Conventional wisdom tells us that we have a wonderful public medical system but it's failing now, partly because of the 'insurance effect.'
Fifty years ago C. Northcote Parkinson wrote that "work expands to fill the time available for it."[1] In the same way, costs increase to consume all the money available to pay them.
Especially when insurance pays, because people who don't pay the bill don't care how much it costs. In many cases the insurer doesn't care either, because insurers get a double benefit from high costs.
One is increased profit, because insurance is a cost-plus business. Premiums are set to cover costs plus a percentage for profit, and the higher the costs the higher the profit. The second is that the higher the costs, the greater the perceived need for insurance. Government insurance is not supposed to make a profit but the people who manage it get a boost from high costs too, because the more money a bureaucrat manages the bigger the department and the more powerful the bureaucrat.
For these and other reasons medical costs are now so high that we have had to close hospitals and some people have to wait months or even years for operations that may save their lives. According to Statistics Canada, at least 3.5 million Canadians have no family doctor.[2]
And the shortage is going to get worse because in 2004 a survey by the College of Family Physicians and the Canadian Medical Association found that nearly 4,000 Canadian doctors planned to retire within two years. The increasing percentage of women doctors will contribute to the shortage because the survey found that, on average, women doctors work an average of seven hours a week less than men doctors. In 1980 about 40% of first-year medical students were women but now women make up about 60% of first-year medical classes.[3 Taken together, these numbers add up to an even more severe shortage of doctors in the future.
The problem is especially acute in areas where medical facilities are limited. In many remote villages -- and even in some towns in settled areas of the country -- there is no full-time doctor.
Many doctors don't want to live in remote villages and, because we have a shortage of doctors, they don't have to.
We have a crisis in medical service and we can't afford to have less than the best because we know that a global plague is coming, and that it is probably not far off. This is not speculation or scare-mongering, it is a virtual certainty that the world of medicine has worried about for at least three decades.[4
It's just a matter of arithmetic. The more people there are in the world and the closer they live together the more chances germs, viruses, parasites and other micro-organisms have to mutate. The more we travel and the more we ship goods around the world the more chance micro-organisms have to find and infect people who have no resistance to them. This is not theory -- it has already been responsible for some of the most horrifying disasters in human history.
In the modern world the danger of diseases invading new areas is increased by the global market. Cholera had been wiped out in South America but it came back in the 1990s, to kill tens of thousands of people in the first few years of its return. Scientists think it was re-introduced by a freighter that discharged ballast water from China off the Peruvian coast. The water carried bacteria which flourished in algae which were eaten by fish and shellfish, which in turn were eaten by people.[5
The Asian tiger mosquito, which can carry dengue fever and other infections, came to the USA in shiploads of tires. It's now found in 18 states and may some day spread to Canada.[6
In 1999 the West Nile virus appeared for the first time in the Americas. Carried by mosquitoes and crows the virus can cause encephalitis and it killed at least seven people in New York City the year it was detected. It now threatens most of the Eastern United States and Canada.[7 As I write this a mystery disease in China has killed at least 19 people and, of the 80 people infected, only two have recovered.[8
People carry germs too, and people from around the world carry known and unknown microbes, viruses and parasites to international airports, hotels, convention centers and other meeting points where they can mix, match and mutate into super-killers that could kill half -- or perhaps all -- of humanity. It has not happened yet and it may not happen, but it is a very real danger.
In the spring of 1997 the government of Hong Kong killed and incinerated more than 1.3 million chickens because a flu virus jumped from chickens to people. The virus infected 14 people and killed four.[9 The death of four people in a city of six million is not a major problem, but the chance of a flu virus getting out of control is.
In an era when there were fewer people and less travel -- and therefore less risk of global epidemics -- flu ravaged the world in 1729, 1732, 1781, 1830, 1833, 1889 and 1918. The 1918 epidemic infected about a billion people and killed more than 21 million of them, including more than 500,000 in the United States. In about seven months from September of 1918 to March of 1919 the flu killed 33,387 people in New York City -- more than one percent of the total population.[10 It killed about 5% of the population of Ghana and 20% of the population of Samoa.
