worlds. I have no idea how we will live on the same planet again.

Recently, I decided to research writers block, thinking there may be suggestions that help. Unfortunately I found none. Advice like ‘Find the right surroundings’ mean little to me. I can write and have written anywhere. ‘Silence your inner critic’? That’ll be a cold day in hell. I’ve met her and write anyway.

 I could go on.

Except I can’t.

With the book that is.

Here’s the next problem: I write in my head anyway. I’m always revising and thinking of the book. Except when I sit with my book. That is the worst - to write but not write. 

So, instead of my book I’m writing an article about writing my book, which is amusing but not even that coerces me enough to write.

The one thing that keeps me hoping is coffee. The night before I have a day with even one block of time, I go to sleep with visions of coffee and writing. It won’t be tomorrow because there is far too much to do.

Maybe Monday?

Airbnbs, Gangs and Pimps.

My hometown of Ottawa is the capital of Canada. Most of us who live here consider it a small, friendly town disguised as a large city.

On January 8th, Ottawa had our first murder of the year. Four young people (ages 20, 19, 18 and 15) were shot inside a home and the 18 year old was killed.

On November 2019, the Ottawa City Council ‘endorsed new rules that will restrict short-term rentals on Airbnb and other similar platforms to primary residences in a bid to crack down on so-called “ghost hotels” run by absentee owners.’

These two things are related. The young men were shot in a ‘ghost’ Airbnb.

These Airbnb ‘ghost hotels’ are “…becoming havens for criminal activity.
Unlike traditional hotels that come with security video cameras, high traffic and paid security guards on the premises, ghost hotels are often cheaper to book and come with less eyes on what’s happening inside, police say. City police are finding that in instances where violence breaks out, the person booking the rental is rarely at the home and there is a degree of anonymity in the booking. Adding to the situation is that homes are often owned by people who don’t live in the neighbourhood, or are rented by property managers. Police say they find there is little allegiance to the communities in which they are situated. It’s a “perfect scenario,” says one officer.”

When I interviewed a Crown Prosecutor for an article, he had informed me that gangs in Ottawa are mobile and change locations often weekly to avoid detection. These ghost hotels are a perfect opportunity for gangs to move every few weeks with little or no scrutiny.

I only rented an Airbnb once. My family was going to an award dinner in Toronto and I was looking for a hotel near the venue. My children argued that we should get an Airbnb. My daughter is a vegan and wanted access to a kitchen. I said I wouldn’t cook. She said I wouldn’t have to but she wanted to at least have access to the means to cook and a place to put her vegan supplies, like oat milk. This went on for a bit and I gave in, which you would only understand if you’ve had the pleasure of arguing with my children.

My daughter carefully examined reviews of Airbnbs and found one that was close to the venue and had excellent reviews. When we pulled up to the place, it was a condo building in a shady area of town. Not deterred, we went in. I found I couldn’t breathe. This makes staying at a place difficult. My asthma only gets this bad when there is mold, so I went outside with my husband to get some fresh air.

The fresh air and a puffer somewhat resolved my breathing problem but presented a new one. Pulling up to the condo were a string a large cars decanting rough looking men, wearing street clothing and women in what looked like scanty clubwear.

Since I couldn’t breathe in the apartment, and I didn’t feel safe outside of the apartment, my husband booked a hotel.

I often wondered about that odd Airbnb experience, but writing this article clarified a few things: “Investigators have noticed an uptick in pimps using Airbnb rentals in recent years. That’s likely because they’re more anonymous, and it’s more challenging for police to get information about them, compared to traditional hotels and motels, said Det.-Sgt. Nunzio Tramontozzi.”

This makes sense of our unusual experience. If I wasn’t so breathless, I might have realized that the rough looking men might have been pimps. They certainly were frightening.

So, back to Airbnbs. They are a boon for many people - both the guests and those who rent them out. My children have had wonderful experiences in Europe, the United States and Australia. It is the modern version of the student hostels that were popular when I was traveling on the cheap in other countries.

It is unfortunate that Airbnbs are being used by gangs and pimps. I hope that limits on 'ghost' Airbnbs, similar to ones Ottawa is using will curbs this. 








Maple Syrup Heist eh?

In Ottawa we celebrate maple syrup season by trekking out to a sugar bush, watching the maple sap being collected and indulging in large stacks of pancakes smothered in maple syrup at one of our many sugar shacks.

So, when Leigh Lundin suggested I write about the Canadian maple syrup heist, I thought ‘heist’ was a strong word for people running through the maple grove stealing buckets of sap.

It turns out that I was wrong, a heist it was: over twelve months, 3,000 tons of syrup, worth $18.7 million, was stolen. None of this was done by stealing buckets collecting sap. Worse, learning about this heist ruined all my lovely and naive sugarbush experiences and I’ll never look at another bottle of maple syrup the same way again.

The heist was possible because of three important facts that blew my preconceived notions about maple syrup out of the water.

 First, "maple syrup comes only from the red- and sugar-maple forests found in the upper right-hand corner of North America, just where you’d sign your name if this were a test." This means that Canada, particularly the province of Quebec, produces 71% of the world’s maple syrup.

Second, since 1966 the Federation of Quebec Maple Syrup Producers has instituted quotas and rules that have increased the price of maple syrup to be, in 2016, "valued at just over $1,300 a barrel, 26 times more expensive than crude".

Third, to control the supply of maple syrup, "members of the federation—Quebec’s bulk producers are required to join—give their harvest over to FPAQ… Some of it is sold immediately; the rest is stored in the Reserve… In this way, the federation steadies supply, filling the coffers in banner years, satisfying demand in fallow."

So, maple syrup production is not a cottage industry, adorably ensconced in sugar shacks dotting our maple groves. It’s a large profitable industry controlled and managed much like the oil industry. Total value of all maple products in 2018 was $384.4 million.

To give a visual recap:

The maple grove where I thought they stole maple syrup from:

The Reserve is in Laurierville, Quebec, where they actually stole maple syrup from:

A total of $18.7 million dollars of maple syrup was stolen from the Reserve in Laurierville. The  thieves used trucks to transport barrels, siphoned off the maple syrup, and refilled the barrels with water and returned them to the facility. Later the thieves siphoned syrup directly from the barrels in the Reserve and left them empty. The stolen syrup was then sold in the United States and in New Brunswick, Canada, to distributors, many of whom were unaware it was stolen.

When the theft was discovered in 2012, the Sûreté du Québec police began an extensive investigation aided by the Royal Canadian Mounted Police (RCMP) and U.S. Customs. The police arrested two alleged ringleaders and 24 other people. A large portion of the syrup would ultimately be recovered.

