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"We are committed to the health and well-being of Ontarians living in long-term care homes and firmly believe in public accountability and transparency," said ministry spokesman David Jensen. Today, the Star profiles the story of former nursing home residents Fatemeh Hajimoradi, who has a serious pressure ulcer on her buttock, and Dorothy Benson, who died from problems related to gaping bedsores on her leg and foot.

Hajimoradi is now in Credit Valley Hospital, thanks to her family's advocacy. But the complaint filed by her granddaughter, Trinos, with the ministry got no results. Trinos emailed those photographs, with a complaint, to the ministry last spring. The ministry inspector didn't visit the home until Aug. 25 - two months after Hajimoradi was permanently moved to the hospital. Without interviewing the family, the investigator discounted the complaint and told Trinos the photos were not accepted because they could be edited or photo-shopped.

"I feel like I'm helpless now," Trinos said, after ending her call with the ministry. "They aren't going to send anyone else in there. They just go in, close the book and that's it." Jensen, the ministry spokesman, said inspectors do accept photos and must interview families in their investigation. Asked why that didn't happen in this case, he said the inspector used notes and photos from Trinos' original complaint with an intake worker. Now Trinos and her mother, Mehdizadeh, want their story made public as a warning to other families: watch closely, speak up and remember that a bedsore isn't a benign skin condition - it's a toxic threat that requires the most vigilant care.

In January 2013, Mehdizadeh entrusted her mother, Hajimoradi, to the Erin Mills Lodge. Hajimoradi has Parkinson's disease and dementia. She isn't able to move on her own and - like a growing number of long-term care residents - requires help with regular repositioning so that pressure from sitting or lying in the same spot does not create bedsores. Mehdizadeh said she understood skin breakdown was a risk but expected the staff to provide intensive care - including proper nutrition and hydration - so as to prevent the agony of serious infections and open wounds.

"My mother is suffering, suffering. We are all suffering," Mehdizadeh said. "I'm speaking out about this for all people in the older generation. Nursing homes are supposed to give them a safe journey home. But where are their rights to proper care?" Two years later, in May 2015, Trinos' notes said a worker at Erin Mills Lodge privately told the family about a serious and smelly bedsore on Hajimoradi's bottom.

Trinos and her mother said they didn't recognize the significance of the sore, nor did they see it, because the dressings that covered it were changed before their visits. "Come at a different time than you usually do, come and surprise (staff)," they recalled the worker telling them. The next day, Trinos' mother, Mehdizadeh, visited in the morning instead of the late afternoon. She told the nurse to open the dressing on her mother's bottom. The pressure ulcer was partially black and smelled like rotting flesh. Horrified, she took the first of many pictures. Several days later, her mother wasn't eating and was shaking with fever and nausea. Mehdizadeh demanded that the home call 911 and took her mother to hospital.

Mehdizadeh said her mother was admitted to hospital with two infections: sepsis, from the bedsore, and a urinary tract infection. In the hospital, Mehdizadeh and Trinos watched as nurses treated the pressure wound with sanitary cleaning kits. They were impressed. When Hajimoradi returned to the nursing home 10 days later, Trinos took photos and notes to document the difference in wound care. She said staff didn't follow the specific instructions sent by the hospital and didn't have the same cleaning kits. She said staff didn't offer pain medication before using undiluted iodine on the open wound "while my grandma was crying and screaming." Unlike the careful cleaning process used in the hospital, where nurses changed their gloves twice, Trinos photographed a worker cleaning the infected sore with one gloved and one bare hand.

On June 21, Trinos and her mother noticed that the dressing for a pressure wound on her hand was missing and the air mattress to help with the bedsore on her grandmother's buttocks was deflated. Eventually, Trinos called 911 and Hajimoradi was returned to Credit Valley Hospital, where she remains. This time, she was admitted with a dark red early-stage ulcer on her tailbone and a deeper ulcer on her buttock.

Erin Mills Lodge was sold by Sifton Properties to Schlegel Villages on July 10 - after Hajimoradi left. Schlegel spokeswoman Rose Lamb said the former operators tried to work with Hajimoradi's family but said the family insisted on taking her to the hospital. Lamb also said a subsequent meeting between Erin Mills workers and hospital staff concluded there had been no neglect. Lamb said the home's current internal monthly data shows that four out of 86 residents have "worsening" pressure ulcers.

She also cited the most recent report from the Canadian Institute for Health Information, which shows the incidence of worsening pressure ulcers at the home declined in 2013-14. That year, Erin Mills' incidence rates dropped to 1.1 per cent from 3.9 per cent the prior year. The Ontario average for 2013-14 was 3.9 per cent. Hajimoradi developed problems with ulcers in the spring of 2015, a period that is not included in the report.

"How can a medicine be too dangerous to import but safe enough to consume? This makes no sense," said Amir Attaran, a law professor and health policy expert at the University of Ottawa. By not ordering a recall, he said, "Health Canada is knowingly leaving adulterated medicines on the pharmacy shelves."

Health Canada said it has restricted imports from the Indian plant as a "temporary precautionary measure," and, so far, a recall is unwarranted. "At this time, no specific safety issues have been identified with these products currently on the market," a government spokesman said in an email.

"If at any time health or safety issues are detected, the department takes immediate action, including a recall, if necessary." Spokespeople for Shoppers, Rexall, Walmart and Costco emphasized that no recall has been made and the regulator has deemed the drugs safe to stay on their shelves. "We will continue to monitor this situation closely," Rexall said in a statement. "If a patient has any concerns or questions about any medications they are taking, we would encourage them to speak with their Rexall pharmacist."

In all the packages the Star purchased in January and early February, the drugs were labelled under the store's own brand, with the name of the tablets' Canadian manufacturer - Pharmascience - in small print. No store had any disclaimer stating products from the company are now under quarantine. Pharmascience, which voluntarily agreed to the government's quarantine, said it retests all of the ingredients it imports and is confident the allergy tablets are safe.

The U.S. agents also raised concerns about the water used to manufacture the drug ingredients. A probe of the microbiology lab found "significant growth of both bacteria and mould, and appeared to be TNTC (too numerous to count)." The company's data used for detecting worrisome trends did not mention the problem, inspectors found. Meanwhile, the facility failed "to have adequate toilet and clean washing facilities supplied with hot water, soap or detergent," inspectors found.

During a November inspection, agents from the U.S. Food and Drug Administration (FDA) found Dr. Reddy staff repeatedly retested raw materials found to have unacceptable levels of impurities and did not document or report the undesirable results. These problems date back to January 2012. The name of the specific products that failed purity tests are redacted by the FDA from the inspection report, making it impossible to tell which specific drugs are affected.

The inspectors' review of one company hard drive "uncovered evidence that analytical raw data had been collected throughout the month of November 2014 and had been deleted," according to FDA inspectors. "The identity of the product(s) analyzed could not be determined." The first day of the inspection, agents found more data and test results sitting in the trash room, tucked in bags listed as waste material.

"Safety is our priority. The desloratadine products that have been released on the Canadian market have passed strict quality control tests and have also been deemed safe by Health Canada," company spokeswoman Maria Angelini said. The company said it has secured a new supplier of the chemical ingredients used to make the allergy medication. The problems at the India facility, Dr. Reddy's Laboratories in Srikakulam District, were troubling and numerous, according to an inspection report obtained by the Star.

A spokesman for Dr. Reddy's said the company agreed to a quarantine and no drug ingredients are currently being exported to Canada. Nick Cappuccino said the firm has conducted its own internal review and has "no reason to question the safety of the products involved. "We are now working collaboratively with (Health Canada) to address their concerns with the goal of lifting the voluntary quarantine as quickly as possible," Cappuccino said.

The University of Ottawa's Attaran, however, said the inspectors' findings should be treated more seriously. "The cheapest greasy spoon in Toronto would be shut down if it had these conditions, but the pharmaceutical company sending stuff to Canada is allowed?" he said. He questions why the government is allowing products originating from the facility to remain on pharmacy shelves, considering Canada's Food and Drugs Act prohibits the sale of any drug manufactured under unsanitary conditions. "The law is very clear on this," he said. "We have evidence here that the product was manufactured under unsanitary conditions, and they're selling it. What more does Health Canada want?"

The government said its decisions about regulatory actions are made on a case-by-case basis and can be "deployed in a graduated and proportional fashion, and tailored to the specifics of individual circumstances." Since a Star investigation in September revealed drug products banned from the U.S. market have been allowed by Health Canada into Canadian pharmacies, the government has banned or quarantined imports from at least nine Indian drug manufacturing facilities. The facilities make more than 100 drugs and drug ingredients imported into Canada. © 2015 Torstar Corporation

That's because home care needs a leader who cares deeply about a system that for too long has seen patients struggle to receive basic services they deserve, suffer when their therapy sessions or personal support visits are cut off or reduced, or who are sent home from hospitals with false promises of services to come to their door. "We know from the feedback that we have received from literally thousands of individuals and families that the care that they are currently receiving is patchy, uneven and fragmented," Hoskins admitted last week. It was just six months ago that Hoskins was refusing even to acknowledge that any patients had their services terminated or reduced because of cutbacks by Community Care Access Centres, which oversee home- and community-care services. In fact, those cuts affected thousand of sick and elderly patients across the province.

Encouragingly, Hoskins unveiled several new measures last week that potentially could help patients receive better and more cost-efficient care. One pilot program would give patients money to hire their own home-care services and health professionals to provide care in their homes. For example, hospitals might be able to work with discharged patients in regards to co-ordinating community supports. Ultimately that could spell the demise of CCACs, which now co-ordinate community care, usually through private companies and non-profit organizations. As good as such steps are, Hoskins could have done so much more to truly improve home care.

