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The Current Transcript for April 13, 2017

Host: Anna Maria Tremonti

STORIES FROM THIS EPISODE

Listen to the full episode

Prologue

[Music: Theme]

SOUNDCLIP

You know, everybody kind of says oh it's not addictive, it's this fun great thing. It's not a fun great thing. The National Institute of Drug Abuse says that about nine per cent of people who use marijuana will become abusers.

ANNA MARIA TREMONTI: It is true that marijuana is not ever likely to be lethal. But like the woman you just heard, an estimated 9 per cent of those who use it suffer from a dependency on cannabis. And in Canada that translates to millions of people. As the government moves today to legalize marijuana use, specialists in addiction say we need to confront the dependency issues we already face with the drug. We'll hear that voice. We'll also hear from a man who runs a treatment centre that uses marijuana to end opiate addictions. That's in half an hour. Later we'll hear from an ER doctor who's erratic schedule sees him spending three quarters of his working year at a state of the art of Toronto hospital and the other quarter at a hospital in Addis Ababa, Ethiopia, where the equipment is almost non-existent and the only medical staff on call are the ones he's teaching.

SOUNDCLIP

The truth is they teach me, because I have Willy Wonka’s golden airplane ticket. I can leave, but yet they have to wake up every day and go to work and deal with missing 18 units of blood and someone who’s bleeding badly.

AMT: James Maskalyk shares the heartbeat and the heartbreak of life between two very different, and in some ways, very similar emergency rooms. Hear him in an hour. But we begin with child's play.

SOUNDCLIP

[Sound: children screaming]

VOICE 1: That’s enough, no no no no, let’s not do that honey. You’ll make him tough that’s for sure.

[Sound: child noises]

AMT: The argument that rough and tumble leads to a smoother school experience. I'm Anna Maria Tremonti, this is The Current.

Roughhousing benefits kids, suggests Quebec daycare guide

Guests: Caroline Payer, Sandra Cheng-Kredl, Barbara Coloroso

SOUNDCLIP

[Sound: children playing]

ANNA MARIA TREMONTI: Sounds of the playground, a place for children to swing, slide, run, climb, and one of the first places they can practice some of the social skills they will need as adults. The playground can be both a site of cooperation and conflict. At dozens of daycares in Quebec’s Eastern Townships a new reference guide will encourage staff to allow for a little rough housing. That could include battle games, pretend sword fights, a different approach to care when things get a little rough and tumble. Some kids already know the value of recreational rowdiness. We asked a couple of students at West Side Montessori school in Toronto how they handle playground conflict.

SOUNDCLIP

[Sound: playground noises]

CHILD 1: I usually fight sometimes. Not really fight but like just play fight with my friends and stuff. I love playing basketball and it can get rough, like pushing people down. I feel like it's fine but some people cry because of it and stuff.

CHILD 2: If we get into fights our teacher breaks it up. But if we get into little little arguments, we just settle it by ourself. It's really, it's mature.

AMT: Well, advocates say a little scrappiness can encourage healthy development, particularly in boys. And for more on that, I am joined by someone who helped draft the new guide to roughhousing. Caroline Payer is the Director General of La Maison des familles FamillAction d'Asbestos, a social services organization in Asbestos, Quebec. That is where we have reached her today. Hello.

CAROLINE PAYER: Hi. Good morning.

AMT: What inspired you to create this guide?

CAROLINE PAYER: Well, actually what happened is that we’re actually more than 22 organization in early childhood and we got together and we looked at what was going on in our region. And this is one of the things that got us preoccupied. The what happens with our boys during their early childhood, their difficulty to adapt to daycare, and those difficulties they tend to maintain during through their primary and secondary school as well. So it got us really preoccupied.

AMT: And so how do you define rough housing?

CAROLINE PAYER: Well, roughhousing actually it's hard to define. It's actually not, it does, it has, I'm sorry. It's not related to violence at all. You have to make that very clear because it is not related to violence. So roughhousing, what we mean by that is maybe a little bit more physical play. It could be playing with swords, but in a way that will not hurt any child. That both kids are going to have fun doing it, they're going to want to participate in it. And if it gets out of control, we have to have an educator there to stop before it gets too close to violence.

AMT: Right. And how does making space for roughhousing help boys?

CAROLINE PAYER: Well, a lot of studies, because I'm not an expert here. I have to say that first, I'm not an expert. I work in a small organization, we have kids around every day, so of course I see the kids but I'm not an expert. So what we did, we went through a lot of studies when we started working on that guide. And one of the studies that we found was made by Daniel Paquette, I'm pretty sure you've heard about him. He’s a specialist at Montreal University. And that was conducted I think in 2005 or something like that. So there are studies that show the benefits of roughhousing or more physical play for the boys as well as for the girls. So that's how we kind of chose to put this element in our guide. But it's one in six other element, you know.

AMT: OK. And one of the suggestions is to create an environment conducive to building a masculine identity. What does that mean?

CAROLINE PAYER: Yeah, it's a good question. [chuckles] We're still trying to find out ourself what exactly it means. But I would say that the preschool world is mostly in a feminine environment. Here in Quebec, in our region at least, a lot of the teachers, our educators are women, so sometimes we find that the boys they don't recognize their place or they don't understand their place as easily in that world. But we believe that those women are professionals, so with our reference guide we wanted to just maybe go a little bit further and make them see that they have to offer

[Sound: child making noises]

CAROLINE PAYER: Various diversity of models in their classroom or in their daycare just to make sure that every kid in the group as models he can refer to, you know. So it could mean more traditionally masculine role models, but it could also mean non-traditional models, it could mean women. It doesn't have to be a man because we believe that those person in place, the teachers and the educator are professionals, so they can try to incorporate in their work other ways to offer role models.

AMT: OK. I hear you have a little one with you this morning.

CAROLINE PAYER: Yes, I'm sorry about that.

AMT: No, that's OK. How old? Is that a boy or a girl.

CAROLINE PAYER: That's a girl and she's three-years-old.

AMT: And do you roughhouse with your kids?

CAROLINE PAYER: Actually, it's mostly my husband does that. And that's what we saw in the studies too. At home, usually it's mostly the fathers that tend to do that with the kids and it's part of a really healthy combination, you know. But I try to do it more since I’ve read a lot about the benefits of that. But yeah, it's mostly my husband who does that.

AMT: OK. Well, thank you for speaking with me today.

CAROLINE PAYER: Well thank you very much.

AMT: That is Caroline Payer, she is the Director General of La Maison des familles FamillAction d'Asbestos. And she is an Asbestos, Quebec. Well, letting kids play rough is a controversial idea. It is not without its supporters, as she just told us. Sandra Chang-Kredl is an Assistant Professor in the Department of Education at Concordia University. She specializes in early childhood teacher education. She's in our Montreal studio. Hello.

SANDRA CHANG-KREDL: Hi.

AMT: Does the idea of permitting or even promoting horseplay have merit?

SANDRA CHANG-KREDL: I think so. I think that the report advocates an interesting position about rough and tumble play. I think it in a way it challenges the protective instincts that we have as educators and parents and as Caroline said, you know, this is more pronounced in women right? Who tend to be 98 per cent of the educators in child care. So we don't want children to get hurt but in limiting them in this sort of play we may be impeding their development in other ways.

