The Next City
September 21, 1996
SINCE 1900, OUR LIFE SPANS HAVE INCREASED BY 30 YEARS, from an average of about 45 to today’s 75 years. This climb has occurred imperceptibly, not in leaps and bounds with medical discoveries and public health breakthroughs but bit by bit. Each year, our longevity inched up several weeks, each decade a year or two or three. This increase has taken place in most countries of the Western world, throughout the Depression and two world wars, in socialist and capitalist countries, in jurisdictions with and without national health insurance. A recent study credits improvement in medical science — new vaccines and treatments — for five of those 30 years, and improvements in our environment and our individual behavior for 25 years. We’ve been living longer due to countless activities by our grandparents, our parents and ourselves that, on balance, influenced our health for the better. Our resourcefulness, our ability to look after ourselves in big ways and small, when sick or when healthy, dwarfs the importance of particular medical resources, necessary as they are.
Today, in both Canada and the United States, national health care systems — the largest sectors of our economies — are being massively restructured amid huge controversy. In both countries, the underlying debate comes down to the life-and-death question of who should control medical decisions that affect our health. Should it be, as in the United States, mainly private sector players — insurance companies, for-profit hospitals and health delivery organizations whose financial interests might conflict with our welfare? Should it be, as in Canada, mainly politicians and government bureaucrats whose spending priority this year might not include our particular medical needs? Or should we, ourselves, after weighing the advice of our doctors and others, be the ones to control decisions that affect our lives? In reality, despite the fierce debate underway in both countries over the future of health care, the choice is not difficult at all.
MRFIT IS AN ACRONYM FOR MULTIPLE RISK FACTOR INTERVENTION TRIAL, one of the most expensive and extensive clinical investigations ever undertaken, involving 250 investigators at 28 institutions over a period of 10 years. Three hundred and sixty thousand men in 22 U.S. cities volunteered to be screened, and the 12,866 found without coronary heart disease, yet at high risk to die from it due to their cigarette smoking, high blood pressure, and high serum cholesterol levels, became the subjects. Half these men at risk, about 6,400 of the volunteers, were treated intensively to lower their risk of contracting heart disease. The other half were left to their own devices.
MRFIT succeeded spectacularly in influencing the lifestyles of the people it treated. After six years, 50 per cent of the smokers stopped smoking — possibly the best record ever achieved in a smoking cessation program — and about half the men with hypertension had it under control. Serum cholesterol levels dropped a substantial 6.7 per cent. Overall, the death rate from cardiac heart disease dropped by more than a quarter, much as MRFIT’s designers had hoped, from a predicted 29 deaths per thousand to 21.3 deaths.
MRFIT provided these 6,400 people with feedback and a sense of support. After individual counselling from a physician, MRFIT put participants into discussion groups of about 10, often with their wives or friends. A team of scientists, nutritionists, nurses, physicians and general health counsellors provided individual counselling, at least once every four months. Because of this combination — personal concern, supportive peers and access to medical resources — 91 per cent of the participants stayed with the program for at least six years, leading to these spectacular outcomes.
Rewarding results are commonplace when motivated individuals, generally with the assistance of skilled practitioners, decide to do something about their health. In another large U.S. medical intervention program, 10,940 men and women participated in a drug program designed to reduce hypertension. Those aged 50 to 59 saw their mortality plummet by 25.3 per cent; while 30- to 49-year-olds saw a 5.7 per cent drop. An Australian National Blood Pressure Study of 3,427 men and women with mild hypertension also reported significantly less disease and death, especially fewer deaths from cardiovascular disease in 30- to 69-year-olds. A coronary heart disease study in Oslo of 1,232 high risk men, aged 40 to 49, succeeded in lowering their cholesterol and reducing their rate of heart disease, sudden death from heart attacks, and overall deaths. If we care to, and know how, the evidence demonstrates overwhelmingly that we can become healthier and extend our lives.
Though MRFIT was a lifesaver to many of those who participated in the trials, it was a heart breaker for its designers. MRFIT was supposed to measure the benefit of special medical intervention. To determine the number of lives MRFIT saved, the researchers planned to compare results to the “control group,” the untreated 6,400 who were on their own in getting treatment. The massive operation proved a research failure; the patients MRFIT didn’t treat lived.
