Ep. 17: Canada's Pandemic Endgame and the U.S. Border
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What’s Canada’s objective for COVID-19 management? To eradicate the virus altogether? To contain it until we have a vaccine? And how does that objective affect our U.S. border strategy? Irfan Dhalla is a physician and a vice-president at Unity Health Toronto who is challenging policy makers to think about such issues. In this episode, he and host Shaun Francis engage in a fulsome debate about the future. For complete show notes visit eatmovethinkpodcast.com.
Follow Irfan Dhalla on Twitter @irfandhalla.
Here’s the thought-provoking article Irfan published in the Globe and Mail.
EPISODE 17: CANADA’S PANDEMIC ENDGAME AND THE U.S. BORDER FULL WEB TRANSCRIPT
Christopher Shulgan: Like a lot of the physicians we've had on Eat Move Think to discuss the pandemic, Irfan Dhalla is more than just a doctor—there's his two masters degrees, one in healthcare management from Harvard, and another in health policy from the London School of Economics. He's also a vice president at Unity Health, Toronto, the Catholic hospital network that includes St. Mike's and St. Joe's. But what convinced us that we had to have Dr. Dhalla on the show was an essay that he wrote for the Globe and Mail. He challenged policymakers to think about the end game—the pandemic management objective. Are we trying to contain it or eradicate COVID-19 altogether? The complicating factor here is the US border. It's tough to eradicate a virus when you share the world's longest undefended border with the country having one of the world's largest outbreaks.
[00:01:03.05]
Christopher Shulgan: All of which sets the stage for Irfan's fascinating discussion with host Shaun Francis. I'm Christopher Shulgan, the executive producer of Eat Move Think, and before we get to the show, I want to say a few words about Medcan's Safe at Work System, which is helping some of Canada's largest companies transition to the next normal. Are you a Canadian employer seeking guidance on how to navigate the pandemic? Then let Medcan tell you about our evidence-based Safe at Work System. To learn more, email corporatesales@medcan.com or consult the webinars that Medcan has been staging for employers every Tuesday at 12:30 p.m., which we archive on the Medcan YouTube channel located at youtube.com/medcanlivewell. Now for Sean's conversation with Dr. Irfan Dhalla.
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Shaun Francis: Welcome to my listeners for our podcast Eat Move Think. I want to welcome Dr. Irfan Dhalla, a physician at the Unity Health System, and the vice president in that system here in Toronto, that includes St. Michael's Hospital. So Irfan, thank you for joining us. You've been a prolific commentator on the current pandemic, and specifically public policy that we might want to be considering here in Canada. So welcome.
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Irfan Dhalla: Thank you very much for having me.
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Shaun Francis: Why don't we back up a bit and just talk about what your pandemic experience has been like? When did it get on your radar, and how has that evolved?
[00:02:39.26]
Irfan Dhalla: You know, it was actually on the hospital's radar definitely in January, maybe even in very late December. Some of your listeners may be aware of Kamran Khan and his company Blue Dot. They were actually the first in the world to really draw people's attention to COVID-19 before it was called COVID-19, back when there was this outbreak in Wuhan. There was even a little bit of a segment on 60 Minutes about Kamran and his company, Kamran is an infectious disease physician at Unity Health Toronto, so he did let folks know I think in late December. He beat the WHO I think by five days. So it was on our radar.
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Shaun Francis: And anything about the disease that has surprised you in clinical practice?
[00:03:29.18]
Irfan Dhalla: Well, it's a brand new disease, so in one sense, everything has been surprising. You know, it's quite clearly a more serious illness than influenza. It's also quite clearly a less serious illness on an individual level than SARS was. But as we start to see more and more patients with COVID-19, we also start to see that there are unusual features of the illness. Probably in some ways maybe the most unusual feature is this multi-system, post-infectious inflammatory syndrome that is occurring in children who are infected with the virus. You know, I haven't seen myself any child who's developed this illness, but I think we now have a few dozen children in Canada who have developed this illness. That's been a very surprising feature of the illness.
[00:04:18.29]
Shaun Francis: And what about from a public health perspective? It hasn't—you said it yourself, it hasn't reached peak capacity in our ICUs like we anticipated. That probably is surprising, because we thought it would be much worse from that perspective.
