consider raising the topic of HIV with sexually active men and women in their practices. Catherine A. Hankins, MD, FRCPC Public health epidemiologist Centre for AIDS Studies Department of Community Health Montreal General Hospital Montreal, Que.
References 1. Global Programme on AIDS. Report of the Meeting on Research Priorities Relating to Women and HI V/AIDS, Geneva, 19-20 November 1990, World Health Organization, Geneva, 1991 2. The European Collaborative Study. Children born to women with HIV-1 infection: natural history and risk of transmission. Lancet 1991; 337: 253260 3. Cassol SA, Lapointe N, Salas T et al: Diagnosis of vertical HIV-1 transmission using the polymerase chain reaction and dried blood spot specimens. J Acquired Immune Defic Syndrome 1991 (in press)
Canadian medicare: view from Utopia
research and on technology. Lack of any kind of copayments or deductibles has led to abuses of the system both by users and by providers. Canada's insistence on public administration as one of the tenets of medicare is surely the silliest example of enforced noncompetitiveness. Private insurers competing with government insurance would surely inject more life (and cash) into the system. The argument that such competitiveness flies in the face of an egalitarian concept of universal medicare is almost as absurd as Canada's insistence that there cannot or should not be two-tiered medicine and that real access to health care actually exists. Consider the predicament of a Newfoundlander who wants to undergo lithotripsy. In all of this the poor Canadian physician has been truly squeezed. Between 1971 and 1985, after adjustment for inflation, Canadian physician fees decreased 18%, while those of US physicians rose 22%.1 Yet Canada spends one-third per capita of the US figure for health care research and little more than 75% of the US figure for hospitals and construction.2 Even if Ontario physicians have been quietly lured into the provincial government's lions' cage, it may not be too late to rattle the cage or even to steal out of it. It will take a blueprint for a restructured medicare system that embraces at least limited competition, some form of copayment, increased funding for research and a collective willingness by Canadians to rely less on government.
ince moving to th&' United States some 4 years ago I have watched with incredulity, pity and exasperation the plight of Canada's medical profession under universal, governmentsponsored medicare. The draconian measures proposed in Quebec's Bill 120 (such as stiff penalties for MDs who don't practise as government deems fit) and the seemingly cosy accord between the Ontario Medical Association (OMA) and Ontario's New Democratic Party government have a common thread: Canadians' willingness to allow governments to exert inordi- David Woods nate control over their affairs. Vice president, publications And that is what's causing Can- ECRI Plymouth Meeting, Pa. adian medicare to unravel. The lack of competitiveness in Canadian health care has led to References rationing, waiting lists, shortages 1. Canadian Health Insurance: Lessons for of equipment and scandalously the U.S. Report to the Chairman, Comlow relative amounts expended on mittee on Government House of Repre1198
CAN MED ASSOC J 1991; 145 (10)
sentatives, US General Accounts Office, Washington, 1991: 5 2. Ibid: 29
[We are delighted that Mr. Woods has found Utopia in suburban Pennsylvania and that he hasn't become ill. - Ed.]
Cognitive impairment in the elderly T Nhe recent correspondence between Graham Worrall and Drs. Louise Teitelbaum, M. Lynne Ginsburg and Robert W. Hopkins (Can Med Assoc J 1991; 145: 196, 198) concerning the prevalence of cognitive impairment in Canada serves as a good introduction to the Canadian Study of Health and Aging, currently under way in 18 centres across Canada. The study directly addresses the points raised in the correspondence. The study will assess the prevalence of cognitive impairment, dementia and Alzheimer'stype dementia in people aged 65 years or more in all provinces of Canada, using representative samples drawn from community and institution populations. A screening instrument is being used in the community samples (total n = 9000). Those with positive results of screening, plus a random sample of others with negative results, receive an extensive clinical diagnostic work-up, including historytaking, physical examination, neurologic and neuropsychologic testing, and laboratory studies. People living in institutions (total n = 1250) proceed directly to the physical examination. Embedded in the study design is a case-control study of risk factors for Alzheimer's-type dementia in which data will be collected via questionnaires to examine current etiologic hypotheses. In addition, a prospective risk factor survey, targeting those found LE 15 NOVEMBRE 1991
to be cognitively normal, will collect baseline data to permit prospective testing of etiologic hypotheses at a future follow-up of those involved. Finally, analyses of blood samples will offer the chance to search for biomarkers for dementia. The study also includes interviews with people caring for the study subjects found to have dementia, whether in the community or in institutions. These will provide information on who cares for these people, what services they use for assistance and how satisfied they are with the services; it will also provide information on the health status of the caregivers in comparison with people who look after elderly people who do not have dementia. The study is funded as part of the Seniors' Independence Research Programme through the Department of National Health and Welfare. It involves more than 100 investigators. Data collection began in February 1991, after development and pilot studies, and should be complete in December; results will become available in the summer of 1992.
