Excuse me, doc - any advice for the uncertain?

What are we to take from the fact that a majority of adult Canadians don’t want to be immunized against the H1N1 flu?
I know how they feel. I’m still on the fence myself about whether to get the shot. Being immunized definitely appears to be the logical, civic-minded choice, but there’s this part of me that’s just really hesitant about getting a flu shot.
And 51 per cent of the Canadians apparently feel the same way.
Asked in an on-line poll this month about whether they’d be getting vaccinated against H1N1, more than half said no. That’s up significantly from July, when only 38 per cent were saying no.
That fact must be a great disappointment to the public-health officials working hard on the H1N1 front. People were alarmed as all get-out when the new strain of influenza first took hold in Mexico, and the task back then looked like it was going to be about keeping a worried public calm until a vaccine could be developed.
Instead we’ve ended up here, with immunization now available but fewer Canadians actually wanting it. That’s a fascinating turn of events.
What it speaks to more than anything is that the public no longer knows who to trust about such things. That’s especially true when it comes to flu shots.
We were terrified of H1N1 when it first started wreaking havoc in Mexico. I followed each new development with great interest as the virus took hold in the spring, and had long conversations with my own adult children in hopes of getting them thinking about vaccination.
But then H1N1 arrived in our own home towns. And in most cases it looked a lot like any other seasonal flu, except with more people getting it.
Public health experts continued to emphasize that H1N1 had the potential to be a much more serious type of flu. People do die from it - 87 so far in Canada. But it seems that the more H1N1 has taken hold in Canada, the more our scepticism has grown about getting immunized.
Canadians are sceptical of flu shots to begin with - less than a third of us get the seasonal shot.
The peculiar thing is that we’re generally pretty happy to get immunized. I got seven immunizations for a trip to Ghana a decade ago, and didn’t second-guess any of them. Most Canadians are quite willing to be immunized against major illnesses and to get their children immunized as well, so it’s not like vaccination is a foreign concept.
Ah, but the flu shot - for some reason, that’s a whole different thing. North Americans overall just haven’t taken to the flu shot, despite years of admonitions from public health officials about the importance of doing so.
Is it because you need a shot every year? Or because you’ve had the flu many times and it hasn’t killed you yet? Is it about the horror stories of vaccinations gone wrong that emerge just often enough to confirm your reluctance, or maybe a secret suspicion that it’s good for your immune system to have to fight off illness on its own once in a while?
I admit to a little of all of those in my own feelings about getting a flu shot. And I know it’s all about having an emotional reaction to the issue rather than a logical one. I hate being sick with the flu and I’m asthmatic to boot, so there’s no sensible reason for me to resist inoculation.
In the case of H1N1, experiences in my own family this past month should have also pushed me toward immunization if logic had anything to do with it. My brother’s wife is still recovering in hospital after a terrible bout of H1N1 that left her incapacitated and on a ventilator in the intensive care unit for almost a week.
But there’s something that I just can’t get my head around when it comes to flu shots. I wish I understood my resistance better, because I like to think I make good choices when it comes to my health. Public health officials might want to try to understand the resistance of people like me as well, because their messages clearly aren’t having the desired effect if the majority of Canadians are saying no to a flu shot.
Please take my musings on this subject as nothing more than that. I offer no advice on whether to get an H1N1 shot. I’m just saying that rightly or wrongly, many of us need more convincing.

