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Next, a little look back.

Ok, not that far back. On July 9th, we played our first big show at Saskatoon’s JazzFest in Victoria Park. We played ninety minutes (JazzFest sets are long) with twelve originals, covers from John Prine, Leonard Cohen and Bruce Cockburn, and wrapped up with a big California Stars singalong.

Liam Richards of Electric Umbrella (no relation 😁) recorded the whole show. Josh Berson took the stills in this post (you may remember him from the photo essay we did on TB a couple of years back). We’ll get the whole show up on YouTube soon. Here’s a preview with Ignorance:

SaskJazz features local artists in their free program, and it doesn’t get a lot more local than Blue Umbrella. All but one of the band lives in the alphabet avenues of Saskatoon’s West Side. We could see Burke’s house from the stage. I hauled my gear over in a red wagon. Most of us caught Modest Mouse the night before or Bruce Cockburn (we covered Tokyo in our set) the night after. We would have been there anyway, we just got to be on stage this time.

Blue Umbrella YouTube

It was a beautiful night for an outdoor show. Golden hour with a God-sky sunset beaming down on the second half of the set.

The pre-show dread, especially getting up in front of a few hundred people after not having played in front of a crowd in years, was a lot. Fortunately, I knew I could count on the amazing musicians in the group to keep things steady even if I was shaking.

Tyson McShane played bass, departing from his usual role as guitarist and lead singer with his band Slow Down Molasses, who are celebrating twenty years with a bunch of shows and new music this fall. And, because he is endlessly engaged, also played JazzFest with Lévi Soulodre’s the Pxrtals.

Luke Ryalls brought the hooks with his guitar solos, harmonica and vocals. He also played two unreleased songs, Lover I Can’t Fall Asleep Tonight and Make It Through the Night, a moving tale of the realities of homelessness in Saskatoon. Look for them when we post the full show!

Sam Corbett, who produced Recklessly Yours, kept us in line and in rhythm on drums and sang a very local tune, Avenue H Blue, from his solo record NUTANA.

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It may have been the wonderful pre-bedtime slot on the program, or the fact that there were so many dads onstage with offspring in attendance, but the kids twirling, careening about and yelling “Hi Sally’s dad!” kept us smiling through the set.

Nearby neighbour Burke Barlow, formerly of The Deep Dark Woods, added layers to the sound with his versatile work on the pedal steel, managing to add very different tones and textures to each song (while looking badass I might add).

A delightful addition to the group was Aiden McRorie Wilson. She plays in femme country duo Gil and Wil and joined up for the show. Not only did she add beautiful harmonies, she also ruled the stage banter, out dad-joking us all. I’m thrilled she’ll be joining us for the Amigos show as well!

Of course, I sang some songs and played guitar. And also of course, messed a few things up, fumbling the words or the chords here and there. Classically, that’s what stuck with me for the first few hours of the show, the perfectionism always gets in the way of the pleasure of performing. With a few weeks past, and having watched the footage and being barely able to find the mistakes, I’m able to really enjoy the sweeter moments of playing together and connecting with the crowd.

The sweetest of all was watching my folks get up to dance. Lea and Wally have always danced when the spirit moved them: in the kitchen, in a restaurant, in the aisles of the grocery store. Their being so affectionate and silly was embarrassing for us as kids, but now I see what a great example they were for us, celebrating life and love.

This moment was even more special because my dad had a major stroke a few years ago. He very nearly died and has been left with disabilities and personality changes. But there he was, nearly eighty, dancing with his wife of fifty-plus years to his son’s band on a beautiful night.

I don’t know how long I’ll keep making music and performing. How could I know? Maybe this is the start of much more, maybe this upcoming show at Amigos wraps up a chapter. We'll find out eventually. All I’m sure of is that life continues to twist and turn and surprise, and with thanks to so many, I’m up for the ride.

Launching a new project always begs the question, will anyone care? Jury’s out on that still, but we did have some great coverage of the album launch.

Check out interviews with CBC BlueSky, CKOM, CTV Morning in Saskatoon and Regina, et même en français a Radio-Canada.

Global Saskatoon even had Aiden and me on to perform Laid Back and Out of The Way.

Thanks for reading and listening. A reminder that paid subscribers (new or pre-existing) receive a free copy of the vinyl record. Just let me know and I’ll get you yours. Or better yet, show up at Amigos and I can hand you one!

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For a lot of years, I spent very little time thinking about sports beyond watching the occasional playoff game. My boys have sucked me back in, rattling off stats and standings and watching Stanley Cup, World Cup, World Series, Grey Cup, you name it. They’ve also been playing; this year I had a blast helping to coach their teams. For all there is to be cynical about when it comes to professional sports, there’s also a ton of genuine entertainment and its a powerful way to connect with kids and community.

But the more I watch, the more I’m bothered by the ubiquitous advertising for gambling sites. At the Berries game, Saskatchewan online betting site playnow.com, was the most visible sponsor. When watching televised matches, the ads in the breaks and on the field are dominated by different gambling platforms. Even the commentators go on about odds and spreads as though that were the point of the contest. The entire structure of sport now centres on gambling, with teams highly dependent on the revenue from advertising and sponsorship from the major betting companies.

All of that money comes from somewhere, and it’s increasingly from the pockets of young fans, particularly men. In 2018, even before legalization, 15% of Canadian aged 18-24 endorsed problem gambling. Since legalization, calls to gambling helplines in Ontario have more than doubled. And, as reports, a shocking number of young people are now using gambling not as entertainment but as part of their long-term investment strategy. This is obviously madness: betting your financial future on an “investment product” that is structurally designed to deliver less than is wagered (these companies aren’t taking any real risk and their profit margins prove it) simply cannot work. But the advertising, with its seductive promise of easy wins and big money, does work.

David Moscrop

Gen Z Is Using Sports Gambling As An "Investment" Strategy. Uh Oh.

On Wednesday, Bloomberg’s Eric Balchunas shared a graphic showing that 52 percent of American Gen Z investors had shifted investment funds to sports betting at least once in the last year…

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20 days ago · 20 likes · 5 comments · David Moscrop

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Not only are young men risking their financial future, some get in so deep as to ruin their lives. Problem gambling is associated with higher rates of relationship failure, employment loss, anxiety and depression, all contributing to a 15-fold increase in risk of suicide mortality.

The decision to legalize single-event sports gambling, led by Saskatchewan MP Kevin Waugh, came with the usual arguments against prohibition: reducing imposition on individual freedoms and decreasing illegal activity in favour of a regulated legal market. What didn’t follow, however, were any restrictions on advertising like those that apply to cannabis or tobacco. It would be unthinkable today to have centre ice lighting up with ads for cigarettes or LEDs for edibles above the stands, but for gambling - an activity far more directly related to the sports events - it’s everywhere. And it’s working, with nearly $100 billion wagered by Canadians in 2025, a 26% increase over the previous year.

A group of Canadian senators has started a campaign to ban advertising for gambling apps and websites and a bill on a national framework for regulating sports-betting ads comes up for second reading in parliament this fall. You can contact your MP here to show your support for this common sense change,

Nearly 65% of Canadians report gambling in the last year, and for the vast majority of them, it’s a bit of harmless entertainment. But for many, including the boys that have pulled me back into caring what happens to the Habs or the Jays, the risks are very real. The ease of use with apps and online sites, and the normalization of betting as an integral part of the game, is sucking people in who can’t afford to play. Gambling on sports isn’t going away, but it’s time to stop shoving it in the face of every fan. Removing betting ads from the games is a simple and obvious choice to reduce the harm.

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We can try to imagine these lives lost and the impact of these deaths on their families and communities, but it’s hard to comprehend something so distant. A person we don’t know dying in a far-off country from a virus we’re unlikely to ever see on our shores can be a tree falling in a forest to Canadians.

How can we understand what’s happening, let alone try to change it? We aren’t immediately affected and have nothing obvious to gain from intervening. Why should we help? Wouldn’t it be better to see international aid as a means of yes, improving life in other countries, but also using that aid to create economic opportunities for Canada?

That short-term thinking has infected the current discourse around overseas development assistance. The most notable example is the dismantling of USAID under Elon Musk and Donald Trump, but the focus on a narrow definition of mutual benefit has led many countries, including Canada, to reduce and restrict their efforts to improve life in the countries where people face the greatest hardships.

So what’s wrong with that? Why should we help others if it doesn’t help ourselves? The most obvious (and, sadly, most easily discarded) reason is the inherent value of human life. Valuing each person is a golden rule that goes beyond our immediate neighbours, beyond those who might someday return the favour, to understanding that we should wish the same health, happiness and opportunity for others that we wish for ourselves. PIH co-founder Paul Farmer famously said that “the idea that some lives matter less than others is the root of all that’s wrong with the world.” Conversely, a recognition of the deep importance of every human life comes the inspiration to do great things.

A world in which poverty is ignored unless its relief is of immediate tangible benefit to donor countries is one where death and disease reign unchecked in the places where suffering is greatest. It is a world of lost opportunity, a world of forced migration, instability and conflict. A world where we lift families out of poverty without asking what’s in it for us, will be a safer, healthier, more enjoyable place to live. Mutual benefit does exist, but, as Mark Brender, Executive Director of PIH Canada makes in today’s guest article, it requires a long-term perspective. That gradual but lasting return stems from the willingness to care about people’s lives as a gift, not a loan. Yes, generosity comes back to us, but the more we focus on cashing in on that return, the less effective we will be at creating a healthier future.

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Mutual benefit in the context of Ebola

Every health emergency is an opportunity to see if we have learned lessons from the past. This is particularly true for the Bundibugyo strain of Ebola now surging in eastern Democratic Republic of Congo, where challenges to an effective response are immense.

No licenced vaccine exists for this strain and it’s difficult to diagnose, meaning the virus went unchecked for weeks before being identified. The outbreak is taking place in an area of longstanding conflict, limiting health worker access and contract tracing. It is difficult to know how many cases exist and how many deaths the outbreak has caused so far, but likely many months -- and more than $700 million, according to the World Health Organization -- will be needed to stop it.

Underlying it all is a health system stretched beyond its limits. The DRC spends about $33 per person a year on health, compared to government health spending of more than $6,900 per person in Canada. For the four billion people who lack access to quality care, weak health systems are at the root of so many challenges, including during disease outbreaks. And yet, almost in parallel, steep aid cuts from Western governments and the return of tied-aid frameworks last seen in the early 2000s – then explicitly rejected as counter-productive by recipient and donor countries alike, including Canada – have also been spreading.

Canada’s most recent federal budget made the most significant cuts to our international assistance commitments in a generation. The government has also stated Canadian aid should be leveraged to advance domestic economic interests, ensuring “mutual benefit” to Canadians and partner countries.

Details on what mutual benefit means and where it applies remain unclear but matter deeply. Global health spending represents less than one quarter of one percent of the federal budget and falling. This raises the urgency for remaining funds to be spent wisely. If Canadian economic benefit is applied to our global health aid, it will only deepen the consequences of global inequality the current Ebola outbreak is exposing. The greater the inequality, the more morally dubious our quest for mutual benefit becomes

As experts have pointed out, Ebola carries a cruel irony in that it is a disease of caregivers. Because it moves from person to person through contact with bodily fluids, Ebola overwhelmingly infects and spreads through those who are showing compassion: family members providing comfort to sick relatives, nurses and doctors, people who prepare bodies for funerals.

Ebola is also a disease of inequality, thriving where health systems and immune systems are weakest. Diseases and health conditions don’t have fatality rates, health systems and social conditions do.

The West Africa Ebola epidemic of 2014-16 killed 11,000 people including 4,000 in Sierra Leone, where up to three out of every four people who contracted Ebola died. Eight of the nine Ebola-infected Western health professionals evacuated from Sierra Leone to Europe or the United States survived because they were able to access and receive the best supportive treatment when ordinary Sierra Leoneans could not.

