Winnipeg Health Region
Wave, September / October 2012
Charlotte Wood knows the routine.
At least once a year, the 14-year-old girl, along with her mother and siblings, visits the Diabetes Education Resource for Children and Adolescents (DER-CA) on William Avenue in Winnipeg.
Once inside, Charlotte, her younger sisters, Savanah and Genevieve, and older brother Curtis, are greeted by a nurse and prepped for their examination.
"First I get weighed and they measure my height," explains Charlotte. "Then they take my blood pressure. Then they do the blood work."
Charlotte and her siblings make regular visits to the clinic for checkups because Type 2 diabetes runs in the family - their mom, Mary Wood, has it, as do their grandparents, and some other family members.
So far, Charlotte is the only one of Mary's daughters diagnosed with the condition. But the girl with the bright eyes and quick smile is learning to keep it in check. "I have to take insulin shots, and I can't eat sweets or junk food or pop," she says.
For most kids, doing without the occasional treat may seem a bit daunting. But Charlotte takes it all in stride - she knows it is important to keep her blood sugar levels in check, a point that is emphasized during her visits to DER-CA.
She understands that her body does not produce enough insulin or use the insulin it does produce to efficiently break down the sudden surge in glucose (sugar) that would come from consuming sweets. And she understands that a high level of glucose in her blood can permanently change the structure and function of her organs, a development that could lead to health issues such as kidney failure.
Not long ago, the notion that a child like Charlotte could be vulnerable to Type 2 diabetes was considered beyond the realm of possibility. Until recently, children were not generally tested for Type 2 diabetes because it was considered an "adult" condition.
Over the last three decades, the number of children diagnosed with Type 2 diabetes within the Winnipeg Health Region's jurisdiction has soared from zero to more than 70 a year. Many of these cases originate in northeastern Manitoba and northwestern Ontario. In fact, the area is one of two hot spots in North America that have recorded huge increases in childhood Type 2 diabetes - the other is in Arizona.
Health officials say the surge in cases represents a major intergenerational health threat, one that could escalate in years to come. But efforts are underway to help the children and their families.
In April, University of Manitoba Faculty of Medicine professors and researchers at the Manitoba Institute of Child Health (MICH) formed a new research group dedicated to tackling the Type 2 diabetes problem. The group is called Diabetes Research Envisioned and Accomplished in Manitoba, or DREAM for short, and features 10 researchers, including members of MICH and DER-CA.
The DREAM team will support the work being done by health-care providers and representatives of First Nations communities at DER-CA. In doing so, it will significantly enhance efforts to better diagnose, treat and, ultimately, prevent childhood Type 2 diabetes.
The first cases of childhood diabetes in northern Manitoba were identified in the early 1980s by Dr. Heather Dean. Today, Dean is Assistant Dean (Academic) and professor of pediatrics and child health at the University of Manitoba's Faculty of Medicine, pediatric endocrinologist at DER-CA, a member of the DREAM team and one of Canada's leading experts on pediatric Type 2 diabetes. But at the time, she had just finished training in pediatrics and pediatric endocrinology and was working as a fly-in physician at northern communities like St. Theresa Point and Garden Hill.
During one of her many northern trips, Dean encountered a 14-year-old girl who was displaying unusual symptoms for a child her age: she was overweight, thirsty and hungry all the time. Dean decided to do blood tests to find the underlying cause. She was astounded when the tests suggested the girl had Type 2 diabetes.
"We knew this shouldn't be happening to a child," says Dean, recalling her reaction to her findings. "We've always had obese children in Manitoba but they don't develop Type 2 diabetes. They don't get high blood sugar. Their bodies can accommodate and compensate. But somehow these children's bodies were not," she said noting that she went on to identify about a dozen similar cases.
Initially, her diagnoses were met with skepticism by diabetes experts. Type 1 diabetes? Maybe. Type 2 diabetes? Never.
The difference between the two types of diabetes is significant. Type 1 diabetes, which can affect people of all ages, is triggered many months before symptoms show. People with Type 1 do not produce insulin, and require a daily source of it.
Type 2 diabetes is much more common. It occurs when the body does not produce enough insulin and does not respond effectively to the insulin it does produce. As a result, glucose levels in the blood can increase unchecked. Studies are starting to show that Type 2 diabetes affects children more rapidly, with many developing other health problems by the time they are in their mid-twenties. In other words, it can cause serious illness if left unchecked.
