MEDICAL REFORM Newsletter of the Medical Reform Group Issue 131 Volume 24, Number 2 Fall, 2004 YOUR MONEY AND YOUR LIFE: THE CONSEQUENCES OF INVESTOR OWNED PRIVATE FOR-PROFIT HEALTH CARE DELIVERY P.J. Devereaux
hen discussing our health care Colombia, and the University at Buffalo care at private not-for-profit hospitals.1 system it is important to have come together to undertake research Our findings suggested if we were to Wdistinguish between funding to directly inform this debate. Our goal convert our Canadian hospitals to (who pays for our health care) and is to move the debate away from investor-owned private for-profit delivery (who owns and runs our health ideology and make it evidence-based. institutions, we would incur more than care facilities). Currently, hospital services In a previous edition of the Newsletter 2100 additional deaths a year in Canada. in Canada are publicly funded– we pay of the Medical Reform Group (Issue This number of deaths is in the range of through our taxes. In terms of delivery, 124, volume 22, Number 3, Winter, how many Canadians die each year from although commonly referred to as public 2003) I reported the results of our first colorectal cancer, motor vehicle accidents, institutions, Canadian hospitals are almost two studies that were published in the or suicide. all private not-for-profit institutions Canadian Medical Association Journal Our second study included data on owned and operated by communities, (CMAJ) and the Journal of the American more that 500,000 patients followed for religious organizations, and regional Medical Association (JAMA). a year and demonstrated once again health authorities. Our first study included data on higher risk adjusted death rates among The debate concerning for-profit more than 38 million patients and patients receiving care at investor-owned versus not-for-profit provision centers demonstrated higher risk adjusted death private for-profit dialysis facilities on delivery: whether we should introduce rates among patients receiving care at compared to patients receiving care at investor-owned private for-profit health investor-owned private for-profit private not-for-profit dialysis facilities.2 care facilities into our dominantly private hospitals compared to patients receiving Our study showed that if American not-for profit health care delivery system. patients received care in private not-for- Advocates of investor-owned private INSIDE profit dialysis facilities instead of for- for-profit health care delivery argue that profit facilities, approximately 2,500 Releases...... 3,4 the profit motive optimizes care and fewer patients would die each year. minimizes costs. However, some fear Rachlis on Niagara Meeting...... 4-6 Further if we were to convert our for-profit facilities are more likely to Waiting lists...... 6 Canadian private not-for-profit dialysis respond to financial pressures by cutting Boutique Medicine...... 7-8 centres to investor-owned private for- the quality of care and charging more to profit centers, we could expect Pharmacare...... 8-10 maintain shareholder returns. These approximately 150 additional deaths each viewpoints have resulted in a heated Delisting...... 11-12 year among Canadian patients receiving debate. Public Health & Women...... 13-14 dialysis. A group of researchers, of which All our Children...... 15-16 Our first two studies clearly I am one, at McMaster University, the documented the negative health Cathy Crowe...... 16-17,19 University of Toronto, the University of consequences (i.e., increased death rates) Western Ontario, the University of Guyatt on Election...... 18 Ottawa, the University of British (continued on page 2)
Medical Reform Group, Box 40074, RPO Marlee Toronto, Ontario M6B 4K4 YOUR MONEY AND YOUR LIFE MedicalReform Medical Reform is the newsletter (continued) of the Medical Reform Group of Ontario. Subscriptions are included with member- ship, or may be purchased separately at at investor-owned private for-profit bias in selecting which studies to $50 per year. Arrangements to purchase multiple copies of individual newsletters compared to private not-for-profit include in our systematic review. We or of annual subscriptions at reduced inpatient and outpatient health care trained research staff to read through rates can be made. facilities. Uncertainty, however, remains all the articles and use a black marker Articles and letters on health-re- about the economic implications of these to obscure the results of the studies. lated issues are welcomed. Submissions forms of health care delivery. Studies Two reviewers then independently should be typed, or sent by e-mail to evaluating the economics of health care examined these articles with the results
2 Medical Reform Volume 24, Number 2 - Fall, 2004 YOUR MONEY AND YOUR LIFE (continued) our systematic review is relevant to Third, if Canada moves to for-profit REFERENCES: Canada. There are three reasons why hospitals, the same large American 1. Devereaux PJ, Choi PT, Lacchetti C, Weaver our results are directly relevant to hospital chains included in the review B, Schunemann HJ, Haines T, et al. A systematic Canada. First, the statistically significant would be purchasing Canadian hospitals. review and meta-analysis of studies comparing higher payments for care at a wide There is no reason to think they will not mortality rates of private for-profit and private not-for-profit hospitals. CMAJ range of investor-owned hospitals bring their same management style with 2002;166(11):1399-406. spanned a 12 year period, despite them across the border. 2. Devereaux PJ, Schunemann HJ, Ravindran important changes to the American Our systematic review shows N, Bhandari M, Garg AX, Choi PT, et al. health care system during this time (for substantially higher payments for patient Comparison of mortality between private for- example, the introduction of managed care at investor-owned private for-profit profit and private not-for-profit hemodialysis care, HMOs, prospective payment hospitals. Combined with our previous centers: a systematic review and meta-analysis. systems). This suggests that no matter two studies that showed higher death JAMA 2002;288(19):2449-57. what the context the investor-owned rates in investor-owned private for-profit 3. Devereaux PJ, Heels-Ansdell D, Lacchetti hospitals result in higher payments for hospitals and dialysis centres, this research C, Haines T, Burns KE, Cook DJ, et al. care. Second, payments proved raises serious concerns about moves to Payments for care at private for-profit and private not-for-profit hospitals: a systematic greater in for-profit facilities among private for-profit care. Evidence strongly review and meta-analysis. CMAJ both publicly funded patients and supports a policy of not-for-profit health 2004;170(12):1817-24. among privately funded patients. care delivery.♦
MRG TO PREMIERS: ABANDON THE FIREWALL
he Medical Reform Group The firewall mentality both “It’s up to the federal government today called on the Premiers, violates the will of the electorate in the to ensure that federal health care money Tmeeting to prepare their last federal election, and the best interests is properly spent,” said another MRG strategy for negotiations with Paul of Canadians. All major parties in the spokesperson, Dr. Ahmed Bayoumi. Martin, to accept the need for national election professed commitment to “That means national standards, and health care programs. universal, high quality, publicly funded national programs, including home care “The narrow-minded selfish- health care. Canadians voted over- and pharmacare. It’s up to the provinces ness of some Premiers could destroy whelmingly for parties most strongly to accept the need for strings-attached our national, public health care committed to these principles. Polls show money that ensures they will behave system,” said MRG spokesperson Dr. that even in Alberta, where Conservatives responsibly in keeping with the national Gordon Guyatt. “The Premiers must dominate both federally and provincially, will.” accept the federal government’s the electorate is split between federalist “Canadians don’t want universal health responsibility to ensure national and isolationist approaches to health care care in some province, two-tier medicine standards, and accountability for the funding and delivery. in others,” Dr. Guyatt concluded. “They money it provides to the provinces.” Publicly funded health care don’t want accessible home care and A group of prominent delivered by not-for-profit providers is adequate coverage for prescription drugs Albertans, including opposition leader both more equitable and more efficient in some provinces and not others. Stephen Harper, called in early 2001 than the two-tier, American-style Canadians want national public programs for a firewall that would allow Alberta approaches to funding and delivery that that make high quality accessible across to violate national policies, including Ralph Klein advocates. The Romanow the country. The Premiers should realize the Canada Health Act. This firewall report recognized our need for national that, and get on board.”♦ mentality continues to reflect the standards of care, national targets of Released July30, 2004 attitudes of some Premiers, including health care delivery goals, a national home Ralph Klein and Gordon Campbell, care program, and a national pharmacare as they call for federal money with program. no strings attached.
