Hannah Institute for the History of Medicine Newsletter (Toronto, Canada), Number 18, Summer, 1993
The idiosyncracies of Canada’s medical schools can be both a strength and a drawback. An exchange program sponsored by the Hannah Institute hopes to bring the schools a little closer by opening up the communication lines from coast to coast.
The first exchange took place this April between the University of Western Ontario and the University of Calgary. Medical students met at Western for three days of talks and socializing.
“One of the objectives is to have each student work up a talk of ten minutes to stimulate further research,” says UWO Hannah Professor Paul Potter, who helped coordinate the exchange along with Calgary’s Dr. Peter Cruse.
Topics ranged from diseases among the Cree of Alberta to the old medical art of uroscopy.
Professor Potter says he hopes the exchange will become a regular annual affair, possibly with next year’s exchange matching Calgary with Halifax’s Dalhousie University.
I worked as Editor and Writer for the newsletter of the Hannah Institute for the History of Medicine (under the direction of the Editor-in-Chief and Hannah Executive Director Dr. J.T. H. Connor) in the early 1990s. Located close to the University of Toronto and within a neighbourhood claiming a long association with medical and scientific discovery (Sir Frederick Banting, co-developer of insulin for the treatment of diabetes, lived at 46 Bedford Road,), the goal was to better connect Canada’s medical history community of scholars and raise the profile of the funding resources available to further the study of medical history in Canada.
“… in recent years it has become a pursuit for a growing number of researchers. … Behind much of this growth has been the Hannah Institute for the History of Medicine which has encouraged writing …”.
27 Years Contributing as a Health and Human Development Communicator | 1991 – 2017
Whilst studying at the University of Toronto in the 1980s, the seeds were sown for much of the work that followed in the 1990s and 2000s. And what came together was the ability to undertake innovative communications initiatives using media and the latest digital tools. I had a strong interest in what constituted a modern, healthy society, and this eventually led my studies from psychology to sociology to history and eventually medical history. Along the way, I further developed my keen interest in communicating, writing for student media and broadcasting on student radio. I also organised various student organisations, from Erindale College’s first Peace Club, to its Amnesty International chapter, and eventually ran on a reforming ticket for the Students Adminstrative Council (SAC) at U of T. I undertook primary research for a history professor (Sidney Aster) working on a book, looking into the British Government’s efforts to organise food supply shipments during World War II (the biography of Lord Salter, Power, Policy and Personality: the Life and Times of Lord Salter, 1881-1975), and catalogued the CIA (Central Intelligence Agency) collection for the University of Toronto (Robarts Library). Being U of T, I also had the privilege of making amazing contacts and meeting some of the brightest Canadian minds of the time (for example, Professor Edward Shorter, co-author of Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness).
The 1990s were an exciting time because it was possible to blaze new trails with emerging digital technologies. And this led to highly influential work with the United Nations and the UK’s National Health Service (NHS). This included an opportunity to head up the communications office for the UN in Mongolia just at the moment in the late 1990s when the Internet was coming online, and undertaking an influential role heading the launch of a child health portal for the prestigious Great Ormond Street Children’s Hospital (GOSH)/Institute of Child Health (ICH), just as the NHS was undertaking its Modernisation Plan in the early 2000s.
1985/1989: Graduate from the University of Toronto with a BA Honours in History (including medical history) and Political Science. One of my final year papers addressed medical quackery involving the drug laetrile as a cancer cure and how the medical establishment and regulatory authorities, in their attempts to prevent its use, in fact played into the prevailing anti-establishment political climate and distrust of institutions and the government.
1989/1991: Begin work as a Unit Coordinator for a chemotherapy ward of the Princess Margaret Cancer Centre (previously Princess Margaret Hospital/Ontario Cancer Institute) in Toronto. First training in health informatics and witness first-hand new computer initiatives to quantify workload on the ward to better allocate resources.
1994/1996: Editor-in-Chief for Watch Magazine, an innovative youth culture and media start-up partly funded by the Government of Canada. Watch Magazine played an important role in Toronto’s recovery from the economic collapse brought about by the combination of the late 1980s crash and government austerity policies. By engaging youth (high school-aged writers, editors and creatives), Watch Magazine showed their energy and perspective could jolt the city back to life, despite the negative media portrayal of youth at the time.
