Saskatchewan’s curse revisited

Posted on May 11, 2001 by Other News Sources

Lawrence Solomon/Norm Wallace
National Post
May 11, 2001

Saskatchewan’s rural dilemma

Mr. Solomon’s column points out one of the myriad of problems in Saskatchewan and exemplifies Canada’s lack of understanding of what they are and how to deal with them.

One must first consider that about half of the farmers and more than half of the farmland under cultivation in Canada are in Saskatchewan, so we are not talking here merely about a regional problem, but one that is truly national in scope. Agriculture in many Western jurisdictions is in trouble, and those jurisdictions often deal with the problem by subsidizing production. Where a subsidy is paid by a taxpayer who does not consume the majority of the subsidized product, production is not a paying proposition. This is the case with some of the crops grown in Western Canada.

State intervention into the economy always results in inept deployment of resources. The payment of transportation subsidies to remove primary agricultural production from the prairie economy was sustainable when crop prices were very high, but it meant that the value-added secondary processing industries were not allowed to develop where they would diversify and stabilize the local economy. To make matters worse, deep interference in free markets by the Canadian Wheat Board resulted in a large portion of the economy becoming dependent on central planners to market their product. This is particularly true in Saskatchewan.

Some Saskatchewan farmers do, however, actually make money. Market forces have resulted in dramatic growth to our livestock industry, which is one obvious way of adding value to grains. Others grow “cash” crops (i.e., crops not under the state monopoly). Still others are not making any money. One of the key reasons is that Canada has dramatically reduced its level of farm subsidies, putting those dependent upon the state’s participation in peril. Mr. Solomon’s answer is typical of the far left-of-centre attitudes that put us in this mess: Let the state intervene further and acquire the productive asset with even more taxpayers’ dollars. This is an old socialist plan known as the Land Bank that died with the government of Allan Blakeney.

Mr. Solomon takes it one step further and, rather than redistributing land, he would simply see it removed from production and left fallow. He obviously does not understand what happens to land that is abandoned. Not only is the revenue that it generates (which is still the largest component of the province’s GDP) lost, but so is the tax revenue to the rural municipality. Worse yet, fallow land will quickly revert to spurious crops and weeds. There is then a huge cost to the state to maintain the land or compensate the neighbours for damage it will cause to their crops.

The answer is painfully obvious and simple: Let the people who can run profitable operations buy the land and farm it without subsidy, and keep our collective nose out of their business. Market forces will dictate what to grow and how to add value to it.

Saskatchewan has had the same size population for more than 70 years, and it has shifted strongly from rural to urban. We will only go forward when we realize that if what we have done for the last half century isn’t working, doing more of it is not likely to improve anything. It’s time to let the people with the desire, resources and ability join with us to play catch up with the rest of the continent.

Norm Wallace, Saskatoon

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Nuclear renaissance or nuclear fantasy?

Posted on May 4, 2001 by Other News Sources

Lawrence Solomon/Neville Nankivell
National Post
May 4, 2001

As concern grows over rising fuel costs and reliable energy supplies, nuclear power is getting a second look. So are the arguments against it.

Nuclear fantasy
By Lawrence Solomon

The nuclear fantasy is back. And the fantasizers today, as before, are mostly button-down conservatives who have their hearts in high-tech machinery, their heads in the sand, and their hands on the public purse.

In Toronto this week, U.S. Vice-President Dick Cheney signaled the nuclear revival at an annual meeting of the Associated Press. Conservation and renewable energy, the environmentalists’ choice, will not be America’s savior, he decreed, but fossil fuels and nuclear power – his choice – will. To help make his picks the winners, Mr. Cheney is boosting subsidies for the fuels he favours while slashing subsidies to their rivals.

In his attempt to resurrect nuclear power – Mr. Cheney deplores the fact that no new reactors have been ordered in decades – he listed its virtues. Nuclear power is “safe, clean and very plentiful,” he asserted. Mr. Cheney prudently omitted “economical” from his list: A nuclear power plant costs about 10 times as much to build as a cogeneration plant of equal size, and about three times as much as its power equivalent in windmills. Not once, anywhere in the world, has a company – public or private – built a nuclear plant over a green technology in an open marketplace.

