25,000 a year left hospital despite doctor's order

Dr. Stephen Hwang of St.Michael's Hospital in Toronto says it is important to be proactive in ensuring followup for patients who leave against medical advice. (The Canadian Press)

People who leave hospital against medical advice are more than twice as likely to be readmitted within a month compared with patients who are discharged as scheduled, a new Canadian report shows.

Patients who leave hospital earlier than their health team recommends are known to be at increased risk of harm, including readmission to hospital and death, according to previous studies.

Tuesday's report from the Canadian Institute for Health Information paints a profile of the characteristics of people who are more likely to leave hospital against medical advice and quantifies readmission rates.

In 2011-2012, a total of 25,137 admission or 1.3 per cent of acute hospital admissions ended with patients leaving against medical advice across the country, excluding Quebec.

Compared with patients with routine discharges, those who left early were:

• More than twice as likely to be readmitted within a month (24 per cent versus nine per cent).
• More than three times as likely to visit emergency within a week (35 per cent versus 11 per cent.)
• Had an average of 2.3 inpatient admissions per year compared with 1.3 for other patients.

Self-discharged patients were more likely to be younger and male, and a have a history of leaving against medical advice, CIHI said. They were also more likely to have mental health issues and diagnoses of psychoactive substance abuse.

"The current study found that patients were more likely to leave against medical advice between evening and early morning hours," the report's authors concluded.

"It is telling that patients who leave against medical advice are also more likely to live in low-income neighbourhoods; they likely have more restricted options for child care and less flexibility in their places of employment."

Dr. Stephen Hwang, a scientist and physician at St. Michael's Hospital in Toronto, speculated on one factor: At night, the team that regularly looks after a patient and has a good understanding of patient issues aren't available, which emphasizes the importance of improving handover instructions for all patients.

"It's very frustrating when a patient wants and insists on leaving when we think it's inadvisable," Hwang said. "I always try to understand the situation from the patient's perspective."

Sometimes, after having an open and honest conversation to understand why the patient wants to leave, he or she will reconsider, Hwang said, adding the majority don't change their mind.

In those cases, Hwang said, it's important to be more proactive in ensuring followup, such as having the patient leave with antibiotics in hand or calling in a couple of days with the aim of giving the patient the best chance of staying out of hospital.

In a second part of the report, the institute's authors said nearly one per cent of discharges — almost 53,000 people — left against medical advice from emergency departments in Alberta and Ontario. The rates are comparable to those in other countries, they said.

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Infertile woman gives birth after ovary treatment in Japan

In this Dec. 28, 2012 photo provided by Dr. Kazuhiro Kawamura of the St. Marianna University School of Medicine in Kawasaki, Japan, Kawamura holds a newborn baby whose 30-year-old mother was treated for primary ovarian insufficiency. (Kazuhiro Kawamura/Associated Press)

A 30-year-old infertile woman gave birth after surgeons removed her ovaries and re-implanted tissue they treated in a lab, researchers report.

The experimental technique was only tried in a small group of Japanese women with a specific kind of infertility problem, but scientists hope it can also help women in their early 40s who have trouble getting pregnant because of their age.

The new mother gave birth to a son in Tokyo last December, and she and the child continue to be healthy, said Dr. Kazuhiro Kawamura of the St. Marianna University School of Medicine in Kawasaki, Japan. He and others describe the technique in a report published online Monday by the Proceedings of the National Academy of Sciences.

The mother, who was not identified, had been diagnosed with primary ovarian insufficiency, an uncommon form of infertility sometimes called premature menopause. It appears in about 1 percent of women of childbearing age. The cause of most cases is unknown, but the outcome is that the ovary has trouble producing eggs.

That leaves women with only a 5 per cent to 10 per cent chance of having a baby unless they get treated. The standard treatment is using donor eggs.

After the experimental procedure, Kawamura and colleagues were able to recover eggs from five of their 27 patients. One woman went on to have a miscarriage, one did not get pregnant, and two more have not yet attempted pregnancy, Kawamura said in an email.

The approach differs from what has been done to preserve fertility in some cancer patients, who had normal ovarian tissue removed and stored while they underwent cancer treatments, and then put back. The new work involved ovaries that were failing to function normally.