“As one of those high school kids and the guy who wrote (most of) this article, I’d like to say thanks to David [South] for all his hard work on Watch magazine! I learned a lot from him and it was a great experience.” William White
In 1995 I worked as a Senior Media Reporter for the Financial Times‘ newsletters New Media Markets and Screen Finance. I covered the rise of new media, including the Internet and cable and satellite television channels. Also covered new film-financing schemes funded by the European Union and the rise of new media in the Nordic countries. Stories included:
Whilst working for a UK-based international development consultancy, I prepared papers for the American Foundation for AIDS Research (AMFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Harvard Institute for International Development (HIID), for various UN agencies including UNCTAD and UNAIDS, and coordinated the preparation of the report and launch strategy for the World Bank’s Task Force on Higher Education and Society (2000).
2001/2003: Project Manager in charge of Web Strategy for the GOSH Child Health Portal at Great Ormond Street Hospital for Children NHS Trust/Institute of Child Health.
2001: Begin work on the development of the award-winning GOSH Child Health Portal for the National Health Service (NHS). As part of the NHS’ Modernisation Plan, it was called a “role model” for the NHS and one of the “three most admired websites in the UK public and voluntary sectors,” and was developed and launched under heavy public and media scrutiny. Each stage of the Portal’s development would coincide with a high-profile media launch. For example, the Hospital’s 150th birthday celebrations included Her Majesty Queen Elizabeth II and pop star Madonna.
“The GOSH/ICH web site to date has been a notable success. Not only has it met a majority of its objectives … and achieved recognition as ‘exemplary’ among NHS resources, but it has also generated a number of spin-off projects, including Children First (as a successor to GOSHKids) and The Virtual Children’s Hospital. …
“In a context in which less than 25% of all projects realise even 50% of their benefits, the satisfaction of 75% of the original objectives .. must rank as a significant achievement.” Consultant’s evaluation of the GOSH Child Health Portal in 2003.
2003/2004: Live and work in Jerusalem, Israel. Travel extensively around the country during the hudna.
2007/2017: Consultant and Editor and Writer for the United Nations Office for South-South Cooperation (UNOSSC) (formerly the Special Unit for South-South Cooperation). Both an e-newsletter (Development Challenges, South-South Solutions) and a magazine (Southern Innovator) are produced chronicling the impact of mobile and information technologies on the global South, and the rise of a 21st-century innovator culture as a result. Both media substantially raise the profile of the global South, Southern Solutions, and the 21st-century global innovation culture, while also being cited as an influential resource in the UN’s adoption of an innovation and South-South Cooperation agenda for its programming and priorities.
The thinking behind this work can be found in two sources:
1) Innovation: Applying Knowledge in Development by The UN Millennium Project, “commissioned by United Nations Secretary-General Kofi Annan to develop a practical plan of action to meet the Millennium Development Goals. As an independent advisory body directed by Professor Jeffrey D. Sachs, the UN Millennium Project submitted its recommendations to the UN Secretary General in January 2005. The core of the UN Millennium Project’s work has been carried out by 10 thematic Task Forces comprising more than 250 experts from around the world, including scientists, development practitioners, parliamentarians, policymakers, and representatives from civil society, UN agencies, the World Bank, the IMF, and the private sector” (Innovation: Applying Knowledge in Development, UN Millennium Development Library, Taylor & Francis, 17 June 2013).
2) Two editors for the e-newsletter and magazine, Cosmas Gitta and Audette Bruce, authored a paper jointly with Professor Calestous Juma (a well-known scholar and leading figure in the study of innovation at the Belfer Center) in 2005 for the Harvard Kennedy School’s Belfer Center for Science and International Affairs titled, Forging New Technology Alliances: The Role of South-South Cooperation.
2007: David South Consulting begins work on the e-newsletter Development Challenges, South-South Solutions for the then-Special Unit for South-South Cooperation (SSC) at the United Nations. The e-newsletter is distributed by email to an influential global subscriber audience working in international development and the United Nations, as well as distributed online via various platforms.
2008: Reader response experiment begins with crowd-powered news website NowPublic. Initial proposal for the development of book or magazine on innovation. Awarded grant for Cuba study tour by BSHF.
2009: Adjust e-newsletter content based on reader responses. Begin posting content on Twitter platform.
2010: Begin development of the new global magazine Southern Innovator with the then-Special Unit for South-South Cooperation (SSC) at the United Nations and a design team in Iceland led by Solveig Rolfsdottir, one of Iceland’s top graphic designers and illustrators.
