UN Secretary General Antonio Guterres says it’s “absolutely essential” countries such as Canada repatriate Canadian women and children currently being held in Syrian prison camps.
Guterres made the remarks to chief political correspondent Rosemary Barton when asked if the Liberal government’s lack of diplomatic staff on the ground and fears over possible links with ISIS are sufficient reasons not to bring them home.
“We understand the concerns of security of countries, but we believe that countries also must have the capacity to deal with those problems of security,” he said in an exclusive interview airing Sunday on Rosemary Barton Live.
“And especially in relation to children and women, I believe it’s absolutely essential that they have an opportunity to to go back.”
Global Affairs Canada told CBC news that it is aware of “Canadian citizens being detained by Kurdish authorities in northeast Syria and is particularly concerned with cases of Canadian children in the region.” It would not say, however, how many Canadian children may be imprisoned in the country.
Speaking at the foreign affairs committee earlier this month, human rights lawyer Paul Champ told MPs there are 64,000 people being held at the Al-Hol and Al-Roj prison camps in Syria, 25 of them Canadian children.
CBC’s Margaret Evans, who visited the region this week, said Al-Roj camp is under the official supervision of the Kurdish-led Syrian Democratic Forces, (SDF), which are running what’s known as the Autonomous Administration of North and East Syria (AANES).
The camp manager told Evans that there are 784 families of ISIS militants in the camp, totalling 2,618 individuals including Syrians, Iraqis and women from a number of other countries, including about 30 Canadians, the majority of them young children.
Dying from dehydration
Global Affairs Canada said that because of the security situation on the ground, its ability to provide “any kind of consular assistance in Syria remains extremely limited.”
The department also told CBC News that consular officials are, however, working actively with Syrian Kurdish authorities to “seek information on Canadians in their custody.” The United States and Germany have, however, been able to provide consular assistance to citizens in the region.
Public Safety Canada says that it is aware of an estimated 190 Canadian extremist travellers that are currently abroad, half of which travelled to Turkey, Syria and Iraq.
On top of that, some 60 foreign fighters have returned to Canada, Public Safety Canada said.
Champ said that the UN has reported that many of the children in Syrian prison camps are dying from malnutrition, dehydration, diarrhea and hypoglycemia.
“Their daily lives could not be more desperate were it not also for the violence in these camps,” he said. “Exploitation and abuse is rife. People are killed by gunfire almost daily.”
Guterres told Barton that the UN has worked with several governments to repatriate citizens and will continue to do so.
“We have a very clear position on this issue. We believe that people should have the possibility to voluntarily go back to their countries of origin,” he said.
Doctors are calling for more supports for essential workers facing “life-or-death” inequities, saying it will do more to control coronavirus outbreaks than high-profile punishments of those who break the rules.
COVID-19 has exacerbated existing problems — not only among long-term residents bearing the brunt of deaths from the virus — but also for people struggling to get by despite working on the front lines on farms, in warehouses and grocery stores.
Now, these vulnerable workers can face additional challenges from authorities such as breaking Quebec’s curfew order or living in cramped, poorly ventilated quarters that make it easy for the coronavirus to spread.
Nav Persaud, a family physician in Toronto who holds the Canada Research Chair in health justice, said he’s “dispirited” by how little attention inequity receives.
“It’s always been a life-or-death issue, health inequities,” Persaud said. “People not being able to afford basic necessities like healthy food, medication, safe housing has always killed people and put people’s health in jeopardy.”
He said much of the coronavirus transmission happening now in the Greater Toronto Area is from people going to work or interacting in ways that won’t be stopped by charging those holding large parties, for instance.
“I think the people who benefit most from those punishments are the authorities, because they can exert their power and give off the impression that they’re being helpful when they’re not,” Persaud said. “It would be better if they were providing supports.”
In Toronto, Persaud said people who rely on public transit to get to work from priority neighbourhoods with a disproportionately higher number of COVID-19 cases may face long, crowded commutes on buses. That’s why the greater supports he’s seeking also includes extended public transit.
But providing more supports is harder for politicians from all levels to do than chastising individual rule breakers, he said.
“I’m in favour of there being rules and the rules do need to be enforced, but I think these are relatively unimportant incidents in the grand scheme of things.”