In the ovary, eggs mature in structures called follicles. For women with the condition the new study targeted, the follicles are either missing or failing to produce eggs. The experimental treatment was designed to stimulate dormant follicles.

First, the women's ovaries were removed and cut into strips, which were frozen. Later the strips were thawed and cut into tiny cubes, a step intended to stimulate maturation of the follicles. Then the cubes were treated with drugs to stimulate further development of the follicles. Cubes were then transplanted just under the surface of the women's fallopian tubes.

Within six months, eight women showed signs of follicle maturation, and five of them produced eggs for fertilization in the lab with their husbands' sperm. The fertilized eggs were grown into early embryos, which were frozen for preservation. In the three attempts at pregnancy, one or two embryos were implanted in the women.

The researchers found that half the 27 patients had no follicles at all, which meant the treatment could not help them, said Aaron Hsueh of Stanford University, senior author of the study. He also said researchers hope to find a way to stimulate follicles without removing the ovaries. .

Dr. Sherman Silber of the Infertility Center of St. Louis criticized the approach, saying he has had success by using drugs rather than surgery to treat the condition. He also disagreed with the researchers' explanation for why their treatment worked.

Some other experts said treatment with drugs often does not work.

The new results, experts cautioned, must be viewed as preliminary.

"It shows a lot of promise [but] I don't think it's even close to being ready" for routine use, said Dr. Mark Sauer of the Columbia University Medical Center in New York. Dr. Amber Cooper of Washington University in St. Louis called the technique "very much an experimental method."

The reported efficiency is very low, and the possible health risk to babies born from the method is unknown, said David Albertini of the University of Kansas Medical Center.

"One success does not mean we have a treatment … Stay tuned," he said.

He and others were also skeptical of the researcher's suggestion that the procedure would help women between ages 40 and 45. Eggs from women of that age often show genetic abnormalities, many of which would prevent a live birth, said Dr. Marcelle Cedars of the University of California, San Francisco Medical Center. Stimulating egg production wouldn't overcome that problem, she said.

Kawamura released a photo of himself holding the newborn shortly after he delivered him. He said the mother hopes to have another child with one of the frozen embryos in storage from her treatment.

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Hormone therapy use in long-term deterred

Hormone therapy for drenching hot flashes may be useful but long-term use is not warranted, doctors say. (Damian Dovarganes/Associated Press)

Hormone therapy is not recommended to prevent heart disease and other chronic illnesses, but it may be appropriate to relieve hot flashes and other menopausal symptoms in the short term for some women, a large 13-year followup study suggests.

The pendulum has swung widely in prescribing hormone therapy. Initially, it was used to manage menopausal symptoms and then in 1980s and 1990s it was prescribed for bone health and to prevent heart disease and Alzheimer's disease.

Prescriptions for HRT started to decline after 2002 after the landmark Women's Health Initiative (WHI) showed combined estrogen and progestin therapy increased women's risk of breast cancer, heart disease and stroke compared with taking a placebo. Now a followup study, published in Tuesday's issue of JAMA, reaffirms those findings and clearly makes a distinction about short-term use of hormone therapy in early menopause.

"Hormone therapy really should not be used for the express purpose of chronic disease prevention, but that it is appropriate for many women in early menopause who have moderate to severe menopausal symptoms," said study author Dr. JoAnn Manson, an endocrinologist at Brigham and Women's Hospital in Boston.

Manson said short-term use is generally five years and women tend to enter early menopause in their 50s. 

While short-term use of hormone therapy may be useful to treat hot flashes, night sweats and other menopausal symptoms that harm quality of life, long-term use for chronic disease prevention "is not warranted," Dr. Elizabeth Nadel, of Brigham and Women's Hospital in Boston, said in a journal editorial published with the study.

The extended followup study looked at 27,347 postmenopausal women, ages 50 through 79 years, who were enrolled throughout the U.S. in 1993.

About 8,000 women with a uterus received conjugated equine estrogens (CEE) plus medroxyprogesterone acetate (MPA) and an equal number received placebos. Another 5,300 women with prior hysterectomy received CEE alone and about an equal number had placebo.

