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The use of remote presence for health
care delivery in a northern Inuit
community: a feasibility study
Ivar Mendez
1
*, Michael Jong
2
, Debra Keays-White
3
and
Gail Turner
4
1
Remote Medicine Program, Division of Neurosurgery, Dalhousie University and Queen Elizabeth II Health
Sciences Centre, Halifax, NS, Canada;
2
Faculty of Medicine, Memorial University, St. John’s, NL, Canada;
3
Health Canada, First Nations and Inuit Health Branch Atlantic, Halifax, NS, Canada;
4
Nunatsiavut Department of Health and Social Development, St. John’s, NL, Canada
Objective. To evaluate the feasibility of remote presence for improving the health of residents in a remote
northern Inuit community.
Study design. A pilot study assessed patient’s, nurse’s and physician’s satisfaction with and the use of the
remote presence technology aiding delivery of health care to a remote community. A preliminary cost analysis
of this technology was also performed.
Methods. This study deployed a remote presence RP-7 robot to the isolated Inuit community of Nain,
Newfoundland and Labrador for 15 months. The RP-7 is wirelessly controlled by a laptop computer equipped
with audiovisual capability and a joystick to maneuver the robot in real time to aid in the assessing and
care of patients from a distant location. Qualitative data on physician’s, patient’s, caregiver’s and staff’s
satisfaction were collected as well as information on its use and characteristics and the number of air
transports required to the referral center and associated costs.
Results. A total of 252 remote presence sessions occurred during the study period, with 89% of the sessions
involving direct patient assessment or monitoring. Air transport was required in only 40% of the cases that
would have been otherwise transported normally. Patients and their caregivers, nurses and physicians all
expressed a high level of satisfaction with the remote presence technology and deemed it beneficial for
improved patient care, workloads and job satisfaction.
Conclusions. These results show the feasibility of deploying a remote presence robot in a distant northern
community and a high degree of satisfaction with the technology. Remote presence in the Canadian North
has potential for delivering a cost-effective health care solution to underserviced communities reducing the
need for the transport of patients and caregivers to distant referral centers.
Keywords: Aboriginal health; air transport; health care costs; patient care; patient satisfaction; remote presence; robots;
telemedicine
P
rofound disparities in the provision of health care
services to Canadians who live in the north have
had a major negative impact on their life expec-
tancy. Indigenous inhabitants such as the Inuit are the
most vulnerable ethnic group in the Canadian North and
have an average life expectancy that is 11 years lower
than the rest of Canadians (1). A low population density
within a vast and remote territorial expanse in the context
of jurisdictional issues, socio-economical and historical
realities have contributed to this inequality in health
status. Inuit have higher rates of preterm birth, stillbirth
and infant mortality than other Canadians (2). The
incidence of chronic diseases, substance abuse and inju-
ries continue to increase in Inuit communities (3). Sixty-
eight percent of Inuit children aged 614 years report
being hungry on a regular basis (4) compared to 1.2%
of children in other Canadian families (5). Infectious
diseases such as lower respiratory tract infections are 11
times more frequent in Nunavik than in other Canadian
regions (6) and Inuit women have higher rates of human
papilloma virus infections compared to other Canadian
women (7).
æ
FEATURED PRESENTATIONS
Int J Circumpolar Health 2013. # 2013 Ivar Mendez et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-
Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction
in any medium, provided the original work is properly cited.
1
Citation: Int J Circumpolar Health 2013, 72: 21112 - http://dx.doi.org/10.3402/ijch.v72i0.21112
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Health expenditure per capita in the Canadian North
is higher than in the rest of Canada (8). For example, the
per capita health expenditure in Nunavut is 2.7 times
greater than the national average and constitutes more
than 30% of its GDP, the highest in the world. These high
levels of health care expenditure do not correlate with
improved health indicators. This failure to achieve better
health outcomes despite high levels of spending is multi-
factorial and complex (9). Although historical, cultural,
socio-economic and geographical dynamics are at play,
the model of health care delivery to remote communities
in the Canadian North may be a critical factor in this
discrepancy.
