[Paul Larson]

Excellent example! Yes I would expect all the steps to apply in some way. A systematic assessment of the problem and change process may help stakeholders identify potential barriers and formulate steps to mitigate their impact. (Ex. Engaged the historical organizers in the new process as active stakeholders of change).

[Paul Larson]

Hi Suzy, outstanding examples. Institutions without Educational RVUs that conflict with clinical productivity incentives is indeed an uphill battle and appealing to professional or personal motives for teachers can undervalue their contribution. A great problem to tackle.
We will discuss the impact of value based payment including bundles for specialty care which can unlock financial support for programs targeting Social Determinants of Health (SDOH). As we will discuss payment models can contribute to long term change strategies including SDOH barriers. Super example.

[Paul Larson]

Fantastic comments Dom on both questions. In Kenya I witnessed glaring gaps in PMTCT. The largest factor was stigma. Pregnant women were terrified of finding out their HIV status and (often rightly) feared rejection in the event of a positive test, even though her male partner/husband was her most likely source. Many women preferred not to know or disclose if positive, even to the obvious detriment to their own health. Access to medications often required “breaking the rules” to initiate triple therapy during pregnancy during a time when we were still only using single dose NVP.

Reliance of antibody testing and lack of localizing signs renders clinical diagnosis in children very challenging. Often pediatric HIV is very advanced and children failed treatment for other miss-diagnoses with profound failure-to-thrive before any diagnosis is confirmed. Even when confirmed access to pediatric formulations is very limited and locations may wait to initiate until disease is clinically apparent.

Just because an effective intervention is known and theoretically available, it does not mean it will be implemented. Social, political and economic barriers frequently supersede clinical need.

[Paul Larson]

I also resonate with the selective hiring approach. In resident physician education it turns out lapses in professional competency are exceptionally hard to remediate. Ignorance is easy to fix but personality and unprofessional behavior can be rigid and in family medicine empathy and communication are key. Better to select for desirable traits up front than try to steer a problematic family doctor into radiology.

[Paul Larson]

I can completely resonate with the decision paralysis resulting from excessive options. Returning to the USA from years in Kenya and shopping at the supermarket or Sam’s CLub was overwhelming with isles of cereal or paper products. Selecting from the many can be stressful! I bought a surround sound system last week, but had not completed research before going to Best Buy. So many options with theoretical differences I couldn’t detect. The sales rep was talkative and worked for Sony. Which brand did I buy?

As Burton also stated COVID accelerated the adoption of telemedicine. Physicians were strongly opposed based on exam quality and relational concerns, but patients overwhelmingly prioritize safe and convenient access. The system realizes significant cost savings so the move was inevitable over 5 years. Now completed in 1. Higher education was a competitive sport with bloated costs and luxury benefits to attract limited tuitions dollars. If degrees can be awarded with virtual learning what is the cost value of the on-campus “college experience”? Many are choosing lower cost options at home or off-campus with virtual learning. University’s may contract in size and wealth with the less well-endowed folding/merging/acquired.

[Paul Larson]

Colleagues,
I am re-posting the response to Question 1 placed by INPH student Dom Luethe. Her description of First Nation populations experience with TB contributes significantly to our understanding. Paul
“ Question #1: From your perspective, why are people living in poverty most likely to suffer from TB, and how should this fact influence efforts to control the disease?
According to the article in question, TB “is the leading infectious killer globally and disproportionately affects disadvantaged populations.” I will use my first-hand experience from working with the Inuit and First Nations populations in Northern Canada to present why I believe people living in poverty are more likely to suffer from TB. In addition, there are various factors that should be considered in terms of efforts to control the disease.
The article states that “there is 280-fold difference in tuberculosis incidence between Canadian Inuits and non-Indigenous Canadian-born population.” Although there are cases of individuals from a penitentiary setting or homeless population, most of the positive TB patients I have directly cared for are on a reservation (First Nations). The presence of TB in these communities makes up a large component of our core community health programming. In Northern Manitoba, where I worked as a remote health station nurse, it was assumed that any patient with a cough or respiratory symptoms had TB. We then x-rayed these patients ourselves, which was a steep learning curve. TB is rampant in many remote northern communities.
A significant factor for the ease of transmission in the northern communities is the lack of housing. It is not uncommon for more than 10-20 individuals to share a small 2 bedroom home. Housing is a political issue on many of the reserves, as there is a lack of physical housing, and the current structures have concerns that would make them inhabitable in non-indigenous communities (mold, entire sides of homes missing that are covered in poly plastic sheets, infestation, sunken roofs, etc.). A number of these communities have no running water, electricity or indoor sanitation. Often there is either an outhouse or a hole cut into the floor for toileting. As these communities are frigid cold, especially in the winter, individuals have no option but to house with many others. Transmission, therefore is high when a household contact is positive, and self-isolation is a challenge. In addition, the northern communities are known as an unhealthy population, where alcoholism, drug use and chronic conditions are widespread. These factors decrease the immune system; therefore, individuals are often more susceptible to opportunistic infection.
Efforts to control TB where housing is an issue has been discussed among healthcare workers and local governments. Nurses have suggested having dwellings designated for TB positive clients while in their infectious stage, transporting patients out to a bigger centre out of community for isolation in an arranged accommodation or hospitalization if needed. These efforts are mostly unsuccessful, mainly because of the lack of cooperation from local governments. Some larger centres have TB designated beds within hospitals, but unless a patient is medically unstable, then they are often not accepted.
Surveillance is another effort that is ongoing in these communities, especially when an outbreak occurs. As nurses in these settings, we use the TST as much as possible in almost all patients (even in absence of TB symptoms). However, in some communities LTBI is very common, so the TST cannot be performed due to prior a positive reading, and adherence to CXR is low.
Adherence to the TB treatment is another challenge, especially with LTBI. This can be due to negative cultural perceptions of healthcare workers (history of poor cultural safety), transportation limitations to the health centre for Direct Observational Therapy (DOT) and psychosocial issues (drug and alcohol use, disruptive living environments, etc.). Side effects of the medication can cause patients on the therapy to want to discontinue (rash, nausea, vomiting, weight loss, discoloured body fluids causing clothing stains). In addition, the lengthy treatment (this varies depending on the medication combination) is another common challenge.
Some of the strategies implemented to ensure adherence, is DOT in the home (if lack of transportation) and issuing fiscal incentives for medication adherence (gift cards of choice). A solution that has been implemented for many years in response to the common negativity towards nurses, is that the DOT worker is almost always a local First Nations individual who has been hired by the health centre to conduct the program. Patients are typically accepting towards this trained worker, as a level of trust is preexisting. In my experience, supportive care while a patient is undergoing treatment is the most important. The frequent side effect checklist helps connect with patients, and the nurse is then able to suggest possible solutions such as: eating before medication administration, antiemetic for nausea or vomiting and wearing darker underwear if staining occurs from the Rifampin. In fact, I have actually bought a patient black underwear and undershirts, as he could not afford to replace his current stained clothing.
Unfortunately, TB will continue to exist in Northern Canada if the conditions remain the same. Healthcare workers in these areas must continue to be vigilant for this disease, or the high rate of infection will not change.”
Dom Luethe

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