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The resident, under pressure to keep the service’s beds moving, believes that this is a ‘weak’ consult.

This story repeats itself over and over in every Canadian Emergency Department. Our system is trying to maximize efficiency, which means that every clinic, department and inpatient service is being asked to do more with less and to account for every minute spent.

“We understand that this is a small group of patients that are affected, but we will go the extra mile to understand what their needs are and provide that service accordingly,” said Dr. Bev Adams, psychiatry department head with Alberta Health Services.

Imagine if a Canadian diagnosed with cancer were told she could receive chemotherapy paid for by the health-care system, but would have to cough up the cash herself if she needed radiation. Or that she could have a few weeks of treatment, and then be sent home even if she needed more. That would never fly. If doctors, say, find a tumour in a patient's colon, the government kicks in and offers the mainstream treatment that is most effective. But for many Canadians diagnosed with a mental illness, the prescription is very different. The treatment they receive, and how much of it they get, will largely be decided not on evidence-based best practices but on their employment benefits and income level: Those who can afford it pay for it privately. Those who cannot are stuck on long wait lists, or have to fall back on prescription medications. Or get no help at all. But according to a large and growing body of research, psychotherapy is not simply a nice-to-have option; it should be a front-line treatment, particularly for the two most costly mental illnesses in Canada: anxiety and depression - which also constitute more than 80 per cent of all psychiatric diagnoses.

Why aren't we providing evidence-based care?" .. The case for psychotherapy Research has found that psychotherapy is as effective as medication - and in some cases works better. It also often does a better job of preventing or forestalling relapse, reducing doctor's appointments and emergency-room visits, and making it more cost-effective in the long run.

Therapy works, researchers say, because it engages the mind of the patient, requires active participation in treatment, and specifically targets the social and stress-related factors that contribute to poor mental health. There are a variety of therapies, but the evidence is strongest for cognitive behavioural therapy - an approach that focuses on changing negative thinking - in large part because CBT, which is timelimited and very structured, lends itself to clinical trials. (Similar support exists for interpersonal therapy, and it is emerging for mindfulness, with researchers trying to find out what works best for which disorders.) Research into the efficacy of therapy is increasing, but there is less of it overall than for drugs - as therapy doesn't have the advantage of well-heeled Big Pharma benefactors. In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs - selective serotonin reuptake inhibitors (SSRIs) - and psychotherapy.

The issue is not one against the other," says Montreal psychiatrist Alain Lesage, director of research at the Douglas Mental Health University Institute. "I am a physician; whatever works, I am good. We know that when patients prefer one to another, they do better if they have choice." Several studies have backed up that notion. Many patients are reluctant to take medication for fear of side effects and the possibility of difficult withdrawal; research shows that more than half of patients receiving medication stop taking it after six months. A small collection of recent studies has found that therapy can cause changes in the brain similar to those brought about by medication. In people with depression, for instance, the amygdala (located deep within the brain, it processes basic memories and controls our instinctive fight-or-flight reaction) works in overdrive, while the prefrontal cortex (which regulates rational thought) is sluggish. Research shows that antidepressants calm the amygdala; therapy does the same, though to a lesser extent.

But psychotherapy also appears to tune up the prefrontal cortex more than does medication. This is why, researchers believe, therapy works especially well in preventing relapse - an important benefit, since extending the time between acute episodes of illnesses prevents them from becoming chronic and more debilitating. The theory, then, is that psychotherapy does a better job of helping patients consciously cope with their unconscious responses to stress.

According to treatment guidelines by leading international professional and scientific organizations - including Canada's own expert panel, the Canadian Network for Mood and Anxiety Treatments - psychotherapy should be considered as a first option in treatment, alone or in combination with medication. And it is "highly recommended" in maintaining recovery in the long term. Britain's independent, research-guided scientific body, the National Institute for Health and Care Excellence, has concluded that therapy should be tried before drugs in mild to moderate cases of depression and anxiety - a finding that led to the creation of a $760million public system, which now handles therapy referrals for nearly one million people a year.

In 2012, Canada's Mental Health Commission estimated that only about one in three adults and one in four children are receiving support and treatment when they need it. Ironically, anti-stigma campaigns designed to help people understand mental illness may only make those statistics worse. In Toronto, for instance, putting up posters in subway stations in 2010 had the unexpected effect of spiking the volume of walk-ins at nearby emergency rooms by as much as 45 per cent in 12 months. Dr. Kurdyak treated many of them at CAMH. The system, he says, "has been conveniently ignoring this unmet need. It functions as if two-thirds of the people suffering won't get help." What would happen if the healthcare system outright "ignored" two-third of tumour diagnoses?

Essentially, argues Dr. Lesage, adding therapy into the health-care system is like putting a new, highly effective drug on the table for doctors. "Think about it," he says. "We have a new antidepressant. It works as well as many others, and it may even have some advantages - it works better for remission - with fewer side effects. The patients may prefer it. And [in the long run] it doesn't cost more than what we have. How can it not be covered?" ..

A heavy price This isn't just a medical issue; it's an economic one. Mental illness accounts for roughly 50 per cent of family doctors' time, and more hospital-bed days than cancer. Nearly four million Canadians have a mood disorder: more than all cases of diabetes (2.2 million) and heart disease (1.4 million) combined.

Mental illness - and depression, in particular - is the leading cause of disability, accounting for 30 per cent of workplace-insurance claims, and 70 per cent of total compensation costs. In 2012, an Ontario study calculated that the burden of mental illness and addiction was 1.5 times that of all cancers, and more than seven times the cost of all infectious diseases. Mental illness is so debilitating because, unlike physical ailments, it often takes root in adolescence and peaks among Canadians in their 20s and 30s, just as they are heading into higher education, or building careers and families. Untreated, symptoms reverberate through all aspects of life, routinely trapping people in poverty and homelessness. More than one-third of Ontario residents receiving social assistance have a mental illness. The cost to society is clearly immense.

Yet, when family doctors were asked why they didn't refer more patients to therapy in a 2008 Canadian survey, the main reason they gave was cost. For many Canadians, private therapy is a luxury, especially if families are already wrestling with the economic fallout from mental illness. Costs vary across provinces, but psychologists in private practice may charge more than $200 an hour in major centres. And it's not just the uninsured who are affected.

Although about 60 per cent of Canadians have some form of private insurance, the amount available for therapy may cover only a handful of sessions. Those with the best benefits are more likely to be higherincome workers with stable employment. Federal public servants, notably, have one of the best plans in the country - their benefits were doubled in 2014 to $2,000 annually for psychotherapy. Many of those who can pay for therapy are doing so: A 2013 consultant's study commissioned by the Canadian Psychological Association found that $950-million is spent annually on private-practice psychologists by Canadians, insurance companies and workers compensation boards. The CPA estimates t

These are the patients that family doctors juggle, the ones who eat up appointment time, and never seem to get better, the ones caught on waiting lists. Sometimes, they have already been bounced in and out of the system, received little help, and have become wary of trying again. A 40-something mother recovering from breast cancer, suffering from chronic depression post-treatment, debilitated by fear her cancer will return. A university student, struggling with anxiety, who hasn't been to class for three weeks and may soon be kicked out of school. A teenager with bulimia removed from an eatingdisorder program because she couldn't follow the rules. They are the ones dangling on waiting lists in the public system for what often amounts to a handful of talk-therapy sessions, who don't have the money to pay for private therapy, or have too little coverage to get the full course of appointments they need.

Canada's investment does not match that burden. Only about 7 per cent of health-care spending goes to mental health. Even recent increases pale when compared to other countries: According to a study by the Canadian Mental Health Association, Canada increased per-capita funding by $5.22 in 2011. The British government, meanwhile, kicked in an extra 12 times that amount per citizen, and Australia added nearly 20 times as much as we did. Falling off a cliff, again and again

In Winnipeg, Dr. Stanley Szajkowski watched for months as his patient, a woman in her 80s, slowly declined. Her husband had died and she was spiralling into a severe depression. At every appointment, she looked thinner, more dishevelled. She wasn't sleeping, she admitted, often through tears. Sometimes she thought of suicide. She lived alone, with no family nearby, and no resources of her own to pay for therapy. "You do what you can," says Dr. Szajkowksi. "You provide some support and encouragement." He did his best, but he always had other patients waiting.

hat 30 per cent of private patients pay out-ofpocket themselves. When the afflicted don't seek help, the cost isn't restricted to their own pocketbook. People with mental-health problems are significantly more likely to abuse drugs and alcohol, and to become physically sick, further increasing health-care costs. A 2014 study by Oxford University researchers found that having a mental illness reduced life expectancy by 10 to 20 years, roughly the same as did smoking and obesity. A 2008 Statistics Canada study linked depression to new-onset heart disease in the general population. A 2014 U.S. study found that women under the age of 55 are twice as likely to suffer or die from a heart attack, or require heart surgery, if they have moderate to severe depression. The result: clogged-up doctors' offices, ERs, and operating rooms. And an inexorable burden for the patients' families forced to fill the gaps in caregiving - or carry on when they lose a loved one.

