Category Archives: Uncategorized

Pharmacare 2020: A remedy for an accident of history

UBC's Michael Law with Saskatchewan health policy analyst Steven Lewis.

UBC’s Michael Law with Saskatchewan health policy analyst Steven Lewis.

VANCOUVER – Canada’s Medicare system stops the minute a doctor writes a prescription.

On the second day of Pharmacare 2020, the talk turned to how we get to a quality system that will leave no Canadian behind, that will be efficient, accountable, and evidence-based.

Saskatoon health policy analyst Steven Lewis says leaving drug coverage out at the dawn of Medicare was an accident of history. If we were to create a pharmacare program from scratch, the task would be much easier. The problem is how do we transition from the house we built for ourselves to the one we want to live in?

Another audience participant astutely remarked that from the 30,000 foot level there is a great degree of consensus, but getting closer to the ground is going to be more difficult.

Lewis is blunt about the reasons why – a public pharmacare system would create winners and losers. Doctors would be the winners – a public pharmacare system would better mirror their existing practices. It would be more difficult for retail pharmacists who may need to define what their role is within the health system. Should they be remunerated as the owners or employees of a retail outlet, or should they join the mainstream of health professions and get remunerated based on the service they render to the public?

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Pharmacare 2020: The evidence is clear, but where is the political will?

Jim Keon and Jody Shkrobot protect their turf during Pharmacare 2020 in Vancouver.

Jim Keon and Jody Shkrobot protect their turf during Pharmacare 2020 in Vancouver.

VANCOUVER – Almost 10 per cent of Canadians never fill their drug prescriptions. They can’t afford it.

We’re here in Vancouver for a unique forum to discuss what every major national health care system review over the last 50 years has recommended – the need for a national pharmacare program. We can no longer ignore the fact that universal access to prescription drugs is a necessary part of any modern health system. Canada is an outlier on the international stage – most countries have some form of universal pharmacare coverage for its citizens. Given the collective wealth of our nation, this is a major embarrassment. As one participant in Pharmacare 2020 noted, we have yet to enter the 21st century when it comes to drugs.

How different our health system might look should we have followed Justice Emmett M. Hall’s recommendations in 1964 that Canada move to a national pharmacare system with a $1 deductible on prescription drugs. Since then we have had the National Health Forum (1994-97) The Romanow Commission (2002) and the recent National Pharmaceutical Strategy which failed to come to any agreement on the objective of providing the basic minimum of catastrophic drug coverage. Seems the provinces could not agree not to bankrupt very ill citizens who are faced with steep drug costs.

It’s not like we are saving the public treasury money.

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A major change in how we donate plasma

It was supposed to take place last fall. Now two private for-profit plasma collection centres are to open shortly in Toronto.

With approval from Health Canada it represents a major shift in how we deal with biological donations – the centres will be paying for plasma from donors contrary to the recommendations of both the Krever Inquiry and the World Health Organization.

Canadian Blood Services says they have nothing to do with the company, although they admitted to us last year that this is something they may reconsider in four or five years. The private company has no relationship with CBS’ counterpart in Quebec either.

Which raises the question of what this company is planning to do with all the plasma they are collecting? The most likely route is to sell it to fractionators in the United States to make intravenous products that could end up back in Canada.

Before Canadian Blood Services closed down the Thunder Bay plasma collection centre last April, plasma was getting shipped from northern Ontario to South Carolina for fractionation into something called Immunoglobulin, better known as IVIG. The IVIG was in turn sent back to CBS for distribution across Canada. CBS was supplying about 25 per cent of the plasma needed to make the Canadian supply of IVIG, the rest coming from American donors — many of whom would have got paid.

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Nicaragua Day 9: “From misery to poverty”

This is one of the better factories in the free trade zones.

This is one of the better factories in the free trade zones.

MANAGUA – At 5:30 am the sun is rising over the Las Mercedes industrial park. The walkway into the park is long, at times multiple railings appear as if organizing queues for a theme park. On either side is a tall chain link fence, giving the appearance that those who come this way are being funnelled into the factories beyond. At the very end is a sentry post where workers bags are inspected by guards before they head into the factories.

Along the walkway market stalls are being set up. It’s an instant mall for the workers, where they can buy anything from toilet paper to prescription drugs – no prescription required. The vendors know what their clientele will need over the course of the day.

We are here to hand out small booklets as part of a campaign organized by Maria Elena Cuadra, a women’s rights organization that is pushing for social change throughout Nicaragua. The booklets describe the contents of a new law about violence against women. This is significant in a country where violence against women, including rape, is not only commonplace, but deeply ingrained in the social culture.

The booklets were produced with funding from Oxfam and CIDA and have a little Canadian flag on the back.

The first few workers arrive and are happy to take the booklets. Soon it turns into a torrent as thousands of workers come down the walkway. We are prepared, the members of our delegation working with the women of MEC to get a booklet to everyone.