Volume 24, Number 2 - Fall, 2004 Medical Reform 3 PUBLIC FUNDING, NOT FOR-PROFIT DELIVERY: HELP FOR UJJAL DOSANJH
he Medical Reform Group, an understands the importance of this rates are higher, and charges increase, organization of physicians evidence.” when investor-owned private for- Tdevoted to maintaining a high “With Premiers like Klein, profit companies deliver care. quality publicly funded, universal health Campbell and Charest asking the federal For-profit corporations make care system, pledged today to help government to butt out on issues like money by diverting resources away federal Health Minister Ujjal Dosanjh enforcement of the Canada Health Act from patients and into the pockets of deliver on his commitment to stop and investor-owned for-profit delivery, their shareholders. Non-profit clinics creeping privatization. The MRG’s letter Dosanjh needs all the help he can get,” and hospitals are able to spend less to Dosanjh applauds his goals, and added another MRG spokesperson, Dr. money on marketing and admini- encourages him not to back down in the Rosana Pellizari. “Our doctors’ group stration, and therefore spend more face of provincial intransigence. has the credibility to let people know that money on patient care. Yet, right-wing Minister Dosanjh has said he wants Dosanjh is on the right track, and the Premiers, including Gordon to “stem the tide of privatization and Premiers are not.” Campbell and Ralph Klein, want to expand public delivery” of health services. Public funding of health care, as increase investor-owned delivery of The MRG supports these goals, and Canada now has for physician and care in hospitals, surgical clinics, believes the group can help make them hospital services, is both equitable and diagnostic test facilities, and home happen. efficient. When the majority of funding care. “MRG members have conducted is private, as it is for prescription drugs, “Canadian health care is the systematic literature reviews that have inefficiencies abound and costs explode. hanging in the balance,” Dr. Dhalla confirmed increased death rates and Studies published in the top concluded. “The MRG will help higher costs in investor-owned for-profit medical journals show that outcomes are Dosanjh ensure the outcome is what health facilities,” said MRG spokesperson better and costs are lower when private Canadians want, and need.♦ Dr. Irfan Dhalla. “The MRG can help non-profit organizations like Canadian Released August 3, 2004 the Minister by ensuring the public hospitals provide health services. Death
THE PREMIERS’ ANNUAL THEATRICAL PERFORMANCE: CONSENSUS MASKS CONFUSION Michael Rachlis
ast week, Ontario Premier home of the Shaw Festival. In keeping parted, the premiers were best friends Dalton McGuinty hosted his 12 with the setting, the conference featured and many of the advocacy groups had Lprovincial and territorial a plot twist, unlikely stars and a surprise joined in the love-fest. colleagues in historic Niagara-on-the- ending. Perhaps fittingly, the premiers’ British Columbia Premier Lake, Ont. theatrical performance may well trump Gordon Campbell fired up the love On Oct. 13, 1813, British Maj.- any history that might have resulted from train with the idea that the feds should Gen. Roger Sheaffe marched his troops their discussions. take over the costs of provincial drug from the town’s garrison to reinforce On Wednesday afternoon, the plans. When Campbell became Gen. Sir Isaac Brock’s men who were premiers arrived to the sound of thunder premier, B.C. had the country’s most losing ground against the invading and loud protests against privatization. generous drug plan. But three years Americans at nearby Queenston Despite McGuinty’s attempts at pre- of cutbacks have slashed coverage. Heights. The British/Canadian forces meeting interprovincial diplomacy, the No doubt he plans further cuts if he won and as a result we have medicare premiers were still deadlocked on the big- is re-elected next year. Why not just and annual premiers’ meetings. ticket issues of for-profit care and unload the political and economic Now Niagara-on-the-Lake is accountability to the feds for new money. costs onto Ottawa? known more as the picture-postcard But by Friday afternoon, the clouds had (continued on page 5) 4 Medical Reform Volume 24, Number 2 - Fall, 2004 THE PREMIERS’ ANNUAL THEATRICAL PERFORMANCE: CONSENSUS MASKS CONFUSION (continued)
Coincidentally, the Ottawa- rendition of Age of Aquarius, followed voters if this so-called policy success based Canadian Federation of by O Canada. resulted in massively increased user fees Nursing Unions brought three Even Quebec Premier Jean for most Canadians with public drug recommendations to Niagara-on-the- Charest’s ritualistic assertion that Quebec coverage. Of course, the feds could Lake, and one of them was for a would continue to run its own plan — “level up” coverage to the best anywhere federal takeover of provincial drug while Ottawa would be expected to pay in the country, and the final tab would programs. Toronto economist Dr. for it — passed with barely a murmur be more than $10 billion. Armine Yalnizyan, who authored the of discontent. CFNU president Silas was Unfortunately, that’s not the end CFNU report, sensibly noted that in a justifiably celebratory mood. Her of the cash controversy. The premiers Ottawa already sets most of the rules organization’s short paper had provided also want Ottawa to cover 25 per cent for drug therapy in this country, the foundation for the most surprising of overall provincial health-care including writing the rules for licensure turn in federal-provincial-territorial expenditures with their Canadian Health and patent protection. Ottawa could relations in a decade. Transfer (CHT). If drug spending would buy the country’s drugs in volume and But like any grand plan, the devil no longer count as provincial spending, lower prices through tough nego- is in the details. And this one has potential then Ottawa would have to pony up at tiations with the manufacturers. demons in every nook. First, and most least another $2 billion. Finally, the Australia, another parliamentary importantly, even a conservative version premiers are also unhappy at the federation, bulk-buys its drugs and has of the premiers’ plan would cost billions equalization program and want another the lowest drug costs of any wealthy more than Ottawa has been prepared to $3 billion-plus for this item. Mais oui, they country. spend. The premiers want Ottawa to want all this money without any strings Dynamic CFNU president pick up the entire cost of provincial drug whatsoever. Linda Silas hails from New Brunswick plans, which totalled $7.6 billion last year While the premiers projected unity, and used her connections with Premier and are growing at more than 10 per discord was never far from the surface. Bernard Lord and Newfoundland cent a year. On the other hand, new The premiers are bitterly divided on the and Labrador Premier Danny federal Health Minister Ujjal Dosanjh role of the private sector in health care. Williams to lobby them. By Thursday was careful to use the phrase “catas- Mr. Klein continues to muse about why afternoon, a national pharmacare plan trophic drug coverage” when he talked Canadians can buy other commodities was the talk of the town. Provincial to reporters. Although he never quan- but not new hips. He would like to see delegates were visibly relieved as they tified the difference, the Romanow more for-profit care within medicare worked through the night and early Commission estimated that a catas- and non-medicare options as well. On morning on the details of the final trophic plan would cost roughly $1 the other hand, Manitoba’s Gary Doer communiqué. billion, assuming the feds would pick up and Saskatchewan’s Lorne Calvert are By Friday afternoon when the the tab for individual drug costs above opposed to for-profit contracting, even premiers met the media, the love-in $1,500 per year. if the public pays the bills. Of course, was in full flight. McGuinty declared Starting off negotiations $7 billion Klein had admitted to the Alberta press that the premiers had made history. apart is bad enough, but it may not be corps in June that his own caucus had Claiming to speak for baby boomers the biggest political hurdle for the plan. overturned plans to establish for-profit and Gen-Xers from coast to coast, he Provincial drug plans now vary orthopedic clinics in Calgary and noted that, as his parents had given considerably. Most provinces already have Edmonton. But the national media their children medicare, now he and better catastrophic coverage than usually don’t keep up with provincial his colleagues could pass pharmacare Romanow recommended, while some news and Klein played them like a violin, on to their children. Other premiers have none. Even if the feds did assume teasing them with his controversial layered on the good feeling. Alberta’s existing provincial plans, they would still language. Ralph Klein said it was a “stroke of have to come up with new money to The final communiqué reasserts brilliance.” Newfoundland’s Williams cover Canadians currently without that all provinces support the Canada enthused about a national vision. At catastrophic plans — or cut coverage in Health Act. Unfortunately, given the one point, it almost seemed they the other provinces. However, it’s difficult auditor general’s documentation of the would burst into a spontaneous to imagine the reaction of already-volatile (continued on page 6)
Volume 24, Number 2 - Fall, 2004 Medical Reform 5 THE PREMIERS’ ANNUAL THEATRICAL PERFORMANCE: CONSENSUS MASKS CONFUSION (continued) lack of federal oversight and action and the process. In May, the Canadian Patient health systems should focus on the premiers’ disagreements, it’s pretty Safety Study revealed that 10,000 to continually reducing waste and clear that this oath of fealty means less 25,000 Canadians die every year from improving quality, rather than simply and less all the time. adverse consequences from their hospital cutting or adding money. The true Accountability for federal cash stays. In February, an Ottawa group strategy for sustainability should be doesn’t bother Ontario or the six smaller showed that one-sixth of area seniors based upon providers delivering provinces. They are either ideologically were readmitted to hospital within 30 quality, patient-centred care from high- onside or so desperate for funding that days of discharge. Most of these quality workplaces. they would sing Dixie if the feds incidents could have been prevented with The premiers may have stage- promised more money for its perfor- better and cheaper community care. managed the Niagara-on-the-Lake mance. Jean Charest has budget problems Adverse effects of prescription drugs kill love-in, but now they have only a as well, but can’t appear to be any thousands and hospitalize tens of month to prepare for their next per- friendlier with Ottawa if he hopes to win thousands every year. Too many formance at the Sept. 13-15 first re-election. And, with oil touching $44 a Canadians wait too long for care, even ministers’ meeting in Ottawa. So far, barrel and Alberta’s debt almost history, though most delays can be fixed with their national pharmacare proposal Mr. Klein scorns even the loosest threads better management rather than more has dazzled the audience. But, it’s of accountability to Ottawa. Forget the money. unlikely that their masks of consensus tight strings. To be fair, premiers continue to will continue to disguise the confusion Unfortunately, the premiers paid talk about tactics such as primary health and controversy seething just below scant attention to the elephant at the care and home care. But, their reform the surface.♦ health-policy table. Poor-quality care costs language is parsed with “more, more.” First appeared in the Winnipeg Free Press, thousands of Canadian their lives every On the other hand, the international Thursday, August 5, 2004. year while wasting billions of dollars in literature increasingly recommends that ARE THERE HARD DATA ON WAITING LISTS?