Initial doubts concerning the diagnosis of children with Type 2 diabetes began to wane as the evidence mounted. By 1988, Dean and Dr. Michael Moffatt, who was a pediatrician at the time and is now Executive Director of Research and Applied Learning for the Winnipeg Health Region, published a report in the journal Arctic Medical Research about their findings. By this time, they'd identified 15 cases of Type 2 diabetes in children.
"We had no idea what was going on. These were kids who were very obese, and all, with the exception of one, were girls," says Dean.
Initially, it was thought Aboriginal children were developing Type 2 diabetes earlier than expected because of lifestyle issues - poor diet and lack of exercise. Once the findings of Dean and Moffatt, who is also a professor of pediatrics and child health and community health sciences at the University of Manitoba's Faculty of Medicine, were accepted, it was thought these cases represented the tip of a giant iceberg.
"After we sounded the alarm, Health Canada originally thought this was a problem generalized across all First Nations people in Canada," says Dean.
But there was another twist in the story. Research revealed that other First Nations communities, including those in nearby Saskatchewan, were not reporting cases of Type 2 diabetes among children, even though their lifestyles were similar to those of young people in northeastern Manitoba and northwestern Ontario.
"We soon discovered that it was localized to people who are from the Sandy Lake area in Ontario, and our group in Manitoba," says Dean.
At that point, Dean began to suspect that the emergence of Type 2 diabetes among children could not be solely attributed to a lack of exercise and a diet heavy in sugars and fats. She began to connect the dots, looking for a genetic component that was shared from parents to children.
Her suspicions were confirmed in the mid-1990s when a study by researchers at the University of Toronto discovered a genetic variance among people living at Sandy Lake First Nation, which had been recording increases in childhood diabetes.
The researchers showed that if a person had this genetic variance - called the HNF-1 alpha polymorphism - they were guaranteed to develop Type 2 diabetes by the time they were 50.
"Using that, we looked at the Manitobans and found they have the same gene. There has been a lot of intermarriage between the Oji-Cree populations in the Island Lake area and northwestern Ontario, so they share the same genes," says Dean.
But Dean knew there was more going on than a genetic variance that led to diabetes later in life. This disease was affecting children.
One theory attributed the problem to a hormonal surge in obese kids during puberty. But Dean's numbers showed that 9.7 per cent of the children diagnosed with Type 2 diabetes in the past five years were under the age of 10. That meant that a hormonal imbalance related to growing up could not be the trigger. The answer was complex, she knew - a combination of genetic inheritance, the environment and lifestyle, and something else. Something yet unknown.
As the number of cases of Type 2 diabetes among young people continued to grow during the 1980s and 1990s, efforts were made to understand and contain the problem.
The Diabetes Education Resource for Children and Adolescents at the Health Sciences Centre campus was established in 1985 to help educate children and their parents on how to manage the condition. Dean was instrumental with colleagues in Manitoba Health and Children's Hospital in developing the program.
Mary Wood was one of the first children to visit DER-CA. She was diagnosed with Type 2 diabetes at age 11 and was enrolled in a DER-CA study by the time she was 12. By her own admission, Mary did not treat her diagnosis with the seriousness it deserved. "When I was young, I didn't listen to my grandparents," she says. "I did what I wanted and ignored my diabetes."
Now, at the age of 40, Mary suffers from a number of complications of the disease, including kidney failure, vision problems, and lack of feeling in her feet and hands. She's on dialysis three times a week and uses a wheel chair for mobility.
Experience is a tough teacher, but it has made Mary much the wiser. Today, she is doing everything she can to ensure her children don't make her mistakes, especially her two children who already have Type 2 diabetes. "I'm talking to you today because it's important that the young people know they need to take care of themselves," she says. "That's what I'm telling my kids."
Mary and her children inspired Dean to focus her research in a new direction. She'd been studying a generation of kids who had grown up and were having children of their own.
The difference here is that never before have there been young women with Type 2 diabetes prior to their pregnancies. This was a whole new dynamic, says Dean, where babies were being exposed to Type 2 diabetes from conception onward.
"We started seeing the offspring coming through. That was when I said, 'Oh-oh.' I knew we had to find the bigger picture - and quickly," she says.
In response, Dean and her colleagues at DER-CA launched the Next Generation project in 2003.
