December 4, 2002
Roy Romanow recommends expanding medical services to rural communities to address the appallingly poor health of rural Canadians. This recommendation, he says, conforms to his goal of being “evidence-based and values-driven.”
Give him a 50% grade on that one.
Values-driven, yes. Mr. Romanow’s values pervade his report. As for being evidence-based, Mr. Romanow falls short, but then again, he has to, because he gave himself a goal that he could not meet.
The evidence and his values do not co-exist.
Mr. Romanow is correct in citing the need for improved health outcomes in rural regions. As Statistics Canada data demonstrates, rural people suffer longer and die sooner than their urban counterparts. Rural cancer and circulatory disease death rates are 10% higher; rural mortality rates are 15% higher; rural infant mortality rates 40% higher.
But Mr. Romanow is incorrect in repeatedly fingering lack of access to health care for the rural regions’ poor health. “Problems in access to health services quite often stem from serious shortages in health-care providers in rural communities,” he states in one passage. Elsewhere he blames “difficulty accessing primary care” and difficulty “accessing diagnostic services” for the urban-rural disparity, and asserts that rural people “are not as well served and have more difficulty accessing health-care services than people in urban centres.” Mr. Romanow then summarizes the disparity in a statistic: “The average resident in rural communities and small towns was 10 kilometres from a physician, compared to less than two kilometres for a resident in larger urban centres.”
The statistic makes for good trivia, but trivia cannot substitute for substance. Had Mr. Romanow’s analysis been evidence-based, he would have accepted the findings of the definitive series of studies on the subject of urban-rural health disparities in Canada produced just this year by Statistics Canada. The series, which analyzes the socio-economic and demographic factors underlying health outcomes, is part of a world-wide realization that hard medical services – whether in the form of doctors, hospitals or drugs – count less than attitudinal and spiritual factors such as individual empowerment, which stems from having control over one’s environment. Statscan found that the availability of doctors, specialists and hospitals in major centres does not explain why urbanites enjoy superior health. Says Statscan: “The variations between regions in the availability of these health-care services do not appear to play a role in accounting for individual health status differences.”
Put another way, the difference between being 10 kilometres away from a doctor and two kilometres away is not meaningful, based on the evidence.
Mr. Romanow, of course, understands that empowerment is important and that the shortcomings of rural society are widespread. His own report acknowledges that rural people not only get sick far more often, they have higher rates of violence, of poisonings, of unintentional injuries leading to death – differences that cannot be explained by a lack of health-care workers.
Yet Mr. Romanow makes the difference between access to urban and rural medical help the basis of his chief rural recommendation: the creation of a Rural and Remote Access Fund that would attract and retain health-care providers.
Why would Mr. Romanow recommend spending scarce health dollars in the absence of any evidence that it would do any good? And why would he want this Rural and Remote Access Fund to “support provinces, territories, communities and health authorities” – everyone but patients themselves, who, the evidence shows, would become empowered by having more say in decisions affecting their health?
The answer lies less in promoting health than in promoting values – Mr. Romanow’s values. In his vision of Canada, the state decides what we’re entitled to and the state makes us what we are. Giving rural Canadians a personal health-care budget, and letting them override the judgment of rural health-care administrators – a form of privatization, he believes – offends Mr. Romanow’s sense of values. So does the notion that Canadians might migrate away from rural areas to cities to obtain more convenient health care. So does allowing immigrant doctors to service rural areas, when we could be using the homegrown kind.
One other value permeates Mr. Romanow’s health-care work: deference to interest groups. To obtain support for his vision, Mr. Romanow has set out to please workers in virtually every existing health-care lobby – from the doctors and nurses who deal directly with the patients to the union workers who toil in more menial work. He has offered them proposals designed to increase their take-home pay, and they have responded with lobbying to have his report adopted.
In Mr. Romanow’s report, his values trump the evidence. The rights of the bureaucrats trump those of the patients. And the health of the rural population, which – as his report notes – worsens with its remoteness, is simply trumped.
Related articles by Lawrence Solomon :