The Left Atrium · De l'Oreille Gauche
The values of reform
Do we care? Renewing Canada's commitment to health
Edited by Margaret A. Somerville
McGill-Queen's University Press, Montreal & Kingston; 1999
166 pp. $44.95 (cloth) ISBN 0-7735-1877-0
$19.95 (paper) ISBN 0-7735-1878-9
Do We Care?, the collected papers from a conference on Canadian health policy held in Toronto in October 1998, offers many interesting analyses of the problems affecting Canada's health care system, but ultimately not enough precision in recommendations for reform. Former Ontario Premier Bob Rae claims that "there is a great deal of consensus across the country on what needs to be done," which raises the question of why it has been so hard to implement the reforms on which there is such evident agreement. The answer appears to be that the Canadian élite no longer support medicare and that this attitude has started to spill over into the general public. Rae observes that we cannot support European-style services with American-style taxes. Canadians used to describe their aspirations as "peace, order and good government," but increasingly we are more likely to be seduced by "life, liberty and the pursuit of happiness." As Alberta law professor Timothy Caulfield notes, medicare's strength is the strong collective values of the population it serves. Its weakness is the individual values of consumers. Several of the authors note that the future of medicare will be defined by how we strike a balance between these two perspectives.
Pharmacare is an excellent example of the challenges facing medicare. Like home care, pharmacare was recommended by Justice Emmett Hall's 1964 Royal Commission on Health Services, but it was not included in the 1966 federal medicare legislation. The provinces did implement drug plans, but these were incomplete and were scaled back further in the 1990s. At the same time, shortened hospital stays mean that patients have to pay more of their drug costs: medications prescribed out of hospital are not covered by the Canada Health Act. The National Forum on Health in 1998 strongly recommended the introduction of a national pharmacare program, claiming that, like medicare, it would lead to more equitable drug coverage, administrative savings and lower overall costs. However, despite lower overall costs to society, the costs to government would rise. University of Toronto Professor Raisa Deber notes that the "first law" of cost control is to shift costs onto others; indeed, in an era when fewer Canadians are interested in collective solutions to their problems, Canadian governments have shifted, and shafted.
Nathalie St-Pierre, executive director of the Federation of Quebec Consumers Associations, describes how the implementation of Quebec's new drug policy shifted costs away from government, left overall costs unchanged and saddled poor and elderly people with greatly increased costs. Other analyses have estimated that the new plan led to hundreds of deaths and thousands of hospital admissions as sick patients were forced to choose between buying food and having a prescription filled.
Given such a toxic policy environment, how can we get medicare back on the rails? First, it's important to reaffirm the values of public finance. After all, medicare is a modern-day miracle. Public finance allows access to high-quality health care for the poor as well as the rich, but it also controls costs. Moreover, medicare is the country's most effective economic development strategy. Despite repeated attacks from the business community, medicare greatly reduces business costs.
One would never know about the virtues of medicare from reading our national newspapers. In his introductory essay John Ralston Saul comments that Canadians would not allow medicare to be eliminated explicitly, but they are now being convinced that it doesn't work — so that a private system can be implemented in its place.
We need to be more precise in our prescriptions for reform. Current recommendations tend to focus on developing intersectoral strategies to improve health as well as improving the efficiency of health care services. However, John Wade, former Manitoba deputy minister of health, notes that intersectoral policy-making failed in his province. He blames the way governments are organized, and no doubt he is at least partly correct. However, perhaps equally to blame has been the tendency to treat health as a bureaucratic or technical construct when, to paraphrase Rudolf Virchow, "health is politics." Governments don't coordinate different policy areas unless there is a pressing need such as a war. Advocates for healthier public policies need to relocate health in the political playing field and then develop new tactics to support local communities in pushing health issues such as early childhood development up the political ladder.
We also need to be more specific about the changes needed in health care delivery. To use the economists' language, most of the recent focus has been on technical efficiency (doing things right) instead of allocative efficiency (doing the right things). We have pared down the costs of cholecystectomies with laparoscopy, timemotion studies and with cost-shifting that requires consumers to recover at home. But should we be removing as many gallbladders as we do? We can now identify the day a stroke patient becomes "subacute," but we have done little to reduce the risk of stroke for the 70% or more of Canadians with hypertension whose blood pressure is poorly controlled.