The Next Generation project looks at the children of First Nations mothers living in Manitoba, who had Type 2 diabetes prior to their pregnancy. The project found that these mothers have a 14 times higher risk of having a child with Type 2 diabetes than mothers without the disease.
"We asked ourselves if pregnancy was the mechanism causing these women to have more children with Type 2," says Dean. Perhaps a diabetic woman's high blood sugars were affecting the development of the fetus, causing the child's metabolism to be disposed toward obesity and Type 2 diabetes.
"We think there is an additional risk factor during the fetal stage," says Dean. "We suspect that the intrauterine environment is affecting organ development and how genes are affected by their environment and express themselves. The mothers with Type 2 have children who inherit the gene for lower secretion of insulin, so their children have an additional inherited inability to make insulin."
That glimpse of an answer has led to more questions for Dean and the others on the Next Generation project.
"Genes don't change that quickly," says Dean. "In my professional lifetime, over the last 30 years, something has changed quickly. We've no idea what the accelerator is, so we're trying with the big teams to intellectually understand what the issues are."
That "big team," of course is the DREAM team, which is located within the Manitoba Institute for Child Health and is funded through a $750,000 grant from the Children's Hospital Foundation.
"We were so excited with the launch of DREAM," says Dean. "It will help us connect the circle of science and care, in that we're now doing scientific research in conjunction with bedside treatment. We have a unique problem in Manitoba, and I'm thrilled that money has been invested into the scientific minds solving that problem."
The DREAM team is focusing on two main research areas: finding out why children are susceptible to Type 2 diabetes, including maternal and early life factors; and preventing complications in children who have Type 2 diabetes by helping them better manage their condition.
Dr. Grant Hatch, Canada Research Chair in Molecular Cardiolipin Metabolism and professor of pharmacology and biochemistry and medical genetics at the University of Manitoba, and Dr. Jon McGavock, assistant professor of pediatrics and child health, lead a team of Manitoba scientists. They include: Dean, fellow pediatric endocrinologists Drs. Elizabeth Sellers and Brandy Wicklow, pediatric nephrologists Drs. Tom Blydt-Hansen and Allison Dart, epigeneticist Dr. Jim Davie, and scientists Drs. Kristi Wittmaier, Christine Doucette and Vern Dolinsky.
Sellars and Wicklow are also professors of pediatrics and child health at the U of M, while Davie is a professor of biochemistry and medical genetics and cell biology. Doucette is an assistant professor of physiology and Dolinsky is an assistant professor of pharmacology.
Some of the DREAM research includes:
- Using magnetic resonance imaging spectroscopy to look for fatty liver disease, which is a promising early warning sign of Type 2 diabetes.
- Studying why children with Type 2 diabetes are five to 10 times more likely to have kidney failure than children with Type 1 diabetes.
- Using an ophthalmology machine to study corneas for changes that can predict a loss of feeling in feet and hands.
The DREAM team is also hoping to secure funding to research changes in heart metabolism in children with Type 2 diabetes, says McGavock.
All of this research is aimed at mapping better treatment for children with Type 2 diabetes by identifying ways to predict how and when it will occur and how to prevent complications, he says. It is also hoped researchers will develop new prevention strategies for women with Type 2 diabetes while they are pregnant, much in the way that women now take folic acid supplements to prevent neural tube defects in their infants.
To achieve its goals, the DREAM team uses a bed-to-bench circle of science, in which children's health conditions are studied and replicated in animals in the laboratory. The lessons learned in the lab are then used to change the way the children are treated.
One of the key objectives of DREAM is to identify early warning signs of Type 2 diabetes. For example, animal studies suggest that fat in the heart, liver and pancreas is an early indicator that the organ is going to fail or is not working properly. This can lead to a loss of glucose tolerance and eventually lead to Type 2 diabetes. "We're using MRI spectroscopy to look at the chemical make-up of different organs of the body," says McGavock. "Our interest is in fat accumulation in places it shouldn't be."
DREAM researchers have decided to focus on the liver as the best spot to predict the risk for Type 2 diabetes. "If there is a fatty infiltration in the liver, it turns out to be a pretty robust biomarker of Type 2 diabetes in kids," says McGavock. "The MRI is a non-invasive study technique, something that's very important to use when working with children. We're also looking for a blood test, something that a family doctor could order, as another early risk test."