In the combination group, risks were increased for coronary heart disease, breast cancer, stroke, pulmonary embolism, dementia (in women 65 years of age and older), gallbladder disease, and urinary incontinence.

Benefits included decreased hip fractures, diabetes, and vasomotor symptoms like hot flashes.

Risks and benefits were more balanced in the estrogen only group, Nadel said.

Increased risks of stroke and blood clots remains a concern for both groups, Manson said.

The re-emphasis of the study is useful for women who have received a mixed message, said Dr. Jerilynn Prior, a professor of epidemiology at the University of British Columbia.

Prior said there's a cultural concept about menopausal women being ridden with risks for disease and estrogen deficiency.

"Despite the fact that we have evidence that says hormone therapy doesn't prevent disease, the cultural concept has not changed," Prior said.

Menopausal women, a year past their last flow, who are waking night after night with hot flashes will be persuaded to take oral estrogen therapy with the hope it will prevent heart disease and osteoporosis, Prior said. But the new data confirms oral estrogen-based hormonal therapies carry small but real increased risks for stroke, blood clots, breast cancer, gall bladder disease, early dementia and incontinence, Prior said.

Prior suggested a lifestyle prevention package for hot flashes that includes:

• Stopping smoking cigarettes. (if relevant)
• Practicising relaxation or yoga breathing.
• Getting regular exercise.
• Eating a balanced diet.

Prior's own research at the Centre for Menstrual Cycle and Ovulation Research is looking at progesterone only therapy.

Doris Hopkirk, 69, of Mt. Pearl, N.L., took hormone therapy for 21 years after a hysterectomy. She says hot flashes and other menopausal symptoms were relieved, but it took a long time to wean herself off HRT.

The WHI study is funded by the U.S. National Heart, Lung, and Blood Institute. Wyeth-Ayerst donated the study drugs.

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Exercise 'as good as medicines' in treating disease

Exercise may be just as good as medication to treat heart disease and should be included as a comparison when new drugs are being developed and tested, scientists say.

In a large review published in the British Medical Journal on Wednesday, researchers from Britain's London School of Economics and Harvard and Stanford universities in the United States found no statistically detectable differences between exercise and drugs for patients with coronary heart disease or prediabetes, when a person shows symptoms that may develop into full-blown diabetes.

For patients recovering from stroke, the review — which analyzed the results of 305 studies covering almost 340,000 participants — found that exercise was more effective than drug treatment.

Cardiovascular disease is the world's number one killer, leading to at least 17 million deaths a year.

"In cases where drug options provide only modest benefit, patients deserve to understand the relative impact that physical activity might have on their condition," the researchers wrote.

The amount of trial evidence on the health benefits of exercise is considerably smaller than that on drugs, researchers say. (Mark Duncan/Associated Press)

The review also said the amount of trial evidence on the health benefits of exercise is considerably smaller than that on drugs, which the scientists said may have had an impact on their results.

They argued that this "blind spot" over exercise in scientific evidence "prevents prescribers and their patients from understanding the clinical circumstances where drugs might provide only modest improvement but exercise could yield more profound or sustainable gains."

The review adds to a large body of evidence showing that regular exercise is key to human health.

According to the Geneva-based World Health Organization (WHO), physical inactivity is the fourth leading risk factor for global mortality, causing an estimated 3.2 million deaths around the world each year.

The WHO says regular moderate intensity physical activity — such as walking, cycling or participating in sports — can reduce the risk of cardiovascular diseases, diabetes, colon and breast cancer, and depression, as well as cutting the risk of bone fractures and helping to control body weight.

At least 150 minutes of moderate-to-vigorous physical activity a week is recommended for adults. But only 53 per cent of adults achieve this, according to the Canadian Health Measures Survey.

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Public umbilical cord blood bank launches in Ottawa

Canada's first national public blood bank for umbilical cord blood began taking donations Monday at the Ottawa Hospital.

Canadian Blood Services said the bank will let the public donate rather than discard umbilical cords, which are a rich source of stem cells.

A newborn baby boy's umbilical cord blood is collected to try to cure his sister of leukemia in Beijing in 2005. Prior to Monday's announcement Canada was the only G8 country without a national cord blood bank. ( China Photos/Getty)

Some 1,000 Canadians are currently waiting for life-saving stem cell transplants to treat diseases such as leukemia, lymphoma or aplastic anemia, according to Canadian Blood Services.