MRFIT’s designers didn’t anticipate that the 6,400 in the untreated group, after being told they were good bets to die, would do something about it. The control group proved to be anything but complacent: Its members reduced their blood pressure and cholesterol counts; 29 per cent of the cigarette smokers quit. These 6,400 actually outlived the treated group, logging five fewer deaths. During the six-year MRFIT study, 219 died among the untreated group, instead of the 442 expected.
Unintentionally, MRFIT uncovered something fundamental: that we can become highly motivated when informed of a threat to our health. Though some in the control group surely went astray, ignoring their unhealthy lifestyle or taking ill-advised measures, the consequences of their mistakes were no more grave than those that befell the treated group (MRFIT treatment wasn’t perfect; it appears to have backfired for a subgroup of patients). And on their own, whether by seeing their family physician, working out at the gym, learning nouvelle cuisine, or quitting the rat race, the untreated group did far better than their counterparts in the population as a whole.
Precisely what they did and how they did it is unknown because MRFIT carefully followed only those singled out for treatment. But the extent to which the public has taken charge of its health destiny is staggering. In a Wall Street Journal/NBC poll taken earlier this year, 82 per cent of respondents said taking care of their health was important to them, and the survey bears them out. To counter heart disease, the single biggest killer, a surprising quarter of respondents regularly do yoga, meditation or other stress-reducing exercises. Ninety-four per cent of seniors (aged 55 or over), 78 per cent of boomers (35- to 54-year olds), and 71 per cent of youths (18 to 34) checked their blood pressure and cholesterol in the past year, and half of all seniors and boomers restrict their consumption of red meat. Half take vitamins or supplements, or try to eat mostly organic foods. Twenty-two per cent of seniors, 46 per cent of boomers and 70 per cent of youths could easily run or jog a mile.
At any given time, 35 per cent of us have a medical problem in our household. When this occurs, most of us (86 per cent) will decide to become informed about it, and 90 per cent will succeed in getting the information we need. A recent study of consumer health information commissioned by the U.S. Department of Health and Social Services — the first publicly released study since one by General Mills in 1979 — shows how today’s health care consumers go about solving their health problems. They’re grazers and skeptics, seeking out multiple sources of information: first to a professional (a doctor, nurse or librarian) who can help them understand or interpret information, then to pamphlets, magazines and books to get more acquainted with the issues, and then to friends and relatives for their support and experiences tackling similar problems. If they ultimately decide to get medical treatment, the first choice and major source of information becomes the health care provider that they’ve settled on.
In taking responsibility for its health, the public has been soaking up information. Health has become the single largest subject for popular (and professional) consumption. To meet this huge demand, over 40,000 producers of information each year publish over 1,000 new health books, 28,000 new audiovisual productions and more health than business periodicals. Five thousand one hundred hospitals have health education programs. Nine per cent of all high school credit hours are in health and physical education.
Yet too few of those are produced for our own good, and too many of them target upper-income, educated health consumers. In every survey or study, income and education significantly affected health and how health information was consumed. People with lower incomes and less education are half as likely to read health-related materials, three times more likely not to seek health information when they have a health problem, and twice as likely to have problems getting the information. Those not oriented to cracking open health manuals get short shrift; while some information does seep through, this trickle-down information market has largely failed to reach them.
For hundreds of years, we have known that people in the bottom rungs of society have the highest rates of virtually every disease and medical condition. Without the financial resources needed to obtain medical help, superior nutrition and adequate shelter, those with less social status — less income, less education, a less desirable occupation — have paid a price in shortened, less healthy lifespan. But much, much more is at play, here, as demonstrated by studies that show an omnipresent relationship between social status and health. It not only holds true for men and women, it applies to their children, who at each stage of life are less likely to be healthy than the children of those with more status.