he Steering Committee has been 2. Robert J. Blendon et al, "Con- respondents nationwide had to watching the waiting list fronting Competing Demands to wait longer than three months for Tdebate during and since the federal Improve Quality," Health Affairs, non-emergency surgery. There were election with some concern. To begin to Vol. 23, No. 3, May-June 2004, 119- no data on emergency surgery or address the data issues, member Irfan 35, comparing hospital executives’ emergency diagnostic testing. Dhalla recently forwarded several views from the same five countries. references we reproduce here as they may Compared to their international 4. The Western Canada Waiting List be of interest to others: counterparts, far more Canadian Project is a consortium of the 1. Robert J. Blendon et al. "Common executives feel that waiting lists have western provinces and regional Concerns Amid Diverse Systems," been getting longer over the last two health authorities and has an Health Affairs, Vol 22, No. 3, May- years. However, the executives’ interesting website with a lot of June 2003, 106-21, comparing patient estimates of waiting lists put Canada resources: http://www.wcwl.org♦ experiences in five countries (Canada, in the middle of the pack. US, UK, NZ, and Australia). Exhibit 7 focuses on patient perceptions of 3. A Statistics Canada summary of the waiting lists, and could easily be waiting list survey they did can be interpreted to argue that waiting list found at: http://www.statcan.ca/ problems are worse in Canada than Daily/English/040630/ in any of the other four countries. d040630b.htm. Seventeen per cent of
6 Medical Reform Volume 24, Number 2 - Fall, 2004 MRG URGES COLLEGE OF PHYSICIANS AND SURGEONS TO ELIMINATE BOUTIQUE MEDICINE Steering Committee member Irfan Dhalla has been monitoring the development of policy on block fees at the College of Physicians and Surgeons of Ontario and on July 19, 2004 sent the following letter to College President Dr. Barry Adams summarizing our concerns with the draft policy, set to come up for discussion in the fall of 2004.
hank you for writing to Dr. does make an inquirey is likely to be 1) In terms of the principles, the Gordon Guyatt asking for reassured by the physician (or the statement should deal with not only Tinput into the draft policy on physician’s support staff) that the block the magnitude of the fee, but the form Block Fees. The Medical Reform fee is in adherence to the College in which the fee is charged. This is Group is responding to this request guideline. obviously critical to the issue of block on behalf of Dr. Guyatt, and other 3) Patients are in an extremely fees. The factors that the physician members of the MRG steering dependent position with regard to their should consider are not only the nature committee. physicians. Very few patients will feel of the service provided and the ability The MRG congratulates the comfortable challenging their of the patient to pay, but the patient’s College on taking on this review, and physician’s practices with respect to dependent relationship on the on developing stricter guidelines block fees because of this dependent physician. regarding block fees. The MRG is, position. 2) The document should specify however, disappointed that the 4) The extreme shortage of that physicians cannot charge patients College has not decided to take what primary care physicians in Ontario at for the more conscientious provision we believe is the appropriate action, the moment substantially increases of an insured service, or for assuring which is to ban block fees altogether. patients’ dependency. Many Ontario greater availability of the physician to The fundamental reason the citizens now feel grateful if they have provide an insured service. To be College should ban block fees is that a primary physician at all, and are even specific, clinicians should not be able whatever regulations the College more unlikely to challenge practices to charge for working harder to gain establishes for block fees, there will because this increased vulnerability. rapid consultation or testing, or continue to be numerous violations of 5) Those for whom block fees are ensuring round-the-clock availability, the regulations. Continued violations most problematic, the poor and or ensuring longer appointments and are inevitable because adherence to the elderly, are least likely to have the more attentive responses. To be proposed regulations would require knowledge, skills and confidence absolutely clear, the document should a patient to either challenge a physician necessary to challenge physicians’ include examples of such current in his or her office or to complain to practices with respect to block fees, practices that should be clearly the College. either in the office or in a formal specified as unacceptable. Physicians will be able to violate complaint to the College. 3) The provision that a physician the regulations with impunity because As a result of the certainty of must not offer to provide preferential patients will not challenge physicians’ practices in violation of the new services to a patient who agrees to pay practices with respect to block fees, guidelines continuing, we strongly a block fee should certainly be and will not report violations to the advocate that the College ban block fees, included. College. The reasons patients will not and aggressively advertise the banning of 4) The practice, highly publicized in challenge physicians’ practices with block fees to physicians and to the general the Globe and Mail and the Hamilton respect to Block Fees or report public. The banning of block fees will Spectator, ...of charging large annual violations include the following: be a policy that the public will be able to fees of over $1,000 for services 1) Patients will be unaware of understand. The regulations as proposed including “a detailed medical the regulations. will not. workup,” “a customized health care 2) Clinicians will choose to Should the College reject the plan,” and “24/7” access should be interpret the regulations as being MRG’s plea to ban block fees, the College explicitly labelled, and explicitly consistent with their current must do all it can to minimize the banned. This kind of practice has been practices, which in many cases will violations of the new standards that will referred to in the United States as violate the new regulations (and inevitably persist. With respect to the “boutique medicine” or “luxury indeed, at least the spirit of the old document itself, the following may help primary care.” ones). The very unusual patient who to minimize violations: (continued on page 8)
Volume 24, Number 2 - Fall, 2004 Medical Reform 7 MRG URGES COLLEGE OF PHYSICIANS AND SURGEONS TO ELIMINATE BOUTIQUE MEDICINE (continued)
Boutique medicine allows physicians 6) The regulations should specify if the College recruits partners in the to aim for practices with 150 patients that doctors who offer patients the effort to get the word out. Such each, rather than the customary 1500 block fee option are required to post partners could include the government or so. It is not suf-ficient to include in their office a CPSO-designed of Ontario, and the Medical Reform provisions – as the current document poster outlining what services cannot Group. does – that if appropriately interpreted be included in the block fee, and In summary, the Medical will lead to the termination of specifying that boutique medicine is a Reform Group believes that the boutique medicine. It is highly likely violation of professional conduct. CPSO should ban block fees. If block they will not be appropriately This poster should be in a highly visible fees continue to be permitted, we interpreted. Thus, the explicit labelling location and should also explain how suggest modifications the new of this form of practice, and clear patients could file a complaint if they proposed block fees policy. The statements of its unacceptability, are feel their doctor is violating the policy. MRG further recommends that the absolutely necessary. To minimize the likelihood of College inform all Ontario physicians 5) A major omission of the revised violations, once the new regulations are of the changes, ensure that those policy is that it does not specify a in place, the College should organize a physicians currently known to be maximum allowable block fee. This campaign to inform both physicians, and violating the new policy are fully aware fee should reflect the value of non- the public, of the new regulations. The of their misconduct, and aggressively OHIP services included in the block College should make an effort to inform the public of the changes. fee (for example., telephone advice, immediately notify those known to be Thank you for the opportunity telephone prescription reviews, form practicing boutique medicine that their to participate in the block fees policy completion, etc.) and should be no current practice is professional review. Please feel free to contact us more than $100. misconduct. The public aspect of the if you would like more information media campaign will be most effective or clarification of our position.♦
PHARMACARE IN THE PUBLIC INTEREST
discussion of pharmacare must the interests of the pharmaceutical and Canada and leave everything else to not deflect attention away from insuraqnce industries. the provinces. Provincial governments Aan essential issue that divides pre- The Canadian Health Coalition's like Alberta, Quebec, Ontario and B.C. miers, namely, the need to curb the pri- key message and recommendations have would be free to privatize all the other vatization of health care services in not changed. Medicare is sustainable, components of national public health Canada. The key condition for federal for-profit care is not. The federal gov- care (hospitals, diagnostics, elective sur- funding must be a prohibition on using ernment must secure the long term fi- geries, home and long-term care...) public funds to privatize the delivery of nancial stability of Medicare and buy the Pharamacare is an important health care services. Health care belongs changes needed--including public cov- element but only one of several con- in the public and not-for-profit sectors, erage for essential medicines--by stitutive elements needed to sustain and not in the hands of unaccountable pri- restoringlong term funding and enforc- expand pubic health care across the vate investors. ing the cirteria and conditions of the country. Canadians do not want a A national pharmacare plan must Canada Health Act. Pharmacare plan if it undermines the not come at the expense of the other The Premiers' Action Plan for other elements of the national health constitutive elecments of a sustainable Better Health Care issued on July 30, 2004 care system. (See the CHC Briefing national health care system. This briefing is focused almost exclusively on a Na- Note "Medicare is sustainable, for profit care note has been prepared to discuss the tional Pharmacare Program.It calls for is not," and the list of 8 recom- elements of a pharmacare plan in the the federal government to assume full mendations to ensure Medicare's public interest, as opposed to a plan in responsibility for pharmacare across sustainability. (continued on page 9)