The group said Canada was the only G8 nation that doesn't have a national public cord blood bank.

Robert Klaassen, a hematologist/oncologist at the Children's Hospital of Eastern Ontario in Ottawa, said the new cord blood bank is "long overdue."

Klaassen said having our own national cord blood bank will shorten wait times and increase the pool of potential matches when stem cells are needed, while cord blood will also provide a more flexible source of stem cells than bone marrow.

"The main problem we have is that many patients when they need a bone marrow transplant don't have a brother or sister or sibling to match to so we have to start looking for unrelated matches," said Klaassen.

"It's very difficult to get the bone marrow itself because you have to get a perfect match, it's very unforgiving whereas the nice thing about cord cells is because they are from a newborn baby they tend to be more accepting of the fact that it's not their normal environment," he said.

By next year hospitals in Brampton, Edmonton and Vancouver will also be able to collect cord blood donations for the public bank.

While this is the first national cord blood bank, there are three other public cord blood banks in Canada: Héma-Quebec, the Alberta Cord Blood Bank and the Victoria Angel Registry of Hope in Toronto.

Similar private banks already operate, but CReATe Cord Blood Bank founder Dr. Clifford Librach said the launch of the public bank taking donations for use in non-family patients will spread the word about umbilical cord donations.

"It increases awareness for patients who may not have been aware of this whole process or their options," said Librach.

Klaassen said his issue with private banks is that the chances of a child needing their own cord blood is infinitesimally small, while those children with rare disorders who may need it won't be able to access it.

CBC News health commentator and physician assistant Maureen Taylor said the cord bank could potentially improve the selection of potential matches for doctors.

"We need a large selection of different people's cord blood in order to be able to get the match right," said Taylor.

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Liver doctors seek hepatitis C screens for baby boomers

Hepatitis C is the most common indication for liver transplantation in North America. (Ken Lambert/Seattle Times/Associated Press)

Baby boomers and those born up to 1975 should be screened for the hepatitis C virus and treated if needed, say researchers who argue Canada is probably underestimating its prevalence.

Hepatitis C infection (HCV) can be eradicated if treated early and successfully, liver specialists say. In Monday's issue of the Canadian Medical Association Journal, three doctors say there's a clear rationale to identify and treat the infections before symptoms appear.

In North America, hepatitis C is the most common indication for liver transplantation, a previous study suggests.

"Canada should follow the lead of the U.S. and begin birth-cohort screening for HCV infection, even if only to collect the data that we need to determine whether we should be screening at all," Drs. Hemant Shah, Jenny Heathcote and Jordon Feld from the Toronto Centre for Liver Disease concluded.

The U.S. Centers for Disease Control and Prevention recommends routine screening of all baby boomers for hep C with a one-time test as well as screening based on risk factors.

Currently, Canada screens based on risk factors, including people who engage in risky behaviours or have been potentially exposed to the virus and people whose clinical signs or symptoms suggest they may be
infected.

But studies from other countries suggest that approach is not effective. Before France introduced an intensive national program, 75 per cent of those infected in the country weren't aware of it, which fell to 44 per cent afterwards.

The Canadian Liver Foundation recommends screening people born from 1945 to 1975 because it says this would include about 77 per cent of infected Canadians

Hepatitis C screening involves an inexpensive blood test. The cost of the test is covered by provincial health care plans.

The study's authors noted that a wider screening program will be more expensive up front, but say the long-term benefits could be significant.

Current treatment for Hep C infection costs about $65,000 for a complete course of weekly injections that cure about 65 to 75 per cent of cases, the authors said. They expect that within three to five years, better oral treatments will be available.

"Screening of people born between 1945 and 1975 coupled with a strategy for follow-up treatment and education is probably the best method to identify and provide care to affected people in Canada," the article said.

The authors have previously received consulting or speaking fees or grants from pharmaceutical companies.

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Elderly populations too much for most countries, UN says

The world is aging so fast that most countries are not prepared to support their swelling numbers of elderly people, according to a global study being issued Tuesday by the United Nations and an elder rights group.