First, Hoskins should radically reform the overall bureaucratic structure of home and community care. Gail Donner, former dean of nursing at the University of Toronto who headed a recent government-appointed panel on home care, has called the issue of structure "the elephant in the room" when it comes to poor delivery and co-ordination of services to patients. The most obvious starting point is the 14 CCACs across Ontario. These government agencies, which are filled with many hard-working and dedicated staffers, have been rightly criticized as being too bureaucratic, inefficient and top heavy with high-paid executives. Hoskins said last week he will wait until Auditor General Bonnie Lysyk releases two reports on CCACs before making any moves. The first report looking into CCACs' financial operations, which was requested by an Ontario all-party legislative committee in March 2014, was to have been ready this spring. It now won't be ready until late fall. The second report, which will look into other aspects of home care, will be included in the auditor general's annual report, tentatively set for early December.

Second, Hoskins should demand more money for rehab services, such as physiotherapy and speech-language pathology. This growing area of need has been effectively gutted over the years in the name of cost-saving, with patients getting as few as two visits from front-line health professionals after being sent home from hospitals. At the same time, hospitals have closed in-patient and outpatient rehab clinics, forcing patients to fight for limited home-care services or pay privately. Third, Hoskins should reverse a unilateral decision by CCACs that forbids charitable non-profit home-care organizations to fundraise among former clients.

Such a move would open the door for not-for-profit organizations to provide vital home-care services that are not now being met or are being under-delivered by CCACs. Low-income and aboriginal groups would be among those most likely to benefit from such a move. If non-profit hospitals can fundraise among former patients, it seems logical that not-for-profit home-care organizations should be allowed to do the same thing. Home-care patients can draw some encouragement from Hoskins' small steps forward. But now is the time for bolder steps that will make a real difference in the lives of patients and caregivers around the province. Bob Hepburn's column appears Thursday. bhepburn@thestar.ca.

The two towers of the development look very much like an upscale residential development. They are connected with a gracious lobby manned around the clock by attentive concierges. There's a gym - complete with personal trainers - on an upper floor, as well as a communal kitchen that can be used for cooking demonstrations. There is enough polished stone and fancy millwork in the suites to satisfy even the most sophisticated of tastes. Outside, residents can putter in the gardens or host a barbecue on the terrace.

The executive chef - who previously worked at high-end Vancouver restaurant Italian Kitchen - sources produce directly from the nearby UBC Farm and refreshes the menu quarterly, with input from the residents.

A community shuttle can take people around to various neighbourhood destinations, although grocery shopping, banking, and medical appointments are all within very easy walking distance. A private car with driver can also be booked for an additional cost.

The meal options at Tapestry may be where it differs the most significantly from other seniors' facilities. Residents can cook for themselves in the fully-equipped kitchens in their individual suites, have meals brought to their suites, meet up with friends at the on-site pub, or entertain friends and family at the restaurant-style dining room. There are no set meal times and there is no assigned seating. The cost of the restaurant meals are debited individually from a monthly credit, much like the dining plan used by students living in dorms.

However, the services available go far beyond what you might find in most condo buildings. People can also take advantage of a beauty salon and spa, play a couple of rounds in a golf simulator, or engage in some mental stimulation in the brain fitness centre. Housekeeping is provided weekly, with medical staff on call around the clock. Medical treatments are delivered privately in the homes of residents, rather than requiring people to move to a hospital wing if they are ill.

"A lot of facilities come from a nursing or hospital style approach," explains Catherine Wallbank, vice-president of operations for Leisure Care. That firm manages Tapestry for developer Concert Properties. "We think about it from the hospitality perspective, and offering opportunities to enjoy life to the fullest."

It's an approach that suits 73-year-old Carol Byram and her 68-year-old husband Adrian. They purchased a home at Tapestry at Wesbrook after Adrian decided to return to school, and after Carol read a September 2010 Vancouver Sun profile of the project. After a long tech and entrepreneurial career in the U.S., Adrian is now working

toward a PhD in neuroethics at UBC. Carol is busy on the strata council and various committees for the building, as well as her work with Ballet BC "I tell people that living here is like being on a cruise ship or at the Four Seasons with all your friends," the former communications director for Sony Electronics says. "There is something to do all the time if you want to."

With isolation being a known hazard for seniors, Byram says she doesn't understand people who hang on to living in single-family homes until the bitter end. Activities at Tapestry include movie nights, day trips, fitness classes, and musical performances. She also says there is no shortage of people to go for a walk or meal with.

Byram enjoys being part of the larger community at UBC, saying there is a noticeable energy on campus as students stream in and out of classes. She volunteered to be a subject for a study examining the effects of companionship and exercise on aging. She is also involved in Project Chef, where students from a nearby elementary school come and cook with residents.

She often runs into her neighbours Yul and Joanne Kwon in the gym. Yul is 79, and Joanne is 77.

Yul has qualified to run the Boston Marathon next year, and is an adjunct professor of economics at SFU, after decades teaching at the University of Regina and a university in Australia. He tends to have his daughter accompany him on his longer runs through Pacific Spirit Park. "I am writing a book, so I am too busy to take advantage of all of these programs right now," he laughs. "But Joanne participates, and as time goes on, we appreciate that the events are available to us." They purchased their home three years ago at the urging of their son, and at the time, had no idea it was even a seniors residence. He and Carol agree that downsizing directly to Tapestry was the right choice to make, because of all of the amenities and the peace of mind offered by the staff.

The Star's analysis shows that at least one patient is seriously injured attempting suicide every three days, and 13 patients take their own lives every year. The hospital suicide rate is too high for psychiatrist Dr. Ian Dawe. "We are committed to making in-hospital suicides a 'never event,'" he said, noting that many hospitals in the United States are in the process of adopting what is known as a "zero suicide" strategy. Last May, after the Star started investigating this story, the government created a task force to develop standards on suicide prevention in hospitals and appointed Dawe as chair.

Suicides and attempts occur in all hospital departments, from maternity to neuro-clinical, emergency, medical and psychiatry. Methods range from strangulation and suffocation to drowning, overdose and electrocution, according to the data. Records show that a 12-year-old patient attempted to hang herself with her nightgown in the Sault Area Hospital, a 71-year-old woman went missing from Homewood Health Centre and jumped to her death from a parking garage and a patient at Alexandra Marine and General Hospital used a broken vase to slit his or her wrists. The three hospitals declined to comment on these incidents. Secrecy is a big part of the problem, the Star found.

Following an in-patient suicide, hospitals hold reviews behind closed doors to identify what went wrong and what can be done to prevent further deaths. But hospitals are not required to share these results publicly, or even with other institutions, under Ontario's health secrecy legislation - the Quality of Care Information Protection Act.

Details about deaths have even been withheld from grieving families. The family of Prashant Tiwari, 20, had to fight Brampton Civic Hospital for basic details about how he died by suicide last year. Tiwari was taken to the hospital after stabbing himself and placed under 15-minute suicide watch. His family eventually learned he had hanged himself in a bathroom after he was not checked for three hours. (Earlier this month, the health minister introduced changes to the protection act to address the problem of families being left in the dark.) Brampton Civic Hospital has refused to comment publicly on the Tiwari case, other than expressing its condolences, but in a letter to the family it said three staff members have not worked at the hospital since the day of his death. The Star's investigation found significant inconsistencies in how hospitals approach suicides: Some hospitals use only clothing and shoes without drawstrings, ties and shoelaces. Others don't take such precautions. Some confiscate personal medication from patients to prevent overdoses. Others don't.

Some lock the windows of mental health units and remove the window handles. Others don't. It's not surprising then that there is confusion about the exact number of in-patient suicides province-wide. While the Star's investigation found more than 96 patients had taken their own lives in half of Ontario's hospitals since 2007, the coroner's office, to which all hospitals must report suicides by law, says there have been only 60. "(I) cannot account for the reasons why our data differs from that offered by the specific hospitals," Chief Coroner Dirk Huyer said. There hasn't been a single coroner's inquest into a hospital suicide in the past nine years because, Huyer said, it is not the coroner's role "to raise issues that are already known." In the previous decade, the coroner's office held six inquests into in-patient suicides resulting in numerous recommendations aimed at preventing these deaths, including the establishment of task forces targeted toward the most at-risk patients. But little has been done and the problem continues.

A few weeks before Ken Coyne committed suicide at Providence Healthcare in Scarborough, he told his sister, Jean Brewster, that he wanted to die because the stroke had left him with only "half a body." She says the doctors knew of his suicidal intent and that she will never understand how he managed to hang himself while he was bed-bound and under 15-minute suicide watch. She recalls exactly what she said to the police officer who delivered the news: "I remember saying to the officer: 'Hang on, how did he do that in a hospital?'" Providence Healthcare said staff members continued to be deeply affected by Coyne's "tragic" death.

Just last week, two major Canadian health organizations identified suicides in hospitals as "preventable" incidents. Health Quality Ontario and the Canadian Patient Safety Institute released a report, "Never Events for Hospital Care in Canada," which said suicides in hospitals "should never happen" when patients are under suicide watch.

The distinction drawn between the procedural advantage now accorded to non-DCO refugee claimants and the disadvantage suffered by DCO refugee claimants ... is discriminatory on its face," wrote Justice Keith M. Boswell in a 118-page decision. "It also serves to further marginalize, prejudice and stereotype refugee claimants from DCO countries which are generally considered safe and 'non-refugee producing.'

"We remain committed to putting the interests of Canadians and the most vulnerable refugees first. Asylum seekers from developed countries such as the European Union or the United States should not benefit from endless appeal processes." The latest court decision means all failed refugee claimants, whether on the list or not, are entitled to appeal negative asylum decisions at the Immigration and Refugee Board's refugee appeal division, better known as the RAD. "This is a very important victory for refugees," said Jared Will, counsel for the refugee lawyers association. "Every refugee deserves to have their claims determined on their own merits."

"This is another Charter loss for the Harper government," noted Lorne Waldman, president of the Canadian Association of Refugee Lawyers, a party to the legal challenge against the DCO regime. The government said it will appeal the decision and ask the court to set it aside while it is under appeal. "Reforms to our asylum system have been successful resulting in faster decisions and greater protection for those who need it most," said a spokesperson for Immigration Minister Chris Alexander.

