egium; the $250 registration fee was to be waived and hotel accommodation to be provided free. Need I say more? Keith Morgan, MD, FRCPC Chest Diseases Unit University Hospital London, Ont.
Privatization and Health Care: the Case of Ontario Nursing Homes I must confess that reading Dr. Eugene Vayda's review (Can Med Assoc J 1991; 145: 325) of Vera Ingrid Tarman's book was both frustrating and maddening. As someone representing a private-sector firm in Ontario's nursing home system I can only decry the lack of information about the economic realities of this industry that was evident in the book being reviewed and in the review. Private-sector nursing homes in Ontario are going into receivership on a regular basis, simply because there is insufficient funding to provide appropriate levels of care, much less profits. Municipally owned nursing homes that provide care to the same kind of clientele as do private homes receive over $30 more per resident per day. In addition, they are not inspected, they have no capital debt to support, and they pay no municipal taxes. The best thing that could happen to the private sector in Ontario now is expropriation. Over the past 7 or 8 years successive governments have constrained funding and increased care requirements in an inexorable fashion that can lead only to bankruptcy for those who have chosen to invest capital in the industry. I have had enough of incompetent socialists accusing the industry in which I operate of 16
CAN MED ASSOC J 1992; 146 (1)
being concerned only about prof- 43%). At the same time the numits and not about the services that ber of nonprofit beds increased by it provides. I have had more than only 2186 (8%), and the proporenough of the immoral activities tion of total beds that were propriof successive Ontario govern- etary increased from 47% to 54%. ments in squeezing out the private Clearly some private nursing sector and effectively confiscating homes are making a profit and its owners' assets. But more than not going into receivership. Many anything, I have had enough of groups are concerned that this misrepresentation of the realities profit is largely at the expense of of Ontario's nursing home indus- appropriate levels of care. Birkett also charges that mutry. nicipally owned nursing homes Charles W. Birkett, MD, MBA are not inspected. They are inPresident spected but to a lesser degree. I Diversicare Incorporated with him that if the public agree Mississauga, Ont. and private sectors are to coexist the same standards must apply to [Dr. Vayda responds.] each. It is probably a measure of the Finally, I also agree with Birambivalence of successive Ontario kett that "the best thing that could governments toward nursing happen to the private sector in homes in the private sector that Ontario now is expropriation." these homes receive only per diem Although his reasons surely differ payments whereas municipal from those of Premier Bob Rae, homes receive both per diem and the CMA, Tarman and me, it is deficit funding from the govern- encouraging that we have all now ment and, as a result, larger per come to the same conclusion. capita payments. The discrepancy between dif- Eugene Vayda, MD, FRCPC ferent categories of municipal Professor of Health Administration homes has been justified because Department University of Toronto it allows for variations among Toronto, Ont. them: homes providing heavy care can receive more money than those providing less care. This justification fails to address the Adverse effects public-private difference and in- of psyllium tensifies the "unresolvable conF n or many years psylliumflict of interest between acceptable levels of care, constrained governcontaining laxatives have been widely used in Canament spending and the need to show a profit." The private nurs- da. Psyllium hydrophilic muciling homes are under increasing loid is derived from the seeds or pressure to reduce costs; advo- husks of the plant Plantago ovata, cates contend this is by increased also known as ispaghul. The adverse effects of psylliefficiency, critics by inadequate levels of care. um have been relatively uncomDr. Birkett invokes a dooms- mon; however, the drug is known day script when he describes pri- to cause IgE-mediated hypersenvate nursing homes as going into sitivity reactions in susceptible receivership, but Statistics Can- people. Allergic symptoms may ada, as quoted by Ms. Tarman be severe and consist of (page 43), tells another story. Be- any of the following: rhinocontween 1979 and 1986 the number junctivitis, skin reactions, asthma, of proprietary beds increased gastrointestinal symptoms and from 23 465 to 33 626 (i.e., by anaphylaxis. LE ler JANVIER 1992