In Quebec City last month, President George W. Bush spread the word to Prime Minister Jean Chrétien, tantalizing him with prospects of selling nuclear power into the U.S. market. Last Tuesday, Ontario Premier Mike Harris revelled in the glories of a nuclear future that the leaders had discussed. “They felt there were great opportunities for more generation, maybe more nuclear plants, more CANDU reactors here in Canada, here in Ontario and … perhaps building surplus power, jobs and investments here to sell to the United States,” an awestruck but visionary Mr. Harris told the Ontario legislature.

His Tory predecessors two decades earlier had similar visions. They proved delusions when Ontario Hydro went bankrupt under the weight of its nuclear debt. While Mr. Harris fantasizes about new nuclear plants supplying the lower 48 states, nine of Ontario’s 21 nuclear plants are today either temporarily or permanently shut down, and Ontario faces blackouts next year if those still operating don’t perform to expectations. In parts of Mr. Harris’s Ontario, the province’s failing reactors contributed to brownouts twice in the last two years.

CANDU reactors in other provinces have performed even worse. One of Quebec’s two reactors, built to run for 40 years, was shut down after running a matter of days. New Brunswick’s sole reactor, which is supposed to supply 30% of the province’s power, was down two-thirds of the time over the last six months. To keep the lights on, New Brunswickers were importing power, not shipping it south.

For more than half a century, a nuclear future has fired the imagination. Atomic automobiles, powered by a single pound of uranium, would travel 5 million miles between refuelings, one Caltech professor predicted in the 1940s. Nuclear batteries would run everything from wristwatch-radios to home appliances, a chemical association president prophesied. Artificial suns made from chunks of uranium mounted on towers would bring the weather under control, ending unwanted fog and snow and allowing corn to be grown indoors, wrote the author of Atomic Power in the Coming Era. “Our children will enjoy electrical energy too cheap to meter; will know of great periodic regional famines only as matters of history; will travel effortlessly over the seas and under them and through the air,” preached Lewis Strauss, the venerated chairman of the U.S. Atomic Energy Commission in 1954.

Amid this euphoria, nuclear power could do no wrong, and could be denied no privilege. Every government in the Western world backed it as necessary; those wealthy enough to afford it blessed it with money and speedy regulatory approvals. An unquestioning public accepted the pronouncements from on high. Even into the 1970s, commercial nuclear power had overwhelming public support; opposition to it was barely discernable. Environmental groups such as Pollution Probe hoped it could replace dirty coal plants.

Decades later, despite hundreds of billions of dollars in investments, the nuclear dreams have gone “poof.” Although governments bestowed it with unprecedented subsidies, nuclear energy meets a small fraction of their citizens’ energy needs; in Canada, nuclear energy provides about one-third as much energy as wood.

The nuclear bubble burst partly because Three Mile Island and Chernobyl put the lie to the industry’s safety claims, and mostly because Margaret Thatcher unintentionally put the lie to the industry’s economic claims. Through her privatization of the U.K.’s power system, the country’s power utility, the Central Electricity Generating Board, had to open up its books. The financial world blanched at the data on the nuclear plants, as the London Observer described in a 1989 editorial entitled “Nuclear fantasy.”

“It has taken the cold stare of the City [London’s financial district] to penetrate the veils of secrecy and deceit that have long enveloped the nuclear industry,” it wrote. “Privatization has proved that nuclear power is hopelessly uneconomic and saddled with decommissioning costs that no private company could accept without huge guarantees from the government. Yet from the 1950s to a few months ago, anyone who breathed the slightest doubt about its viability was met with a blizzard of faulty figures and downright lies.”

Privatization doomed the U.K.’s nuclear expansion plans and spawned a private sector building boom in high-efficiency power plants. More importantly, the U.K.’s success — power prices dropped while environmental quality improved — became the dominant worldwide model for electricity deregulation, also dooming nuclear expansion plans elsewhere.

Yet true believers do not easily quit. They read tea leaves for signs that destiny will out, and grasp at any straw — no matter how absurd — to bring about the second coming. Mr. Cheney — a man committed to unleashing coal production and pumping hydrocarbons from the Arctic reserve, off the sensitive Florida coast, and in the Rocky Mountains — mocks himself by championing nuclear power as an antidote to global warming, as if his nuclear-hydrocarbon combination will address anyone’s concerns over climate change.

Mr. Cheney scoffs at the term “do more with less,” saying “conservation may be a sign of personal virtue,” but is no basis for a sound comprehensive energy policy.