Patients refer to it as falling repeatedly off a cliff. And they can only manage the climb back up so many times. Family doctors interviewed for this story admitted that they are often "handholding" patients with nowhere else to go. "I am making them feel cared for, I am providing a supportive ear that they may not get anywhere else," says Dr. Batya Grundland, a physician who has been in family practice at Toronto's Women's College Hospital for almost a decade. "But do I think I am moving them forward with regard to their illness, and helping them cope better? I am going to say rarely." More senior doctors have told her that once in a while "a light bulb goes off" for the patients, but often only after many years. That's not an efficient use of health dollars, she points out - not when there are trained therapists who could do the job better. However, she says, "in some cases, I may be the only person they have."

Family doctors aren't the only ones struggling to find therapy for their patients. "I do a hundred consultations a year," says clinical psychiatrist Joel Paris, a professor at McGill University and research associate at the Montreal Jewish General, "and one of the most common situations is that the patient has tried a few anti-depressants, they have not responded very well, and from their story it is obvious they would benefit from psychotherapy. But where do they go? We have community clinics here in Montreal with six-to-12-month waiting lists even for brief therapy." A fractured, inefficient system

"You fall into the role that is handed to you," says Antoine Gagnon, a family doctor in Osgoode, on the outskirts of Ottawa. He tries to set aside 20-minute appointments before lunch or at the end of the day to provide "active listening" to his patients with anxiety and depression. Many of them are farmers or self-employed, without any private coverage for therapy. "Five of those minutes are spent talking about the weather," he says, "and then maybe you get into the meat of the problem, but the reality is we don't have the appropriate amount of time to give to therapy, even to listen, really." Often, he watches his patients' symptoms worsen over several months, until they meet the threshold of a clinical diagnosis. "The whole system could save on productivity and money if people were actually able to get the treatment they needed."

But these issues aren't insurmountable, as other countries have demonstrated. Britain, for instance, has trained thousands of university graduates to become therapists in its new public program, following research showing that, as long they have the proper skills, people don't need PhDs to be effective therapists. Australia, which has created a pay-for-service system, also makes wide use of online support to cost-effectively reach remote communities.

Except for a small fraction of GPs who specialize in psychotherapy, few family doctors have the training - or the time - to provide structured therapy. Saadia Hameed, a GP in a family-health team in London, Ont., has been researching access to psychotherapy for an advanced degree. Many of the doctors she has interviewed had trouble even producing a clear definition of therapy. One told her, "If a patient cries, than it's psychotherapy." Another described it as "listening to their woes." A 2007 survey of 163 family doctors in Ontario found that almost four out of five had not received training in cognitive behavioural therapy, and knew little about it. "Do family doctors really need to do that much psychotherapy," Dr. Hameed asks, "when there are other people trained - and better trained - to do it?"

What further frustrates treatment for physicians and patients is lack of access to specialists within the system. Across the country, family doctors describe the difficulty of reaching a psychiatrist to consult on a diagnosis or followup with their patients. In a telling 2011 study, published in the Canadian Journal of Psychiatry, researchers conducted a real-world experiment to see how easily a GP could locate a psychiatrist willing to see a patient with depression. Researchers called 297 psychiatrists in Vancouver, and reached 230. Of the 70 who said they would consider taking referrals, 64 required extensive written documentation, and could not give a wait-time estimate. Only six were willing to take the patient "immediately," but even then, their wait times ranged from four to 55 days. Psychiatrists are in increasingly short supply in Canada, and there's strong evidence that we're not making the best use of these highly trained specialists. They can - and often do - provide fee-for-service psychotherapy in a private setting, which limits their ability to meet the huge demand to consult with family doctors and treat the most severe cases.

A recent Ontario study by a team at CAMH found that while waiting lists exist in both urban and rural centres, the practices of psychiatrists in those locations tend to look very different. Among full-time psychiatrists in Toronto, 10 per cent saw fewer than 40 patients, and 40 per cent saw fewer than 100 - on average, their practices were half the size of psychiatrists in smaller centres. The patients for those urban psychiatrists with the smallest practices were also more likely to fall in the highest income bracket, and less likely to have been previously hospitalized for a mental illness than those in the smaller centres.

And those therapy sessions are being billed with no monitoring from a health-care system already scrimping on dollars, yet spending a lot on this care: On average, psychiatrists earn $216,000 a year. There is nothing to stop psychiatrists from seeing the same patients for years, and no system to ensure the patients with the greatest need get priority. In Australia, Britain and the United States, by contrast, billing for psychiatrists has been adjusted to encourage them to reduce psychotherapy sessions and serve more as consultants, particularly for the most severe cases, as other specialists do.

As the Canadian system exists now, says Benoit Mulsant, the physician-in-chief at CAMH and also a psychiatrist, the doctors in his specialty "can do whatever they please. If I wanted, I could have a roster of actor patients who tell me entertaining stories, and I would be paid the same as someone who is treating homeless people. ... By treating the rich and famous, there is zero risk of being punched in the face by a patient." Left out in all this, by and large, are other professionals who can provide therapy. It doesn't help that the rules are often murky around who can call themselves psychotherapists. While psychologists and social workers are licensed under their professional associations, in some provinces a person can call himself a marriage counsellor or music therapist with no one demanding they be certified. In 2007, Ontario passed a law to regulate psychotherapists, requiring them to register with a provincial college that would set standards and handle complaints. Currently, however, the law is in limbo, although the government has said it will finally bring it into force by December. The brain keeps many secrets

Science, however, has yet to find depression's equivalent of insulin. Despite being scanned, poked and stimulated over and over and over again, the brain keeps its secrets. The "chemical imbalance" theory is now viewed as simplistic at best. It may not do much for patients, either: A 2014 study published in the journal Behaviour Research and Therapy suggested that, rather than reassuring them, focusing on the biological explanation for depression actually made patients feel more pessimistic and lacking in control. SSRIs work by increasing the amount of serotonin, a chemical that helps deliver messages within the brain and is known to influence mood. But researchers aren't sure why the drugs help some patients and fail with others. "Basically, it's like we have a bucket of water and we pour it over the patient's head," says Dr. Georg Northoff, the University of Ottawa's Michael Smith chair of Neurosciences and Mental Health. "But you want a drug that injects the water in a very specific brain regions or brain system, which we don't have."

Critics of therapy have argued that it's basically "good listening" - comparable to having a sympathetic friend across the kitchen table - and that in the real world of mercurial patients and practitioners of varying abilities, a pill just works better. That's true in many cases, especially when the symptoms are severe and the patients is suicidal: a fast-acting medication is safer, and may even be necessary before starting talk therapy. The staunchest advocates of therapy do not suggest it should be the first course of treatment for psychosis, or debilitating chronic depression, or mania - although, in those cases, there is evidence that psychotherapy and medication work well in tandem. (A 2011 meta-analysis found that patients with severe depression who received a combination approach had higher recovery rates and were less likely to drop out of treatment.) But drugs also don't work as well as the manufacturers would like us to think. Roughly one-third of patients given a drug will see no benefit (although they often respond to a second or third medication). In randomly controlled trials, drugs often perform only marginally better than sugar pills.

Yet it's talk therapy that the public often views most skeptically. "Until you go to a therapist, or a member of your family has a serious psychological problem, people are unsympathetic [about therapy]," says Dr. Paris, the Montreal psychiatrist. "They are very skeptical, and they don't believe the research. It's amazing, because pharmaceutical trials will get approval for a drug on the basis of two clinical trials that they paid for. And we have 100 clinical trials and no one believes us."