Psyllium is frequently used in powdered form. When it is mixed or poured fine dust particles are readily dispersed into the air and can then be inhaled and cause sensitization. Workers in the pharmaceutical firms that manufacture the drug and health care workers dispensing it are at particular risk for a hypersensitivity reaction. In one epidemiologic survey 42% of pharmaceutical workers were found to have allergic symptoms.' In a subsequent, more objective survey of 130 pharmaceutical workers the prevalence rates of occupational asthma and IgE sensitization were found to be 3.6% and 27.9% respectively.2 Orally ingested psyllium seems to be less likely to induce sensitization. However, when prior sensitization has occurred (a fact of which the person may be unaware) subsequent oral ingestion of psyllium has been associated with severe allergic reactions.3'4 We suggest several measures to reduce the risk of psyllium allergy in health care workers. * Health care workers suspected of being allergic to psyllium should report their concerns to the occupational nurse or physician and receive definitive testing. * Workers known to be allergic to psyllium should avoid mixing and dispensing psyllium products. Also, they should avoid being present when others are handling the drug, since psyllium dust particles are easily dispersed in the air. * Measures to decrease exposure to psyllium dust particles are recommended for all personnel; these include the use of face masks and fume hoods while the drug is being mixed and dispensed. Fume hoods are available in the pharmacies of large institutions but not generally in smaller facilities.
JANUARY 1,1992
* The use of granulated as opposed to finely powdered formulations is theoretically less likely to induce sensitization. Brian F. Gillespie, MD Acting chief Flora J. Rathbun, MSc, MD Medical officer Drug Evaluation Division Bureau of Nonprescription Drugs Department of National Health and Welfare Ottawa, Ont.
References 1. Goransson K, Michaelson NG: Ispagula powder: an allergen in the work environment. Scand J Work Environ Health 1979; 5: 257-261 2. Bardy JD, Malo JL, Seguin P et al: Occupational asthma and IgE sensitization in a pharmaceutical company processing psyllium. Am Rev Respir Dis 1987; 135: 1033-1038 3. Lantner RR, Baltazar BR, Zumerchik P et al: Anaphylaxis following ingestion of a psyllium-containing cereal. JAMA 1990; 264: 2534-2536 4. Ontario Medical Association's Committee on Drugs and Pharmacotherapy: Hazards of psyllium. Drug Rep 1989; 28: 1
Don't forget the NHRDP I n a recent issue of CMAJ there was a report by Patrick
Sullivan, "Research-funding drought leads to call for letterwriting campaign by MDs, researchers" (1991; 145: 153), about the campaign by Canadians for Health Research (CHR) to increase the funding for the Medical Research Council (MRC). It was noted that in 1991-92 the MRC received only a 3.7% increase from the previous year. Although I strongly support the basic position expressed in Sullivan's report I would appreciate it if both CMAJ and the CHR could give equal attention to the disastrous funding at the National Health Research and Develop-
ment Program (NHRDP), run by the Department of National Health and Welfare, Ottawa. For the 1990-91 fiscal year the NHRDP budget was cut by about $4 million, which represents a 12% reduction in total funding and an 18% reduction in
funding for investigator-initiated research. As a result of this cut, funding of new projects was essentially put on hold for a full year. This year the NHRDP budget was maintained at its new level without even an increase to adjust for inflation. NHRDP is the only federal source of funding for research into community health and prevention. For example, the MRC will not fund studies on physician education or methods to improve the cost-effectiveness of health care delivery. Therefore, NHRDP provides an essential complement to the MRC, particularly given the current financial pressures on physicians and the health care community. Most health care workers and most of the general public are not aware of the role of NHRDP in supporting health care research. This makes it an easy target for financial cutbacks. When the NHRDP budget was cut last year only 300 letters were sent to the minister of national health and welfare to protest his action. Can you imagine the outcry that would follow an 18% reduction in the budget of the MRC? I urge the medical community to actively recognize the value of NHRDP to medical research in Canada. I hope that the CHR and other lobby organizations will pressure the federal government to maintain and expand all aspects of medical research funding. Nicholas Birkett, MD, MSc Department of Epidemiology and Community Medicine University of Ottawa Ottawa, Ont.