Remote northern Canadian communities typically have
community health clinics that are staffed by advanced
care regional nurses who practice in an extended role
with the support of off-site family physicians located
in regional health centers that help with the delivery of
elective and emergent care. Although there are periodic
visits from physicians to the remote clinics, the system
relies heavily on air transport as the main conduit for
accessing physician care in the regional or specialized
referral centers (9). The reliability and sustainability of
air transport in providing services to remote locations
is heavily dependent on financial resources and climatic
conditions which are unpredictable in the North. Tele-
medicine has opened the door for the development of
solutions that may help address the unmet needs of
remote communities. Although telemedicine applications
in the Canadian North were initially conducted in the late
1970s and early 1980s (10,11) with some focused programs
having been successful over the years (1214), the adop-
tion of telemedicine as a widespread and effective pathway
for health care delivery to remote northern communities
has not occurred. Several barriers and challenges have
impeded the adoption of telemedicine as a routine strat-
egy for the effective and timely delivery of health care
to underserviced remote regions (15,16). As part of our
telehealth partnership program, we have explored the
feasibility of using a remote presence robot to deliver real-
time physician expertise to Nain, a remote Inuit commu-
nity in northern Newfoundland and Labrador, Canada.
Methods
The Nain community health clinic
The community of Nain is located at the northern tip
of the province of Newfoundland and Labrador, on
Canada’s east coast and is the administrative capital of
Nunatsiavut, the newest Inuit land claim. Nunatsiavut is
located on a geographically diverse area of approximately
72,000 km
2
of land and 48,690 km
2
of sea that is home
to a population of about 2,200 Inuit. The community of
Nain has 1,188 residents (17) and is served by a com-
munity health clinic staffed by 6 regional nurses.
The Nain clinic provides primary care to the commu-
nity (it is not an inpatient facility) with 4 holding beds
and a treatment room with basic resuscitation equipment.
The referral center for the Nain Clinic is at the Labrador
Health Center in Happy Valley-Goose Bay, 367 km south
of Nain. Emergency or urgent care patients are evacuated
to the referral center by air. Although a physician from
the Labrador-Grenfell Regional Health Center visits
Nain once a month, patients requiring further diagnostic
tests or assessment are transported by air to Happy
Valley-Goose Bay or the tertiary care referral center in
St. John’s, 1,207 km away.
Physician support for the Nain nurses has been mainly
through telephone complemented in the past 5 years with
videoconferencing equipment and a telehealth coordina-
tor stationed in Happy Valley-Goose Bay. Air transport
from Nain to the referral centers is dependent upon
weather conditions and restricted to the day time as the
Nain runway has no night time capabilities.
Remote presence robot
To provide physician remote presence expertise to the
Nain clinic, we used the RP-7 remote presence robot (In
Touch Health Inc., Santa Barbara, CA, USA). The RP-7
has been designated by the US Food and Drug Admin-
istration (FDA) as a class II medical device and fulfills
the US FDA requirements for active patient monitoring
in clinical situations in which immediate clinical action
may be required (18). The RP-7 was flown to Nain and
deployed in the community clinic, the robot was nick-
named ‘‘Rosie’’ by the clinical staff in Nain. Physicians in
the referral center in Happy Valley-Goose Bay and nurses
in the Nain clinic were trained on the use of the system
before its operation.
The RP-7 is controlled wirelessly by a laptop computer
(control station) equipped with headphones, microphones
and a joystick to maneuver the robot in real time. The
RP-7 is 165 cm in height and has a wheeled triangular
base of 6376 cm, roughly comparable to the size of a
human. The robot can travel at speeds of about 3 km/h
and has an 8-h rechargeable battery (Fig. 1).
The head of the RP-7 has a mobile flat screen monitor
that displays the image of the operator and a picture-in-
picture window that displays the image of the person
standing in front of the robot. The head of the robot
is movable and is fitted with two sophisticated digital
cameras as well as audio, microphone and amplification
components allowing for real-time two-way audiovisual
communication (Fig. 1B). The robot also has a digital
stethoscope, privacy handset and a printer capable of
providing hard copies of orders and recommendations
with the digital signature of the physician conducting the
remote presence clinical session (Fig. 1C). Connectivity
between the control station and the RP-7 robot is pro-
vided by a standard 802.11 Wi-Fi internet link.