A recent opinion article by three physicians points to how Ontario’s modelling showed three times more daily confirmed cases among communities with the most essential workers compared with communities with the least. Researchers in California reported a similar observation that hasn’t yet been peer reviewed by outside experts.
Call for supports to control outbreaks faster
Martha Fulford, an associate professor of infectious diseases at McMaster University in Hamilton, Ont., would like to see an immediate “liveable support” such as paid sick leave as a fundamental for essential workers.
“It’s extremely easy to stay home and be in isolation for somebody like me. I have a big house, I have a big yard, I can click on Amazon and get my stuff delivered,” Fulford said. “But who’s delivering it? What choice does the person delivering to my house have?
“If we don’t provide the same sorts of supports for all the essential workers, this is never going to come under control.”
Doctors say if essential workers are now a key driver of transmission then the coronavirus won’t be contained unless they’re able to stay home when sick or potentially exposed without having to worry about putting food on the table.
Fulford also noted that the highest rates of transmission are among people living in crowded conditions or working in large warehouses.
“I’m not an economist, I’m just a physician, but I can’t help but think in the long term, it would be far more cost effective to invest money in the areas where we’re seeing the highest transmission, and support them, than shut down an entire economy.”
Facilitate work from home when possible
Persaud said punishments such as charges and fines for violating COVID-19 safety rules often hit individuals rather than institutions such as employers.
He sees the charges laid against Cargill for the country’s largest workplace outbreak in High River, Alta., as an exception and “a fairly extreme example.” The allegations haven’t been tested in court.
For other workplaces, Persaud suggested addressing larger, underlying issues contributing to outbreaks, such as office managers asking staff to come in to perform duties that could be done from the safety of home.
WATCH | Why Peel Region’s workplaces struggle with COVID-19 outbreaks:
Ontario’s Peel Region, just west of Toronto, has long been a hotspot for COVID-19, but the high number of warehouses and transportation facilities may be partly to blame. 2:15
Another recent high-profile case of charges being laid include a couple in Durham, Ont., east of Toronto, who are accused of obstructing contract-tracing efforts of public health officials investigating the introduction of the B117 variant of the coronavirus first identified in the U.K.
In contrast to charges, Fulford highlights a role model for countering conditions for outbreaks: hospitals.
“We have had hospital outbreaks and we’re not pointing fingers or getting angry because we understand, we do a root-cause analysis to figure out where we went wrong and we do better next time,” Fulford said.
Despite the best efforts of employers and workers, outbreaks can sometimes happen because of sheer bad luck.
Fulford said when an outbreak occurs in a workplace, bringing in infection prevention and control experts is a more productive approach than laying charges
“It’s a very unusual situation for me that we would be criminalizing public health interventions.”
In the context of COVID-19, Fulford gives the example of someone who decides to meet family members from outside their household at a park and gets charged for breaking pandemic public health rules.
In such a case, Fulford favours educating people and explaining why such behaviour is a problem to encourage them not to do it again — not naming and shaming. Otherwise, there could be unforeseen consequences for public health.
“Contact tracing is going to become a hundred times more difficult if the fear is that you’re going to be charged, your name is going to be in the newspaper.”
Jody Vance said her heart skipped a beat when she got an unexpected phone call from the long-term care facility where her elderly father lives.
She braced herself for bad news, but instead the voice on the other end told her something so many Canadians would love to hear: a dose of the Pfizer-BionTech COVID-19 vaccine was being set aside for her.
“It was kind of was a little bit surreal,” she said. “It felt like hope.”
Vance got the shot because staff at the long-term care facility in Delta, B.C., declared her an “essential” visitor for her 82-year-old father. Driving him to emergency cancer surgeries during the pandemic made her eligible for such status.
To Vance, the main benefit of being vaccinated is that her dad won’t need to be isolated from her for his own protection.
B.C. is one of the few provinces — Ontario and Nova Scotia are taking a similar approach — ushering essential visitors to the front of the vaccine line as a priority group. It’s up to the discretion of each facility to determine who is considered essential.
There is no cap in B.C. on the number of approved essential visitors, but only one will be allowed at a time with exceptions made for end-of-life care.
Those left to wait say they are also left to wonder if the delay could ultimately be too long.