However, this not the end of the story because it raises interesting questions about the Federation of Quebec Maple Syrup Producers.

One of the ring leaders was Étienne St-Pierre, a maple syrup buyer from Kedgwick, New Brunswick, who bought the stolen syrup.

"You can't prove what tree the syrup came from," St-Pierre told the jury.

“St-Pierre also admitted he had long been an opponent of the Federation of Quebec Maple Syrup Producers, and resented their control of the market.

“The Crown produced evidence suggesting St-Pierre considered the federation to be akin to the Mafia.”

Is the Federation of Quebec Maple Syrup Producers like a maple syrup mafia? It is “a powerful marketing board with almost absolute control over the provincial industry…all Quebec maple syrup must pass through the federation, which dictates how much each producer can sell, and penalizes unauthorized production and selling.”

So, not a mafia, but certainly restrictive.

Before his sentencing, this is what St. Pierre said: he’ll continue to ignore those rules. And he’ll keep buying maple syrup from Quebec’s scofflaw producers. “I will never stop. I didn’t steal nothing.”

Étienne St-Pierre was found guilty of fraud and trafficking in 2017 and sentenced to two years less a day to serve in the community, as well as a three-year probation.

Phyllis

Stories from Canada and the United States are mirroring each other. In the United States, many patients have no access to doctors because they are either uninsured or underinsured. In Canada, our growing doctor shortage is leaving patients without access.

Please note that I didn’t say anything about the healthcare system, because talk like that is too impersonal; when it comes to patients, not having a doctor when you need one is very personal.

Let me introduce you to Phyllis Smallman, a feisty and funny writer, mother, grandmother and wife of over 50 years to her best friend and high school sweetheart. Phyllis was the first recipient of the Crime Writers of Canada Unhanged Arthur Ellis award and wrote, among other books, the Sheri Travis mystery series. She won multiple awards for her writing. She grew up in Southern Ontario but, at an age when most people retire, she and her husband moved to Salt Spring Island, B.C. to be closer to her children and embark on a new adventure.

In October 2017, 72-year-old Phyllis found blood in her urine. Her family doctor was concerned but couldn’t get an appointment with a specialist to do a cystoscopy before the spring of 2018. Phyllis trusted that the system would keep her safe, but her family began to worry as she developed other symptoms. Phyllis, a self-described foodie with the personality of a small energetic terrier, was too nauseous to eat and was experiencing extreme fatigue.

My point of contact to this story was through her daughter, Elle Wild, another Arthur Ellis Award-winning writer. Elle was worried and wanted her mother to be seen sooner. Elle, her brother and father spent a great deal of time trying to get Phyllis into a specialist. They called everywhere and finally found a specialist who could see her before Christmas. When the cystoscopy was done there was too much blood for a definitive diagnosis, but an infection secondary to a previously-inserted mesh was thought to be the problem. Phyllis was put on a six-week-long course of antibiotics and then put in the queue for a second cystoscopy and a CT of the kidney.  The antibiotics did not improve Phyllis’s health. Her nausea became more severe, she lost weight and became so weak that she couldn’t even walk across the room. She slept most of the day.

Through conversations with Elle, the growing anxiety of the family was palpable as Phyllis, their lively matriarch, began to disappear into long sleeps and uncharacteristic exhaustion. Phyllis’s deterioration continued day by painful day, and by February, the family had had enough. Despite Phyllis’s objections, partly because she continued to trust that she would get taken care of in our system and partly because she was too exhausted to go to appointments, the family paid for a private CT and she was diagnosed with a kidney tumour.

However, there was another queue for a specialist to do the biopsy and yet another one to see an oncologist. It was only on April 16, 2018 that Phyllis finally received a definitive oncologist report: an advanced and aggressive form of cancer that had started in her bladder and had spread to her kidneys. She was given six months to live and offered palliative chemotherapy. Her daughter, Elle, moved with her family to Salt Spring Island to spend time with Phyllis and to provide emotional support to her distraught father.

Phyllis did her best to complete the course of chemotherapy, but was only able to do half of the treatment because of fatigue, nausea and her emaciated state. Phyllis Smallman died on October 1st, 2018.

In her obituary, her family wrote: “Those who spent time with Phyllis knew her as a caring person who loved fiercely, laughed loudly, and was always a friend to anyone in need. In keeping with her dark sense of humour, her last book was ironically titled Last Call, the final Sherri Travis mystery. The night Phyllis died, Last Call won a Reader’s Favourite Book Award. Our Phyllis knew how to make a grand exit.”
Tragedy is defined as a story involving a great person destined to experience downfall or utter destruction through a conflict with some overpowering force, such as fate or an unyielding society.

The story of how Phyllis spent her final year is a tragedy. The unyielding social truth she faced was that Phyllis simply could not get access to the doctors she needed: this reality met her faith in our healthcare system and made a mockery of it. The lack of physicians left her family alone in their growing worry for Phyllis and isolated as they watched her die, without a doctor to tell them what was happening and perhaps even intervene to help.

When people say that healthcare is a human right, I agree. There is nothing as inhumane as a patient unable to get the care they need.

Mental Illness Is Not a Political Football

I have previously written about the myth that those with mental illness are dangerous. Spoiler: they are not.

What is happening now politically is very concerning. Politicians are blaming mass shootings on mental illness and – as I cited before – Dr. Michael Stone, a forensic psychiatrist at Columbia University who maintains a database of 350 mass killers going back more than a century, has found that only one in five are psychotic or delusional. This means that 4 out of 5 mass murderers are people who are clinically sane.



Why do politicians blame mass murders on the mentally ill? Many agree with Fareed Zakaria that “turning immediately to the "sickness" of the shooter and piously calling for better mental-health care is, more often than not, an attempt to divert attention from the main issue: guns.”

This may well be true but it is damaging to label those with mental illness as dangerous to society. The prevalence of mental illness is difficult to nail down but “Around 1-in-7 people globally (11-18 percent) have one or more mental or substance use disorders. Globally, this means around one billion people in 2017 experienced one.”

This means that when we think of those with mental illness we should think of our family members, our partners, our children our friends and neighbours because that’s where you will find them. Or not find them because many hide their symptoms and suffering for fear of - you know - being labeled dangerous. That’ll certainly send someone into hiding.

Worse - mental illness is being used as an insult to those with political views we disagree with.


This is my tweet from this week:






The politician my tweet was directed at is not as important as the patients this politician’s tweet was directed at: those with mental illness have become the scapegoats of politicians.

Paraphrasing MLK gave me pause. However, his writings are filled with empathy for those suffering from discrimination and I thought that it might be appropriate to use this for this very maligned minority.