The magazine was produced to the UN’s design standards, as well as abiding by the UN’s Global Compact. With production in Iceland, the magazine could be designed and laid out using 100 per cent renewable energy sources.
Launch David South Consulting as Senior Partner working with talented global professionals.
It is called “a terrific tour de force of what is interesting, cutting edge and relevant in the global mobile/ICT space…”. Launch www.southerninnovator.org website (now www.southerninnovator.com) and social media including Twitter account @SouthSouth1.
To avoid censorship and interference, Southern Innovator‘s editorial operations were based in London, UK and its design studio was based in Reykjavik, Iceland (a high-ranking country in the World Press Freedom rankings and a former top place holder in the UNDP Human Development Index). Using a women-led design studio, it developed a design vision that could communicate across borders using clear graphic design and high-quality images. For example, when it launched in 2011, infographics were rare in development publications and at the UN; now they are commonplace. It also tried to be as ‘green’ as possible. The studio was powered on 100 per cent renewable energy (in particular, geothermal energy); the hard copy of the magazine is printed on paper from sustainable forests.
2012: Launch second and third issues of Southern Innovator Magazine at the GSSD Expo in Vienna, Austria.
Called a “Beautiful, inspiring magazine from UNDP on South-South innovation.”
With 201 Development Challenges, South-South Solutions stories posted on the NowPublic platform, a total of 336,289 views by 2012 had occurred, according to the NowPublic counter (Closed in December 2013, the stories published on NowPublic were able to reach a large, global audience, receiving 201,109 views as of 27 June 2010, and reaching 420,151 views by 31 July 2013. The stories were cited in many other media resources and also in books. This includes Export Now: Five Keys to Entering New Markets by Frank Lavin and Peter Cohan (2011) and The Canadian).
2013: Launch fourth issue of Southern Innovator Magazine at the GSSD Expo in Nairobi, Kenya.
Called “fantastic, great content and a beautiful design!” and “Always inspiring.”.
2014: Launch fifth issue of Southern Innovator Magazine at the GSSD Expo in Washington, D.C. U.S.A. The Twitter account @SouthSouth1 called “ one of the best sources out there for news and info on #solutions to #SouthSouth challenges.” Final issues of e-newsletter Development Challenges, South-South Solutions published.
The two publications proved influential on a number of fronts, being early to draw attention to the following: the rising use of mobile phones and information technology in development, the world becoming an urban place, innovative food solutions including the nascent insect food sector (now a big thing), altering perspectives on what is possible in Africa, the use of data science to innovate development, and tracking the growing number of technology hubs and the fast-growing start-up culture in the global South. The publications were cited for shaping the new strategic direction adopted by the United Nations Development Programme (UNDP) (the UN’s leading development organisation) and its first youth strategy, and the development of the Sustainable Development Goals (SDGs). As the world’s first global innovator magazine, Southern Innovator’s design had to be appropriate for a diverse audience. It has drawn praise for being both “beautiful” and “inspiring”, while its use of sharp, modern graphic design and infographics inspired others in the UN to up their game when it comes to design.
2015: Develop scale-up plan for Southern Innovator Magazine. The UNOSSC was promoted from being a Special Unit to an Office. It also had its budget increased.
South-South cooperation and innovation have now become the key methodology for the UN’s delivery of its programmes and projects. In 2015, China pledged US $2 billion to “support South-South cooperation” and called for the international community to “deepen South-South and tripartite cooperation”. In development parlance, they have been “Mainstreaming South-South and Triangular Cooperation” in their plans.
The current policy vogue for innovation in developing and developed countries can trace its roots back to some of the early work done by these two publications (and which was further amplified by the annual Global South-South Development Expo (GSSD Expo), which often would feature innovators from the two publications, spreading the innovation message around the world). Both publications had set out to inspire and “champion a global 21st century innovator culture”. And they have done this, as can be seen from concrete evidence and anecdotal responses from individuals and organizations alike.
“Anybody going into medicine should read a whole bunch of good novels.” Dr. Alvin Newman isn’t kidding. The head of curriculum renewal at the largest English-speaking medical school in the world, the University of Toronto, feels strongly that doctors have been ill-prepared for their profession’s challenges.