A frustrating process
“I don’t know how long she’ll be with us,” said Niovi Patsicakis, speaking about her 98-year-old mother, who lives at Evergreen Long-Term Care in White Rock.
Patsicakis said her mom has been mostly confined to her room in the facility for nearly three months, and Patsicakis hasn’t been able to visit since before Christmas. She said she fears the lack of in-person mother-daughter visits has affected her mom’s health.
But unlike Vance, Patsicakis said she has not been deemed essential by her mom’s long-term care facility.
According to the B.C. Centre for Disease Control (BCCDC), essential visits include those for compassionate care reasons such as critical illness, hospice care, end of life and medical assistance in dying. They can also include visits by a person who assists with feeding, mobility and communication needs.
WATCH | British Columbians with loved ones in long-term care talk about their experiences trying to get vaccine priority:
As the vaccine rolls out in long-term care homes across the country, some provinces, including British Columbia, are also prioritizing essential caregivers for a shot to benefit residents and staff. But there’s some inconsistency about who qualifies as essential. 2:03
The B.C. Health Ministry has also said a clergy member can be designated as an essential visitor.
Health authority and facility staff, in collaboration with the long-term care resident, determine who gets essential visitor status, according to BCCDC in guidelines published on Jan. 7.
Patsicakis’ visits in the past have tended to be social in nature, but Patsicakis said her mother’s health seems to be deteriorating since their loss of contact.
“I can see a huge difference in how mom has gotten much worse,” said Patsicakis. “Her language skills have weakened as well as her mood. Sometimes, she’s confused or doesn’t want to get out of bed.”
Trying to get an essential designation has been difficult and frustrating, she said.
Patsicakis said essential visitors to Evergreen are evaluated by a group that includes facility faculty and a representative from the local health authority, Fraser Health. She said she wrote Evergreen administration three times to plead her case and filed a complaint with an advocate at the health authority’s patient quality care office.
She said she requested Evergreen’s decision be sent to her in writing in November and never received it. As of Jan. 20, she said hadn’t heard anything from Fraser Health either.
“I know so many people are devastated,” she said, adding she is part of a social media group of others like herself who are supporting one another as best they can.
The National Institute on Ageing said families in British Columbia are enduring the most restrictive long-term care home visitation policies in the country.
B.C. Seniors Advocate Isobel Mackenzie said the lack of an association that represents residents and their families at the 300 care homes in B.C. means they don’t have a voice in policy discussions between the government and care-home operators.
She said care home operators seem to be arbitrarily deciding who qualifies as an essential or designated visitor.
Dr. Bonnie Henry, B.C.’s provincial health officer, provided the latest numbers of people who had qualified as essential visitors during a press event on Jan. 18.
Henry said about 8,000 people have met the criteria and will receive a vaccination during the province’s first phase of a four-phase immunization program, which is underway. There are approximately 30,000 people living in long-term care facilities
“The default, we believe, should be that every person, every resident who has a person who can care for them, should have a designated essential visitor, but that has been a challenge to operationalize,” said Henry.
Applications for essential status are available on the provincial health ministry’s website. There is an appeal process for people who do not like the initial decision.
One Abbotsford long-term care home operator said the more people who are designated essential, the better.
“Because of staffing levels, this gives us that extra layer of assistance — they are doing things like supporting their loved one with feeding or mobility,” said Dan Levitt, executive director of Tabor Village. “So they need that vaccine, and that’ll make a big difference for all of us.”
During a Friday press briefing, B.C. Health Minister Adrian Dix addressed the frustration felt by people disappointed to hear they are not considered essential.
“Everyone should feel that their participation, their social life, their visiting of their loved ones is essential,” he said.
Dix said vaccinating residents and staff in long-term care and assisted living facilities now could lead to eased restrictions around social visits by March, when all residents and staff are expected to have received both doses of their vaccines.
“It’s going to allow a lot of things to happen, including more visits from family members and loved ones and friends,” he said.
As Canadians await the rollout of the first round of COVID-19 vaccines, experts say Canada needs to double down on protecting essential workers most at risk of exposure to the coronavirus in the coming months.