AMT: So what are the benefits of roughhousing?

SANDRA CHANG-KREDL: Well, I mean there are a few. Physically they learn body control coordination, I think mostly though it's social development. They learn how to read other children's body language, facial expressions, there's a lot of decoding social cues when you're playing in this way. So building friendships, knowing when to stop, knowing when it's enough. You know, knowing how close to get and also learning to take turns. And I think, you know, if children have a natural urge to play physically, and I kind of picture puppies when they're play fighting right? To give them either her or him the message that this is wrong behaviour is going to make the child doubt himself or herself in some ways right?

AMT: Now, the guide was developed to support boys in school. Do girls also benefit from roughhousing?

SANDRA CHANG-KREDL: I definitely think so. I mean, there is a nature versus nurture factor and overall or on a whole, boys tend to engage in more physically active play like rough and tumble play than girls. Girls tend to be more communicative and cooperative. But, you know, there are always exceptions. You know, the girl who wants to roughhouse, the boy who prefers quiet play. So yeah, I think it could benefit girls as well.

AMT: And the guide instructs people to quote, “positively welcome war games and battle games,” and that's the end of the quote. Are there benefits to battle play?

SANDRA CHANG-KREDL: Yeah. I think war play, you know, which is one form of rough and tumble play, it's more contentious. You know, some, you know, there's been a lot of discussion about war play in the research, and some would argue that war toys and war play feeds into this sort of hype about war while diminishing how horrific war actually is, right? So I don't know that we want to give tacit approval for war play, but that's a little different from rough and tumble play. Star Wars for instance, you've got lightsabers and blasters, and it's almost like sanitized version of weapons, right? So I would distinguish between rough and tumble roughhousing and war play.

AMT: And what about toy weapons then? Like the pretend saber or the pretend sword is OK, but the gun?

SANDRA CHANG-KREDL: Yeah, you know, I mean, the other type of rough and tumble play that, you know, there's a certain pretend element, right? So superhero play would be part of it. And I think children, they need superheroes. They need to, children, they are and they feel kind of powerless in a lot of ways, they're small. So allowing them to sort of channel this super power and to pretend in these ways can be great. I mean, I think that they need that and it can help with their self-confidence and it's something that they naturally kind of go towards.

AMT: Is this about having kids who have aggression work it out in a different way?

SANDRA CHANG-KREDL: Well you see, I don't think it's aggression. I think, as the author of the report was saying, it's different. It's not violent. We have to distinguish between rough play and aggressive behaviour, they're not the same I don't think.

AMT: And this will help kids figure that out?

SANDRA CHANG-KREDL: Well, I mean, I think what you need, I think teachers need to be very knowledgeable about this type of play. You know, I'm not sure if I'm answering your question here but they need to be able to distinguish between rough play in which the children are smiling, laughing, they still want to hang out together afterwards. You can tell, you know, their hands are open, they're not angry, no one's crying. Versus actual aggressive behaviour. And so children, they need to learn that as well. And sometimes it can devolve into aggressive play but not usually right? And that's where the teacher needs to step in.

AMT: Right. And I was just going to ask you about that, because the guide is essentially saying don't, like, you know, usually that stuff is stopped but maybe you should let kids have a little roughhousing. So what advice do you have for parents or educators on when to intervene during rough play?

SANDRA CHANG-KREDL: Well, OK, I would say first I wouldn't necessarily actively push for this type of play but I would accept it and support it when it occurred naturally, right? And so you need to provide a safe environment. And usually this type of play happens almost always outdoors not indoors, right? So you need to give them open space. And then when you start seeing, like say some children they don't, you know, some children who aren't as mature socially, they don't know when to stop, so at that point you need to step in and say no, maybe you should listen to your friend when your friend says stop.

AMT: OK well, Sandra Chang-Kredl, thank you for your thoughts on this today.

SANDRA CHANG-KREDL: Thank you.

AMT: Sandra Chang-Kredl is an Assistant Professor in the Department of Education at Concordia University. She joined us from our Montreal studio. Now, not everyone is a fan of roughhousing. Some worry it is a slippery slope from rough and tumble play to outright aggression. Barbara Coloroso is a parenting expert, she specializes in nonviolent conflict resolution. She's also the author of the bestselling book Kids Are Worth It. And Barbara Coloroso joins us from Littleton, Colorado. Hello.

BARBARA COLOROSO: Good morning Anna Maria, thank you for having me. And I've enjoyed the discussion.

AMT: Well I'm glad you want to be part of it. What are your concerns about allowing rough and tumble play in school and in daycare settings?

BARBARA COLOROSO: Well when I heard Sandra I had to agree with her almost wholeheartedly. Two my Canadian heroes are Terry Orlick and Mark Tewksbury, both gold medalists and both of them advocating more cooperative rough and tumble play as opposed to competitive rough and tumble play. And I have a daughter who's a stuntwoman, so she leaps off cliffs and has gone to the point where she gets set on fire and loved it. [chuckles] So, and I have a son who's an artist, so I'm not so hooked into that we have to let our boys play war games, in fact I’m as opposed as Sandra is to that as well. I think though rock walls, obstacle courses, having kids help one another solve a problem about a maze, those kinds of activities, I want children to play with one another and overcome challenges out there. Because they do learn about body language, they do learn about limits and boundaries, they do learn to step in when somebody needs help rather than mock them or shame them or see somebody that they can overcome aggressively. So I think we need to have more of those kinds of activities, and I think it's important that men and women get actively involved with our young children so that they have this fluid ability to engage in lots of different kinds of activities. And are we there to support them? I want to teach kids how to deal with their conflicts. I mean, kids are going to have conflicts, even in these cooperative activities where they are overcoming an obstacle or climbing a rock wall or swinging back and forth on the monkey bars.

AMT: So--

BARBARA COLOROSO: If we still allow monkey bars. [laughs]

AMT: Right, but you're talking about challenging physical activities versus roughhousing are you not? Like.

BARBARA COLOROSO: Well, roughhousing, oh you can have some real roughhousing going as you're going through obstacles, and two kids trying to get through the same obstacle course, where do they have to learn to handle body space and recognize when somebody is struggling and recognize when somebody is trying to take over their own personal space. And I think we can create dynamic play areas outside and inside for young people to do that. And the next time they fight, first thing I want you to say is they’re normal. Children who do not fight grow up to make lousy spouses. I mean, we need people willing to enter into conflict. But our job is to teach them that when you have a conflict, whether it's on the playground, in the classroom, in the hallways, that there are ways to handle it non-violently. And so I think that’s a skill we need to make sure our kids have. I go through the three kinds of families, the brick wall, the jellyfish, and the backbone. The brick wall parent or child care provider, when two kids are having a dispute over a soccer ball or over who's going to build the sand castle where, the inclination of brick wall is to say stop it stop it stop it, nobody's going to play with it. So we resolve their conflict and then we don't allow them to engage in ways to solve it. A jellyfish says well, as long as there's no blood we'll let it go. But a backbone childcare provider offers flexibility but also gives that environment where it’s creative, constructive and responsible. Where I say to the two of them, oh you're fighting over the soccer ball, give it to me and you can have it back as soon as you both have a plan how you're going to play with it.