8 Medical Reform Volume 24, Number 2 - Fall, 2004 PHARMACARE IN THE PUBLIC INTEREST (continued)
National Objectives of costs, provide universal coverage to language which list possible Pharmacare in the Public essential medicines and improve alternativesto taking the drug where Interest prescribing practices. Access to essential appropriate The goals of a national phar- medicine is a human right that takes macare plan in Canada should be: precedence over intellectual "property 5. Enforce the Ban on Consumer Advertising 1. Equity of Access rights" and walth creation for of Prescription Drugs 2. Safety and efficiency pharmaceutical giants. • institute adequate sanctions to prevent 3. Cost containment To ensure equity, appropriateness prescription drug advertising aimed at It is time to extend the prin- and sustainability for a natinoal the public, and establish strict rules ciples of Medicare and the Canada pharmacare plan, cost control measures govening industry promotion and Health Act to essential medicines. are essential. These include drug patent marketing to health professionals Currently, Medicare covers less and reforms, strict controls on drug less as care is shifted out of hospital marketing, promotion, dispensing fees, 6. Accountable and transparent Decision settings. Millions of Canadians are bulk purchasing, and paying only for Making denied access to essential medicines what works safely and is cost-effective. • public plan pays only for what works, when they need them because of not for useless, dangerous, or financial barriers. 10 Elements of Pharmacare in the unnecessarily expensive new drugs; Canadians currently have for Public Interest • public access to all information upon drug delivery what the Americans 1. Universal Public Drug Insurance Plan which decisions on drug apporvals and have for medical care. It's a mix of • first dollar coverage; no user fees, co- financing are made, including pre- public and private payment instead of payments or premiums clinical and clinical data a single payer; it is not universal but • fully public insurance plan to control inequitable and dysfunctional. Patents costs (no private "partnerships") 7. National Prescribing Service and pharmaceutical profits are • integrate support for for protected instead of the sick and the 2. National Formulary for Essential Drugs appropriate drug prescribing into health poor. The current system is designed • use WHO list of 329 essential drugs care system to drive up drug sales and profits-- as a model, with decision on inclusion • work through College of Physicians regardless of health outcomes. Access based on evidence of efficacy, safety and Surgeons, College of Family to new and expensive treatments is and comparative cost-effectiveness Physicians limited to those who can afford them. (More than 5,000 drugs ae marketed This approach to medicine is unethical in Canada) 8. Establish Public Drug Information System and unsustainable. • formulary committee to make • independent comparative infor- Economically disadvantaged allowance for special needs mation on drug and non-drug segments of society and entire regions • bulk purchasing with pargaining treatments of the country are suffering because power to reduce prices • of this U.S. style approach to medi- fund pharmacists to run a medicine cine. The problem will get worse if information line 3. Patent Reform to End Abuses Canada continues to encourage • access to essential medicines has monopoly drug patents on 9. Systematic Follow-up of Treatment primacy over monopoly drug patents pharmaceuticals and biopharma- Outcomes • ceuticals. As an illustration of the change current regulations and • compulsory adverse reaction perverse effects of the federal prohibit 'evergreening' of patents reporting by physicians approach to health as a commodity to be commercialized--a drug com- 4. Safety and Transparency Paramount in 10. Regulations for Ethical Conduct in Clinical pany is now charging $3,850 per Drug Regulation Trials and Research person for a genetic test for breast • replace Health Canada's Therapeutic • monitor and enforce national rules cancer. There is wealth creation. But Products Directorate with an for ethical conduct in clinical trials and what about treating the sick. accountable and transparentregulatory health research♦ Pharmacare in the public agency--free of conflict of interest This fact sheet was released by the Canadian Health interest would lower overall drug • proper safety warnings in plain Coalition August 23, 2004.
Volume 24, Number 2 - Fall, 2004 Medical Reform 9 CAN WE GET NATIONAL PHARMACARE NOW? Joel Lexchin summarizes the issues around national pharmacare for a recent e-mail list
y reading is that Romanow Under a first-dollar national that would then work through the Royal rejected the plan for two pharmacare plan overall drug expenditures College of Physicians and Surgeons and Mreasons. First he sees this as would be less than they currently are even the College of Family Physicians. an attempt by the provinces to off-load allowing for increased use because there Finally, of course, aside from the a huge expenditure on the federal would not be any direct charges to patients. financial aspects of a national plan there government - no provincial sharing of The savings would come from lower is also the question of equity. Right now responsibility. Second, he is worried administrative costs (large provincial plans there is very little of it when it comes to about the overall cost of the proposal. like the ones in Ontario and Quebec have drug insurance: out-of-pocket expenses for The response below is largely administrative costs of 2 to 3 per cent the elderly vary wildly depending on what about the economics of a national versus commer-cial plans costs of 8 to 9 province you live in. The working poor pharmacare plan not the politics. The per cent) and lower purchasing costs. tend to lack coverage in almost all problem that the feds face is that if However, the latter would require the provinces and even in Quebec where they they offer a cost-sharing program then federal government to take an aggressive get coverage there are huge copayments. the provinces would reject it because stance in bargaining with the drug Private drug insurance is actually a of past experience with federal pro- companies in order to get lower prices. regressive form of taxation. Under vincial cost sharing programs in health Australia does this and achieves Canadian tax legislation the portion of care - i.e., unilateral changes by the prices on new drugs that are about 9 per health insurance that is paid for by the federal government. cent lower than ours. Without aggressive employer is tax free. By subsidizing The feds are very unlikely to bargaining by the government a national insurance through the tax system, the value agree only to change programs with the Pharmacare plan would be a profit of the subsidy depends on the person¹s consent of the provinces since this bonanza for the pharmaceutical com- marginal tax rate. What this means is that would give up too much control. That’s panies larger markets and same prices. the more you make the larger your subsidy. probably why Dosanjh is only talking However, aggressive bargaining is not the According to Marc Stabile, an economist about a catastrophic program. It only only thing that would be necessary. The at the University of Toronto, the subsidy commits the federal govern-ment to a idea that a Pharmacare plan should only for someone in the highest 20 per cent limited expenditure. cover essential drugs is a good one but I income bracket is 3 times what it is for There are probably a couple of think that for a wealthy country like someone in the lowest 20 per cnet income solutions to this problem. One is simply Canada the WHO essential drugs list would bracket. to offer a 50-50 cost sharing program probably be too restrictive -- it could leave Canada long ago rejected the idea to the provinces. For provinces that sign people with uncommon diseases without that there should be a difference in on to this program all drugs covered coverage since drugs for these conditions coverage for hospital and doctors¹ services would be bought by a single purchasing tend to be relatively expensive and aren¹t and we got Medicare. However, when it agent. If the government was aggressive included on EDLs. comes to outpatient drugs we have adopted enough this could lower prices by We would require a national the American model of coverage for some probably 10 to 20 per cent. The lower formulary committee to come up with a but not others, deductibles and prices plus the universal coverage might list of drugs to be included plus there would copayments. If we look south of the create enough public pressure to force have to be some kind of allowance made border we can see what the consequences the provinces to sign on. for people who genu-inely need products of this model are for the American health A second possibility could be the that are not on the formulary. Another care system. federal government running the aspect that would have to go along with a To those who say that none of the program but using progressive national Pharmacare plan is a program to countries that have drug insurance have premiums to finance some of the cost. pro-mote appropriate prescribing. Such a first dollar coverage there are a couple of Third would be a federal pro-gram that program might generate considerable answers. In England, although there are only pays for a list of “essential drugs” friction with the provinces since it might copays there are also broad exemptions that would be developed by an be considered interference with the from the copays such that 80% of the independent medical committee. If the practice of medicine and would therefore prescriptions written are exempt. Wales is provinces wanted coverage for things be intruding on provincial toes. One ap- going a step further and will eliminate all outside these essential drugs that would proach might be for the federal govern- copays by 2007. It can be done if the be up to them. ment to fund a National Prescribing politicians have the gumption to act....♦ Service (similar to the one in Australia)
10 Medical Reform Volume 24, Number 2 - Fall, 2004 IS THERE A LOGIC TO DELISTING? Ahmed Bayoumi summarizes the issues discussed in a recent Steering Committee review of yet another round of delisting of procedures from the OHIP fee schedule.