Dr. Ajantha Jayabarathan, an assistant professor at Dalhousie University's medical school, spent her early years as a family doctor in Spryfield, N.S., trying to manage an overload of mental-health cases. Most of her patients had little insurance; there was one reduced-cost counselling service in town, but the waiting lists were long. In 2000, her group practice became a test site for a shared-care project, which gave the doctors access to a mental-health team, including weekly in-person consultations with a psychiatrist. "It was transformative," she says. "We looked after everything in-house.

Over time, Dr. Jayabarathan says, she learned how to properly assess mental illness in patients, and how to use medication more effectively. "I just made it my business to teach myself what to do." It's the kind of workaround GPs are increasingly experimenting with, waiting for the system to catch up. Who would pay - and how?

The case for expanding publicly funded access to therapy is gaining traction in Canada. In 2012, the health commissioner of Quebec recommended therapy be covered by the province; it is now being studied by Quebec's science-based health body (INESSS), which is expected to report back next year. A new Quebec-based organization of doctors, researchers and mental-health advocates called the Coalition for Access to Psychotherapy (CAP) is lobbying the government.

In Manitoba, the Liberal Party - albeit well behind in the polls - has made the public funding of psychologists one of its campaign platforms for the province's spring 2016 election. In Saskatchewan, the government commissioned, and has since endorsed, a mental-health action plan that includes providing online therapy - though politicians have given themselves 10 years to accomplish it. Michael Kirby, the former head of the Canadian Mental Health Commission, has been advocating for eight annual sessions of therapy to be covered for children and youth in need.

There are significant hurdles: Which practitioners would provide therapy, and how would they be paid? What therapies would be covered, and for how long? Complicating every aspect of major mentalhealth change in Canada is the question of who should shoulder the cost: the provinces or Ottawa. In a written statement in response to questions from The Globe and Mail, federal Health Minister Rona Ambrose lobbed the issue back at her provincial counterparts, pointing out that the Canada Health Act does not "preclude provinces and territories from extending public coverage to other services or providers such as psychologists."

One result can be overloaded family doctors minimizing mental-health problems. "If you have nothing to offer someone," asks Dr. Anderson, "how much are you going to dig around to find out what is going on?" Some doctors also admit that the lack of resources can lead to physicians cherry-picking patients who don't have mental illness. And yet family physicians alone bill about $361million a year for counselling or psychotherapy in Canada - 5.6 million visits of roughly 30 minutes each. This is a broad category, and not always specifically related to mental health (some of it includes drug counselling, and a certain amount of coaching is a necessary part of the patient-doctor relationship). When it is psychotherapy, however, doctors admit it's often more supportive listening than actual therapy.

So how would Canada pay for access to such therapy? It wouldn't be cheap, in the short term. The savings would come from what Canadians would not have to spend in the long term: in additional medical and drug costs, emergency-room visits and hospital stays, and in unnecessary disability payments, to say nothing of better long-term health outcomes for patients given good care earlier. Some of the figures being tossed around sound staggering. Rolling out a version of Britain's centre-based program across Canada would cost $950-million. Michael Kirby's plan would amount to $1,000 annually per patient. A 2013 report commissioned by the Canadian Psychological Association calculated that, based on predicted need, and assuming no coverage from private health-care plans, providing an average of six sessions of therapy a year would cost an estimated $2.8-billion annually.

But any of those figures would still be a fraction of the roughly $210-billion that Canada spends annually on health care. Figuring out how to make the system most costeffective is, according to sources, currently delaying the INESSS report to the Quebec government. "You need to facilitate the government," says Helen- Maria Vasiliadis, a professor of community health at the University of Sherbrooke. "You can't be going to policymakers and showing them billions and billions of dollars. People start having heart attacks. With evidence in hand, we have to present possible solutions."

An insurance-based plan is the proposal that has emerged from the Quebec-based CAP group, which sent its proposal to Quebec's health minister last month. In its design, the system would work much like Quebec's public drug plan - Quebeckers not covered through work plans would contribute to a provincial insurance program for therapy. That would be similar to the system that Germany has used for decades. One step forward, one step back

Last year, the Sherbrooke clinic where Marie Hayes works received provincial funding for a part-time psychologist and a full-time social worker. With a roster of 25,000 patients, the clinic team laid out clear guidelines for the psychologist, who would consult on cases and screen patients, and be limited to a mere four sessions of actual counselling with any one patient. "We wanted to be careful she didn't become a waiting list - like everything in the system," says Dr. Hayes. The social worker helps guide patients into services such as housing and addiction counselling. They have also offered group sessions for depression management at the clinic. As stretched as those new professionals are in such a large practice, Dr. Hayes says the addition of that mental-health team is improving the care she can provide patients. Recently, for instance, the 32- year-old mother with anxiety attended sessions with the psychologist. "She is making progress," says Dr. Hayes, "slowly."

At Women's College Hospital in Toronto, Dr. Grundland is not so lucky. Asked to describe a difficult case, the family-practice physician mentions a patient suffering from depression after a lifechanging accident. Every month, doctor and patient would repeat the same conversation they'd already had more than a dozen times - and make little real headway. Her patient, says Dr. Grundland, needs a trained therapist: someone she can see regularly, to help her move past her frustration, counsel her about addiction, and ease the burden on her family.

But there's no extra money in the patient's budget for a psychologist. "I do my best," Dr. Grundland says, "but it's not my area of expertise." Meanwhile, the patient isn't getting better, and in the time that it takes to make it through one appointment with her, Dr. Grundland could see three other people with problems she was actually trained to treat. "But," says Dr. Grundland, "she has nowhere else to go." Erin Anderssen is a feature writer at The Globe and Mail. OPEN MINDS How to build a better mental health care system

The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other story in the series. $20.7-billion The cost, according to a 2012 Conference Board of Canada report, of lost productivity each year due to mental illness. What else does $20-billion represent?

$20B: Canadian spending on national defence, 2012-13 $20B: Market valuation of Airbnb, 2015 $21B: Kitchener-CambridgeWaterloo region's GDP, 2009 $21B: Amount food manufacturing contributed to the economy, 2012

After decorating Halloween cookies together, Han brings his own masterpiece, smothered in smarties and sprinkles, to Clark and encourages her to try it. Few words are exchanged, but smiles and giggles are constant at the intergenerational program at Youville Residence, a long-term care facility for seniors in Vancouver. Han Jr. is among a half dozen children visiting this day from the Montessori Children's Community - a daycare located on the same site as Youville, at 33rd and Heather.

Montessori Children's Community administrator Kristina Yang said it's a win-win situation. "Even if there is not a lot of communication with words you can see the beautiful smiles on everyone's face. Many of the children come to know a lot of the seniors and when they pass by our window they'll be excited waving and saying 'Hi ,'" Yang said.

Youville occupational therapist Sheralyn Manning said the children's visits are a big part of the seniors'day. Besides planned events, such as doing crafts together, every so often the children will visit when the weather is bad and they are not able to play outdoors. Manning pointed out the friendship between Clark and Han has been particularly touching to watch and Clark has a recent craft project Han gave her prominently displayed in her room. When most people think of nursing homes the image that comes to mind is a stand-alone building offering residential care only for the aged.

It's a place seldom visited unless you are a family member, friend or volunteer. But these days more homes are trying to build bridges to the wider community. Of B. C.'s 460 government and private nursing homes, only a handful have daycares or doctor's offices on site, said Daniel Fontaine, CEO of the B. C. Care Providers Association, which represents 60 per cent of the privately-operated homes. But none are attached to a facility that offers a large variety of community services. One of the best Canadian examples of a nursing home that achieves just that, said Fontaine, is Niverville Heritage Centre, near Winnipeg. It is home to 116 seniors but is also a gathering place for major community events.

The centre hosts 100 weddings each year. As well, about 50,000 visitors drop in at the centre annually to access their doctor's office, dentist and pharmacist or visit the full-service restaurant and pub. "We found seniors don't want to be retired to a quiet part of the community and left to live out their lives. They want to live in an active community and retreat back to their suite when they want that peace and quiet ," said Niverville Heritage Centre's CEO Steven Neufeld.