For Ebola, as with all infectious diseases, prevention of transmission in times of crisis is linked with confidence and trust people feel for their health system. Once a crisis is underway, it’s too late to earn that trust. To be willing to follow public health protocols, people need to know from experience that their interactions with clinics, hospitals, and health professionals will make them and their loved ones well. Too often, in resource-poor settings, that’s not the case. Local communities know all too well that hastily assembled Ebola treatment units might be little more than containment centres designed only to prevent transmission rather than provide life-saving care.

Whether we place blame on legacies of colonialism, conflicts or unfair debt burdens and structural adjustment programs – or even on governments themselves – too many countries don’t have the fiscal space to invest appropriately in health. Ripples from these health system failures spread around the globe in lost trade, fractured relationships, and ill-advised border closures that make it harder to mobilize an effective response. It follows that strengthening weak health systems should be among our top aid objectives.

Investing in health systems costs far less than epidemic response in lives and in dollars – and we know how to do it. Partners In Health leverages the ‘5-S’ approach for health system strengthening: staff, stuff, space, systems, and social support. When we put them in place in partnership with local and national governments, we see better patient outcomes and stronger public sector capacity eventually leading to the country ownership and self-sufficiency everyone desires.

We also know what is ineffective: donor governments using aid as an opportunity to advance domestic agendas rather than contributing to country-led responses.

Responsive health systems and high citizen trust can and do exist in low-income countries. Rwanda ended a 2024 Marburg outbreak, equally dangerous to Ebola, in less than three months due to strong public health measures including activation of thousands of community health workers and a robust underlying health system designed to serve the most vulnerable.

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In the aftermath of the 2010 Haiti earthquake and the failure of international assistance to advance Haiti’s long-term development, Paul Farmer outlined principles for improving aid effectiveness in what he called ‘acute on chronic’ contexts, when a crisis magnifies underlying health system weakness. Among his recommendations: The global community should localize aid dollars to create local jobs and boost local economies. Donors should allow ministries of health and other agencies to coordinate implementation in line with their needs and priorities. We also need to reassess how we see risk; we often overestimate risks to ourselves and underestimate “the risk of people living in poverty and dying needlessly.”

Finally, we need to make commitments that allow the transfer of aid functions to local authorities – what we now call ‘localization’ – to meaningfully take place. “This is not meant to be an excuse for aid agencies to leave before their local counterparts are strengthened,” Farmer wrote, “but rather a challenge for them to stay as long as it takes until these systems can stand on their own, and possibly even beyond, if needed.”

These are principles of the long-term mutual benefit of a safer and healthier world. The zeitgeist may be moving in the opposite direction, but disease outbreaks will end sooner and many more lives will be saved if we keep these ideas in mind rather than trying to extract transactional short-term gains that undermine the health of those most at risk.

Mark Brender is the National Director of PIH Canada.

Mark will be joining me in Saskatoon this Friday, June 26, at Hunger Cure Resto Bar from 7pm – 9pm. If you’d like to connect for informal conversation on Partners In Health, global health equity, our recent experiences in Rwanda and whatever else comes up, we’d love to see you there!

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You can hear it on streaming services like this:

Or you can find it at bandcamp for downloads and vinyl orders:

Speaking of the record: it has arrived. Check out the sky blue vinyl!

Now that the album is here, I have a special offer to share. New subscribers to A Larger Scale will receive a free copy of the record in the mail (or a digital download if you’re not that analog).

And one last reminder, we’re live at Somewhere Else Pub in Saskatoon this Thursday.

Hope to see you there!

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This is not a Blue Umbrella post, but I did think you might like to know about our new single: Tropical Storm, now streaming where you stream:

This past week, I had a uniquely Canadian experience. It was the last day of a locum (substitute doctor) stint in Whale Cove, Nunavut, on the Hudson Bay coast,

and I had some time to kill before my plane left. The week had gone by quickly, with full days of clinic and walks on the rocks.

This was my second time in Whale Cove, and my fourth visit to Nunavut in the past year. Two of those trips were in the summer’s midnight sun, two in the midday dark of winter. I’d gone up last summer with colleagues from Partners In Health Canada to explore the possibility of connecting the PIH approach to addressing health challenges in the territory.

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My first Whale Cove visit, filling in for a colleague who’s currently in Malawi with PIH and has been working in NU for years, was in February. Wind chills of fifty below meant the explorations were minimal and I hardly left the clinic.

That first tour taught me a lot about the Nunavut health system and the challenges of providing care in a small, remote community. I also returned to Iqaluit for more meetings and learning, with a focus on the role of community health workers.

There are winter things to say about health in Nunavut, including about the similarities with the caribou country of Northern Saskatchewan, about crowded housing and tuberculosis and high rates of youth suicide.

Through this work, I’ve been learning more deeply about the social determinants of Inuit health, the unfair health burden faced by Inuit as a result of gross inequities. We also learned more of about the tremendous challenges of serving a territory with the population of Moose Jaw spread over a land mass the size of Mexico, and doing so amid constant personnel and housing shortages and huge distances to cover with minimal infrastructure.

The challenges, and the harm to people’s health from the inequities, are real. It can be easy to focus only on the tough parts. Especially in February when the sun rises only briefly (if at all, depending how far North you are) and the wind tries to remove your face.

This trip, where I was able to see more of the community in the light of day, was a good reminder of the incredible strength that has allowed Inuit to survive and thrive in conditions that would be beyond most people. Chatting with patients and visiting providers, hearing about people’s lives, the love of family, love of the land: it was a joy to hear about people’s joys. I also took advantage of long days and warm weather to explore and hike the rocks around the community.

With shows coming up in a couple of weeks, I spent my evenings rehearsing. One sunny evening, I decided to go practice outside. I climbed to the top of the hill by the church with my guitar and played a while where I thought no one could hear me. I even perched my phone on the rocks and recorded a video of a Blue Umbrella song. Just as I was finishing, a girl and two little boys came running up from some nearby houses. They asked me if I was a singer. I said kind of, but mostly a doctor. They asked me to play them a song, so I played them one of mine. They tolerated it.

They then asked me to make up a song on the spot about sunshine. So I did, singing about the midnight sun melting the snow in Whale Cove, and putting their names in thee second verse. They laughed and beamed, and so did I.

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So that Canadian experience I was talking about? Well, it’s census time, and there were three census-takers, Hugo, Carlos and Jeff, in town from Ontario going house-to-house, enumerating the people of Whale Cove. I’d been chatting with them, mostly apologizing for playing the guitar too loudly in my hotel room, and we got to talking about getting out on the land, and they’d heard there were caribou about ten km from town.

I had a couple of hours between finishing up at the Health Centre and catching my plane, so we took their rented truck out past the airport onto a rocky road that led out on the tundra. After driving for half an hour or so, past inukshuks and pothole lakes, we came upon a small cabin. We pulled off the road (important detail) and stopped to say hello. There we met Nasser. Nasser is from Iraq and has lived in Nunavut for nearly twenty years. He is married to an Inuk woman and likes to hunt caribou and fish for trout and char. While we were hearing his story, his stepdaughter Janelle pulled up on her ATV, her baby in the hood of her parka. After we chatted for a while, we decided it was time to turn back and get me to my flight.

The truck, and the wet sand Hugo had parked it in, had other ideas. We cleared the sand with shovels, wedged boards under the wheels, rocked back and forth like you do for a snowbank, and pushed with all our might. But every time the tires spun they just dug deeper. The other guys looked at me and said I needed to catch my flight, they’d get someone to come from town to tow them out.

So we strapped my guitar and bag to the back of Janelle’s Honda and I hopped on behind her and the baby, fast asleep again in the hood. We ripped off down the road, rounding the curves at speed, wind just cool enough to sting. Headed back home after another adventure, I thought about all the ways this minor misadventure represented the best of Canada. People from all over the country, newcomers and Indigenous, good humour, generosity to strangers, and a love of the land. I’ve rarely been happier.

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This makes me happy for many reasons, not least of which being that it’s right down the street from my house. Every year we wander down to the river, meet up with friends, enjoy the shows, and let the kids run wild. It’s a scene and I hope you’ll join us and stick around after to hear 2025 SK Rock Artist of the Year, Dump Babes. Admission is free, fun times await.

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And, exciting as it is to play a ninety-minute set in front of a couple of thousand people as our first show, it’s also mildly terrifying. So let’s not do that! You can catch the Blue Umbrella live debut on June 18th at Somewhere Else Pub& Grill.

It was great to hear back from a lot of you about the first single, Ignorance, many telling me you’re hearing early Hip and REM in the sound. Not necessarily intentional, just how the song came to life, but I’m not complaining! It’s up on Spotify now if you missed hearing it the first time (or want to share with a friend.)

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And, because I know you’re dying to hear more, here’s a sneak preview of our second single from Recklessly Yours: Tropical Storm.

Let us know what you think. More songs and backstory to come. Meanwhile, off to rehearsal!!!

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Nope.

One of the simplest things for a party to do when it’s in trouble is to dump the person on the billboards. That person, elected by the members, is the most visible representation of a party’s success or lack thereof. This includes things they have little or no control of: internal party processes, the actions of individual MLAs etc. That said, in our legislative system, the leader has a great deal of power and a great deal of influence on the party’s fortunes.

So when a leader isn’t operating in the way you’d like, ideologically or electorally, why not ditch them at the first sign of trouble? Well, first off, a party is not a Kleenex box. There’s no guarantee of someone sitting in the wings who will be immediately able to step into the role

.

One of the biggest assets for a leader is familiarity. This is especially true in a place like Saskatchewan, where personal connections mean so much, and in a media environment where it’s harder than ever to reach a general audience. Elections are million-dollar investments in developing name recognition and trust. Putting up a newly-named nobody against a well-known incumbent is a huge risk.

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For anyone reading this newsletter that doesn’t know, I used to have Carla’s job: leader of the Sask NDP and Her Majesty’s (it was still Liz II at the time) Loyal Opposition. And I left after one election. This means I have both some insight and some bias on this question.

In my 2023 book, A Healthy Future, the penultimate chapter was about leaving politics and about the general experience of burnout post-COVID. In that chapter I wrote, somewhat cryptically, that “The drama within the party had grown increasingly toxic and taxing.” That obviously wasn’t the whole story. This won’t be either; I’m not here to spill tea or settle scores, but I can say there was a lot of unhelpful division led by people who thought a change in leadership was all the party needed.

It’s not the whole story, but it was part of why I stepped down. I have very intentionally avoided commenting on NDP internal politics ever since. I have my views on different choices made by the party since then, some supportive, some critical, but I never wanted to be the leader who left and knocked their successor from the sidelines. For the good of Saskatchewan, I want my former colleagues and the new members to do well. I do, however, want to speak against the kind of infighting and self-sabotage that made my job much harder than it needed to be.

But wait, Ryan, aren’t you the example of why a party should change leaders? Didn’t they do a lot better after you left. Yep, they sure did. A gain of fourteen seats, a big rise in the popular vote. But was it because I left? Maybe if I stayed, we would have won government. Or maybe we would have done even worse. That we’ll never know, we can’t run the A-B test. My point is not to litigate what happened during or after my time in politics, but to caution against leadership change as a knee-jerk reaction.

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That’s not to say changing leaders is never a good idea. Clearly, there are cases where changing leaders is exactly the right move. The federal Liberals offer us two recent examples: Justin Trudeau on the way in and on the way out. A new face brought a tired party that had been cycling leaders and losing ground back into relevance. Then, when the Canadian public had tired of Trudeau, the last-minute replacement with Mark Carney snatched victory from the jaws of what appeared to be certain defeat. These counterexamples overshadow the majority, according to a study of the history of provincial politics in Canada, of cases in which the opposite occurs: new leaders get a brief polling bump and then go on to do worse in the subsequent election. They also underscore the key point: the leader will change eventually, but in politics as in comedy, timing is everything. Removing a leader who has worn out their welcome or failed to launch can be the right move. Ditching one who has had a good showing and only one shot at an election is premature and self-defeating.