This is another example of how the Stephen Harper government "flagrantly" overreaches its authority and disregards the Charter rights, he said, and "the court decision is confirming that." Calling the issues "complex," a spokesperson for the refugee board said it will respect the court ruling and "take the necessary time to examine the decision and its potential impacts." In December 2012, the federal government overhauled the asylum system in order to eliminate the growing backlog and expedite the processing of claims.

Not only do claimants face tighter timelines in filing their claims and scheduling a hearing and removal, those from DCO are ineligible to work for six months, appeal a rejected claim or receive a pre-removal risk assessment within three years after an asylum decision. Three refugee claimants - only identified in court by their initials - challenged the constitutionality of the DCO regime after they were denied asylum and subsequently the opportunity to appeal to the newly established refugee appeal tribunal.

Lawyers for the trio criticized the arbitrariness of the country designation process, arguing the DCO regime subjected some claimants to an "inferior determination process" - and discrimination - by limiting their access to opportunities and benefits that are afforded to others. They also argued that the government's branding of DCO claims as bogus, and the use of refugee statistics to trigger designation, feeds into the stereotype that their fears are less worthy of attention. In its defence, the government contended that it does not draw distinctions among claimants based on their national origin but rather whether they come from regions that are generally safe.

The government said the expedited processing for DCO claims is legitimate and conforms to Canada's international obligation. It explained that it limits the access to an appeal to the RAD only on the basis of a thorough assessment of the country conditions. However, Justice Boswell rejected its arguments: "This is a denial of substantive equality to claimants from DCO countries based upon the national origin of such claimants." He sent all three claims involved in the case to the refugee appeal tribunal for redetermination.

Hospital stays for lung patients have been shortened by up to 33 per cent. Post-discharge emergency room visits for that same group have fallen by half, and rates of readmission within 60 days to any hospital have been slashed by 56 per cent. Plus, the program is saving up to $4,000 per patient.

Those results are so "dramatic," said St. Joseph's CEO Dr. Kevin Smith, that a call from the Ministry of Health and Long-term Care seeking others interested in adopting such an initiative has drawn about 50 expressions of interest. The program has nabbed a 20 Faces of Change Award - part of an Ontario-wide competition honouring systems that break new ground with innovative patient care - and praise from Health Minister Dr. Eric Hoskins. In a statement released to the Star, Hoskins called the program "a real leader."

"Real innovations in health-care funding, such as the St Joe's experience, happen when we adopt an evidence-based approach to patient care, prioritizing programs and interventions that deliver the highest standards of care," he said. "We are transforming the health-care system to put patients first, while making our health-care system more sustainable." But perhaps the biggest praise of all has come from patients, who usually find themselves shuffled from department to department or institution to institution, repeating the same questions and being given very different expectations with every move. The project gives each patient a care co-ordinator - usually a nurse or personal support worker - who becomes the main point of contact for patients, cutting out tussles over who to turn to for help. For 82-year-old Audrey Holwerda, who entered the hospital to have a cancerous mass removed from her lung, that co-ordinator is Anna Tran, a surgical nurse of about 20 years.

Any time I need her, day or not, I can call, and I have called her a few times and she has been great," Holwerda said. "I feel like I know her, and when I go to see the doctor, she is there. I feel like she's a friend." Holwerda said it's a big difference from the "poor" care her ailing sister experienced when she had a lung removed. Her daughter, Wendy, even compared her mother's treatment from Tran to "being in a hotel." "In the long run, it has made (mom's) recovery better," Wendy said.

And for Tran, it's provided a sense of autonomy and a pride in her work that is worth the calls in the middle of the night. "The good thing is, I'm not married," she said, laughing and teasing the other co-ordinators, who are parents and have had to find ways to juggle their children's baseball games with answering patient queries on an iPad from the stands. If all goes to plan, more co-ordinators will be added and the program will expand beyond its current focus on five types of patients - those with compromised lung functions, congestive heart failure and lung cancer, and those needing open-heart surgery or knee and leg procedures. There's no word on when that could happen, but Smith and others who are already raving about the program are keeping their fingers crossed it will be soon.

Yet a glance at the actual data shows that the unemployment rate has been steady at 6.8 per cent for several months - an enviably low rate that most countries around the world would kill for. Another bogus Unifor claim is that the federal government has cut health care transfers to the provinces by $36 billion. In fact, the feds have merely reduced the rate of growth of health care transfers from an unsustainable 6 per cent per year to a more realistic 3 per cent per year, still well in excess of inflation. Facts show that the federal government will transfer $34 billion to the provinces this year for health care, which represents 23 per cent of provincial health budgets, up from 15 per cent in the late 1990s. Over the past decade federal health transfers have increased 70 per cent - hardly a pittance. These fabrications are only two of the many whoppers in the Unifor ads.

In addition to reiterating the false claims of Unifor concerning health care spending and other issues, the unionbacked group Engage Canada, which interestingly is an alliance of Liberal and New Democratic Party interests, has made other inaccurate claims in its advertising. For instance, they say tax measures introduced by the federal government will merely benefit the rich. To choose one of these tax measures, the enhanced contribution limits for Tax Free Savings Accounts (TFSAs), the facts show quite the contrary. Currently about half of Canadians have TFSAs, and 60 per cent of those who have maxed out their TFSAs earn less than $60,000 annually - hardly the rich. Also, TFSAs are a great tool for older Canadians for whom RRSPs are no longer useful.

Another falsehood promoted by the left is that Canada has a pension crisis with a majority of Canadians not saving enough for their retirement. As noted by knowledgeable professionals such as tax expert Jack Mintz of the University of Calgary and Morneau and Shepell actuary Fred Vettese , no such crisis exists.

Facts indicate that most Canadians are well prepared for retirement and do not need another forced savings plan such as higher CPP premiums or the very flawed Ontario Retirement Pension Plan promoted by the Ontario government. The motivation behind the unions' and other left groups' advocacy for more forced savings is that it will mean more taxpayer funds in government hands to spend on even higher pay and benefits for government workers and more funds for pet government programs.

All political parties are campaigning for the middle class vote in this election, as is always the case since that is where most votes are. Recent results from a study conducted by the New York Times, as well as information from other sources, show that the Canadian middle class is currently the most prosperous in the world. In the last couple of months, an annual analysis from the international Reputation Institute concluded that in 2015 Canada is the most respected nation in the world, with the best reputation. Not too shabb

So why all of the fabrication and dishonesty from our brethren on the left? One reason is that the left always thrives on misery and, despite facts to the contrary, must constantly tell people they are doing badly, should be doing better, are ill-treated, etc. This is true no matter which political party is in government. Look no further than our very wellpaid and entitled teachers in the public school system, who constantly whine about how "disrespected" and poorly treated they are while earning very generous salaries, having lots of time off, retiring early and having one of the best pension plans around.

Another key reason is that the money behind all of these leftist groups is largely coming from unions, and most Canadian union members these days are government workers. It is hardly surprising that the ads of the Public Service Alliance of Canada are claiming that services are suffering because of cuts in the number of federal workers. Yet once again, a quick look at the facts show that there are still more federal government workers today than there were in 2006 when the current government was initially elected. It is completely understandable that government unions want more government employees and therefore more union dues in their coffers, but the 80 per cent of Canadians who do not work for government should realize that they are hurt when government unions prevail.

Interestingly enough, whenever I get into a debate with union folks about all of the horrendous things the current federal government has supposedly inflicted on the Canadian people, I always ask them one question, which is "Where in the world would you rather live?" Tellingly, I have not ever gotten an answer to that question. And perhaps that is answer enough.

Catherine Swift is Spokesperson for Working Canadians. www.workingcanadians. ca, @WorkingCdns

As analysts Ake Blomqvist and Colin Busby note in a new C.D. Howe Institute study, "Many other countries, in Europe and elsewhere, also have systems that cost much less than the American one and that, arguably, are at least as equitable as Canada's, if not more so." Yet, "No other country is modelling their health-financing system around the Canadian example," they add. "None of them seem to think that a monopoly approach to paying for most health services is the best way to achieve equity and efficiency goals."

Many of these restrictions do not flow from the Canada Health Act, but rather from provincial laws. For example, Victoria, not Ottawa, prohibits doctors who opt out of the Medicare system from getting any payments from public funds, or doctors who work within the public system from billing patients over and above what the government pays. These restrictions, the study argues, impose big costs. To illustrate this, it focuses on how health care is paid for in four countries - the U.K., Australia, Switzerland and the Netherlands - whose health systems are considered to be among the world's best.

"Their guiding principles are similar to those within the Canadian health care system. All endorse universal public coverage and access for a defined core set of services, the belief that costs should be borne by society at large ... and high standards of care." In all these countries, public spending covers a significantly smaller percentage of hospital and doctor-related costs than in Canada, leaving the balance to be paid by private insurance for those who have it. (The range is from 65-85 per cent for hospital costs, compared to 92 per cent in Canada, and 60-90 per cent for doctors fees, compared with 99 per cent in Canada.)

But their governments also cover 45-67 per cent of drug and other outpatient medical costs, compared with 35 per cent in Canada. The authors consider, and ultimately dismiss, the view that any deviation from Canada's single-payer system would result in higher costs - an often-cited factor when sky-high U.S. health costs are dissected, but not an issue in countries that have a more carefully balanced mix of public and private funders.

Nor do they buy the argument that the public sector would lose out if privately paid health services were allowed to compete for doctors and patients. Indeed, other countries have found that competition can improve service and lower costs. The bottom line is that Canada's health care system only looks as good as many of us like to think it is when we compare it to the American system. And other countries have figured out better ways to fully respect the same vaunted principles Canada aspires to while providing more or better care at comparable cost. We could learn from them.