girl not yet two years old, a fairhaired, blue-eyed pet, who was as healthy as the birds when she was born. For more than a year past, ever since she was old enough to be less in the nursery and more with her father and me, she has ailed mysteriously. I could not say she was ill, yet she was hardly ever well. I was kept in a perpetual state of anxiety about her. The symptoms were absence of appetite, complaints of sickness, stomach and digestion altogether out of order. Last August, I took her to a country town, where we stayed two months.
After the first week, she flourished like a young bay-tree, ate and drank and laughed and played and slept, and kept me forever busy enlarging her garments. I brought her home rosy and robust. In one week, all the old symptoms reappeared, - loss of appetite, dark lines under the eyes, listless ways, restless nights. Some one suggested that the neighborhood did not suit her, and I was cogitating how to take her away again, when she caught a severe cold, and was confined entirely to one room for three weeks. She recovered her general health completely. Appetite, spirits, sleep, all returned. It could not be the neighborhood.
evening, when she was particularly merry and mad; and the truth flashed upon me. It was his tobacco that upset her. He has been away now for a month; and the child's limbs daily get firmer and rounder, and she is the merriest, healthiest little mortal possible. He always smoked after breakfast, and after lunch, with her in the room, neither of us dreaming it was injurious to her. But for his providential absence this time, I doubt whether it would ever have occurred to me; and we might have lost our darling, for she was wasting sadly. It was acting like a slow poison upon her. This is a true, unvarnished statement, which my nurse can corroborate. When shall we have a parliament that will dare to tax our slow poisons to the utmost? I enclose my card, and remain your obedient servant. - E.H. in Pall Mall Gazette A. Stewart Allen, FRCSC Rosedale, RR 1 Brockville, Ont.
Serious childhood injuries caused by air guns
After her cold, she joined us downstairs again, as usual, two or three T read with interest the correspondence in the Aug. 1, times a day. In less than a week, Ian McDowell, PhD .L1991, issue of CMAJ resulting sickness, etc., returned. I was in dePrincipal investigator For from I the article by Drs. Amir spair. three nearly Canadian Study of Health and Aging months, Department of Epidemiology racked my brains about drains, wall- Shanon and William Feldman University of Ottawa papers, milk, water, saucepans, any (Can Med Assoc J 1991; 144: 723Ottawa, Ont. and every thing in vain, - the child 725). slowly wasted. The weather was too The letter by Dr. Donald R. severe to take her away. In an agony MacInnis (Can Med Assoc J 1991; of mind, I noticed one day that, so far 145: 200-201) makes an entirely from outgrowing her clothes as I had Secondhand tobacco expected, they were too large for her. valid point that should be taken to smoke: early insights The little thing was not eating enough heart by all journal editors. Feldto keep up her strength, and we could man attempts to respond with I believe that the following let- not coax her to eat. Yet she was not such puffery as quoting the defter is the first written evi- really ill: she ran about and played in inition of "science" from a dicdence of the damage caused a quiet way, and looked fairly well to tionary. by the inhalation of secondhand those who had not seen her more Simply because the use of air tobacco smoke. I found it among robust. guns as sporting equipment obvisome items in a scrapbook and Suddenly, my husband was sum- ously does not appeal to Shanon believe it may have been written moned into the country. A week after and Feldman, they recommend in the 1880s. he went, the child began to eat with banning air guns altogether on the eager relish. In a fortnight, she was basis of the series of injuries that May I give my recent experience of her own happy self, full of riotous, they documented superbly in their tobacco smoke? It may be a warning childish spirits. "Her father has never article. However, the implications to others. I have one child, -a little seen her like this," I remarked one for personal freedom in their "leg1200
CAN MED ASSOC J
1991; 145 (10)
LE 15 NOVEMBRE 1991
References 1. Global Programme on AIDS. Report of the Meeting on Research Priorities Relating to Women and HI V/AIDS, Geneva, 19-20 November 1990, World Health Organization, Geneva, 1991 2. The European Collaborative Study. Children born to women with HIV-1 infection: natural history and risk of transmission. Lancet 1991; 337: 253260 3. Cassol SA, Lapointe N, Salas T et al: Diagnosis of vertical HIV-1 transmission using the polymerase chain reaction and dried blood spot specimens. J Acquired Immune Defic Syndrome 1991 (in press)
Canadian medicare: view from Utopia