Confessions of a disease vector

Like many other Greater Victorians, I caught a bug recently and am sick this week.
I doubt it’s the infamous “swine flu,” seeing as any number of more common colds and flus are hanging around out there right now. But for a moment let’s pretend that it is, if only for the purposes of demonstrating that there isn’t a sniff of hope in these modern times for containing the spread of new viruses.
The new H1N1 flu is contagious 24 hours before you show any symptoms and for at least seven days after you get sick, as are all flu viruses. That means I was contagious as of last Saturday.
That was the day I was shopping in Seattle with my daughter and stepdaughter. We were jammed into the basement of Nordstrom Rack with at least a thousand other women over the course of the afternoon. I can’t imagine how many articles of clothing I handled that day - how many hangers I jostled, changing-room doors I pushed open, people I brushed up against while engaging in the intense contact sport of discount shopping.
That night, I went to a packed restaurant full of Saturday-night revellers and beautiful young people in prom clothes, out celebrating their high-school grad. I hugged a friend from Seattle who had joined us for dinner, and we all shared an appetizer that involved us breaking off pieces of flatbread and dipping it in a single dish of melted cheese. I spent the night in a very small hotel room with my daughters, both of whom were already sick with some cold-like illness.
On Sunday, my stepdaughter flew back home to England, taking whatever bug she had - and perhaps mine, too - onto two planes, through three airports, and aboard a train ride to Exeter. My other daughter and I spent the morning weaving through throngs of tourists and locals packed into Pike Street Market, then went on to more discount shopping at the bustling outlet mall near the Tulalip Casino.
My credit card passed from me to a store clerk and back again any number of times over the weekend. I shared pens, passed along my passport at the border, handled a whole lot of merchandise in a whole lot of stores. I took a busy BC Ferry back to Victoria on Sunday night.
You get the picture: I shared public space with large numbers of people before I even knew I was sick. I know now, of course, which should mean I’ll take steps to avoid infecting anyone from this point on. But here we stumble into another unworkable theory for flu management: That people will stay home for seven days after the onset of symptoms to prevent the spread of the virus.
Are there people who can just close up their lives for seven days due to possibly having the flu? I know I can’t.
For one thing, I’m self-employed, which means no paid sick time. But even when I did have that fringe benefit, there was no way I would have stayed home for seven days straight just because I thought I had the flu. The truth is that people work through sickness all the time, and the modern workplace depends on it.
On the bright side, I work at home, sans co-workers. But I’ve got two contracts hitting deadlines over the next two weeks, and they require me to get out there and meet with people, flu or no flu. My plan: A couple Dayquils when needed and onward into my regular life, albeit with a bit more attention to hand-washing and avoiding close spaces.
The flu experts want me to wear a mask if I have to go out in public. Maybe I’d consider that if knew absolutely that I had some virulent flu strain and not just a garden-variety cold.
But therein lies the other difficult aspect of controlling the spread of influenza: How often do any of us actually know that we even have a confirmed case of the flu? It’s my opinion that I’ve had the flu many times in my lifetime, but I’ve never gone for a blood test to confirm any of it. Health officials anticipate confirming as few as five per cent of the H1N1 cases currently spreading around the world.
A pandemic strategy is a good thing, of course, and I’m glad for all the stockpiled Tamiflu and scientists working away on new vaccines. But best practice and human habits are leagues apart when it comes to spreading the flu. Eat your veggies and hope for the best, because avoiding each other simply isn’t an option.

