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The latest Intergovernmental Panel on Climate Change report, released in 2014, outlined more clearly and with greater certainty than ever before how both climate change and pollution from the combustion of fossil fuels have killed thousands of people and will threaten the lives of many more.2

In 2010, a position statement from the Canadian Medical Association3 called for physicians to take action, but it focused largely on developing strategies to deal with the impending effects of climate change on health and health systems. In 2013, a CMAJ editorial4 discussed the role of physicians on the front line of climate change and examined how they can make a difference at the political, professional and individual levels. These recommendations remain pertinent.

Prompt action on reducing fossil fuel emissions in the near term, to prevent irredeemable downstream effects, is just as important as responding to current and imminent threats. An emergency medicine physician based in Yellowknife summed it up well when she likened the relatively small window for action to the urgency following a myocardial infarction or the onset of sepsis. “We either get the job done in the next decade or so or we prepare for palliative care.”5

Yet achieving international binding agreements seems to be happening at a slower pace than that of receding glaciers. When world leaders convene, issues related to saving the world from economic collapse, terrorist threats and oil crises seem to come before those related to saving the world from the threat of climate change. However, things are changing at the macro-economic level. The World Bank has made strides in coordinating international efforts to develop renewable energy, develop globally networked carbon markets and “enhance the flow of finance toward the ongoing effort to limit global warming.”6 One can perhaps see the influence of the current president of the World Bank, who is a physician and social anthropologist, in these recent actions.

Humans are bad at envisioning or appreciating the long-term consequences of behaviour. Behavioural scientists call the phenomenon “delayed reward discounting.” In short, we need salience now. In developed countries such as Canada, many of the adverse effects of climate change will only affect future generations. Although we may believe the science and many of us may support our government in making binding agreements to reduce carbon emissions, changing our personal behaviours may be costly, inconvenient and difficult. How do we galvanize to combat global warming?

Health promotion campaigns are most effective when delivered on multiple levels at once, combining information on the health benefits of a behaviour change with modelling of the behaviour, reduced barriers to its adoption, a good system of social support for those who adopt it, and person-to-person promotional initiatives and media campaigns.7

We need such a multipronged campaign to drive real action on climate change. Physicians are agents for change at all levels, and we can do more to bring climate change to the forefront of people’s consciousness. With our unique comprehension of stages of change and skill at intervening to help individuals make lifestyle changes at whichever stage they may find themselves, we can make a big impact.

We have managed to effect social change regarding smoking despite the power of industry, and we are beginning to turn the tide against the anti-vaccine lobby. Our approach to overcoming the stalling tactics of climate-change deniers should be no different. A few years ago, it was unusual to ask patients about how much physical activity they engaged in or how much sitting their job demanded. Now, we counsel about the risks of being underactive and write exercise prescriptions. It is time for physicians to talk about the effects of climate change routinely in daily practice. We should not forget that we are respected, influential advocates.

The only vestige that remains is a modest Conservative tax break. Seeking to undercut the Liberals on the eve of the 2011 campaign, Prime Minister Stephen Harper announced a family caregiver tax credit of less than $1 a day. It applies to just 18 per cent of the 2.7 million Canadians who sacrifice their income, career prospects and sometimes their health to care for loved ones. With another federal election approaching - and the baby boom generation entering retirement - caregivers have been pushed to the periphery of the federal agenda.

The provinces still talk about them - praising their dedication and selflessness - but don't provide enough home care or respite care to ease the physical burden or alleviate the loneliness of caring for a family member with dementia, severe disabilities or chronic illness. Advocacy groups lobby for seniors but seldom focus on the family members who feed, clothe, bathe and clean up after those who need round-the-clock care.

Only when caregivers burn out requiring medical attention do policy-makers pay attention. Ken Wong, a robotics engineer who quit his job to care for his wife, diagnosed seven years ago with early-onset dementia, wants to avoid that fate. Last week, he wrote a poignant letter to his MPP, Helena Jaczek (who represents Oak Ridges-Markham and serves as minister of community and social services), pleading for relief. With his permission, here are a few excerpts:

"Some days are very tough to get through. She (his 53-year-old wife Nada) frequently screams and becomes agitated - sometimes for hours on end, night and day. It is a very exhausting and challenging role. "It is a lonely job. For whatever reasons, most friends and family seem to have distanced themselves. Sometimes there is more compassion from strangers.

"I am keeping my promise to my wife to cherish and protect her for better or worse, in sickness and in health till death do us part. But it is a long goodbye." Wong didn't ask for much. He suggested that Ontario look at Nova Scotia's five-year-old caregiver benefit. Early research shows the $400-a month payment has reduced the probability of institutionalization by 56 per cent. He appealed to Jaczek to take the idea to the cabinet table for consideration in this spring's budget. He ended his letter with a heartfelt plea: "Caregivers need your support to be strong physically, emotionally and spiritually to endure the daily demands for many years."