So, to those who want to fire Carla Beck, I say hold your horses. She performed well in the last election, has done a good job of keeping a new, expanded caucus on target, and is well-liked by Saskatchewan people. She deserves to contest a second election. You may have legitimate reasons to want a different approach, but a) it’s not going to work, and b) if it did, it wouldn’t help. An online removal petition that has gathered a paltry 240 signatures (from whom? There’s nothing to stop Scott Moe himself from signing) is not a sign of resounding support for your position. And whatever your criticism of the leader may be, it is far too early in her tenure to give up and replace her with an as-yet unknown quantity.

My advice is this. If you’re not satisfied with your party, whatever party that is, work to make it better. Sure, send a message at convention if you’re not happy. Maybe leaders shouldn’t get the expected Kim Jong-Il levels of support that make leadership reviews ridiculous. Remind the caucus that the membership matters; the divide between the actions of the elected members and the views of their supporters is a perennial problem in what is meant to be a democratic movement. Bridge that divide by getting closer. Build up your party by working within it, and by reaching outward to create demand in your community for the changes you want to see. This is the much harder groundwork – firing a leader is the easier way to feel like you’re changing something – but it’s what’s needed to make any lasting and meaningful difference.

In the meantime, keep a leader, help them grow, give them a chance to succeed. Their job is maddeningly complex, frantic and inherently compromising. The learning curve is vertical; they won’t get everything right, but the commitment they make to serve in that role and the investment the party makes in them are tremendous. The choice of whether or not to change should be taken with as much gravity, or perhaps even more, than the choice of who should be leader in the first place.

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You may have most noticed a few more posts from this Substack lately. Perhaps you wondered why I went quiet in the first place. Probably not, though; a symptom of our online lives is we often forget the people who aren’t in our feeds or inboxes. Which is part of why I spend a lot less time communicating this way, especially after my time in politics, I wanted to connect more with people in real life and think less about likes and clicks. On the other hand, it’s also a delightful surprise how often I run into subscribers who want to talk to me about my most recent post and encourage me to keep writing.

The other reason I’ve been quiet here is that I was busy making noise in real life. Over the last year and a half, I’ve been working with a group of friends on a new project, Blue Umbrella. I’m excited to announce we’ve just sent our new album, Recklessly Yours, off to the presses. We will be releasing a dozen songs on vinyl and on streaming platforms over the coming weeks.

I started writing songs in my early twenties and used to do the occasional performance, sometimes solo, sometimes with friends. I had hopes back then to make a record, but medicine, kids, politics - the joys and challenges of a full life - pushed that out of the way. A couple of years ago, I turned 49. Being pretty good at math, I realized what was coming next and decided that, despite the rust, it was finally time.

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A Look Under the Umbrella

Fortunately, I had some friends, old and new, who had never stopped playing music and were up for the challenge of a new project.

Tyson McShane is one of my best and oldest friends, and a former bandmate from university days. He’s had an international career as the frontman for Slow Down Molasses and plays bass with Blue Umbrella. Luke Ryalls, fronted with the Fjords and released a solo album, The City, is an incredible guitarist and singer. For the first few months we played with Charles Lemire, another old friend and drummer for Saskatoon bands Runway, Blue Fantasy, etc. The etc. caught up with him, and he decided to leave the group, but not before contributing driving drums on the first four tracks we recorded.

At that time, Sam Corbett was already hard at work producing the album. He’d previously produced Ellen Froese’s album For Each Flower Growing and his own ridiculously good record, NUTANA. When Charles moved on, Sam also stepped in on drums. Seeing as he toured the world as drummer for the Sheepdogs for twenty years, that was light work for him and a great addition to Blue Umbrella. He dove into the production and the playing, coming up with ideas for arrangements and adding various great performances on percussion, keys and vocals.

We were recently joined by Burke Barlow, formerly of Deep Dark Woods, who recorded pedal steel for a few tracks and will be a part of the live shows. The album also includes contributions from Saskatoon singer-songwriter Ellen Froese on vocals, a feature with up-and-coming songwriter Lachlan Neville, a non-political guest performance from MLA Meara Conway on cello, and Barrett Ross of Dump Babes on organ and synth. Barrett also engineered and mixed the recording at Rec Hall Studios.

A friend referred to us the other day as a Saskatchewan-famous dad rock supergroup. I’ll take it. The regular band is all busy dads, which means finding time to rehearse and record can be a challenge. Luckily, everyone’s experience and talent has meant for a set of songs that came together quickly and, in my unbiased opinion, sound pretty terrific.

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Recklessly Yours

The songs on Recklessly Yours are probably best described as Canadian folk-rock. The name Blue Umbrella comes from a 1975 song by John Prine. It’s one of my all-time favourite songs, and a nod to Prine’s influence on my songwriting and composition. The contributing musicians brought their wide range of influences and well-developed styles to the arrangements, resulting in a collection of songs that range from sweet and simple acoustic to hooky, driving rock. The record consists of ten Blue Umbrella originals and two deep cut Canadian covers from the Hip and Leonard Cohen.

The album is now ready for pre-order over on bandcamp. We’ll be rolling out a couple of singles over the next few weeks. The full album is slated to be available online when we have records in hand on July 1st.

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The first single, Ignorance, will be released this coming Monday, but here’s an exclusive early listen for A Larger Scale subscribers: Song 1 - Ignorance.

Playing with all of these incredible musicians has been so fun and I’m proud of what we’ve put together. I hope a lot of people will hear it. For that reason, I’ll be posting here, on Instagram and on Facebook. I’m going to try to keep perspective in this, not get too caught up in reaction and reach, but I’ll be as widely as I can without worrying too much about the metrics.

So what does this mean for A Larger Scale? Well, I haven’t quit my day job. I’ll still be practicing medicine and paying attention to the politics of health. You can expect the frequency of those posts to increase. It’s just that now there will be some Blue Umbrella content in the mix. I hope you’ll enjoy it.

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Earlier this week, my colleagues and I ran out the back door of the West Side Community Clinic to respond to someone who had overdosed and was unconscious in the back alley. She was a young woman who had lost consciousness but was fortunately still breathing. People around her had been keeping an eye on her and she was able to wake up long enough to let us know she didn’t want any help. At least for the time being, she was going to be okay.

The next day I showed up at work for a meeting and stopped to check if another young woman was breathing, this one lying between two parked cars behind our building. Again, I made sure she was alive and that someone would keep an eye on her and went about my day. These are pretty benign versions of the overdose response story, but it’s the banality, the ordinary, everyday experience of seeing people this far gone out in public that strikes me.

It’s a story that is now repeating itself multiple times a week at our clinic and in many places across Saskatoon. The fire department has responded to dozens of overdoses over the city this past weekend, already over 200 since the beginning of April. Some of the people who overdose require multiple doses of naloxone or even chest compressions. Some will die.

This most recent rash of drug poisonings is the result of two things. The first appears to be a batch of bad drugs, the periodic arrival in the city of fentanyl mixed with benzodiazepines or veterinary tranquilizers, making the drugs more potent and less responsive to the medications that reverse them. The second factor is that there used to be an organization that, along with many other services, had facilities to identify contaminated drugs so that people could see if what they were about to smoke or shoot was what they thought it was.

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This past week, Prairie Harm Reduction (PHR), formerly AIDS Saskatoon, permanently closed its doors. This is an organization that for 40 years had offered a variety of services in the core neighbourhoods of the city, services that evolved along with the needs of the community. Established during the height of the AIDS epidemic, the organization was a leading advocacy voice for people affected by HIV or at risk of infection. As Saskatchewan has seen (and continues to see) HIV rates triple the national average and a growing rate of overdose deaths, AIDS Saskatoon worked to provide clean needles and other supplies to prevent the transmission of HIV and Hep C. Eventually, the organization made disease transmission and overdose prevention its more explicit mission, changing its name to PHR and opening the first safe consumption site in Saskatchewan.

The safe consumption site was the most publicized service offered by PHR, but they also provided a drop-in centre, support in finding housing and connections to counselling and recovery programs. PHR employed 70 people in case management and other key community support roles. This included many of my patients, people with lived experience of addiction and street life who were able to use their employment with PHR as a stabilizing factor in their own lives and a bridge to support others in circumstances they could understand. With PHR gone, overdoses are rising. This is because people will still use, now they are just doing it out of sight of people who can help. It’s also because PHR was the only place that offered testing for contaminated drugs, meaning health leadership isn’t even able to identify what drugs are the problem to issue an alert. Response to the crises in the core comes from a web of organizations that rely on each other; pulling one thread out puts all of the others under increased pressure.

I won’t pretend to know the ins and outs of PHR’s financial troubles or how things got to the point they had to close their doors. I do know that failure is not just a PHR story, it’s a societal one. An organization that sought to help people on the margins was consistently rebuffed by the provincial government, all while social services policies have contributed to a tripling of homelessness in the city. PHR was left to go it alone in many ways, and yet was also relied upon as an essential service in the core. The specific way things ended are just details, the fact is the model was never sustainable without wider support. As I’ve written before, the opioid and crystal meth crises are wicked, complex problems that demand creative, full-system solutions.

Senseless loss of life

It’s a situation that has those who work in the core worried, and rightly so. In this CBC interview. Chief Operations Officer of the West Side Community Clinic, Toby Esterby (and my purported doppelganger, you decide), outlines how more lives will be lost in the weeks ahead because of the sudden closure of PHR.

The loss of PHR means the loss of another organization that cares about those lives, that sees the people on the street as real people who matter. Staff members that know their names, faces and stories, because they have a relationship with them, are now no longer in a position to help.

Last week, I posted the above photo, taken from across the street at the former St. Mary’s Credit Union, with the following caption on Instagram:

With the closure of @prairieharmreduction and bad drugs on the streets of #yxe, overdoses are already on the rise. I’m worried about my patients who access services there, and the ones who are losing the jobs at PHR that allowed them to improve their own lives and those of their neighbours. Please consider contacting your elected representatives, federal and provincial, to let them know that the lives of people in inner-city Saskatoon matter and new supports are needed to help in this difficult moment.

I shared the same post on Facebook where it garnered hundreds of reactions. Many of these were notes of concern similar to my own, others were thoughtful questions or critiques of PHR, all fair game. What disturbed me was the number of posts that saw the loss of life Toby described and decided that was a good thing. Here’s a small selection:

• If we ban free narcan repeat overdoses drop drastic

• it’s a real shame that narcan works more than once for a person

• Improve the survival rate of overdoses? That’s not positive.

• Some of the WEAK will be gone from that area, time to celebrate

• Make narcan illegal. Then flood the market with potent drugs and the addiction crisis will peter off pretty quick

• Stop giving narcan and reviving them and let the increase in over doses pay off

• A funeral is cheaper than being a burden on your family, our police, our emergency services our health care system and a safety risk to the community. Sorry not sorry.

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As I read through these, one woman in particular came to mind, a patient I’ve known since I was a medical student. She has led a deeply difficult life and struggled with addictions and managing her HIV. She is also funny and sweet and deeply devoted to her two dogs that she has cared for even when she was homeless and hungry. While working as a peer at PHR trying to help others get clean, she has slipped at times and returned to using Fentanyl. To the people posting on Facebook, the world would be a better place if she just died.

These posters are talking in general terms, but each of the people they think the world would be better off without is a real and specific person. They are also people who have lived through hardships and trauma that most of us would rather not imagine. In a world with so much suffering, the idea of our shared humanity, that every life matters as much as any other, must be our guiding light. This ugly celebration of the deaths of poor people, posted from the safety of a screen, is a stain on humanity that could drive us to despair.

The work of people who get out from behind their keyboards, who go out to help in the hardest places, who find joy in connecting with those who others would reject; I see it every day and that gives me hope. The closure of PHR will worsen real problems, but it won’t stop the people who care from working for solutions. Hopefully, we can use this moment to create a better response to the current crisis, one that outshines these hateful comments, one where we see poverty, homelessness and the drugs used to escape them as the problem, not the people who are suffering.

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The list of his accomplishments – leader of the Ontario NDP and Official Opposition, Canada’s Ambassador to the United Nations during the fight against apartheid, deputy director of UNICEF, UN Special Envoy on HIV/AIDS in Africa, and founder of the eponymous Stephen Lewis Foundation – is beyond impressive, his was a remarkable life of service at the highest echelons.