"We've been managing our budgetary costs for years," she said, "but this is the first year we've considered staffing restructuring as a practice to balance the budget's bottom line." Since PSWs are trained for a smaller scope of work than RPNs, they are compensated at a lower rate. Wilson-Trider said it should be made clear that there will still be RPNs on the hospital's team. Though there will be fewer RPNs, the team of PSWs will work to lighten their workload by taking care of certain tasks. The restructuring of the care model for the hospital's Rosamond Unit is just one aspect of the changes made to the AGH's budget this year. During the winter months, AGH conducted an internal comprehensive review of the hospital's revenues and expenditures, looking for efficiencies and asking for suggestions from staff.

The review, Wilson-Trider said, had a target figure of a five per cent change to the budget's bottom line, either in increased revenue or decreased expenditures. The cuts to RPN positions will account for some of that five per cent change, but the review also found other areas to cut costs, such as supply cost savings and energy management practices. Also, the hospital reviewed their service costs and found that they were charging below the average for private rooms, something they've adjusted for 2015. "These changes are a way of living within our means from a budget standpoint while providing the least impact to current patient care and the patient experience," Wilson-Trider said.

Protest Anita Comfort, one of the RPNs whose job is being eliminated, has been working at AGH for 21 years. She's among one of many soon-to-be-laidoff RPNs who have been at the hospital for decades, and she says that level of dedication can't be replaced. "We know our hospital, we know our patients and we know how to care for them," she said. "There's simply not going to be the same level of care without us." Comfort was one of more than 30 demonstrators who marched the street in front of AGH on March 16, asking for honks of support from passing cars.

Affected RPNs, friends, family, union representatives and even patients came out to show their support, holding signs boasting messages such as "Cuts hurt everybody," and "My skills are vital to patient care." Linda Melbrew, president of the local chapter of the Canadian Union of Public Employees (CUPE), which represents the RPNs, was present for the demonstration, showing the union's support for saving their jobs. "We're asking the hospital to reconsider their decision," she said, "and we're also asking for the province to provide better funding for our hospitals so something like this doesn't have to happen at all." Representatives from the Ontario Nurses Association also showed their support during the demonstration, holding signs and marching among the affected RPNs.

Cathy Porteous, another of the RPNs who will lose her job because of the cuts, also mentioned the hospital's appearance on the Sunshine List: a list of employees whose annual salary rates are $100,000 or more. She said she heard there are 10 such employees with the AGH. "Why can't they make cuts in that area," that's what we want to know," she said. "Instead of cutting from the front lines of patient care, maybe they should take a look at their own salaries." When asked about the Sunshine List later in an interview, Wilson-Trider said the hospital doesn't have 10 employees being paid more than $100,000 annually - instead, they have nine.

Those employees, she explained, are all high-level employees and not all of them are paid by AGH itself. Among those on the Sunshine List are the director of care for the hospital's Fairview Manor (FVM) and the manager for Lanark County Ambulance Services. "These managers are already stretched," she said. "Between managing the hospital and their accountability to the LHIN (Local Health Integration Network) and the ministry, they're stretched." Many of the demonstrators voiced another concern as well: that patients will not receive the same level of care with a team of PSWs than they would with RPNs. "The don't call it complex care for nothing," said Debbie Tipping, whose husband, like Marie Campbell's, receives care in the Rosamond Unit, also called the Complex Continuing Care Unit.

Since PSWs don't go through the same level of training as RPNs and therefore are not qualified to perform certain tasks, Tipping said she is concerned her husband's care could suffer. "We don't want to lose the nurses we've come to know and love," Campbell said. Patient care While Wilson-Trider said the AGH is appreciative of the work the affected RPNs have put in over the years, she also said that she thinks the new care model will benefit patient care. "I actually think that this will be good for patient care," she said. "The new PSWs will be there to support the RPNs, who will be working at their full scope of practice."

"Patient care," she added, "is of the utmost importance here, and we have taken every measure to ensure that that level of care is maintained." Over the next few months, as the new model of care is phased in and positions are jostled around, Wilson-Trider said that the AGH will be following the union's collective agreement and working with the union the whole way through. "We appreciate the commitment and high quality of care that all of our staff has demonstrated and continues to demonstrate," she said, "and we're also very appreciative of the care they've given to our patients." Illustration: • Kelly Kent, Metroland / On Monday, March 16, more than 30 demonstrators took to the street outside Almonte General Hospital (AGH) to protest the hospital's new model of care that will cut 10 registered practical nurse (RPN) positions from its team of sta . AGH's new model of care comes in light of budget challenges passed down from the province's freeze on funding. Some of the a ected RPNs, above, held signs reading "My skills are vital to patient care."

DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Well, I think it's probably not divided properly and I also think that we need to be very mindful of the ways in which advertising and marketing, whether it's direct to patients or consumers as we often consume from the American media on our television screens, or whether it's direct to physicians. So, you know, in fact, even in the U.S. under the Affordable Care Act, physicians are now required to declare any amount of money that they take from the pharmaceutical industry. We have no such sunshine law here in Canada. Don't Canadian patients want to know if your doctor has had their vacation or their last meal or their speakers' fees paid by the company that makes the drug they have just prescribed for you? WENDY MESLEY (HOST): Well, we saw in those ads they'll say: Ask your doctor. Is there a lot of pressure and is that contributing to the number of pills on the market? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK):

WENDY MESLEY (HOST): What are you seeing, David? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): I think this is right and it's a surprise to somebody from outside of Canada to find that in a country with a good comprehensive care system, there is not drug coverage. So patients with chronic disease, for instance diabetics, ironically in the city where insulin was discovered, are relying on free handouts from their physicians to provide what is really an essential medication; it's keeping them alive. WENDY MESLEY (HOST): Who do you think is falling through the cracks? What are you seeing?

CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): The vulnerable population in my mind are older adults with multiple medical conditions who are taking 5, 10, 15 medications at the same time and have to pay the deductible on that. And that adds up for a lot of them who don't have a lot of money to begin with, so they start making choices about will I take my drugs until the end of the month? Will I take every single medication that I have to? Do I really need those three medications for my high blood pressure, or can I let one go? And that could have effects on their health. WENDY MESLEY (HOST): Well, you mentioned diabetes, David. We heard earlier on "The National" this week from a woman in B.C. She has diabetes. That's a life-threatening disease if it's not looked after. This is what she said.

SASHA JANICH (PHON.) (DIABETES PATIENT): Roughly about 600 to 800 bucks a month. I don't get any help until I spend at last 3500 a year and then they'll kick in, you know, whatever portion they decide to cover. WENDY MESLEY (HOST): So, David, that's really common? People on diabetes aren't fully covered?

DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): Well, they're covered to a degree in B.C., but it's what we call the co- payment level that they have to make even under an insurance program. In Ontario, they don't have any insurance at all. They're going to pay the full market price if they don't have insurance through their employer, and they may lose that if they're out of work. WENDY MESLEY (HOST): What are you seeing? What's not covered? Give me an example. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL):

Well, actually, one thing that I think is surprising to a lot of people is the variability in coverage among public drug plans in Canada. So something that's covered, even if you're covered under a public drug plan, for example if you have cancer and you have to take chemotherapy outside of the hospital, in many Canadian provinces that's taken care of. In Ontario, for example, it's not. And I think that many Canadians are surprised to discover, imagine the, you know, enormous stress of a cancer diagnosis, that on top of that you're going to have to pay out of pocket at least to very… sometimes to very, very high levels, in fact. WENDY MESLEY (HOST): Samir? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And even just the other day, I just was debating with a pharmacy about the cost of some vitamin D. I have a person who's under house, he's on social assistance, and they said: We'll give you a free blister pack, you know, so he can sort his meds. We'll give you this. And we were actually, you know, working out a pricing system so this guy could even afford something so that he wouldn't break bones and actually have a fracture down the road. So it's amazing how some of the basic things we think are important aren't even covered. WENDY MESLEY (HOST):

Well, we saw that the drug costs have almost doubled in the last 11, 12 years. Is part of the problem… there's only so much, it seems, money to go around for prescription drugs. Is part of the problem that there's too many… some drugs are too easily available while people who really need them are not getting them? And there's marketing playing into that. We see a lot of ads in the last ten years. Check this out. VOICE OF UNIDENTIFIED WOMAN (ANNOUNCER): (Advertisement) We know a place where tossing and turning have given way to sleeping, where sleepless nights yield to restful sleep. And Lunesta can help you get there.

UNIDENTIFIED MAN #1: (Advertisement) Anyone with high cholesterol may be at increased risk of heart attack. I stopped kidding myself. VOICE OF UNIDENTIFIED MAN #2 (ANNOUNCER): (Advertisement) Talk to your doctor about your risk. VOICE OF UNIDENTIFIED WOMAN (ANNOUNCER): (Advertisement) Ask your doctor if Lunesta is right for you.

WENDY MESLEY (HOST): It's funny, you know, we hear our health plan discussed in the United States and now you talk about our socialized medicine and it's sort of until you have a health problem, you assume everything is covered. But who falls through the cracks that you see, Samir? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Yeah, I mean, I treat a lot of older patients and those who are 65 and older generally are covered by a provincial drug plan. But, you know, I'm seeing more and more, especially after the recent recession, we have people who are closer to that age who lose their jobs and if they lose their jobs and they were relying on private drug coverage plans, they are not covered. And then they find themselves they can't afford their medications, they get sicker and they literally have to wait and be sick until they can actually get their medications.

Well, it's a huge amount of pressure, I think, you know, for… you know, if you're a doctor that relies on information or supports from pharmaceutical representatives, for example, then there is that pressure that you're put under, there is that influence that you have. But also, we know that if your patient asks you specifically and says, you know, what about this medication, you may say, well, it's easier to prescribe you that medication if that's what you really want. But there's actually five things you can do to improve your sleep and actually avoid being on that medication, but we don't get asked for that. WENDY MESLEY (HOST): But I want to be like the lady with the wings.

SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And that's what I hear: Why can't I be like that? But I think it's important to think about the other options. WENDY MESLEY (HOST): David, what do you think? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): I would like to focus a little bit on the prices that are being paid. We talked about usage and whether drug use is appropriate. There's also the price that is paid. Canada is paying too much. And if we can just return for a second or two to the idea of a national program, there's a huge advantage in being the sole purchaser on behalf of 35 million people, as it would be with a national program in Canada. And we know from experience you can reduce drug prices by 30, 40 percent. That's billions of dollars a year. WENDY MESLEY (HOST):

That's a political debate that you have launched and I hope that it gets taken up by the politicians. Who is buying these drugs? We have seen that there are more people having trouble getting drugs, more people using drugs. Who is it? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): That are taking prescription drugs in Canada? WENDY MESLEY (HOST): Yeah. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL):

Well, you know, interestingly over the last decade, we have seen an increase in prescription drug use in every single age category. So the answer is we all are. We're all taking more drugs than our equivalent people did a decade ago and I think… WENDY MESLEY (HOST): Teenagers? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Absolutely, teenagers and the elderly and everybody in between. And so the question really becomes: Are we any healthier as a result? You know, in some cases we're talking about truly life-saving treatment that are medical breakthroughs and, of course, we all want to see every Canadian have unfettered access to those important treatments. In other cases we may actually be talking about overdiagnosis, overprescription and as you say, Cara, sort of chemical coping of all different kinds. And I think that's what we need to kind of get at and try to tease out. WENDY MESLEY (HOST):

Well, and the largest group of all on prescription drugs right now, Cara, are the seniors. CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): The seniors, yes, and I'm very passionate about this topic because sometimes I see patients come into my office on 23 different drug classes, and that's when we don't talk about what drugs should we add but what drugs can we take away, and the concept of de-prescribing. And imagine if we could get people who are on unnecessary drugs, because as you get older you get added this drug and a second drug and this specialist gives you this and that specialist gives you that, but then there starts to be interactions between the different drugs that could cause side effects and hospitalization. And maybe it's time to start asking, well, what's the right drug for you at this time, at this age, with these medical conditions? And personalized medicine is something that we have been talking about. It would be nice if we could introduce that conversation into therapy and not just drug therapy, but all therapy. Maybe the drug isn't needed. Maybe physiotherapy is needed or a psychologist or better exercise or nutrition. So I think it's really a bigger question. WENDY MESLEY (HOST): Samir?

SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Exactly. I mean, in my clinic the other day I had a patient who was on eight medications when she came with me, and… WENDY MESLEY (HOST): This is a senior? You deal with seniors as well. SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Absolutely. And when she left my office, she was thrilled because she was only on two medications, mainly because some of the medications are prescribed to treat the side effects of other medications, for example, or the indications for those medications were no longer valid in her. But we added some vitamins and we just balanced things out appropriately. And she was thrilled because, as Cara was saying before, the co-pays, the other payments that one needs to pay for medications you don't want to take, that's a problem as well. WENDY MESLEY (HOST): We're going to take a short break, but we have one more discussion area which is: What are the next challenges that Canadians might face with prescription drugs? We'll be right back.

(Commercial break) WENDY MESLEY (HOST): Welcome back to our "National Checkup" panel. Danielle Martin, Samir Sinha, Cara Tannenbaum and David Henry are all here to talk about the next frontier. So we're hearing all of this exciting new science marches on and there's all of these new drugs, new treatments. Everyone wants them or everyone who needs them wants them, but they're expensive, right, Danielle? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): They can be extremely expensive. So, you know, what we call these blockbuster drugs coming onto the market, some of them truly do represent breakthroughs in medical treatment and in some cases they can cost tens or hundreds of thousands of dollars a year. So they really are very expensive. But what I think many people may not realize is that the number of drugs coming out, even the expensive ones that are truly breakthroughs, is still a very small portion of the drugs coming out on the market. Many, many drugs that are being released and are expensive are marginally, if at all, really any better than their predecessor. So just because it's new and fancy and costs a lot doesn't necessarily mean that it's all that much better.

WENDY MESLEY (HOST): So what's going to happen, David? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): We need to find a plan. These drugs may cost hundreds of thousands of dollars. Nobody can afford that individually. Tens of thousands, rich people can afford them but the average person cannot. So there's really no way we can cope with these unless we've got a plan and, in my view, it has to be a national plan. And the advantage of that are that when you're buying or you're subsidizing on behalf of 35 million people, you're going to get better prices and your insurance pool that covers these costs is much greater. So the country can afford drugs that individuals can't.

WENDY MESLEY (HOST): Samir, what do you see as the new frontier here? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): I think the new frontier is going to be more personalized treatments in terms of how do we actually treat cancers, how do we treat certain rare conditions with more personalized treatments. WENDY MESLEY (HOST): Because it's very exciting, right? You have this cancer that's not that common and then you hear that there's a treatment for it and you want it. SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And it has the possibility of alleviating a lot of suffering from unnecessary treatments that may not actually be… you know, be effective. But I think this is the challenge. If we want to be able to afford these, if we actually work together we're actually more able to afford them when we bulk-buy these medications. But the key is going to be that, you know, this is where the future is going and we're going to have to figure out a way to pay for them.

WENDY MESLEY (HOST): What are you looking forward to? CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): I'm really looking forward to seeing all these new treatments that we have spent decades researching. You know what the investment in health research has been in order to find new targets for drugs, in order to increase quality of live, in order to cure cancer, and then to send a message, oh, sorry, we're not going to give them to you or you can't afford to pay for them, then I think there is a lack of consistency in the messaging that we're giving to Canadians around equity for health care. So you could get your diagnosis and you could see a physician, but we way not be able to afford treating you. So I think this is something we need to think about it. It's very exciting, I think we live in exciting times, and looking at different funding strategies to make sure that people get the appropriate care that they need at the right time to improve their health is really what we're going to be looking forward to. WENDY MESLEY (HOST):

Tricky, though. It's a provincial jurisdiction, you've got to get all the provinces to agree to a list, and the list is getting longer. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Absolutely. I mean, I think actually one of the big myths out there about drug plans is that higher-quality plans are the ones that cover everything. And, in fact, that's not true. You know, we can use a national plan or a pan- Canadian plan or whatever you want to call it to target our prescribing and guide our prescribing in order to make it more appropriate, and that's another way that we're going to save money in the long run. WENDY MESLEY (HOST): Well, I learned a lot tonight. I hope our audience did too. Thanks so much for being with us. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Thank you.

"You feel isolated and shunned - it hurts your feelings and it just doesn't make sense in this day and age. It just seems like, why wouldn't you help women here?" It is a ritual that plays out routinely for women in the only province in Canada that does not provide surgical abortions within its borders, and one that pro-choice advocates say remains fraught with challenges despite pledges by the provincial government to remove barriers to abortion access.

Liberal Premier Wade MacLaughlan announced soon after his election in May that women from P.E.I. would be able to get surgical abortions in Moncton without the need for a doctor's referral, a measure that received guarded praise from pro-choice advocates. Under the arrangement, women who are less than 14 weeks pregnant can call a toll-free line for an appointment and have everything done in one day, when possible. Previously, women needed a

doctor's approval and had to have blood and diagnostic work done on the Island before travelling almost four hours to Halifax for the operation. Or they could go to a private clinic and pay upwards of $700 for the procedure. Abortion rights advocates say both are costly and stressful options for women, who rely on volunteers to do everything from finding people to accompany them to the hospital to arranging childcare. Becka Viau of the Abortion Rights Network helps women figure out requirements for bloodwork and pinpoint how far along they are in their pregnancy, as well as line up drivers, babysitters and meals while raising funds to cover things like the $45 bridge toll, phone cards and lost wages.

The pressure on the community to carry the safety of Island woman is ridiculous," she said. "You can only look at the facts for so long to see the kind of harm that's being done to women in this province by not having access." Still, for some MacLauchlan's announcement was a significant change for a province that has fought for decades to keep abortions out of its jurisdiction, with some seeing it as the beginning of the end of the restrictive policy. Some say opposition to abortion access is quietly waning on the Island, where it is not uncommon to see pro-choice rallies and political candidates.

Colleen MacQuarrie, a psychology professor at the University of Prince Edward Island who has studied the issue for years, said the Moncton plan had been discussed with former premier Robert Ghiz and was considered a first step toward making abortions available in the province. But a month after those discussions, Ghiz resigned. Reached at his home, he refused to comment on the talks but said everything was on the table. "We've created the evidence and we've gotten community support," said MacQuarrie, who published a report in 2014 that chronicled the experiences of women who got abortions off Island. "It has gotten better, but better is not enough. We need to have local access."

Rev. John Moses, a United Church minister in Charlottetown, published a sermon that condemned abortion opponents for not respecting a woman's right to control her health and called on politicians to "stop ducking the issue." "To tell people that they can't or to make it as difficult as we possibly can for them to gain access to that service strikes me as a kind of patriarchal control of women's bodies," he said in an interview. "It's a cheap form of righteousness."

Holly Pierlot, president of the P.E.I. Right to Life Association, says she's concerned about the easing of restrictions and plans to respond with education campaigns aimed specifically at youth. "Politically, we've certainly got a bit of a problem," she said. "We were disappointed by the new policies brought in by the provincial government and we are concerned by the federal move to increase access to abortion." Horizon Health in New Brunswick says the Moncton clinic saw 61 women from P.E.I. from July through to Nov. 30. P.E.I. Health Minister Doug Currie did not agree to an interview, but a department spokeswoman says that from April to October the province covered 44 abortions in Halifax and 33 in Moncton.

"The government made a commitment to address the barriers to access and they acted very quickly on it," Jean Doherty said. It's not clear whether that will be enough to satisfy the new federal Liberal government under Prime Minister Justin Trudeau, who told the Charlottetown Guardian in September that "it's important that every Canadian across this country has access to a full range of health services, including full reproductive services, in every province." The party also passed a resolution in 2012 to financially penalize provinces that do not ensure access to abortion services. In an interview, Federal Health Minister Jane Philpott would only say the issue is on her radar.