Here are other personal virtues for Mr. Cheney to consider, ones suitable for a conservative political leader. Stop picking winners and losers. Understand that doing more with less — also known as increasing efficiency — remains the single biggest solution to meeting our energy needs. Don’t discount, in Luddite fashion, the new generation of advanced technologies. Trust the marketplace. And take heed of the advice from the London Observer’s editorial of 1989: “The country should construct an energy policy based on the real world, rather than a nuclear fantasy.”

Nuclear renaissance
By Neville Nankivell

The nuclear option is suddenly back on the policy table as part of the future electricity-generation mix for most major industrialized economies. As natural gas costs keep rising and concerns grow over reliable electricity supplies, this is a sensible change from many earlier intentions to phase out nuclear power eventually. As a Canadian government official put it recently: “we need every arrow in the energy quiver.”

In the United States, Canada and some European Union countries, applications to upgrade existing nuclear plants and extend their operating licences are now being looked upon more favourably. New plants are also being seriously considered again after years of moratoriums. This is the case in Finland, whose president recently declared it would be absurd to renounce nuclear power. As part of its long-range energy supply policy, the Bush administration favours granting permits for new U.S. plants. Japan is sticking to its construction program.

In Canada, there’s even some talk of the future possibility of a nuclear power plant in Alberta so the province won’t be so dependent on natural gas. New Brunswick and Quebec are expected to extend the working lives of their existing nuclear units through refurbishing proposals that are now under review. Ontario will soon have a group of its laid-up reactors back in service. Its plan to lease another plant to a consortium headed by British Energy, a private sector group, will involve substantial new capital investment in nuclear facilities.

Some 30 nuclear power plants in the United States, or one-third of the total, have applied for license extensions — typically 20 years — on the basis of plans to invest in upgrades. Most others are expected to follow suit. Yet just a few years ago there had been predictions that a third of the nuclear power plants in the United States would be closed rather than have their licences renewed.

These developments portend a renaissance for an industry in which Canada is particularly advanced technologically, and is also a major world supplier of commercial uranium used in the fuel fabrication process. There is, however, still formidable public hostility to nuclear power — although the industry has had an excellent safety record since the chilling accidents at Chernobyl and Three Mile Island some 15 to 20 years ago. Recent surveys in the United States suggest the mood may be changing.

A clear majority there now supports the building of new plants, compared with 42% a couple of years ago. Behind the swing: sharply rising electricity prices and power shortages in California and other parts of the country. Nonetheless, the industry will have its work cut out to get the public truly onside for nuclear renewal. It will have to show, for instance, that zero tolerance is in force for lapses such as those that happened last decade in Ontario, where sloppy maintenance procedures led to several nuclear units being taken off-line for intensive inspections and work to get them up to proper operating performance.

That said, the industry, which is tightly regulated, has a lot going for it now. Nuclear power is becoming more price competitive because of the rising costs of conventional fuel sources such as natural gas, coal and oil. In the United States, nuclear power is now cheaper than coal in terms of operating costs for thermal generation, and well below gas and oil. Nuclear plants are more expensive to build than gas-fired ones, but technological advances are now improving the efficiency of existing plants. Industry consolidation is helping too. Overall output of nuclear plants in the United States is up 20%. An increasing number of private sector-owned U.S. plants are now quite profitable. Next-generation reactors promise even better operating results. New construction techniques should help hold down capital costs.

The industry is also rightly promoting the positive role that “blue skies” nuclear power can play in reducing greenhouse gas emissions. The 1997 Kyoto Protocol, aimed at establishing specific emission reduction targets internationally, is effectively dead because U.S. President George

W. Bush has said his administration won’t ratify it. But this doesn’t mean the United States or other governments will abandon efforts to encourage production of more environmentally friendly energy. The best way to do this, said U.S. Vice-President Dick Cheney in Toronto this week, is to extend the operating lives of existing nuclear plants and allow new ones to be built. Mr. Cheney is heading an energy task force on behalf of the President. To fill this bill properly, low-emission nuclear power will have to be market competitive and not propped up by government subsidies.

There’s still the problem of permanent disposal of hazardous nuclear waste, although various concepts — including a deep-storage proposal for Canada — have been judged technically feasible. Opposition from anti-nuclear groups, including violent protests in Europe over the movement of radioactive waste, has spooked governments from moving more expeditiously on this issue. Yet those who do ship radioactive material have had an exemplary safety record.