If the next outbreak is as bad as the 1918 virus it will probably kill about 60 million people -- but the evidence is that it will be much worse. Around the world the 1918 flu killed about 2.5% of the people who caught it but the Asian bird flu, which may cause the next pandemic, kills between 55 and 75% of its victims.[11
In its present form you can catch bird flu only from a bird, not from a sick person, but that could change. On Aug 5/05 CTV News reported that computer simulations show that if the disease mutates so it can spread from human to human, we will have to stop it within 21 days or it will become a global plague.
And the flu is just an old friend that sometimes gets out of hand. Some diseases that are now emerging from the jungles of Africa, Asia and South America are much more dangerous.
The Marburg virus was first identified in a medical lab in Marburg, West Germany in 1967. The lab used kidney cells from African monkeys to make vaccines and, in one shipment, it got an infected monkey.
Thirty one veterinarians, lab technicians, animal handlers and their close contacts were infected. Seven died.[12
In April of 2005 the Marburg virus got loose in Luanda, a city of 3.5 million people that is the capital of Angola, and killed several hundred. As of August/05 it was found in seven of Angola's 18 provinces, and the World Health Organization had warned Congo, The Democratic Republic of Congo, Namibia and Zambia that they were in danger.[13
Marburg is a close relative of Ebola, which is one of the most feared viruses of the modern world. In 1989 one of the four known varieties of Ebola raged through an animal quarantine center in Reston, Virginia, in a situation so dangerous that the US Army Research Institute for Infectious Diseases was called in to contain it.
Hundreds of monkeys were killed and the building was decontaminated by a three-day soak in formaldehyde gas, which was expected to kill every living thing in it. Months later the same variety of Ebola broke out again, killed all the monkeys, and infected all the people who worked in the building.[14
By pure luck this turned out to be the only known variety of the Ebola virus that is harmless to humans. In fact this variety was not known until it appeared in Reston. With the other three varieties of the virus the death rate for humans varies from 50% to 90%, and there is no known cure. If the monkeys in Reston had carried one of the dangerous varieties of Ebola, the US would have faced a national catastrophe. That still might happen, because the Reston virus is now loose in the United States and it may mutate.
The three deadly forms of Ebola are part of a group of viruses that doctors describe as 'level 4,' which are usually fatal and for which there is no known treatment. We have had several outbreaks of level 4 viruses so far and, as long as we maintain the fiction of a global village around which people can travel at will and through which goods are shipped in large quantities, we can expect more.
Nobody knows when or how it will come, but governments are taking precautions. We have seen armed troops used to isolate areas of Zaire where Ebola fever has broken out, and US Army medical teams sent to study and help contain it. When Ebola or one of the other super-deadly diseases gets loose, we can expect a plague that will kill more people than a major war. Even the relatively-innocuous West Nile virus is a threat, because our mosquitoes will carry it forever. If it mutates -- as it might -- into something more dangerous, it could decimate our population.[15
And while we worry about a single super-plague we also know that we are vulnerable to a potential plague of plagues. In 2003 Toronto and other cities were struck by an outbreak of Severe Atypical Respiratory Syndrome -- SARS -- and by late spring of that year Ontario politicians and health officials had coined a phrase, "the new normal," to describe the situation in which schools and hospitals were closed and thousands of people quarantined in efforts to control a plague.
This while we have a crucial shortage of doctors! The problem is obvious and some doctors and politicians suggest that 'private' medicine should be available for those who can afford it. On one level that makes sense.
We might privatize medical procedures that are so expensive and/or questionable that we just can't offer them to everyone. If the chances are 99% that the patient will die anyway and the treatment will cost $100 million, should the public pay for it? On the other hand if the patient is wealthy, should he not be allowed to spend his own money on any slim chance that he might survive?
But if we allow private medicine we need to demand that any politicians or civil servants who are not happy with the public system must pay their own way if they go private. Otherwise, the government will never see any need to improve public medicine.
Senior politicians and their friends can afford private medicine, and civil servants get free medical care through their jobs. The people who will suffer from the introduction of private medicine are those who can't afford more suffering.
Still, we might privatize optional surgery that serves vanity rather than health needs. On the other hand dental treatment, which most of us need sooner or later, could and should be provided by the government.
Some of the pressure for private medicine may come from drug companies, some of which make obscene profits. The catch is that some provincial health programs refuse to pay for some very expensive drugs.