This is something I am aware of, that I will be looking into and discussing with my team here and with my provincial and territorial counterparts," she said. Successive provincial governments have argued that the small province cannot provide every medical service on the Island or that there are no doctors willing to perform abortions, something pro-choice activist Josie Baker says is untrue. "We're tired of being given the run around when it comes to a really basic medical service that should have been solved 30 years ago," she said. "The most vulnerable people in our society are the ones that are suffering the most from it. There's no reason for it other than lack of political will."

Seniors must find help for house cleaning, shopping or errands elsewhere, either by paying privately, relying on family and friends or turning to a replacement program funded by the United Way called Better at Home, which has received $22 million from the province. Vancouver-Mt. Pleasant NDP MLA Jenny Kwan says Mayer's story is similar to those she's heard from other seniors in her riding during the last month. At least five couples and individuals - most of them Chinese-speaking - contacted her about having their weekly home care hours cut in half. Most have gone from two hours to one, just enough time for a bath. "The government wants seniors to live longer at home, but if you don't provide the supports for them to live successfully and safely, how are they going to manage? That will only mean they are going to need hospitalization, residential care or assisted living," Kwan said. "It's pay now or pay later and pay more," she added, noting that a day in an acute care hospital bed costs taxpayers about $1,500, enough to pay for plenty of routine in-home care. The change in home support hours from Vancouver Coastal Health is part of a move to follow provincial rules more closely, said Bonnie Wilson, director of home and community care for the health authority.

Home support is supposed to help clients with daily needs including bathing, dressing, using the toilet, taking medication or setting up a meal. These are considered medical services. Home support workers are paid only to do those tasks and not a wider range of duties that were covered before policy changes about 10 years ago: visiting, transportation, light yard work, minor home repairs, light housekeeping and grocery shopping. "VCH's home support guidelines are consistent with the Ministry of Health and other health authorities. Historically the mandate for home support services used to be broader, but this was sometime before 2004 (the guidelines that preceded our current ones)," Wilson explained in an email. "This was at a time when there was no distinction between medical and non-medical support services, and when clients went to residential care much sooner than they are now."

The complex medical problems experienced by some of Canada's oldest residents reflect a growing trend: people are living much longer, but not necessarily in good health. They can often stay at home - and avoid the high cost of either private or publicly funded nursing in residential care - but home support workers are being called upon to deliver some services that formerly fell to nurses. Doing laundry or picking up groceries are long gone from their to-do list. Exceptions to that, says Wilson, are allowed if it's unsafe for workers or the client to be in the home because of the mess, or if a client risks eviction or has been refused other government-subsidized services such as HandyDart because of a lack of cleanliness.

In British Columbia, home care is typically provided and subsidized - depending on income - by a local health authority that contracts the duty to a handful of accredited private companies. Clients with higher incomes often hire their own help. In 2013-14, B.C's health authorities spent $1.1 billion on home support for about 39,000 clients. That compares to $1.8 billion spent on residential care for 27,308 seniors. In 2012-13, the province funded 7.37 million hours of home support, according to the Ministry of Health, 23 per cent more than three years earlier. B.C.'s Office of the Seniors Advocate is planning to survey all recipients of publicly funded home support in the province about their experiences for an upcoming report. The Minister of Health was unavailable for comment by press time.

Scientists overseeing the studies say the apps could transform medical research by helping them collect information more frequently and from more people, across larger and more diverse regions, than they're able to reach with traditional health studies. A smartphone "is a great platform for research," said Dr. Michael McConnell, a Stanford University cardiologist, who's using an app to study heart disease. "It's one thing that people have with them every day." While the studies are in early stages, researchers also say a smartphone's microphone, motion sensors and touchscreen can take precise readings that, in some cases, may be more reliable than a doctor's observations. These can be correlated with other health or fitness data and even environmental conditions, such as smog levels, based on the phone's GPS locator.

"Participating in clinical studies is often a burden," he explained. "You have to live near where the study's being conducted. You have to be able to take time off work and go in for frequent assessments." Smartphones also offer the ability to collect precise readings, Dorsey added. One test in the Parkinson's study measures the speed at which participants tap their fingers in a particular sequence on the iPhone's touchscreen. Dorsey said that's more objective than a process still used in clinics, where doctors watch patients tap their fingers and assign them a numerical score.

The most important is safeguarding privacy and the data that's collected, according to ethics experts. In addition, researchers say apps must be designed to ask questions that produce useful information, without overloading participants or making them lose interest after a few weeks. Study organizers also acknowledge that iPhone owners tend to be more affluent and not necessarily an accurate mirror of the world's population. Apple had previously created software called HealthKit for apps that track iPhone owners' health statistics and exercise habits. Senior vice-president Jeff Williams said the company wants to help scientists by creating additional software for more specialized apps, using the iPhone's capabilities and vast user base - estimated at 70 million or more in North America alone. "This is advancing research and helping to democratize medicine," Williams said in an interview.

Others have had similar ideas. Google Inc. says it's developing a health-tracking wristband specifically designed for medical studies. Researchers also have tried limited studies that gather data from apps on Android phones. But if smartphones hold great promise for medical research, experts say there are issues to consider when turning vast numbers of people into walking test subjects.

Apple launched its ResearchKit program in March with five apps to investigate Parkinson's, asthma, heart disease, diabetes and breast cancer. A sixth app was released last month to collect information for a long-term health study of gays and lesbians by the University of California, San Francisco. Williams said more are being developed. For scientists, a smartphone app is a relatively inexpensive way to reach thousands of people living in different settings and geographic areas. Traditional studies may only draw a few hundred participants, said Dr. Ray Dorsey, a University of Rochester neurologist who's leading the Parkinson's app study, called mPower.

Some apps rely on participants to provide data. Elizabeth Ortiz, a 48-year-old New York nurse with asthma, measures her lung power each day by breathing into an inexpensive plastic device. She types the results into the Asthma Health app, which also asks if she's had difficulty breathing or sleeping, or taken medication that day. "I'm a Latina woman and there's a high rate of asthma in my community," said Ortiz, who said she already used her iPhone "constantly" for things such as banking and email. "I figured that participating would help my family and friends, and anyone else who suffers from asthma."

None of the apps test experimental drugs or surgeries. Instead, they're designed to explore such questions as how diseases develop or how sufferers respond to stress, exercise or standard treatment regimens. Stanford's McConnell said he also wants to study the effect of giving participants feedback on their progress, or reminders about exercise and medication. In the future, researchers might be able to incorporate data from participants' hospital records, said McConnell. But first, he added, they must build a track record of safeguarding data they collect. "We need to get to the stage where we've passed the privacy test and made sure that people feel comfortable with this."

Toward that end, the enrolment process for each app requires participants to read an explanation of how their information will be used, before giving formal consent. The studies all promise to meet federal health confidentiality rules and remove identifying information from other data that's collected. Apple says it won't have access to any data or use it for commercial purposes.

Elizabeth Ortiz uses the Asthma Health smartphone app to track her condition. • Richard Drew/the associated press

"Health care is an industry about people," says Andreas Laupacis, the creator of the website, which launched in July. "But there's a strain on the ways patients interact with their health-care providers and the people that create the policies and manage the system are sometimes so removed from the reality of it."

Mr. Laupacis is in the health field, as the executive director of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, board chair of Health Quality Ontario and a board member of Cancer Care Ontario. The new site is linked to HealthyDebate.ca, an online health policy magazine and another one of Mr. Laupacis's creations.

As technology is further integrated in the system, he says, there are fewer face-to-face interactions, and sometimes patients become a "drop-down menu" rather than a human being. With a group of writers and photojournalists, Mr. Laupacis aims to tell the stories of the people affected by health-care decisions, both positively and negatively, as well as all the murky in-betweens.

His collaborators are either in the health-care field or have a strong interest in it, such as Dr. Jeremy Petch, a photographer, and Wendy Glauser, the main writer for HealthyDebate.ca. "Even those of us that work in the health care system, we only work in a certain part of it, so we only have an idea of a certain side," he says. "I think it's really valuable for us to be able to hear and see those faces and stories."

Policy makers and managers of health care are often removed from the realities of giving and receiving care, they explain on their website. So they rarely see the human consequences, both good and bad of their decisions. The project is meant to give voice to those impacted by the decisions and spark a different way of thinking. For Cathie Hofstetter, a woman living with rheumatoid arthritis for the past 23 years, who was profiled by the site, it was a great opportunity. "They're doing a wonderful thing," she says.

"These voices really need to be heard. How else are you going to know if something is working or failing?" So far, it's been positively received. In a 30-day crowdfunding campaign to help pay for the website's operations, $15,000 was raised. The site has also been met by positive feedback from people reaching out to share their own experiences. The plan, Mr. Laupacis says, is to have two new faces up on the site every week and expand outward from Toronto, where the stories are based now, to other parts of Ontario, and then across Canada. Next month, he is travelling to Quebec to interview people in small towns, hoping to encompass a wider range of health issues.

"I'm looking for diversity on the site, different stories from people who haven't had the chance to share them," he says. IN THEIR WORDS When you go into someone's home, it is a different power relationship. I am a guest.

You have to win them over. A lot of the folks who are living at home in dire circumstances, or in supported circumstances, are there because they are fiercely independent. So, they don't like this bossy nurse telling them what to do. Lorna, a nurse practitioner I walked into the office of my old family doctor and told her I was trans and that I wanted surgery. She said she would look into it but I could tell she was not very comfortable with it. Within a couple weeks, she called me at my home. 'I'm really sorry but I just don't know what to do with you' were her words.

Lucas I just knew that I wanted my mom to be where she could be comfortable and have somebody with her all the time, and that I wouldn't have to hear from somebody 'Oh, your mom's died'. So that I would be there with her. Pat When we were initially told that our four year old had cancer, aside from being in shock, I remember how polished the doctor was in his presentation. I remember thinking how sad it was that a man could be so polished and deliver such devastating news. Kirby, father of Indira (pictured)

The average number of people on wait lists as of May, 2015, is 611. Some regions have shorter wait lists, such as Toronto Central, which currently has zero. Others are in the four digits, such as the Central East CCAC, which stretches east from Victoria Park Avenue in Scarborough and north to Algonquin Park, and has 1,516 children waiting for speech therapy. Waiting that long can have a large impact on a child's ability to do well in school, according to Anila Punnoose, a director of Speech-Language and Audiology Canada. During the months or years children are waiting to get speech services, they can quickly fall behind in school, she said. A 1996 study found children with language deficits are more likely to experience social difficulties including interacting with their peers, which impacts their behaviour. Other studies have shown that children who don't get speech therapy early are at a greater risk of problems in their academic performance and mental health.