One man says he likes to hit women. Another man says he wants copies to give his friends and thinks the work MEC is doing in important.

The security guards do not hassle us, only asking that we shoot our video a little further away from the main gate. The new law is supported by the First Lady of Nicaragua, although the government appears to be doing little itself to advance the issue. The companies inside the gates are supportive and ask for their own copies.

MEC has loudspeakers at the entrance playing music in between ads promoting MEC’s campaign. The workers are well aware of who MEC are.

At 7 pm it stops abruptly, that last few workers trickling into the zone. When we see the emptied walkway it’s evident that not a single worker discarded the booklet.

On the way back to our bus the music was still playing and a bus driver was dancing on the steps of his vehicle while finishing the last of his breakfast. All around are numerous buses that have brought the workers here.

The free trade zones were begun in Nicaragua to attract investment. In an age of savage capitalism, the government of the day felt it necessary to get into the game. Free trade zones do not play by the same labour rules as the rest of the economy. Today more than 100,000 Nicaraguans work here for low pay and in often deplorable conditions. Most of these workers will start at 7 am and finish at 7 pm. Many will work longer than that if they have not met their production quota that day.

We are told that while the U.S.-owned factories are the best, it is the Korean factories that raise the ire of the workers. Women who have worked in these factories tell us of the difficulty in receiving the pay they are owed, in getting the factories to honour their state-legislated benefits, of monstrous working conditions including a limit of one visit to the toilet all day long. Another worker is assigned to time these toilet breaks. Some factories do not permit workers to move freely within the factory, insisting that they stay at their post for the full shift.

Factory workers make Levis Dockers at one of the better employers in the free trade zone.

Factory workers make Levis Dockers at one of the better employers in the free trade zone.

Later than morning we visit one of the better U.S. factories. The factory has been in existence for 12 years. For the past nine years the factory’s client has been Levis. Today the workers are making Dockers pants destined for the U.S. and Argentina.

It is unusual for us to be let inside one of these factories, but management here have had a good working relationship with both MEC and the local union.

Workers at the plant work from 7 am to 5:30 pm each day. They receive a 30-minute lunch and a morning break of 15-minutes. Minimum pay in this factory is $50 per week – which is high in the free trade zone. Minimum wage in the zone is $70 per month. Keep in mind an average family needs almost $500 a month to be able to afford the most basic of needs.

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Nicaragua Day 8 – Fear of flying

View of Managua from our flight.

View of Managua from our flight.

MANAGUA – Outside the Managua airport we were met by a representative from the Best Western hotel who asked about our flight. The Best Western Las Mercedes is located across the street from the airport, but still a van is required to take us there given the highway is not an easy crossing.

We asked if the hotel representative had ever been to the Atlantic Coast? He said no, that he had never flown in a plane. This is despite the fact that he worked to the sound of arrivals and take offs all day long. Like many who have never flown before, he said he was afraid to fly.

It’s an hour-long flight from Puerto Cabezas to Managua, from the Atlantic to the Pacific. The roads across the country are not good, and a bus will take up the better part of a day to undertake the same journey. Some travel through Honduras to reach the Atlantic Coast, but the route is not considered safe.

The day began with a previously unscheduled meeting with the Mayor of Puerto Cabezas. Reynaldo Francis Watson has only been in the job for a month, but he already looks like he carries the weight of the world on his shoulders.

The Mayor of Puerto Cabezas addresses the delegation from Horizons of Friendship.

The Mayor of Puerto Cabezas addresses the delegation from Horizons of Friendship.

Puerto Cabezas extends far beyond the immediate urban area. It takes in more than 80 local communities and covers a region with 320,000 citizens. About 40 per cent of the municipality live in the city. More are coming every day.

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The Mayor tells us that he has a budget of $1.6 million, about 250 municipal staff, and the city owns one garbage truck. Turns out we had seen it for the first time that morning – more of a dump truck than the garbage trucks we are accustomed to seeing on the streets of our Canadian municipalities.

Garbage is everywhere, often providing food for the wild dogs and cats that wander the city. Along the roadside we encounter smoke as residents burn their garbage in the streets. Passing a creek we noticed that it is full of plastic bags waiting for a torrential rainfall to wash it all out to sea.

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Nicaragua Day 7: Some bumps along the road

Dog chases our bus on the highway to Santa Marta.

Dog chases our bus on the highway to Santa Marta.

SANTA MARTA – We were thankful for the rain. Without it we would have been forced to choose between the dust or the heat on the small Toyota bus as we made our way to Santa Marta. In Puerto Cabezas, none of the buses have air conditioning and opening the windows would have normally resulted in us choking from the dust rising up from the dirt highway.