Canada will only have a limited supply of vaccines to start, with just 3 million expected to be vaccinated in the first few months of 2021, but the news of COVID-19 vaccines on the horizon could not come at a more critical time.
Over 400,000 Canadians have tested positive for the coronavirus since the pandemic began and the situation in our hardest-hit provinces shows no signs of slowing down.
The percentage of COVID-19 tests across the country that have come back positive during the past week has skyrocketed to 7.4 per cent — up from 1.4 per cent in mid-September and 4.7 per cent in early November. A rising positivity rate can signal that cases are being missed and more people could unwittingly be spreading the virus.
“There’s a light at the end of the tunnel, but we still have to get through the tunnel to get there,” said Dr. Sumon Chakrabarti, an infectious disease specialist at Trillium Health Partners in Mississauga, Ont.
“You also don’t want to be in a situation where you have a raging fire that’s going on and when you’re trying to roll out a vaccine, you’re doing it in a setting where the hospital is overwhelmed and health-care workers are getting sick.”
Alberta positivity rate tops 10 per cent
Of all the COVID hotspots, Alberta has the biggest fire to put out at the moment, and this week asked the federal government and the Red Cross to supply field hospitals to help offset the strain COVID-19 is having on the health-care system.
There, the percentage of COVID-19 tests coming back positive hit an astonishing 10.5 per centon Friday.
COVID-19 cases in Alberta are growing at such an explosive rate they’ve even outpaced Ontario, a province with 10 million more people, for the first time in the pandemic — with cases in Edmonton alone totalling more than those in Toronto and Peel Region combined.
“If you think this is a hoax, talk to my friend in the ICU, fighting for his life,” Alberta Premier Jason Kenney said during a Facebook livestream Thursday.
“If you’re thinking of going to an anti-mask rally this weekend, how about instead send me an email, call me all the names you want, send me a letter, organize an online rally.”
Yet while much of the focus on public health messaging throughout the pandemic has been focused on individual actions, experts say Canada isn’t doing enough to protect those most in need of support in the coming months.
Ontario, Quebec see surge in workplace outbreaks
While elderly Canadians are most at risk for severe outcomes from COVID-19, totalling close to 90 per cent of all deaths, essential workers on the front lines are facing a worsening situation.
For the first time in the pandemic, active outbreaks in workplaces in Canada’s biggest provinces have outpaced those in long-term care facilities — accounting for 30 per cent of the outbreaks in Ontario and 40 per cent in Quebec, as first reported by The Globe and Mail.
While limited information is available on exactly where the spread of COVID-19 is occurring, Ontario’s ministry of health said in a statement to CBC News the hardest-hit industries include construction, manufacturing, mining, warehousing and transportation.
WATCH | Essential workers talk about being on the front lines of the COVID-19 pandemic
Essential workers — from grocery store employees to truck drivers — talk about their experiences on the front lines of the COVID-19 pandemic share how it has affected them and why they do it. 11:43
Because of the disproportionate risk of exposure they face, the union for workers in food retail, manufacturing, long-term care, home care and security said Friday that frontline workers should also be among the first recipients of COVID-19 vaccines.
“Workplaces are a big deal,” said Dr. Zain Chagla, an infectious diseases physician at St. Joseph’s Healthcare Hamilton and an associate professor at McMaster University.
“There are people that need to go to work, unfortunately, for us to support society, and again we have to be willing and able to give them at least some measures of safety in their workplace.”
Paid sick leave key to stopping spread of COVID-19
Chakrabarti says one area that could help address rising transmission rates in workplaces is more paid sick leave for those who are unable to miss work due to COVID-19.
Unlike policing people’s contacts in their own homes, it’s a problem policy could tackle, he said.
“Workplaces are things that are really important because you can only do so much to keep things safe.”
If people are going to decide between putting food on their table … or going into isolation … they’re going to show up to work sick.– Dr. Zain Chagla
Chakrabarti says mask wearing and physical distancing aren’t always possible in certain situations in workplaces, especially those that involve workers in close quarters indoors — as evidenced by outbreaks in meatpacking plants, warehouses, and mines.
“Many people are financially unstable and they’re scared because if they do have to go off work, they’ll end up losing income,” he said. Undocumented workers may also be hesitant to speak up about symptoms for fear of being deported.