We have downsized the hospital at the bottom of the cliff, but we have not yet put a fence around the top. Why should we be surprised that the bodies continue to fall? There is a great potential pay-off from the better monitoring of chronic illness in the community, but we need to identify this clearly as a management challenge. We should then deal with the systemic barriers to a truly comprehensive primary health care system. Ironically, the only author who touches on this issue in Do We Care? is Terrence Montague, who found such little support for his ideas within government and academia that he now works for the drug company that sponsored this conference.
Although this volume fails to offer many solutions, readers will still find it a useful addition to the section of their library that diagnoses problems. Many of the authors identify the crucial issue as one of values. John Ralston Saul declares, "If we decide that we care, and choose the direction we want to go in, then we will find a way to make it happen." I believe Canadians do care. But do their politicians have the skill to mobilize the support medicare needs to survive?
Michael M. Rachlis, MD, MSc
Toronto, Ont.
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[Contents]
Room for a view
The music of mourning
Kate sat in the wing-back chair, diminished. The silent intricacies of the Persian carpet absorbed the weight of the room. Sobre crown moulding undulated from the grey wall to the shadowed ceiling, casting tunnels of darkness. Oboe music clung to the curtains and hung in the air.
She stirred in her chair and invited me to sit down. Staring into the middle of the room, she remarked, "All I can do is listen to this music, music I knew as a child ... and Edith Piaf ... and Jacques Brel. It soothes me, reminds me who I was."
It had been two weeks since Kate's husband died. Simon's dying had been gradual, and the months of care, consuming. The rush of condolences was over and now she was alone, her resources depleted, her focused intensity gone.
"Toward the end," Kate said, "Simon was so, so thin — as you know. Even though it was early summer he was cold at night. I kept him warm in bed — and, you know, in the last days, when his dreadful pain was better, he was content. He died peacefully, here at home as he wished. But for me there is no contentment."
The oboe fell silent, and a rich, powerful voice filled the room. It was a voice that had known pain and suffering. Non, je ne regret rien. Kate listened intently and sighed.
"I have music, this music, and just enough energy to listen. Food doesn't interest me. Reading is impossible. The house has to look after itself. But a strange thing happens late at night: I have an urge to write letters. I write until three or four in the morning. Then I have to mail them — and not just in the box down the street. I get in the car and drive to the main post office. The city seems deserted at that hour. But I feel compelled to mail the letters at the main post office. Don't you think that's strange?"
"Sometimes when we grieve the abnormal becomes normal," I offered.
The insistent rhythm of Quand on a que l'amour began in the background. Kate murmured the lyric, "If only we have love, death has no shadow." She looked up at me. "Two nights after Simon died I was sitting at the kitchen table with my son and daughter. We had finished supper and were having our tea. Suddenly we were aware that Simon was in the room. He was there for only a moment. Several times since then I have gone into a room and sensed his presence.
"How does that make you feel?'
"At first I wondered if I was losing my mind. But now I like to think that Simon is trying to comfort me. The minutes are so heavy, the hours endless. How do you fill this emptiness? My children, my source of strength, are grieving too. We are dry wells in a desert."
Lying on the table was a collection of Chekhov's short stories. I picked it up and examined the table of contents. The story I was looking for, "Heartache," was not there.
I put the book down. "One of my favourite Chekhov stories," I began, "is about a cab driver whose son had just died. The story takes place late at night, in winter. As the snow falls the cabby drives his sleigh from one place to another, and as his passengers come and go he tries to tell them about his son. But no one pays attention. Finally he returns to the stable. In the darkness of the stall he does his chores and starts to talk to his horse: 'Now, let's say you had a little colt, and you were that little colt's own mother. And suddenly, let's say, that little colt departed this life ... .' "
The background music changed. Now it was choral music, polyphonic and bleak.
"I know what Chekhov means," Kate replied. "To whom shall I tell my sorrow?" I have a good friend, Theresa. She gets me through the little things that seem so difficult now. She listens to my music, and to me."