For the very young, social status predicts infant mortality rates, premature births, low birth weight and late births. The better off their parents, the healthier the infants are likely to be. For adolescents and young adults, lower social status means a higher incidence of diabetes, heart disease and high blood pressure. Unintentional injuries account for two-thirds of young deaths; those less well off are likelier to die in a motor vehicle accident, to drown, to be murdered. For those over 40, social status predicts heart disease, lung cancer, arthritis, ulcers, diabetes, high blood pressure, emphysema and other diseases, as well as injuries from falls, house fires and motor vehicle accidents. In old age, the social status factor shows up in prostate and other cancers, in diabetes and influenza, in hearing impairments and back problems. Go up the social ladder, rates of death and ill health decline; go down, they increase. These links are strong when comparing people’s income, education, area of residence, level of prestige, either alone or in combination.
The gap between the top and bottom rungs of the social ladder is too great to be explained simply by bad habits among the lower class. In a study of British civil servants, those at the bottom of the hierarchy had heart disease rates four times those at the top. Even after adjusting for lifestyle differences between these groups such as their smoking, hypertension, cholesterol and physical activity, a three-fold difference remained. Perhaps that can be explained — there’s more to lifestyle than the differences the study surveyed. But why would doctors and lawyers in the civil service, just one step from the top tier, also have higher rates of heart disease? They surely did not lack for food and shelter, for education, or for the best medicine that money can buy.
The longevity gap between rich and poor may have increased over the decades: One study of trends in England and Wales shows the gap narrowed in the 1920s, then increased in the 1950s and 1960s, and then by the 1970s was greater than it had been in the 1920s. Similar results that flow from other studies are variously attributed to changes in lifestyle — particularly the poor’s smoking, drinking and eating habits — and to the poor’s increased exposure to workplace pollution.
Of the different indicators of social status, a consistent predictor of a long and healthy life is occupation. The bulk of evidence points to an association between heart disease and dull, high demand jobs in which the worker has little control over the job’s pace and his schedule.
Of 41 occupational groups studied, bus drivers have been singled out for numerous studies because they, along with taxi drivers, have the highest rates of death and heart disease mortality. Bus drivers also suffer disproportionately from gastrointestinal illnesses, including ulcers and digestive problems and back and neck ailments. To determine why bus driving is fraught with so much danger, two dozen studies have tested various hypotheses. In one theory, bus drivers inhale automobile fumes all day long. But that doesn’t explain why, in a study of 31,000 London bus drivers and conductors, the drivers had twice the conductors’ death rate from cardiac disease. When the inner city bus drivers were compared to bus drivers with suburban routes, where traffic was less stressful and buses could stay on their demanding schedule, the rate of heart disease dropped, for both drivers and conductors. A study of Italian bus drivers and conductors, using medical records of the previous 17 years, found the same doubling of heart disease among drivers.
The best explanation for the relationship between social status and longevity is control — as people rise in social class, they have more opportunity to influence events affecting their lives. The more they feel in control of their environment — the more their job satisfaction and self-esteem — the greater their well-being. The relationship between our physical and spiritual well-being has been long recognized. Research bodies such as Harvard University’s Mind/Body Medical Institute have begun documenting the mind’s effect on the immune system. Their catalogue includes more than 200 studies showing how our thoughts and feelings, which get translated into brain cell patterns, influence health. In one study at Dartmouth Medical School in New Hampshire, men were polled on their beliefs and support structures prior to open heart surgery. Those who believed in God had one-third the death rate of those who didn’t; those who both believed in God and had an active social support network had one-tenth the death rate of non-believers.
The relationship between our physical and spiritual health can also be seen in the strong link between pessimistic people and their likelihood of suffering depression and ill health. Pessimists believe their bad luck stems from factors beyond their control, and blame external factors, while optimists assume they can overcome setbacks by doing things differently or trying harder. According to Martin Seligman, a University of Pennsylvania professor and incoming president of the American Psychological Association, people’s pessimism — the sense that they cannot control their environment — can be treated as a risk factor. When people learn optimistic behavior through therapy, they become empowered and assume control.