research and on technology. Lack of any kind of copayments or deductibles has led to abuses of the system both by users and by providers. Canada's insistence on public administration as one of the tenets of medicare is surely the silliest example of enforced noncompetitiveness. Private insurers competing with government insurance would surely inject more life (and cash) into the system. The argument that such competitiveness flies in the face of an egalitarian concept of universal medicare is almost as absurd as Canada's insistence that there cannot or should not be two-tiered medicine and that real access to health care actually exists. Consider the predicament of a Newfoundlander who wants to undergo lithotripsy. In all of this the poor Canadian physician has been truly squeezed. Between 1971 and 1985, after adjustment for inflation, Canadian physician fees decreased 18%, while those of US physicians rose 22%.1 Yet Canada spends one-third per capita of the US figure for health care research and little more than 75% of the US figure for hospitals and construction.2 Even if Ontario physicians have been quietly lured into the provincial government's lions' cage, it may not be too late to rattle the cage or even to steal out of it. It will take a blueprint for a restructured medicare system that embraces at least limited competition, some form of copayment, increased funding for research and a collective willingness by Canadians to rely less on government.
ince moving to th&' United States some 4 years ago I have watched with incredulity, pity and exasperation the plight of Canada's medical profession under universal, governmentsponsored medicare. The draconian measures proposed in Quebec's Bill 120 (such as stiff penalties for MDs who don't practise as government deems fit) and the seemingly cosy accord between the Ontario Medical Association (OMA) and Ontario's New Democratic Party government have a common thread: Canadians' willingness to allow governments to exert inordi- David Woods nate control over their affairs. Vice president, publications And that is what's causing Can- ECRI Plymouth Meeting, Pa. adian medicare to unravel. The lack of competitiveness in Canadian health care has led to References rationing, waiting lists, shortages 1. Canadian Health Insurance: Lessons for of equipment and scandalously the U.S. Report to the Chairman, Comlow relative amounts expended on mittee on Government House of Repre1198
CAN MED ASSOC J 1991; 145 (10)
sentatives, US General Accounts Office, Washington, 1991: 5 2. Ibid: 29
[We are delighted that Mr. Woods has found Utopia in suburban Pennsylvania and that he hasn't become ill. - Ed.]
Cognitive impairment in the elderly T Nhe recent correspondence between Graham Worrall and Drs. Louise Teitelbaum, M. Lynne Ginsburg and Robert W. Hopkins (Can Med Assoc J 1991; 145: 196, 198) concerning the prevalence of cognitive impairment in Canada serves as a good introduction to the Canadian Study of Health and Aging, currently under way in 18 centres across Canada. The study directly addresses the points raised in the correspondence. The study will assess the prevalence of cognitive impairment, dementia and Alzheimer'stype dementia in people aged 65 years or more in all provinces of Canada, using representative samples drawn from community and institution populations. A screening instrument is being used in the community samples (total n = 9000). Those with positive results of screening, plus a random sample of others with negative results, receive an extensive clinical diagnostic work-up, including historytaking, physical examination, neurologic and neuropsychologic testing, and laboratory studies. People living in institutions (total n = 1250) proceed directly to the physical examination. Embedded in the study design is a case-control study of risk factors for Alzheimer's-type dementia in which data will be collected via questionnaires to examine current etiologic hypotheses. In addition, a prospective risk factor survey, targeting those found LE 15 NOVEMBRE 1991
to be cognitively normal, will collect baseline data to permit prospective testing of etiologic hypotheses at a future follow-up of those involved. Finally, analyses of blood samples will offer the chance to search for biomarkers for dementia. The study also includes interviews with people caring for the study subjects found to have dementia, whether in the community or in institutions. These will provide information on who cares for these people, what services they use for assistance and how satisfied they are with the services; it will also provide information on the health status of the caregivers in comparison with people who look after elderly people who do not have dementia. The study is funded as part of the Seniors' Independence Research Programme through the Department of National Health and Welfare. It involves more than 100 investigators. Data collection began in February 1991, after development and pilot studies, and should be complete in December; results will become available in the summer of 1992.