CAN MED ASSOC J 1992; 146 (1)
17
Privatization and Health Care: the Case of Ontario Nursing Homes I must confess that reading Dr. Eugene Vayda's review (Can Med Assoc J 1991; 145: 325) of Vera Ingrid Tarman's book was both frustrating and maddening. As someone representing a private-sector firm in Ontario's nursing home system I can only decry the lack of information about the economic realities of this industry that was evident in the book being reviewed and in the review. Private-sector nursing homes in Ontario are going into receivership on a regular basis, simply because there is insufficient funding to provide appropriate levels of care, much less profits. Municipally owned nursing homes that provide care to the same kind of clientele as do private homes receive over $30 more per resident per day. In addition, they are not inspected, they have no capital debt to support, and they pay no municipal taxes. The best thing that could happen to the private sector in Ontario now is expropriation. Over the past 7 or 8 years successive governments have constrained funding and increased care requirements in an inexorable fashion that can lead only to bankruptcy for those who have chosen to invest capital in the industry. I have had enough of incompetent socialists accusing the industry in which I operate of 16
CAN MED ASSOC J 1992; 146 (1)
being concerned only about prof- 43%). At the same time the numits and not about the services that ber of nonprofit beds increased by it provides. I have had more than only 2186 (8%), and the proporenough of the immoral activities tion of total beds that were propriof successive Ontario govern- etary increased from 47% to 54%. ments in squeezing out the private Clearly some private nursing sector and effectively confiscating homes are making a profit and its owners' assets. But more than not going into receivership. Many anything, I have had enough of groups are concerned that this misrepresentation of the realities profit is largely at the expense of of Ontario's nursing home indus- appropriate levels of care. Birkett also charges that mutry. nicipally owned nursing homes Charles W. Birkett, MD, MBA are not inspected. They are inPresident spected but to a lesser degree. I Diversicare Incorporated with him that if the public agree Mississauga, Ont. and private sectors are to coexist the same standards must apply to [Dr. Vayda responds.] each. It is probably a measure of the Finally, I also agree with Birambivalence of successive Ontario kett that "the best thing that could governments toward nursing happen to the private sector in homes in the private sector that Ontario now is expropriation." these homes receive only per diem Although his reasons surely differ payments whereas municipal from those of Premier Bob Rae, homes receive both per diem and the CMA, Tarman and me, it is deficit funding from the govern- encouraging that we have all now ment and, as a result, larger per come to the same conclusion. capita payments. The discrepancy between dif- Eugene Vayda, MD, FRCPC ferent categories of municipal Professor of Health Administration homes has been justified because Department University of Toronto it allows for variations among Toronto, Ont. them: homes providing heavy care can receive more money than those providing less care. This justification fails to address the Adverse effects public-private difference and in- of psyllium tensifies the "unresolvable conF n or many years psylliumflict of interest between acceptable levels of care, constrained governcontaining laxatives have been widely used in Canament spending and the need to show a profit." The private nurs- da. Psyllium hydrophilic muciling homes are under increasing loid is derived from the seeds or pressure to reduce costs; advo- husks of the plant Plantago ovata, cates contend this is by increased also known as ispaghul. The adverse effects of psylliefficiency, critics by inadequate levels of care. um have been relatively uncomDr. Birkett invokes a dooms- mon; however, the drug is known day script when he describes pri- to cause IgE-mediated hypersenvate nursing homes as going into sitivity reactions in susceptible receivership, but Statistics Can- people. Allergic symptoms may ada, as quoted by Ms. Tarman be severe and consist of (page 43), tells another story. Be- any of the following: rhinocontween 1979 and 1986 the number junctivitis, skin reactions, asthma, of proprietary beds increased gastrointestinal symptoms and from 23 465 to 33 626 (i.e., by anaphylaxis. LE ler JANVIER 1992
Psyllium is frequently used in powdered form. When it is mixed or poured fine dust particles are readily dispersed into the air and can then be inhaled and cause sensitization. Workers in the pharmaceutical firms that manufacture the drug and health care workers dispensing it are at particular risk for a hypersensitivity reaction. In one epidemiologic survey 42% of pharmaceutical workers were found to have allergic symptoms.' In a subsequent, more objective survey of 130 pharmaceutical workers the prevalence rates of occupational asthma and IgE sensitization were found to be 3.6% and 27.9% respectively.2 Orally ingested psyllium seems to be less likely to induce sensitization. However, when prior sensitization has occurred (a fact of which the person may be unaware) subsequent oral ingestion of psyllium has been associated with severe allergic reactions.3'4 We suggest several measures to reduce the risk of psyllium allergy in health care workers. * Health care workers suspected of being allergic to psyllium should report their concerns to the occupational nurse or physician and receive definitive testing. * Workers known to be allergic to psyllium should avoid mixing and dispensing psyllium products. Also, they should avoid being present when others are handling the drug, since psyllium dust particles are easily dispersed in the air. * Measures to decrease exposure to psyllium dust particles are recommended for all personnel; these include the use of face masks and fume hoods while the drug is being mixed and dispensed. Fume hoods are available in the pharmacies of large institutions but not generally in smaller facilities.