Before the centre opened in 2007, he said, members from the non-profit board that operates the centre visited traditional nursing homes and discovered that the lounges that were built for seniors were seldom used. "I remember going to one place where there was a screened-in porch that was packed. The seniors were all there wanting to watch the soccer game of the school next door ," he said. Having services like doctors'offices, dentists, a daycare, a full-service restaurant, and hair styling shop on site fulfil the centre's mission of being an "inter-generational meeting place which fosters personal and community well-being." Fontaine said it's worth noting that Niverville was able to "pull all of this together in a community with a population of less than 5,000 people." He hopes more B. C. nursing homes follow Niverville's lead.

Elim Village in Surrey, which offers all levels of residential senior care on its 25-acre site, is on that track. There are 250 independent living units, 109 assisted living units and 193 traditional nursing home beds. The village also has a 500-seat auditorium, located in the centre of the village, that hosts weddings and is available for rent for other public events. Elim Village also rents out space in one of its 10 buildings to a school, which allows inter-generational programs to take place easily between students and seniors. Another "continuing care hub " at Menno Place, in Abbotsford, has a public restaurant called Fireside Cafe, popular with staff from nearby Abbotsford Regional Hospital and Cancer Centre. There's also a pharmacy and hairdresser on its 11-acre "campus " site but these services are available only to the 700 residents and staff. "We purposely try to involve the community as much as possible ," said Menno Place CEO Karen Baillie. "It's Niverville on a smaller scale." She said Menno Place partners with high schools and church groups and hundreds of volunteers visit regularly. "Seniors are often challenged with isolation and fight depression. That's why we have different programs to encourage them to socialize ," she said.

Research shows 44 per cent of seniors in residential care in Canada have been diagnosed with depression, and one in four seniors live with a mental health problem, such as depression or anxiety, whether they live in their own home or are in residential care. A 2014 report by the National Seniors Council found socially isolated seniors are at a higher risk for negative health behaviours including drinking, smoking, not eating well and being sedentary. The report also found social isolation is a predictor of mortality from coronary disease and stroke, and socially isolated seniors are four to five times more likely to be hospitalized.

Since more seniors now remain in their own homes longer those who move into care homes are often more frail and need a higher level of assistance, said Menno Place director of communications and marketing Sharon Simpson. Seniors with dementia, in particular, can be socially isolated as friends and family often find it more difficult to visit them as they decline, she said. But Simpson said an intergenerational dance program, run by ballet teacher Lee Kwidzinski, has been a wonderful opportunity for seniors with dementia to be connected to the community. The program is also offered in four other nursing homes in the Fraser Valley. "For them it's an opportunity to see children. You can see the seniors come to life, smiling and giggling at the girls'antics. It's very engaging ," she said. "Some may not be verbal but they are still able to connect. They feel their emotions and they know whether someone is good to them. They feel these girls and become vibrantly alive. It's one of the most powerful things I've ever seen."

Creating community connections is key as Providence Health begins its planning stage to replace some of its older nursing homes in Vancouver, said David Thompson, who is responsible for the Elder Care Program and Palliative Services. Providence Health operates five long-term-care homes for approximately 700 residents at four different sites in the city. "It's always been our vision to create a campus of care on the land ," said Thompson, of the six acres owned by Providence Health where Youville is located.

He said the plan is to build another facility nearby, with 320 traditional nursing home beds. One of the ways to partly fund the cost is to include facilities that could be rented out by the larger community, which would be a benefit to the seniors as well, he said. There is already child care on site, and future plans to help draw in the community include a restaurant, retail space and an art gallery. He said another idea is to partner with nearby Eric Hamber Secondary School by providing a music room for students to practise.

"Cambie is at our doorsteps. If you have people coming in (to a residential care facility) it brings vibrancy and liveliness ," Thompson said

Recognizing this, employers should offer workers access to psychological counselling and networks of other caregivers. Compressed workweeks are helpful, since support services for the elderly are often only open during office hours." - Linda Duxbury, lead researcher for the coming National Study on Balancing Work and Caregiving "Seek information about what to expect and what help is available before you need it. The heat of the moment is not the time to start trying to negotiate with family or navigate a very complex network of services and supports." - Janet Fast, co-director of research on aging, policies and practice at the University of Alberta THE READERS "I am a full-time caregiver of five years for my husband who has early-onset Alzheimer's disease. Do not isolate yourself. Since time is very limited I belong to an online support group. Coping strategies like yoga and meditation and regular massages may relieve some stress. We need to rally together and ask our politicians for much needed change in the health-care system to provide adequate help for our loved ones.

Three hours of respite a week is not acceptable." - Karen'15 "For the caregiver, realize what you can and cannot do. Do not try to be a hero or a martyr. It is essential that you carve out some time to care for yourself. Only you can make sure that you are taken care of." - Hinda Goodman "A most helpful resource for me was my local Alzheimer's group meetings where I gained knowledge, support and was able to give the same to other participants." - Heather Hamilton73 Online now: How can we get our families cooking together? tgam.ca/giving

"Where beds have been cut in the community, there has been a spike in re-admission rates," said Jackson. His own hospital saw 12 beds, six at each site, cut back in 2013. "I can't speak about individual cases," he added, but Mike Rodrigues, vice president of CUPE local 1974, who works at the Kingston General Hospital (KGH), has seen, first-hand, patients being sent home to free up beds at his workplace. "There are two huddles a day," said Rodrigues, where upper management and the hospital's chief executive officer confer at 9:15 a.m. and 2:15 p.m. to discuss "Who can go today? Who can we get out?" when there is "gridlock," at the hospital, such as long waiting room times. "It's difficult," Rodrigues said. But, "you tow the party line. They do what they are told."

He conceded that the doctors and nurses likely do a triage of who is best able, of all of the patients on the floor, to go home, but he has seen, in the last 10 years alone, women being sent home 10 to 12 hours after giving birth to a child, whereas, in 2005, that mother could have stayed three to four days in the hospital. Hurley said he has heard of patients who "are not well enough to be sent home...fighting with their doctors," who are trying to discharge them. "A lot of pressure is put on the family," from the hospital administration and doctors, Hurley added, with the hospital threatening to charge families as much as $300 to $1,000 a day for each additional day their loved one remains in hospital - something he says is illegal. He saw such a scenario with his own mother.

"She can't stay here," he was told. "'What're you going to do with her?' She died in hospital." Very often, according to Hurley, a patient may acquire a hospital-borne virus while recovering from a surgery, but "people are being moved through the system much more quickly," than they used to be, sometimes without sufficient recovery periods, and then, "the system has a second go at making them better." But this not only causes distress for the family and the health system, but also in the workforce too. "A huge number of people in Ontario do not have paid sick leave," said Hurley. "The personal cost to me (as a returning patient) is significant...It's a health setback, it's a psychological setback."

Hurley added that hospitals in both Kingston and Ottawa were experiencing similar re-admission rates. He added that he did not think that it was "entirely valid," to dismiss re-admission rates on the rising number of older people in the area, as Baby Boomers reach their retirement years. "They will try to downplay this," said Hurley, before adding that it was not a problem created at the Smiths Falls or Perth hospital sites themselves. "This is a system problem because they have been starved of funding." As for blaming the issue on the elderly, Hurley said that that was ageism.

Jackson lamented that while the hospital administration has tried its best to be as kind as it can with its cuts - with only one outright layoff - getting 12 beds cut from the local hospital system seems to be "how you get rewarded for efficiency." "It's time for the province to start funding the hospitals properly," said Hurley. One way that this could be addressed would be to raise the corporate tax rate. Administration response Later that week, in her office at the Great War Memorial Hospital site of the Perth and Smiths Falls District Hospital, president and chief administrative officer Bev McFarlane held a mini press conference of her own, alongside board chair Richard Schooley, to refute some of the union's allegations, starting with some of their numbers. "There is often another aspect of re-admissions," said Schooley during the interview on Thursday, Oct. 1. A patient could be, theoretically, discharged from hospital after recovering from heart surgery, then be re-admitted two weeks later after falling on some ice while shoveling snow from his driveway. Any admission to hospital within 30 days after a discharge would be counted as a re-admission - even if the cause was not directly related to the initial admission.