What I want to address is my dream: blaming and insulting (along with the unrealistic depictions in books and on screen) presents a very unrealistic portrait of those suffering from mental illness. After a long career of treating mental illness, I can describe them with some degree of confidence. They are just like you and your family, friends and children. They have the same wonderful qualities and the same vulnerabilities, the same bad jokes and the same hilarious ones. I could go on, but you get the picture.


I feel I must say this very loud for the people at the back: mental illness is a medical diagnosis no different than that for diabetes. It requires diagnosis and treatment and both should be given with care and compassion. Just like someone with diabetes or cancer - everyone with mental illness will have their own unique personalty but not the ones that politicians try to give them.

I was pondering - ok, I was fuming - about this issue the other day and thought about the origins of medicine. Originally all disease was thought to be in some way connected with the evil doings of those who are ill. So, diabetes, cancer and depression fell into the same category: “In prehistory, people believed that pain and disease originated from evil spirits. Disease resulted when these evil spirits entered the body. Witch doctors and shamans were employed to exorcise wicked beings…”

The belief that illness is caused by evil spirits taking residence in a patient changed when modern medicine discovered the actual etiology of physical illnesses. However, some still think that there is something evil in people who have mental illness.

Today many use the term ‘mental health’ “… to reduce the stigma surrounding mental illness, and said ‘illness’ reinforced prejudices against asylum patients because it implied segregation between the sick and the well. Focusing on health countered a persistent misconception that only some people are prone to psychiatric problems.”

This terminology is a double edged sword. Focusing on what is healthy in these patients is a good thing. However, there is value in identifying an illness. To tell a patient they have a physical illness is often a relief because they finally have an explanation for the symptoms from which they are suffering. They can explain this to those close to them, and get comfort and help when the symptoms flare up. The same applies to those with mental illness. I have found patients are immensely relieved to finally have a diagnosis and treatment plan. I have seen their relief when they can speak to those they love and get support in the same way those with physical illness get to lean on those in their life. 



 I’m comfortable with the term ‘mental illness’ and also happy to use the term ‘mental health’ if people prefer. What I want is to end the stigma, to treat each patient as just that: a person with an illness that can be be diagnosed and treated. The illness doesn’t define the person. Their character defines them.

Canada responds to the U.S. on mass exportation of our drugs: Sorry.

Rarely does American primary politics impact Canada, but Senator Bernie Sanders’ ‘Insulin Caravan’ has certainly led to a situation that has ruffled Canadian feathers.

First, let’s be clear on why Sen. Sanders came: “By traveling to Canada, which has a single-payer, government-backed health care system, he was also making an implicit case for his "Medicare for All" plan, which would create a similar system in this country."

The people who came in the caravan didn’t come for political reasons but, rather, for heartbreakingly personal reasons: “Kathy Sego, who made a 7-hour trip from Indiana with her son, Hunter, who requires insulin and has rationed his intake, became emotional as she described choosing between paying a power bill or for the teen's medicine.”

What is the response in Canada? The average Canadian believes that healthcare is a human right and this compassion is best expressed by the Canadian mother of an eight-year-old Type 1 diabetic : "When I see headlines of people passing away because they're having to ration their insulin and they can't afford it [and] when you live with someone with Type 1, I can't imagine," she said. "What if it was your mother? Your brother? Any family member? I would give anything I could to afford the insulin to buy it — but we shouldn't need to do that.”

Then this happened: “[The Trump] administration said it was weighing plans to allow for the legal importation of prescription drugs from Canada to help Americans coping with skyrocketing drug prices in the United States.
The response from Canadians? Sorry, but back off.”

Why such a different response to the individuals coming for drugs and the American government promoting a mass importation of Canadian drugs? It is because Canada has a small population of 37M compared to the massive population of 325M. We already have drug shortages and cannot sustain a mass exodus of our life-saving drugs.

In fact, “the Canadian Medical Association and 14 other groups representing patients, health-care professionals, pharmacists and hospitals wrote last week to Health Minister Ginette Petitpas Taylor. The supply simply does not, and will not, exist within Canada to meet such demands…John Adams, the chair of the Best Medicines Coalition, an advocacy group for access to drugs that signed the letter last week to the health minister, said he’s not encouraged by the Canadian government’s “nonspecific” response to Trump’s proposal.
He called it “a clear and present danger” to the health of Canadians.
This is not the sort of thing that good neighbors do to each other.”

This is Canadian-speak for no, we won’t do that.

So, the consensus seems to be this: if you are in dire need, come here and we’ll share.

 If you want - as a nation - to pull drugs away from Canadians, then no. And no again. 

Perhaps it’s time that Americans use the Canadian method of price regulation. “The reason for the discrepancy is because Canada regulates drug prices through the quasi-judicial Patented Medicine Prices Review Board designed to prevent gouging...In the U.S., market forces are the lay of the land.” 


In speaking to the character of Canada, I would like to thank the Canadian who invented insulin: “Banting famously sold his patent for $1 because he believed his discovery belonged to the world and not for profit.”

I hope America takes Banting’s message and actions to heart and creates a system where citizens can access drugs at a fair price. However, when it comes to pilfering Canadian drugs on a large scale, Canadians have clearly said, sorry but no.

In case our response is misunderstood, translated into American speak, the answer is, “Hell no.”

Undercover: Covert Work of Consular Officials

If you’re on vacation and get arrested and thrown into a foreign jail, how do you get word out about your situation and how do you get released?

There are stories in the news about attempts by governments to get their nationals back home - with more or less success. We usually hear Prime Ministers or Presidents discussing the progress of these cases. 


The names you will never hear in the news are the names of the people who will be informed of your arrest, arrange visits to ensure you are well treated and, often, will broker you release. These people are consular officials.

I had the privilege of interviewing one of these individuals – an experienced consular official who has worked internationally. Since her name is unknown to most people except those who work with her, I’ll call her Undercover. Many of Undercover’s stories – told over a leisurely dinner – can’t be shared. The details can be recognized and many are secret.

Undercover pointed me to a document, The Vienna Convention on Consular Relations, that is a multilateral treaty that codifies consular rights and obligations and is the cornerstone of consular relations. “The treaty makes it possible for [your country] to assist its nationals abroad while respecting the sovereignty of other countries”

Undercover points out that “You are subjected to the local laws in foreign countries.” This is a statement that one should not take lightly. The laws in foreign countries may be quite unexpected.