How doctors become doctors is being hotly debated as Ontario’s five medical schools institute a potpourri of curriculum reforms. After a century of taking a back seat to scientific achievement, bedside manners and the art of medicine are in vogue again.
“Around the world, medical education is undergoing significant changes,” says Newman. “Medical schools must strike a balance between the incredible explosion of scientific knowledge and re-establish the role of the physician as wise counsel and empathic healer.”
It’s a role that many feel doctors have ignored. An American Medical Association poll, conducted between 1985 and 1988, found that fewer than 50 per cent of respondents said they thought doctors listened well and half believed doctors no longer care as much about patients as they used to.
In response to these criticisms, current reforms are shifting medical education away from reliance on the turn-of-the-century science-based approach, says Professor Jackie Duffin, a medical historian at Queen’s University who helped organize the new curriculum introduced there in 1991.
“In the old days doctors could probably make a diagnosis and tell people what was happening to them, but not do very much for them,” says Newman.
“Yet society had more trust and fondness for physicians than they do now. Much of the condemnation of the medical profession is because we have become the custodians of high-tech medicine.”
While the Ontario government embarks on the most sweeping reforms to health care since the 1966 introduction of comprehensive health insurance in Ontario and the founding of national medicare in 1968, many doctors feel their profession cannot afford to maintain the status quo.
The concensus at Ontario’s five medical schools – U of T, Queen’s, University of Western Ontario, University of Ottawa and McMaster University – has gelled around a belief that doctors need to be as comfortable dealing with people as they are with scientific medicine. To this end, revamped curricula supplement basic science and clinical medicine with emphasis on early exposure to patients, communication skills, psychological issues, medical ethics, medical literacy and health promotion.
These schools hope to produce new doctors to fit into a rapidly-changing health care system – one that many believe will rely far less on large hospitals.
Instead, many procedures will take place in the home or in the day clinics. Expanding community health care care centres will try to tackle extensive social and health problems. This preventive approach ot medical education was pioneered by Hamilton’s McMaster medical school.
Since its founding in 1967, McMaster has experimented with teaching methods that steer away from mass lectures to concentrate on the individual student. The evolution of McMaster’s curriculum has placed greater emphasis on communication skills, psychosocial aspects of medicine, community issues, and disease prevention and health promotion.
How do McMaster students rate against other medical students?
Last year they scored above the national average on licencing exams. A higher proportion of McMaster students enter research and academic medicine than their counterparts from other schools. One study comparing them to U of T suggested they were more motivated to be life-long learners.
Dr. Rosanna Pellizzari practices the kind of medicine everyone is talking about these days. Working out of renovated church, Pellizzari’s practice at the Davenport/Perth Community Health Centre in west end Toronto serves a working class neighbourhood that has been home to generations of recent immigrants.
A member of the Medical Reform Group – which has long advocated significant reforms to health care – and trained at McMaster, Pellizzari can be seen to represent the doctor of the future: Sensitive, salaried and working in community health.
“McMaster’s curriculum attracts people with innovative ideas,” says Pellizzari, who was active in community health education before going to medical school. “It is a very supportive environment.
“I think the important question is: Who do we choose to be medical students? They should open up medical schools to those who know what it’s like to be a parent, a mother or disabled. Doctors should represent the population they serve. We are still getting mostly white, inexperienced young males as physicians. They aren’t going to practice the way that is necessary.”
In Ontario, many doctors see the 1986 doctors’ strike as a watershed for public opinion.
As a result of the negative fallout from the strike and perceived gap between physicians andhe public they serve, a five-year project entitled Educating Future Physicians for Ontario became a major advocate for reform.
Started in 1988, EFPO has examined fundamental issues in designing and implementing new medical school curricula. These issues include defining societal health care needs and expectations, faculty development and student evaluation. While each medical school has adapted reforms to its particular situation, EFPO hopes to prod further reforms.
“This is a unique venture in Canada, and could have implications far beyond Ontario if successful,” says Dr. William Seidelman, a key player in EFPO. “It captures the unique sense of the Canadian scene, and will build on the implied contact in the Canadian health system.”
Pellizzari sees the attitude of medical schools and teaching hospitals towards medical students as a significant factor in creating insensitive doctors. She recalls the high rate of suicide among medical students and the abusive work environment that forces doctors-in-training to work shifts unthinkable for other workers.