Anyone who ever saw Stephen Lewis speak will recognize how words like eponymous and echelon are fitting elements in a description of his life. He never evaded erudition, using terms like antediluvian without sounding old-fashioned. His speeches were challenges to our minds, and our morals, calling on us to be our best selves.

I recall seeing him speak at the Knox United Church in Saskatoon when I was in medical school. He would get the crowd rolling with his sparkling wit and vocabulary. This would include his go-to Saskatchewan story of being an organizer near Estevan in the sixties, with a joke about how the local pronunciation of the town Bienfait (if you know you know) did more to set back relations with French Canadians than any federal policy. Once he had the audience enthralled with his wit, he would then recount the heart-wrenching stories of a generation of orphans being raised by grandparents because all of the parents were dying of AIDS.

I left that event with a group of inspired friends and an idea that would eventually become Making the Links, a program that trains students to work with underserved populations in Canada and overseas. It’s a small thing, but an example of the way Lewis motivated those who heard him to be unsatisfied with the state of the world yet still believe that change was possible.

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Lewis was outspoken in his work as UN Special Envoy, including in his landmark book, Race Against Time. His efforts were part of a greater movement that eventually led to a profound change in policy and in people’s lives. When I was first in Mozambique in 2002, we watched patients die of the opportunistic infections that characterize advanced HIV and had nothing to offer them. Over the years, as the world finally stopped resisting the idea that African people could and should receive care for this deadly disease, we saw the rates of new cases and deaths from AIDS decline steadily. Today, access to treatment is widespread and HIV is a manageable chronic illness. This is threatened by the withdrawal of the US from meaningful aid programs, but I am hopeful we will never go back to those dark times.

Over the years, through politics and medicine, I had a chance to speak with Stephen a few times. He was gracious and generous with his time, and was especially enthusiastic about our work in Lesotho, where he’d been honoured by the king for his work advocating on behalf of the tiny, landlocked country that had been hit so hard by HIV.

Stephen was diagnosed with cancer eight years ago and had held on for far longer than expected. Perhaps now we know what he was holding on for, as he passed just two days after his son, Avi, was elected leader of the federal NDP. In his acceptance speech, the junior Lewis described how his father was demanding daily, in-depth campaign updates from his hospital bed, an “IV drip of campaign data.”

Avi now takes on an enormous role without the day-to-day counsel of his father. Hopefully, he will be able to draw on those extra years of time together and wisdom shared as he works through the challenges of rebuilding a battered federal party. His leadership is already facing its first such challenge, with Western party leaders distancing themselves from his leadership. The exception is Manitoba Premier Wab Kinew. His family has been close with Lewis’s, and he was on stage at the federal convention and posted a moving tribute on Stephen’s passing, though they too will have policy differences.

For my own part, I can’t say I agree with all of Avi’s policies, and were I still in provincial politics, we would likely butt heads over some ideas. That said, I was struck by his undeniably impressive leadership campaign and by his boldness and passion, qualities a rebuilding party can’t do without. I’ve also found him to be, like his father, decent, approachable and generous with his time.

These tensions between provincial and federal parties are not new, though they may be intensifying. This is perhaps something Stephen would understand, having had to face down the Waffle in his own time as a party leader. I do note that there have been fitting tributes to his father from those same Western NDP leaders and even offers to connect. Perhaps this moment of loss and reflection can also lead to a rapprochement (to use a Stephen-worthy word) and better relations moving forward.

For now, we celebrate a life of unparalleled leadership at home and on the world stage. Canada may never see another human rights advocate like Stephen Lewis. But we can continue to benefit from his example. May his legacy be a continued call for many, many more Canadians to be as caring and as daring in their commitment to a better, healthier world.

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Today, I’m posting about Primary Care Reform in Saskatchewan, but of you’re keen on some TB content, here’s a post on the reality of TB in Saskatchewan today:

and a reflection on the role of Community Health Workers in supporting TB care in Lesotho:

In the lead-up to last week’s provincial budget, Saskatchewan Premier Scott Moe and Minister of Health Jeremy Cockrill released the Patients First Health Care Plan. The broad strokes of this plan are positive. Emphasis on expanding access to primary care, increasing training spots, shortening wait times for surgeries, increasing the number of hospital beds, these are all good things.

And I won’t spend a ton of time on the fact that much of what is in this report, right down to the tagline of “Right Care. Right time.”, we’ve seen before. If you’re interested in that recycling history, check out Opposition Health Critic Meara Conway’s Instagram reel or Tammy Robert’s walk down health reform memory lane at Our Sask. They have valid criticisms; repeated plans without follow-through leave people frustrated and disillusioned. I remember being invited to contribute to a review of Primary Care during this government’s first term. Good work was done and the model proposed was quite promising. Unfortunately, it was shelved in favour of the next shiny thing. In that case, the shiny thing was “Lean,” with the government looking to cut corners as though health care was akin to car manufacturing, instead of investing in humans and building capacity

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Nonetheless, I don’t think the “fooled me once” critique is the most important. While the fact that previous efforts didn’t pan out may be reason for some skepticism, you can’t disregard the current effort outright. There will be reforms in health care, there will be investments, it is better to engage in trying to make sure they are the best possible. Taking this document at face value I see a sincere desire to improve health care in the province and in particular access to primary health care. That’s a good thing. There is still a need for constructive criticism, and in this case that means pointing out the missed opportunities. With a little imagination, there are readily available examples that can guide a better health care reform.

The biggest problem with the current plan is the emphasis on expanding nurse practitioner-led clinics as the central solution. That’s no knock on the skill set of nurse practitioners. I’m fortunate enough to work closely with NP colleagues who are excellent clinicians and leaders on our team. The problem is that this plan sets NPs up for failure by plunking them into the same situation that hasn’t worked for family physicians.

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The primary way that physicians, and under this new model NPs, are paid is fee-for-service. Each patient visit is charged to the government based on the service rendered. This results in some perverse incentives away from the best quality care. For example, a regular clinic visit is assigned a numeric code, for physicians a 5B, and it pays the same amount whether the visit is for a sore throat or a new diagnosis of cancer. As you can imagine, these visits take very different amounts of time, knowledge, and concentration. In essence, the system encourages speedy care of minor problems and the avoidance of complexity. Shifting to salary or mixed payment schedules encourages providers to spend more time at the front end of care, taking the time to address all the issues of a patient before they get out of hand. This plan’s emphasis on NPs billing the government directly just expands and perpetuates the same fee-for-service model, emphasizing volume over quality.

This approach, by doubling down on a flawed model, misses out on real primary care reform. And it does so at a time when real changes are happening elsewhere in Canada and right here at home. The most exciting model currently under exploration is being led in Ontario by former federal Minister of Health, Dr. Jane Philpott. As she described in her book, Health for All, primary health care should be available wherever someone goes in Canada. She describes how, if you live in a neighbourhood or a town, your kids can just enroll in the local school. You don’t have to call around and beg to see who is accepting new students. She asks why it isn’t the same for health care.

We could organize primary care clinics with geographic catchment areas, staffing based on need rather than on what will give the highest billings for the easiest work. It’s a radically different approach, more systemic and planned than we’ve seen before in Canadian medicine, but that’s the point. The current reality is that care is more accessible in the highest income communities rather than where the need is greatest, and even in those better off areas finding care is increasingly difficult. This new model would allow for better allocation of resources, more satisfying and rewarding (financially and professionally) primary care work that attracts providers and, most importantly, better outcomes for patients through well-organized evidence-based care.

Read an excerpt from Jane’s book in this previous post on trust and health care:

Dr. Philpott started clinics in Kingston designed in this locally responsive way during her time as Dean of Medicine at Queens University. She is now leading a province-wide effort to make sure every Ontarian has access to primary care. On a related note, she has also been successful in convincing her province to introduce a single Electronic Medical Record (EMR), increasing the efficiency of care delivery and making sure complete information follows the patient to each clinical visit. These reforms are taking place at scale two provinces over, they are not news to the Saskatchewan Ministry, but similar efforts don’t appear anywhere in this new provincial plan.

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The other successful model to be emulated sits closer to home. It always strikes me that when the province gets excited about team-based care we see it looking to examples like Alaska Native Medical Centre or the Crowfoot Clinic in Calgary as though they have invented something new. These are great examples, but Saskatchewan has already been quietly leading the way in team-based care for over fifty years.

I know this because I get to work with that team at the West Side Community Clinic on 20^th Street in Saskatoon. The Community Clinic opened its doors in July of 1962, established by a group of doctors who were in favour of the introduction of universal health insurance. At the time, the medical establishment was fighting against Medicare, even going on strike, refusing to see patients for 23 days in 1962. From the beginning, the Community Clinic pushed back against the lone practitioner approach, building up teams of a broad range of health professionals working together to meet the needs of patients.

At West Side, we start the day with a team huddle, with everyone in the building coming together in the upstairs meeting room to talk about the day ahead: which patients might need extra support from outreach, who we haven’t seen in a while and are concerned about, what health-related events – positive or negative – are happening in the community, etc. This sets the stage for the day, with everyone understanding how busy we’ll be and where we need to put our best efforts. Upstairs we have counsellors supporting people with mental health and addictions as well as a team from the health authority supporting people living with HIV. On the main floor is the front desk, the lab, the clinic rooms to see patients, and a pharmacy in the back.

Between patient visits, I spend my time in the Shared Space. Depending on who’s in for the day, we may have three or four family doctors and NPs, a physiotherapist, Registered Nurse (RN), occupational therapist, dietitian, or visiting specialists from Psychiatry or Infectious Diseases.

This is where the teamwork magic happens, when we run into tricky medical problems, or confront the social challenges our patients face, we turn to each other. We share medical knowledge, advice on navigating the system, and lend an ear for the frustrations that have no simple fix. It’s a place of collective learning and support that benefits us as providers and delivers better care. When the physio has a no-show on his schedule and fits the patient who just came to see me with an injured shoulder, when the counsellor can chat about the parent whose adult child has died and arrange to console them in their grief, when a more experienced doc can help demonstrate a tricky procedure, when the RN can take the lead on an in-depth review of a patient’s diabetes or the Medical Office Assistant gets the supplies ready for an injection – professionals can use their best skills and people get faster and higher quality care in one place. It’s messy at times, inevitably so given where we work, but it makes a difference.

The downtown clinic serves a different population and thus provides a different mix of professionals, but the same approach of collaborative team-based care is at work. And that’s the point of a team-based model: what the team looks like is determined by the needs of the community it serves. It’s a full-service approach to delivering the “Right Care. Right Time.” that the province is looking for.

It’s hard to say what the obstacles are to seeing the success of Community Clinics and expanding it across the province. Perhaps the association with the establishment of Medicare carries political baggage, perhaps no one is a prophet in their hometown. Whatever the barrier is, if the province is serious about expanding access to quality care, it needs to be overcome. Real primary care reform, with expanded access and better quality is possible. Combining the community clinic model and the geographic approach proposed by Dr. Philpott are key ingredients to making it happen. They are real, replicable examples of what care can be. Fortunately, experience shows that broad strokes health care plans like what was recently released are not set in stone. There is still time to integrate these ideas and truly put patients first.

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Mahli and I have just returned home two weeks in Rwanda. That’s a short time I realize – I prefer to spend a longer time in countries and really get to know the people, the language and history – but this was a special experience. PIH Canada had organized a site visit with members of the board, donors and supporters, to learn more about the work of Inshuti Mu Buzima (PIH Rwanda) and the University of Global Health Equity.

To many Canadians, Rwanda was a country they’d never heard of until the horrific genocide of 1994, where nearly a million people were murdered in a hundred days. And many haven’t thought a great deal about the tiny central African nation since. The country today still bears the scars, with collective trauma and a complicated political situation, but it is so much more than the legacy of those atrocious events. There are deeper questions as to just how that progress is being achieved, but one cannot visit without being struck by not only the stunning views from the country’s “thousand hills” but also the cleanliness, safety and visible economic growth.