The report ranks the social and economic well-being of elders in 91 countries, with Sweden coming out on top and Afghanistan at the bottom.

Canada is at fifth place.

"In 2011, an estimated five million Canadians were 65 years of age or older, a number that is expected to double in the next 25 years," the report said.

'You have to keep working no matter how old you are — no one is rich enough to stop. Life is very difficult.'- Abdul Wasay, 75, Afghanistan

The study reflects what advocates for the old have been warning, with increasing urgency, for years: Countries are simply not working quickly enough to cope with a population greying faster than ever before. By the year 2050, for the first time in history, seniors older than 60 will outnumber children younger than 15.

Truong Tien Thao, who runs a small tea shop on the sidewalk near his home in Hanoi, Vietnam, is 65 and acutely aware that he, like millions of others, is plunging into old age without a safety net. He wishes he could retire, but he and his 61-year-old wife depend on the $50 US a month they earn from the shop. And so every day, Thao rises early to open the stall at 6 a.m. and works until 2 p.m., when his wife takes over until closing.

"People at my age should have a rest, but I still have to work to make our ends meet," he says, while waiting for customers at the shop, which sells green tea, cigarettes and chewing gum. "My wife and I have no pension, no health insurance. I'm scared of thinking of being sick — I don't know how I can pay for the medical care."

Developing countries are aging fastest

Thao's story reflects a key point in the report, which was released early to The Associated Press: Aging is an issue across the world. Perhaps surprisingly, the report shows that the fastest aging countries are developing ones, such as Jordan, Laos, Mongolia, Nicaragua and Vietnam, where the number of older people will more than triple by 2050. All ranked in the bottom half of the index.

The Global AgeWatch Index was created by elder advocacy group HelpAge International and the UN Population Fund in part to address a lack of international data on the extent and impact of global aging. The index, released on the UN's International Day of Older Persons, compiles data from the UN, World Health Organization, World Bank and other global agencies, and analyzes income, health, education, employment and age-friendly environment in each country.

The index was welcomed by elder rights advocates, who have long complained that a lack of data has thwarted their attempts to raise the issue on government agendas.

"Unless you measure something, it doesn't really exist in the minds of decision-makers," said John Beard, director of Aging and Life Course for the World Health Organization. "One of the challenges for population aging is that we don't even collect the data, let alone start to analyze it... For example, we've been talking about how people are living longer, but I can't tell you people are living longer and sicker, or longer in good health."

Increasingly complex picture of aging

The report fits into an increasingly complex picture of aging and what it means to the world. On the one hand, the fact that people are living longer is a testament to advances in health care and nutrition, and advocates emphasize that the elderly should be seen not as a burden but as a resource. On the other, many countries still lack a basic social protection floor that provides income, health care and housing for their senior citizens.

Afghanistan, for example, offers no pension to those not in the government. Life expectancy is 59 years for men and 61 for women, compared to a global average of 68 for men and 72 for women, according to UN data.

That leaves Abdul Wasay struggling to survive. At 75, the former cook and blacksmith spends most of his day trying to sell toothbrushes and toothpaste on a busy street corner in Kabul's main market. The job nets him just $6 a day — barely enough to support his wife. He can only afford to buy meat twice a month; the family relies mainly on potatoes and curried vegetables.

"It's difficult because my knees are weak and I can't really stand for a long time," he says. "But what can I do? It's even harder in winter, but I can't afford treatment."

Although government hospitals are free, Wasay complains that they provide little treatment and hardly any medicine. He wants to stop working in three years, but is not sure his children can support him. He says many older people cannot find work because they are not strong enough to do day labour, and some resort to begging.

"You have to keep working no matter how old you are — no one is rich enough to stop," he says. "Life is very difficult."

Many governments have resisted tackling the issue partly because it is viewed as hugely complicated, negative and costly — which is not necessarily true, says Silvia Stefanoni, chief executive of HelpAge International. Japan and Germany, she says, have among the highest proportions of elders in the world, but also boast steady economies.

"There's no evidence that an aging population is a population that is economically damaged," she says.

Prosperity in itself does not guarantee protection for the old. The world's rising economic powers — the so-called BRICS countries of Brazil, Russia, India, China and South Africa — rank lower in the index than some poorer countries such as Uruguay and Panama.