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The control station allows the clinician to have real-
time control of the robot’s movement, videoconferencing
systems, digital stethoscope and printer. The clinician
operating the robot is able to telestrate using a cursor
that is seen in the robot’s head screen. Telestration is
important, as the clinician can use it to impart real-time
visual instructions in the remote location environment
such as pointing to the patient’s anatomy while conduct-
ing a physical examination with the aid of a nurse (Fig. 2).
The control station is also capable of storing video and
still images of the remote presence sessions for further
analysis and archival purposes.
Assessments
The project duration was 15 months, from January 1, 2010
to March 31, 2011, and data were collected using a com-
bination of surveys, qualitative interviews and compiling
information on travel and communication costs as well as
the network time used during the RP-7 sessions. As regu-
lar videoconferencing continued to be used in Nain, com-
parison data were collected for the same period of time.
Evaluation forms were completed after each remote
presence session by the physician, the Nain nurse and
the patient or caregiver accompanying the patient. The
remote session surveys provided data on the demograph-
ics of the patients, diagnosis, outcome after the session,
ease of RP-7 use as well as the participant’s satisfaction
with the session.
A third-party evaluator conducted qualitative inter-
views at the end of the project with physicians and nurses
participating in the study. Data on the number and cost
of air transport, accommodation and meals for Nain
patients and caregivers accompanying the patient for the
period of this study were collected. The number and
duration of RP-7 activations were recorded. Activations
were divided into 3 session categories; clinical sessions,
education sessions and technical/maintenance activations.
Results
Remote presence usage
There were 252 activations of the RP-7 robot during the
15-month study period of which the majority (89%) were
for patient care (Table I). There was an average of 11.8
robotic remote presence clinical sessions per month.
During this time, regular videoconference clinical ses-
sions remained relatively stable from 9.3 per month prior
to commencement of the project to 7.8 per month during
Fig. 1. Photographs of the (A) RP-7 remote presence robot that is 165 cm in height and has a 63 76 cm wheeled triangular base;
(B) a close-up view of the RP-7 monitor and the two affixed high-resolution cameras; and (C) is capable of connecting diagnostic
peripherals, such as a stethoscope. The RP-7 robot has a printer (P) for printing orders and prescriptions from the referring physician
and a telephone handset (H) for private communication with the distant physician.
Remote presence in the Canadian North
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the course of the study. The combination of the RP-7
clinical sessions and regular videoconferencing sessions
represented a 150% increase in telehealth access to the
residents of Nain. Forty-nine percent of the clinical
sessions were for mental health care assessments and
follow-up. Although only 3% of RP-7 activations were for
purely education purposes, the Nain nurses placed a high
value on these sessions, and reported that in 50% of the
clinical sessions they had learned something new.
Impact on air transport
Air transport of patients from remote communities to
the referral center is a major economic burden to health
care delivery in remote northern Labrador communities.
There are two methods for transporting patients by air
from Nain to the referral center in Happy Valley-Goose
Bay; (1) Medical Evacuation (Medivac) which is a
dedicated flight for patient transport or (2) a regularly
scheduled commercial flight. The costs associated with
these two flights are significantly different. A regularly
scheduled flight costs $875 CND round trip, in compar-
ison to a Medivac flight, which costs $1,800 CND one-
way (not included escort costs and call-back costs for
ambulance dispatch staff). Other costs that are incurred
when patients are referred for outpatient assessments and
diagnostic tests to the Happy Valley-Goose Bay Center
are accommodations ($150 CND per night) and meals
($29 CND per day). These costs are also applicable to the
patient’s caregiver/translator that usually accompanies
the patient on these trips. The flight costs are subsidized
by the provincial government and the associated costs
of travel are born by the Nunatsiavut government-
administered Non-Insured Health Benefits Program.
Analysis of air transportation parameters for 47
remote presence sessions where data were complete in-
dicated that in 60% of those cases air transport to the
referral center was avoided, where it normally would have
been considered (Table II). In those cases, the physician
conducting the remote session felt satisfied that the
Fig. 2. Photographs of the RP-7 remote presence robot, nicknamed ‘‘Rosie’’ (A) at a patient’s bedside assessment; (B) the remote
physician interacting with the patient and the clinical team in Nain; (C) control station used by the remote physician conducting the
clinical assessment in the Nain clinic and (D) snapshot of the control screen for the RP-7 remote presence robot.