AMT: Hm. OK.

BARBARA COLOROSO: And they’ll either share, both get up and leave it or come up with a plan they both can live with.

AMT: OK.

BARBARA COLOROSO: As long as the one who doesn't say I'm going to beat you over the head with it and I say not a good plan, but I let them come up with a way to solve it when it gets to the point where adults need to step in. I rarely step in.

AMT: We don't have a lot of time left Barbara Coloroso, but I wanted to ask you, you heard that part of this is to help build a masculine identity. Are boys struggling with masculine identities do you think?

BARBARA COLOROSO: I think boys are struggling because of the way we've structured our day cares, our play centres and our schools. Girls are more ready to sit down and read younger than boys, but boys like to identify letters and words. And maybe it's a matter of how we teach them. And I'm not so much into the masculine identity as much as I am being who you are and being able to express yourself. I think it’s important, as we see on TV, for young little boys to be in the kitchen because we have master chefs, and for little girls not to be mocked for being quote unquote the tomboy. So I think it should be more fluid. And I believe we women need to get out there and show them that we can be rough and tumbly too and that we can also be gentle and caring. I want strong boys who are also very deeply caring and cooperative and competent in who they are with the gifts that they bring. And so we're going to have children across the spectrum. We're going to have some little girls who like to get out there and do that rough and tumble and other little girls who would rather not. I encourage them all to participate. But they'll find their own niches out there. It's a matter of inviting them all to explore who they individually are. In more males in early childhood, I think it’s very important too. But again look at--

AMT: [interposing] Barbara Coloroso, we have to leave it there. But thank you for your thoughts today.

BARBARA COLOROSO: Oh, thank you for having me.

AMT: Bye bye. That is Barbara Coloroso, parenting expert. She specializes in nonviolent conflict resolution. She's also the author of the bestselling book Kids Are Worth It. Over to you now, what do you think? Should roughhousing be allowed, even encouraged? Look us up on Facebook, find us on Twitter, we’re @TheCurrentCBC. Send us an email, click on the contact us link on our website, cbc.ca/thecurrent. And stay with us, the news is next. And then the smell of controversy.

[Music: Peter Tosh]

AMT: Reggae artist Peter Tosh’s debut solo album Legalize It. Now that more than 40 years later Canada is doing just that, we're talking about legalizing marijuana and dependency on cannabis when we return. This is The Current.

Will legalized marijuana lead to more addictions?

Guests: Susan Shapiro, Vanessa Markov, Dr. Benedikt Fischer, Joe Schrank

ANNA MARIA TREMONTI: Hello, I'm Anna Maria Tremonti and you're listening to The Current.

[Music: Theme]

AMT: Still to come, Dr. James Maskalyk has been in emergency rooms from Toronto to Addis Ababa and he says they’re a window on society. He'll talk about what the ER has taught him about life and death. But first, the legalization of marijuana has lit up the debate about dependency and addiction.

SOUNDCLIP

I should say right away that I don't think anybody should be in jail for smoking marijuana. And I think medical marijuana can definitely help people with illnesses and diseases. But it's a lie that pot is not addictive or dangerous. And I would say I would put it on the level of a substance like nicotine or alcohol, but I think it is stronger and much harder to regulate on every level.

AMT: Well that's Susan Shapiro, she's a New York based author and journalist who used to be addicted to marijuana. Today as the federal government brings in new legislation on the legalization of marijuana as a recreational drug. Former addicts such as Susan Shapiro want people to remember that it has an ugly side, one she fears has been forgotten.

SOUNDCLIP

You know, everybody kind of says oh it's not addictive, it's this fun great thing, it's not a fun great thing. It can be very addictive. I mean, they say right now, they're saying that the National Institute of Drug Abuse says that about nine per cent of people who use marijuana will become abusers.

AMT: For a lot of Canadians the pushback against marijuana smells a little like moral panic, a throwback to the Reefer Madness era of the last century, when toking was seen as a gateway to hard drugs. But marijuana has had a destructive effect on some people's lives. Vanessa Markov is one of them. She describes her marijuana use as an addiction. She's joined me in our Toronto studio. Hi.

VANESSA MARKOV: Good morning Anna Maria.

AMT: When did you know you were addicted to marijuana?

VANESSA MARKOV: It was about a year and a half ago when I first sought treatment for what I thought was mental illness. And during the assessment, the discussion around substance abuse came up and that's when I was first introduced to the idea that perhaps marijuana was causing some of the symptoms that I was having.

AMT: Did you see marijuana substance abuse until that point?

VANESSA MARKOV: No I didn't.

AMT: How much were you using?

VANESSA MARKOV: Oh I was smoking all day every day.

AMT: OK. How long had you been addicted to marijuana?

VANESSA MARKOV: About 15 years.

AMT: And what did it do to you?

VANESSA MARKOV: Oh, lots of things. Chronic fatigue, emotional instability, general irritability, I had anxiety, I had just little spurts of motivation where everything, all of my ambitions plans, ideas would always be pushed back to tomorrow. Lots of symptoms.

AMT: And how old were you when you started smoking?

VANESSA MARKOV: 15.

AMT: And did your friends say anything? Like, did people notice? What were they?

VANESSA MARKOV: Some family had raised questions. But the majority of my friends were also daily smokers.

AMT: And so when you went to get help and you identified this as the problem, what did you do?

VANESSA MARKOV: I immediately sought treatment and support to reduce my use. When reduction didn't work, I went for straight abstinence and it was a bit of a rocky road for the first six months but then it worked. And couldn't have made a better decision.

AMT: And reduction didn't work because why?

VANESSA MARKOV: Because I couldn't control how much I was using. As soon as I would use again I would just want to use again and again and again.

AMT: Uh huh, and did you go through any kind of withdrawal?

VANESSA MARKOV: Yes. Very subtle withdrawal symptoms, you know, for the first couple of weeks some nightmares, some cold sweats, inability to sleep, after a couple of months it was more of a reintroduction to the full spectrum of my emotions. But overall the benefits far outweighed any of the withdrawal symptoms.

AMT: And so what is life like for you now? Tell me how different, what the differences are that you see?

VANESSA MARKOV: Oh the difference is night and day. I am so much more calm. I can listen. I can focus. I get a lot more done in a day. I sleep better. Just overall my work life, my relationships and my ability to actually do what I set out to do every single day is completely back.

AMT: Mm. And so again, when this was identified you were surprised?

VANESSA MARKOV: Yes, I was surprised.

AMT: And you went because you thought you had some kind of a mental illness?

VANESSA MARKOV: Yes.

AMT: And you have no symptoms now?

VANESSA MARKOV: None.

AMT: OK. And so what do you think we can learn from what you went through?

VANESSA MARKOV: I think that there are a lot of people who smoke pot that just believe it's not addictive and it is. But I also don't think it's the drug itself. I don't think that everybody who uses pot will become addicted. I do believe in recreational and medicinal use. But that it is very possible to become addicted to marijuana and to believe that it's not addictive can be very very dangerous.

AMT: So it's like the use of alcohol, for example. Some people become very dependent on it and other people do not.

VANESSA MARKOV: Yes. Exactly.

AMT: So we just need to know it’s there?

VANESSA MARKOV: Exactly.

AMT: And how long has it been for you now that you've recovered from this?