“The way we train doctors is inhumane,” she says. “We don’t expect other workers to put in 30-hour shifts. It creates in new physicians the attitude that they paid their dues and now society owes them.”
Many critics feel that changing training methods isn’t enough; the whole ethos and selection process must be changed. If doctors are to better serve the population, they must better reflect it.
“We are getting very close to gender equality and a laudable distribution of ethnic and racial backgrounds,” says Newman. “But students still come from a fairly narrow social spectrum, very middle class kids. Their exposure to the extremes of society, to poverty, to homelessness and related illnesses have been very limited.”
Pellizzari found how out-of-date the medical profession was in her first year. One teacher wanted her to work till 10 at night. When told that she needed 24 hours notice for a babysitter, the teacher shot back that motherhood and medicine don’t mix.
“I was a mother before I was a physician. When I get a call at night from a mother, I understand this. With 30 per cent of visits to doctors having no biological basis – like depression due to unemployment – you can’t do anything unless you have experienced life.
“If we don’t address this, you can design the best training in the world, but things won’t change.”
But Newman also feels many factors outside of medical school discourage a more diverse student body.
“To go through medical school in the United States requires large indebtedness. That’s not true in Canada. You can calculate what a year of medical school costs in terms of a finite number of CDs, a leather jacket and ghetto blaster. So something is dissuading people from pursuing this career, and it isn’t money.”
While there is a concensus among academics that medical schools haven’t prepared doctors well enough, there is little support for a dramatic change in selection criteria. “I can’t muster a lot of support from colleagues for serious changes,” says Newman.
Dr. Jock Murray, the former dean of Dalhousie medical school in Halifax, recently told an EFPO meeting he doesn’t see any significant changes ahead.
“Physicians have a reputation for being conservative and self-serving,” says Murray. “If reform is going to be successful we have to be clear that it is about what is good for the people.”
Pellizzari believes life experience and empathy with social circumstances just can’t be taught.
“I grew up in this neighbourhood. I understand their powerlessness, the conditions. Doctors have to see themselves as a member of a team of health professionals, not as the top of the social and medical totem pole.”
U of T’s experience is a classic example of the hurdles ahead. Newman admits it has come as a shock to students loaded with society’s ingrained expectations.
“They spend half a day a week in the community seeing things like drug rehab clinics and community health centres. But being out in the community doesn’t make the students feel comfortable. Their image of what they are going to do involves big buildings, chrome and steel, scurrying personnel and banks of computers.”
Your health is your wealth, my grandmother used to say. It certainly is our most valuable resource – and when its caretaker, universal health care, is under attack, people take notice.
Provincial health ministries across Canada are scrambling to find new cost-efficient ways to deliver health care, and community health care is an increasingly talked-about option.
“Every royal commission has suggested we need to shift resources to community care and stop focusing on institutions,” says Carol Kushner, co-author, with Dr. Michael Rachlis, of Second Opinion (HarperCollins, 1990), a blockbuster book that challenges the way we approach health care in Canada. According to Rachlis, health care nationally cost more than $60 billion in 1992 and is primarily delivered through hospitals and doctors’ private practices. Yet 20 per cent of all patients in acute care hospitals don’t belong there, and about five per cent of hospital admissions for people over age 65 are the result of improper use of prescription drugs.
One study of the Toronto Health Unit found that as many as 50 per cent of seniors residing in nursing homes who were admitted to hospitals with pneumonia had contracted it through mouth infections. If they had received regular dental check-ups in the community or at institutions, these unnecessary and costly admissions could have been avoided.
Increasing numbers of people see community health care as the way of the future. In this model, health care providers – doctors, nurses and support staff – work as a team, and users of health care are involved in making important decisions. Community-based care supplements a medical approach to illness, with emphasis on social and environmental factors like work-related stress. Its advocates say community care can wean us off our addication to expensive hospitals (where one bed costs at least $100,000 a year), drugs and surgery – and make us all healthier.
“Fee for service” encourages doctors to see as many people as possible, emphasizing quantity over quality. In community health centres, doctors are put on a salary and encouraged to give as much attention as necessary to each patient. By simply spending more time with each patient, and by taking into account factors such as illiteracy and cultural differences, community clinics can cut down on misuse of medication.