[00:04:37.29]
Irfan Dhalla: Yeah, you know, I think that the school closures, and basically the shutdown of the economy and the restrictions on social gatherings and the advice to physical distancing all worked. People did what they were asked to do, and together we have been able to make things dramatically better than they would have been otherwise, right? So, you know, even if you look at Ontario compared to the United States, the mortality rates here are much lower overall. You know, the initial goal I think was to prevent our intensive care units in our hospitals from being overloaded, and we definitely succeeded in achieving that goal. I think what's been a little bit less clear is what is the next goal, right? Is the goal to just stay like that? So we achieved the goal, now is that the only goal to prevent the intensive care units from being overloaded? What is the end goal? I would say the goal is to really contain this disease successfully so that we can all get on with our lives as much as we can in the new normal, so people can go back to work, so people can go back to school, so that people can have other health care services that they need. People can have their joints replaced if they're waiting for a joint replacement, people can go to the dentist if they need to have their teeth attended to. All of those sorts of things that we can't do right now, and we're not going to be able to do those things very effectively if we still have several hundred new cases of COVID-19 every day in Ontario.
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Shaun Francis: So, from that vantage or from that perspective, how do you start to get back to that level of normal that you described, if, in fact, we're still seeing new cases every day?
[00:06:32.27]
Irfan Dhalla: Yeah. So I mean, I think there are things that individuals can do, you know, your listeners can do, and then there are things that people working in the healthcare system and people working in government need to do. What we in the healthcare system need to do is to make sure that we are ramping up the capacity to do the kinds of things that we need to do so that we can contain this disease. You know, basically, the focused public health intervention. So one way to look at it is the blunt public health intervention was to do the whole lockdown, right? Close schools, close workplaces, basically tell everybody to stay home—a very blunt instrument. We need to move away from the blunt instrument to focused instruments. And the focused instruments, you're doing things like ramping up testing capacity so that everybody who has any symptoms at all can be tested. Another focused intervention that we need to double down on is contact tracing. So, you know, if I turn out to have COVID-19, basically the moment that it becomes clear that I have COVID-19, or even before my test result is back, if the probability of me having COVID-19 is high, well, everybody I've come in contact with needs to be told that they are now exposed, and they need to quarantine themselves for 10 to 14 days—14 days in Canada is the current guidance—and get tested if they develop any symptoms.
[00:07:56.24]
Irfan Dhalla: And then, you know, it's not so easy for everybody to actually go into quarantine. The city of Toronto released some maps to show what neighbourhoods have been hardest hit by COVID-19, and it's pretty clear that the neighbourhoods that have been hardest hit are those where dwellings tend to be smaller, where lots of people are living in one bedroom or two bedroom apartments. And, you know, if you have a family of four or six living in a one-bedroom apartment, it's going to be pretty hard to isolate the individual who's infected with COVID-19 from others living in that apartment. You know, other countries have been much more forward-thinking in my view about offering hotel rooms to families like that so that we can bring down household transmission of COVID-19.
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Shaun Francis: So play this out. This virus, it's going to be something that will disappear? Or is this something that's going to be with us for years?
[00:08:56.11]
Irfan Dhalla: You know, I don't think anybody thinks this virus is just going to magically go away. No, I don't think that's going to happen. In all likelihood, it probably will be with us for years. Nobody knows when we will have a vaccine or when we will have a treatment that is very, very effective against this virus. You know. I'm not a virologist or an expert in vaccine development or anything like that, but the experts say that the earliest we can sort of hope for a vaccine is probably 12 to 18 months from now. There will also be issues related to vaccine production. You know, scaling up the production of a vaccine that will hopefully be available to many billions of people is going to take some time, and so I think we should all be prepared to live with this virus for a few years.
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Shaun Francis: And so does that mean the masking and social distancing as you described it for years, potentially?
[00:10:02.08]
Irfan Dhalla: Well, that's a really good question. So, you know, part of it depends on how successful we are at containing this virus. So if you go back maybe 12 weeks, one of the countries that seemed to be hardest hit at that time was South Korea, right? Well, South Korea has an extraordinarily effective public health system, and they have learned a lot from SARS and from MERS, the other coronavirus that is quite serious. And so they were really ready, and they implemented massive testing very quickly, and supported isolation. You know, they're a bit more authoritarian about it than we would probably have comfort with here in Canada, but they rode the curve, and then basically successfully contained the disease.
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Irfan Dhalla: And if you look at South Korea now versus Canada now, adjusting for population size, I think we have 25 times as many deaths from COVID-19, as they do in South Korea. And because they were able to successfully contain the disease, they were also able to reopen. So they've reopened schools, they've reopened most workplaces. They did however probably go one step too far: they even reopened nightclubs, and now they're dealing with another outbreak related to reopening nightclubs in Seoul. So, you know, when you ask, "Well, what does the future look like?" It's hard to imagine a time when we will really get together in crowds of hundreds—or even dozens—but it's hard to know how the future will unfold. I said at the beginning that there are still a lot of things we don't know about the virus, and how this would be one of those things. It's almost impossible to imagine that nightclubs will be open in the fall, or that large gatherings will be happening in churches or synagogues or mosques or other prayer halls in the fall, are hard for me to see how that will happen safely, at least in Ontario, where we don't have this virus contained yet.