Take Singapore for example:

“Tourists that visit Singapore are allowed to bring chewing gum with them, but only a maximum of two packs per person. Any more than that and they will be susceptible to be charged with "gum smuggling" which carries the penalty of one year in jail and $5,500 fine. People that are caught with leaving chewing gum remains in the public space can be charged with the monetary fine, community work, or often - public beating with the bamboo stick.”

So, what happens when someone is arrested in a foreign country, when they may not even be aware of the local laws? “When a foreign national is arrested in a country, the country that detains them has to inform the embassy and request consular access. If there is no embassy, they have to inform an accredited embassy in the region.”

“Someone in the region has to start the process of consular access.” This is to verify the nationality of person and to determine whether the person is being treated properly and it is no small matter. We have heard of detainees in foreign countries who have been tortured and raped, so, consular access - and the knowledge that these people will be visited and watched over, is important protection for them. This access can be daily, weekly or monthly.

How is someone’s release negotiated? This is negotiated by consular officials, often based on relationships, with police and the officials of the host country. Many times the consular official will point out how this will cause bad publicity and it would be preferable to have the person released into their custody.

“Sometimes it is just saying ‘This is not a bad kid, let’s get this person out of your country’,” says Undercover. “Sometimes, there is another dimension to the crimes committed and the authorities are angry. In some countries, someone may be arrested for the human rights work they are doing but they are held onto because they are angry the person is gay.”

“A country can also take someone into custody on spurious charges like espionage, but they are using this person to achieve some political end. This could even be to get their companies considered for contracts.” Or to make a political point.

Lack of consular access and consular negotiations can be extremely dangerous. Take the case of Otto Warmbier, the 22-year-old student who was arrested in 2016 in North Korea for taking a poster from his hotel room and sentenced to 15 years of hard labour. After 17 months, he was medically evacuated from North Korea and returned home “in a state of unresponsive wakefulness” and died within a week.

So, when we travel, what keeps us safe, what saves us at the worst of times, is so often laws – in this case international laws. But it is the also personal relationships and contacts consular officials have in the host countries that are crucial. Without these personal connections on the ground, more travellers would spend more time in difficult situations. The people who find us and keep us safe and often negotiate our release are people whose names the public will never know.

After our long dinner hearing Undercover’s stories, I was left pondering how these consular officials and their often covert work has the making of a great novel. I was also left wishing that I could share some of the stories I heard. I hope one day these stories are written.

How Long Does Grief Last?

In a few weeks it will be one year since Carol died. She was my dearest friend since childhood. I hesitate to write about Carol because using words to describe a friendship like ours is like trying to carve a sculpture from water. 

We met when we were seven years old and throughout our childhood we wandered our neighbourhood chatting and laughing. During our teens we talked intensely about every dream, every heartbreak and all the new feelings descending on us. As we became adults we discussed university - all our courses, all our insecurities and, eventually, our marriages. She shared her stories of students she taught in her lab and I shared stories of my patients.

When my children were born, she was the first one in the door. She spent countless hours with my children, wandering the woods, reading books and calling every birthday with her lovely rendition of Happy Birthday. My children were almost in their teens before they realized that their beloved Aunty Carol wasn’t related to them. 

Over our decades of friendship we never fought. We thought that was odd since we were both intensely passionate people. What we did do was to find the humour in every and all incidents in our lives - no matter how trivial or serious. The closest we came to fighting was when we had spirited discussions about who paid the restaurant tab. We discussed this intensely and decided it was not as serious as a squabble but also more serious than a quibble, so we named these squibbles. We found that so funny and even our restaurant tabs became hilarious.

Once as the tab arrived, I asked Carol if this was going to be another squibble. She said it was going to be an outright squabble. We were grinning ridiculously at each other and the waitress asked - as we were often asked - about our relationship. People were perplexed by this Viking Beauty and WOC with a mass of curls and how we were so impossibly close. Carol, completely deadpan, replied, "Twins." Then, without missing a beat when the waitress looked perplexed, Carol continued. She pointed at me and said, "The lipstick always throws people." I have no idea how funny the politely smiling waitress found this exchange but we chuckled about it all evening. 

Over the nine months from her breast cancer diagnosis to her death, I visited, spent as much time as I could at her home. When she had her mastectomy, I was there and stayed for her recovery. We chatted and talked as we always did about everything. When we found out that the breast cancer had spread to her bones, we continued talking about that too. All through that time, we found so many things funny. Including cancer. When she was in hospital I stayed in her room when she was frightened.

Near the end, I had left to go home and her sister called and said she was asking for me. I went immediately and spent the last conscious night of her life with her. She lay there so quietly when I walked into the room that I pulled up a chair and held her hand. She said, “Mary! I would know that tiny hand anywhere.” We hugged. And then she slept. As I watched her sleep, I marvelled how, with her brain full of cancer, she still knew my hand. Still loved me. 

Many people have wondered when I’ll stop grieving Carol’s death.

A friend recently sent me an article that looked at a study where “They collected data from 26,515 people over 14 years, and found a range of negative consequences experienced by those who had a close friend die. In the four years after a death, significantly adverse wellbeing was found in people both physically and psychologically.”



This reminded me of a question I asked my supervisor when I started practice. I was trying to understand a patient who appeared to still be in mourning 15 years after the death of his child. I asked  about the length of the normal mourning period. I was young, didn’t have children but that question, quite frankly, was incredibly stupid. My supervisor kindly answered that the normal mourning period for a child was a lifetime. 

But what about a friend? Not just any friend, but a friend who forged me, who made me who I am and when there is nothing, nothing at all I have ever done that Carol wasn’t a part of? That kind of friend. My supervisor was a wise and kind man. If he were alive today, I would call and ask. I long for that conversation. 

There is something else about Carol and me. 

I was never the person I wanted to be. I wanted to be carefree, bold and irrepressibly confident. What I am is hopelessly serious, full of thoughts when I want to just be easy going. Carol was bold enough to climb apple trees without fear as a child and throw a knapsack on her back and head to Europe on her own after high school. She was far more carefree than I could ever be. She was a brilliant research scientist and a talented teacher. Maybe more so because she treated the meticulous and painstaking work of molecular biology like an adventurous journey with pipettes and gene splicing.

But we were also similar.  We both were totally honest, so we talked about our insecurities, our painful embarrassing incidents with ease. We also deeply loved kindness and recoiled from cruelty so we talked endlessly about the treatment of animals, children and people of all ages.  

For me to have someone as wonderful as Carol love me so deeply, so loyally 

for so long, made me feel better. Somehow less serious. Less hopelessly awkward. 

Carol was beautiful. Tall and blond. She was also strong. Until the last few months of her life. This photo of her as a young student leaving the apartment now is so poignant - it is her leaving me.