Norway, Germany among top countries

However, the report found, wealthy countries are in general better prepared for aging than poorer ones. Sweden, where the pension system is now 100 years old, makes the top of the list because of its social support, education and health coverage, followed by Norway, Germany, the Netherlands and Canada. The United States comes in eighth.

Sweden's health system earns praise from Marianne Blomberg, an 80-year-old Stockholm resident.

"The health-care system, for me, has worked extraordinarily well," she says. "I suffer from atrial fibrillation and from the minute I call emergency until I am discharged, it is absolutely amazing. I can't complain about anything — even the food is good."

Still, even in an elder-friendly country like Sweden, aging is not without its challenges. The Swedish government has suggested people continue working beyond 65, a prospect Blomberg cautiously welcomes but warns should not be a requirement. Blomberg also criticized the country's finance minister, Anders Borg, for cutting taxes sharply for working Swedes but only marginally for retirees.

"I go to lectures and museums and the theatre and those kinds of things, but I probably have to stop that soon because it gets terribly expensive," she says. "If you want to be active like me, it is hard. But to sit home and stare at the walls doesn't cost anything."

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Infertile woman gives birth after ovary treatment in Japan

In this Dec. 28, 2012 photo provided by Dr. Kazuhiro Kawamura of the St. Marianna University School of Medicine in Kawasaki, Japan, Kawamura holds a newborn baby whose 30-year-old mother was treated for primary ovarian insufficiency. (Kazuhiro Kawamura/Associated Press)

A 30-year-old infertile woman gave birth after surgeons removed her ovaries and re-implanted tissue they treated in a lab, researchers report.

The experimental technique was only tried in a small group of Japanese women with a specific kind of infertility problem, but scientists hope it can also help women in their early 40s who have trouble getting pregnant because of their age.

The new mother gave birth to a son in Tokyo last December, and she and the child continue to be healthy, said Dr. Kazuhiro Kawamura of the St. Marianna University School of Medicine in Kawasaki, Japan. He and others describe the technique in a report published online Monday by the Proceedings of the National Academy of Sciences.

The mother, who was not identified, had been diagnosed with primary ovarian insufficiency, an uncommon form of infertility sometimes called premature menopause. It appears in about 1 percent of women of childbearing age. The cause of most cases is unknown, but the outcome is that the ovary has trouble producing eggs.

That leaves women with only a 5 per cent to 10 per cent chance of having a baby unless they get treated. The standard treatment is using donor eggs.

After the experimental procedure, Kawamura and colleagues were able to recover eggs from five of their 27 patients. One woman went on to have a miscarriage, one did not get pregnant, and two more have not yet attempted pregnancy, Kawamura said in an email.

The approach differs from what has been done to preserve fertility in some cancer patients, who had normal ovarian tissue removed and stored while they underwent cancer treatments, and then put back. The new work involved ovaries that were failing to function normally.

In the ovary, eggs mature in structures called follicles. For women with the condition the new study targeted, the follicles are either missing or failing to produce eggs. The experimental treatment was designed to stimulate dormant follicles.

First, the women's ovaries were removed and cut into strips, which were frozen. Later the strips were thawed and cut into tiny cubes, a step intended to stimulate maturation of the follicles. Then the cubes were treated with drugs to stimulate further development of the follicles. Cubes were then transplanted just under the surface of the women's fallopian tubes.

Within six months, eight women showed signs of follicle maturation, and five of them produced eggs for fertilization in the lab with their husbands' sperm. The fertilized eggs were grown into early embryos, which were frozen for preservation. In the three attempts at pregnancy, one or two embryos were implanted in the women.

The researchers found that half the 27 patients had no follicles at all, which meant the treatment could not help them, said Aaron Hsueh of Stanford University, senior author of the study. He also said researchers hope to find a way to stimulate follicles without removing the ovaries. .

Dr. Sherman Silber of the Infertility Center of St. Louis criticized the approach, saying he has had success by using drugs rather than surgery to treat the condition. He also disagreed with the researchers' explanation for why their treatment worked.

Some other experts said treatment with drugs often does not work.

The new results, experts cautioned, must be viewed as preliminary.

