 I remember when I was training, when I was doing my medical training, I remember we were doing our cardio, I went to the University of Ottawa and we did our cardiology rotation there. And we were at the Heart Institute and I remember a cardiologist telling me about rheumatic fever and like, oh, you'll never see this. And I remember when I finished residency and when I started working up in Sulu account, I remember the first time I had heard of a diagnosis of rheumatic fever. And it was of a patient who died and we got back the report from the coroner's office and it said, you know, findings consistent with acute rheumatic fever. And I remember thinking to myself, wow, this was something that during my med school matriculation I was taught that was a non-issue anymore, right? At least in Canada, right? And here we are seeing it in Northern Ontario. All right, so basics, what is acute rheumatic fever? We believe it originates from group A streptococcal infection. It's sort of typically it can affect, it's typically can affect the skin, the joints, the brain. The heart can of course be affected or so and lead to permanent valvular disease. We think it's mostly from the pharynx shittic strains of group A streptococcus. Now that's been challenged by some recent data out of Australia that may suggest that some skin strains may be implicated as well. Very can be common in children. Now again, very rare in Canada, very, very rare in Canada, but rheumatic heart disease globally is one of the most common forms of acquired heart disease globally, right? So something that we see globally, not infrequently. All right, it's still with us and we still see it in the North, right? I remember back in about almost 10 years ago now we started to see cases of rheumatic fever when I was working in, when I was working in Sulekout. So I worked in Sulekout for approximately 16 years and I worked in Moose Factory for about another two and a half years. And I remember in about 2013, 2014 starting to see cases of rheumatic fever. In fact, we had seen eight cases of rheumatic fever over about a year, year and a half period of time. And there were two children that died because of rheumatic fever. And when we looked at the rates and when we tried to look at the rates, what is the actual incidence of this? We found that the rate was about 75 times what it is in other regions of the country, right? So the question is, why are we seeing it? And why are we seeing such a high number of cases of rheumatic fever? Now, when we have rheumatic fever, just to go through a little bit about what happens, we know there's an antecedent, usually streptococcal infection. We know there's some degree of immune system priming that you encounter. And then with repeated streptococcal infections, you get repeated sort of immune response. And that leads to, that can lead to permanent valvealopathy, right? And rheumatic heart disease, right? Okay, just a little video here. I wanna show, I'm not sure if it's gonna play. So I apologize. One of the things that we started to see was you might remember from medical school, Sydenham's Korea, right? So we used to have children or be referred to us because their teachers were noticing that they were getting ticks, right? And maybe there was a concern that they were having an interaction of their ADHD medication or something else going on or something. This is just a quick little video here. This is a young patient that came to the clinic for ticks. And this child eventually had, we diagnosed with Sydenham's Korea. So this is an example of Sydenham's Korea. We see this not infrequently, not infrequently in loose factories, as well as throughout the North and stuff. So we might remember that from our med school, med school, med school time. So the big question is the why? Why are we seeing so many cases of rheumatic fever? I didn't want this talk to be focused on pathophysiology and heart valves and echoes and that type of thing because the big question that I ask is the why? Why were we seeing so many cases? What is driving some of these cases? Why? Why are we seeing 75 times the number of cases that we see in other places in Southern Ontario? And what are some of the reasons for that? And we looked at the patients and we realized very quickly that rheumatic fever is not reportable. So it was very difficult to even track cases of rheumatic fever because it's not reportable. So the public health infrastructure that you need to track cases and do adequate surveillance, it doesn't apply for rheumatic fever. So that was an incredible challenge. And when we extended it even further into the public health care system that existed in indigenous communities at the time, it's not the same as the provincial system. You see, you can have what we call jurisdictional ambiguity instead of jurisdictional responsibility. Who is ultimately responsible? You know, in most places in the province of Ontario, we have provincial public health laws and there's a provincial medical officer of health and provincial public health and they have that provincial authority over a specified region. And, you know, if there are outbreaks, they have provincial legislation that they can enact that can ensure that there's adequate surveillance. Within the federal system up North, that system, it's unclear who's responsible for that. Is it the provincial system or is it the federal system? And plus two, the federal public health system doesn't have the same type of infrastructure. It doesn't have the same type of legislative teeth as the provincial system. So again, you have a lot of challenges in terms of even keeping track of the number of cases. A lot of the cases that we're seeing was just sort of word of mouth. I remember when you'd be on in the emergency, you'd hear from a physician that was working the night before and says, yeah, we have this kid and I think they might have rheumatic fever and you were going and you'd go back and check the chart and okay, we'll add that child to the list and make sure that they get adequate