he Ontario budget of May 2004 health insurance system is eminently that some activities “would be removed three services reasonable. The circumstances under eliminated or done by others to free T(chiropractic services, physio- which insured services were once up funds to reduce the deficit or to therapy [except for seniors through deemed appropriate for coverage under invest in new and better ways of homecare and long-term care facilities], the health insurance plan are never delivering public services”. and routine eye examinations for people constant – technology advances, new 20 to 64) from the list of insured services evidence about effectiveness accumulates, Yet the process of prioritizing under the OHIP, effectively privatizing prices of services change, and the what should be covered by the these services. A reasonable expectation available budget for health care may provincial health care plan is much is that these services will be readily increase or decrease. more complex than this simple available only to individuals with sup- It would be irrational and statement suggests and involves a plementary health insurance, usually unfortunate if coverage decisions could number of considerations including through their place of employment, and never be revisited. So, as a general efficient use of resources, the those wealthy enough to pay out of principle, it makes sense to look at the magnitude of health gains, and the pocket. People without extra insurance services and consider adding some and distribution of benefits. or ready cash will simply have to go simultaneously removing others. Indeed, without. at the same time as the budget delisted Is there any evidence that such The latest items to be delisted can some services, it listed three new considerations are considered in be added to a now lengthy list of services immunizations for chickenpox, coverage decisions? that were once covered by health meningitis and pneumonia. insurance plans but no longer are, The delisted services including reversal of sterilization, general This coupling of delisting old enumerated above generally share two anaesthesia for uninsured dental services and listing new ones leads considerations. First, many of the procedures performed in hospital, to the second question – what are the issues they address are considered routine newborn circumcision, removal criteria for removing elements from relatively minor or discretionary (such of tattoos, repair of deformed earlobes the list? as travel clinics) or may seem to be resulting from use of pierced earrings, more “lifestyle” and less strictly removal of acne pimples, injection of Are they the same as the criteria “health” issues (such as cosmetic varicose veins, otoplasty to correct for adding new services? The health surgery). Yet this classification has two outstanding ears, removal of benign skin services literature has several guidelines significant limitations. lesions, removal of port wine stains in for what should or should not be First, some people may have adults, in vitro fertilization, weight loss covered, including considerations of cost- significant concerns about classifying clinics, travel assessments, immunization effectiveness (the amount of money spent some issues as minor or non-health- clinics, insertion of testicular prostheses, relative to the amount of health related – such as infertility. Second, penal prostheses and intracorporeal obtained), equity (providing health care the health of individuals who use the injection for erectile dysfunction, and to those who need it most), and medical services can be very heterogeneous. others. necessity (defining what is needed to For example, some individuals who In looking at this list, several maintain health and deciding coverage may potentially benefit from questions come to mind. Does delisting decisions on this basis). physiotherapy may have minor aches make sense? What are the criteria for Unfortunately, the criteria by whereas others could be in severe pain. removing elements from the list? What which listing and de-listing of services A disturbing observation is that these process should be used in deciding what are conducted is unclear. The government considerations are more relevant for to insure and not insure? has promised a “more transparent and the recently delisted services. accountable” budget and committed The second, and more Does delisting make sense? itself to a process of priority-setting. The troubling, criteria that delisted services government’s Town Hall budget seem to share is that they are politically We believe a periodic review of consultations state that citizens recognize what is and is not covered under the (continued on page 12)
Volume 24, Number 2 - Fall, 2004 Medical Reform 11 IS THERE A LOGIC TO DELISTING? (continued)
expedient. Most insured services in decision making without also necessary if services to be delisted Ontario are delivered by physicians – considering the values Ontarians have implications for a broad- a group in active negotiations with the have with regard to how services based population. government regarding the fee schedule are distributed. For example, A precedent for most of these when the budget was tabled. Notably, Ontarians may accept having some criteria already exists – insurance of drugs none of the three recently delisted less efficient services insured if they under the Ontario Drug Benefit services are delivered by physicians. promote health equity gains. Yet Formulary. Drugs are considered after Together, these observations raise the vague dis-cussions about core an impartial committee evaluates the worrisome suggestion that the values are unlikely to be helpful. evidence and makes recommendations government delisted services Instead, priority setting exercises to the minister. Appeals for uninsured according to what they could get need to be detailed and tackle drugs are handled through individual away with, rather than according to difficult tradeoffs. Such requests (Section 8) mechanisms. While criteria that flowed from a priority consultations need to be explicit the ways in which decisions are made are setting exercise. about which values are important to not always clear, the process for deciding Ontarians and how these values are about insured services could be even If the current process is opaque, reflected in insurance decisions. more transparent than that for drugs, and perhaps open to political since the proprietary rights of patent manipulation, is there an · Establish a transparent public holders (such as drug companies) are alterative? process for decision making. rarely at issue when considering coverage The process for decision making should decisions. What process should be used be open, accessible, and free from Delisting may be occasionally in deciding what to insure and not undue influence by any particular necessary – and sometimes desirable – insure? We believe the following group of providers. The best way to have a rational and efficient health considerations are important when to ensure this is to establish an insurance system. Nevertheless, delisting considering what services to remove independent advisory committee, will often be viewed as a loss and, given from the insurance list: with broad representation from the natural aversion to such situations, may community members and experts, be politically difficult. The worst delisting · Examine the evidence base for which will issue recommendations decisions will be those that are seen to a service’s effectiveness and to the minister about appropriate be politically expedient rather than cost-effectiveness. services to be listed. principled. We believe a decision about what to The MRG believes that insure should be evidence-based, · Incorporate mechanisms that establishing criteria to consider listing of including data on both clinical address coverage in exceptional services and incorporating broad public effectiveness and economic circumstances. input will help improve the quality of efficiency. A rich field of tech- The services most recently delisted the decisions that are made. How do nology assessment exists for share the characteristic that affected the most recent decisions stack up against synthesizing evidence, identifying individuals do not fit a ‘typical’ our criteria? It’s impossible to say without priority areas for future research, pattern. For each service, it is easy taking the time to evaluate the evidence and evaluating the costs relative to imagine an individual for whom and consider Ontarians values. It seems to the effects of the inter- the service represents a major clear, however, that the process of ventions. We believe such health service which they will have deciding what is insured under OHIP is information is a necessary pre- to do without. Although there is a in need of reform.♦ requisite for coverage decisions. limited and cumbersome mechanism of appeal for asking · Establish priority-setting OHIP to insure otherwise exercises that assess public uninsured services, a better values in meaningful ways. mechanism for dealing with Determinations of effectiveness and individual reviews for exceptional efficiency are insufficient for circumstances will become
12 Medical Reform Volume 24, Number 2 - Fall, 2004 PUBLIC HEALTH AND WOMEN'S REPRODUCTIVE HEALTH RIGHTS Rosana Pellizzari