"It shows a lot of promise [but] I don't think it's even close to being ready" for routine use, said Dr. Mark Sauer of the Columbia University Medical Center in New York. Dr. Amber Cooper of Washington University in St. Louis called the technique "very much an experimental method."

The reported efficiency is very low, and the possible health risk to babies born from the method is unknown, said David Albertini of the University of Kansas Medical Center.

"One success does not mean we have a treatment … Stay tuned," he said.

He and others were also skeptical of the researcher's suggestion that the procedure would help women between ages 40 and 45. Eggs from women of that age often show genetic abnormalities, many of which would prevent a live birth, said Dr. Marcelle Cedars of the University of California, San Francisco Medical Center. Stimulating egg production wouldn't overcome that problem, she said.

Kawamura released a photo of himself holding the newborn shortly after he delivered him. He said the mother hopes to have another child with one of the frozen embryos in storage from her treatment.

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For many Canadian doctors, managing pain is 'not a high priority'

This week on The Sunday Edition

Michael's Essay: Atheists should stop behaving like persecuted outsiders.

Understanding pain

Dr. Fernando Cervero is working to change the way we think about and treat pain. He's a professor of anesthesia and the director of the Alan Edwards Centre for Research on Pain at McGill University in Montreal. He's also president of the International Association for the Study of Pain.

Documentary: Figures in Flight

We meet a group of convicted murderers, drug dealers and sex offenders, who have spent many decades behind bars. Now... they are learning to dance.

Tackling public pensions

Demographics are threatening public pensions, and two provinces are tackling the problem head on. Michael talks with Alberta's finance minister, Doug Horner, and with the chair of New Brunswick's Pension Task Force, Sue Rowland.

Rebecca Solnit

Rebecca Solnit's new book is called The Faraway Nearby. She's wise and insightful, passionate and compassionate. Among other things, she talks to Michael about what her mother's descent into Alzheimer's taught her about letting go. 

Craig's Retreat

What's it like to live like a monk? Craig Desson reports from his 10-day silent meditation retreat -- waking at 4 a.m. and not reading, writing, speaking or eating after noon.

The headlines are full of breakthroughs heralding new treatments and cures for a host of debilitating and lethal diseases and conditions. 

But for the millions of Canadians who suffer from chronic pain, relief - let alone a cure - is still elusive. 

According to the Canadian Pain Society, one in five Canadians suffers from chronic pain. Yet treatment has not been a priority in our health care system; instead, people who complain of chronic pain are all too often derided as whiners. 

They say doctors are incredulous that their pain - which might have no apparent cause - could possibly be that bad. Or else they're just counselled to grin and bear it.

That nonchalance reflects an attitude in western cultures, where pain is largely considered a sign of virtue and a test of character, says Dr. Fernando Cervero, director of the Alan Edwards Centre for Research on Pain at McGill University.

Attitudes slowly changing

But Dr. Cervero notes that social attitudes are changing. Patients and their advocates are demanding better and more timely treatment for chronic pain. But the medical establishment has not kept pace with those changes. For example, veterinary students receive much more training in pain management than medical students.

The societal change in attitudes toward pain "has not completely permeated all the way to the medical schools," Dr. Cervero told The Sunday Edition's Michael Enright. "In a curriculum that is getting more and more busy with more and more discoveries in medicine – and we all have to fight for time in the medical curriculum – pain is not a high priority."

Dr. Cervero, who will be speaking at an international symposium on pain at McGill University on Oct. 3, says more must be done to make the relief of pain, especially for chronic pain sufferers, a top priority in Canadian health care.

"It's not right for people to suffer unnecessarily," he said.

You can hear Michael Enright's full conversation with Dr. Fernando Cervero on CBC Radio's The Sunday Edition on Radio One this Sunday, just after the 9 a.m. news.

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$1.3B medical marijuana free market coming to Canada

Medical marijuana by the numbers

• Current number of users approved by Health Canada: 37,359.
• Number of patients with personal licences to grow marijuana for themselves: 25,600.
• Number of growers licensed to produce marijuana for a maximum of two patients each: 4,200.
• Current number of entrepreneur applications to grow medical marijuana under new rules: 156.

The Conservative government is launching a $1.3-billion free market in medical marijuana on Tuesday, eventually providing an expected 450,000 Canadians with quality weed.