“So you have a lot of these kinds of factors that I think are barriers for people getting tested.”
Chagla says more targeted education, oversight and internal audits to control COVID-19 transmission are needed in high-risk workplaces, in order to ensure compliance and accountability.
“There’s certainly tons of essential workplaces that will continue to have issues unless people actually intervene and do this type of stuff,” he said.
Last month, the federal government created Canada Recovery Sickness Benefit to give up to $ 1,000 of support to workers with COVID-19 over two weeks, but Chagla said more could be done.
“You have to incentivize people to get tested,” Chagla said. “If people are going to decide between putting food on their table and paying their rent, going to work or going into isolation … they’re going to show up to work sick.”
Isolating, outreach better than ‘finger wagging’
Chakrabarti says another way to protect essential workers is through the creation of more dedicated isolation facilities for those recovering from COVID-19.
“One big place that amplification is happening is in large families,” he said. “So if you have a place for people to have their meals covered and they can isolate away from their family, that’s going to really help to reduce amplification of the cases that we’re seeing in workplaces.”
Chakrabarti says the “condescension and finger wagging” in public health messaging across the country against individual actions isn’t always effective — especially nine months into the pandemic.
“Community outreach often helps,” said Chakrabati, who is also a member of a recently formed South Asian task force to connect with and inform people in Peel Region.
“I think that a lot of the focus right now is on people. ‘Hey, you stay home, stay home, stop partying,’ that kind of stuff. Whereas we don’t hear a lot of what’s happening in these workplaces.”
“This is going to be a problem throughout the entire pandemic,” said Chagla. “Because they have to stay open.”
Alberta Premier Jason Kenney wants the federal government to help clear the way for NHL players to come to Edmonton.
His counterpart in British Columbia, John Horgan, says his province isn’t interested in making any concessions.
The two premiers had markedly different responses to the NHL’s plan to resume the 2019-20 season, in which teams would play at two hub cities, one for each conference.
Edmonton and Vancouver, as well as Toronto, are three of the 10 cities still in the running to be host cities, should the plan come to fruition. But the NHL said Tuesday the Canadian government’s mandatory 14-day quarantine for anyone entering the country would make markets north of the 49th parallel a non-starter during the COVID-19 pandemic.
Kenney responded by sending a letter to Prime Minister Justin Trudeau in which he encouraged the federal government to deem professional athletes and team staff as essential workers — similar to what U.S. officials announced late last week.
“Such an exemption from the Canadian government would be necessary for (Edmonton’s) bid,” Kenney wrote. “The Government of Alberta believes there are effective strategies in place to mitigate any risk to our province if such an exemption was granted.”
Alberta: Cohort quarantine
Alberta’s chief medical officer, Dr. Deena Hinshaw, said the province was working on alternatives that would still observe the 14-day quarantine.
“What we’ve put together is an opportunity for a cohort quarantine, which would mean that a group that came in from international travel, such as an individual team, would have to stay together in that quarantine period and would not be able to interact with others outside of that cohort group,” she said. “They would be effectively sealed off from the rest of the community.”
“I want to be clear we’re not talking about waiving the quarantine requirements,” Hinshaw added.
Depending on how long training camps were should the season resume, teams could feasibly conduct their camps under cohort quarantine before facing off against other teams.
B.C.: ‘Rules in place’
Horgan has been vocal about Vancouver as a hub in the past, but struck a more cautious tone than his Alberta counterpart Wednesday.
Horgan’s comments have been in line with Dr. Bonnie Henry, the province’s health officer, who said the government won’t be making any concessions in a jurisdiction that has done well to minimize infections.
“We have rules in place today that we worked very hard to establish,” Horgan said.
“Because the NHL made an announcement that involved Vancouver, we’re not going to go rushing to change that. Two weeks from now, four weeks from now, it could be a completely different situation provided we continue to see the progress that we’ve seen here in British Columbia.
“I don’t want to rule out the NHL coming here. They haven’t presented a plan to us … When I talked to commissioner (Gary) Bettman, I said Dr. Henry was enthusiastic about looking at a plan and we haven’t seen one yet.”
“Today there’s a 14-day, self-isolation period in place and I expect that will be there for the foreseeable future.”