Table I. Purpose for activation of the remote RP-7 robot during
a 15-month period in Nain, Labrador
Type of session % of sessions (252 total)
Initial consult 20
Follow-up 44
Emergent/urgent 25
Charting/nurse consult 7
Education/in-service 3
Technical/maintenance 1
Total 100
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patient could be effectively managed and followed in
Nain and did not require transport to the referral center.
Furthermore, 7 of the 14 patients who were assessed
using the RP-7 robot for emergency or urgent reasons
and would have potentially required Medivac transport,
were effectively managed in Nain Of these 7 patients,
6 patients (43%) were deferred to a regularly scheduled
commercial flight and only 1 patient (7%) required a
Medivac flight (Table II).
Satisfaction assessments
Physicians
The learning curve for driving the RP-7 robot is not steep
as the controls and operability are very intuitive. Parti-
cipating physicians required approximately 1 h of training
prior to being comfortable in operating the RP-7 robot.
All physicians participating in the project indicated that
the technical capabilities of the RP-7 robot were superior
to that of the conventional videoconference setup for
telehealth delivery routinely used in Nain (Fig. 2). There
was a high degree of satisfaction with use of the RP-7
robot for making real-time clinical decisions, patient
follow-up and enhanced interaction with both nurses
and patients. Furthermore, 100% of physicians felt the
RP-7 improved clinical collaboration with nurses, facili-
tated workflow and decreased stress levels when making
diagnostic and management decisions from a distant
central location.
Nurses
Deployment of the RP-7 robot in Nain had a very
positive impact on the nurses with 100% of the nurses
feeling that the RP-7 robot was superior to the conven-
tional videoconference telehealth setup. Eighty-four per-
cent of the nurses felt that remote presence facilitated the
diagnosis and management of the patient and 80% of
nurses reported that the RP-7 robot facilitated physician
patient interaction. All nurses reported that improved
access to physician support in real time as provided by
the RP-7 robot could facilitate retention and recruitment
of nurses to remote northern communities in Canada.
Patients
There was a high degree of satisfaction amongst patients
being evaluated in the Nain clinic using the RP-7 robot
by physicians located in the referral center. Ninety-five
percent of the patients indicated that they would use the
RP-7 robot again for their clinical evaluations, with 84%
of patients reporting that they were ‘‘very comfortable’’ in
their interaction with the assessing physician using the
RP-7 robot. In 53% of the remote presence sessions, an
interpreter or family member accompanied the patient.
Ninety percent of those caregivers felt that the use of the
RP-7 robot was very helpful in promoting interaction
with the physician conducting the session.
Discussion
The Nain experience
This is the first experience using a remote presence
robot to provide real-time physician expertise to a remote
community in the Canadian North. The transport,
deployment and operation of the RP-7 robot in the
Nain clinic were straightforward and well-received. The
learning curve for physicians and nurses in the routine
operation of the RP-7 robot was not steep and could be
accomplished with about 1 h of training. Physicians and
nurses reported that the intuitive controls of the robot, its
mobility, stable connectivity, high-resolution cameras and
two-way audiovisual capabilities were distinct advantages
over the conventional videoconference setup for tele-
health routinely used in Nain. The ability to drive the
RP-7 robot to the patients’ location and have high-
resolution real-time audiovisual connectivity with the
patient, nurses and family members improved both the
physicians’ and nurses’ comfort with the clinical assess-
ment as well as enhanced the interaction with the patient.
All physicians and nurses reported that use of the RP-7
robot improved workflow and reduced stress levels.
Nurses reported that the higher level of collaboration
with physicians during remote presence sessions was
paramount to gaining community confidence in the new
technology. This collaboration was particularly effective
during mental health sessions that represented 49% of all
remote presence sessions. Those sessions were reported to
be ‘‘extremely helpful’’ in managing the high prevalence
of mental health issues in the community. The nurses also
felt that remote presence technology may have a crucial
impact in retention and recruitment of nurses to isolated
northern communities and empower them to provide a
Table II. Remote presence assessments performed and the outcome of the sessions
Assessment Medivac Scheduled flight Number of transport required Total
Initial consult 0 0 10 10
Follow-up 9 3 11 23
Emergent/urgent 1 6 7 14
Total 10 9 28 47
% of total 21 19 60 100
Remote presence in the Canadian North
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wider range of services in collaboration with real-time
input from physicians using remote presence.