The Butaro Level 2 Teaching Hospital was established by PIH in 2011 at the request of the government in one of the poorest and most remote regions of the country, at that time inaccessible by road and without power or running water. The hospital is now a centre of excellence for cancer care. Cancer, despite being a major cause of mortality in Africa (and an increasing one as life expectancies increase with development), is an oft-neglected element of global health care. It is seen as too expensive and too complicated to treat, and thus lives are sacrificed on the altar of “sustainability.” PIH fights back against this framing of poor people, whose health needs are greater, deserving lesser care, instead insisting that the benefits of medical science should serve everyone, not just those living in the world’s wealthiest countries.

To bring the best in health to those most in need, you need to train health workers who understand the science and the ethic of care. UGHE is a shining city on the next hilltop over from Butaro Hospital. Established ten years ago, with a single program, a Master’s in Global Health Delivery, it now offers three degrees, graduated its first class of medical students this year, and is ranked as the fourth best university in Sub-Saharan Africa. It’s an incredible arc for a tiny university in what was once the middle of nowhere.

It was at UGHE that Mahli and I started our Rwanda experience. She saw patients on the pediatrics ward while I worked with the clerks (senior medical students on clinical rotations) in internal medicine. Butaro hospital is better resourced than any rural African hospital I’ve worked in, with a broad range of laboratory testing, available medications and even a CT scanner. Nonetheless, it is still limited and the medicine challenging, not least of all because there are high levels of infectious and non-communicable diseases in the community, and people often encounter clinical care late in the course of their illness.

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Angels and Secrets

Midway through that first week, our internal medicine team had a tough day. After developing a plan that we were hopeful would make a difference for a complicated patient, we returned to the hospital to discover that she had died suddenly overnight. The visiting internal medicine resident and I led an emotional debrief session with the four med students on our team, then continued teaching and caring for the rest of the patients on our service. Before leaving for the day, I ran into the patient’s husband and sat with him a while, explaining what I could and sharing in his sorrow.

Instead of joining the staff bus back to UGHE, I decided to walk through the hills back to campus. That’s where I met an angel on the road. Angel is sixteen and had been briefly admitted for an asthma exacerbation. She stood out with her beautiful, shaved head and big, funky glasses. She joined me on my walk, quizzing me on where I was from and what I was doing in Butaro. When I said I was on my way to UGHE, she pointed out the path to me and told me confidently that she would go there and become a doctor. She goes to high school in a village near the hospital and is working hard in her science classes to get the marks she needs to qualify. I left her feeling inspired, but also wondering, was it really possible someone from the local area would have the academic advantages and opportunities needed to be accepted into this elite academic institution?

A few days later, I learned the secret answer to that question. Secret is in her fifth year of medical school at UGHE, currently doing the Master’s in Global Health Delivery portion of her program. She comes from a village a two-hour hike through the hills from campus. When she first heard UGHE was coming to Butaro, she couldn’t believe it. Why would anyone build a university way out here? It was only when the infrastructure started to be built – the roads and power and water lines – that she started to think it was real. In many ways, it’s that infrastructure that may make the biggest difference in people’s health, as employment opportunities have increased and gender wage gaps flattened in the area since the school was established.

As for Secret, she dreamt of becoming a doctor while attending boarding school across the border in Uganda. She went through the rigorous application process and wasn’t accepted. The first time. Then she tried again and was successful. When she was accepted, there was no phone, internet or even road access to her home, so someone had to walk to her house to tell her she got in. From the first year on, neighbours in her village started coming to her for advice, long before she had any clinical training. She had to tell them she didn’t have any training yet, but they were so proud of her for being in the school that they kept coming. Now she volunteers at the health post on her holidays and is planning to do her internship in Butaro, wanting to serve where she knows the patients, and they know her. She’s considering further training in obstetrics or emergency medicine. Wherever she ends up, she – like the rest of her colleagues – will be a health leader instructed in a philosophy of medicine that puts the needs of patients first.

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Following the Thread

For the second week, Mahli stayed at Butaro, rounding daily in a busy pediatric ward. I joined the rest of the visiting PIH Canada delegation to tour the other IMB sites: Rwinkwavu, the first place Paul Farmer started work on integrating HIV into primary care in 2005, and Kirehe, where the focus is on Maternal and Child Health. After touring the Kirehe Pediatric Development Clinic (PDC) and NICU, we went to visit a local family.

We were welcomed into the home of the parents of three-year-old twins. She didn’t know she was having twins until the delivery, and there were pregnancy complications that led to one twin being smaller and having leg deformities. She is being followed at the PDC and treated with special shoes and leg braces. Because the twins were born early and with complications, they were in the hospital for three months after being born and have to be seen regularly at clinic.

While they are happy that the children are improving through medical support, their parents are struggling to feed them. The father has had a hard time finding work, but the children’s mother used to support the family income by sewing. She’s not able to do this anymore because they had to sell the sewing machine because of the time and transport costs of accessing care. It’s a classic example of how poverty makes people sick and sickness makes people poor. This is why PIH also has their Program on Economic and Social Rights (POSER) that helps support families’ needs beyond the clinical. The new sewing machine, cloth and thread that PIH is providing her may go further to help the family’s health than any medication or therapy could.

There are nearly 15,000 villages across Rwanda, and each village has four Community Health Workers (CHWs). These volunteers support maternal and child health, diagnose and treat malaria and respiratory illnesses and share health promotion messages. It’s an essential extension of the health workforce, embedded in and made up of the community it serves. Accompaniment of patients at the community level is an essential element of PIH’s work in all its care delivery sites. In the districts where they work in Rwanda, they provide additional training and materials to the CHWs and support them in delivering special programs.

In Butaro, the CHWs work with a psychologist to support a group of people who are part of a unique approach to mental health. While depression, anxiety and other mental conditions are worldwide phenomena, Rwanda’s history of trauma has left many people especially wounded. Mental illness often leaves people lonely, isolated from their community. This group meets every other day to sew, making bags and clothing from the traditional kitenge cloths. They told us how this chance to be together and do productive work gives them a sense of community and pride.

This visit to Rwanda gave us a greater appreciation for the breadth of the work of PIH, the possibilities in higher education for greater health equity, and the essential role of accompaniment in reaching the patients most in need.

You can support the work of PIH in Rwanda and around the world by donating to PIH Canada through the link below.

Murakoze cyane

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PS, I’ll be releasing more information over the next few weeks about a new project Blue Umbrella, stay tuned for more on Instagram.

These abandonments of relationships and responsibilities in Europe and North America follow on decisions that are already doing incredible damage to the health of millions. Trump and Elon Musk are essentially shutting down USAID, cancelling tens of billions in funding that goes to provide essential medications and other supports in the world’s poorest countries.

In early February, I visited Socios En Salud (Partners In Health Peru) in Lima, learning about their innovative programs fighting tuberculosis and HIV, supporting people with mental illness, and serving the most marginalized people in the country. We went to the home of a TB patient who was raising her two granddaughters in a single room among the impromptu dwellings of an informal neighbourhood. As always with PIH, it was clear how the connection between accompaniment workers and patient made it possible to deliver care in seemingly impossible situations.

My visit came just days after the USAID cuts were announced, and numerous life-saving programs were already being compromised. Staff hired the Friday before on a US grant to support Venezuelan migrants with chronic illnesses were being let go on the Monday. Aside from the bare humanity of caring for people in need, perhaps a nation as worried as the United States about people crossing its borders would want to help people feel they had a chance to thrive where they are. Instead, the Trump/Musk cuts will lead to desperation all over the world, putting America’s borders under even greater strain.

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A Structural Massacre

One of the programs funded through USAID is called PEPFAR: the President’s Emergency Fund for AIDS Relief. Established under George W. Bush, with Paul Farmer and PIH advising on its development, PEPFAR has provided anti-retroviral medications (ARVs) to people living with HIV in 50 countries around the world. The program has been estimated to save over 25 million lives in the twenty years it has been operating.

I worked in rural hospitals in Mozambique and Zambia before ARVs were widely available. The doctors didn’t want to tell patients they had HIV because they were simply delivering a death sentence. Our wards were full of young people dying from meningitis, TB, Kaposi’s sarcoma and other opportunistic diseases, with no real treatment to offer them, let alone any hope. Every day was filled with heartbreaking tragedy as patients moaned in pain and families wept for those who had died.

Twenty years later, the rates of new cases and of HIV deaths have been cut in half, with PEPFAR the largest provider of the ARVs responsible in many countries. Working in Lesotho, (a country nobody’s ever heard of?!!?) one of our colleagues described HIV medicine as boring. The medicines were now so simple and effective that it had become easy to reach people and successfully monitor and support their care. At the same time, there was a tacit acknowledgment that if anything happened to PEPFAR we might find ourselves right back in the horrific circumstances of the late 1990s.

With PEPFAR’s future now in danger and present a confusing mess amidst the on-again, off-again freeze and thaw of funding, patients and the programs that serve them are left hanging. Experts estimate that even the proposed 90 day freeze in funding would result in 100,000 additional deaths in the next year. Longer-term loss of US support would be even more devastating, increasing sixfold the cases of worldwide in the next four years and leading to six million additional deaths.

Just as repulsive is the news that the USAID cuts are stopping shipments of RUTF (Ready-to-Use-Therapeutic Food) from two of the world’s largest suppliers. This peanut butter-like paste (the original was called PlumpyNut) was invented in the 1990s as a highly nutritious food to help children from malnutrition. Writing from Burundi, Dr. Jennifer Burin describes how the cupboards that once held boxes of this life-saving treatment bearing the familiar label “from the American people” are now as empty as the bellies of the children.

Paul Farmer often spoke of “structural violence,” the way social structures and inequalities harmed the bodies of innocent people. Depriving millions of life-saving medications is a structural massacre. The wealthiest nation in the world is looking over its fortress walls and saying “we’ve been far too generous with these serfs, time for them to die.” It’s as obscene as it sounds and there’s no reason to paint it lighter colours.

Elbows Up

But why am I talking about things happening in Africa and South America today when our problem is in North America? Canada is under economic attack from a former ally. Our Prime Minister is talking seriously about the risk of annexation. Don’t we have our own issues to be concerned about? Shouldn’t we be putting Canada First?

Without question, we need to respond forcefully to attacks from our once-reliable ally and get our house in order. It is a time for positive patriotism, for caring about who we are and what we do that sets us apart. It is time, as I wrote a few weeks ago, to be unapologetically Canadian, the anti-America. With rare exception, I’m pleased to say, that’s what ordinary Canadians and our nation’s leaders are doing. The surge of national unity in the face of disrespect and threats of annexation is an incredible source of hope.

But there is one leader who has been slow to come around, and whose message still contains the wrong kind of red flags. Pierre Poilievre’s much-vaunted Flag Day pivot to a new message of “Canada First” has been clumsy as he tries to keep his MAGA North base onside. He understood the moment he thought he was in. A right-wing renaissance with objective journalism in freefall and his Republican fellow-travellers ascendant. A fight with Trudeau over a moribund carbon tax. An enormous lead in the polls and an apparently easy stroll from Stornaway to Sussex Drive. Shifting gears to the new moment has been hard, and it’s awkward to watch a politician asking himself in public whether he should do the right thing. Poilievre’s hedging of bets up until this latest moment of crisis say a lot about his instincts and who he’s worried about displeasing.

More specific to the question of Canada’s place in the world, however, was something he said in Iqaluit last month. He was promising investments in Arctic defence, an admittedly much-needed be part of a robust rebuild of Canadian defence capacity in a more dangerous world. It’s how he said he would pay for it that set off alarms.

"All of these improvements will be funded by dramatically cutting foreign aid, a lot of which goes to dictators, terrorists and global bureaucracies. I will be bringing our money home with massive cuts to these wasteful and corrupt foreign aid grants."

- Pierre Poilievre, 10/2/25

This was after Trump and Musk had frozen US Aid and were starting to dismantle the structures that assist countries in need. At a time when Canada’s neighbour is cutting foreign aid and alienating allies, Poilievre thinks we should be doing the same. Is this his pivot? To follow Trump’s down the same cruel and counterproductive isolationist path?