As the federal government announced today a multibillion-dollar deal with the provinces and territories to top up payments for low-wage essential workers, Prime Minister Justin Trudeau said that Canada needs to reflect on how it treats frontline and marginalized workers.
“I think one of the things that we’re seeing through this pandemic is that there are people who are tremendously economically vulnerable, and vulnerable in other ways in our society, who are extremely important to the functioning of our society,” Trudeau said during this morning’s daily briefing outside of Rideau Cottage.
“We know, however, that once we get through this, in the months and years to come, we’re also going to have to have reflections about how we manage and how we maintain our long-term care facilities, how we support essential workers who are very low paid, how we move forward as a society to make sure that our vulnerable are properly taken care of and properly rewarded for the important work they do.”
Last month, after talks with the premiers, the federal government announced that a plan was in the works to boost the salaries of essential workers who make less than $ 2,500 a month — including those working in long-term care facilities for the elderly, front-line workers in hospitals and people working in the food industry.
Today, Ottawa announced it has reached a $ 4 billion agreement with all the provinces and territories and is finalizing the details. The federal government will kick in $ 3 billion while the provinces will contribute the rest.
A spokesperson for the Prime Minister’s Office said the $ 2,500 rule has been dropped, to better reflect the wide range of wages paid to essential workers.
WATCH | Time to reflect on how essential workers are supported: Trudeau
Prime Minister Justin Trudeau says Canada needs to reflect on how long-term care homes are maintained and how the economy compensates essential workers. 0:59
The prime minister said all the provinces and territories have confirmed, or are in the process of confirming, plans to cost-share wage top-ups — but decisions about who qualifies will rest with the provinces and territories.
“It will be up to each province and territory to determine who exactly qualifies for this wage increase, but the bottom line is this — if you are risking your health to keep this country moving and you’re still making minimum wage, you deserve a raise,” Trudeau said.
Some provinces already have moved ahead.
For example, the Saskatchewan government recently announced that employees making less than $ 2,500 a month while working with vulnerable people are eligible for a wage top-up of $ 400 per month for 16 weeks. That includes people working at long-term care homes, daycares and shelters.
Ontario has announced a $ 4-per-hour increase for front-line workers at long-term care homes, retirement homes, emergency shelters, supportive housing, group homes, correctional institutions and youth justice facilities, as well as for those providing home and community care and some hospital staff.
WATCH | $ 4B deal between feds, provinces to top up essential workers’ pay
Prime Minister Justin Trudeau announced a $ 4-billion deal to boost pay for low-wage essential workers. 2:22
Quebec moved to top up essential workers’ pay even before Trudeau’s initial offer, announcing a $ 4-per-hour pay hike for workers in private long-term care homes, as well as a $ 24.28-per-hour salary to attract new workers to fill in as attendants at the facilities.
The crisis emerging in Canada’s long-term care facilities, where residents have accounted for a disproportionate number of Canada’s pandemic deaths so far, has shone a spotlight on health and personal care workers’ typically lower salaries. They often work in multiple homes, which can spread the virus.
With some facilities struggling to keep a full staff, both Ontario and Quebec, which lead in coronavirus cases, have requested help from the military.
When people who couldn’t afford essential medications to lower blood pressure or control diabetes received the treatments free, their health improved, according to a randomized trial that could inform Canada’s pharmacare discussion.
Medicines are not universally publicly funded in Canada the way hospitalization and physician care are.
Dr. Nav Persaud of St. Michael’s Hospital in Toronto and his co-authors followed 395 people in Toronto and the Ontario communities of Blind River and Manitoulin Island assigned to receive free medications and 391 others to usual care for a year.
“We partly did this study because we were so concerned about what was happening to our patients here who couldn’t afford medications,” Persaud said. “We hope that by the time this study ends there’ll be a public policy change that will mean everyone in Canada who needs access to medications will have it.”
In Monday’s issue of the journal JAMA Internal Medicine, Persaud and his team reported giving medications free resulted in 11.6 per cent better adherence to treatment.
The researchers monitored patients taking medications for high blood pressure and blood glucose in diabetes, as well as antiretrovirals for HIV, antipsychotics, antibiotics and analgesics.