VANESSA MARKOV: One year as of this week.

AMT: Congratulations.

VANESSA MARKOV: Thank you.

AMT: Thank you for coming in.

VANESSA MARKOV: Thank you very much.

AMT: That's Vanessa Markov, she's a recovering marijuana addict and she joined me in our Toronto studio. Legalization brings with it an opportunity to confront some of the difficult realities of marijuana use. Dr. Benedikt Fischer is a Senior Scientist at the Institute for Mental Health Policy Research in the Centre for Addiction and Mental Health, or CAMH. He's also a Professor in the Department of Psychiatry at the University of Toronto. He's in Sao Paulo, Brazil today. Hello Dr. Fischer.

DR. BENEDIKT FISCHER: Hello Anna Maria.

AMT: You were just listening to Vanessa Markoff, how common is her story?

DR. BENEDIKT FISCHER: It's relatively common, although it is not the norm I would say. We know from scientific data that certain minority, it's estimated between 10 and 20 per cent of cannabis users actually become dependent on the drugs. So it's a minority of users and it's the outcome of dependents is typically predicted by a number of behavioural factors. So for example, intensive use, highly frequent use of cannabis, but also the types of cannabis products that people consume. For example, high THC products, can predict the likelihood for people becoming dependent, but also as Vanessa actually points out quite rightly, it depends on the personalities. So it’s an interaction of the drug, the behavioural patterns and the person, so we can't reliably predict, you know, whether this will happen to person one versus person two. But compared to alcohol, we should also point out compared to alcohol and compared to nicotine, the abuse or the dependence liability of cannabis is relatively small, the likelihood of people becoming dependent on nicotine or alcohol is actually considerably higher than for cannabis. But cannabis dependency definitely exists. And, you know, it's part of the things, list of things that we need to be concerned about when dealing with this drug in a public health approach. But that's irrespective of whether it's legalized or not. We have the problem of dependence today or had it yesterday as much as we will have it after today and the introduction of the legislation.

AMT: Well, before we go on any further, let's get the terminology correct. Most people say addiction, the medical community now uses the word dependency. What's the difference?

DR. BENEDIKT FISCHER: The difference is simply that addiction is an old term that's still inferred basically moral failure or a criminal profile if you will, a criminal intentional wrongdoing on society by substance users. Whereas dependence basically embodies the disease model, the disease approach to substance abuse, treating it as a disease versus a crime.

AMT: OK. Now, you also made the point that some fewer people, a lower percentage of people becomes dependent on cannabis than alcohol or tobacco. What are the numbers for the other two?

DR. BENEDIKT FISCHER: The scientific data suggest that somewhere between 20 and 30 per cent of alcohol users but about 50 to 60 per cent of nicotine users develop dependence. As I said, for cannabis it's estimated to be around 10 to 20 per cent of users in any given user population. But again, it depends on those variables that I pointed out earlier.

AMT: So many people who use marijuana do not think it's habit forming, what has allowed that myth to perpetuate?

DR. BENEDIKT FISCHER: You know, I think it's partly a little bit of a counter reaction to the fact that we have this paradoxical situation where we dealt with the legal drugs, alcohol and tobacco specifically, as if they were fine. We sold them as legal commodity, they were accessible to people and we criminalized cannabis. And basically, you know, put it away and demonized it as if it's the worst of all drugs. Whereas sort of the both the acute and long term health outcomes did not warrant that at all. And then so I think what people's beliefs or these realities were amplified in a lot of people's belief system. They knew that cannabis was clearly less dangerous on many fronts than alcohol and nicotine and that's sort of how what settled in people's belief system. But there is no drug out there without any risks. Clearly for cannabis we know that the risks exist on certain fronts, but compared to alcohol and tobacco they are relatively limited. But it’s definitely not risk free.

AMT: And so what's your estimate of the number of people who might be cannabis dependent in this country already?

DR. BENEDIKT FISCHER: It's an interesting question because we don't have terribly reliable data. We’ve estimated that somewhere between 250 to 400,000 users currently are dependent. These are very very rough estimates. We don't have reliable statistics on those things and of course, only a proportion of those people are actually actively seeking help or are involved with the treatment system. But given that we have several millions of cannabis users in this country, people who will develop these kinds of problems with dependence are part of the problem spectrum that we need to deal with, again, irrespective of legalisation or not. That this is part of the phenomenon of substance use or even, you know, when we have things like gambling, we know that a certain percentage of people will develop gambling problems and dependence. So this is part of what the systems need to be prepared for and deal with in order to help those people who've developed dependence. Vanessa I think it's a relatively lucky case in that she's clearly a very reflexive woman who understood what is happening with her, she took the right steps to help herself. And it sounds like she succeeded greatly. For the majority of people who enter treatment for cannabis dependence, the stories are not typically not that positive in that not every, certainly not every treatment attempt at the first attempt is effective, a lot of people relapse, have to go back and struggle with this for a long period of time.

AMT: And what kinds of things do you see in their symptoms as they struggle with that dependence? What falls away?

DR. BENEDIKT FISCHER: Well, of course problems related to dependence are withdrawal symptoms, people have fatigue as Vanessa also pointed out, they're unable to fulfill their daily responsibilities around work or family, their physical symptoms and symptoms that are often perceived as mental health symptoms. And there's of course drug seeking. People when they're dependent, they want to do what gives them relief, which is to use the drug that they're dependent on. So it's a variety of symptoms that can really greatly interfere with people's health, well-being, and ability to function on an everyday basis.

AMT: How equipped our addiction centres or provinces, whoever looks after addiction in this country, how well equipped are they to deal with that dependency?

DR. BENEDIKT FISCHER: To a limited extent I would say. We definitely know that in general the addiction help and treatment system is under resourced. There's definitely not as much supply as there is demand overall. So that's probably one of the things that we definitely need to look into. Also now, given that this drug is likely to become legal, to improve treatment availability and access. For cannabis, is one of the specific challenges is that we at this point rely exclusively on psychosocial or cognitive behavioural approaches, in other words there's no pharmacotherapy like methadone for opioids, for example, that can be prescribed or provided to people. These psychosocial or cognitive behavioural approaches are effective to a limited extent, but they're also quite resource intensive. So we're talking psychotherapeutic approaches or group therapy, which are quite resource and labour intensive. They cost a lot of money, they take a lot of time and it would be greatly desirable that the so-called toolbox of evidence based treatment available for this particular substance would be greater. And so that's definitely one area where investments and resources need to go to develop and expand the availability of effective treatment.

AMT: Well that's provincial health care though right?

DR. BENEDIKT FISCHER: Yeah, that is under the auspices of provincial health and addiction care. That's not a federal, not a federal mandate.

AMT: OK. Dr. Fischer, thank you for your insights into this.

DR. BENEDIKT FISCHER: You're very welcome.

AMT: Dr. Benedikt Fischer, Senior Scientist at CAMH and a Professor in the Department of Psychiatry at the University of Toronto. Today he's in Sao Paulo, Brazil, that's where we reached him. Joe Schrank thinks cannabis can be an ally in the fight against some addictions or dependencies. He's the founder of High Sobriety, a rehab facility based in Los Angeles. That's where he is today. Hello.