follow up. But there was no provincial system that was in place to be able to adequately track and adequately follow these patients and there was no adequate surveillance system. And again, because of this idea of jurisdictional ambiguity. And a lot of things that what is driving these things are the fact that we have systemic inequities. There's the effects of systemic racism and the effects of colonization within the healthcare system that produces differential results based on who you are. So, we're getting these cases and going through and again, it was a lot of just word of mouth, right? Who did you see in the emergency? Who did you see in the emergency? Yeah, I saw this one patient that I got on phones. Yeah, I had this other person that passed through the emergency and they had some unexplained tachycardia. We did an echo, we found a huge level of mitral regurgitation and a clinical picture consistent with rheumatic fever. That's how a lot of these cases were recognized. And we were able to sort of assemble a team of people to at least on an informal way try to track the number of patients, the number of children. And what did we learn? We published a little an article in the Canadian Family Physician Journal about acute rheumatic fever in First Nations communities in Northwestern Ontario, social determinants of health a bite to the heart. Because you realize very quickly that medicine is very interesting. A very little bit of inequity can counteract a whole lot of medical ingenuity. That we were sending these patients to tertiary care centers and they were having access to some of the greatest minds in the medical world. And to think that people didn't have access to running water and people didn't have access to adequate housing or had access to overcrowded in adequate housing. That was what was driving some of these outcomes. So a little bit of inequity can counterbalance a hell of a lot of medical ingenuity. As an example of the Sioux Lookout zone, vast, vast zone, right? This is an area the size of France just to put things in a little bit of scale, right? And there's a number of communities in this region. Right now I work in the Moose Factory zone and this is along the James Bay Colts and they face a lot of similar issues. But you can see we're talking about a vast, vast geographic area, right? So what do we find that we're driving some of these things? Housing, a huge, huge issue is housing. If you're thinking about group-based strep, it's a bacteria. And if you have inadequate access to clean running water and you have a lot of overcrowding and housing, you're gonna have a problem with group-based strep. It's gonna go from person to person very, very easily. And if you have a house that's 600 square feet and 17 people living inside, that's gonna create huge, huge opportunities for this bacteria to spread. These bacteria don't grow in agar exclusively, they grow in inequity and injustice and unfairness. But when you have that level of overcrowding, it's going to lead to significant, significant challenges with group-based strep and with rheumatic fever. The housing was inadequate. Building standards in the North are not the same as building standards in the South. There's poor ventilation. There's no such thing as consistent fire codes. Building materials are inadequate compared to what building materials are in the South. So you can see how a situation of overcrowding and the lack of access to adequate housing can create a perfect storm, water. And this has been well publicized that there have been significant challenges in Northern communities for accessing clean running water. Some communities have been under a boil water advisory for 25 years. That's a whole generation. Imagine for 25 years if a community has not known what it's like to drink clean drinking water. And these factors can contribute significantly to the proliferation of group-based strep. But not only group-based strep, the proliferation of other bugs like MRSA and staph aureus. We published on that that our rates of MRSA and just are very, very high and our rates of invasive MRSA were many fold higher than comparable regions in Southern Ontario. So I would say that we don't have a group-based strep problem and we don't have a rheumatic fever problem. We have an injustice problem and we have an inequity problem and we have an unfairness problem. And it's just manifesting with rheumatic fever. And one of the key things that must happen is that we must address what we call the primordial causes of rheumatic fever. Looking at things like overcrowding, looking at things like adequate housing, looking at things like ensuring communities have access to clean running water. If you address those things, you're going to see rheumatic fever incidents goes down. Remember, rheumatic fever 100 years ago was a very common condition. Very, very common condition. And when you look at rheumatic fever incidents, its incidents started to drop significantly not with the introduction of penicillin in the 1940s and 1950s. But 50 years before when we have better sanitation, when public health units were initially being created, when we were recognizing that we couldn't have 50 people living in one space anymore and we started introducing better sanitation laws and better building codes, that's when we saw rheumatic fever incidents start to plummet well before the introduction of antibiotics. So it's those issues that are going to be crucial in keeping the rates low. You know, it's interesting. There are high levels of rheumatic fever in Australia and New Zealand and in their indigenous communities in those countries. But it's interesting because they have much better statewide and provincial wide surveillance systems, much more robust public health in regards to surveillance. They have an echo program that can actually go and make sure that people are getting their echoes with rheumatic fever so that we can prevent some of the sequelae. They have a much better system that is going to do those things than what we