We can get some indication of the kind of profits we're talking about -- and of the lengths to which drug companies will go to get them -- from the article "Wining, dining MDs" by Tom Blackwell, on page A1 of the Apr 27/05 edition of the National Post.
Blackwell writes of a free dinner for doctors, paid for by a drug manufacturer at the most expensive restaurant in Montreal. Doctors who accepted the free meal also got a $350 'honorarium' for participating in an 'advisory board meeting.' The same company later paid doctors $400 each to 'evaluate training of the company's salesmen,' at a meeting at the Casino de Montreal followed by free admission to the casino's show. Another drug company offered an 'honorarium' of $6,000 to doctors who referred patients to a test of two anti-cholesterol drugs.
A sidebar titled "Breaking the rules" on page A15 of the paper lists some freebies that were listed as infractions of the industry's code of conduct. One company paid for designer hairdos for doctors and their families, another invited doctors to free baseball games, one offered a three-day 'conference' on the French Riviera and another offered four days in Jamaica. Conventional wisdom tells us that the doctor who prescribes a drug does it for our health but, with freebies like these to consider, we have to assume that some doctors will prescribe some drugs as a favour to the companies that provide the freebies.
I leave that for discussion but, in the meantime, I have some suggestions. One change I would like to see is a central registry for all health records.
I have a personal interest in this because about five years ago I paid to have my records moved from the office of a doctor I had been seeing to one that had accepted me as a patient. About a month after the records were moved 'my' new doctor disappeared and for years I had no idea where my records are.
But aside from that, a central registry makes sense for a lot of reasons. One is that it would keep records on the hundreds of thousands of Canadians who have no family doctor, and who get treatment only at walk-in clinics. Another is that if you get sick anywhere in the country, any doctor you go to would have access to your records.
Some people might worry about privacy, but that should be no problem. My bank records are in a public computer but you can't get at them. Medical records could be equally private.
But while names would be private statistics would not, and the computer could be programmed to give us early warning of a developing problem. In a city the size of Toronto a hundred or more people could come down with a new disease the same day and, if they all go to different doctors, the city would have no warning of what could be the start of a serious plague. If all health records are kept in the same computer, the computer could warn us of a developing problem.
Central records might also keep a tab on the effectiveness of doctors. My records were moved because I wanted to move away from a doctor who seemed to me to find too many chronic conditions that could be treated but not cured. A problem she had been unable to cure in a couple of years was cleared up by one visit to another doctor who recognized it as a common yeast infection.
We also need to train more doctors, and to find doctors willing to work in remote areas. As I write this, in May of 2005, TV news reports tell us that the town of Geraldton in northern Ontario is desperately trying to find a doctor willing to work for a salary of $300,000 a year. If it costs that much to hire a doctor we can certainly afford to pay for a doctor's training in exchange for, say, five or ten years' service at a salary that would keep a young doctor in comfort but not luxury. Doctors who choose to remain on salary beyond the required time might qualify for higher wages.
I propose that the federal government establish new medical and nursing schools, with free tuition and perhaps a living allowance for students. To pay for their education graduates of the free schools would be required to work wherever the government sends them. Doctors and nurses who refuse to work where they are assigned would be required to pay the full cost of their education before they can be licensed to practice.
Doctors have to intern to complete their education and apparently some immigrant doctors are unable to get internships. Here again, a federal program could and should help.
Medical care is supposed to be a provincial responsibility but it might not be practical for each province to establish its own medical school. Where doctors trained by the federal government work for a provincial government, some cost-sharing arrangement could be worked out.
That might be a problem, but it would not be reasonable to allow red tape to interfere with anything as important as health care and responsible governments would not allow it to happen.
Immigrant doctors who are qualified in their own countries might also be required or allowed to work for a government, for a stated period, if the medical standards of their home countries are adequate.
After a specified period of government work immigrants and doctors who graduate from the free school would be allowed to practice as they choose. With an adequate supply of doctors assured, the government could even allow private practice. Regular medical schools would continue in operation and students who pay for their education would be free to practice as they choose as soon as they qualify. In exchange for this freedom they could be required to pay a higher percentage of the cost of their education than medical students do now.