A second area of focus is research into the complications of Type 2 diabetes, in a study called I-Care, short for Improving Cardiovascular Outcomes. Here, Allison Dart made an important discovery: children with Type 2 diabetes have extraordinarily high rates of health complications, at a rate of five to ten times higher than children with Type 1 diabetes. The complications include endstage renal disease and cardiovascular events. "Allison started asking herself: 'Why do the kidneys fail so quickly in this cohort of youth? Are there any biological markers we could measure in a clinical setting that would allow us to pick up the high-risk kids?'" says McGavock.
To find those biological markers, Dart has begun measuring kidney function in children with Type 2 diabetes, looking for the moment when kidney damage begins showing up. She's also looking at other influences, such as physical activity levels, sleep, diet, stress and early childhood trauma. Her theory is that it is not only the child's physical body, but the environment they're growing up in that adds up to kidney failure. She suspects a socioeconomic influence.
"Sixty per cent of the kids are living at the bottom of the economic scale. Their families are dealing with economic pressures, and this is reflected in their diet, activity levels and more," says McGavock.
Both the environmental and physical sides of a child's life are measured at DREAM. Testing of the children occurs over 24 hours in the clinic and at home, allowing researchers to accurately measure blood pressure variations and urinary protein loss.
The clinical space has a non-invasive imaging suite where researchers can do ultrasounds of the heart, blood vessels, liver, and soon, the kidneys, to look at the structure and function of these organs. They also have a fitness testing room with a bike and treadmill, to test fitness and do exercise training. Many of the kids enrolled in the various studies are seen every three to four months, so it's important to have a clinic that is welcoming.
McGavock uses the fitness room to study the impact of rigorous physical activity in overweight kids who have Type 2 diabetes. In particular, he's looking at how exercise affects insulin sensitivity, and why some of the children go on to develop changes in the function of their heart, and others don't. Along with putting children through exercise programs, McGavock is hoping to secure a grant to do ultrasound imaging of the kids' hearts.
Like other research tracks at DREAM, studying the children in the clinic leads to questions to be answered by the scientists.
For example, McGavock's research with children will be duplicated in the lab. Here, scientist Vern Dolinsky will work on specially bred mice that have Type 2 diabetes, looking to see how quickly they develop heart trouble, and whether exercise has a positive effect on their heart. "The research team will try to understand how energy production problems arise and can be managed in these mice. Collectively, we'll make a small advancement in research, which will advance our knowledge in both directions," says McGavock. His research at DREAM goes beyond the confines of the clinic and laboratory walls. This fall, McGavock launched a lifestyle and exercise study, working with teens at R.B. Russell High School. He's hoping to enroll 20 students from this inner-city vocational school as peer mentors, and develop exercises and lifestyle programming that can be used in Manitoba's north for teens living in similar socio-economic circumstances.
"We look at what's been successful in the past at achieving weight loss and increasing physical activity in kids," he says.
The daily programming features 45 minutes of games, like basketball and soccer, that get the blood pumping. There's also a healthy snack and 45 minutes of education on healthy eating, goal-setting, self-esteem and environmental engineering - how to change your life to make healthy decisions and avoid temptations.
"Depending on what you're exposed to and your background, people think it's a simple message. But until you walk a mile in their shoes, you don't know how hard it is. Support is a key here," says McGavock.
In her work within the DREAM team, Elizabeth Sellers is also focusing on the complications associated with Type 2 diabetes, from kidney failure and vision problems through to heart disease and high lipids. Children with Type 2 diabetes will have one or more serious health complications by the time they are 30.
"There is data suggesting that complications for Type 2 diabetes are more aggressive in children than adults who get the disease later in life," says Sellers. "The onset of complications in these kids is also more aggressive than it is for kids with Type 1 diabetes."
One of those complications is neuropathy - a change in nerve structure that causes people with diabetes to lose feeling in their hands and feet. Sellers says that in the five years between the ages of 18 and 23, many who have Type 2 diabetes will develop neuropathy.
She's studying a way to detect early warning signs of nerve damage by looking deep into people's eyes. Her test uses corneal confocal microscopy. This looks for damage in nerves in the eye's cornea, as a predictor of nerve damage elsewhere in the body.