Some industrialized countries, such as Germany, remain opposed to further nuclear power development and intend to stick to phase-out plans. But increasingly, more governments are keeping an open mind on the issue. This is the realistic way forward. Global electricity demand continues to grow robustly. Meeting it is key to maintaining economic growth.

Neville Nankivell is a columnist and former editor-in-chief of the Financial Post.

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Saskatchewan’s curse

Posted on April 24, 2001 by Other News Sources

Lawrence Solomon
National Post
April 24, 2001

Canadian citizens and Canadian corporations support Saskatchewan’s money-losing rural economy with tax dollars. Some may resent it, but because there are relatively few Saskatchewan farmers and other rural residents, and relatively many Canadian taxpayers, the cost for each federal taxpayer is small.

Not so for residents and businesses in Saskatoon and Regina, who rival the province’s rural residents in number. These city residents must support the rest of the province not only with their small share as federal taxpayers but – because the federal government and the province split the cost of farm subsidies – with an immense share as provincial taxpayers.

Worse, these city residents don’t pay just in dollars. The cost of supporting an outsized rural economy has crippled the province, stifling innovation, hamstringing the province’s many viable industries, giving its universities among the worst ranking in Maclean’s annual survey, removing opportunities for the province’s young, and compelling them to leave to the heartbreak of their parents.

Saskatchewan’s curse is its vast expanse of flat, arable land, uninterrupted by mountains, lakes, or other geographical boundaries that might concentrate the population. When the land was first settled, communities were built 10 miles apart, along the railroad lines, to service the steam engines with water towers. From the railroad communities, the road system evolved, creating a dispersed rural infrastructure. Because the land could be farmed, it was, leading to Canada’s most dispersed population. The steam engines are all gone now, but not the rural communities that no longer have a productive economic purpose, and not the infrastructure that was established for a bygone era.

“We have the most miles of highway of any province, more than Ontario or Quebec,” which have much larger economies to support the expense, explains Mike Woods, Saskatchewan’s director of communications. “We have 9% of Canada’s national highways and 3% of the population. To make it worse, we have 159,000 kilometres of rural grid roads.”

That comes to roughly one kilometre of grid road per rural family to be maintained and rebuilt, an expense rural residents balk at paying. That’s why the people in Saskatoon and Regina must kick in.

Roads aren’t the half of it, Kenneth Fyke, the head of the province’s Commission on Medicare, recently explained. “A province of only a million people spread over a vast landscape faces enormous challenges in ensuring the accessibility of high quality service to all its citizens,” stated his report, Sustaining a Quality System. “Medicine now goes far beyond what any small town hospital can provide … quality of care requires a critical mass of service that only larger centres can provide.”

Under the current, impossibly decentralized hospital system, Saskatchewan supports 50% more hospital beds per capita than British Columbia or Ontario. Even so, rural people must often drive two to five hours for a 10-minute pre-check, and then must return later, the Commission explained. This inefficient system, and the inefficient use of scarce health-care dollars to maintain rural hospitals, also has other costs. It artificially undermines Saskatoon and Regina hospitals, whose specialists need to service larger populations to maintain their skills – and their interest in remaining in the province.

Four or five large hospitals could efficiently provide acute care for 1 million people, Mr. Fyke notes. Saskatchewan has 70 hospitals, many of them serving rural areas that are steadily losing population.

The Commission proposes triage. Rather than risk the health-care system’s collapse, the Commission recommends shutting down most of the rural hospitals – which, in any case, poorly serve rural areas – while improving primary care.

Roads in the rural areas, too, are in danger of disappearing, just like the grain elevators – a decade ago Saskatchewan had 500 grain delivery points; soon there will be 50 – and just like the 3,000 kilometres of abandoned railroad branch lines that no longer carry grain to the elevators. The eight-axle trucks that now carry the grain destroy the fragile roads, which are being forced to carry excessive loads.

In 1993, the province contemplated letting its low-volume highways revert to gravel. An outcry then caused the government to back off from most of its plans, and last September it tried and failed again, although on a small scale. But the plans remain, as does the logic of switching to gravel. To maintain the low-volume highways costs $5,000 per kilometre per year, and another $100,000 to $200,000 per kilometre when they must eventually be rebuilt – the situation today.