This year has been tough. My father died. My mother is now ill. I so needed to talk with Carol - these were the first hardships that I haven’t been able to share with her. Also, my daughter won a prestigious award and got a cat. My son went to Australia and published some exciting papers. Carol would have been eager to hear all of this and we would have chatted endlessly - and then she would have called the children for more details.

I miss hearing about the adventures of her life - her story was cut off mid-sentence. I want to know what would have happened if her story went on till we were old and ornery.

This was one of our last texts:

If there was ever a testament to the calibre of Carol, this is it. With cancer in her bones, spreading to her brain, unable to breathe and this, this is what she worried about: not being there for me. Steel in her spine. Pure steel.

This is the story of Carol and me, but each death leaves people with stories cutoff in mid-sentence. While some friends wonder when I'll get over my grief - my longing for Carol - my children and husband don't wonder. They share memories - sometimes we cry, sometimes we laugh - but always we miss her. We expect nothing less. 

Since I can’t ask my supervisor, I’m going to call this one. 

I will miss Carol for my whole life. 

When I die, missing her will be one of the last thoughts I have.

Epigenetics and Elephants

Most of the time I interview people and allow the things they ponder to guide my writing. This is not that article. This is about my late night pondering. Excuse the indulgence, but it’s been a a tough year and I’m prone to sleepless nights and thoughts.

Unable to sleep, I was ruminating on epigenetics and elephants. They may seem odd things to stay up at night about, but these are seriously important.


What epigenetics does is shake things up. DNA decides who we are but life turns our genes on and off - impacting everything from the architecture of our brain to the diseases we have. 

If you want to keep up at night too, just read about how this happens and how we can reverse the DNA changes that happened to your grandmother.

What actually jolted me out of a slide into a lovely slumber was a child. In a shopping cart. 

I was young - probably around 8 - and shopping with my mother. A child less than 2 in a cart passed by and she was sobbing. Her mother, her face clenched in that angry way that makes people truly ugly, slapped the child and said, “Cry again and I’ll give you something to cry about.’ As if that poor child didn’t have enough to cry about. I said to my mother, “Do something!” She said, “Shh.” Afterwards, my strong, well-educated mother told me that much as she would like to, it’s impossible to change how people parent.

There are many things that make us decide on our profession and making medicine my choice was about a series of decisions. All of them started at that moment. I was going to get an education that could help that child.


Choosing medicine would never have been something I did if I didn’t see a road to working with the damaged, the broken and, as I eventually did, stop the breaking and beating. I only went into medicine to work in mental illness.  

Let me tell you about mental illness and medicine and the place it has.  Many wonder why anyone would chose it. I have literally had people ask why I gave up medicine and chose to work with mental illness. Let me get this perfectly clear, I am a doctor who works with the mentally ill. As a doctor, I bring skills to the table because no brain tumour masquerading as depression gets past me. So, I am a doctor. Who works in one of the most important fields of medicine: with the mentally ill. I didn’t fall into it. I marched toward it, and went through medical training and 8 years of specialty training to have the privilege of working with patients that I wanted desperately to work for.

And that’s where epigenetic comes back in. Changing someone’s mental illness changes their genes. Leaving it does too. Those illnesses that all doctors battle, well I battle them too. In a different way, on a different battlefield, but it’s all medicine.

This all made me think of Dr. Fraser Mustard, who I had the honour of meeting numerous times. The last time I saw him was in his lovely home in Toronto, where his children lived in the apartment above him. After an illustrious career in medicine he had ended up pondering epigenetics and childhood trauma. He wrote about it brilliantly. He advocated for children. He was very old when i met him but this belief in helping children made him seem ageless. Children do that to you. In his apartment, so full of interesting things, was where I first thought of how he must stayed up at night worrying about children and that made it his life’s work at the end.



Sometimes, at the end of a career, you ponder the beginning. The thing that started it all. The work you have done and the value of it all.

Now I’m writing another book. It isn’t a departure from any of my other work. It is about the lost, the damaged and the suffering. I can’t change course because I simply don’t want to. It is what we see, truly see, that decides our course in life.

There is an African Zulu greeting: “I see you.” It is a haunting saying. When I was young, I visited many zoos around the world because my biologist father would meet other biologists and talk about the conservation efforts they were making at their zoos. I understand the conservation part. I do. But I really didn’t give a damn then, or even now. I hated zoos. Seeing the animals, really seeing them, in cages that were far too small or chained up - because that was the way zoos were then - I could see that the cages and chains around the elephant legs were truly like beatings. They diminished these animals, and their suffering was evident to anyone who bothered to look. In East Africa, where we spent many months on various trips, I saw wild animals on the plains. My first sight of elephants, not in chains but walking and taking such tender care of each other, made me fall in love. For the wildness of them. For the beauty of them. For the tenderness. I saw them.

Medicine or writing or elephants - it is all about seeing. All of it will keep you up at night if you let it. And these days I do.

And that child, being beaten in a shopping cart for all the world to see but not intervene. That too. That always. It shaped my life. I wish I could have told that tiny darling that. 











DNA Testing for Crimes by Twins

Science is on the verge of distinguishing between identical twins. Consider cases of crimes where DNA material leads not to one person, but two: identical twins. Until now, no one could say with certainty which twin might be guilty. Here's why.

Each twin comes from the same egg, split into two, creating two eggs with identical DNA. Old DNA testing was unable to distinguish between identical twins, but there are two fascinating options on the horizon that might just help.

The first difference between identical twins begins immediately. Although each is endowed with the same DNA - “When a fertilized egg starts dividing, there’s a small chance each new cell will gain a new mutation. When the cells separate into twin embryos, one gets some of the mutant cells and the other gets the rest. Unique mutations will end up in cells throughout each twin’s body.”

“Such a test would be difficult, then — but it would also be definitive. Just a single mutation, confirmed by multiple analyses, would be enough to implicate one twin and exonerate the other.”

“It’s not something that’s going to happen every day in every laboratory,” said Dr. Krawczak (a geneticist who now teaches at Kiel University in Germany). “But once people become aware of this, there may be a lot of cold cases that come back to life.”

However, this testing is in its infancy and is both expensive and time consuming.

The next set of DNA changes are called epigenetic changes and happen during embryonic development and continues for the rest of our lives.

Dia Rahman, a PhD student in Public Health at University of Waterloo has a special interest in social impacts on health and, therefore, is fascinated with epigenetics. “We are born with our DNA but what is impacted by the environment is the dance between active and inactive genes,” Dia says. “That is what is impacted by our upbringing and experiences. That is epigenetics.”