[00:12:11.25]
Shaun Francis: And do you look at an approach of risk stratification, where for those people where it's not much different than flu, for example, for the young and the healthy, do they get back to more of a normal than, say, folks who might be immunocompromised?
[00:12:30.21]
Irfan Dhalla: Yeah, that's a really good question. I'm not sure there is a group that this is really not much more than the flu. And then the other problem with taking that approach is that it's impossible to keep the disease contained among young, healthy people. So you may recall, that was the strategy in the UK at the outset. Their government decided that they would basically encourage people who are 70 or older, I think, to isolate, and that otherwise they would just sort of let society go on. And if you sort of fast forward two months to where we are now, they now have the highest mortality rate from COVID-19 in the world. It's higher even than the United States. People who are younger, if they get infected with COVID-19, even though they may not become critically ill or die themselves, they will transmit the disease to others. And you can't just wall off older people from the rest of society, people who are immunocompromised from the rest of society. You know, everybody needs to go grocery shopping, everybody needs to get healthcare. So I don't think that, as we've learned more and more about this disease, I think it's become clear that that kind of an approach won't work.
[00:13:48.25]
Shaun Francis: When I look at the CDC data, I know what they're modelling in terms of survival, and they say if you get the flu, you have a 99.9 percent chance of surviving. And for COVID-19, you have a 99.6 percent to 99.7 percent chance of surviving. So when you think of it in those terms, it does seem alarmist when you think we're talking tenths of a percentile.
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Irfan Dhalla: Yeah.
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Shaun Francis: That we might be living like this for years, when we don't even think about the flu, right? That 0.1 percent for the flu isn't even on the radar, right? Never covered, people don't get their flu shots. I mean, I know you see it at the hospital.
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Irfan Dhalla: I get my flu shot, and I hope you get your flu shot, and I hope your listeners get their flu shot. So some of us think about it. But I agree. I mean, I hear what you're saying. Like, am I terrified to leave my home? No. Do I still go outside to parks? Absolutely. Do I go grocery shopping? Of course. I don't just order everything online. But I do wear a mask when I go grocery shopping, I think I will probably continue to wear a mask when I go grocery shopping until it's clear that COVID-19 isn't circulating in Toronto anymore. To me, I don't even feel like that's a price to pay if it's going to, you know, first of all, keep me healthy, but maybe more importantly, prevent me from spreading COVID-19 to somebody who does have a compromised immune system, to one of my patients. My own parents don't live in Toronto, but my in-laws. I mean, I haven't seen my in-laws up close since this all started, but eventually we will probably go back to seeing my in-laws and, you know, they're in their 70s, and I wouldn't want to infect them with COVID-19. So there are a whole bunch of reasons to wear a mask. And then I guess even on the numbers, like, first of all, the survival rate may be as high as 99.6 percent as you say, but that's still—what would that be? 0.4 percent mortality, so one out of every 250 people would die. It's not quite Russian Roulette, but that's not a probability I would say that most people who are in their 30s or 40s are comfortable with. One out of 250.
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Shaun Francis: You've written about borders. How do we reopen the borders? Because it's inevitable that we need to just to get ourselves back economically.
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Irfan Dhalla: Yeah.
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Shaun Francis: What are your current thoughts on that?
[00:16:23.10]
Irfan Dhalla: Well, it's going to be a lot easier for countries that have contained this successfully to reopen their borders with other countries that have contained this successfully. So I wouldn't be surprised if, in the next few weeks, we see an agreement, a reciprocity agreement between Australia and New Zealand, for example. You know, New Zealand hasn't had a new case now for several days. Australia, I think, is in the kind of single digits of new cases per day. Now they're both islands, so it's easier, I think, for them to have dealt with COVID-19 than it is for a country like Canada. But I think we'll see some kind of reciprocal agreements. The same kinds of agreements may start to happen in some of the Asian countries that have been very successful at containing this disease. And then we'll probably start to see those kinds of agreements in Europe as well.
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Irfan Dhalla: With Canada and the United States, it's going to be difficult. You know, I don't know. I think it will take some serious thinking about what to do at the border, whether to test people who are coming over the border, whether people go into self-isolation. So, you know, I think we're going to have to live with some restrictions on travel for a while. Even if they're not absolute restrictions, there will be restrictions like you can't travel if you have any symptoms, or you need to get a test, or you need to isolate for some number of days after you travel.