She hastened to add that her hospital was recently awarded the distinction of being one of the top five hospitals in the province for quick-time responses, for getting patients seen to and into an in-patient bed. According to the hospital's numbers, the occupancy rate for acute care hospital beds was as low as the high 60s per cent over the summer, and in the high 70s per cent this past spring. "You have to look at all of the other indicators," said Mc-Farlane. Schooley also noted that the hospital's admissions have gone up from more than 31,000 in 2009 to more than 37,000 in 2014-15, and that they estimate the real re-admission rate at about seven per cent.

How can you deal with more admissions with fewer beds?" asked McFarlane. "We are able to make you feel better in a shorter period of time." Gall bladder surgery used to require a seven-day stay in hospital, she said. Now, it is considered day surgery. "You aren't even admitted," she said. "The business of hospital care has changed over the years. The worst thing you can do is keep someone in an acute care bed when they don't need to be there." As for charging patients who refuse to leave the hospital because they do not believe that they are fully healed yet, Mc-Farlane did admit that "there is a rate that is charged, if there is a reasonable discharge plan and people refuse to leave," but she added that "I don't think we've ever done that here."

As for the union's assertion that the hospital had less money on hand, Schooley pointed out that gross hospital revenues rose from $43 million in 2010 to $51 million in 2015. In fact, the LHIN is giving the hospital more money as a type of efficiency bonus, having wrestled five years worth of deficits into a $1.2 million surplus in 2014, with a projected surplus of $1.6 million for 2015. "That's the cushion we are building," said Schooley, in anticipation of the LHIN providing them with less money in the coming years. "In case some of these funding change realities manifest themselves."

We have seen increases in our LHIN and Ministry of Health funding," added Schooley.

The penalties are assessed on a dollar-for-dollar basis, meaning they are equal to the amounts patients complained about paying for procedures. B.C. and Newfoundland were the only provinces assessed penalties for the last three years. When the 2013-14 annual report comes out soon, B.C. will once again be penalized, this time $224,000, said provincial Health Ministry spokesman Ryan Jabs.

Since 1994, the federal government has docked B.C. $3.2 million, slightly lower than the record-holder Alberta ($3.6 million). Since 1994, provinces have been assessed nearly $10 million in penalties for extra billing charges. A Health Canada spokesman could not explain why Quebec has never been penalized, even though it reportedly has a thriving private medicine sector. Ontario has also not faced any penalties.

The penalty to B.C. is paltry in relation to the province's $20-billion health budget announced Tuesday. It is also insignificant relative to the federal transfer payments B.C. will collect this year ($4.4 billion) and next ($4.7 billion). In 2006, the then-deputy health minister of B.C., Penny Ballem (now Vancouver city manager) questioned whether B.C. was really the only province where extra billing and private sector queue jumping was taking place. Jabs said Wednesday he can't comment on what happens elsewhere.

In 2005, the B.C. government did not submit a dollar value to the federal government for such extra billing, so Health Canada bureaucrats based the penalty sum on news releases from anti-privatization unions and newspaper clippings about patients who accessed the private system. The Sun learned about that through a Freedom of Information request. The story detailed how discretionary the penalties appear to be and that they are based on "guesstimates" of user fees. Provincial Health Ministry officials often base their reports submitted to the federal government on complaints from patients who go to private clinics for expedited care and then try to collect the fees paid from government. One such patient is Mariel Schoof, who had sinus surgery at a private clinic in 2003. She paid $6,150 for the "facility fee" and then tried to recover the fee from the provincial government or the clinic. She is now one of the interveners in a private versus public medicine trial starting March 2 between Dr. Brian Day and the provincial government. Timeline of Canada Health transfer compliance in B.C.

Early 1990s: As a result of a dispute between the British Columbia Medical Association and the B.C. government over compensation, several doctors opt out of the provincial health insurance plan and began billing their patients directly, some at a rate greater than the amount the patients could recover from the provincial health insurance plan. May 1994: Canada Health deductions began and continue until extra-billing by physicians is banned when changes to B.C.'s Medicare Protection Act come into effect in September 1995. In total, $2,025,000 was deducted from B.C.'s cash contribution for extra billing that occurred in the province between 1992-1993 and 1995-1996. These deductions were non-refundable, as were all subsequent deductions. January 2003: B.C. provides a financial statement in accordance with the Canada Health Act Extra-billing and User Charges Information Regulations, indicating aggregate amounts charged with respect to extra billing and user charges during fiscal 2000-2001 totalling $4,610.

Accordingly, a deduction of $4,610 was made to the March 2003 federal transfer payment. 2004: A $126,775 deduction was taken from B.C.'s March 2004 Canada Health Act payment, based on the amount of extra billing estimated to have been charged during the 2001-2002 fiscal year. Since 2005: $786,940 in cash transfer deductions have been taken from B.C.'s federal health transfer payments on the basis of charges reported by the province to Health Canada. January 2011: Vancouver General Hospital begins charging patients a fee when they elect to have robot-assisted surgery versus the conventional surgical alternative for certain medically necessary procedures. 2013: Deductions in the amount of $280,019 are taken from the March 2013 federal transfer payments of B.C. in respect to extra billing and user charges for insured health services at private clinics. Source: Canada Health Act Annual Report 2012-2013

The branch investigates about 30 cases a year of extra billing, usually related to private surgical facilities or expedited visits to specialists. The government is not sure whether it will be penalized in the future for allowing Vancouver General Hospital to charge patients fees for robotic surgery. VGH spokesman Gavin Wilson says since 2012 patients choosing to have surgeons remove their prostates using the robot have been charged on a partialcost-recovery basis. The B.C. government allows the extra billing because robotic surgery is discretionary, not medically necessary, and there are higher costs associated with it. In 2012, however, Health Canada began examining the Canada Health Act implications of patient charges for robotassisted surgeries. The process convinced the health minister that VGH should stop charging for robot-assisted surgeries as of Jan. 1, 2015. Vancouver Coastal Health collected $345,000 a year for the procedures; most recently, the patient fee was $5,700. Sun health issues reporter pfayerman@vancouversun.com

industry partnering

Corresponding to the devolution process have been revisions to the Indian Act as it relates to Indian status. From the "honorary white man" policy of the 1850s, Canadian legislation has intended to unmake Indians in the legal sense. Much of this strategy has focused on attacking women, removing their status if they marry a non-status Indian, which resulted in the disenrollment of tens of thousands of individuals who rightfully belonged within their nations. In post-Charter Canada, the Indian Act was successfully challenged and amendments in 1985 and 2011 partly ended the discrimination, precipitating a surge in the "official" First Nation population.

While much has been made of the "marry out, get out" provision at Kahnawake, the membership law, as well as many other First Nation membership laws, is more complex. The objective is to separate Indian status from band membership and take control of the latter from the federal government. "Membership" in this sense includes residency qualifications, electoral rules and treaty rights, eligibility guidelines on business operations and even burial plot designation. In reserve politics, or "reserve nationalism" as Audra Simpson calls it, this might be described as citizenship and even immigration policy. In a general sense, it is about who belongs.

There are two extremes in this conversation. The "exclusive" membership perspective views lineage as the crucial qualification to belonging. Citizens must be descended from indigenous peoples, inculcated in indigenous culture. They exclude those with weak lineage or none at all, especially if taking up land or resources. Of course, communities today have increasing numbers of both groups. About three-dozen of those who share this conservative approach to membership at Kahnawake are responsible for taking the initiative to evict non-indigenous people from the community.

The "inclusive" perspective advocates for a more open community not necessarily delimited by strict ancestral connection but inter-community relationships. It is the far more common practice among indigenous peoples (extending the rafters of the longhouse, the ever-expanding circle, etc.). Non-indigenous people who can make a contribution to the community while reflecting indigenous values should be welcome. In the case of Kahnawake, a handful of these inclusive proponents are appealing to the Quebec Superior Court to protect this view. In many ways, the debate revolves around claims of authenticity: a contentious notion after 150 years of Indian policies that have cultivated artificial governments and islands of reserved lands, imposed patriarchy and domesticated sovereignty.

Indeed, indigenous peoples would be justified in evicting white people from the little land we have left if that were the case. But this is a crude simplification.