They don't appear to be a high priority for Health Minister Eric Hoskins. His "action plan for health care," released last week, did not mention caregivers. (Officials in his department pointed out that families can request temporary respite care at their local community care access centre.) The federal outlook is cloudy-to-bleak. The Conservatives are content with the status quo. The Liberals have said nothing specific, although Justin Trudeau has talked about the overstretched sandwich generation (families with young children and elderly parents). Only the Democrats, who are running third in popular support, are offering tangible help. They would introduce a caregiver tax benefit modelled on the child disability benefit (which provides a monthly payment of up to $220 for parents caring for a severely impaired child).

For the most part, caregivers are out of sight and out of mind. They are easy to take for granted. They're quiet, steadfast and undemanding. They deplete their savings and sacrifice their freedom. Without them, the cost of health care would skyrocket. A smart government would safeguard such a vital asset. Carol Goar's column appears Monday, Wednesday and Friday.

According to researchers at Liverpool University, the actual production costs of Sovaldi for the 12-week course is in the range $68-$136. Indeed, generic sofosbuvir is currently being marketed in India at $300 per treatment course, after India refused to grant Gilead a patent for the Indian market. In other words, the U.S. price-cost markup is roughly 1,000-to-1!

This builds off active fall and winter seasons which saw, among other events, a massive Halloween demonstration in Montreal dubbed "Austerity: A Horror Story", and at the end of February a week over 100 educational and mobilization actions throughout Quebec including banner drops, lectures, singing in bank lobbies, and occupying ministers' offices.

Unlike the spring of 2012 in Quebec, the core of this mobilization is much broader than students and includes community groups, professors, day-care workers, parents, unions and more. 

Quebec's public-sector unions are currently in contract negotiations with the government and some may be in a position to strike legally as early as April 1. There is mobilization happening at local union levels, especially in those focused on health and education, where the cuts and legal changes  will be strongly felt. 

Organizers in the rest of Canada are hoping the movement in Quebec can inspire action in their English-speaking communities. And it may be starting. 

David Gray-Donald

Seniors: no new strategy

Drugs: bulk-buying proposal may be counterproductive

Bulk-buying is one part of the solution but in and of itself it is not a national Pharmacare plan.

CUPE will continue to pressure all levels of government to commit to a new health accord. On January 26, many CUPE members joined 130 activists from the Canadian Health Coalition in a lobby of 140 Members of Parliament, in Ottawa.

Stakeholders throughout the province's health-care system have been lobbying successive provincial governments for at least a decade, urging them to lift restrictions that force the province's roughly 35 advanced-care paramedics to work below their full scope of practice. In February, the provincial government announced it had set aside $580,000 for a new pilot project, which will help New Brunswick figure out how best to make use of these valued health-care providers.

Health Minister Victor Boudreau said two committees have been formed to complete the behind-the-scenes work that is needed to introduce them to the existing ambulance service. So far, he said, things are going well, though he's not sure when advanced-care paramedics will be ready to use their skills on the streets. "We're still trying to put a pilot project together, making sure that we're respecting all the different moving parts to this," he said. "The money is still in the budget for this year. It's just sometimes these things prove to be a little more difficult than you'd like to put together. But it's certainly still on the table."

Chris Hood, executive director of the Paramedic Association of New Brunswick and a participating member of the committee tasked with sorting out the clinical issues around such a change, said that work is progressing nicely and he expects to see advanced-care paramedics in use within the provincial ambulance service soon. "I know the meetings have been happening and, by all indications, we're getting close," he said.

"The committees are still meeting. I've missed the last two meetings, but we had a representative there. They're getting into discussions about the protocols for practitioners, what they'll be following. From what we hear, it sounds like full-steam ahead. They accelerated the meeting times and it seems like everything is on the right track ... All of the prep-work that is necessary is, I would say, probably 80 per cent done, 85 per cent done." Ambulance New Brunswick is also completing some preparatory work, said Hood.

"They're looking at curriculum - refresher programs and things like that. From the clinical side of the business, which is what we're concerned with, that stuff is almost complete," he said. "If form follows function, we should be moving forward rather quickly."

When asked if the province's advanced-care paramedics are excited they'll finally be able to put all of their training to use in this province, Hood said many are still frustrated from the long struggle to lift these restrictions on their scope of practice. "I think many ACPs are still a bit, 'I'll believe it when I see it.' But some are very excited about it. We've had a couple of people enquire about attending ACP school and I know that the requests for enrolments in ACP classes both in New Brunswick and in the state of Maine are increasing," he said.

People are starting to feel more comfortable in spending the money to upgrade their skills, to take the education they need. But with the existing practitioners, I think, it's a wait-and-see mentality." Judy Astle, president of paramedics' union CUPE Local 4848, said she's anxious to learn what the pilot project may look like and how advanced-care paramedics will be used alongside primary-care paramedics across the province.

It's going to be a positive," she said. "But we're still waiting to find out the details."