Stigma one of the worst 'symptoms' of HIV

It’s a rainy Tuesday, and the group of women who put on this year’s Viral Monologues are debriefing over bowls of moose-meat stew about their performance the previous weekend.
There were some challenging moments. One of the six performers backed out at the last minute, unable to bear the thought of putting her HIV status out there for all the world to see. That left an empty chair on stage.
But the group decided to leave the chair there anyway, as a reminder of the stigma that still lingers when it comes to HIV. The effect was powerful.
The Viral Monologues models itself after Eve Ensler’s popular Vagina Monologues. The “viral” version of the play was launched in 2002 by the Voice Collective, the AIDS Vancouver Island women’s group who is meeting on this day to dissect its sixth and most recent production.
The “monologue” premise a la Ensler is simple enough: Women sit on stage and tell personal stories from their lives - from the point of view of their vaginas in Ensler’s case, or through the lens of HIV in the case of the Viral Monologues.
Ensler’s stories are real-life, but presented by actors. What distinguishes the Viral Monologues is that the stories are told by the women who are actually living them. Today at the debrief, talk turns to how challenging that can be.
Revealing the intimate details of your life to an audience of strangers would be difficult at the best of times. But when the story is about HIV, anything can happen. One member of the Voice Collective is learning that the hard way, having been ordered out of Canada after years of living here with her Canadian husband when word got out that she was HIV-positive.
A shift on AVI’s information line is a painful reminder of the stigma that continues to cling to HIV, says AVI manager Heidi Exner.
“I’ve had people ask me whether they should bleach their dishes now that they’ve found out their friend has HIV,” she says. “It’s not the people with HIV who change. We change the people.”
Media attention is a mixed blessing, the women agree. The stories need to get out there, because they put a face on HIV. Those who still envision HIV as the quick and brutish killer it once was need to meet the new generation of people who are living into old age with the virus due to major advances in treatment.
But the risk to those who go public shouldn’t be underestimated, because there’s just no predicting what might happen once the story of you and your HIV hits the daily paper. Even when things go as well as they possibly could, there’s a potential for something to go very wrong when it comes to a disease as stigmatized as HIV.
An uninformed and fearful landlord could see your name in the paper, for instance, and start working on ways to evict you. A potential employer could see the story and choose somebody else for the job. The guy at your bank, or your kid’s teacher, might start looking at you funny. The pity in people’s eyes might drive you mad.
Once you and your disease are featured in the media, you’re “out” wherever you go. There’s no taking your privacy back.
If it’s a story about living with asthma or cancer, no problem. Nobody gets judged for having asthma or cancer, or a whole roster of other diseases. But the same can’t be said for HIV.
Even the way a person gets HIV determines whether they’ll be more or less stigmatized . There’s one kind of stigma for those who catch HIV through a blood transfusion, and quite another for those infected through injection drug use. As for sex, better to have contracted HIV through your unfaithful spouse than to have gotten it through a promiscuous lifestyle.
Exner tells a funny/tragic story of a hospital doctor relentlessly questioning her one time about the source of a friend’s HIV, as if her answer would make all the difference as to how the patient was treated. The sad thing is, it might have.
With new medications turning HIV into a chronic health condition rather than a death sentence, it’s stigma that often gives the disease its sharpest edge these days. The women around the table agree it’s tough to go public with your story in the face of such judgment, but recognize that staying silent just feeds the sense of shame.
“It’s part of our life,” says one. “We’ve grown a lot by telling our stories.”

Traumatic brain injury a common and life-altering experience
July 11, 2008

One hard fall is all it takes. One punch. One smashup. One bolt out of the blue - a stroke, a case of meningitis.
The official name for what results is “traumatic brain injury,” but that little label barely touches on what it means to have to live with one. Life will never be the same for those whose brains sustain a severe injury. People sometimes feel so dramatically altered that they come to consider the date of their injury as their new birthday.
For Victoria man Des Christie, the injury was from a car accident at the age of 14. For the other 10,000 to 14,000 British Columbians who incur a traumatic brain injury in any given year, it might be a workplace accident, fall around the home, sports injury, medical problem, or any number of weird and unpredictable twists of fate.
“In this organization alone, we’ve got a staff member, my younger brother, another staff member’s daughter and another staff member’s husband - all of them with an acquired brain injury,” says Cridge Centre CEO Shelley Morris. “It’s much more common than people realize.”
The Cridge - more commonly known for its work with children and seniors - operates the region’s sole group home for people with traumatic brain injury. It’s for men only, but then again, men are twice as likely to experience a brain injury. The most common cause is a car accident, and the most common victim is a young man between the age of 19 and 25 injured while taking part in a risky activity.
McDonald House provides housing for 10 men. Christie has been living there for 14 years, but first had to put in a hard and trouble-ridden 22 years trying to make it on his own before finding a place that understood his challenges. Geoff Sing, the Cridge’s manager of brain-injury services and a brain-injury survivor himself, figures he could easily fill “three more McDonald Houses” if the resources were there.
One of the many little cruelties of brain injury is that it’s frequently invisible. The person looks unchanged to outward appearances, but no longer acts the same. They might not be able to hold their emotions in check. They’ll have memory problems. They tire much more easily. They may have suffered a permanent loss of motor control and brain function, and are unable to keep work or sustain a happy family life.
“The divorce rates after a brain injury are 85 per cent,” notes Sing.
Anecdotally, traumatic brain injury is presumed to be a major contributor to problems on Victoria’s streets. For some, the brain injury came first and resulted in a fall to the streets. For others, the street came first and the brain injury followed. Beatings, accidents and drug-induced disasters are daily possibilities for many of those on the streets, and injury rates overall are high.
The Cridge Centre wants to get a survey off the ground in the next few months to ascertain the level of brain injury on the street in a more formal fashion, in hopes of making a case for more resources.
“If we can get some specific numbers in the homeless community, my hope is that it will arm us - and the Vancouver Island Health Authority - with what we need to put more money into this,” says Morris. “I think it would be staggering to see the stats on this.”
As with any chronic and complex health condition, what’s needed for those with traumatic brain injury is a continuum of services. People typically start out in an acute-care hospital after their injury, then transfer to a rehabilitative facility. But what happens after that - or along the way - varies wildly. Without advocacy and support, life gets dicey quickly for those with brain injuries, and problems pile up fast.
Real work for real wages figures prominently in maintaining quality of life for those with a brain injury, says Morris. For the past two years, the Cridge has partnered with Camosun College to provide work training and on-the-job support for 36 people; Thrifty Foods, Carmanah Technologies and Rogers Chocolates are among the employers hiring from the program.
It’s not about lowering standards to suit people with brain injuries, stresses Sing, but rather about building flexibility and training into the work. Christie hadn’t worked for years before landing a job at Carmanah through the program, and is delighted with the boost to his disability income and his self-esteem: “I feel happier when I’m working. Otherwise, I just feel useless.”
Like the saying goes, it’s not exactly rocket science. “We want to grow residential housing and a job for people,” says Morris. “Can it get any more basic than that?”