A lot of speech problems carry over to literacy, because a knowledge of speech sounds is crucial when learning to read, Punnoose said. "It's all about what you hear in those sounds. ... Do you know the beginning sounds in that word? A child who doesn't have good phonological awareness doesn't understand any of that," she said. When looking at school performance, Punnoose said early struggles carry through to later years. A child with speech problems who has difficulties learning in the early years won't be able to build on those lessons in later years as effectively as their peers, she said. Early intervention can mitigate and prevent those problems, she said. "If children are having severe difficulties with speech in kindergarten, it's a predictor that there's going to be academic difficulties, and especially reading and writing difficulties, by Grade 3," she said.

Jocelyn Fedyczko, Eddie's speech pathologist, has worked in a range that includes children from preschool all the way to teenagers. She said early intervention is crucial with young children such as Eddie. "The earlier you can help a child out, the more progress you see," she said. When a child gets to the top of the wait list, they get assessed again, and receive a block of treatment, usually around 10 or 12 sessions, says Peggy Allen, president of the Ontario Association of Speech-Language Pathologists and Audiologists (OSLA). That's often not enough to treat even minor to moderate issues such as Eddie's. Fedyczko said she can get through two to three sounds in that time, depending on the child. Many children have problems with more sounds than that, she said. But when a child finishes their block of treatment and needs more, because they haven't worked through all the sounds, for example, they go back to the bottom of the wait list, Allen said.

A spokesperson for the Toronto Central CCAC said they do not have an upper limit to the number of sessions per block assigned by a speech-language pathologist. The pathologist determines three goals for a child to achieve and assigns the number of sessions according to that. If after these sessions more goals are identified, the child is re-referred to the program, the spokesperson said. Parents who are worried about the impact waiting can have on their child can go to private clinics, if they have coverage or can afford the sessions out of pocket. Trish Bentley, Eddie's mother, decided to go for private therapy with Eddie's older brother Oliver. He was put on a six-month wait list for speech problems slightly more acute than Eddie's.

B.C.: Children's speech therapy is organized through the Ministry of Health, Ministry of Children and Family Development (MCFD) and through the Ministry of Education by way of school districts. Children are divided between preschool and school age. Preschool children go through regional health authorities. School-age children go through the school boards, but the pathologists there will often offer consultative services, rather than oneon-one speech therapy. B.C. also has a "no-wait-list" policy for children with autism, which translates to parents getting around $22,000 a year for therapy until the age of six, and $6,000 a year after that. Alberta: Health Services is in charge of speech therapy in that province. It offers both a preschool and a school program. The school program, unlike Ontario's, is done completely through the schools, with no CCAC-type system to refer out to. Saskatchewan: The school districts are responsible for speech therapy. Each school district divides up services slightly differently, though they all differentiate between children under three years, from three to five years, and from six to 18 years.

Rather than wait those six months, Bentley took him to Canoe. "As time went on, we said enough of this, he's going to be past the point of catching the problem," she said. For families who don't have coverage and who can't afford private services, though, the only option is to wait. Finding the cause of the long waits is hard, but one thing is certain: It's not due to a lack of speech pathologists, according to Shanda Hunter-Trottier, the owner of S.L. Hunter Speechworks, another private clinic in Toronto. She used to have problems finding qualified speech pathologists, but now she's facing the opposite problem. "I've been practising for 26 years. ... In the last five years, [I] have more resumes than I can keep track of," she said. Rather, she says, it's a large web of problems that slows down the system. First among these is a lack of public funding. "There's a lot of speech pathologists that don't have jobs, but these places aren't hiring. The cutbacks have been atrocious," she said.

Dividing services by language issues and other issues doesn't make sense when treating a child, she said. "You shouldn't be splitting up the kid," she said. Punnoose said she wants to see speech therapy come together under one roof. It would mean co-operation from all three ministries, as well as a major reorganization of the funding, but she believes it would be a better model for children. "Students are in schools the better waking part of their lives. Why wouldn't we have the services right there in an authentic environment where it's totally accessible," she said. There are changes coming.

Last December, the Ontario government announced more funding for preschool speech and language programs, as well as efforts to integrate speech services better, through its Special Needs Strategy. Punnoose says it's a good step. "The government recognizes that the system was broken," she said. For now, the choice for parents in many CCACs will be between long wait lists and paying for private service. Hunter-Trottier said many parents, even those with coverage, don't know about the latter option. "We sometimes get parents here in tears, saying, 'Oh my goodness, the services here, I wish I had known about that a year ago,' " she said. Bentley said she won't be looking at public services for Eddie, as she's happy with the service she gets at Canoe. "I'd be open to it, but I'm not going to actively seek that out," she said.

For Eddie, what matters is the progress he makes. Within 10 minutes of his trouble saying "lipstick," he was opening up a treasure chest, with a key. With little prompting, he used the same technique as before, separating the sounds of the word. "Kuh-ey," he said. Could he try it all together? He pauses for a second. "Key," he says, almost flawlessly, beaming at his success. SPEECH THERAPY IN EACH PROVINCE

Speech therapy, like all healthcare matters, is regulated differently in each province and territory in Canada. Information on how each system works is difficult to come by. But generally, most provinces have very similar systems - and challenges - according to Joanne Charlebois, CEO of Speech-Language and Audiology Canada. Charlebois said Ontario's wait times are probably worse than those in other provinces, but she's spoken to people across Canada who tell her similar stories. Here's a breakdown of how it works across the country. Ontario: Speech therapy for children falls under the responsibility of three ministries: the Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. Children in Ontario are divided by age and by the nature of their speech problem. Children under school age qualify for Ontario's preschool speech and language program. Once in school, those children with language problems - major problems speaking or understanding words or sentences - go to a school speech pathologist, while any other problems, such as pronunciation, stuttering, voice and articulation are referred to the Community Care Access Centres, which employ contract speech pathologists.

But the problems go deeper than a lack of funding, according to Allen. She said many of the issues in Ontario stem back to a series of agreements in the 1980s between the provincial Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. These agreements divided up who is in charge of different treatments, between the school boards and the CCACs. At the time of their creation, these agreements made sense, but times and needs have changed, she said. "It's difficult when ministries make agreements that are frozen in time. It's very difficult to provide the kind of services that we all expect and want Ontarians to receive," she said. Dividing up the services is necessary when trying to manage resources, but the fragmentation is hurting children more than it's helping, Punnoose said.

Manitoba: School districts are also in charge here. The inschool speech-language pathologists offer services from classroom-based programming to individual therapy. Quebec: The system here is more like Ontario's. Speechtherapy services are offered through the local community service centres (CLSC), similar to Ontario's CCACs. The CLSCs are not obliged to provide speech therapy in English, though some, especially in areas with a large anglophone population, usually do. Nova Scotia: The province has 28 speech and hearing centres, with 35 pathologists in total. They assess and provide treatment for children and adults. School boards in the province also have speech-language pathologists who also have a teacher's certificate.

Prince Edward Island: The province provides free speech services for children until they enter school. Northwest Territories: Speech therapists are only able to visit some remote communities once or twice a year. Instead, the province offers a service called Telespeech, where pathologists can help people without having to be physically present. Nunavut: The territory had no speech pathologists in 2013, according to Statistics Canada.

The gestures stem not only from the country's growing diversity, but a generally more patient-focused system - and a recognition treating solely physical ailments is not always enough. "If we don't engage in the (cultural) discussion, we won't fully understand their health needs and they won't get met," says Marie Serdynska, who heads a pioneering project in the field, the Montreal Children's Hospital's socio-cultural consultation and interpretation services.

So ultimately they will get sicker and be a greater cost to the health-care system." But with the topic being featured at national pediatric and bioethics conferences recently, medical professionals are debating a difficult question: is there is a point at which catering to cultural preferences crosses a moral - or even legal - line? While a physician in the neonatal intensive care unit at Toronto's SickKids hospital, Dr. Jonathan Hellman was sometimes asked by fathers from "patriarchal" cultures not to discuss a child's condition with the mother unless the husband was also present.

Agreeing to such a request not only raises ethical and practical questions, he says, but might even violate Ontario's Health-Care Consent Act - unless the mother explicitly agreed to the arrangement. "It's challenging to the caregivers in that situation, when the mother is at the bedside and the father is able to visit only in the evenings," says Hellman. "And we believe that both equally have decision-making power, both should have information." Even hospitals that try to be sensitive to specific cultural groups, like Ontario's Hamilton Health Sciences Centre, with its aboriginal patient "navigator," can face vexing dilemmas. When two First Nations girls with leukemia decided to withdraw from chemotherapy at the facility and try native remedies, an emotional courtroom battle followed.

And it recently emerged that a Vancouver-area intensive-care unit was asked to keep a braindead patient on life support for days until he could be flown to his country of origin, the family's culture rejecting the concept of neurological death. Still, for every demanding request, there are dozens of positive incidents - even if they involve once-unheard-of accommodation, say ethicists, doctors and patient advocates.

Some Halifax hospitals have convinced the fire marshal to allow smudging, aboriginal purification rituals in which sweetgrass is burned. Sometimes, this means adjusting the smoke detector in a patient's room temporarily so it doesn't set off an alarm, says Christy Simpson, a bioethicist at Dalhousie University in Halifax. Randi Zlotnik Shaul, director of bioethics at SickKids, said she's aware of a request for a drumming circle in a neonatal intensive care unit, a normally very quiet environment. Steps were taken to comply with the proposal - and not interfere with other tiny patients - but the need for an open fire eventually made it impossible, she said.