Of Canada’s total international aid in 2022-23, over a third went to Ukraine. Trump has called Ukrainian President Volodymyr Zelensky a dictator, is that what Poilievre is referring to? His recent comments following Trump and Vance’s disgraceful treatment of Zelensky in the White House suggest otherwise, but would he be ready to step up with added support for Ukraine now that the US is siding with Russia? With Elon Musk echoing Putin on Ukraine by calling Canada “not a real country”, the archaic notion that only empires deserve independence is again gaining ground. Canada needs to be a stalwart defender of sovereignty and international law everywhere.

Or perhaps he’s talking about the other two-thirds which go either through multilateral programs like the Global Fund, or are delivered in partnership with Canadian agencies through bodies like Global Affairs Canada? Anyone who has had anything to do with these programs can tell you that they are highly vetted with strict reporting requirements. Even in countries where the governments are repressive, the programs are designed to get aid to the people being repressed. Poilievre has been around parliament long enough that he knows this very well, he’s just hoping a vague scapegoat of foreign, crooked others will be a useful tool to anger Canadian voters.

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And then there’s the slogan. In response to Trump overturning every international norm, Poilievre boldly sought out new branding. His podium placards now read “Canada First”. So what’s wrong with that? Well, if imitation is the sincerest form of flattery, Trump should be blushing above his own “America First” signs, a slogan he’s been using since 2016. But not only is it derivative of the person we should be distancing ourselves from, it’s also a motto with an infamous history, a direct descendant of the America First Committee. This was the organization, with such luminary anti-semites at its head as Henry Ford and Charles Lindbergh, that advocated for Hitler and against American involvement in World War II.

I’ll leave it to readers to decide whether Poilievre’s echo of Trump’s echo is ahistoric ignorance or a protofascist DOGEwhistle. The point is that Canada cannot, in our language or our actions, be sending the message that we’re going to go it alone. We cannot put our most immediate and selfish interests ahead of what the world needs, because we will need the world.

When it comes to foreign aid, Canada is a responsible and respected actor in assisting countries in need to develop their capacity to support their own citizens. This is generosity, but also self-interest, an investment in a safer and healthier world. Foreign aid is part of a larger strategy of building alliances of mutual support among sovereign nations, and of participating alongside other wealthy nations in a shared project of a better world.

In the months ahead, Canadians will draw on incredible reserves of fortitude. But if we only look inward for strength, we may end up emulating Trump instead of repudiating him. Now is no time to turn our back on the rest of the world. With our closest neighbour giving us the cold shoulder, or worse, it’s time to build bridges, not burn them down.

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Speaking of being as Canadian as can be, Canadian Doctors for Medicare will be hosting their first ever health summit this weekend in Toronto. I’m honoured to be the opening keynote, and would love to see you there if you’re in town. I’ll come back to this space to share some of the learnings from the day.

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Or at least it has until now. Donald Trump is now musing regularly about Canada becoming the 51^st US state and has talked about using economic force - including 25% tariffs on all Canadian imports as soon as next month - to bring us to heel. This language and the economic actions that follow pose an existential threat to our independence. To counter it, we will need to repurpose a part of our culture that is less conciliatory.

The similarities between the US and us are myriad and our countries are deeply interconnected. But the differences are real, and they amount to much more than long vowel sounds and pastimes on ice. In a recent interview, Justin Trudeau pulled out an oft-used definition of Canadians, “we’re not Americans.” There is a long history in our country of defining ourselves in contrast to the excesses and extremes of American politics and culture.

Predictable though it may be, the statement is an interesting turn from a Prime Minister who famously said early in his term that “'There is no core identity, no mainstream in Canada.” That comment was met with some shock, a strange thing for the leader of a nation to suggest there is no real, cohesive nation to lead. He wasn’t the first to think about our country in these passive terms. Marshall McLuhan once said in 1963 that “Canada is the only country in the world that knows how to live without an identity.” Trudeau Senior’s policy of multiculturalism was the colour print of this photographic negative, the idea that by embracing all cultures rather than imposing a single one we create something new.

Former US President Obama once told a swooning House of Commons that “the world needs more Canada.” The only thing Canadians enjoy more than looking down at Americans is being noticed by them. But like the high schooler who can’t break into the good clique, the only road to cool is to stop caring about being cool. As Ukraine has learned in the face of Russian aggression, a nation’s independence can’t simply be a question of borders and international conventions, it must be one of spirit. To bastardize Kant, if a Canadian identity didn’t exist, it would necessary to invent one.

Canada needs more Canada.

Defining ourselves in contrast risks a jingoistic anti-Americanism: a knee-jerk patriotism of the kind we would criticize if practiced by the object of our scorn. The best kind of patriotism is the kind that says “this is my place so I will care for it and make it the best I can” rather than “this is the best place because I’m from here.” That’s the love Canadians should have for Canada. It should lead us not to be anti-American, but to work to become the anti-America. We can further define ourselves by looking at the extremes and excesses of States and, rather than our standard fashion of adopting them a few years later, move decisively in the opposite direction.

In researching a book I’m currently writing about a great Canadian of the 20^th century, a clear idea emerges of what made Canada one of the most successful and unified countries of that period despite our differences. We are brought together as a nation by caring for one another.

The United States is a casino; the stakes are high but everyone believes they have a shot at the jackpot. If you can pay you can play. Canada has deliberately chosen a different path, one that is not so winner-take-all. This means leaving room for great individual success while still ensuring everyone benefits. The rights conferred by the signature social programs and institutions built over the last 158 years – when they are functioning as they should be – are central to national unity because they send a message of belonging. We are bound to each other by the freedom of knowing there is help when we need it and that we all pitch in to make that possible. Far more than questions of climate, geography, entertainment and cuisine, this is what makes us Canadian.

So what do we do in the face of a threat to our country and that unique approach to building a better life for the people who call it home? Well first, we don’t roll over. We fight fire with fire when it comes to tariffs. That much is obvious, and it’s infuriating to see the premiers of Alberta and Saskatchewan cowardly capitulating in advance. Trump’s endgame may not be actual domination of the dominion, but neither is this is a brief spat. He intends to reshape America’s economy and its use of power in the world, and he has his eyes on us. He imagines a world where the US is incredibly wealthy, a net exporter, and other countries pay dearly to access that market. He wants us to bend to his will. The more we give, the more he will take; we need to strengthen our spine. We need to be more Canadian than we’ve ever been.

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Ten Ways to be the Anti-America

1. Be the myth. Emphasize, above all, an image of Canada as welcoming and kind to our friends and civil but resolute with our adversaries. As we witness human rights being trampled, government services being dismantled and hate being sown in every direction, we must not only refuse to mimic but also offer an alternative to that destructive approach.

2. Celebrate Canada. We must acknowledge the wrongs in Canada’s past and present, but as a springboard for improvement, not as perpetual shame. At a time like this, we need to find pride in and be inspired by the remarkable in our history, by the challenges overcome and the marvels achieved.

3. Don’t allow identities to divide us. Policies must respond to the different needs of different groups, but we can’t fall for the culture war bait. The source of unity, and the strengths of universality in public programs, is that everyone feels included. The more our terminology or our policies divide us along the lines of class, gender, language, ethnicity etc., the more that feeling and the commitment to a common project are lost.

4. Strengthen the federation. With the Parti Québecois leading in the polls, we once again face the question of Quebec independence. There are no easy answers to this, but sleepwalking into another referendum will play right into the hands of those who would see us weaken. Any thought that anything resembling Canada survives separation, or that Trump would be any gentler with an independent Quebec, is purely delusional.

5. Minimize the damage done by our own politics. The opposition parties have promised to force an election the next chance they get. I understand that, I’ve been an opposition politician. You always want your shot at replacing your rivals. I’m also no apologist for the frequently feckless LPC. The fact is, there is a real crisis and important work to be done. It’s no time for a prorogued parliament, and cooler heads should be asking whether it’s time for a rushed election.

6. Fix primary health care. People are mocking Trump for saying Canadians would have better health care if we joined the US, and rightly so, but for a lot of people anything would seem better than what we’re dealing with today. Scenes of patients lined up overnight for a chance at a family doctor reveal a growing sense of desperation and defeat. Accessible, quality care is always important. It’s now a national emergency. How can we point to shared values when the value proposition is coming up so short? The work of Jane Philpott on access to primary care in Ontario may provide some guidance for how to get this done. It needs to move quickly and effectively to give people the access they need and a chance to once again feel proud of the Canadian health care.

7. Keep people whole. With trade wars will come economic hardship. We learned during the pandemic that it is possible to quickly mobilize social supports. We also saw how quickly political and social instability can rise when tens of thousands of people suddenly find themselves without work at the same time as prices rise. Leadership needs to be looking to ways to facilitate growth in Canadian-owned industry, seek new export markets, and be ready to support people who find themselves out of work.

8. Keep a channel open for the facts. Despite the railing against legacy media as fake news, the rise of the MAGAverse is a symbiotic relationship between far-right politics and far-right media outlets that are unmoored from the truth. Having some degree of shared knowledge informed by professional, ethical journalism is an essential antidote to this poisoning of our information ecosystem. The CBC is an underappreciated social program, a factual safety net that Max Fawcett calls “a deliberate instrument of national unity.” The crucial role of the CBC can’t be underestimated in a time of plummeting news quality and national crisis. See A Modest Proposal for the Mother Corp in my previous series on trust for a novel idea on widening its reach and impact.

9. Strengthen the public service. Donald Trump is freezing, firing and otherwise effing the functions of government at all levels. Health, justice, the military, regulations, fiscal policy, social services; the chaos of his disruption will impact tens of millions people. This is unlikely to produce an enviable experience. A country that works is something to be proud of; a commitment to an efficient, reliable and functional government is worth the effort. This strengthening must also include finally taking seriously the decline of Canada’s military to better secure of our own borders and be a better partner to allies in a time of mutual need.

10. Be the Canada the world needs. Economist recently Paul Krugman warned that “Donald Trump wants you to die.” Trump appears hell-bent on undermining public health in his own country through the crippling of the NIH and the CDC and putting vaccine cynic RFK Jr. in charge of the country’s health. On the global scale, he plans to freeze foreign aid and pull the US out of the World Health Organization. US foreign aid has been instrumental in tackling disease around the world. For example, the President’s Emergency Plan for AIDS Relief (PEPFAR), started under George W. Bush, pays for the bulk of anti-retroviral treatment in Africa and has been credited with saving 26 million lives. A ninety-day freeze will cause enough damage, but if this program is ended it will mean the repeat of a humanitarian catastrophe. In this environment, rather than cutting foreign aid as Pierre Poilievre has promised to do, Canada will need to an active part of international efforts to fill the gap left by Trump’s abandonment of the world’s richest nation’s commitments to the world.

So much of what we thought we knew about the world has been upended by the rise of Trump and those who share his worldview. For Canadians, this has moved from a worrisome and disorienting spectacle to real danger to our continued existence. To chart a path to an independent future, we need to look back to what has made us a proud and connected nation in the past.

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PostScript: No One’s Interested in Something You Didn’t Do.

If you are a regular reader of A Larger Scale you’ll have noticed there hasn’t been any regular reading to do. I took a deliberate pause during the Saskatchewan provincial election this fall, not wanting to be a backseat driver and potential distraction during that campaign. I’m also working on two larger writing projects which I’ll be sharing more about with you in the future, and that longer-form work requires sustained attention that is divided by trying to produce regular posts. All of which is to say, while I may occasionally weigh in on issues I can’t stay silent about, I’m not sure when a more regular pace will resume. For now, my assurance that all paid subscriptions have been paused indefinitely, and that when and if I return to writing more regular posts, you’ll hear about it here first.

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Skipping to the end of that piece, I wrote that, “I’m hopeful that the message from these town halls will be, just as it was with the Romanow Commission, that all Canadians - docs included - value the principles of Medicare and are ready to do the work to fulfill that promise.” Happily, that turned out to be the case. the policy makes clear recommendations against user fees and duplicate insurance for medically necessary care. They also made thoughtful recommendations governing for-profit clinics contracted for the provision of publicly-funded services and the role of private equity in health care facility ownership. As well as these “don’t”s there are a number of important “do’s,” including direction on sharing information across jurisdictions, shortening waitlists, and a clear statement in support of Pharmacare.