Homeless needle exchange hits road for better or worse
May 9, 2008

We’re about to become the first major city in Canada to pull the plug on its needle exchange, without a clue what will happen as a result.
As of the end of May, the region’s largest needle exchange will close its doors on Cormorant Street and begin a mobile service. The business of exchanging as many as 2,000 needles a day will be done on the street from that point on.
What’s the rationale? There isn’t one. It’s just what happens when the chips are left to fall where they may. The needle exchange is going mobile not because it’s an effective strategy on any front, but simply because no place can be found for it.
Greater Victoria has had a needle exchange for almost 20 years, operated by AIDS Vancouver Island. You’d never know it from the hand-wringing and hysteria that has accompanied any mention of the exchange this past year or two, but once upon a time the exchange had neighbours who actually wrote letters supporting it, and a day-care centre right across the street.
Those days are long gone, and for reasons that have little to do with the needle exchange itself.
Most notably, the number of people using the needle exchange has increased dramatically - from 500 clients in 1996 to more than 1,500 today, with no concurrent increase in funding. Up until a small lift last fall in the midst of a community uproar over Cormorant Street, the exchange had been juggling triple the number of clients with the same staffing levels as a decade ago.
The drugs have changed as well, says AVI communications co-ordinator Andrea Langlois. More mellow drugs like heroin have given way to intense ones like cocaine and crystal meth, which can crank up negative behaviours in users due to the way they affect brain chemicals.
Both of those drugs are also injected far more frequently by addicted users - sometimes 20 or more times a day. That has increased traffic at the exchange.
Then there’s just the sheer volume of people out there. The number of people living on the streets has grown fivefold since the exchange moved into its current Cormorant Street location in 2001. With most other services closed up at night, the exchange evolved into a place where the street community could hang out.
No surprise, then, that the neighbours gradually worked themselves into a fury over the discarded needles, garbage and steady stream of sick, scabby people they were seeing outside their doors. The owner of the building that housed the exchange gave AVI notice last fall that the service had to go.
Months of fruitless searching for another location followed. There was a plan to move the exchange into a Pandora Avenue building next to Our Place drop-in, but that fell through after alarmed parents from a private school a couple blocks away nixed the move. With the May 31 eviction date now looming, AVI has no choice but to go mobile.
It’s a most peculiar development for a region that really can’t afford any more evidence of the social decay in its core. Up until now, we’ve had one needle exchange; now we’ll have one wherever AVI’s van stops. What’s our plan for when those neighbourhoods inevitably start to complain?
Langlois is especially worried about the clients who like to maintain a low profile - the ones who stop by every night after work to pick up a needle or two.
They’re not going to want to risk being identified by having to make their exchange in a public place, especially if TV camera crew decide to make a big deal out of following the van on its route. The opportunity to connect clients with other services - including detox and treatment - will also be lost when the exchange goes mobile.
“We really don’t know how successful we’ll be in maintaining the number of needles exchanged once we’re mobile,” says Langlois, adding that if the number of exchanges drops off, “there’s potential for an epidemic of hepatitis-C in this city.”
The needles may be what bring people through the door, says Steve Bradley, a Christian outreach worker and recovering addict who used to run a support group at the exchange. But it’s the support and sense of connection that people get while there that can change their lives, he notes. Without it, there’s no way out.
“You close the needle exchange, you’re going to see crime downtown increasing,” predicts Bradley. “We can’t afford to lose that place.”