Throughout human history, we have been demanding more and more control over all aspects of our lives. In this century, especially, environmental activism has been steadily building, and a paternalistic medical establishment has been steadily losing power. We see it in the empowerment of women over birthing issues: Women increasingly decide if they want an epidural, and if they want a hospital or home birth. In 1979, just three per cent of women had a vaginal birth after a Cesarian section; today it’s more than 10 times that. The physician’s status has changed. We see it in patients deciding whether they want general anaesthesia, or local, and if local, how sedated they want to be. We see it in the breakdown of the medical doctors’ monopoly: Chiropractors, midwives, naturopaths, acupuncturists, therapeutic touch and numerous other services once considered quack medicine are now licensed or otherwise recognized by the Canadian and U.S. medical systems. AIDS research is now directed by coalitions that include patient advocacy groups. We see it in the individual’s refusal to accept an initial medical diagnosis, or even a second or third opinion; in the burgeoning self-help movement; and in demands by the Arthritis Society and the Canadian Association of Retired Persons that pharmaceutical companies be permitted to advertise directly to consumers. We see it in the growing recognition that no one physician can possibly keep up with the explosion of medical information, and that no physician is likely to be as interested in our particular medical condition as we ourselves are. We see it in our decision to seek out information everywhere and, ultimately to take our own counsel.
The medical profession may have come a long way from the days physicians healed us by drawing our blood with leeches, but so have we. Give us a system that limits our ability to be healed, or to heal ourselves, as we see fit and there will be a fight.
The genius of Canada’s medicare system
THROUGH GREAT PERCEPTION OR GREAT LUCK, POLITICIANS DELIVERED a medicare system that gives Canadians great control over our health. Because the Canada Health Act requires accessibility, universality, portability and comprehensiveness, all Canadians have been able to count on the health system, all the time. Because the Canada Health Act also requires public administration, Canadians have not needed to be concerned that the profit motive would unduly influence medical decisions. And within this publicly funded health infrastructure, we have had virtually unlimited choice of health care providers in a predominantly private sector system of individual doctors, private medical clinics and private nonprofit hospitals. The cost of all this? Far less than that of medical care in the U.S. We seemed to have it all.
The system does have serious, even shameful drawbacks, however: To control costs, the government rations the number of specialists medical schools can graduate, leading to a brain drain, and to a relatively low-skilled professional class. Over half of our doctors are general practitioners, while only 13 per cent of U.S. physicians stop their education at that point, 87 per cent carrying on to be specialists. The brain drain also affects graduates. Half of the neurosurgeons Canada has trained in the last decade, for example, have left within two years of graduating. Our medicare system also rations hospitals. Canada now invests less than most Western countries in hi-tech hospital equipment such as MRIs. Medical research is so underfunded that the United Nations, while rating Canada as the best place on earth to live, has also castigated us for our failure to invest in medical research.
But gross medical spending affects health less than other factors, such as our sense of control. While Americans have many enviable results — they keep and attract the best medical talent; they dominate medical research, winning almost as many Nobel Prizes as all other countries combined; they have many of the world’s most talented medical practitioners and finest hospitals — we outlive them, our death rates lower in most respects.
Infant mortality in Canada is lower than in the U.S., even when U.S. blacks, whose infant mortality rate is more than twice that of U.S. whites, are removed from the calculations. Children of almost any age in Canada have a lower death rate than white American children. So do Canadians of almost any age. Canadians have done better than Americans, in part, because our universal health system gives us more control over our environment. The anxieties it allays contributes to the two-and-a-half years in added life expectancy that Canadians enjoy over Americans. Canadians common view of our medical system as our government’s best gift to us is, in fact, well grounded.
Despite the overwhelming support for our health system, it is crumbling daily. A 1995 poll showed that while 83 per cent still rate our system good or excellent, almost 60 per cent of Canadians, and 75 per cent of physicians, consider it to be in jeopardy, an expectation borne out by hospital closings, by curbs on physicians, by longer and longer queues for surgery, by limitations on drugs for the elderly, by limitations on our insurable services and soon on our choice of physicians. In a 1996 poll of Ontario nurses, 86 per cent of hospital nurses, 83 per cent of those in community work and 88 per cent in nursing homes noticed a “significant decline” in patient care. The principles of the Canada Health Act are being undermined as our provincial governments — in the name of preserving medicare — take rationing to new levels, affecting us in alarming ways: Our doctors, nurses and hospital staff are unhappy; our hospital administrators are under pressure; we’re losing hospital beds and services we’ve come to rely on, and we’re unsure of what the future will bring. The federal government has cut medicare funding; the Reform Party contemplates less access to the health care system through the introduction of a private tier of health care.