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Shaun Francis: You brought up Australia and New Zealand, and it makes me recall an interview I saw on—I want to say it was Australian television, where they had the chief epidemiologist of Sweden. And he did congratulate them on their approach, and like you said, I think it's almost completely contained in New Zealand, for example. But he said, "What I don't understand is how you will travel for the next 30 years," because it's inevitable that over the long term, you'll see the same prevalence as we have in Sweden. So he described it more as a short-term strategy, and not a long-term strategy.
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Irfan Dhalla: You know, that's the bet, right? That's the bet they're taking in Sweden, and right now, they're losing that bet because their mortality rates are several times what they are in Denmark, Norway, Finland, the countries nearby. It's a very controversial issue for sure in Sweden. You know, I suppose it's possible that 10 years from now, everything will even out, and the number of people who've died from COVID-19 in all of those countries will be roughly the same, and then maybe that fellow, who is in the interview you heard can say, "Ha, ha! I was right!" But I think it's also quite possible that, if we go out 10 years from now, we will find that well, there was a vaccine two years down the road, and all of those people who never got COVID-19 in Denmark and Norway and Finland survived, and that actually, there were many thousands of unnecessary and preventable deaths in Sweden. You know, they're not looking like they're winning that bet right now.
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Shaun Francis: So you're saying technically, he may be right, but if we get a vaccine, that strategy would be proven to be faulty because you'd save more lives if we were to get a vaccine.
[00:19:41.08]
Irfan Dhalla: Yeah, or an effective treatment. I mean, I think if you take the view that we're all going to get infected with COVID-19 at some point in our life, and we're either going to survive or die, well then, I understand the argument. But I'm not taking that view, right? I'm taking the view that hopefully, in 18 months or something like that, there will be a vaccine. Maybe even before that, there will be some effective treatments, and maybe I will never get COVID-19 because of the vaccine, or because of successful containment. But that if I do get COVID-19, maybe there will be an effective treatment.
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Shaun Francis: But you're not advocating that we stay locked down.
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Irfan Dhalla: No, absolutely not.
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Shaun Francis: What I heard you say is common sense public health: wash your hands, masks where you can't socially distance.
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Irfan Dhalla: Yeah, no large gatherings. I mean, large gatherings I think are very risky. You know, we're certainly seeing around the world that when people get together in large groups, whether it's at a choir practice or whether it's in a large restaurant or in a greenhouse, and not to say people don't need to go to a greenhouse because that's kind of an essential work, but those are the high-risk kind of venues. And so, you know, I don't think indoor choir practices, you know, they're not going to happen for a while, or they shouldn't happen for a while. But I think kind of locking everything down doesn't work either, right? I mean, people need to work, people need to earn an income. There is also just the quality of life aspect. And I think, you know, in Canada what we can do, of course, is reopen in places where the disease has been successfully contained.
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Shaun Francis: But it's inevitable—well, certainly in my view, is that we are, through economic necessity, going to have to reopen in the next month, right? I mean, because we can't afford to pay everyone to stay home.
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Irfan Dhalla: Yeah, I guess it's a question of reopen what? And what do we do? Like, you know, I wouldn't go to a nightclub in the next month even if it reopened. And so I think the other thing is, when we reopen, we will also have to have what—I'm not an economist, but what I think economists call "consumer confidence," right? Like, will people have the consumer confidence to go to a restaurant, to go shopping inside a shopping mall? I don't think people will, or at least a lot of people won't have the confidence to do those kinds of things if we still have hundreds of new cases every day in the Greater Toronto Area.
[00:22:14.26]
Shaun Francis: But we could—I mean, if this is a low ember, so even though we're containing it and our hospitals are not getting overwhelmed, it could be like this for years, right? Where we do get new cases, but it's not exponential cases.
[00:22:31.02]
Irfan Dhalla: Well, I think that's why we should double down on the focused public health interventions, so that we can drive that number of new cases down to a very small number. I don't think it's an either/or question. It's not either we take a public health approach or we lock down the economy. It's not one or the other, right? We have to do both. We have to do the right things from a public health perspective, so that we can reopen the economy more quickly. And what we're seeing from around the world is actually, the places where they have aggressively contained the disease are the same places where people are able to get back to work and kids are able to get back to school.
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Shaun Francis: Just going back to the border, so if we talk about waiting for the vaccine, or hoping we get the vaccine, do you view us as having these border controls up until that point? Or do we create these corridors between countries where it feels like the numbers are under control?