The acceptance of the RP-7 robot by patients was
very high with 95% of the patients indicating that they
would use the RP-7 robot again and 84% reporting being
‘‘very comfortable’’ interacting with their physician via the
robot. Having access to physician expertise in their own
community without the need for transport to the referral
center has profound implications on the attitudes of the
community for seeking medical attention. These attitudes
have been influenced by historical events in northern
Canadian communities related to tuberculosis outbreaks
as far back as two generations ago. It is possible that the
availability of remote presence systems such as the RP-7
robot and an increase in their sophistication for point-of-
care diagnosis, such as real-time blood chemistry analysis,
portable imaging systems, electrophysiological assessment
tools and other diagnostic implements will not only
change these attitudes but also remove barriers of distance
and time for providing effective health care to under-
serviced populations such as Nain.
Although health expenditures per capita in the Cana-
dian North are high, they are not correlated with
improved health care access or health indicators. The
model of care in the Canadian North relies heavily upon
transportation of patients by air to regional referral
centers for hospital admissions, outpatient clinical assess-
ments, follow-up and diagnostic tests. The costs of flights
and other associated expenses such as meals and accom-
modation for the patients and in many cases their
companions can be overwhelming (9). Providing effective
clinical care using remote presence devices and avoiding
unnecessary air transportation to referral centers can
significantly improve the cost-effectiveness of health care
provision in the Canadian North. Our results in Nain
provide some initial evidence that remote presence can
dramatically reduce the number of flights to a distant
referral center by about 60%. Although a reduction in the
number of flights could lead to obvious savings in the costs
associated with transportation and accommodation of
patients, redirection of this money to the timely diagnosis
and improved management of patients in remote commu-
nities is the foremost benefit of remote presence.
Robotic telepresence
Developments in robotic and telecommunications tech-
nology may help address the provision of medical ex-
pertise in underserviced remote communities. In fact,
there is growing evidence for the benefits of the RP-7
robotic system in clinical applications and telementoring.
One of the earliest applications of the RP-7 has been in
critical care where there is a chronic shortage of intensi-
vists and increasing demands, resulting in challenges
for providing on-site coverage (19). Several studies have
demonstrated the utility of remote presence using the
RP-7 in providing critical care coverage, resulting in
decreased lengths of stay in the intensive care unit
(ICU), reduced unexpected events, cost savings and high
satisfaction scores by patients, ICU staff and intensivists
(20,21). Furthermore, a recent study has showed that
robotic telepresence was viewed positively by ICU
patients and their families and they felt that the use of
the RP-7 was beneficial to their care and indicated their
support for its continued use (22). Remote presence has
also been recently used for the treatment of stroke through
acute thrombolytic therapy, where it has been crucial for
facilitating remote neurological assessments reducing the
time for onset of therapy, thereby resulting in improved
neurological outcomes (2325). Use of the RP-7 in the
perioperative follow-up of patients undergoing laparo-
scopic gastric bypass showed significant savings by
decreasing the length of stay (26).
Robotic telepresence has also been used in surgical
mentoring, the RP-7 and its earlier version the RP-6
were used in mentoring laparoscopic surgery for adult
and pediatric procedures and considered very useful and
reliable for mentoring minimally invasive surgery (27,28).
Long-distance telementoring in laparoscopic urological
procedures has also been performed with the RP-7 system
(29), and we have also used a remote robotic telecollabora-
tion system capable of controlling robotic arm movements
for long-distance telementoring of cranial and spine
surgeries (30).
Remote presence systems provide an expert the ability
to telementor in real-time, a non-expert individual to
perform sophisticated diagnostic tests. Complex ultra-
sound examinations under real-time remote guidance
have been conducted aboard the International Space
Station where crewmembers in orbit performed thoracic,
vascular and echocardiographic examinations under the
guidance of an earth-based expert (31). Furthermore,
a recent study has shown the feasibility of telementor-
ing paramedics with no previous experience to perform
ultrasound trauma assessments with great accuracy under
the guidance of a remote expert (32).