JOE SCHRANK: Hello. How are you?

AMT: I'm well thank you. What do you think about what you just heard about marijuana being a drug that can cause a serious dependency?

JOE SCHRANK: Well, I mean, my first reaction is I love how reasonable Canadians are on all this, because Americans are hysterical about it. It can be, people can absolutely develop dependencies on cannabis. It's not without risk. That is correct, it is that that is a fallacy and that is myth. All drugs have a risk. It is important to draw the distinction between addiction and a dependency. When we're honest with ourselves, we're all dependent on something. I'm dependent on coffee or I couldn't speak to at this moment at 5:00 in the morning in LA. And so I think it's an important thing to know we utilize cannabis as an exit drug from harder and more dangerous addictions such as heroin.

AMT: How so?

JOE SCHRANK: Well, it's a softer landing. You know, the people who are dependent on opiates or dependent on alcohol and we never really take a hard look at alcohol. Alcohol kills 88,000 Americans a year. I’m sure, I don't know what the statistics are in Canada. But cannabis can help people move towards harm reduction, move towards a better life. You know, dead is dead. So if somebody overdoses on heroin and dies, that’s the end of the story. If somebody drinks themselves to death that's the end of the story. If they're able to utilize cannabis and move toward cessation of drug use or even stabilize at just using cannabis, it's really up to them to make the decision if they're dependent on it and if it's causing impairment in their lives.

AMT: So what proof is there that cannabis use can cut down on opioid addiction?

JOE SCHRANK: Well, there is there is some research out there. In America cannabis is still a Schedule 1 drug, meaning it's classified the same as heroin and cocaine. And so the clinical trials are illegal to do. So a lot of the information that we have is based on states that have medicalized cannabis. We know in California for example, people who have a medical marijuana card, 90 per cent of them report that they don't drink alcohol. So they're immediately safer by not drinking alcohol, just the fact that there's no lethal dose of cannabis. There are theoretical lethal doses of it but it's almost, it would be impossible to achieve. It's like 200 pounds in 15 minutes or something like that. So when people stop drinking we know that they're safer. There's a lot of evidence that suggests that that can happen, there's a lot of evidence that suggests that people can circumvent the use of opiates by using cannabis for pain management and other ailments.

AMT: Have you seen--

JOE SCHRANK: And they’re also, I’m sorry.

AMT: Sorry, have you seen any stats in the states where marijuana, medical marijuana is legal, where opioid use has dropped?

JOE SCHRANK: Yeah absolutely. And that's one of the most important stats that we have is that states with legal accessible cannabis have 23 per cent fewer overdose deaths. And so it is working in some way for some people. Clearly we need more knowledge, we need more empirical evidence and that needs to grow. But that becomes an issue of culture because people are, you know, in America people are still very afraid of it and they do believe that there is a connection between the Pandora's Box that that cannabis use opens.

AMT: So--

JOE SCHRANK: Yes.

AMT: Let me just ask you then, so at High Sobriety you are actually treating drug dependence with cannabis?

JOE SCHRANK: That is correct.

AMT: What do you do?

JOE SCHRANK: I’m sorry?

AMT: Tell us what you do. Sorry.

JOE SCHRANK: Well, the first thing that cannabis helps is the detox. People who are dependent on opiates or alcohol are very afraid of the detox and that becomes a preventative for them to enter any kind of treatment system. When they understand that this is a softer landing for them, that the corners are not as sharp, that they will be allowed to use medically dispensed cannabis under the supervision of a physician. So that means that it's not just at will, they don't just smoke pot all day. That's not what we're doing here, but they are allowed to use that. That really really really helps their detox. Without question it provides symptomatic care. So people who have the symptoms with, you know, an opiate detox can be very painful and it's a very hard process. So it helps with the nausea, the bone pain, the insomnia, all of the things that happen when people are coming off of opiates. So that can really help them. You know, from there it operates as a replacement because people who are dependent on opiates and alcohol really they need to be offered some kind of replacement, at least for a period, to tell people come into treatment 30 days you'll be drug free and you'll never drink or use again is wrong and the efficacy of that is minimal. It doesn't support enough people to make that even really an ethical recommendation.

AMT: OK. Are you one of the only ones doing this in the US?

JOE SCHRANK: As far as I know, we're the only ones doing this. You know, I mean, it is controversial to say the least, the recovery community has pushed back pretty hard. You know, the abstinence based advocates, and that's sort of one of the ironies I guess of this is that I am an abstinent person, I haven't had a drink or a drug in 20 years. I'm a member of a 12 step community. But America we have over 100 people a day dropping dead of an opiate overdose. And so there are people falling through the cracks in our system. And people need an alternative for sure. And cannabis can help. I don't mean to give the impression and I hope I'm not giving the impression that it's without risk or that it's benign. It is not. There are people who have cannabis dependencies and it can impair somebody's life. That's a different question for then what we do at High Sobriety.

AMT: OK. Well, Joe Schrank, thank you for speaking with me today.

JOE SCHRANK: Thank you.

AMT: That is Joe Schrank, founder of High Sobriety. He joined us from Los Angeles, California.

[Music]

AMT: On Tuesday on The Current we had a discussion on teaching kids about death, whether the topic should be included in the school curriculum. Dr. Jessica Zitter thinks it's time. She's a Montreal born doctor who practices clinical and palliative care medicine at Highland Hospital in Oakland, California. She once taught a course on death to her daughter's high school class.

SOUNDCLIP

We were very pleasantly surprised. The kids were really receptive and open and interested and yes, a little surprised by some of the things that we told them. But I think that hopefully the surprise will translate into a lifetime of being more empowered to understand this important topic.

AMT: A lot of you had something to say about death education. Carrie Mae Garber posted this on Facebook, “in our death phobic society and being a nurse, I think it would be fabulous to have end of life integrated through all subjects at an age appropriate level from grades two or three through university, rather than a separate subject.” Dan Malleck tweeted some thoughts, “we need more death literacy. We need to relearn how to support each other at times of loss. Rediscover community.” Steve Fairbairn of Elkford, BC had this to say, “as a soon to be retired high school teacher, let me express my dismay at this concept. It is but one more attempt to offload the responsibility of the family onto an already overloaded bureaucracy. Just what exactly should be removed from what we're supposed to teach now so that there is time to teach this?” And finally Roberta Seed of Lillooet, BC had this to say, “I think that parents need to handle this subject with their children. Parents have different beliefs about death and dying. It's their duty to their kids to help them understand this topic.” If you have thoughts on death ed or anything else you hear on the program, we want to hear about it. Look us up on Facebook, find us on Twitter, we’re @TheCurrentCBC. Send us an email, just click on the contact link on our website cbc.ca/thecurrent. Coming up in our next half hour, emergency rooms from Canada to Ethiopia, providing a lens into society's problems. Forcing one doctor to confront his own. I'm Anna Maria Tremonti, this is The Current.

[Music: Extro]

From Toronto to Addis Ababa: Life lessons from an ER doctor

Guest: James Maskalyk

ANNA MARIA TREMONTI: Hello, I'm Anna Maria Tremonti and this is The Current.