Yet fulfilling such appeals, often made for dying patients, can be a question simply of innovation and compromise, like when someone asks that a patient's bed face Mecca, she says. "Some might respond very categorically, 'Nope, in this place all beds face the same way,' "she says. "Someone oriented another way might say, 'Yeah, they are all faced that way, but maybe if we got an extension cord, there is actually something we can do.' " Serdynska says she knows of hospitals providing "mementos" of births to new mothers whose cultures traditionally require them to bury their placenta. Dr. Tara Kiran, a Toronto family physician, was taken aback when she first encountered patients from Bangladesh and Pakistan at an inner-city clinic who insisted on fasting between sunrise and sunset during Ramadan, despite health issues like diabetes that normally require strict regulation of diet and medication.

Her patients, however, happily embraced what they saw as the experience's beneficial, spiritual benefits. "It was an interesting challenge to my assumptions," says Kiran. "My gut reaction was that fasting has negative impacts on health." In London, Ont., St. Joseph's Health Centre runs a special clinic during Ramadan to help the city's estimated 3,000 diabetic Muslims. Muslim needs, including heightened privacy for female hospital patients instead of the usual, unannounced arrival of staff at the bedside, were once given short shrift, says Khadija Haffajee, spokeswoman for the National Council of Canadian Muslims. But the system has generally made great strides, adds Haffajee, who has addressed classes of nursing students on her faith's practices. "It's about reasonable accommodation and understanding," she says. "When people are ill, you're dealing with very vulnerable people, so empathy goes a long way."

Accommodation can sometimes simply be a case of bridging the cultural divide, says Montreal's Serdynska. Medical teams at her hospital once saw Vietnamese patients with unexplained bruising and immediately suspected child abuse. Further inquiry revealed the marks were the result of "capping," or "coining," a traditional southeast Asian treatment that involves scraping a smooth edge across the body in the belief it releases unhealthy elements. Her service now has cultural interpreters who will talk to immigrant parents when, for instance, drug treatment is not working. Sometimes, it relates to the side effects and contraindications spelled out on unfamiliar packaging, she says. "For some cultures who do not generally take pharmaceutical medication, this is very frightening." The institutional, impersonal nature of a hospital alone makes it a daunting place for aboriginal people, especially if they attended residential schools, says Margo Greenwood, academic leader at the National Collaborating Centre for Aboriginal Health in Prince George, B.C. Hanging indigenous art, providing culturally appropriate prayer space and consulting local native communities all help alleviate that anxiety, as does being open to other forms of treatment.

You're dealing with two different systems of knowledge: one is what I learned when I went to university and one is what I learned in my community," she says. "People (are) saying ... 'I want the two to work together.' "But what are health-care providers to do when the request stemming from an ethnic or religious practice appears to breach their own ethical boundaries? Reports in 2013 of doctors in Quebec issuing virginity certificates earned a swift response from the province's medical regulatory body. Physicians must refuse to comply, insisted the College des Médecins, and explain such a service has nothing to do with health care. Less black-and-white, perhaps, is the patient asking for a doctor of a particular sex or, less commonly, of a specific race. On the surface, at least, the idea is a repudiation of fundamental human-rights principles, yet for some patients it could be a religious imperative or a fallout from past abuse.

Some hospitals say they will try as much as possible to provide a female doctor for Muslim women, for instance, when asked. In Montreal, about half the obstetrician-gynecologists are women, so supplying a female one is usually quite feasible, said Togas Tulandi, interim head of the McGill University medical school's obstetrics and gynecology department. More troublesome, say ethicists and physicians, are patients who insist they not be treated by a doctor or nurse of a certain race - typically Caucasians rejecting non-white workers in today's multi-hued medical workforce - or want one of their own colour. Ethicists at Toronto's University Health Network (UHN) published a nine-page paper on how to tackle "discriminatory" requests of this sort, suggesting the affected health-care worker should often have the final say.

"It's ugly, it's unfair," says Linda Wright, a bioethicist at UHN, of the potential impact on medical staff. "To ... have someone say you're not good enough because of the colour of your skin is offensive." How often Canadian hospitals have to deal with the dilemma is unclear. A 2010 U.S. study of emergency doctors, though, concluded the scenario is common, with hospitals frequently accommodating requests for race-specific practitioners. And that is not such a bad thing, argued U.S. law professor Kimani Paul-Emile in a provocative 2012 article. He cited evidence that having a "race-concordant" doctor can bring health benefits, especially for blacks and others who have historically faced prejudice. In the meantime, hospitals here are still more likely to encounter less-contentious culturally based issues, such as whether to loosen age-old restrictions on the number of well-wishers in a patient's room.

"In some cultures ... you have everybody there. You have all the aunts and all the uncles, and all the family members and friends," says Dalhousie's Simpson. "For me, that's been one of the really interesting changes. Why did we say it only had to be two? Why did we limit it so much? Because clearly there's value to having your loved ones around you."

Wayne Brown, the president of the New Brunswick Council of Nursing Home Unions, which falls under the Canadian Union of Public Employees umbrella, said the members of the locals representing the two nursing homes don't plan on going away without assurances their issues will be dealt with. "We're getting more and more pressure on him and I know he has to tow the party line but he also has to step up to the plate for those folks who are his constituents," Brown said.

"So we're certainly not done yet - it all hinges on that RFP that is coming out and my feeling is that they are certainly revisiting that RFP, so maybe they're looking at something ... hopefully they will blink on this one because there are ways for them to save face." During a town hall meeting organized by government officials in Miramichi last Thursday, Rogers and Fraser stopped short of guaranteeing the union concerns would be addressed in full.

Fraser said he would like to engage in deeper dialogue with officials from the Senior Citizens Home about how they could partner up to help ensure that programming like Meals on Wheels and adult daycare are enhanced in the transition to the new place. In terms of the labour concerns, Fraser said the government team is "well aware" of them and said high-level discussions have taken place to discuss how to mitigate some of them and potentially work some of them into the RFP.

But on the P3 model, he said the government has to make strategic changes to the way it has traditionally done things in order to trim expenditures and free up efficiencies. The government has made a commitment to building any new nursing homes moving forward using a P3 model and it just so happens that the Miramichi facility is first in line for this new way of doing things. That setup, he stressed, allows the government to dictate the standards of care without adding to its financial burden and it is clear the province doesn't have any current plan to back away from that strategy.

Fraser said people have to "get past the fact that we're going to an RFP" for the new nursing home. "The province is in a fiscal situation that is at the brink - the interest payment on our debt alone is in excess of $650 million a year ... that's not the debt, that's the interest payment," Fraser said.

"Think of the good things we could do if we could get that under control, and this home would not be possible any other way without going through the RFP process to ensure the best economic return on our dollar and for the best care, safety and comfort of our seniors." There are presently three private nursing homes in New Brunswick and all of them are operated by Shannex. Fraser said the main reason the province is committing to this project is to alleviate some of the strain being put on the delivery of front-line health services at the Miramichi Regional Hospital, where many seniors are forced to reside until a new nursing home bed opens up. He said the community "needs to come together" on this.

But both ministers said they were actively listening to what the workers were saying and would attempt to work some of those issues into the request for proposals which will ultimately lead to the proponent that will build and maintain the home. Speaking last Friday, Fraser said once again he understands how staff would be nervous about the situation given that a new entity will be coming in to run the new building.

"Are we going to guarantee everything? Probably not, but are we going to do our best to address as many of the issues as we can? Absolutely we are," he said. "Because at the end of the day we want our residents to be cared for by people they know in an environment they love, and I'm confident that's going to happen." As for the CUPE membership, Brown said they aren't willing to compromise on the issues they've outlined and he hopes the government understands why.

Sadly, the offerings in our health system are driven as much by tradition as they are by evidence. We needn't be prisoners of our outmoded structures. In the fifties and sixties, we created a system to provide care in hospitals and in physicians' offices and it's almost impossible to break that mould and innovate - for example, by putting psychological care on an even footing with psychiatric/medicinal treatment. What we really need to do is provide care where people bring their mental-health problems - in primary care. As most provinces try to transition from a solo, fee-for-service model to multidisciplinary teams, it provides a perfect opportunity to bolster mental-health care by integrating psychologists onto teams. Other countries have done so, notably Britain and Australia, and the early evidence is that it's paying off. The fear, of course, is that providing public funding of psychological care will cost more. Of course it will. Estimates range from $950-million to $2.8-billion a year.

But the offering of psychological care doesn't have to be an open buffet like other aspects of health care, and some of the hundreds of millions now paid for (not always trained) doctors to provide psychotherapy can be spent more smartly. If done right, the investment should pay off down the road, in lower health costs, disability-insurance payouts and absenteeism. Because the greatest costs of mental illness arise when it is left untreated, and festers. Mental illness is common: 10 per cent to 25 per cent of women and 5 per cent to 12 per cent of men experience a major depression; 4 per cent to 7 per cent of Canadians suffer from anxiety disorder; 7 per cent to 12 per cent experience posttraumatic stress disorder; 10 per cent suffer from phobias; 5 per cent experience panic disorders; 2 per cent to 4 per cent suffer from obsessive compulsive disorder or eating disorders; 1 per cent to 2 per cent suffer from bipolar disorder or schizophrenia. For years, we have been focusing efforts on combatting the stigma, urging Canadians with mental-health disorders to come forward. But the care is not available for those who need it; waits stretch from months to years, and an estimated one in three adults and one in four children don't get care at all.

Psychotherapy can help fill the gap. There are 8,000 psychologists in Canada. About three-quarters are in private practice, charging $100 to $200 an hour, and roughly one-third work exclusively in the public system, where there is no charge to patients. Canadians spend about $950million on psychological care, most of it covered by private insurance and workers compensation; but a good chunk, about one-third, is paid out of pocket. We have a mixed health-funding model in this country, but when it comes to mental-health care, we don't have the mix right. Too many people are being denied care because they can't afford it, or because their workbased insurance provides paltry benefits for psychological care. As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care.