have. Where there's no provincial level surveillance. We have jurisdictional ambiguity with the federal public health versus provincial public health. There's no provincial echo strategies for follow-up. There's nothing to guarantee that I have a child and they have rheumatic fever that's seven or eight years from now they're going to get an echo at some particular point. There's nothing, there's no system, there's no safety net that's going to ensure that that happens. So it's not uncommon that you'll have children that in 2014 and 2014-15, does that make sense? That were identified with rheumatic fever and got maybe a couple echoes but they haven't gotten any in the last several years. One of the big challenges as well too is that it's not reportable. We're still dealing with something that is not reportable. And maybe you could make an argument that for Southern Ontario or Toronto or Ottawa or Kitchener, maybe it doesn't need to be instances so low. But what about in our Northern communities where this is still affecting people's lives? You know, our last paragraph of our article that we submitted, I just put it up here because this is not new. We said our case series serves to demonstrate as detailed by the Auditor General of Canada. In 2015, the Auditor General of Canada did an audit on how our health services in the North, in Northern Indigenous communities. And what did the Auditor General find? The Auditor General said that Health Canada has not adequately managed its support of access to health services for remote First Nations. And we remember the Truth and Reconciliation Commission. We also said this community-based research also highlights areas identified by the Recent Truth and Reconciliation Commission. This was in 2015, in which we must close the gaps in health outcomes between Aboriginal and non-Aboriginal communities. And action is urgently, urgently needed. So when I look at rheumatic fever, I don't look at rheumatic fever just on a pathophysiological sense. I look at it in terms of there are justice, fairness, and equity issues that need to be urgently addressed. Because we will, unless we address them, we will always have complex cases of rheumatic fever. And we will always have children, unfortunately, dying of rheumatic fever. Because the solution is not exclusively medicine it's also equity. We have to make sure that the tenants of justice, fairness, and equity are being applied to everyone. And as long as we don't have the proper provision of those, we will always have rheumatic fever. We will always have rheumatic fever. You know, one of the things that we need to watch out that we don't do, and I'm guilty of this, is that sometimes we can normalize dysfunction, right? Like I remember at a time, you were seeing so much rheumatic fever that it almost became normal. I remember when the residents would come up and we would present and they'd be like, I think this kid has rheumatic fever, I've never seen this before. And we'd be like, yes, this child has rheumatic fever. We knew the penicillin goes off by heart. We knew when they would get their echo. We knew the criteria. In fact, we knew the criteria off by heart for both the high risk environments, right? So we just knew those things. So we were just splurging out all this knowledge about rheumatic fever. But what I found I was doing is I was normalizing dysfunction. And the problem is is that when you normalize dysfunction, you don't see it anymore. It's just, it's another case of rheumatic fever. It's another case of rheumatic fever. It's another case of rheumatic fever. And what happens is that when you do that, you lose the ability or your ability to ask the why becomes impaired. So I want to encourage all of us that when we're hearing about these things, we ask ourselves the why. Because sometimes when you're in an environment where you see this all the time, you can normalize the dysfunction. You can normalize the fact that there's rheumatic fever in high incidence still in Canada. And then you just don't see it anymore. You know, sometimes it's not dysfunction that's problematic, but when you normalize dysfunction because when you normalize dysfunction, you can't see it, right? I want to encourage everyone as well is that you know what I want? I want change. I'll be quite honest with you. I want change. Like it is, it bothers me to know that here in 2022, almost 2023, we still have issues with rheumatic fever. We still have children dying of rheumatic fever. We still have mitral valves in children that are not good with rheumatic fever. And I always ask myself like, you know, what we're gonna have, how are we gonna need to get some change? What is going to need to happen to get some change? And you know what? Change doesn't happen exclusively by education, but change comes by challenging belief systems and practices. That's how change is gonna come. We have to challenge a system, a healthcare system that unfortunately has in some respects systemic racism built into it against indigenous people. We have a system in this country right now that is very effective at triaging people based on race to vastly differential levels of care. And we need to challenge those systems. We need to take a look in a mirror. I remember an elder once said, we've all been dipped in a little bit of colonial tea, whether we like it or not. We all have received an education in a colonial system and that can potentially affect the way on how we look at other individuals. So I challenge everybody today that, you know what, what are we gonna do to get a bit more justice, a bit more equity, a bit more fairness in our healthcare system right now? So maybe the next time this perioperative conference comes up, that we can say that the rates of rheumatic fever are down, not because we not only have excellent access, but we also are addressing some of the primordial issues, housing, overcrowding, lack of clean running water. All right, thank you so much. I think that's about my time. I hope I didn't go over, I apologize for that. Yeah.