The microscopy machine, normally used by ophthalmologists and other eye specialists, is relatively portable, so Sellers can take it on the outreach visits the DER-CA team makes to northern Manitoba to look at the eyes of all children who have Type 2 diabetes.
"We've shown that the kids will tolerate the test, because it's noninvasive," says Sellers. "The next step is to show its accuracy and that using it is a way to monitor nerve damage so we can try to prevent progression of the neuropathy."
Sellers is also a member of the team that writes the clinical practice guidelines for pediatric diabetes care in Canada.
"At the moment, lifestyle management is the mainstay of treatment for Type 2 diabetes in youth. There haven't been that many studies of medication use in children, so I tend to be more aggressive in using insulin and lifestyle changes," says Sellers, adding that most of the children need shots of a mix of shortacting and longer-acting insulin twice a day. "Between the work we do treating the kids in the clinic and the research done at DREAM, we're helping fill in the gaps in our knowledge."
All the research underway in the area of pediatric Type 2 diabetes could not take place without the help of all the community health-care staff and community partners, including those in First Nations organizations.
As Dean explains, most of the youth in the various studies live in remote communities, and any treatment strategy has to be culturally sensitive. She says workers like Bertha Flett, who was the first clinical research nurse in the Next Generation project, are critical to future success. "Bertha knows everyone in the North, and if we can't find someone, we ask her for help," says Dean.
Flett worked with the Next Generation project until she retired in 2009, testing children in northern communities for Type 2 diabetes. Flett says that out of the 900-some children she tested in nursery to Grade 12 classes over the years, six had Type 2 diabetes. In comparison, the Canadian average is 1.5 in 100,000 children. In British Columbia, where the numbers are 2 in 100,000 kids, all the affected children are of Indo- Asian heritage, and children from Haiti. Saskatchewan is not even on the radar, because it has only recorded five cases in total. When you compare the Manitoba to the national numbers, finding six in 900 is like finding over 650 children out of 100,000.
In the course of her work for the Next Generation project, Flett worked with the schools, setting up tests, and then reassuring the children who tested positive. She spoke with their parents, and referred the children to the local health clinic for treatment, along with recruiting them for study at DER-CA.
"You have to hunt for the kids with Type 2 diabetes, because they don't feel sick when they first have it," says Flett, who was diagnosed with Type 2 diabetes herself when she was an adult. "And people - despite all the education we do and workshops we teach - don't listen to the message: that they should be taking care of themselves so they won't get diabetes."
Flett's work with the Next Generation project came with both a professional and a personal motivation.
Years earlier, her own daughter had been mistakenly diagnosed as having Type 1 diabetes. This came about before the medical community understood that children could develop Type 2 diabetes. As a result, the proper treatment wasn't put in place, and her daughter's Type 2 diabetes worsened rapidly.
"My daughter died at age 25," says Flett, who is now raising her granddaughter. "It's hard. It's hard to know that she's gone. It's hard that I have the same thing. But it gave me direction. I wanted to work with kids who have Type 2 so they can have hope."
Part of that hope might come from an idea generated by the Next Generation project to encourage new mothers to breastfeed their infants. Breastfeeding has been associated with a lower risk of Type 2 diabetes in children. This may require one-on-one support, coaching the mothers through the experience, along with talking about serving healthy food and increasing their daily amount of exercise.
Summer student Karla Muskego is another integral part of the community outreach being done by the Next Generation project. A fourth-year biochemistry student at the University of Manitoba who hails from northern Manitoba, Muskego's job this past summer was to encourage the families to come in for their check-ups. She says it took patience and persistence to do the job.
"There are about 130 kids in the cohort in Manitoba. My role is to try to get 80 per cent of those kids in for testing," says Muskego. "But it's challenging. Most of the people live up north and find it hard to come into Winnipeg. But I'm so thrilled when they do come in. It shows their commitment to keeping their children healthy."
Life in remote communities comes with a number of problems that need to be solved, before children and their parents can be healthy, says Lyna Hart, the acting Tribal Nursing Officer with the Southeast Resource Development Council.
Since the call to action in 1999, when representatives from tribal councils and independent First Nations communities in Manitoba came together to talk about treating Type 2 diabetes, they knew they would be fighting a disease that was affecting three generations at once. It's also a disease that needs more than a diabetes-only health care program to tackle, says Hart.