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Recommendation #1 of the report had the most helpful intervention: Governments scale up collaborative, interprofessional, publicly funded primary care teams so that more Canadians can access timely and integrated care provided by family doctors together with other primary care practitioners. The CMA calls on governments to establish primary care teams for 50% of Canadians within five years, and 80% within 10 years.

This lines up almost exactly with what Dr. Jane Philpott has been proposing in her new book Health For All. Establishing a national Primary Health Care plan that ensured every Canadian was connected to a clinic is achievable. It would have a major impact on improving health outcomes and reducing the pressures on our struggling health care system. It’s encouraging to see this idea gaining steam and I can only hope that the federal government will see that the wisdom of this goes beyond partisan stripes.

I discussed this idea and shared an excerpt from Jane’s book in this post in April:

And shared video of my book launch with Dr. Philpott at Queen’s last fall where she hosted me for a conversation on A Healthy Future.

I’m excited to invite you to continue that conversation. This Friday (August 9, 2024) I’ll be interviewing Dr. Philpott at McNally Robinson in Saskatoon. And on Saturday, Jane and I will be at the Manitou Beach Literary Festival in Watrous for an afternoon panel discussion on both of our books. We’ll be digging deeper into solutions for what ails health care in Canada and would love to see you out at either event!

And just for fun, a photo taken at a recent conference on tackling TB in Saskatchewan. I was inspired to hear Dr. Tam talk of her belief that we can eliminate endemic tuberculosis in Canada and of work on a new national strategy that will help us reach that goal.

But the best part was that the photographer told me he was very moved by the book (see credit in caption).

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We flew home to Canada from Lesotho almost a month ago now. Our experience there was incredible. We learned so much about TB, about the history and realities of Southern Africa, about ourselves as a family. We came back with Basotho blankets, pointy hats and inside jokes.

Now the kids are back in their old schools. Mahli’s on call. I’ve been flying up North for TB clinics and seeing patients at West Side. We’re back to the life we knew. Happy to see people we love. Happy to find the comforts of home.

But returning is harder than leaving. You come back changed to a town that hasn’t. The new landmarks and language, the culture and connections you were so desperate to learn now have no local application. The family drifts off into its own activities. If people are interested, they’re not sure what to ask, you’re not sure what to share, so you boil down to generalities, to an anecdote or two.

As for the pleasures of the familiar, they’re real. A comfortable bed, a closetful of clothes instead of a suitcase, unfailing WiFi, good peanut butter. Life is nice and easy. Too nice and easy. Away, something as simple as driving to work seemed like a new adventure every morning. Back home, autopilot takes over and you hardly notice you’re going anywhere at all. Time speeds up again, blurring by like an over-travelled highway.

At the same time, when you’re a visitor you aren’t completely real. You’re ephemeral, trying on a life like an actor tries on a character. All of your relationships, no matter how rich, are coloured by the temporary. It’s flirtation with no question of fidelity.

There’s nothing novel about these feelings, and it is a luxury to have them. Going from fruitful but rootless explorations to the ordinary life of home is a liminal space, the disorienting feeling of not belonging where you were expected to belong. What do we bring back from away? What did we leave behind? What did we find missing upon our return?

And in that space, you wonder whether you ought to re-root or reroute, to touch down or find somewhere else to float away. We gravitate toward comfort, but it’s in discomfort that we learn and grow. When the return of the routine threatens to choke that growth, back in the real world, how can we continue to find enough novelty in the normal to feel alive?

In this in-between moment, and with a couple of longer writing projects that need to move forward, I’ve decided to spend less time on this Substack for the summer. In the fall I’ll be back with a new project and a lot more content that I’m very excited to share. Until then, I’ve paused all paid subscriptions and will be reducing the frequency of posts. Thank you for reading along with our adventures these last few months. See you in the real world.

We met a lot of amazing people in Lesotho. Two of our favourites were Retsepile, our colleague from PIH, and her husband, SABC journalist Ntate Raps. Here’s his story on the recent snowfall in Maseru, first time they’ve seen snow in the capitol in over a decade (and we just missed it!).

Tout Moun Se Moun. The philosophy that Farmer brought to his medical practice and to the foundation of PIH can be summed up with the Haitian Creole saying “Tout Moun Se Moun.” Literally, “every person is a person.” It’s the simple message that at the life of every human being is as important as the life of any other. While that may sound obvious, the unequal and inequitable distribution of what’s needed to live a healthy life show that our world today, and the political choices that shape it, don’t reflect that value. It’s radical in the true sense, a return to a root core belief that changes every decision to follow.

Put another way, you have Paul Farmer’s most famous quote: the idea that some lives matter less than others is the root of all that’s wrong with the world.

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Structural violence

Another term for “all that’s wrong with the world” is structural violence. Farmer describes this as “a broad rubric that includes a host of offensives against human dignity: extreme and relative poverty, social inequalities ranging from racism to gender inequality, and the more spectacular forms of violence that are uncontestably human rights abuses.”1 Political systems, class structures and global markets conspire, intentionally or not, to keep people in poverty: near to the causes of illness, and far from the cures. Any serious effort to counter the world’s greatest health challenges must go beyond providing great care to challenge the structures that enable a world where, as Sir Michael Marmot tells us, “social inequalities are killing on a grand scale.”  

Preferential option for the poor

The mission statement of PIH is “to provide a preferential option for the poor in health care.” This phrase, like the accompaniment model, are borrowed from liberation theology, a branch of social justice-oriented Catholicism that emerged in Latin America in the 1960s. Here is where Paul Farmer’s work has been perhaps the most courageous. In the secular world of medical research and international aid, Farmer was fearlessly open about a faith that challenged more than it consoled.

Liberation theology challenged the church to direct its outreach to the poorest of the poor, and to advocate politically for them to be raised out of poverty. It’s a belief that Jesus’ message of salvation is relevant in this world, not only the next, with “whatsoever you do to the least of my brother, that you do unto me”2 the guiding principle.

Farmer and PIH extended this idea into their vision of health care, arguing those who need care the most should get the best care. Rather than scraps and neglect sold as sustainability, it’s the poor and underserved of the world who have the greatest claim to the benefits of modern medical science. Along with working upstream to help people get out of poverty, we should be fighting to get care to the hardest-to-reach places and the people most in need.

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Failure of imagination

Faced with this profound call for justice in an unfair world, Farmer fought against narrow notions of sustainability. Too often, when it comes to treatment of illness in low-income countries, people argue for appropriate technology. This is code for giving substandard care under the guise of sustainability. The most perverse examples of this were the arguments in the 1990s and early 2000s that it was impossible to treat HIV in Africa and we needed to focus exclusively on prevention. Ignoring the fact that this meant standing by while millions of people died painful and preventable deaths, it also missed the point of prevention entirely. If you don’t treat HIV, or TB, or any other number of infectious diseases, you ensure their propagation. What’s truly unsustainable is prevention without treatment.

Saying it’s simply too difficult or too expensive to treat disease is a failure to recognize just how expensive and difficult life becomes when disease runs rampant. The social and economic costs of HIV or malaria or cancer are incalculable. The decision to look away rather than innovating new solutions is the failure of imagination that Farmer decried and is rooted in a devaluation of certain human lives. Addressing the gross health inequities in the world demands a creativity that refuses to accept avoidable illness and death as “just the way things are” It demands an invitation to what Farmer called “the House of Yes” in a world where too often the first answer to a cry for help is a list of excuses why it isn’t possible to care for those who need it most.

The Long Defeat

The final concept I want to talk about from Farmer’s work is that of the long defeat. I wrote the following in A Healthy Future:

I’ve been thinking a lot about Farmer since he died suddenly in Rwanda in 2022 at the age of sixty-two. No contemporary physician can compare with the influence Paul Farmer has had on a generation of doctors. In his seminal 2003 book, Pathologies of Power, he wrote: “It took me a relatively short time in Haiti to discover that I could never serve as a dispassionate reporter or chronicler of misery. I am only on the side of the destitute sick and have never sought to represent myself as some sort of neutral party.”3 Reading his articulation of structural violence in Haiti and Peru helped give me the vocabulary to describe what I was seeing in Mozambique or inner-city Saskatoon. His writing on the connection between liberation theology and social medicine spoke directly to my reasons for becoming a doctor.

Farmer used to speak of the “long defeat” of siding with those whose lives are stacked against them. This is inherent in the kind of medicine he practised, a preferential option for the poor against the crushing inequities within countries and between the poorest countries and the wealthiest. He won a lot – his work and the work of PIH have saved millions of lives – but it was still the long defeat. To extend the analogy, it’s a concept inherent to medicine as well: no matter how good your treatment, all of your patients will die. As Dr. Rieux admitted in The Plague, all our victories against illness and death are temporary, “but that is not a reason to give up the struggle.”19

Farmer was never a politician, but his work and writing were deeply political. Politics, too, is a game of the long defeat. Win or lose elections, the change you hope to make will always be receding. For me, the experience of elected life was all a part of the long defeat, and believing that, because the lives of human beings matter, it’s still worth fighting for every win you can even when the ultimate outcome is certain.

Despite acknowledging the inevitability of defeat, this approach is anything but defeatist. His was ultimately a vision of hope for a better, healthier world.  

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The Harvest Is Plentiful

When introducing Farmer for an address to the Harvard Kennedy School in 2011, dean David Ellwood told the audience, “no matter what you do, and no matter how hard you work, think about Paul Farmer as a model of someone that we can aim for.…I aspire for all of you, as I aspire for all of us, the chance to be Paul Farmer.”

In contrast, there was apparently once a sign at PIH headquarters that said “If Paul Farmer is the model we’re golden.” Only golden was crossed out and replace by “f**’d,” the message being that no one can repeat what Farmer has done. As Bill Gates said, “there will never be another Paul Farmer.” Anyone who tries to replicate his life or impact will not only fall short, but likely hurt themselves and others along the way.

That much is obvious, but when walking in his literal footsteps, it’s impossible not to ask whether you’re following in metaphorical ones as well. It’s only natural to compare one’s own willingness and ability to serve with such a remarkable role model, to aspire in the way Ellwood urged the HKS students to aspire.

Psychiatrist and medical anthropologist Dr. Arthur Kleinman, himself a mentor of Farmer’s, wrote recently about this dilemma. “I have spoken with several of Paul's former students and coworkers who were drawn by his example into global health work in some of the same desperate settings. They all said that his perseverance motivated them to do the same, but inevitably realized that the scope and scale of his work could not be replicated. Nonetheless, because of his example, they kept trying.

The point is not to become Paul Farmer. The point is for each of us to find our own selves as healers at some point along the astonishing trajectory that he set out. Our capacities will vary. It is about making the radical effort that matters and will continue to matter for each of us who define purpose in our lives through seeking to do the hard work of global health delivery.”  

There will never be another Dr. Paul Farmer. We can’t and shouldn’t try to become Paul Farmer’s, but we can each become farmers in our own way. As one of our PIH colleagues reminded us recently, “the harvest is plentiful, but the workers are few.”4

Just as farmers take some of this year’s harvest to seed next year’s crops, the ideas behind his work can inform each new effort to address health inequities. We can take the best of his example and the PIH model and use them to guide us in our own fields, cultivating a practice of compassionate care for human health and reaping the quiet rewards of service that makes a difference.

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Adults are always asking kids what they want to be when they grow up. It’s boilerplate cross-generational conversation material. When I would look up from a book long enough to reply, the answer would always be the same. “I’m going to be a farmer and a writer. In the summer I’ll think up the stories on the tractor and in the winter I’ll write them down.”

It turned out that, while I may have some aptitude as a writer, I had next to none as a farmer. It’s a hell of a hard job, equal parts crop scientist, agronomist, chemist, heavy duty mechanic, environmental engineer and soothsayer. My brother Jim, who farms our family land, would attest that I was better at breaking the machinery than fixing it.