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Irfan Dhalla: I mean, I think there will definitely be corridors between the countries where the numbers are under control. You know, what we do with the Canada-US border, or what we and the US do with our border will be interesting to see. I mean, obviously it's not closed even as we speak, right? Goods are coming across the border in both directions. Canadians are obviously allowed back into the country. People who are coming here to work are allowed to come across the border. Yeah, I don't have a good answer. I mean, I don't think there's a black-and-white solution to the border, and I don't think it would be—it would definitely be wrong to totally close the border right now. I also think it would be the wrong decision for Canada to totally open it up. We probably need some thoughtful group of people to be looking at it on an ongoing basis, and it might even be different for different parts of the border. So there might be more restrictions in Quebec and Ontario and the parts of the border where Quebec and Ontario are, compared to the parts of the border in British Columbia probably will become the case that it's okay to cross the border.
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Shaun Francis: Yeah, I know coming back into Canada now, you are required to quarantine for two weeks. And they call you, even.
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Irfan Dhalla: Yeah. That's good. You know, in the more authoritarian countries in the world, they don't just call. Sometimes they use tracking devices, and if you violate the self-isolation, it's a criminal offence and you can get arrested. You know, I don't know whether it's a criminal offence in Canada if you don't follow the self-isolation directions, but it's something we should all be doing to protect not only ourselves but people who are more vulnerable in our society.
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Shaun Francis: On that point though, if you have similar caseloads between two different regions, I don't really understand the need to quarantine for two weeks, because on that basis, that's in fact saying we should all just stay locked down.
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Irfan Dhalla: Yeah. It sort of gets to my question about, well, what is the goal? Is the goal to say okay, we're fine with this? Or is the goal to actually reduce the number of cases in each of those two regions? And if you want to reduce the number of cases in each of those two regions, well, you want to slow down travel between those two regions, and you also want to slow down travel within those regions, right? Right now, if you're in some places in Ontario, Northern Ontario, where there's very little COVID-19, well, you certainly see in the news that people in these communities aren't super thrilled about people from Toronto coming up there because they've got COVID-19 contained and we don't have COVID-19 contained. And so why would you want people from Toronto coming up and potentially reintroducing COVID-19 into your community?
[00:26:25.09]
Shaun Francis: Well, I think by this summer, we will really see how much prevalence there is, right? I mean, the curves are going down. So the question is, do we get to that? You know, have we contained it? And the testing is going up dramatically in the US.
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Irfan Dhalla: Yes.
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Shaun Francis: You know, you can get it at the drugstore now, right? So we have more testing, more ICU capacity, don't have to worry about PPE—which we shouldn't by the fall. We understand it's way more survivable than we thought.
[00:26:52.17]
Irfan Dhalla: I think people will move on when it's no longer in their community. It's hard to move on when, you know, people you know are getting sick from it. And I think what we will also see is that countries and states and provinces that have successfully contained the disease, are also the places where the knock-on economic effects will be less severe. I mean, I'm not an economist, so that's a prediction that I don't really have the knowledge to make, but I think the economists who I've sort of heard from, who look at this in what seems to me to be a reasonably thoughtful way are saying that that's what's happened in previous pandemics, and that that's likely what will happen in this pandemic. And even sort of common sense observations support that, because people in areas where the disease is successfully contained, you can see people going shopping. You know, I talked about South Korea, people were going to nightclubs, which in retrospect was obviously the wrong thing to do, but they felt confident enough to actually go.
[00:27:58.05]
Shaun Francis: Irfan, thank you very much.
[00:27:59.25]
Irfan Dhalla: Oh, thanks so much for having me on.
[00:28:00.13]
Shaun Francis: Really privileged, really appreciated your perspective on what's happening at Unity Health, at St. Mike's, academically from a public health perspective. Really informative, and I certainly enjoyed it. So thank you very much.
[00:28:16.01]
Irfan Dhalla: Thank you. It's a lot of fun.
[00:28:25.10]
Christopher Shulgan: That's it for us today. We'll post complete show notes on the website at Eatmovethinkpodcast.com. Follow Irfan Dhalla on Twitter @IrfanDhalla. This episode was produced by Ghost Bureau's Russell Gragg and Chantal Guertin. Remember to rate and subscribe to Eat Move Think on your favourite podcast platform. Follow Shaun on Twitter and Instagram @ShaunCFrancis—that's Shaun with a U—and Medcan @Medcanlivewell. We'll be back very soon with a new episode examining the latest in health and wellness.
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