“A common analogy used to describe the epigenome is to consider genes as instruments in the “symphony” of life. But they don’t play themselves. They need musicians. Epigenetics would be the musicians that help express (or silence) the performance of our genes. Exercise, sleep, trauma, aging, stress, disease, and diet have all shown significant effects on the epigenome.”

Detecting epigenetic changes is faster and cheaper than looking for mutations. Graham Williams at the University of Huddersfield, UK, has found that epigenetic changes alter the melting point of DNA. “When the team heated up the twins’ DNA samples, they found the melting points were different – allowing them to tell the twins apart genetically. The test was also much quicker than whole genome sequencing, says Williams. “It can be done in just a few hours.”

So, essentially, we are born with our DNA - an entwined gift from our mother and father. This is not immutable. Some of our DNA can be altered by mutations. Parts of our DNA is also turned off and on by how our life impacts us. As our DNA testing improves, we can distinguish between identical twins.

Perhaps the most important part of all this has nothing to do with crime. It show that our DNA we once thought never changed is actually impacted by the life we live. And that is fascinating.

The New Playground of Criminals: Sexting and Phishing.

Amanda Todd was in grade seven when an on-line stranger convinced her to expose her breasts. Then he attempted to blackmail her, saying he would send Amanda’s naked image to family and friends if she didn't provide him with more nudes. She refused. He sent her nudes and, from that point on, she was ridiculed and bullied. 

After making a heartbreaking video, Amanda took her own life at fifteen.

Research looking at 110,000 children, all younger than 18 and some as young as 11, found that one in four young people had received sexts, and one in seven reported sending them. 


This is the new back alley rife with predator crime: the internet.

Darren Laur spent 30 years of his life as an inner city policeman. He retired three years ago, got certified in Open Source Intelligence and now specializes in online investigations.

“To date we have saved 186 youth who were considering suicide and self-harm in response to bullying and a full third of these were because of sexting,” says Darren in a voice that marries authority and empathy in equal measure. “We have the resources to do these investigations and put a package together to bring to law enforcement.”



As a policeman he wants to do what he has always done - he wants to put the bad guys away. He also wants to continue the work he did in the inner city - to help people by steering them in the right direction. Through his company - White Hatters - he does outreach for teens. His research shows that 1/4 of teens have sent nudes by the age of 16, and the youngest one was in grade 4. 79% of them were pressured into sending these nudes - often in the context of relationship building.

So, while explaining the dangers of sexting, Darren also recognizes a painful truth: preaching abstinence will only work for some. Just like with sex education with young people, an abstinence-only message is not as useful as giving a more robust message of safe sex and protection. With sexting that is the message he offers. Safe sexting.

If you are going to sext- because young people will - Daren teaches harm reduction. Sexting should be done without your face, or anything that can identify you like tattoos, clothing, background. This way,  if it goes public it is not evident it is you and there is deniability. He also teaches how to scrub any metadata that identifies the individual.


Darren explains that safe internet interaction applies to a far wider area than sexting. Those of us on the internet might want to be aware of another internet crime: Phishing. 

This is the use of a phishing link on twitter, email or texts, where a simple click can open you up to identity theft and fraud. Fraudsters will use social engineering to assess our likes and dislikes and use them to fool us into clicking links.

“According to Symantec’s 2018 Internet Security Threat Report (ISTR), a whopping 54.6% of all email is spam. Even more to the point, their data show that the average user receives 16 malicious spam emails per month”

“There were two bits of very bad news for consumers in the recent annual survey of identity-based fraud. First, there were 16.7 million victims in 2017, easily the most ever, fuelled in part by a series of high-profile data breaches. But even worse, criminals are migrating to more sophisticated, multistep frauds, with the rates of new account fraud and noncredit credit card fraud soaring. Why should you care? Those are the crimes with the most potential to hurt your credit score.”



Darren explains, “We can strengthen internet security, but the weakest link is always the human link.”

Every day, I join many others in clicking sites on searches, opening emails and texts and clicking interesting URLs on Twitter - oh, a cute dog video! Click. Click. 

 I agree with Daren. I’m a weak link. Wandering around like Bambi in the wild west of the internet. 



 I’m grateful that we have Darren Laur and investigators like him to educate us and – if we become a victim of identity theft or a number of other crimes – we have someone to fish us out.

Pun intended. 



Nurse burnout: Maitre d' or Sentinel?

“The hospital doesn’t have Splenda.” was a response on a Patient-satisfaction survey. “This somehow became the fault of the nurse and ended up being placed in her personnel file.”
That happened.

Surveys used to assess nurses also ask questions like, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” 

Hospitals with high patient-satisfaction scores get more money, so nurses are under pressure to do everything they can to make patients happy.


Also in the news: “Forty-nine percent of registered nurses under 30 and 40 percent of registered nurses over 30 experience burnout, according to one study — a sobering statistic for healthcare providers who want to improve patient care.”

These two things are related.

“Nurses are not waitresses or waiters,” says Nurse Smith, who has been a floor nurse and is now a nurse educator. “I see nurses as sentinels. A sentinel stands guard and is constantly on alert.

 “When a nurse walks into a patient’s room, there are a hundred things going through their mind. They are looking at monitors, carefully selecting which ones are important given the patient’s disease and treatment. They need to understand not just the physiology but the pathophysiology of the disease so that they can assess the patient and monitor their progress or decline.

“If an elderly demented patient starts to act a little wonky, is it just the waxing and waning of their dementia? Could it be some form of a hypoxia, perhaps a stroke? They need to have the assessment abilities to know if this could be a serious issue, when to call in the doctor and which tests could help clarify what is happening with the patient.

“They also need to assess when patients need more time. And it is not always the loudest patient. It may be the very ill patient whose blood pressure is dropping and a good nurse needs to attend to them.”

 The name of the game is not patient satisfaction - it’s patient safety.

So, surveys asking patients if the nurse came when they were called are completely inappropriate. The nurse must be given the clinical respect to make decisions about which patient needs attending to urgently and which patient can wait. What matters is did the patient get better? Did that nurse monitor and save lives of the very ill first? Even if some patients had to wait for ice chips. 

Nurse Jonathon - a nurse with over a decade of experience in the emergency room, critical care and in management - explains that numerous issues contribute to burnout in nurses.

“There are often too few nurses per patient and that is not safe,” says Nurse Jonathon. He points out that in an emergency room there could be a number of patients that should be admitted to the ICU but are waiting for a bed. These patients require constant care but there may be six to 9 other patients, or more, that the nurse needs to watch over and care for.

‘We are the ones who monitor patients,” says Nurse Jonathan, “No one else but your nurse monitors you 24/7. Everything from heart rates to breathing to blood pressure. We constantly assess patients.