omen in many parts of the Since the 1860’s, the Roman Catholic introduce new legislation later in the world lack access to basic Church teaches that life begins at the time year, increasing access to EC gained Wsexual and reproductive rights. of union between sperm and ovum. To the informal support it needed to get This is something with which I have had interfere with this process is to potentially it on to the policy agenda. first hand experience, the most recent, a breech constitutional law in Costa Rica. Although physicians in Costa three month field placement with the A recent study funded by the Pan Rica were not prescribing EC, Centre for Research in Women’s Health, American Health Organization found that opportunities existed to promote its University of Toronto, and the Centro none of San Jose emergency department use. Costa Rica’s Planned Parenthood de Investigaciones en Estudios de la workers had provided sexual assault association is committed to using its Mujer, Universidad de Costa Rica victims with EC. To fill this gap, national international connections to bring a (CIEM) in San Jose, Costa Rica. non-governmental groups have trained Levonorgestrel product to market. From January 3rd to March 31st, 911 operators to refer victims to NGOs Neighbouring countries such as my work on the issues of violence against rather than hospitals for information on Nicaragua and the Dominican Repub- women, sexual assault and access to how to access EC. Since a dedicated lic already have a fairly inexpensive emergency contraception served as a product is not currently licensed in Costa product available. In addition, women reminder of how important it is to take Rica, women must purchase birth control can purchase oral contraceptives from a human rights approach to basic public pills and follow the “Yuzpe” method. pharmacists in Costa Rica without a health issues such as women’s access to Not as effective as Levonorgestrel doctor’s prescription. health care. Lack of access, whether and associated with more side effects, Here in Canada, only a handful secondary to economic, geographic, the Yuzpe method involves taking two of provinces have made Levon- religious or social barriers, translates to doses of 2-4 oral contraceptives 12 orgestrel available “behind the lack of choice for women in Costa Rica hours apart. However, to many Costa counter”. Health Canada announced and elsewhere. Rican women, the cost of purchasing an earlier this year, its intention to make Although Costa Rica is one of the entire package of Ovral, or it equivalent, Levonorgestrel available to all more prosperous and stable countries in is prohibitive. Recent Canadian consensus Canadian women without pre- Central America, it is politically guidelines published by the Society of scription, through pharmacists. conservative and still dominated by the Obstetricians and Gynecologist of Research headed by Sheila Dunn here powerful Roman Catholic Church, which Canada recommend Levonorgestrel, in Ontario has shown that young managed to establish a foothold in the and not Yuzpe, as the drug of choice women will access EC quickly and country’s constitution. It is this foothold for EC. A review of the published effectively from pharmacies, if that has shut down the country’s in vitro research shows that Levonorgestel can directed by a 1-800 hotline to an open fertilization program, eliminated the be taken in one dose, rather than two, and participating pharmacy in their Ministry of Health’s sexual education up to 120 hours after unprotected community. program, banned abortion, and intercourse. Awareness of EC in Costa prevented the introduction of emergency By the end of January, I had joined Rica, although growing, is limited. contraception (EC). the emergency contraception (EC) University students comfortable with Although the International workgroup (a coalition of government using the internet are beginning to Federation of Gynecologists and and non-governmental representatives) request it. In preparation of the Obstetricians (FIGO) has made it clear and assisted with the development of a national forum, links to the Latin that is unethical to deny victims of sexual position paper on EC in Costa Rica. A American Coalition on Emergency violence treatment with EC, physicians meeting with the Minister of Health on Contraception, International Planned in Costa Rica are fearful that, by pre- February 2nd to discuss a national strategy Parenthood, the Costa Rican national scribing EC to women, they will be and gain approval led to approval to society of Obstetricians and found guilty of breaking existing laws hold a forum for key stakeholders on Gynecologists, and the University of that guarantee protection to all unborn March 24th, 2004. Given the Ministry’s Costa Rica were cultivated and children from the time of conception. agenda to promote sexual rights and (continued on page 14)
Volume 24, Number 2 - Fall, 2004 Medical Reform 13 PUBLIC HEALTH AND WOMEN'S REPRODUCTIVE HEALTH RIGHTS (continued)
strengthened. Toronto’s Dr Sheila violence and strengthen the health sector’s who need it. Many public health units will Dunn agreed to attend the forum and response. provide it at subsidized prices, or even assist with physician meetings at three Unfortunately, the Centre for free to women who can’t afford to of the four hospitals in San Jose. Research in Women’s Health has just purchase it. But, for women in towns During the week of March recently made a decision to discontinue too far from a clinic, or too small for a 22nd to March 26th, Dr Sheila Dunn all its international work and the Costa pharmacy, EC remains inaccessible. and I held hospital rounds with Rican project, among others, is on the Public health units have a major physicians, conducted a training chopping block. For the University in role to play to bridge those access gaps, workshop for providers working Toronto, as for Canadian women, sexual particularly for young women who face with students and presented at the rights are a given, and access to care is even bigger barriers. Sheila Dunn’s work National Forum on Emergency more or less guaranteed. That is not the has demonstrated that if young women Contraception. Following the forum, case for women in Costa Rica. The recent are assisted in accessing post-coital the Minister of Health requested a decision is particularly lamentable, given contraception in emergencies, pregnancies briefing document on EC, which we how little of current international research and abortions can be prevented. helped Ministry staff prepare and is spent on matters that are of importance A hotline, pharmacies open 24 submit on March 29th. to poor women and children. hours, public health nurses, proactive What was instrumental in Back home, I find myself physicians who provide all their moving the agenda forward was the working in rural Ontario. A recent article contracepting patients with advance fact that I was a physician. As an about me in the Listowel Banner prescriptions for Levonorgestrel, or even international expert, Dr Sheila Dunn prompted the local Right to Lifer to write better, Health Canada’s proposal to was extremely valuable in using her a letter to the Editor, denouncing my amend the Food and Drug Regulations expertise and credibility to dispel position on emergency contraception and – Schedule 1272 regarding Levonor- myths and build confidence. The asserting that EC is dangerous and gestrel to make it a non-prescription University of Toronto had, in its unsafe. product are all important pieces of an partnership with Costa Rica, an The lies and distortions are almost, effective strategy. At least here in Canada, excellent opportunity to support the word for word, identical to those being preventing pregnancy is not an illegal act. ongoing work of institutions to plan, propagated in Central America. But at For that, we should all be grateful.♦ implement and evaluate inter-sectorial least in Canada, women have a choice efforts to protect women from and Levonorgestrel is available to those NEW BOOK ON SOCIAL DETERMINANTS OF HEALTH e recently received the eleven social determinants of health distribution, social safety net, social following notice from across Canada, and provides an analysis exclusion, as well as unemployment and WDennis Raphael, health of how these determinants affect employment security. Gender, and how policy professor at York University, Canadians’ health. In each case, the book its meaning is constructed within for a new collection of articles entitled explores what policy options would Canadian society, is another important Social Determinants of Health: contribute to better health outcomes, and social determinant of health. All Canadian Perspectives. how to ensure that these options are contributors systematically consider how The collection, featuring Pat pursued. it impacts upon and interacts with their Armstrong, Andrew Jackson, Michael Eleven critical areas are specific social determinant of health to Rachlis, Martha Friendly, and many investigated: Aboriginal status, early life, influence health. others, summarizes how socio- education, employment and working The volume is $45.95 from economic factors affect the health of conditions, food security, health care Canadian Scholars' Press in Toronto.♦ Canadians, surveys the current state of services, housing, income and its
14 Medical Reform Volume 24, Number 2 - Fall, 2004 ALL OUR CHILDREN Anne Mullens
ow a research project in his own Chair in Population Health and Human questionnaire didn’t identify individual backyard turned one health Development. He is also a fellow with children, but rather measured the Hresearcher into a social activist the Canadian Institute for Advanced group as a whole on physical health If a virulent microbe was making Research. and well-being, social competence, children sick and undermining their health These days he finds himself emotional maturity, and language and for the rest of their lives, everyone would overseeing a busy research agenda while cognitive development. Amazingly, expect the leading scientific expert in the donning the cap of social activist to help some 97 percent of the teachers field to become an activist to eradicate change B.C. communities, especially to responded and completed the the bug. improve their social programs and neigh- questionnaire. That’s the analogy British bourhoods in ways that enhance early Dr. Hertzman’s team analysed Columbia epidemiologist Clyde childhood development. While those the results, comparing the “learning Hertzman uses to explain his transition dual roles might make som e academics readiness” factors to characteristics from detached health researcher to social uncomfortable, to Dr. Hertzman it is a such as income level, affordability of activist – only in his case the “bug” isn’t natural combination and one that gives housing in the area, neighbourhood an infectious microbe, it is early his research focus and application. crime rate, the number of parks, play- childhood experiences and their impact Usually social science researchers grounds, libraries and childcare throughout life. comment on what they observe, but they options, and other measures of social “It is a bit more political than rarely take their research to the next level cohesion at the neighbourhood level. dealing with an infectious agent where – designing research programs to spe- The researchers then plotted the results you are convincing surgeons to wear cifically gather evidence that can be used on maps of the city. The maps masks or people to wash their hands,” to fuel change. Dr. Hertzman’s team revealed distinctive relationships says Dr. Hertzman, a professor in the gives community workers the kind of between the level of school readiness department of health care and epide- evidence-based information that allows in children and the characteristics of miology in the University of British them to plan strategically and “make the the neighbourhoods they lived in. Columbia’s faculty of medicine. “The right changes,” he says. The team concluded that not logical outcome of my research is to talk Earning degrees in medicine, only do parental income, education about how we structure society and community medicine and epidemiology and parenting style have a strong whether we can alter social arrangements from McMaster University in the 1970s, influence on whether children are that could improve the lives of kids in Dr. Hertzman has been at UBC since ready for schooling, but that neigh- those early years.” 