SOUNDCLIP

[Sound: sirens, phone ringing and busy chatter]

AMT: The rush of a busy emergency room at St. Michael's Hospital in downtown Toronto, this sound plays during crash simulations to get doctors in training used to the noise and commotion. It's a buzz James Maskalyk knows well. He is an emergency room physician who also teaches medical students in Toronto and in Addis Ababa, Ethiopia. He tries to prepare them for the stresses of the job.

SOUNDCLIP

JAMES MASKALYK: Everyone is fourth year right? You guys are going into your exams and then your residency program. Has anybody ever seen someone bleed to death before? So watching someone bleed to death sucks because you have what they need. We have blood. It's sometimes not possible, no matter how much blood you give them because it's a physics equation. How much is going out versus how much you can put it. So if someone comes in and they’re multiply injured, if they endured a blunt trauma, no matter how much blood you give them they're going to die. And so it's a hard job.

AMT: That is Dr. James Maskalyk, talking to students at the University of Toronto earlier this month. And as much as he has taught, he has also learned from his time in the emergency room. And he's written all about it in his new book Life on the Ground Floor: Letters From the Edge of Emergency Medicine. Dr. James Maskalyk joins me in our Toronto studio. Welcome.

DR. JAMES MASKALYK: Thank you, I’m glad to be here.

AMT: It's a tough job huh?

DR. JAMES MASKALYK: It is yeah. But, you know, with time you learn to appreciate it more and more.

AMT: And what does it, do you have to be tough to work in an emergency room?

DR. JAMES MASKALYK: I think that's a bit of a misconception or, you know, it's changed for me as I've gotten more mature in my career. And I think the rewards that I find are there when I'm softer, when I don't put up the barrier that, you know, it's possible to do. But when I let in the emotion, it's kind of guides me to be a better doctor.

AMT: In that lecture you go on to say that the job of an emergency doctor is to pay attention. What's at the core of what you're paying attention to?

DR. JAMES MASKALYK: Well I think that, you know, if you retreat back to, you know, deeper and deeper questions it is, you know, how can I do the best for the person in front of me with as little bias as possible? So the more I pay attention to that intention the better the outcome is in terms of making decisions, even in ones that require haste. And how to care for myself in the midst of all that. How to treat my colleagues. How to like I said, mourn when it's time.

AMT: There's something called the knack, what is that?

DR. JAMES MASKALYK: Yeah, it’s, you know, a friend of mine Brian [unintelligible], he was a teacher and a colleague now. But he talked about it, just how being able to glance around in a room full of sick people and pick out the one who you know is not doing well, even though you haven't asked them a single question, even though you haven't looked at their blood work. Just that energetic read of someone who's got a deep struggle energetically inside of them. Whether it's an infection because they're bleeding badly and it's you can see it often in their eyes, how their consciousness is able to reach out and engage because the sickest people they're dimming, you know, that light is gradually fading.

AMT: It's not always the one who is screaming the loudest is it?

DR. JAMES MASKALYK: No, very rarely is that the case. That's why, you know, it's in Ethiopia where, you know, I write about in my book, that sometimes people come alone, I write about one of those people in it and they don't have anyone to advocate for them. You know, they’d taken buses because they've heard about Black Lion Hospital, maybe they've come from, you know, a day away. And so they don't have that person at the front, you know, saying hey my friend is sick. So you really have to be active in that process. At St. Mike’s, you know, that’s already exists, we have people looking in the waiting room and scanning it. But that really deep teaching is that people who sometimes need the help the most have the weakest voice.

AMT: And before we get to Addis Ababa, let's just stick with Toronto emergency room first. So there's a lot going on on a really busy night, because you always work the night shift?

DR. JAMES MASKALYK: No, when I have to, like all my friends. But often.

AMT: Yeah, you've got to then be aware, you got to have like every spidey sense going I guess huh?

DR. JAMES MASKALYK: Mhm.

AMT: Like, you have to be aware of everything. But you also said you have to take care of yourself. What does that mean?

DR. JAMES MASKALYK: I think, you know, it’s changed, like I said, over the years. And I think it means that, you know, take care of my mind and continue to learn and grow in my skills. I think there's nothing I want more of my future than to be clinically excellent because it's what my patients deserve and take care of my body. You know, sleep and rest and turn my phone off and be in nature and reflect on why you're struggling so mightily to help people. Well because life is beautiful. And so be in that contact with it as much as I can is what my patients need from me. So that's part of it, you know.

AMT: Mm. Because you're making split second decisions that affect how they will survive.

DR. JAMES MASKALYK: Sometimes that's the case, yeah.

AMT: Yeah. And you see death.

DR. JAMES MASKALYK: Mhm.

AMT: You see it a lot.

DR. JAMES MASKALYK: Yeah, yeah. I've certainly developed a relationship with that part of it.

AMT: So let's go to Addis Ababa, because you end up at the Black Lion Hospital, which has an emergency room that is different from a Western emergency room because who shows up in an emergency room in a place like that?

DR. JAMES MASKALYK: You know, it's someone who has run out of options basically. You know, at St. Mike’s in Toronto, it's our pleasure to help anyone who comes through the door. But sometimes people don't want to wait to see their family doctor for instance. At Black Lion, it’s people who have exhausted, you know, any other treatment they might have. And you know the truth is, as you can appreciate, when you're working in somewhere like Ethiopia, there's a large number of people who are subsistence living, meaning they make enough daily to live daily. So when they get sick the option isn't well I’m just going to go hang out for a couple of days and make my way to a Black Lion. They don't have the money to get into the taxi, so they maybe borrow some of that, they give a goat, they leave their children and they arrive sometimes after the disease has gotten advanced. So at Black Lion there's no one there holding their thumb, right? There's people there with badly broken legs or who have advanced cancer. So as hard as the job is in Toronto, it's even more so to stay well from the doctors who have left in Ethiopia.

AMT: When you first started working there, they didn't really have an emergency room to speak of did they?

DR. JAMES MASKALYK: You know, they would call it an emergency room and what’s so interesting for me and where the title of the book comes from is every place I've ever been has an emergency room. It's like an emergent phenomenon. So, you know, whether it's in Cambodia or Bolivia, and it's just one room or one nurse or one doctor said there seem to be people who come at all hours. And I kind of wish I could go home too but I'm going to stick it out for a little bit longer because I've heard about this person that's going to come and someone told me they're on their way and they're kind of sick. And so that flourishing of care is something that is why it looks this way in Toronto and why it looks this way in Ethiopia is, you know, a question I'm going to live my entire life, you know, in the way I write or what I do.

AMT: Mm.

DR. JAMES MASKALYK: Mhm.

AMT: You have a former student there who's now an emergency doctor. Finot?

DR. JAMES MASKALYK: Finot.

AMT: Finot Debebe. We called her.

DR. JAMES MASKALYK: Oh boy.

AMT: in the hope of including her today. We couldn't get a clear enough phone line, which tells you again something about, you know, some of the technology sometimes. But we did record her and we voiced over what she had to say. And she told us about some of the difficulties of emergency medicine in that hospital in Ethiopia. Let's listen.

SOUNDCLIP

FINOT DEBEBE: [through voiceover] The hardest day is when you cannot choose to give the resources for patients, especially for example if you have two patients and they need a machine and you have only one machine. That's one of the hardest days. And the way you don't know where to put the patients because the number of beds in the hospital are small. Sometimes we’re forced to put two or three patients on the floor and it's frustrating.