Got a widemouth plastic water bottle to throw out in the wake of the bisphenol-A scare? Drop it off at the needle exchange this month - they’ll hand the bottles out to clients as “sharps” containers for needle disposal.

We shine at solving non-problems
May 2, 2008


Our water bottles are safe once more, thanks to a federal response so speedy and decisive that you could almost believe a new day was dawning in Canada.
In less than a year, bisphenol A went from a chemical that few Canadians had heard of to one of the most talked about and roundly condemned toxins in the country. Were it not for my ongoing frustration at our penchant to rally around obscure concerns, I’d take last month’s BPA ban as a heartening sign that our federal government can still rally to a cause if it needs to.
Don’t get me wrong: I’m sure the world will be a better place without bisphenol A. It’s OK with me that we’ve banned the stuff. But in terms of tackling the issues that really ail us in this country and around the world, a ban on BPA gets us exactly nowhere.
North American scientists have actually known about the more unsettling aspects of the man-made chemical for more than 70 years. The media didn’t have much to say on the topic until about a decade ago, however, and only really got an appetite for it in the past year. Of the 115 stories on BPA that have collectively run in B.C. newspapers over the years, 100 of them have been in the last year.
If you haven’t heard - although I can’t imagine that - BPA is a chemical used in the manufacturing of hard plastic and epoxies. Researchers first identified it as an “estrogen mimic” way back in the 1930s. Men working in plastics factories can develop breasts from breathing in BPA fumes day after day.
BPA exposure is thought to put people at greater risk of hormone-related diseases like breast and prostate cancer. It’s also been linked to smaller penis size in infants.
Not good. But as a priority for public health, this loud fussing about BPA exposure is really just noisy distraction from the things that are actually killing us in this country.
The government wants us to believe it’s making the planet a little safer for all of us by banning toxins like BPA. But if that’s the case, how is it that truly disastrous toxins such as tobacco and alcohol remain readily available? Could it have something to do with the $14 billion a year in tax revenue generated through the sale of cigarettes and booze?
Smoking accounts for more than a fifth of all deaths in Canada. Alcohol-related harms cost us $14.6 billion annually. Consumption of either toxin over a lifetime is associated with all kinds of cancers, organ damage, heart and lung problems, and chronic health issues. Together, tobacco and alcohol use account for most of the burden of disease, death and disability in Canada.
BPA is used in the manufacture of plastic baby bottles, something which no doubt helped make it an “It” issue. But if it’s children and youth we’re worried about, why don’t we do something to protect the nearly 400 babies born each year in Canada with the lifelong brain damage caused by a mother’s alcohol consumption during pregnancy - and the untold thousands who go undiagnosed? How come suicide is a leading cause of death for Canadians ages 15 to 24, and we don’t even talk about it?


Facts and figures around BPA-related harms are far less certain. Studies of the chemical’s toxic properties have generally involved rats, which were either injected with BPA or had BPA implants placed in their brains. That doesn’t much resemble the way humans ingest the chemical, so it’s difficult to draw parallels.
Nor do rats and humans respond the same way to toxins. Even the rats aren’t responding uniformly to BPA exposure; some don’t react to the chemical at all, and researchers are calling for more study to sort that out. In the meantime, we just don’t know the effects of low-dose BPA exposure on people’s health.
Again, that’s not to say that we should keep the stuff around. If we don’t need it, why use it? But at the risk of sounding cynical, what I conclude from Canada’s rush to ban BPA is that the plastics industry must not have much of a lobby, and that the media hullabaloo leading up to the ban certainly did a fine job of distracting us from all the other things Ottawa isn’t doing.
But please, drink deeply from your new BPA-free water bottle, and take what comfort you can from the knowledge that an uncertain and possibly non-existent threat to your health has been avoided. As for the real killers, they’re still out there.