These roads typically serve but 200 to 300 vehicles per day on stretches that might range to 100 kilometres. Cost per vehicle per year to maintain a single 100 kilometre stretch: $2,000. Because the cost of rebuilding these roads is so high, the government hasn’t: About 2,500 kilometres are classed as under “great stress.” Translation: the road has lots of potholes, its asphalt often broken up into chunks.

These low-volume highways – 800 kilometres of those most stressed – have just received a reprieve, thanks to high energy prices: Saskatchewan is an oil producer – oil is run to generate profits, unlike agriculture – and the government has put about $100-million in added royalties into its low volume roads. Those royalties could have lowered taxes for the poor, to help them cope with difficult times, or for businesses, to help them succeed and make Saskatchewan a magnet – instead of a repellent – for talent. Or – the most sensible choice of all – the $100-million could have bought out many of the province’s unprofitable farms, letting the land revert to wilderness and lowering the future burden on Saskatoon and Regina of supporting the rural economy.

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Car deals

Posted on April 23, 2001 by Other News Sources

Kevin McLaughlin/Lawrence Solomon
National Post
April 23, 2001

Lawrence Solomon has missed the big picture: It’s true, Pay-per-minute Auto Insurance (April 10) will “begin to tame the worst excesses of the private automobile.” But why stop there? Why not pay for your car by the minute, too?

With the average car driven only about 66 minutes per day, yet costing over $8,000 a year, owning a car is the worst investment most people will ever make. The same “smart technologies” that are enabling pay-per-minute insurance have also launched pay-by-the-hour, instant-access car use in cities around the world through “car sharing.”

As the chairman of Ford Motors said recently, “If you live in a city, you don’t need to own a car.”

Kevin McLaughlin, AutoShare.com, Toronto

Click here to read Lawrence Solomon’s article, “Pay-per-minute Auto Insurance.”

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Fyke report’s missing link: health-care allowances

Posted on April 17, 2001 by Other News Sources

Lawrence Solomon
National Post
April 17, 2001

Saskatchewan’s Commission on Medicare brutally described the country’s health-care system last week in its report, Sustaining a Quality System.

Our publicly funded system is dysfunctional, Commissioner Kenneth J. Fyke’s report explains time and again, killing and injuring us in large numbers through clinical errors – he suggests these may dwarf the toll taken by highway accidents – and failing us in numerous other ways. It is “a system unintentionally designed to produce an unacceptable degree of error and waste. The most talented and committed individual can neither overcome bad system design nor compensate for the absence of timely and comprehensive information.”

Mr. Fyke, whose career in the Canadian health bureaucracy spans 35 years, understands that ours is a politicized system that largely operates for the convenience of the various special interests involved – chiefly the government bureaucracy and the various health-care workers who “have focused on their own entitlements rather than their obligations.” The rigid system that results creates obsolete practices, bad morale, general frustration and impersonal care that’s dispensed on a volume basis with little regard to the patient’s actual needs. Needless work is routinely performed. “Essentially the system pays for activity and is indifferent to result,” the report states.

The U.S. health-care system may have problems, but “it is inconceivable that American health-care organizations pay less attention to quality and service than ours given their competitive insurance structure and their litigation-friendly jurisdiction. In fact, given that quality has more funding and champions in the United States than in Canada, it is likely that, if anything, our circumstances are worse.”

Under the status quo, our doctors poorly dispense drugs – as one example, adverse drug reactions account for 20% of elderly admissions to hospital – and they operate whether surgery is called for or not. Instead of using medical resources better, the health-care establishment insists it needs more money, and typically gets it. Yet more money, Mr. Fyke believes, is part of the problem: “Adding money without changing the culture of the system provides only temporary relief.”

The culture that Mr. Fyke sensibly wants for us is less paternalistic and more customer-oriented. He shudders at a system that “would frankly be an embarrassment in any other human service industry. Long waits, anonymity, isolation, embarrassment, confusion, non-response, physical discomfort and infantilization are all common characteristics of health-care settings from patients’ and families’ points of view.” Why does a consumer of an automobile have access to superb information, the report asks, while consumers of health services are kept in the dark?