People living in remote communities in Manitoba are dealing with a lack of fresh food, clean drinking water and quality housing. Many are survivors of the residential school system, and have to cope with the trauma of those years, which can lead to family violence, substance abuse and suicide. That stress affects a person's health, including pregnant mothers who have Type 2 diabetes and their children.
"Food insecurity is a big issue," says Hart. "When you go into a store in the North, and the fruit and vegetables are beyond ripe, you don't buy them. We know that breast feeding is the first line of defense for mothers who are diabetic and who have babies. But those mothers can't meet their nutritional needs, so they can't breast feed."
Many communities in the North are under water boiling advisories. Bottled water is too expensive to fly in, so people drink pop instead. "People eat what's available, and what's available isn't nutritious, so it's no wonder obesity is a big problem," says Hart, who was diagnosed with Type 2 diabetes in midlife.
Hart says federal funding for diabetes programs in Manitoba's First Nations communities is limited, so she's effusive in her praise for work being done by Dr. Heather Dean and the team of researchers at DER-CA and DREAM. "They keep us in the loop. We're very happy to be guiding the questions they ask. We're hopeful they will lead the work to find an answer," she says. "I believe that all children need to be screened for Type 2 diabetes, both First Nations and non-First Nations. People worry that it will cost money, but it's better than waiting until those children grow up, and their health is worse by the time they find out they have it. We have to ensure the future of our children."
Maintaining contact with people living in far-flung communities is part of the role of the Maestro Project, an outreach effort on the part of DREAM to ensure children with diabetes make a successful jump from pediatric to adult care, no matter where they're living in the province.
Maestro - named so because Dean envisioned a conductor reminding the musicians in an orchestra of when it was time to play their part - forms a bridge of contact for patients leaving pediatric diabetes care at age 18 and who are struggling to learn to take care of themselves as adults.
The Maestro Project was established in 2002 to support youth with Type 1 diabetes who were transferring to adult care. As the numbers of children with Type 2 diabetes began growing, there soon was a need for a parallel program, which has been named Maestro 2.
"Young adults have a bad habit of not showing up for their medical appointments," says Catherine MacDonald, Transition Care Co-ordinator for Maestro. "They don't always make the best choices at 18, 19 and 20. And when they do end up re-engaging with healthcare services, there's often irreversible damage done to them, complications that often can't be reversed."
The numbers back up the decision to launch Maestro 2. Ten years after diagnosis, the survival rate for children with Type 2 diabetes is 91.4 per cent, compared to 99.5 per cent in children with Type 1, and 100 per cent in children without either disease. Renal survival is only 55 per cent after 20 years in youth and young adults with Type 2 diabetes.
Maestro is tracking 1,600 young adults between the ages of 18 and 25, including 387 with Type 2 diabetes. MacDonald first makes contact with patients when they are around 14 years old, to begin building a relationship that will help the young adults know who to turn to when they get into the somewhat bewildering adult side of diabetes treatment. She uses the phone, e-mail, Facebook and texts to keep in contact with the adults.
"We've had 82 people graduate from us at age 25," she says. "But during the time from 2002 to 2011, we've had 16 deaths, including five from complications of Type 2. Our goal is to reduce the dropout from follow-up care in pediatrics from 60 to 30 per cent, and to track 80 per cent of those moving on to adult care, using programs like the Diabetes Integration Project in rural and northern Manitoba."
Between the DREAM researchers and the clinic and educational efforts at DER-CA, Dean and her colleagues hope to get a handle on pediatric Type 2 diabetes in the next five years and be able to offer new treatments and preventions. It's an ambitious goal, but one that must be met in order to contain the surge in childhood Type 2 diabetes.
"I'm an optimistic person," says Dean. "We have a great team of researchers, clinicians, community leaders and families working on the problem."
As Charlotte and her siblings grow older, they will come to depend more and more on the work being done by these health-care and research teams. Charlotte is as full of life as any 14-year-old, and should be able to keep her condition under control. And she can count on her mother to keep a watchful eye on her compliance with her medication and diet.
"Diabetes put me through the gutter," says Mary Wood. "That's what's so important for the kids. The elders tell us that we'll run into trouble with our health if we don't look after our diabetes. So I tell my kids, look after your sugars, or you'll be like me in 20 or 30 years. That's why I'm talking to you about this, so that everyone will know."
Susie Strachan is a communications advisor with the Winnipeg Health Region.