The call came for medicine instead, with a particular pull toward working with those most in need. I had some naïve and romantic notions about serving the sick where the need was greatest. Though they’ve changed shape over years of contact with what that means in real life, I guess I still do.

Partners and Paul

We’re con our way home now after six months in Lesotho, working with Partners In Health (PIH) at the Botšabelo MDR-TB hospital. Today, I’m taking some time to reflect on the idea behind the work we were involved in. Like most people, I heard about PIH because of co-founder Dr. Paul Farmer, a global leader in care for those who need it most. Dr. Farmer died suddenly in Rwanda in 2022 at the age of 62.

Neither Mahli nor I ever had the chance to meet Farmer, but many of our colleagues have shared their stories of working together. More importantly, we see his ideas, and the philosophy of care that he outlined in books like Pathologies of Power, demonstrated in the way our friends and colleagues approach patient care and advocacy.

Paul Farmer was an extraordinary human being, but a human being nonetheless, someone with brilliant insights and blind spots. As with any organization with a charismatic founder, there’s a risk for PIH of making him into a saviour or a saint, especially after his unexpected and early passing. WWPFD (What Would Paul Farmer Do) is too narrow a view for a mission that stretches across a dozen countries and hopefully decades into the future.

That said, Farmer brought together an inspiring vision, a remarkable team of people on a mission to “repair the world,” and clear ideas on how to make it happen. For today’s post, I present some of those ideas as a reflection of how Paul Farmer’s spirit of service plays out in that work, first in the unique nature of the PIH model, and then in the philosophical challenges presented to a world where poverty and oppression persist.

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5 S’s Stuff, Staff, Space, Systems, and Social Support. This is the most nuts-and-bolts element of what makes PIH work well. Complex situations require a systematic approach. This may sound straightforward, but the difference with PIH is a commitment to providing the best possible care in a limited number of countries rather than spreading themselves too thin. I used to work in Mozambique in a rural hospital where we never had working oxygen tanks, couldn’t test blood sugars, and were constantly running out of the most basic antibiotics. At PIH Lesotho things aren’t perfect, we have occasional stockouts and blackouts, but there is a well-trained team, a fully stocked ICU, a reliable Oxygen plant (ref O2 plant story), and first line medications. Good people, good buildings and good supply chains are huge, but the real difference is in the last two S’s, which are best seen through another idea: accompaniment.

Radical Accompaniment

At the heart of what PIH does is accompaniment. It’s an idea borrowed from liberation theology (more on this in Part II), that “calls upon the privileged to live in solidarity with and give preferential treatment to people who are poor, ill, and marginalized.” PIH integrates this notion into its care model; among the organization’s first staff in Haiti in the 1980s were the “accompagnateurs,” health workers recruited from their communities to help people take treatment and make it to their appointments. That accompaniment helps to level differences in power and privilege and maintain the focus on what really matters: the health and wellbeing of patients. It also leads to better outcomes: accompanied patients are far more likely to stick with treatment and get better than those left to their own devices. This is true in Canada as well and is a model that should be explored anywhere that people struggle to access or follow through with care.

For a look at the accompaniment model in action, see Love and Consolation, an essay featuring the photos of Joshua Berson.

Beyond the individual patient, PIH as an organization accompanies providers to make sure they have the support and training they need to succeed. They also accompany governments to strengthen their ability to support functioning health systems. PIH can’t compare in size to government-sponsored aid programs like USAID or larger charities like MSF or the Red Cross. Instead, PIH strives to provide exceptional and innovative care that can then be scaled up by government and non-government actors. The decision to treat MDR-TB in Peru and HIV in Haiti when all the experts said it would fail revolutionized the world’s approach to these diseases.

The direct individual patient care of PIH is crucial, the effort put in to care for each patient is worth it because each person’s life matters. On top of that, the spillover policy effect and scaling up of new approaches is what creates global change for millions.

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Doing hard things with friends

The name of the organization, Partners In Health, is no accident. PIH goes where things are hard, which means the work is hard as well. But it’s easier when done alongside people you enjoy and can rely on. From the leadership and management to the colleagues in the hospital and community, people are welcoming and approachable. That doesn’t mean people never butt heads, in fact I’ve seen some of the fiercest clinical arguments here, but they are focussed on making sure we follow another important maxim, as PIH Canada’s Mark Brender wrote in his tribute to Farmer: the patients are our bosses. It’s ok to push back, to ask for more, to debate and disagree. In fact, it’s expected, so long as what you’re pushing for is what’s best for the people we serve.

More often, however, the experience working at PIH is one of finding joy in the struggles. We marvel at the beauty of the mountains while grumbling about the bumpy roads. We groan at the daily barriers to care, and work to find solutions instead of throwing up our hands in frustration. And we laugh, amused and delighted by the absurdity and poetry of interactions across language and culture. In the face of overwhelming need, it would be easy to get discouraged and disillusioned. Approaching this work with a spirit of camaraderie and a sense of humour, what Farmer called “doing hard things with friends,” is what keeps the PIH team fighting the good fight against tremendous odds.

PIH Stays. Those friendships don’t happen overnight, it’s a product of individual and institutional attitudes and relationships built up over years. When first looking into working with PIH, we were discussing which places would be the best fit. I asked if any of the projects were close to wrapping up. The answer was, “we don’t do that.” The exact nature of the involvement will necessarily shift over time, but when PIH decides to work in a country, it’s for the long haul. From Haiti to Peru, Kazakhstan to Sierra Leone, through changes in governments, natural disasters and conflicts. As Farmer described in Haiti After the Earthquake, the ability of PIH to respond quickly and effectively in response to the 2010 Haiti earthquake was the fact that they were already there. They had the relationships and the knowledge of local context to be able to help where it was needed right away.

These are some of the practical differences in the PIH model that stem from Farmer’s philosophy. In Part II I will explore that philosophy and the challenge it poses to those who would try to build a healthier world.

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This is the third in a short series on issues of trust and misinformation.

In this final instalment (for now), I want to move from health experts and elected leaders to the people who tell their stories. Not only has the profitability of traditional media been undercut by social media, but its credibility as well. There’s great value in critical thought and interrogation of official and mainstream sources, but we’re now well past the point of any common understanding of the world around us. COVID briefly presented a moment of looking in the same direction, but this singular event soon passed through the prism of our scattered and views, leaving people to interpret a common experience in completely opposite ways. This fragmentation makes the work of journalists and the companies that distribute their work more important than ever, and potentially more dangerous.

In Saskatchewan, reporters did a tremendous job of reporting the substance behind the spin during and post-COVID. For example, this April 2024 article from Alexander Quon and Zak Vescera that digs back into what Scott Moe and co. really knew as the Delta wave was set to overwhelm Saskatchewan hospitals. As much as it may be a struggle to push through the noise, what reporters choose to cover, and their newspapers, websites and broadcasters choose to publish, still matters. At a time when trust in media to tell the truth about health issues is falling around the world, we need people committed to the craft of telling the truth and telling it well.

From Both Sides Now

People in media write a lot about media, as you would expect, and for reasons the graph above explains, trust is the topic of the day. At the heart of the debate is a battle over the idea of impartiality, a two-sided argument about bothsidesism. In this year’s Massey Article, The Trust Spiral, journalist Tara Henley describes a loss of confidence in mainstream media that is preceded and precipitated by a loss of profits and players. She makes a case for objectivity and points the finger at the “wokeness” or “identitarian moralism” of young, left-leaning reporters as the source of its decay.

There are good points in the piece, including the critique of what can be an alienating focus on group identity as a stand-in for equity. She’s right to argue for a reporting of the facts rather than infusing writing with the moral views of the observer. On the other hand, she fails to note that there isn’t always another hand.

Journalists should report the facts, including those that are ideologically inconvenient. They aren’t, however, obliged to include information that has been disproven. The world is not flat. Donald Trump didn’t win the 2020 US election. People have the right to believe the contrary, but reporters shouldn’t include their views in serious reporting, that’s false balance. This is where Henley’s argument fails her own test. She discounts things she disagrees with, such as coverage of COVID and the Freedom Convoy, with a broad brush, for example over-stating the degree to which the Public Order Emergency Commission exonerated convoy protesters. She then fails to include arguments from those who would think these things were covered well or to include concerns of journalistic malpractice from right-leaning outlets such as Fox News where misinformation has been flourishing.

 A similar story unfolded in the US, where longtime NPR contributor Uri Berliner said that his (now former) workplace was losing the trust of Americans because of a lack of viewpoint diversity. His NPR colleague Steve Inskeep reviewed the piece, pointed out numerous errors and the lack of any dissenting views, pointing out that, “Berliner gave a perfect example of the kind of journalism he says he’s against.” This is where we need to be cautious, when actors like Matt Taibbi or Bari Weiss call for the inclusion of more viewpoints, are they calling for broader objectivity, or for more media to reflect their own opinions and exclude others? A return to fact-based reporting has to find a path that avoids the delegitimizing practice of false balance and that interrogates bias from all directions.

A Modest Proposal for the Mother Corp

Good quality news is an essential public service. What if, instead of defunding our public broadcaster, we improved it and widened its reach with a CBC newspaper?

Some people will hate this idea, of course, as support for the CBC has become a defining political line. Its continued existence under a potential Poilievre government is very much in question, and the country would be poorer as a result.

In Canada, we have a failing or failed newspaper industry. Many regional papers are now the “ghost papers” Henley describes in her article, reprinting national coverage and advertorial content with very little local information. This leads to what former Boston Globe editor calls a “corruption tax,” where communities like my hometown of Moose Jaw, that lost the Times Herald after over 125 years, or the Whitehorse Star that closed last month after a similar tenure, lose the watchdog function that can keep local officials honest.

A national CBC newspaper, publishing on paper the stories that are already being produced for radio, TV and online, could make sure that good local reporting happens while giving readers across Canada a shared experience of the news. It could also help revitalize the information deserts where local papers have disappeared or are so empty that no one would notice the difference.

Now to the objections:

1) It would cost too much. This is a blue-sky exercise, I won’t pretend to have done the math, but it surely couldn’t cost more than the $600 million public dollars to private corporations that still shed jobs and close bureaus. Public bailouts of private media have worsened trust in media without achieving the intended preservation of quality coverage.

2) It would drive existing papers out of business. To some degree that’s a moot point; they’re already going or gone. It’s also worth pointing out that TV, radio and online news have not been harmed by the existence of the CBC. If anything, it contributes to competition that enhances the media landscape.

3) It would tip the scales. Isn’t this article about bias and trust? Wouldn’t this just be more Liberal propaganda? Here’s where work would need to be done. The CBC’s reputation for bias is far worse than the reality. But it isn’t just perception. Independent media bias reports do score the corp as highly factual but with a left-centre bias.

My experience is that a more liberal worldview tends to show up more in stories on public stories rather than coverage of partisan politics, for example in reporting on LGBT issues or First Nations concerns. As a left-of-centre politician, my interviews with CBC reporters were frequently more combative, with some reporters telling me they needed to be tougher on the NDP than the Sask Party to overcome the perception of bias. For this newspaper idea to succeed, or for the existing programming to stop being a political football, the CBC needs to strive for greater objectivity and impartiality.

Before we get too carried away about bias at the CBC, however, let’s remember what we’re talking about with every other outlet. While reporters may skew left, newspaper owners certainly don’t. The CBC has never endorsed a candidate or a party, whereas PostMedia will endorse the Conservatives no matter what they do. The editorial pages of most of Canada’s newspapers make no bones about where their sympathies lie and they aren’t on the left. Private companies and have the right to promote their own opinions, that’s their business, though it does ger stranger when public dollars are flowing their way. Nonetheless, as a public news agency, the CBC should be held to a higher standard and take further measures to be and appear impartial.

A factual, objective and well-written CBC broadsheet in the mailboxes of Canadians could reverse the erosion of our information landscape. It could be a source of unity rather than division, helping to build back trust in the news and each other.

Thank you for reading (and trusting) A Larger Scale. This post is public, feel free to share it.

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