JANUARY 1,1992
* The use of granulated as opposed to finely powdered formulations is theoretically less likely to induce sensitization. Brian F. Gillespie, MD Acting chief Flora J. Rathbun, MSc, MD Medical officer Drug Evaluation Division Bureau of Nonprescription Drugs Department of National Health and Welfare Ottawa, Ont.
References 1. Goransson K, Michaelson NG: Ispagula powder: an allergen in the work environment. Scand J Work Environ Health 1979; 5: 257-261 2. Bardy JD, Malo JL, Seguin P et al: Occupational asthma and IgE sensitization in a pharmaceutical company processing psyllium. Am Rev Respir Dis 1987; 135: 1033-1038 3. Lantner RR, Baltazar BR, Zumerchik P et al: Anaphylaxis following ingestion of a psyllium-containing cereal. JAMA 1990; 264: 2534-2536 4. Ontario Medical Association's Committee on Drugs and Pharmacotherapy: Hazards of psyllium. Drug Rep 1989; 28: 1
Don't forget the NHRDP I n a recent issue of CMAJ there was a report by Patrick
Sullivan, "Research-funding drought leads to call for letterwriting campaign by MDs, researchers" (1991; 145: 153), about the campaign by Canadians for Health Research (CHR) to increase the funding for the Medical Research Council (MRC). It was noted that in 1991-92 the MRC received only a 3.7% increase from the previous year. Although I strongly support the basic position expressed in Sullivan's report I would appreciate it if both CMAJ and the CHR could give equal attention to the disastrous funding at the National Health Research and Develop-
ment Program (NHRDP), run by the Department of National Health and Welfare, Ottawa. For the 1990-91 fiscal year the NHRDP budget was cut by about $4 million, which represents a 12% reduction in total funding and an 18% reduction in
funding for investigator-initiated research. As a result of this cut, funding of new projects was essentially put on hold for a full year. This year the NHRDP budget was maintained at its new level without even an increase to adjust for inflation. NHRDP is the only federal source of funding for research into community health and prevention. For example, the MRC will not fund studies on physician education or methods to improve the cost-effectiveness of health care delivery. Therefore, NHRDP provides an essential complement to the MRC, particularly given the current financial pressures on physicians and the health care community. Most health care workers and most of the general public are not aware of the role of NHRDP in supporting health care research. This makes it an easy target for financial cutbacks. When the NHRDP budget was cut last year only 300 letters were sent to the minister of national health and welfare to protest his action. Can you imagine the outcry that would follow an 18% reduction in the budget of the MRC? I urge the medical community to actively recognize the value of NHRDP to medical research in Canada. I hope that the CHR and other lobby organizations will pressure the federal government to maintain and expand all aspects of medical research funding. Nicholas Birkett, MD, MSc Department of Epidemiology and Community Medicine University of Ottawa Ottawa, Ont.
CAN MED ASSOC J 1992; 146 (1)
17