The rain meant there was no dust, but it didn’t mean we would be spared the potholes which rattled us for almost two hours on our 60 kilometre journey. The bus itself was a hodge podge of seating cobbled together from other vehicles. The bench at the back of the bus was particularly stiff, sending us slipping both up and down and left and right as the driver swerved to miss the worst of the indentations on the road.

The highway turns into a dirt road before you even emerge from Puerto Cabezas, the landscape softly rolling before emerging onto a flat plain where the trees become fewer in number. You can count on one hand the number of vehicles we pass going in the opposite direction, most comprising motorcycles or trucks.

At the first village we encounter a rope across the road just before a wooden bridge fording a river. A soldier asks us the purpose of our visit given we are about to enter an area that is controlled by Miskitu indigenous peoples.

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Nicaragua Day 6: The Mayor cuts class to greet us

The Mayor of Puerto Cabezas (left) cuts out of class to greet us.

The Mayor of Puerto Cabezas (left) cuts out of class to greet us.

PUERTO CABEZAS – The Mayor of Puerto Cabezas came out of his Saturday law class to greet us in the hallway. As little kids sold us bags of fruit outside the classrooms, arrangements were made for a more formal audience before we left town. Today we were at the local campus of Bluefields Indian Caribbean University where among other things, they are trying to educate local leaders in the law.

The University sees itself as answering the needs of its region accommodating more than 2,500 students in their degree programs. Prior to 1992 no university existed in the Atlantic Coast of Nicaragua. Those with academic ambition had to travel to the Pacific coast to study. Given these are five-year programs, few professionals ever made their way back to Puerto Cabezas.

One official told us “you could count on your fingers the number of professionals” that worked in the region prior to 1992.

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Day 5: The other Nicaragua

GAme day at the Puerto Carvaza ball park.

Game day at the Puerto Cabezas ball park.

PUERTO CABEZAS – The lobster fisherman of Puerto Cabezas don’t take boats out and cast traps in into the sea. Instead they take groups of men out in boats to dive into the sea to catch the lobsters by hand. It may be less efficient than their counterparts in Atlantic Canada, but it employs nearly 5,000 in this municipality of 320,000.

The problem is there are too many divers and the lobsters in the shallow waters have become less bountiful. That has pushed the divers into deeper waters. We were told that 1,400 divers have become ill from decompression illness. Some have died.

At the offices of the regional government we were told they were like to change the way fisherman gather lobster, but setting traps would employ many fewer in a region that already suffers from high unemployment. Like all Nicaraguan problems, this is one that will have to be solved over time. A new form of employment is needed for those that would be displaced by changing the nature of the fishery.

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Puerto Cabezas is on the northern end of the Atlantic coast of Nicaragua. The colonial powers that have come and gone have left the residents speaking both Spanish and a Creole English in addition to the Miskitu language. It has also influenced the housing, a mix of Caribbean and Spanish styles, that is when the four walls aren’t made up of scrap wood and the roof a hunk of tin. Many of the homes here are up on stilts to avoid the flooding from hurricanes that sweep in from the Caribbean.

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Nicaragua Day 4: Love and friendship on Valentine’s Day

A youth dance troupe performs for us at the Oscar Arnulfo Romero Community Centre in Nanaime.

A youth dance troupe performs for us at the Oscar Arnulfo Romero Community Centre in Nandaime.

NANDAIME – Valentine’s Day in Nicaragua is as much about friendship as it is love. Before the day was out, we would be finding both.

Nandaime is a quiet town of 40,000 residents – 20,000 in the so-called “urban area” – located south of Masaya. It fits the form of many other Spanish colonial towns built around an open square with the municipal building on one side and a church on the other.

In a country where people are continually in the streets, there were few people about town until the local high school emptied at about 11:30 am of the first shift of the day.

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Education is a challenge in Nicaragua, and the local high school accommodates the local population by teaching three different groups per day in consecutive shifts.

You also notice that water runs through the streets of the town, turning into a significant flow on the street where the Oscar Arnulfo Romero Community Centre is located. Nandaime cannot afford a sewage system.

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Nicaragua Day 3: And Then The Chicken Walked In

A chicken decided to crash our briefing from the Masaya women's co-op.

A chicken decided to crash our briefing from the Masaya women’s co-op.

MASAYA – It shouldn’t have come as any surprise when the large chicken joined the meeting, striding around as if waiting for her turn to talk.

After all the dog had already done his inspection, and the cat made a brief cameo prior to the chicks deciding they were going to make a crossing. Nobody seemed to mind.

We had travelled from the capital to Masaya to visit a former Horizons of Friendship partnership project that no longer needed Horizons. In the development world, that’s an outstanding success. Goal achieved.

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Fifty-five women belong to the Masaya-based co-op that is involved with everything from mixed farming to embroidered clothes, artwork and producing dolls. The farm was just one site where we could see the co-op at work.

Gathered in a circle in an open shelter, several co-op members introduced themselves and talked about what the co-op meant to them.

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