1985, researching the socioeconomic and bourhood characteristics do, too. For Dr. Hertzman, 51, has long psychosocial factors that influence example, areas with a variety of good specialized in the social determinants of people’s health. resources for children – libraries, health – how factors like income, In January 2001, however, one playgrounds, preschools, child care, education, employment and upbringing specific project caused Dr. Hertzman’s community centres and enrichment affect how healthy we are. In particular, life to change dramatically and programs – correlated to better- Dr. Hertzman has become internationally completed his metamorphosis into a adjusted children who were more renowned for his work in early bona fide social activist for early prepared to learn. childhood development. He pioneered childhood development. For a year he Not surprisingly, the the concept of “biological embedding,” and his research team had been working proportion of children identified as where biological factors of early on the Vancouver Early Childhood less ready for school increased childhood fuse with the social and Development Mapping Project. dramatically as one moved from the psychological factors to influence a The research entailed asking all most affluent west-side neigh- person’s health into the adult years. He kindergarten teachers in the Vancouver bourhoods to the poorest east-end directs the Human Early Learning School Board to complete a checklist parts of Vancouver. But while the Partnership (HELP), an interdisciplinary questionnaire, called the Early biggest proportion of vulnerable network of early childhood deve- Development Instrument, to assess the children were in the poorest lopment researchers from B.C. children in their classroom based on neighbourhoods, in fact the biggest universities, and holds a Canada Research whether they were ready to learn. The (continued on page 16)
Volume 24, Number 2 - Fall, 2004 Medical Reform 15 ALL OUR CHILDREN (continued) CATHY CROWE-- PROGRESS number of vulnerable children were “The biggest part of the lesson spread throughout the city’s large to me is that, from an academic REPORT middle-class sections. That, says Dr. standpoint, the journals and other In the spring of 2004, Cathy Crowe received the Hertzman, is “a vitally important academics don’t care if you are dealing Atkinson Economic Award which permits her to finding,” because “if you concentrate with random samples rather than real pursue, for up to three years, my passions for nursing all your energy in the least-advantaged children in real neighbourhoods. But the and working on homelessness and housing issues. We've excerpted some items from her August 2004 group, then you miss the majority of world cares. By switching over to what newsletter, which attempts to report on the situation kids who are developmentally the world cares about we have been able as she sees it and stimulate discussion. delayed.” to create information bases that actually The maps were published in lead to structural advances and not just January 2001 in the Vancouver Sun. casual interest among scientists.” A rising sense of depression And his phone hasn’t stopped ringing Dr. Hertzman finds that the public raise this topic with tentativeness, but it’s important that we talk about it ever since. concern has given his work new impetus, openly. I have noticed how depressed, “It created a huge response more sources of funding and more I both physically and psychologically, organi- because people could see the interest from other researchers, zations working for the homeless have information so clearly, and it particularly PhD students who want to become. This is not the fault of any one represented their children in their do this kind of applied research. of us, but it is now a fact of life. neighbourhoods, rather than a “No research granting agency Many organizations serving the random sample of the population in would ever fund you to do the same homeless started in the last two decades. a hypothetical neighbourhood,” says research project, over and over again, in They assumed they would be doing good Dr. Hertzman. “They were the parents, 60 different communities. But now that work for a season or two and then the crisis the school officials, the neigh- we have this database, we have PhD would be resolved. As we know, what has bourhood planners, the politicians – students lining up to do secondary happened instead is that the problem has it created a level of interest that was research on a whole range of things with intensified and many organizations - way beyond normal.” traditional research funding.” ranging from Out of the Cold to more Suddenly he was deluged with For Dr. Hertzman, a father of formal social agencies - are serving two or requests to speak to a wide range of three grown children, there has been very three times the number of people that they groups, not just to fellow researchers, little downside: “Not only are you started with. but to school boards, Rotary Clubs, creating a research environment that These agencies often got underway Chambers of Commerce, various city supports social change, but you are in whatever space they were easily able to officials and various ministries in the creating an environment where young find, such as churches or other space that provincial government. Before the researchers can do their best work, with no one else was using. The facilities were newspaper story, “we pretty much more resources, more opportunities and old to begin with and often in poor had to beg the school board to let us more credibility.” condition, and they have only gotten do the research,” he says, but after the And not surprisingly, over the worse. The applications that are now being piece ran in the Vancouver Sun, all the years his findings directly influenced his made to improve these facilities with school boards in the province wanted own parenting style, particularly in the limited grants from the federal government him to examine their schools and interplay between “nature and nurture.” (through the Supporting Community neighbourhoods and were offering “The key corollary of my work is that Partners Initiative, SCPI, or “Skippy” as it the research money to conduct the for every child there are environments is called) are for changes like installing studies. and experiences which will give them the better toilets, improving floors, making the Over the last three years, Dr. best chance to thrive, but they will be heating function and so forth. The result Hertzman and his teams have mapped different for different kids. As a result, is that space which was in the first place the school readiness of all kindergarten we’ve been careful to tailor each of our only second rate, is being patched together. It feels depressed.. children in more than 60 school children’s early opportunities to their This can be seen in every kind of districts across B.C., creating a aptitudes and vulnerabilities.”♦ agency helping the homeless. Daytime database on how children are Reprinted with permission of the author and the drop-in centres, for instance, are developing in every neighbourhood in Association of Universities and Colleges of Canada overflowing. Not only are more people the province. from the August/September 2004 issue of using the services provided but they have University Affairs. (continued on page 17)
16 Medical Reform Volume 24, Number 2 - Fall, 2004 CATHY CROWE--PROGRESS REPORT (continued) higher service needs. Often these agencies there’s such a growing sense of depression. and federal leaders scheduled for mid- find they do not have enough staff It is depressing. September. The provincial premiers talk resources or physical resources on a day Depression in many cases actually about the need for more money to be by day basis. For example, many agencies impairs cognitive abilities – it becomes devoted to health care, and the federal are not able to provide enough food, both much more difficult to think clearly and leaders seem to agree, although they are because of limited food budgets and coherently. Choices seem more limited. sure to differ on the amounts and/or because of the huge demand. The crisis There is a rising sense of desperation. the conditions. which includes crowding and scarce Sometimes it can prompt individuals or If more affordable social resources results in trauma of various groups to lash out inappropriately or housing is made available, health care kinds – frustration, frayed tempers, and unwisely. Depression and vicarious trauma costs are sure to be reduced, so it increased violence. It feels desperate. impede our collective struggle for solutions. makes sense to link these two matters. Added to these burdens on agencies Many people with experience Governments should agree that more is the fact that certain aspects of the believe that the best “cure” for depression money should be available for community create pressure (aka is, when possible, to get engaged and affordable housing if there’s an NIMBYism) around these facilities to try become involved. Taking concrete action, agreement to spend money on health and contain their activities. It is as though even on a small scale, can be the best care. I’m not sure what the actual ratio the organizations that are trying to help medicine. While depression often prompts should be, but I’d venture this idea: for the homeless get the blame for the individuals or groups to become every extra four dollars spent on health, existence of the problem rather than being disengaged, the simple truth is that the best we should be spending one more dollar lauded for trying to respond to it. It feels response for this type of systemic on affordable housing, at least for the insecure. depression is to get active. Therefore, even next ten years. These conditions lead to vicarious small, local initiatives can be very This would mean that if an extra trauma, not only for homeless people therapeutic in that they may help people $4 billion is spent on health care each using the services but also for staff. Many to move beyond the depression to action year, then $1 billion should be spent on staff who have been working in homeless and solutions affordable housing. If $8 billion extra facilities have been doing so for much too We’ve faced difficult times in the is agreed to be the amount spent