Fully 75 per cent of Canadians, 60 per cent vehemently so, do not believe they and their families would receive fair treatment under a two-tiered system. The anxiety that the medical system won’t be there for us, quite apart from the difficulties we may face when we actually need to call upon it, is destructive. Ironically, our politicians’ attempts to maintain the character of Canada’s health system are driving it closer and closer to the worst aspects of the American system.
What makes our system different from the American system
DESPITE ALL THE DIFFERENCES, CANADA’S HEALTH CARE SYSTEM has much in common with that of the U.S. While American health care depends less on public funding, the private sector dominates its delivery in both countries through independent doctors, private, nonprofit hospitals and, increasingly, doctors in the pay of large private companies. Although we pride ourselves for having the same system for rich and poor, rich Canadians do obtain better drugs, better hospital rooms and numerous services that aren’t insured; their connections often move them up the queue for hospital care; and increasingly, the rich have been going to the U.S., not just to avoid the queues but also to obtain specialty care. As in the U.S., Canadian employers often step in to provide health insurance for their employees. Liberty Health, Canada’s largest private insurer, serves 5,000 employers — private companies like General Motors but also public sector government employers, providing drug plans and other services that other Canadians don’t enjoy. Canada’s publicly funded medicare system — available to 30 million Canadians — is similar to America’s publicly funded Medicare, which serves 33 million seniors.
Although many Canadians assume that, in a mixed system, those privately insured would get better service, experience shows otherwise. U.S. Medicare patients get treated by the very best physicians in the very best hospitals the country has to offer. U.S. firms like Cardiology Associates, a Texas-based team of cardiologists notorious for its aggressive heart surgery and six-figures incomes, treat their Medicare and private sector patients alike. So do specialists at Harvard Medical School and John Hopkins Medical Institution, private nonprofits that attract the very brightest doctors and scientists. This fine care for seniors, who enjoy universal Medicare, is one reason that death rates of U.S. seniors improve relative to Canadians as they get old: those in the 75- to 84-year-old category start to outlive Canadians, the gap widens still for those over 85.
Where the U.S. differs from Canada for the worse is in its failure to provide universal coverage: Due to a tax system that favors employers at the expense of health care consumers, millions of Americans are without insurance at any time, and, until the passage of recent legislation, tens of millions more feared the consequence of losing their coverage if they lost their jobs. Where it differs for the better is in its diversity. U.S. health care is not one system but many, not two-tiered, as Canadians fear our system might become, but multitiered — hospitals can be owned by the private sector, by universities, by the federal, state and municipal governments, by churches. Physicians can work for themselves, for universities, for multibillion Health Maintenance Organizations. In the U.S., private nonprofits can be big business. A recent merger between two elite institutions — New York Hospital-Cornell Medical Center and Columbia-Presbyterian Medical Center — will create a nonprofit colossus of over 20 hospitals, nursing homes and ambulatory care services, staffed by the 2,800 doctors from prestigious Columbia and Cornell. This one complex expects a 17 per cent share of the massive New York metropolitan market — serving private and Medicare patients alike from New York, New Jersey and Connecticut.
While both Canada and the United States have watched their health costs soar above inflation since the mid-1960s, U.S. health inflation — which increased at four times the rate of inflation since 1965 — especially took off, leading to today’s wide gap between the two countries. But the U.S. system also started to adapt. In 1984, its traditional employer-sponsored fee-for-service insurance plans covered 95 per cent of all full-time workers. But a steady shift in the U.S. away from these costly plans, and toward Health Maintenance Organization, or HMOs, led to dramatic savings. By 1989, inflation in the employer-sponsored insurance policies began to slow, and last year, it actually rose less than inflation — just 0.1 per cent, the smallest rise on record. The HMO portion of the U.S. health care business is driving down costs. By abandoning the normal doctor-patient relationship, the HMOs posted a 10 per cent decline in price last year.