Health Canada is phasing out an older system on Monday that mostly relied on small-scale, homegrown medical marijuana of varying quality, often diverted illegally to the black market.

In its place, large indoor marijuana farms certified by the RCMP and health inspectors will produce, package and distribute a range of standardized weed, all of it sold for whatever price the market will bear. The first sales are expected in the next few weeks, delivered directly by secure courier.

"We're fairly confident that we'll have a healthy commercial industry in time," Sophie Galarneau, a senior official with the department, said in an interview.

"It's a whole other ball game."

The sanctioned birth of large-scale, free-market marijuana production comes as the Conservatives pillory Liberal Leader Justin Trudeau's campaign to legalize recreational marijuana.

Health Canada is placing no limits on the number of these new capital-intensive facilities, which will have mandatory vaults and security systems. Private-dwelling production will be banned. Imports from places such as the Netherlands will be allowed.

Already 156 firms have applied for lucrative producer and distributor status since June, with the first two receiving licences just last week.

'Enormous' potential profit

The old system fostered only a cottage industry, with 4,200 growers licensed to produce for a maximum of two patients each. The Mounties have complained repeatedly these grow-ops were often a front for criminal organizations.

The next six months are a transition period, as Health Canada phases out the old system by March 31, while encouraging medical marijuana users to register under the replacement regime and to start buying from the new factory-farms.

There are currently 37,400 medical marijuana users recognized by the department, but officials project that number will swell more than 10-fold, to as many as 450,000 people, by 2024.

The profit potential is enormous. A gram of dried marijuana bud on the street sells for about $10 and Health Canada projects the legal stuff will average about $7.60 next year, as producers set prices without interference from government.

Chuck Rifici of Tweed Inc. has applied for a licence to produce medical weed in an abandoned Hershey chocolate factory in hard-scrabble Smiths Falls, Ont.

Rifici, who is also a senior adviser to Trudeau, was cited in a Conservative cabinet minister's news release Friday that said the Liberals plan to "push pot," with no reference to Health Canada's own encouragement of marijuana entrepreneurs.

Rifici says he's trying to help a struggling community by providing jobs while giving suffering patients a quality product.

"There's a real need," he said in an interview. "You see what this medicine does to them."

Revenue to hit $1.3 billion

Tweed Inc. proposes to produce at least 20 strains to start, and will reserve 10 per cent of production for compassionate, low-cost prescriptions for impoverished patients, he says.

Patients often use several grams a day to alleviate a wide range of symptoms, including cancer-related pain and nausea. They'll no longer be allowed to grow it for themselves under the new rules.

Revenues for the burgeoning new industry are expected to hit $1.3 billion a year by 2024, according to federal projections. And operators would be favourably positioned were marijuana ever legalized for recreational use, as it has been in two American states.

Eric Nash of Island Harvest in Duncan, B.C., has applied for one of the new licences, banking on his experience as a licensed grower since 2002 in the current system.

"The opportunity in the industry is significant," he said in an interview.

"We'll see a lot of moving and shaking within the industry, with companies positioning. And I think we'll see some mergers and acquisitions, strategic alliances formed."

"It'll definitely yield benefits to the consumers and certainly for the economy and society in general."

Competition to keep prices in check

Veterans Affairs Canada currently pays for medical marijuana for some patients, even though the product lacks official drug status. Some provinces are also being pressed to cover costs, as many users are too sick to work and rely on welfare.

Health Canada currently sells medical marijuana, produced on contract by Prairie Plant Systems, for $5 a gram, and acknowledges the new system will be more expensive for patients.

But Galarneau says competition will help keep prices in check.

"We expect that over time, prices will be driven down by the free market," she said. "The lower price range will likely be around $3 a gram. ... It's hard to predict."

Saskatoon-based Prairie Plant Systems, and its subsidiary CanniMed Ltd., were granted the first two licences under the system and are already advertising their new products on the web.

Prospective patients, including those under the current system, must get a medical professional to prescribe medical marijuana using a government-approved form.

Health Canada only reluctantly established its medical marijuana program, driven by court decisions from 2001 forward that supported the rights of suffering patients, even as medical science has been slow to verify efficacy.

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