on long and understandably, the burnout rate past and engaged in terrific solutions that health each year, then $2 billion should is growing. Because of the increased mobilized Canadians and led to major be spent annually on affordable housing workloads and day to day crises, workers funding initiatives – the Rupert Hotel (The 1 Per Cent Solution!). What’s are less likely to be allowed to engage in Coalition, the Toronto Coalition against amazing about this kind of formula is community-wide activities or actions which Homelessness’ cry for an inquest into that spending money on housing will would help press decision makers for freezing deaths, the 1998 declaration by actually dampen the demand for health change. Their political voice is minimized. groups across the country that expenditures from those who are better This means that the kind of mutual homelessness qualified as a national housed, so the bang for the extra health support and solidarity that develops disaster. There are many more! dollars will be big. among staff and organizations at One of my colleagues has community mobilizing events is harder to Health care expenditure: suggested how this can be put in create. Worse, the organizations that serve opportunities for affordable government language, and that’s by the homeless perceive that they are no housing. saying that expenditures for health and longer able to participate in certain types Here’s a truism: housing is a housing have to come from the same of advocacy because it may be seen as a determinant of health. Poor housing leads ‘envelope’, so that what happens in one risk to their funding, to their non- profit to poor health, just as better housing can sphere of the envelope affects another status, to their reputation. It feels like we’re lead to better health. Those who are sphere. silenced. homeless incur very significant medical This is an issue I’m hoping to These are difficult long term expenses. In Canada , where health care take up during the next few months and problems which we never thought would costs are mostly bore by the public, it I hope others will embrace it as well. exist, but which we have seen grow as the makes sense to ensure there is good Health care can’t be talked about in a disaster intensifies. The homeless have housing in order to minimize health care vacuum, and there’s no better context become a sizeable underclass in our cities costs. to put it in than affordable housing. and towns, a group of individuals who We are currently in the midst of a Maybe our attention to health care will have no sense of privilege and whose massive political debate about health care lead to a way out of homelessness. After sense of hope is disappearing. No wonder costs, and there’s a summit of provincial (continued on page 19)
Volume 24, Number 2 - Fall, 2004 Medical Reform 17 “WHY SHOULD I TRUST YOU?” Gordon Guyatt
hat was the question I heard most simply not their job. Nor is protecting little good. As public representatives, frequently as I went door-to-door the environment for future generations. Canadians expect politicians to achieve Tas a candidate in the recent federal For most of us, however, the quality of a far higher standard than the business election. People expressed the question public health care, education and the community. The only solution to in a variety of ways, but the underlying environment is vital to our well-being. public cynicism is delivering that higher message was clear, and providing an In tough times, access to income standard. answer was not easy. supports, social programs, and Fulfilling that objective will not The public’s disappointment with affordable housing is even more crucial. be easy. It will mean resisting a host politicians is profound, and almost If citizens cannot look to government of temptations. As a candidate, I saw universal. As a candidate involved in to protect what they value, to whom can how much easier it is to get attention doorstep discussions, I was seeking a they look? If they feel disenfranchised at for attacks on opponents than for quick way to engage voters in the minute election time, how can they act to look one’s own positive policies. Yet, a or two of discussion available to explain after their common interests? “throw the blackguards out” strategy my party’s platform. “Canadians are fed Alienation from the political merely feeds public cynicism. up with broken promises,” proved to process leaves Canadians helpless, and I saw how difficult it is to be a statement that elicited nods, or their deep anger at this helplessness is acknowledge all the problems that, exclamations of agreement, from almost understandable - indeed, it is inevitable. because of financial or political everyone. Are politicians the dishonest, obstacles, one will not be able to solve. Even more disturbing, many unreliable, unscrupulous individuals that Yet, yielding to the temptation to make potential voters have passed beyond so many members of the public are promises one cannot keep has been disappointment, and become deeply seeing? Overwhelmingly, I think not. disastrous in undermining the cynical. For these individuals, all politicians Indeed, one finds evidence of credibility of our political process. are the same. Since you can’t rely on any frank dishonesty and violation of trust I haven’t been elected, but it of them to keep their word, engaging in far more often in the business community isn’t difficult for me to imagine the the political process is pointless. Gradually than in politicians or government temptations to reward friends and but persistently falling voter turnouts bureaucracies. One need only look to supporters, a practice that in most reflect the growing number of Canadians Enron and Nortel, and a host of other areas of life is simply decent behavior. joining the ranks of the terminally cynical. scandals, to realize how widespread Yet, when dealing with public This ever-increasing alienation unsavory practices are within big business. resources, such recognition represents profoundly threatens the very core of In the area that I, as a health policy analyst, a betrayal of trust. Canadian society, democracy. Who know best, the magnitude of fraud When Paul Martin was elected, determines the directions our country among for-profit companies is he acknowledged that his government takes? Those with power, and those with staggering. Columbia/HCA, the largest must do much better. If Canadian leadership positions, in both the private investor-owned for-profit hospital firm politicians are to regain the public trust, and public sector. Large corporations, in the United States, has paid the US all parties and political leaders must often with multinational interests, and the government US $1.7 billion in settlements respond Martin’s call for better senior executives who run these for overbilling of Medicare. Tenet, the performance and higher standards.♦ corporations, constitute one extremely second largest US for-profit hospital First published August 21, 2004 with the powerful force in shaping Canadian firm, paid more half a billion dollars to Hamilton Spectator headline, "Voters demand society. settle charges of giving kickbacks for trust: Higher ethical standards needed to overcome Big business leaders have a referrals and inappropriately detaining alienation of citizen that threatens our legitimate primary interest in their psychiatric patients. These are but the democracy." companies’ growth and profits. While largest of dozens of such settlements, many business leaders are community- and even they represent only those firms minded, it is unreasonable to expect them that were caught. to look after the interests of ordinary Nevertheless, bemoaning the Canadians. Ensuring equitable access to disproportionate attention the media high quality health care, education, gives to the occasional serious misconduct childcare, and affordable housing is among politicians and bureaucrats does
18 Medical Reform Volume 24, Number 2 - Fall, 2004 CATHY CROWE PROGRESS REPORT (continued)
all, that’s the history of public health directly by providing truly affordable housing There is no charge for her initiatives in Canada , and it’s what has for the homeless then the substantial health newsletter and she encourages you to helped drive me as a nurse to focus so dollars we now spend on the homeless would forward it to your friends and others much on the public health tragedy known decline considerably. who you think may be interested in it as homelessness. If you would like to subscribe to and share any feedback and ideas with Thinking about health and Cathy's newsletter, pleasee send a message her at [email protected] or at affordable housing in the same envelope to [email protected] . For more the Sherbourne Health Centre, 365 of expenditure is the opportunity that’s information on her work, please visit her Bloor Street East, Suite 301, Toronto, before us right now. I hope we seize it. web page at www.tdrc.net/cathycrowe.htm ON, M4W 3L4♦ If we address the homeless questions
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Volume 24, Number 2 - Fall, 2004 Medical Reform 19 MARK YOUR CALENDARS NOW!! MEDICAL REFORM Hospitals - Public Policy and GROUP MARKS Progressive Reform TWENTY-FIVE
A one-day conference for hospital trustees, city-councillors, policy-makers, health YEARS professionals and workers, union staff and academics. The goal of the conference is to introduce ideas for progressive reform of hospitals into the public policy arena, and, through peer discussion and critical review, expand on and improve the collection of Saturday evening, progressive policy options. November 13, 2004
To this end, we will be presenting new research on hospital capital finance, Toronto contracting out and contracting in, cost containment for pharmaceuticals, progressive work organization, the hospital’s role in the community, and factors impacting on Founding member and Steering infection control. Committee veteran Mimi Divinsky is leading in the preparations. Sunday November 14th, 2004 Leave her an e-mail messageat [email protected] or Toronto Metro Hall [email protected] for 10-5 more information. You can also call at (416) 787-5246, send a fax to (416) 352-1454 or write Box 40074, RPO to register, make suggestions, or obtain more details please contact: Nicole Wall Marlee, Toronto, Ontario M6B 4K4 Ontario Health Coalition 15 Gervais Drive, Ste. 305 Toronto, ON M3C 1Y8
Medical Reform Group Box 40074 RPO Marlee Toronto, Ontario M6B 4K4
Please visit and comment on our web-site at http://www.hwcn.org/link/mrg Please also make a note of our current telephone (416) 787-5246; fax (416) 352-1454; e-mail: [email protected]
20 Medical Reform Volume 24, Number 2 - Fall, 2004