AMT: James Maskalyk, it's got to be frustrating to choose which patient to go to. And you have to do that anyway, but in a place like the Black Lion emergency room, just take us through some of the other struggles.

DR. JAMES MASKALYK: You know, [sighs] it's, I’m going to point out that because of the attention that these young doctors have been able to give this emergent phenomenon, they're building a new ER. And in fact, some of these students are working in a new ER so. But the one thing that exists now, the one that I try to evoke in the book was one room and now it's a good bit expanded but it's dark, when it rains the water pours through the ceiling. The power is mostly there but it's intermittent at times. It's very crowded. There is very little air flow, so as soon as you step over the threshold you get the sense of the smell of sickness and people who've traveled a long way. And there is no, it's not often joy is felt in that small tin room. Yet successes are growing. I mean, there is now a triage and trained nurses who are asking the same questions we do at St. Mike’s. There are now doctors 24 hours a day soon, to be covering the sickest and most injured people. But as you walk through, you know, the striped curtains and you work your way to the back, there are still people, particularly with broken backs and broken legs and as you may know, you know, in places like Ethiopia, emergencies happen most often in the poor people because they're the ones who are walking beside the side of the road because they can't afford bus fare because they can't be in a taxi.

AMT: Mm.

DR. JAMES MASKALYK: Certainly if they're in a taxi it's not one with seatbelts. So, you know, as you walk to the back hall you see these young broken men and women who are waiting for surgery if the parts, if the implements come in, and they can be there for days. So unfortunately one of the most difficult parts for Finot and her colleagues is taking care of these people for days and days and days, which is something I don't even know how to do.

AMT: Right, because in emergency here you deal with them and then they either go to another floor or they leave, right?

DR. JAMES MASKALYK: There's a whole system that takes care of that.

AMT: How long have you been going back and forth?

DR. JAMES MASKALYK: I think went 2008. That was the year after I got back from Sudan. I went in for the first time.

AMT: Yeah. Why do you do this?

DR. JAMES MASKALYK: [sighs] Well, you know, I believe so much in the idea that life is valuable and sacred no matter where it happens to be. And when I first stepped off a plane as a medical student, it was clear that if I was being told it was my job to take care of the sick ones and if you're on a plane you put up your hand no matter where you are or what stage of training you're in. It appeared the sicker people were in other places. And, you know, that's the general part of it. But in particular in Ethiopia working with MSF as I've done and I hope to do again soon, when I left those missions in, you know, in Sudan and Dadaab, I left with a feeling of, you know, now what? And what's going to happen in Ethiopia is the what.

AMT: And you have seen it grow because you've gone back, you go back and you teach like three months a year now right?

DR. JAMES MASKALYK: Mhm.

AMT: And so you've seen all of this grow. How difficult is it to get donations? How much is that the reliance for a place like that?

DR. JAMES MASKALYK: Well I've been really blessed to be part of University of Toronto. And, you know, the departments of family medicine and medicine have given us a small amount of money to continue the program as well as the emergency doctor groups in Toronto believe in this idea too. It's been remarkable really. But what's so important and what I really like to continue with is the Ethiopians contribute as well too. They pay for the plane tickets of the teachers. They pay for the accommodations. So I really like that relationship because they have the right to expect things of us then. So what I tell my designates or my delegates I mean, when they go, my colleagues, is the point is to be 100 per cent effective as soon as you step off the plane. And this isn't a trip where you go leave early to buy scarves. It's one where you're in the ER with these young men and women, you know, full time. And they really get it and they do a great job. So the donations are partly money but a lot of the time of the volunteers that go.

AMT: What's it like for you to be to juxtapose your professional life that way. You're in an ER at the Black Lion hospital. You just explained how acute the need is and then you come to Toronto and you get a real mix of people who show up in ER, including people who are very impatient.

DR. JAMES MASKALYK: Mhm. Yeah, you know, I discover is that whenever I have less than a positive encounter in the ER in Toronto, it's always the do with me. It’s never to do with the person. They don't want to be there, most of them don't want to be there, pretty much all of them don't want to be there. And some of them have nowhere else to go. But if I take that personally that's my problem. So for me it's an opportunity to work on my myself in that way so I can get out of my own way, so I can actually do what's expected of me, which is address their deeper needs. Now, sometimes they don't know what that is or we have to spend some time figuring that out. But I think that it's rare that I feel the dissonance as much as I used to when I first started doing this work.

AMT: You use the example of a mother who comes in with a son who's got a suspected concussion and it's a night when there's lots going on. Do you remember that exchange?

DR. JAMES MASKALYK: I do remember that exact exchange.

AMT: What’d you say to her?

DR. JAMES MASKALYK: You know, I think that it's pretty common when you have more demands on your time than your emotions that you can keep up with. And in the ER we're not very good at taking breaks, we're not very, you know, there's so much inertia to see patients and pick out the sick ones and your colleagues expect it. You don't want to hand over a mess in the department, so you work diligently. And so it's almost with a sad pleasure that you say to someone when they ask, you know, how much longer is the wait? And you say I don't know, there's so much, you know, it’s so busy here today, almost diminishing the legitimacy of their complaint. But it's always a mistake. It's always a mistake. And I write about it because for that reason, you know, it's so much easier to say hey you must be worried, but we're going to get to you I promise. And they feel so reassured when they hear that. And sometimes I’d say you know what maybe it's too long I'm going to come back another day if they can. But that's why I write about that.

AMT: We need to understand that right? Because the doctors are facing and the nurses are facing those same pressures of wanting to get to everyone. The other thing you do in your book is you talk about your grandfather. How old is he?

DR. JAMES MASKALYK: He's 94.

AMT: Uh huh, and he lives alone?

DR. JAMES MASKALYK: He does, yeah.

AMT: Northern Alberta.

DR. JAMES MASKALYK: He lives in northern Alberta.

AMT: You’re an Alberta boy, you grew up in Alberta.

DR. JAMES MASKALYK: I am proudly Albertan.

AMT: What has your grandfather taught you about life and end of life that you can use in the work that you do?

DR. JAMES MASKALYK: I think that, you know, he, I watch with great love and interest the way he lives his life. And he's unafraid, you know, he understands that, you know, death has been part of this business right from the very beginning. You know, he was a trapper and taught me how to hunt and all those things. So right from the get go he understands that it's a process, you're part of a process. And yet he shows so little fear. He maintains such a sense of himself to everyone he meets that is a great teaching for me about how to live with that knowledge. Not to be afraid and to get up and take it day by day. And, you know, in the book I use him, you know, the book goes from the first part is about the body and the middle third is the system that takes care of the body and then it comes back to the body again. And I use him because I love him so much. And I think at the end of the day that's something we all share is that deep sense of love for a family and our friends and hopefully for ourselves. And from it come emergency rooms with all the stuff and from it come emergency rooms in Ethiopia that need more stuff and we open our hearts to them.

AMT: Mm. And so when you see someone with a loved one walking in.

DR. JAMES MASKALYK: Yeah.

AMT: You know, through those sliding doors, you understand at another level that that they're worried and what that connection is. Because of the connections you have.

DR. JAMES MASKALYK: Right. They want communion with that thing. Mhm.