Despite the opinions of pundits or politicians on the allegedly racist law at Kahnawake (or elsewhere), this is fundamentally about people passionately and earnestly working towards visions of community well-being amid very real, long-standing and external constraints. This is about striving to be Kanien'keha:ka or Anishinaabe in a place traditionally hostile to that very proposition. Hayden King is Anishinaabe from Beausoleil First Nation. He is the director of the Centre for Indigenous Governance at Ryerson University. Jessica Deer is a Kanien'keha:ka from Kahnawake. She is a reporter for The Eastern Door.

The numbers underscore the need for improvements to hospital staff safety measures, something the Ontario Nurses' Association (ONA) has long been calling for to better protect health-care providers. "Violence isn't part of this job. It shouldn't be part of this job," said Andy Summers, vice-president of health and safety with ONA. "Eventually, somebody will get killed."

Summers called the current situation of violence against nurses in Ontario "completely unacceptable." At UHN, which includes Toronto General Hospital and Toronto Western Hospital, there has been a consistent increase in reports of assault in the past three years. The number of reported violent incidents doubled in two years, jumping from 166 incidents in 2012 to 331 in 2014, according to data provided to the Star. In 2014, 11 workers who were injured were unable to return to work for their shift following the assault. Spokeswoman Gillian Howard said changes in reporting standards probably account for the rise. The changes include a Behaviour Safety Alert, implemented at UHN in 2014, which requires staff to put an alert on patient records if the patient has aggressive or violent behaviour. Howard also said increased reporting could be attributed to the fact that unions are encouraging staff to report every incident: "a very good thing," she said.

"We do not want any staff member at risk from a patient, but given the care we provide, the medications used, the fact that some patients have cognitive impairment as a result of injury or aging, the impairment of some patients when they arrive, and the risks associated with some of the treatments, it is not likely that we will see a year with no incidents," said Howard, adding that UHN employs approximately 13,000 staff and has over one million patient visits per year. But ONA lashed out at this explanation, saying employers are trying to downplay the issue.

Erna Bujna, occupational health and safety specialist with ONA, said some employers "absolutely" still discourage staff from reporting incidents, by telling workers that violence is just part of the job. ONA wants to see a violence strategy implemented at hospitals across the province. The strategy would include mandatory reporting of every violent incident reported to the Ministry of Labour - currently, employers are only required to report fatalities and critical incidents to the ministry - mandatory risk assessment of every patient, increased security and more health-care providers hired. They also want the Ministry to charge individual hospital CEOs when workers are not adequately protected from violence.

He added that legislation requires employers to assess the risks of workplace violence, create workplace violence and harassment policies, develop programs to implement those policies, and take every precaution reasonable to protect workers from workplace violence. ONA's call for an updated safety strategy comes on the heels of a decision by the Ministry of Labour to lay charges against Toronto's Centre for Addiction and Mental Health (CAMH) in December 2014. The charges - made under the Occupational Health and Safety Act and relating to failure to protect workers from workplace violence - stem from a violent incident in January 2014 in which a nurse was dragged, kicked and beaten beyond recognition, according to ONA.

Toronto police later charged the patient, who was found guilty of assault causing bodily harm, according to court documents. "We don't want staff ever to feel that aggression is the norm," said Rani Srivastava, chief of nursing and professional practice at CAMH, in response to the comments. "We are committed to a culture of safety and recovery and that means safety for staff and patients." Jean Dobson, a nurse at University Hospital in London, Ont., said she's been strangled with a stethoscope, stabbed with a metal fork and spat at by patients over the course of her 42-year career. "People think that they can hurt a nurse and that's OK," she said. "We have to smile and take it."

In one incident, Dobson had her nose broken when she was kicked in the face by a patient. She was forced off work for weeks and suffered from PTSD, she said. Dobson said she's seen the frequency of patient-on-nurse assaults and the severity of violence increase during her career. At Sunnybrook Hospital, reports of abuse against staff by patients and visitors jumped from 140 in 2012 to 320 in 2013. The hospital attributes the increase mainly to their move to electronic reporting, which makes it easier to record violent incidents, a spokesperson told the Star. According to a 2005 national study from Statistics Canada, 34 per cent of nurses surveyed reported being physically assaulted by a patient in the previous year, and 47 per cent reported experiencing emotional abuse. For those working in psychiatric and mental-health settings, 70 per cent of nurses reported experiencing emotional abuse.

Fetterly said there could be violent blows and spitting from patients but also the threat of violence from visitors to a facility. "This kind of abuse has to stop and we'll be going to the provincial government to put some demands on to make some changes," she said.

"We have had nurses stabbed, beaten up, punched in the head, fallen to the floor, cracked their head on the floor, kicked, punched," Tracey Newton, a nurse at Providence Care and a chief steward with the Ontario Public Service Employees Union Local 431, said at the time. "Quite often, on a daily basis, nurses are subjected to violent assaults. We still have five nurses offwork with head injuries." Clayborne said the stories are the same where she works in Hamilton. "We've had quite a few incidents that have been brought to the public," she said.

Recently, according to the council, nurses have been attacked in Hamilton, North Bay, Cornwall and Kingston. Last November, about a dozen staff members from the Providence Care Mental Health Services site on King Street West held an information picket at the hospital entrance to bring public attention to what they say are dangerous conditions inside the building caused by having too few staffto deal with too many high-risk patients.

According to a news release from the union, its recommendations to the province include: increasing funding and staffing at least to the Canadian average in hospitals and long-term care facilities; beefing up legislation to protect healthcare workers from violence, giving health-care workers the same right to refuse unsafe work as other workers in the public sector; laying criminal charges against patients and family members who commit violence on health-care workers; and also improving security at these facilities.

In December, the hospital reported five attacks on staffby patients over a 10-day period. "We've had two nurses who were attacked: one left unconscious and suffered a severe concussion from a violent patient and another girl who had hot coffee thrown in her face on the forensic unit." Fetterly said about 85 per cent of RPNs in Ontario are women. Clayborne said St. Joseph's has five forensic units housing patients, some of whom have committed serious crimes and have mental health issues as well. "Short staffing led to those assaults," she said.

Clayborne said the patients know when the nurses are understaffed and take advantage of that. She said the nurses have to see patients without the benefit of security officers nearby. "The hospital has contracted out the security at our facility," she said. "The security guards make approximately $11.50 an hour and their job is to just show up and be there as a support, they're not supposed to put their hands on the patients." Nurses are trained in non-violent crisis intervention, Clayborne said, but when being attacked by a stronger and heavier person, the training doesn't help very much. Nurses wear panic alarms, but the alarms don't work all the time, Clayborne said.

"In violent situations, we press our alarms, nothing happens and nobody comes to help you," she said. When the alarms do work, there's a one-to three-minute delay before the call goes out. "That makes a big difference when you're being beaten before somebody comes to help you," After a violent incident, the RPNs often suffer from post-traumatic stress disorder, fear and anxiety before returning to work, and sometimes the incident also takes a psychological toll on the nurses' family members. Fetterly agreed that the issue should be considered a crisis.

Because of the funding and the funding freezes, we're working with less and less staffand the bed occupancy is at an all-time high," she said. Fetterly believes people will ultimately leave the profession. "Why should you go to work every day and be exposed to someone beating on you, intimidating you or spitting in your face. I didn't sign up for that. I signed up to give quality patient care." - With a file from Michael Lea ian.macalpine@sunmedia.ca Twitter.com @IanMacAlpine

Ian Macalpine, The Whig-Standard / Ontario Council of Hospital Unions officials Helen Fetterly, left, and Linda Clayborne attended a two-day conference on the safety of registered practical nurses in Ontario's mental health facilities.

Dr. Isabelle Leblanc, president of the pro-medicare group Médecins québécois pour le régime public, said the survey results show that radiologists in Quebec are increasingly choosing to work in the private sector to the detriment of the public system. "For us, this is the best example of how mixing the public and private systems can lead to decreased accessibility for most patients and increased accessibility for those who have the money to pay," Leblanc said. "Radiologists have no incentive to increase access in the public system, and in fact, they're draining resources from the public system." Leblanc explained that radiologists can earn more money charging patients for scans in private clinics than they would if they worked exclusively in hospital and billed the Régie de l'assurance maladie du Québec. Leblanc's group warned in a report three years ago that wait times for MRIs in hospital would increase.