I saw Kate in my office two months later. It was one of her first ventures into public. She had more energy and had begun to take an interest in reorganizing her house. But her speech was less than animated, and her face showed the effort of the visit. I asked about her music.
"I still play Edith Piaf, but not as much. Her songs have absorbed most of the pain. Now I listen to Schumann. I began with the little piano pieces, the Kinderscenen, and moved on to the works for oboe and piano. Now I'm listening to the second symphony. I still prefer simple, sad pieces. But I do find myself paying attention to the music and the little complexities."
Toward the end of October I ran into Kate in the grocery store. Some of the old spark had returned to her eyes, and she told me that she was having several friends over for supper that night.
"I'm not preparing anything fancy, just soup and salad and a little fish."
"What music are you listening to now?"
"Schubert. I began with his string quartet in D minor; now I'm listening to the string quartet in C major and the symphony in B minor. Tonight I think I'll play the Trout Quintet."
Kate returned to the office in January. Her energy and animation had returned. She had gone through her seed catalogues and started some garden designs. She had a trip planned for late March and had been to the symphony twice.
"What music are you listening to now?" I asked.
"The Emperor Concerto. You know I couldn't have listened to that music even two months ago."
Not long after that conversation I listened to Beethoven's fifth concerto, the Emperor. The piano engaged the orchestra in a joyful, triumphant collaboration. I didn't need any special knowledge of music to understand that Kate had completed her tasks of mourning.
Ian A. Cameron, MD
Department of Family Medicine
Dalhousie University, Halifax
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[Contents]
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[Contents]
Lifeworks
The art of self-examination
Reflections on the Artist: Portraits and Self-Portraits, on view at the National Gallery of Canada until Jan. 2, 2000, is an eclectic mix of prints, drawings and photographs in which artists are represented by themselves (e.g., Rembrandt by Rembrandt), by their contemporaries (Cézanne by Pissarro) and by latter-day saints (Rembrandt by Picasso). Most eclectic of all is the Genetic Self-Portrait by New York-based artist Gary Schneider. This installation of 55 black-and-white images examines structures and tissues of the artist's own body, ranging from hands and eyes (the obvious and yet intensely expressive matter of conventional portraiture) to such obscurities as a buccal musoca cell. Drawing on the technologies of radiography, micrography and genome amplification testing, this self-portrait is, on a literal level, far more complete than that achievable on canvas or in a studio photograph. However, replacing self-examination is a forensic preoccupation with self-identification — as in, rather amusingly, a panoramic dental radiograph of the artist's teeth. Schneider's photograms of hands and ears bear the imprint of a biological uniqueness encrypted in the pairs of chromosomes displayed along one wall, but what he is describing is a body more than a self — and, for that matter, a body fragmented by the specialization of imaging techniques. From this self-portrait, the persona has escaped.
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Such intimate details of physiology are generally confined to the confidential preserve of medical consultation. Thus Schneider reassumes ownership of privileged information. On the other hand, the information he puts on view confides little. To the layperson, DNA sequences from a hair follicle or testis may suggest the idea of an intelligible pattern, but they disclose nothing of the person, with or without the label "Mitochondrial DNA sequence from a hair follicle showing the respiratory chain energy producing gene NDI." Someone versed in the arcana of DNA analysis may descry goodness knows what predisposition to future illness, which leaves one to contemplate the ways in which genetic testing is making the future just visible enough to trouble us. At the same time, images of Schneider's handprints suggest a much older tradition of fortune-telling, raising the question: Does the science of genetics serve an ancient desire for prescience? At any rate, the sense of futurity in this quasi-clinical self-examination is rarely so evident in conventional portraiture, which generally concerns itself with the here and now. The mute determinism that Schneider invokes makes one ponder to what extent the previously inaccessible knowledge now being made available by biomedical science, and genetics in particular, will result in a reconfiguration of our personal notions of destiny, self-determination and, indeed, of the self.
Anne Marie Todkill
Editor, The Left Atrium
© 1999 Canadian Medical Association or its licensors