AMT: How is your grandfather's health?

DR. JAMES MASKALYK: It’s OK.

AMT: He’s got a doctor grandson.

DR. JAMES MASKALYK: Yeah yeah. So we do a lot of patient doctor interactions. You know, 94 is not easy on a person's body. You know, it's hard for him to get around. I think your, you know, your spirit it's interesting, your body falls away around this quick of a spirit and it's still as it ever was, for him anyway. Yet he can’t move so well anymore. And your world kind of shrinks, you know, and you go from having this world that included something as far as a trap line to maybe now it's really hard to leave a single room. So we go to him, you know, my parents go to him quite a lot. I go to him when I can and I know he values that.

AMT: It's taught you a lot about life and death though, hasn’t it? In terms of just accepting.

DR. JAMES MASKALYK: Mhm. And, you know, in the book I write w is for waiting. And I don't know if you get the sense sometimes, I certainly did, this feeling is very strong, you're waiting for something to begin but you're not quite sure what it is. It's just like but it's life and it's right here and it's there to be lived. So, you know, make sure that you're able to spend as much time around people that you care about and live your truth.

AMT: And even the people that you only meet for a few hours.

DR. JAMES MASKALYK: Exactly.

AMT: You have that connection with them. But you talk about when someone starts to complain that it's cold, they're all wrapped up in blankets and they say I'm so cold. And that's your cue.

DR. JAMES MASKALYK: Mhm.

AMT: What's going to happen to them?

DR. JAMES MASKALYK: Yeah. You know, a few times that I've, one of my teachers again Brian Steinhart taught me that is that it's very commonly in young men with a lot of muscle mass and they're bleeding heavily inside and you don't know and their heart rate is high and but their blood pressure is normal. And then they say I feel cold. They're going to die. Their heart is going to go up to 150, the blood pressure is going to fall 180, 190 and then they're going to go into cardiac arrest. So as soon as that happens, you know to get two large [unintelligible] wide open, saline if you have it, blood is better. Yeah, it’s a hard feeling.

AMT: You know what to do, it's just instinctive huh?

DR. JAMES MASKALYK: Yeah. And not just me. You know, the nurses and doctors I know how to work with they’re all excellent. I'm really proud to be working at St. Mike’s and in Ethiopia too, to be sharing that with those Finot and her friends.

AMT: [crosstalk] St. Mike’s and Black Lion has that connection. Your grandfather does tell you life is not just one big funeral, that it is about living.

DR. JAMES MASKALYK: Mhm.

AMT: How do you see life, as someone who goes back and forth between these places?

DR. JAMES MASKALYK: Yeah. You know, it's something that is worth fighting for in all the ways that matter. And, you know, for me the ER and the promise that it holds, you know, that, and I'm kind of not the same person I was when I stepped off the plane with MSF to go into Sudan and that's fine. I wouldn't go back if I could. But once you see that world that is happening right now, this one can seem strange, that one seems to make more sense. And as you work and, you know, I think my friend James Orbinski says when you have questions like that, even if you don't have an answer, you have no choice but to live the question. So for me, creating something like an ER where once you pass the threshold it doesn't matter if you're a Muslim or a Christian or an old person or a young person, what matters is what's your pain on a 10 point scale? You know, and that's the antidote to some of, you know, what we're seeing in the modern world today where borders seem to matter more than ever before, where you're from seems to matter, you know, more than ever before. And it seems like a fiction because at least from where I stand it doesn't.

AMT: I get the impression that you need to write it out. This is your second book.

DR. JAMES MASKALYK: Yeah yeah. It's been this one was a long time in coming and it is, you know, trying to wrestle with the heart’s language and figure and get it wrong and then try to understand it as deeply as you can is something that gives me more clarity about this project and the human project of how to live and learn how to let go.

AMT: And when your ER shift is over and you go home, whether home is in Addis Ababa or here in Toronto, after an ER shift what stays with you?

DR. JAMES MASKALYK: Yeah, just the I love my job. I get to go to work and practice being better to people on a day to day to day basis. And, you know, it's what the lucky part is I get to continue to focus on how to make myself happy, what freedom looks like to me. And so I do what I mentioned I think is part of the part of the process is try to figure out how to see the world, learn how to be alone with myself and learn how to spend time with people I care about and working on things that matter.

AMT: Thanks for your book. Thanks for coming in.

DR. JAMES MASKALYK: Thanks for having me, it's a pleasure to talk to you.

AMT: Dr. James Maskalyk, his book is called Life on the Ground Floor: Letters from the Edge of Emergency Medicine. He is an emergency room doctor at St. Michael's Hospital in Toronto. He's an Assistant Professor in the Department of Medicine at the University of Toronto and he's also a Visiting Professor of Emergency Medicine at Addis Ababa University. He joined me in our Toronto studio.

[Music]

KARIN MARLEY: Hi, I'm Karen Marley one of the producers here at The Current. This week the show is produced by Idella Sturino, Howard Goldenthal, Ines Calabrese, John Chipman, Sam Colbert, Lara O’brien, Shannon Higgins, Sujata Berry, Kristin Nelson, Liz Hoath, Samira Mohyeddin, Pacinte Mattar, who's filling in as writer this week, Ashley Mak, Willow Smith, and our intern is Seher Asaf. Special thanks to our network producer Mary-Catherine McIntosh in Halifax and Anne Penman in Vancouver. The Current’s writer is Peter Mitton. Our producers are Lisa Ayuso and Sarah Claydon. Ruby Buiza is our interactive producer. Transcriptions are provided by Eunice Kim and Rignam Wangkhang. Our technical producers are Gary Francis and Jennifer Rowley. Our documentary editor is Josh Bloch. Our senior producers are Richard Goddard in Toronto and Cathy Simon in Vancouver. And the executive producer of The Current is Kathleen Goldhar.

AMT: That is our program for today. A reminder that you can take The Current with you on the CBC Radio app, it is free from the App Store and Google Play. And we're going to end today with some words of optimism from another doctor. Yesterday, Canada lost a force in the fight against HIV/AIDS. Dr. Mark Wainberg, a Montreal based trailblazer and internationally renowned scientist drowned while swimming in southern Florida. He was 71-years-old. Dr. Wainberg had devoted his life to AIDS research and awareness. He served as President of the International Aid Society from 1998 to 2000. We are giving Dr. Mark Wainberg the last word today. I'm Anna Maria Tremonti thank you for listening to The Current.

SOUNDCLIP

DR. MARK WAINBERG: You know, one of the difficulties now is that we're almost a victim of our success as a field. We've done so well in regard to drug development and getting the drugs to work with much less toxicity than before and much greater efficacy than ever before. So, you know, with fewer people dying of HIV, the press sort of have the attitude, you know, this problem has been solved. Of course it hasn't and of course we know that it hasn't. I'm an optimist. I think we're going to be able to cure HIV over the next two decades. I really mean that. I think the research community is for the first time galvanized toward accomplishing this goal. And I think our understanding of HIV disease has grown so much in regard to how the virus does what it does, in other words, pathogenesis, that we will soon have many more tools available to us to combat HIV and hopefully cure HIV than have been available until now. So I'm a real optimist in this regard.

[Music: Extro]

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April 13, 2017 full episode transcript

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