“Most nurses have a passion for excellence and we want to get everything right. If something happens to our patient, we can’t stop. We must move on and take care of the next patient. We can’t stop for a second. These are peoples’ lives.

“Hospitals don't help staff to cope with these feelings. A debriefing would help. To understand what happened.”

Nurse Smith explains, “As the patient goes through their journey in hospital, it’s the goal of the nurse to help them advance every shift - to get home or at least get better. At the change of shift, it’s like a relay race - you pass the baton to the next nurse who continues the journey.”

Handing off your patients and doing so safely is one thing. But what if you are handing over too many patients for the next nurse to handle? Worry. Because all good sentinels watch and keep those they stand guard over safe. 

Many surveys demand nurses do a job that has no resemblance to the job they were trained to do. Nurses feel the pressure to do certain things to get good scores on these surveys. Ultimately though, nurses want to do their real job. The one they were trained to do. They want to keep watch over patients to keep them safe, to intervene when they need to and to have enough time to do this job well. They were trained as no one else is to do their job.

Letting nurses do their job, having enough nurses to do the work safely and having an opportunity to debrief from stress would go a long way to reducing burnout. Oh, and holding the Splenda comments.

Note: The real names of the nurses were not used. Both practice in the United States.

Part Two: Physician Burn Out and Suicide – The Road She Forged.

Dr. Mamta Gautam developed complications in her pregnancy and, after delivering twins in 1991, she was in a coma for days. She was soon forced to return to work with an open abdominal wound. She realized then and there that, “Medicine doesn't care about the health of their healthcare workers.”
What Dr. Gautam did with this knowledge was to carve out a new way to do medicine. A psychiatrist by training, she became the “Doctor’s Doctor” and, in the 1990’s, began work with individuals and organizations to address burnout and suicide before it was on anyones radar.
A pioneer in the field of Physician Health, Dr. Gautam founded the University Of Ottawa Faculty Of Medicine Wellness Program, the first in the world to deal with physician health issues. She is now an international expert in physician health and leadership. 

So, when I was searching for answers on how to help reduce burnout and suicides in physicians, I reached out to her to find solutions.

Dr. Gautam said, “Before I answer, I want to talk about complexity theory.”

At this point, I had my pen poised. When interviewing people, I always wait for what Virginia Wolfe eloquently asked of them: “…to hand you after an hour’s discourse a nugget of pure truth to wrap up between the pages of your notebooks and keep on the mantelpiece forever.” I was a little disappointed to be sidelined by a theory I hadn't heard of, rather than an actual solution to the serious problem we were discussing.

Luckily, my disappointment was short-lived because that theory, and how it applies not just to medicine but all professions, actually was a nugget of pure truth. So, here it is for you to wrap and put on your mantelpiece. Forever. Whatever your profession.

• Dr. Gautam explained that some problems are Simple and can be solved by following simple instructions, like baking a cake. There are instructions, and if they are followed, we have a cake.
• Some problems are Complicated but can be solved by following more detailed instructions and require expertise, like sending a man to the moon. With the right expertise, we can again have a solution that we can replicate.
• Some problems are so Complex that their solution cannot be boiled down to a list of steps and and expertise doesn't always help, like parenting. If you add people in, we have different outcomes depending on the person (in this case both the child and the parent). So, we are better off with guiding principles, rather than strict recommendations and rules. 

With physician burnout and suicides, prevention is best thought of in terms of guiding principles, at the level of the individual physician, the culture of medicine, and the healthcare system.

One key principle is the need for community. For some this may be implemented by re-creating the doctors’ lounge. This where we can gather and talk about the day; the hard parts, the best parts and the funny parts. It is the ability to break out of the isolation and connect. For all of us, no matter what profession we are in, the trauma of our day can haunt us. For physicians, this might be the patients who died despite our best effort, the metallic smell of the blood that covered the patient, the room and us in surgery as we struggled to save a trauma patient, the young baby who fought valiantly and the breathless sobs of her parents after she died. Those traumas we need to talk about. 

The next part - and the crux of the matter: doctors are human. They should not be so tough that their hearts aren't wrenched when patients suffer. We can and should viscerally feel the often soundless sobs of the families that mourn. That is who we are, and that is the best of us. So, there must be an end to the ‘tough doctor’ and a new opening for the human doctor.

This is a principle for all healthcare workers and for all professions. We have many ideals that we strive towards, never being able to truly fulfil them but always keeping them in mind as we move through life. Many are worthy ideals. However, the ideal of the very strong, very together, never broken and beaten down person is an ideal that many of us hold dear. That person, that ideal, is actually a Trojan horse: if we let it into our lives, it will become stuffed full of all that will defeat us. It will be filled to the brim with the guilt of not living up to this ideal and the feelings of vulnerability that we stuff in it because we are terrified that the feelings are not worthy of the person we should be. It will be filled with the trauma we face, the small and large wounds we suffer but do not speak about. So, it is time to find another ideal and recognize the Trojan horse for what it is. We need to be human, striving to be strong when we need to be and allowing ourselves to be vulnerable, weepy and sad, infuriated and needy too. Because our empathy, our compassion, that makes us vulnerable, is actually the true iron in our spine. Wholly and wonderfully complexly human.

So, how to recreate community where we are allowed to be fully human?

Dr. Gautam said, “There is not one answer. If people accept the need for community and allow each person to be human, how they create that community depends on where they are and what they need.” 

So, Dr. Gautam asks for solutions to this, from each of us. The principle matters, the execution of the solution, like all good answers to difficult problems, is written on water and open to life. 

She sees this article, and others like it, as an opportunity to ask each person what they need and how to carve out this solution. It is a beginning of a conversation we all need to have.

Hell hath no fury...

Imagine being so ill that you cannot even get out of bed. Or being too sick to spend time with your family and friends. Now imagine being too frightened and ashamed to tell anyone you are ill. Being so humiliated by your disease, that you can’t even tell your own doctor that you are ill.

One out of five people, 20% worldwide, have a mental illness. Many often go through this scenario. Some bravely ask for help. Some hide in the shadows. Some hide in alcohol or drugs.

When I was a young, inexperienced doctor, I was certain that the unfair stigma of mental illness would and should be eradicated in my lifetime. I felt that mental and physical illness were both simply illnesses to be treated. Now, after treating mental illness for decades, I know that I was correct. 

The suffering of those with mental illness is real, and as varied, as patients suffering from anything from a broken leg to heart disease. Just as there is nothing shameful in having cancer, there is nothing shameful about having a mental illness.