"We're the province that has the highest number of MRI and CT scan machines per capita in the country - with a third of the machines in the private sector - and yet our public wait times are going up," Leblanc added. Health Minister Gaétan Barrette, a radiologist by profession who had worked in a private clinic before entering politics, was unavailable for comment. Officials with the Association des radiologistes du Québec could not be reached for comment, either. The Fraser Institute report observed little progress in cutting wait times for medically necessary surgery or treatments. The median wait time in Canada for treatment inched up to 18.3 weeks from 18.2 weeks last year. In Quebec, the median wait time for treatment by a specialist rose to 16.4 weeks from 7.3 weeks in 1993, when the Fraser Institute first started compiling such data. The median wait time denotes the midpoint for those waiting, as opposed to an average. In Quebec, the median wait time to see a medical specialist following referral from a general practitioner rose to 7.3 weeks from 7.1 weeks last year. The survey found that the longest median waits in Canada were for orthopedic surgery at 35.7 weeks, or almost nine months.

"These protracted wait times are not the result of insufficient spending but because of poor policy," Bacchus Barua, the author of the Fraser survey, said in a statement. "In fact, it's possible to reduce wait times without higher spending or abandoning universality. The key is to better understand the health policy experiences of other more successful universal healthcare systems around the developed world." aderfel@montrealgazette.com Twitter.com/Aaron_Derfel

The median wait time in hospital for a magnetic resonance imaging (MRI) scan in Quebec jumped to 12 weeks this year from eight in 2014, a survey has revealed. Wait times also increased slightly for other medical imaging. ALLEN McINNIS-MONTREAL GAZETTE FILES • MONTREAL GAZETTE / Source: Fraser Institute

However, we should avoid diagnosing this problem merely as a failure of law enforcement. Murders represent the tip of an iceberg of problems related to endemic violence in communities. Many Aboriginal women and girls, and indeed men and boys, live each day under the threat of interpersonal violence and its myriad consequences.

Initial statements from the three federal ministers tasked with leading the forthcoming inquiry — the ministers of Indigenous and Northern Affairs, Justice and Status of Women — suggest that its purpose is to achieve justice, to renew trust between indigenous communities and the Canadian government and law enforcement bodies, and to start a process of healing.

The inquiry surely must also endeavour to lay the groundwork for a clear plan to address the broader problem of interpersonal violence, which, in turn, is rooted in several key determinants. Addressing interpersonal violence is not merely an issue of justice; it is also a public health concern.

Factors associated with both the experience and perpetration of interpersonal violence are manifold. They include but are not limited to mental health issues, drug and alcohol misuse, unemployment, social isolation, low income and a history of experiencing disrupted parenting and physical discipline as a child. The Truth and Reconciliation Commission’s report has highlighted that many of these factors are widespread in the Aboriginal populations of Canada.4 Many of the same factors contribute to disparities between Aboriginal and non-Aboriginal peoples in areas such as education, socioeconomic circumstances and justice. T

here is also substantial overlap with identified determinants of poor health in Aboriginal communities both in Canada and elsewhere.5,6 These are the factors associated with higher rates of youth suicide, adverse birth outcomes and tuberculosis, and poorer child health. It’s clear that a common web — woven of a legacy of colonization and cultural genocide, and a cumulative history of societal neglect, discrimination and injustice — underlies both endemic interpersonal violence and health disparities in Canada’s indigenous populations. There is no conversation to be had about one without a conversation about the other — if the aim is healing — because the root causes are the same.

The World Health Organization (WHO) is currently engaged in developing a global plan of action to strengthen the role of health systems in addressing interpersonal violence, particularly that involving women and girls.7 A draft report by the WHO acknowledges interpersonal violence as a strongly health-related issue that nevertheless requires a multisectoral response tailored to the specific context. Evidence from Aboriginal community models in Canada gives hope for healing.

A recent report from the Canadian Council on Social Determinants of Health highlighted important strides that some Aboriginal communities have made to address the root causes of, and to mitigate, inequities through efforts to restore the people’s connection with indigenous culture.8 Increasing community control over social, political and physical environments has been linked to improvements in health and health determinants.

The public health sector in many parts of Canada has embraced the need for strong community involvement in restoring Aboriginal people to the health that is their right. In many community-led projects over the past few decades, the health care sector has worked with others to address common proximal and distal determinants of disparities.

We are presented with not just an opportunity for renewing trust between indigenous communities and the Government of Canada but also for extending the roles of public health and the health care sector in the facilitation of trust and healing. There is much that the health sector can contribute to the forthcoming inquiry. Health Canada should be involved from the start to ensure that public health is properly represented

And dozens of occupations, some that you've never even heard of, are exempt from basic rights entirely. "Keepers of fur-bearing mammals" have no right to minimum wage. Sod layers have no limits on their daily hours of work. Shrub growers don't get a lunch break. The system is so complicated that the Ministry of Labour has developed a special online tool to help decipher who's entitled to what. But as the province reviews its antiquated Employment Standards Act, critics argue that its confusing web of exemptions makes it harder for the so-called precariously employed to defend their rights - and easier for bosses to ignore them.

"When you distil it down to what these exemptions are seeking to achieve, really they are to give employers more control over work and more control over wages," says Mary Gellatly of Parkdale Community Legal Services. "It sends the message to employers that they can get away without complying." The Act was first introduced in Ontario in 1968 to set basic work standards, especially for non-unionized employees who don't have a collective agreement to provide extra protections. But there are at least 45 occupations in Ontario that are exempt from a variety of its fundamental entitlements, many of them low-wage jobs in industries where precarious work is rife.

The Ministry of Labour says many of the exemptions are "long standing" and related to "the nature of the work performed." But York University professor Leah Vosko, who leads research into employment standards protections for the precariously employed, says exemptions have come at least in part from industry pressure, leaving the Act a "complex patchwork that is difficult for workers and even officials to comprehend." Even when there are clear violations, speaking out can come at a cost. Reprisal is illegal under the Act, meaning bosses can't penalize employees for exercising their workplace rights. But the Act gives workers no protection against wrongful dismissal. Employers do not have to give cause for firing someone.

Unionized employees are generally protected by their collective agreements, and workers can sue employers if they think they have been unfairly terminated. But most precarious, low-income employees are not unionized, and most do not have the money to take legal action against an employer, says Parkdale's Gellatly. "It's the big reason why many people can't do anything if they're in a workplace with substandard conditions, because they can get fired without cause." Linda Wang, who worked at a Toronto cosmetics manufacturer for four years, was fired less than two weeks after asking her employer for the extra pay she was owed for working a public holiday. She says no reason was given for her termination. Wang, a mother of two, claims her employer repeatedly bullied her and her colleagues, and says she believes she was dismissed for asking for the wages.

She has filed a reprisal complaint with the Ministry of Labour, but Wang cannot afford to take her employer to court. "I feel the system is against workers," she says. "It's in favour of employers." "Whatever job you have, you put so much of yourself into it," adds Gellatly. "The fact that employers can just fire you without a reason is incredibly devastating for folks." The Act also contains significant gaps when it comes to sick leave and overtime. The legislation provides most workers with 10 unpaid days of job-protected emergency leave, which means they can't be fired for taking a day off due to illness or family crisis. Critics call this measure subpar by most standards, since it still causes many workers to lose a day's income for being ill. An estimated 145 countries give employees some form of paid sick leave.

"Unfortunately, we stand out for our inadequacy," says Brock University professor Kendra Coulter. But the 10-day protected leave doesn't apply to almost one in three of the province's most vulnerable workers. An exemption that excludes employees in workplaces of fewer than 50 people from that right means 1.6 million workers in Ontario are not even entitled to a single, unpaid, job-protected sick day. Fast-growing, low-wage sectors such as retail, food services and health care are most likely to be exempt according to a recent report by the Workers' Action Centre. While many small businesses voluntarily give their employees paid sick days, the loophole leaves many workers - especially the precariously employed - exposed.

Toronto resident Gordon Butler asked his employer, a small construction company in Markham, for one day off work after he sliced his thumb open on the job. He says his boss told him not to come back. "I didn't believe him," says Butler, 44, who has an 8-month-old child. "I tried to plead with him, and he said 'No, too bad.'" "The way it's stacked up right now is there are very few options for people who are in low-wage and precarious work to actually take sick leave when they're sick," says Steve Barnes, director of policy at Toronto's Wellesley Institute, a health-policy think-tank. "They not only have to worry about lost income, but the potential for losing their jobs," adds Brock's Coulter. "It's unkind and unnecessary." The stress caused by the province's meagre sick-leave provisions is compounded by exemptions to overtime pay, to which around 1.5 million don't have full access.