More people who received drugs free took the essential medications as prescribed (151 of 395 or 38.2 per cent) compared with those in the group with usual access to medicine (104 of 391 or 26.6 per cent).
Those who had their antihypertensive medications covered had reduced systolic blood pressure.
Diabetes control also showed clinical improvements in reducing complications although the differences weren’t statistically significant, Persaud said.
Free statins to improve low-density lipoprotein cholesterol levels were not affected.
Matthew Herder, director of the Health Law Institute at Dalhousie University in Halifax, studies health care policy. He wasn’t involved in the new study.
Herder said about one in four Canadian households say they have trouble accessing medicines they need, and this trial shows the importance of easing that financial barrier and adding pharmacare to the health-care system.
“This study provides clear evidence that adherence improves for those who don’t have to pay for their own medicines,” Herder said.
Beulah Jarvis of Toronto was enrolled in the study after she had trouble affording her $ 180 asthma inhaler.
“That was the albatross around my neck for the longest time because not having this made it very hard to breathe at night and sleeping was horrible,” Jarvis, 51, recalled.
The self-employed woman said she’d skip doses, stretching the monthly inhaler to last two months.
“It was really stressful and there were a lot of things that I couldn’t buy foodwise,” Jarvis said.
When she took her medications regularly, her health improved. Jarvis said she’s also now better able to afford what she needs.
The research was supported by the Canadian Institutes of Health Research, the Ontario SPOR Support Unit that is supported by the Canadian Institutes of Health Research and the Ontario government, the Canada Research Chairs program, and the St. Michael’s Hospital Foundation.
The development of caches and caching is one of the most significant events in the history of computing. Virtually every modern CPU core from ultra-low power chips like the ARM Cortex-A5 to the highest-end Intel Core i7 use caches. Even higher-end microcontrollers often have small caches or offer them as options — the performance benefits are too large to ignore, even in ultra low-power designs.
Caching was invented to solve a significant problem. In the early decades of computing, main memory was extremely slow and incredibly expensive — but CPUs weren’t particularly fast, either. Starting in the 1980s, the gap began to widen quickly. Microprocessor clock speeds took off, but memory access times improved far less dramatically. As this gap grew, it became increasingly clear that a new type of fast memory was needed to bridge the gap.
While it only runs up to 2000, the growing discrepancies of the 1980s led to the development of the first CPU caches
How caching works
CPU caches are small pools of memory that store information the CPU is most likely to need next. Which information is loaded into cache depends on sophisticated algorithms and certain assumptions about programming code. The goal of the cache system is to ensure that the CPU has the next bit of data it will need already loaded into cache by the time it goes looking for it (also called a cache hit).
A cache miss, on the other hand, means the CPU has to go scampering off to find the data elsewhere. This is where the L2 cache comes into play — while it’s slower, it’s also much larger. Some processors use an inclusive cache design (meaning data stored in the L1 cache is also duplicated in the L2 cache) while others are exclusive (meaning the two caches never share data). If data can’t be found in the L2 cache, the CPU continues down the chain to L3 (typically still on-die), then L4 (if it exists) and main memory (DRAM).
This chart shows the relationship between an L1 cache with a constant hit rate, but a larger L2 cache. Note that the total hit rate goes up sharply as the size of the L2 increases. A larger, slower, cheaper L2 can provide all the benefits of a large L1 — but without the die size and power consumption penalty. Most modern L1 cache rates have hit rates far above the theoretical 50 percent shown here — Intel and AMD both typically field cache hit rates of 95 percent or higher.
The next important topic is the set-associativity. Every CPU contains a specific type of RAM called tag RAM. The tag RAM is a record of all the memory locations that can map to any given block of cache. If a cache is fully associative, it means that any block of RAM data can be stored in any block of cache. The advantage of such a system is that the hit rate is high, but the search time is extremely long — the CPU has to look through its entire cache to find out if the data is present before searching main memory.
At the opposite end of the spectrum we have direct-mapped caches. A direct-mapped cache is a cache where each cache block can contain one and only one block of main memory. This type of cache can be searched extremely quickly, but since it maps 1:1 to memory locations, it has a low hit rate. In between these two extremes are n-way associative caches. A 2-way associative cache (Piledriver’s L1 is 2-way) means that each main memory block can map to one of two cache blocks. An eight-way associative cache means that each block of main memory could be in one of eight cache blocks.