Where I might have been a tad optimistic was in my hope that all the stigma of mental illness would be eradicated in my lifetime. However, since I am not dead yet there is, indeed, time. I have seen a lifting of the stigma of mental illness, a willingness to talk about it and reach out and get help. 

What we still need to do is reach into the dark corners, the places where this stigma grows, and open the curtains and let the light disinfect the place. 

The one prevailing myth that needs some attention is that the mentally ill are dangerous. This comes from articles about murders or violent crime, where mental illness is brought up as a possible cause. Also, from the books where murderers are often mentally ill: yes, I mean novels about crime.



If there is a disinfectant for myth, it is fact. 

Since the U.S. has one of the highest incarceration rates in the world, with 666 citizens in jail per 100,000 of the population, we can assume that most of the dangerous people do end up in jail. However, if all those who are mentally ill were dangerous, that would mean that 20% of the population, more like 20,000 per 100,000 population, would be in prison. 

How about an analysis of those who are in prison? Large scale reviews have shown that, in the prison population, less than 4% have psychotic illnesses. 

The myths of mental illness and murder arise most frequently with the worst offenders: mass murderers. Dr. Michael Stone, a forensic psychiatrist at Columbia University who maintains a database of 350 mass killers going back more than a century, has found that only one in five are psychotic or delusional. This means that 4 out of 5 mass murderers are people who are clinically sane. 

Even analyses of those who are mentally ill and commit crimes shows that only 7.5 percent were directly related to symptoms of mental illness. 

So, is there NO connection between mental illness and crime, particularly violent crime? The answer is that there is a very small connection, and one that is present largely in those who are not treated and who also abuse alcohol/drugs.

Those who are depressed are three times as likely to commit a violent crime. However, 60% of people who kill themselves have a mood disorder and suicide is the tenth leading cause of death in the US overall, and the second leading cause of death of 15- 34 year olds. Since there are twice as many suicides as homicides, the most likely violence done by depressed people is to themselves, not to others. 



With schizophrenia, the risk of committing a violent crime was 3-5 times greater, but this was found largely in those not on medication. This research on violence and mental illness also showed that those who are mentally ill are more likely to be victims of violence than perpetrators.

For a final look at mental illness and murder, I present the full quote from the title of this article: “Hell hath no fury like a woman scorned.” Most of us would say that scorn is a good motivation for murder and that Shakespeare was insightful for writing this. However, Shakespeare didn't write it -  it was written by the playwright William Congreve. Further, this isn’t even what was written - the actual line is ‘“Heaven has no rage like love to hatred turned / Nor hell a fury like a woman scorned.”

Common, widespread ideas can be wrong - like the origin of this “Shakespeare” phrase and the idea that those with mental illness are inherently violent. Certainty is meaningless unless it can be backed by facts, and in this case the facts do not support the certainty that most people feel.

Sometimes our first impression is wrong. Even with things we feel that we know, such as Shakespeare or mental illness.

The High Passion of a Woman: Men Are Victims Too

“I’m embarrassed. I’m supposed to be the man of the house, and these things don't happen to a man.”

I’ll call him James because he doesn't want his real name to be used. However, James wants his story to be told: it is a story about a woman he was living with.

“She was charming. Sexy. Everyone wanted to be friends with her. My parents loved her, but her own mother was a nightmare. I felt sorry for her.”

The escalations were small, each a little more violent. Each incident was followed by abject apology. At first, her abuse was just verbal, then it became physical. She was a mean drunk. She would put away a litre of wine and then scream, throw things and hit and kick. Once she drove her car into James.

Out of his depth, he determined to leave, but each time, piteous tears and wretched apologies reopened his heart. One day at work, for example, he found a note from her with a little cartoon that said “Every child deserves love, especially when they don't deserve it.” His heart broke for her; it would be quite a long time before he recognised manipulation.

At first, James felt he could put his own needs on hold, compensate for her terrible mother and lend her some of his strength. He soon realized that the violent escalations were too much for him: “The constant dripping of water creates a gorge.”

One day he watched a T.V. show with a woman talking about her husband’s abuse. She said he had a dead look in his eyes when he would start abusing her. Afterwards, he would promise never to do it again.

“I understood that,” said James. “A dead look would come into her eyes and I would think that this was going to be one of those nights… Like the girl on the parapet, I'm convinced a kind of self-deluding madness overtakes the perpetrator. Like in a Russian novel, they can't change their behaviour no matter how mutually destructive their actions are… The language of perpetrators indicate they're at the mercy of outside forces– this or that event 'made' them do it.”

The next time she turned physically violent, James called the police. “She was in such a rage that she took it out on the cops. They warned her that this was a warning and there would be consequences.”

James found that there was no place in domestic abuse shelters for men. He started to spend time away from home. Eventually, she departed.

Looking back on this relationship, and one with a similarly needy and violent woman in college, James said, “I felt I was bigger, tougher and could outlast the hardships. But the difficulties didn't go away and, instead, became emotional black holes. My sympathy for her turned into my own misery.”

Once, in response to an email request by a research student on assault, he answered the questionnaire but had trouble with some of the questions because they were geared to women, such as “Who was the first man who assaulted you?” When James explained that he was a man and had been assaulted by a woman, the student said “Women don’t assault men. You’ve got to be lying.”

In fact, studies estimate that about 2 in 5 victims of domestic violence are men. They are less likely to report than women and less likely to be believed.

“Does stuff that happens in childhood affect what happens later in life?” asks James. He points to his parents, who loved him but also believed in physical discipline.

Raised by a extremely strict parents, James’ mother would use a switch to punish him, which is a branch with the leaves removed. It was painful and left large welts. This history of harsh corporal punishment in childhood is strongly linked with developing relationships in later life that involve domestic violence.

To date, 53 countries have banned corporal punishment because of the lasting impacts on children. I know this is a contentious issue for many who believe in corporal punishment, however, the evidence is unequivocal.

I am deeply moved that James told his story. It is a story that shows that men can be victims of domestic violence. Men are less likely to come forward and more likely to be dismissed when they do. Let’s change that.

I’ll leave you with another story about James. He met a very intriguing woman. She was sexy, smart and funny. She swore at him a few times. He asked her never to speak to him like that. She continued. She tried to sleep with him but he had concerns, so he refused to sleep with her. When he left her after she swore at him yet again, she said “If you slept with me, you wouldn't be leaving me now.”

James said “She was right. It’s easy to get sexually besotted and then emotionally unable to walk away. Enticing as she was, I realized she wasn't going to change. I felt I had grown up just a little. It is the high passion of a woman that draws me in, but that highly charged, highly sexual passion can be a cover for a whole lot of problems.”

Yes it can.