The entrenchment of MRSA
Jan. 5, 2007

More than 1,000 people in our region will catch a terrible infection this year that no antibiotic will easily defeat. The worst cases will be fatal, but even the ones that aren’t will still be dangerous, unpleasant and extremely difficult to clear up.
Once upon a time, an infection like the one taking root right now was a problem only for very specific populations. A few isolated tribes of Australian aborigines. People living on the streets. Athletes playing contact sports. Military recruits.
Not anymore. The staph infections showing up in our community lately are occurring in people with no known risk factors. “We are the epicentre of the country,” local infection specialist Dr. Pamela Kibsey said this week.
Human beings have been grappling with staphylococcus infections for millennia, of course. No small wonder penicillin was given a hero’s welcome upon its invention in the 1940s, considering how many people had been killed by infection up to that point.
Alas, you can’t keep a bad bug down. From the emergence of penicillin-resistant staph barely a decade after penicillin’s discovery, to the multi-resistant “superbugs” of today, we have yet to vanquish a very old foe.
Bacteria are clever beasts, and likely would have given us a run for our money no matter what strategy we took for surviving their onslaughts. Staph bacteria have reached the point of being able to mutate almost as fast as the latest wonder drug is being rushed to market.
But we’ve also aided the bugs’ cause immensely by doing just about everything wrong in terms of infection control. It starts with years of gulping antibiotics like candy and continues through a long series of health-care and social policy changes made for reasons of economy rather than disease management.
And now we’ve all got a problem.
The latest version of staph has a big name: Community-acquired Methicillin Resistant Staphylococcus Aureus. The experts call it CA-MRSA.
In this region, we’ve been living with HA-MRSA - the kind you get in hospital - for almost a decade. What’s going on now is basically the result of the same bug, except you don’t have to go to the hospital anymore to end up infected.
My dad had the dubious honour in the late 1990s of being one of the first hospital patients in the region to acquire MRSA. The bacteria got into a surgical wound. The ensuing infection almost killed him, and the heavy-duty antibiotics he had to be on took almost as serious a toll.
More pertinently to those beyond his immediate family, he cost the system a fortune. He was in isolation in hospital for five months, on an antibiotic drip that cost more than $150 a day.
The intensity of his illness definitely would have pushed up his nursing costs. And every day he was in hospital meant another day of risk for everyone else who was in there, because staphylococcus aureas spreads like crazy among the sick and weak.
Add eight years of inflation and the spiralling costs of pharmaceuticals, and you can figure out how much this same scenario would cost today. If my dad had been in his working years and not yet retired, the financial hit he’d have taken from being laid up for five months would have been disastrous on a whole other level for my family.
Not all of the 1,000 cases of MRSA in the coming year will be as dramatic, of course. Staph presents differently in everybody, from relatively minor boils to ravaged lungs. A few of us live with MRSA in our bodies all the time, and never get sick.
Still, the entrenchment of MRSA over time is the alarming part. I used to think the trick was to stay away from antibiotics and hospitals, but now it seems that even those ramparts have been breached. The world is growing ill enough that individual efforts to stay healthy are no longer a guarantee.
Why the rise in infection? Pick your theory. We now have ghettos of street people being left to sicken in our downtowns. We’ve seen huge changes in health care. Our food supply is downright alarming, saturated in antibiotics.
Start with an increasingly privatized and mobile health-care force that travels from site to site, inadvertently spreading infection. Mix in ever-shorter hospital stays, heightening the risk that someone is released into the community before their brewing infection is even noticed. Then there’s the overcrowded emergency rooms, stacked with those sickly victims of the street and everybody jammed together for hours.
We eat meat and eggs from antibiotic-laden animals, the poor sods would not survive the miserable conditions of factory farming without the drugs. We overuse antibiotics ourselves, continuing to take them for the wrong things, at the wrong time, in the wrong way.
It doesn’t have to be this way. But for as long as it is, brace yourself for the consequences.