As a rule, employees should get paid time and a half after 44 hours a week on the job, according to the Employment Standards Act. But in 2014, more than one million people in the province worked overtime, and 59 per cent of them did not get any pay whatsoever for it, Statistics Canada data shows. This, experts say, is partly because enforcement is poor. But in Ontario, a variety of occupations don't even have the right to overtime pay, including farmworkers, flower growers, IT workers, fishers and accountants. Managers are also not entitled to overtime. Vladimir Sanchez Rivera, a 45-year-old seasonal farmworker in the Niagara region, says he has worked 96-hour weeks doing back-breaking labour picking cucumbers and other produce.

We don't have access to protections when we are working in agriculture," he says. "And our employers tell us that." Low-wage workers are even more likely to be excluded from full overtime pay coverage, according to the Workers' Action Centre's research. Less than one third of low-income employees are fully covered by the Act's overtime provisions, compared to around 70 per cent of higher earners, because they are more likely to work in jobs that aren't eligible. Workplaces can also sign so-called "averaging provisions" with their employees, which allow bosses to average a worker's overtime over a period of up to four weeks. That means an employee could work 60 hours one week and 50 the next, but not receive any overtime as long as they don't work more than a total of 176 hours a month.

Critics say the measure means more work for less pay, and paves the way to erratic, unpredictable schedules. "That's a huge impact on workers and their families in terms of lost income and having to work extra hours," says Parkdale's Gellatly. "It's certainly not good for workers, for their families, and it's not good for creating decent jobs in terms of rebooting our economy," she adds. For many of the precariously employed, falling through the gaps ruins lives. "Even now, when I think about the working environment, I feel very depressed," says Wang, who, 10 months later, is still waiting for the Ministry of Labour to issue a ruling on her complaint. "I feel panic."

Sara Mojtehedzadeh can be reached at 416-869-4195 or smojtehedzadeh@thestar.ca. By the numbers 1.6 million non-unionized Ontario employees with no right to an unpaid, job-protected sick day 59%

of Ontario workers who worked overtime in 2014 did not get any pay whatsoever for it 71% of low-wage, non-unionized Ontario employees don't have full access to overtime pay 29%

of high-income employees don't have full access to overtime pay Sources: Workers' Action Centre, Statistics Canada Proposed solutions A recent report by the Workers' Action Centre makes a number of recommendations to rebuild the basic floor of rights for workers. The proposed reforms include: Amending the ESA to include protection from wrongful dismissal

Eliminating all occupational exemptions to ESA rights Repealing overtime exemptions and special rules Repealing overtime averaging provisions Repealing the emergency leave exemption for workplaces with less than 50 people Requiring employers to provide up to seven days of paid sick leave

"Rotund, funny and occasionally pompous, Dr. Porter was everyone's friend and nobody's confidante, the life of the party and an agile dancer, both in political circles and around a ballroom floor. A member of Air Canada's board of directors, he travelled the world free. His former friend Prime Minister Stephen Harper had him sworn in as a member of the Privy Council so he could serve as chairman of the Security Intelligence Review Committee, or SIRC, the country's spy watchdog agency. "And he was close to Quebec Premier Philippe Couillard, a relationship that began in 2004 when the politician, a neurosurgeon by training, was provincial health minister. Like many of Dr. Porter's friendships, theirs ended with the news of the hospital's megacost overrun and a $22.5-million fraud inquiry connected to the MUHC's decision to award the construction contract to a consortium led by the Montreal-based engineering firm SNC-Lavalin Group Inc.

""In a way, Arthur was like Icarus, who came crashing down to earth when his wax wings melted because he flew too close to the sun," Jeff Todd, an Ottawabased journalist who first met Dr. Porter in the Bahamas and co-authored the memoir, said. ""He told me that if he did anything wrong, it was to go way too fast," Mr. Todd continued. "There was never a peak he didn't want to climb and if there was a huge challenge, he always thought he would simply fly over it. But he couldn't always do that." "The first indication was in November, 2011, when the National Post revealed he had signed a commercial agreement the year before with Ari BenMenashe, a Montreal-based Israeli security consultant and arms dealer, all while he was head of both the MUHC and Canada's spy watchdog. Mr. BenMenashe was to secure a $120million grant from Russia for "infrastructure development" in Sierra Leone. In return, a company called the Africa Infrastructure Group, which was controlled by Dr. Porter's family, would manage what he wrote were "bridges, dams, ferries and other infrastructure projects" built with the Russian money.

"Within days, he was gone from SIRC. Less than a month later, he resigned from the MUHC, departing on the grounds that he had accomplished what he had set out to do in 2004: bring together a private-public partnership and get a long-dreamed-of facility built. "Unbeknownst to the public at the time, under his watch, a planned project deficit of $12million had somehow escalated to $115-million. "The following year, fraud charges were laid, but by then Dr. Porter was on to other projects and living in a gated community in the Bahamas, where he had maintained a home for years. After Interpol issued a warrant for his arrest, he and his wife, Pamela Mattock Porter, were detained June, 2013, by authorities at Tocumen International Airport in Panama City. "Despite claiming he could not be arrested because he was on a diplomatic mission for Sierra Leone, he was soon confined to overcrowded quarters in a wing reserved for foreigners in filthy La Joya prison. Toting an oxygen tank, he became known there as "Doc," ministering to inmates who included drug dealers and murderers. The man who had begun his ascent to the top as a doctor beloved by his patients would end at the bottom as a doctor beloved by his patients again.

"He was smart, perhaps too smart for his own good, and affable, with an ability to zero in on the most powerful person in the room with laser-like focus. His long-time friend and former teacher Karol Sikora, who partnered with Dr. Porter in a Bahamian medical clinic and is also the medical director of their joint private health-care company, Cancer Partners UK, said he was uncannily good at getting people together everywhere he touched down, even if they had opposing views. ""People like that are rare and they are very good at running big institutions," Dr. Sikora said. ""Arthur reached the peak of his career in 2010, when he was all glowing and bigger than sliced bread. Then it all went wrong." "Although Dr. Porter claimed the money from SNC was payment for other consulting work he'd done for them, his friend opined that the truth will probably never come out now. ""I'd like to think Arthur was never part of this monkey business, but we'll never know," he said.

"Others were not so kind. Responding to news of his death, the MUHC issued a terse statement that extended condolences to his family and offered no further comment, while Mr. Harper suspended the protocol that would have seen the Peace Tower flag fly at half-mast to mark the death of a Privy Council member. "In prison, living in unsanitary surroundings and denied proper treatment in a hospital for the cancer that many doubted he had, Dr. Porter, who leaves his father, sister, wife and four daughters, was outwardly still full of bravado until near the end. ""I just have to survive and make do," he told CBC reporter Dave Seglins in a phone interview in March that revolved around his treatment at the prison and his successful complaint to the United Nations torture watchdog that his human rights were being trampled on. ""[The] water, food, bedding and the fact that one has to urinate in a bucket shared by about 50 to 100 people ... for someone who has an illness and needs treatment, it was pretty obvious, I presume, the UN clearly found in my favour." "In addition, Dr. Porter continued, his raspy voice rising, he had not had a single court hearing in 22 months.

"I've never left here to go into the city. I have no idea what the inside of a courtroom looks like, not in Panama, Canada, the Bahamas or anywhere," he cried. "I've never been to court in my life." "In the end, though, he seemed to be aware that the stain on his reputation would not be erased, not even in death. ""My entire life has been devoted to climbing, winning and succeeding," he wrote in his memoir. "But with the end drawing near, it is inevitable that I, like anyone else, wonder if what I have accomplished truly matters. I wonder how I will be remembered." "To submit an I Remember: obit@globeandmail.com Send us a memory of someone we have recently profiled on the Obituaries page. Please include I Remember in the subject field.

"In his memoir, Dr. Porter said his life was 'devoted to ... winning.' " "Arthur Porter, left, chats with Stephen Harper at Montreal General Hospital in 2006. The Prime Minister had Dr. Porter sworn in as a member of the Privy Council.