girl not yet two years old, a fairhaired, blue-eyed pet, who was as healthy as the birds when she was born. For more than a year past, ever since she was old enough to be less in the nursery and more with her father and me, she has ailed mysteriously. I could not say she was ill, yet she was hardly ever well. I was kept in a perpetual state of anxiety about her. The symptoms were absence of appetite, complaints of sickness, stomach and digestion altogether out of order. Last August, I took her to a country town, where we stayed two months.
After the first week, she flourished like a young bay-tree, ate and drank and laughed and played and slept, and kept me forever busy enlarging her garments. I brought her home rosy and robust. In one week, all the old symptoms reappeared, - loss of appetite, dark lines under the eyes, listless ways, restless nights. Some one suggested that the neighborhood did not suit her, and I was cogitating how to take her away again, when she caught a severe cold, and was confined entirely to one room for three weeks. She recovered her general health completely. Appetite, spirits, sleep, all returned. It could not be the neighborhood.
evening, when she was particularly merry and mad; and the truth flashed upon me. It was his tobacco that upset her. He has been away now for a month; and the child's limbs daily get firmer and rounder, and she is the merriest, healthiest little mortal possible. He always smoked after breakfast, and after lunch, with her in the room, neither of us dreaming it was injurious to her. But for his providential absence this time, I doubt whether it would ever have occurred to me; and we might have lost our darling, for she was wasting sadly. It was acting like a slow poison upon her. This is a true, unvarnished statement, which my nurse can corroborate. When shall we have a parliament that will dare to tax our slow poisons to the utmost? I enclose my card, and remain your obedient servant. - E.H. in Pall Mall Gazette A. Stewart Allen, FRCSC Rosedale, RR 1 Brockville, Ont.
Serious childhood injuries caused by air guns
After her cold, she joined us downstairs again, as usual, two or three T read with interest the correspondence in the Aug. 1, times a day. In less than a week, Ian McDowell, PhD .L1991, issue of CMAJ resulting sickness, etc., returned. I was in dePrincipal investigator For from I the article by Drs. Amir spair. three nearly Canadian Study of Health and Aging months, Department of Epidemiology racked my brains about drains, wall- Shanon and William Feldman University of Ottawa papers, milk, water, saucepans, any (Can Med Assoc J 1991; 144: 723Ottawa, Ont. and every thing in vain, - the child 725). slowly wasted. The weather was too The letter by Dr. Donald R. severe to take her away. In an agony MacInnis (Can Med Assoc J 1991; of mind, I noticed one day that, so far 145: 200-201) makes an entirely from outgrowing her clothes as I had Secondhand tobacco expected, they were too large for her. valid point that should be taken to smoke: early insights The little thing was not eating enough heart by all journal editors. Feldto keep up her strength, and we could man attempts to respond with I believe that the following let- not coax her to eat. Yet she was not such puffery as quoting the defter is the first written evi- really ill: she ran about and played in inition of "science" from a dicdence of the damage caused a quiet way, and looked fairly well to tionary. by the inhalation of secondhand those who had not seen her more Simply because the use of air tobacco smoke. I found it among robust. guns as sporting equipment obvisome items in a scrapbook and Suddenly, my husband was sum- ously does not appeal to Shanon believe it may have been written moned into the country. A week after and Feldman, they recommend in the 1880s. he went, the child began to eat with banning air guns altogether on the eager relish. In a fortnight, she was basis of the series of injuries that May I give my recent experience of her own happy self, full of riotous, they documented superbly in their tobacco smoke? It may be a warning childish spirits. "Her father has never article. However, the implications to others. I have one child, -a little seen her like this," I remarked one for personal freedom in their "leg1200
CAN MED ASSOC J
1991; 145 (10)
LE 15 NOVEMBRE 1991