Our experience in Nain showed that physicians in a
regional referral center were able to provide real-time
medical expertise to nurses in a remote Canadian Inuit
northern community for the diagnosis and management
of patients seen on an emergency or elective basis at
the community health clinic. High satisfaction scores by
physicians, nurses and patients using the RP-7 robot and
a reduction of patient transport to the referral center
strongly suggest that remote presence may help provide
effective and cost-efficient health care delivery to remote
communities lacking on-site physician expertise.
Potential barriers
Potential barriers for the implementation of remote
presence in remote communities would not likely be
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technological. The exponential advances in the telecom-
munications, robotics and mobile device industry provide
a solid platform for implementing remote presence
systems such as the RP-7 robot used in Nain. The barriers
are likely to be related to issues pertaining to medical
liability, jurisdictional legal considerations, provider re-
muneration, data and patient confidentiality, competing
health priorities, and the lack of regional and national
strategies and standards for implementation of this type
of telemedicine application. A recent study examining the
barriers for implementing robotic telemedicine has deter-
mined that the top barriers for adoption of telemedicine
solutions in emergency and critical care are regulatory
barriers for physician’s privileges, financial barriers for
billing of remote presence services and resistance to the
change of established clinical paradigms (16). However,
the explosive increase in the use of consumer mobile
devices for medical applications may force streamlining of
the regulatory and remuneration issues. Public expecta-
tions and pressure for cost-effective and decentralized
health care provision may play a significant role in
removing cultural barriers to remote presence medicine,
especially in underserviced communities such as Nain in
the Canadian North. The acceptance of patients and their
families to remote presence solutions for health care
delivery is quite favorable (22). In this study, 95% of the
patients indicated that they would use the RP-7 robot
again for their clinical evaluations.
Health expenditure per capita in the Canadian North
is higher than in the rest of Canada (8); however, they are
not correlated with improved health indicators or health
care access within northern communities. Although the
costs of emerging technologies such as the RP-7 are
initially high (the RP-7 cost is approximately $145,000
USD), it will decrease substantially as the adoption of the
technology increases and savings in air transport would
foreseeably offset its costs.
Future directions
This study established the feasibility of using the RP-7
remote presence system to provide real-time access to
physician expertise in a remote northern Inuit community.
This initial experience was felt to be so positive for the
community of Nain that the Nunatsiavut Government
has decided to deploy an RP-7 robot in the community
permanently. This is a great opportunity to explore long-
term impact of remote presence technology for health care
delivery in remote northern Canadian communities.
Although consumer portable communication devices
such as smart phones and tablets are being increasingly
used to transmit medical information, it is likely that
portable remote presence devices that fulfill standards and
regulatory parameters for dedicated medical use will see
more widespread use due to their enhanced capabilities.
Cellular phone networks have grown exponentially in the
world. The latest survey by the International Commu-
nication Union indicated that by 2010, 90% of the world’s
population was covered by mobile cellular networks
and that the number of mobile cell subscriptions was
approaching 6 billion (33). Mobile broadband is also
increasing with 4G connectivity rapidly becoming the
norm and will likely continue to increase allowing for the
transmission of more complex data. This exponential
advance in telecommunications technology may be a
powerful and cost-efficient tool in narrowing the gap of
inequality in health care delivery to remote northern
communities in the near future.
Acknowledgements
The authors thank K. Adam Baker (Atlantic Clinical Consultants)
for his assistance in the formatting and editing of this article and
Tatjana Vukoya for her help with the figures.
Conflict of interest and funding
The authors have not received any funding or benefits from
industry or elsewhere to conduct this study.
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*Ivar Mendez
Division of Neurosurgery
QEII Health Sciences Centre
Halifax Infirmary
#3806-1796 Summer Street
Halifax, NS B3H 4H7, Canada
Tel: 1-902-473-7046
Fax: 1-902-494-4013
Email: mendez@dal.ca
Ivar Mendez et al.
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Citation: Int J Circumpolar Health 2013, 72: 21112 - http://dx.doi.org/10.3402/ijch.v72i0.21112