The next two slides show how hit rate improves with set associativity. Keep in mind that things like hit rate are highly particular — different applications will have different hit rates.
Why CPU caches keep getting larger
So why add continually larger caches in the first place? Because each additional memory pool pushes back the need to access main memory and can improve performance in specific cases.
This chart from Anandtech’s Haswell review is useful because it actually illustrates the performance impact of adding a huge (128MB) L4 cache as well as the conventional L1/L2/L3 structures. Each stair step represents a new level of cache. The red line is the chip with an L4 — note that for large file sizes, it’s still almost twice as fast as the other two Intel chips.
It might seem logical, then, to devote huge amounts of on-die resources to cache — but it turns out there’s a diminishing marginal return to doing so. Larger caches are both slower and more expensive. At six transistors per bit of SRAM (6T), cache is also expensive (in terms of die size, and therefore dollar cost). Past a certain point, it makes more sense to spend the chip’s power budget and transistor count on more execution units, better branch prediction, or additional cores. At the top of the story you can see an image of the Pentium M (Centrino/Dothan) chip; the entire left side of the die is dedicated to a massive L2 cache.
How cache design impacts performance
The performance impact of adding a CPU cache is directly related to its efficiency or hit rate; repeated cache misses can have a catastrophic impact on CPU performance. The following example is vastly simplified but should serve to illustrate the point.
Imagine that a CPU has to load data from the L1 cache 100 times in a row. The L1 cache has a 1ns access latency and a 100% hit rate. It therefore takes our CPU 100 nanoseconds to perform this operation.
Haswell-E die shot (click to zoom in). The repetitive structures in the middle of the chip are 20MB of shared L3 cache.
Now, assume the cache has a 99 percent hit rate, but the data the CPU actually needs for its 100th access is sitting in L2, with a 10-cycle (10ns) access latency. That means it takes the CPU 99 nanoseconds to perform the first 99 reads and 10 nanoseconds to perform the 100th. A 1 percent reduction in hit rate has just slowed the CPU down by 10 percent.
In the real world, an L1 cache typically has a hit rate between 95 and 97 percent, but the performance impact of those two values in our simple example isn’t 2 percent — it’s 14 percent. Keep in mind, we’re assuming the missed data is always sitting in the L2 cache. If the data has been evicted from the cache and is sitting in main memory, with an access latency of 80-120ns, the performance difference between a 95 and 97 percent hit rate could nearly double the total time needed to execute the code.
Back when AMD’s Bulldozer family was compared with Intel’s processors, the topic of cache design and performance impact came up a great deal. It’s not clear how much of Bulldozer’s lackluster performance could be blamed on its relatively slow cache subsystem — in addition to having relatively high latencies, the Bulldozer family also suffered from a high amount of cache contention. Each Bulldozer/Piledriver/Steamroller module shared its L1 instruction cache, as shown below:
A cache is contended when two different threads are writing and overwriting data in the same memory space. It hurts performance of both threads — each core is forced to spend time writing its own preferred data into the L1, only for the other core promptly overwrite that information. AMD’S OLDER Steamroller still gets whacked by this problem, even though AMD increased the L1 code cache to 96KB and made it three-way associative instead of two. Later Ryzen CPUs do not share cache in this fashion and do not suffer from this problem.
This graph shows how the hit rate of the Opteron 6276 (an original Bulldozer processor) dropped off when both cores were active, in at least some tests. Clearly, however, cache contention isn’t the only problem — the 6276 historically struggled to outperform the 6174 even when both processors had equal hit rates.
Cache structure and design are still being fine-tuned as researchers look for ways to squeeze higher performance out of smaller caches. So far, manufacturers like Intel and AMD haven’t dramatically pushed for larger caches or taken designs all the way out to an L4 yet. There are some Intel CPUs with onboard EDRAM that have what amounts to an L4 cache, but this approach is unusual (that’s why we used the Haswell example above, even though that CPU is older at this point. Presumably, the benefits of an L4 cache do not yet outweigh the costs.
Regardless, cache design, power consumption, and performance will be critical to the performance of future processors, and substantive improvements to current designs could boost the status of whichever company can implement them.
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