The answer, of course, partly lies in the auto companies’ need to compete for our business, leading them to lavish us with information. More fundamentally, the availability of myriad choices in the types of cars we can purchase, and the manner in which they’re outfitted, creates an industry of independent information providers skilled at understanding the many niches in the auto marketplace, and at conveying information about those niches to those of us who seek it. If the automobile sector were managed as a giant monopolized utility by auto bureaucrats deciding what cars with which options we needed and when – if it operated as the health industry does – we would have no meaningful choices, giving us little reason to gather data and giving information providers little incentive to gather it for us.

But amazingly, Mr. Fyke does not see that the culture that he deplores will not change as long as the system operates as a monopoly, without competition to give customers choice. To span the information gap, he suggests more bureaucracy in the form of performance indicators, a redesigned annual report by Saskatchewan’s health ministry and another government body – a Quality Council – that would, among other tasks, issue report cards.

These recommendations turn an otherwise insightful report into so much paper. And yet an answer to our medicare woes does exist, one which Mr. Fyke entirely ignored, even though it meets his desire to maintain a publicly funded, one-tier system. The answer, which goes by the name of health-care allowances, would provide every Canadian, rich or poor, with an annual allowance equal to what he currently costs the system, plus an annual top-up. It has been analyzed for Canada by one of the world’s top health-care actuarial firms and confirms Mr. Fyke’s finding that a publicly financed health-care system can deliver quality at lower cost by finding the kind of efficiencies that excellent systems find. But even more, health-care allowances would solve many problems that Mr. Fyke identifies, such as how to provide free prescription drugs without bankrupting the medicare system.

The Fyke report may yet prove valuable, however. The person who commissioned it, Saskatchewan’s former premier, Roy Romanow, is now heading up a federal inquiry into medicare and he plans to use it as a building block. Good. Mr. Fyke’s diagnosis of the disease is excellent: It’s his prescription that’s wanting.

Mr. Romanow has his foundation in the Fyke report. To make for medicare a magnificent edifice, he should now direct his energy to the one medical instrument – health-care allowances – that can deliver the quality and meaningful choices that will allow medicare to fulfill the dream that Canadians have for it.

Why isn’t buying surgery like buying a car?

From Sustaining A Quality System, a report from Saskatchewan’s Commission on Medicare released April 11.

Emily Pelletier wants to buy a new car. Bill Kozak needs surgery. Both want the best possible information to answer their questions and enable them to make informed judgments and decisions. In Saskatchewan at the dawn of the millennium, what will their quest for information find?

Emily Pelletier, a savvy consumer who knows her way around the Internet, the library, and the newsstand, is in great shape. The specifications for the car – dimensions, features, engine size and power, fuel efficiency – are supplied by the manufacturer. There are numerous magazines, journals, and Web sites that publish independent comparative reviews of cars in the same class.

She can find out the dealer cost and the typical mark-up. She can consult buyers’ guides to find out how the car holds up over time, what components are most likely to break down, what repairs will cost, and the typical rate of depreciation. She can read real-time, up-to-date customer satisfaction survey information. And Emily’s car will come with a warranty that guarantees quality and service for a defined period of time.

Thirty years ago, Emily would have had a much more difficult time finding any of this information. Buying a car in those days was much more of a gamble. For such a major purchase, the public wanted reliable, comprehensive information to aid their decisions. As the information got better and easier to get, the auto industry transformed. In the 1980s, for example, it became clear that Japanese cars were better than American cars – mainly because of advanced design and manufacturing processes, and a commitment to quality. Millions of buyers bought Japanese cars as a result.

After surveying the wreckage of their market share, the American manufacturers responded by making better cars. Today almost every car is much better than the cars of twenty years ago. Quality improvement has been driven by consumer expectations and fuelled by sound evaluative data.

Now let us consider Bill Kozak, the patient about to undergo surgery. What information is available to him? Not very much. He probably knows little about his family physician – where she graduated, where she placed in her class, what type of continuing medical education she has pursued, even her main areas of interest. She may refer him to a specialist, whose characteristics are similarly unknown. How many procedures has the specialist done? What is the complication rate, and how does this compare to the peer group? Are there other specialists around and if so, why refer to one and not the others? How does the hospital compare to others in terms of outcomes? If Bill is a sophisticated, energetic, and assertive patient, he might get a smattering of the information he requires. But much of it is not available to either Bill, his providers, their managers, or the provincial ministry of health. They are in a sense shopping unarmed.

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