Conventional wisdom tells us that doctors are high-minded servants of humanity and many of them are, but some appear to be more interested in making big money than in serving humanity. That's their right, of course, but if we pay for their education we have a right to demand a few years' service in return. With a corps of salaried doctors we could have fully-staffed hospitals in all cities, clinics in every town and at least one readily-accessible general practitioner in every village.
With enough doctors, we could prepare for an emergency. SARS was just a scare but doctors and government alike panicked because they know that a real plague is going to come, sooner or later.
When it does it will be a disaster because the government thinks it can prepare for it by appointing bureaucrats to make plans to allocate the resources we don't have. What we really need is several complete military-style field hospitals, able to set up at short notice anywhere in Canada or around the world. This could be nearly as expensive as maintaining a military force but when we count the cost we must remember that any plague anywhere in the world is a threat to all of us, and well-equipped field hospitals could offer our first line of defence.
These hospitals could be staffed by salaried doctors from the free medical schools. Most of the time there would be no plague to fight, of course, but hospital staffs could also work on vaccination and other programs for the UN or for foreign aid.
We could also take some load off the government system by making businesses or individuals who cause injuries pay for them. If someone is bitten by a dog, for example, the provincial health system should sue the dog's owner for the cost of treatment. If someone is injured on a job where the employer has allowed violations of safety regulations, the health system should sue the employer. If someone is injured in the course of a crime, the health system should sue the perpetrator of the crime. The health system could not always collect, of course, but the threat of such a suit would make at least some people more aware of their responsibility to others.
A national health system should also be authorized to levy a tax on sources of pollution that threaten human health. If a factory emits toxic smoke or fumes, the health system could and should be authorized to estimate the cost of those fumes to the health system, and sue to recover that cost. In the short term this would create a lot of work for lawyers, but in the long term it will result in a cleaner environment and lower costs for health care.
And whatever happens, health insurance must remain with the government. I concede that a government operation will probably be inefficient but the alternative is private insurance and, because insurance is a cost-plus business, private insurers have a direct interest in making health care more expensive.
Further, private medical insurance can tie people to jobs because the insurance company that charges a reasonable rate to corporate clients can charge extortionate rates to private customers. In a world in which most employers are as loyal to their employees as a shark to a codfish, job-related insurance and benefits are liable to be wiped out at any time.
We also need to question the very expensive efforts some doctors make to preserve life when it appears to be hopeless. We consider life to be sacred and believe that it should be preserved where possible -- but what if the cost of preserving one life takes resources that could have preserved many?
A couple of times a year charitable groups fly children from the third world to Toronto for very expensive surgery. At the same time we have thousands of children in Canada's own third world -- the world of Indian Reserves -- who could benefit from much cheaper procedures. It's a fine thing for Canadian doctors to separate conjoined twins from Asia, but should we not take care of Canadian problems first?
Even where Canadian hospitals serve Canadians, they do not do it as well as they might. Hospitals tell us that one of the reasons about 8,000 Canadians die every year from super-bugs they pick up in hospitals is that Canadian hospitals can't afford proper infection-control systems and practices.
It sounds very noble to worry about the inadequate medical treatment available in some African and Asian countries but, as Canadians, we should worry first about the treatment available to Canadians in Canada. I sympathize with the third world, but the part of the third world I have the most sympathy for is the part within Canada.
We also need to address the problem of organ donation. Canadians are asked to fill out and carry a card if they are willing to donate their eyes, heart, liver or whatever after death but, even though many of us would be willing, few make the effort. Twenty-two countries around the world now use a "negative option" on organ donations -- if you don't fill out and carry a card that says your organs are not to be donated, it is assumed you are willing to donate. This makes a lot of sense and while it might require a referendum, we should at least consider it.
Some people think abortion is a crime. Maybe so, but in my world there are worse sins.
Life is a chemical process. I destroy life every time I swat a mosquito or eat a carrot.
The difference between a mosquito and a carrot and a human baby is that the baby can develop into that wonderful entity that we call a human being.
I don't like the idea of abortion because I suspect it may be traumatic for the mother, but I consider it a positive sin to bring a baby into the world if it is not wanted and will not be given a chance to develop to its full potential.
It's ironic that some people who insist on the "right to life" of unborn babies have no compunction about killing children and adults. If the abortion of a fetus is a sin how can you describe the bombing of a city or the use of depleted uranium weapons, cluster bombs or land mines?
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