Instead of paying doctors a fee for each service that they perform, insurance companies and others pay HMOs a flat fee for every person, sick or healthy, that they look after, giving the HMOs an incentive to keep patients healthy. HMOs and other so-called “managed care” companies market themselves as practising preventative care — they encourage patients to see HMO-approved doctors for regular check ups, for example, and to adopt healthy lifestyles.
But HMOs limit the freedom to choose a physician — a distinguishing feature of the Canadian system — lessening the consumer’s control over health care. Because the HMO is unambiguously in business to make money — giant conglomerates, even multinationals can own HMOs — they have powerful incentives to cut costs and ration services. Salick Health Care Inc., a U.S. chain of 12 for-profit health cancer centres, half owned by a British multinational drug company, demonstrates the conflicts of interest inherent in private sector rationing of health services. For each person that this HMO looks after, it receives a fixed fee of $6 to $7 per member per month, based on actuarial forecasts of how many members will contract cancer and the cost of treating them. To Salick’s credit, most patients are pleased with the care they receive, finding it personalized and compassionate. Its Cadillac service resembles nothing Canadians are accustomed to. One 57-year-old breast cancer patient reports she “was treated like a queen” after Salick picked her up in a limousine and ushered her to a resort hotel near Salick’s cancer centre outside Los Angeles. Another 42-year-old breast cancer patient, although sorry she can no longer use her personal physician, gives Salick a “10 for all the work they did making sure I was taken care of.”
But Salick’s success depends on cutting costs in cancer care, a lucrative market that accounts for $50 billion, or five per cent, of the entire U.S. medical bill. Physicians critical of its fixed price-per-head approach, called “capitation,” claim that the company’s cost-cutting takes priority over the patient’s best interests. One physician, who quit the company last year along with two others, complained of being continually hassled for keeping patients in hospital longer than the company’s cost cutters might have liked. In January of this year, an oncologist sent a letter to the company protesting an “edict” that prostate-cancer patients should receive a “painful and unpleasant” injection of a drug called Zoladex rather than a more costly but less painful alternative. Zoladex is sold by Salick Health’s co-owner, the British multinational.
While Salick denies the existence of any edict, the fact remains that this company, and not the patients, decide what services they receive. The pressure on HMOs to provide patients with minimum, as opposed to optimum, service has led to widespread denial of pain killing drugs — including epidurals during childbirth. And, since no one wants publicity for measures like these, it has also led to an insidious trend to keeping patients in the dark through informal and even formal understandings between HMOs and doctors. Because of so-called “gag” clauses in physicians’ contracts with HMOs, patients weren’t told of treatment options not covered by their health plans, even if the treatments were safe, effective and necessary. Some gag clauses also prevented physicians from referring very sick patients outside their health plans to physicians with rare expertise in the types of care needed.
Following repeated HMO scandals, the American Medical Association in 1994 declared gag clauses unethical, called on all managed care plans to cancel them, and earlier this year offered to review all contracts upon request, to see if they meet its Code of Ethics. But with or without gag clauses, the problem of rationing remains: HMOs are in business to make money, and often the way to make money will involve denying, diminishing or deferring service to patients who might need it. All HMOs, no matter how ethical, confront this uneasy fact, which necessarily undermines the doctor-patient relationship. As put by Lee Newcomer, the chief medical officer for United HealthCare Inc., a Minnesota HMO, when the trauma of illness rubs up against an imperative to cut costs, “it’s an emotionally charged subject.”
HMOs’ great popularity with insurers stems from their stellar performance at cost containment. Where Canadian governments have largely failed in their approach to rationing health services, the HMOs and similar managed care systems are coming to dominate U.S. health insurance by fiercely applying corporate methods to make rationing pay. Because of their success, Canada’s public system is now following their lead and introducing “capitation.” But U.S.-style rationing is financially unnecessary and medically counterproductive. In fact, by promoting the Canadian advantage — patient choice — more fully, by putting more power in patients’ hands, we can not only preserve the Canadian approach but also further remove differences between the rich and poor, use our public health care dollars more efficiently, increase the medical services and medical choices available to us, and provide these services at far lower cost than either the current Canadian or current American system now does.
Giving power to consumers will cure Canada’s ailing medicare system