Jane Underwood, director of public health nursing for the regional municipality of Hamilton-Wentworth in Ontario, says we have reached the limit of what hospitals can do to improve health. “Other factors are now more important than a strictly medical approach, which was the foundation of the old health care system. In 1974, a Health and Welfare paper urged a behavioral approach – stop smoking, get more exercise. Now we are moving to a socio-environmental approach, looking at poverty, social isolation, and unemployment, and their effects on health.”
“Community health care is inevitable because we can now do many procedures on an outpatient basis. With the new technology, all kinds of things can be done outside institutions,” says University of Toronto professor Raisa Deber, co-editor of the recently released book Restructuring Canada’s Health Services System (University of Toronto Press, 1992).
“Just as people can work out of their homes because of computers and faxes, technology can take medical care to the home.” This trend can already be seen in the treatment of cancer. Many patients now receive their chemotherapy at home, with the help of computerized IV pumps.”
If the debate over community health care often seems confusing, it may be because of the haphazard patchwork of programs across Canada. Quebec is the only province that took community health care seriously enough to set up clinics across the province in the 1970s and make those clinics an integral part of the provincial system. Elsewhere in Canada, programs sprang up in the ’60s and ’70s at the initiative of community activists but were met with indifference or hostility from government.
The challenge for community care advocates is to educate both the public and governments. Jane Underwood admits it will be a tough struggle. “Governments are beginning to understand, but the public still has reservations. They panic when there are fewer surgeries and feel that lots of high tech will provide a safety net for health. In fact, it is more scientific to probe for the true causes of illness and not think that just taking a pill will make us better.”
Four Innovators in Community Health
South Riverdale Community Health Centre, Toronto
This fully functioning health centre opened in 1976 in Riverdale, a multicultural and economically diverse neighborhood. The staff consists of doctors, nurses, chiropodists, social workers, health promoters and a nutritionist. Innovative in taking on economic concerns of the community, the centre has set up a community food market to provide cheap and healthful food and recently started workshops with business and community members to come up with strategies to recover jobs lost during the recession. “We consider ourselves part of a movement,” says executive director Liz Feltes. And this is played out in projects with local groups and citizens on a variety of issues – from wife assault, drug abuse and sexually transmitted diseases, to medication literacy for seniors.
Victoria Health Project, Victoria
Originally started in 1988 to tackle the problem of poor communication between hospitals and community health providers, the project first targeted Victoria’s large senior citizen population. Twelve programs were launched, including Wellness Centres, palliative support teams for patients dying at home and elderly outreach service focused on mental health. The project has been successful at getting local services to cooperate and eliminate duplication. “There are 500 different agencies for seniors in Victoria, so we linked up with them and increased cooperation,” says Susan Lles, excutive coordinator of the project.
It was such a great success that the minister of health created the Capital Health Council to expand the program to the rest of the community. Now, for example, in hospital emergency rooms, quick response teams of nurses assess whether a patient would be better served by other services in the community or by being admitted to hospital.
Centres locaux de services communautaires (CLSC), across Quebec
Started in 1972 as part of province-wide health reforms, these comprehensive health centres now number 158, with more than 500 satellite offices all over Quebec. Every citizen is guaranteed access to a CLSC, even in remote areas. With five per cent of the provincial health budget, they are able to serve 41 pr cent of the population. They also involve the community through elected boards. “We think it is a unique model in that it integrates health and social services in the same place – both prevention and cure,” says Maurice Payette, president of the federation of CLSCs. Because CLSCs are close to the community, governments, schools, community groups and other organizations have turned to them for advice during the last five years. In rural areas, CLSCs have been crucial in reducing the number of farm accidents.
Canadian Healthy Communities Project (CHCP), across Canada
Started in 1989, the program is aimed at municipalities and gets them to pledge that they will review all their actions with community health (including impact on the environment and economy) in mind. CHCP is part of an international movement linked with the World Health Organization’s Healthy Cities movement. With more than 150 participating programs, it is an innovative attempt at getting the powers that be to plan for overall health. “We bring together community leaders to make a list of top 10 health problems and then decide what can be done with the existing budgets and staffing,” says David Sherwood, project director. The city of Sherbrooke, Que., is a classic example. Facing reduced funds for road and sidewalk repairs, the city concentrated on repairs in neighborhoods with hig numbers of the disabled and elderly, thereby reducing the number of accidents. Unfortunately, funding was recently reduced dramatically by Health and Welfare Canada, but programs in Ontario, British Columbia and Quebec continue with the help of their own provincial government.