Urban Renaissance Institute

The Next City
September 21, 1996

The rediscovery of human nature

Good Natured: The Origins of Right and Wrong in Humans and Other Animals

by Frans de Waal
(Harvard University Press, 1996. 296 pages) $37

TRADITIONAL MORALITY HAS BEEN ERODING since the 1920s. But even as the grasp of right and wrong has weakened in the social sciences and humanities, evolutionary biology is laying the foundations of a new body of natural law. Good Natured is a cornerstone in this edifice.

No mere popularizer, Frans de Waal is one of the world’s leading primatologists, yet he also writes for the general public. Anyone who reads THE NEXT CITY  with enjoyment will be able to follow de Waal’s train of thought and understand his fascinating examples, drawn from thousands of hours of personal observation of chimpanzees, rhesus monkeys and other primate species. Dozens of carefully chosen photographs drive home the book’s argument and justify the slightly higher than usual price.

Because of Herbert Spencer’s phrase, “survival of the fittest,” and the title of Richard Dawkins’s best-selling book, The Selfish Gene, many readers probably think of evolution in purely competitive terms; but de Waal has another story to tell about social mammals, such as wolves, dolphins, elephants and the primates, including humans. All social mammals, according to de Waal, share four characteristics that lie at the root of morality. These characteristics, while enormously amplified in human beings because of our intelligence and cumulative culture, are also recognizable in other species.

First is sympathy. Social mammals recognize each other as individuals, appreciating each other’s feelings. They show pleasure upon reuniting after a period of separation. They try to help a sick or injured member of their community. They recognize death and may linger by departed ones. The book’s most moving photograph shows an elephant who returns regularly to touch the skull of her deceased mother. This ability to recognize others and sympathize with their feelings is at the foundation of morality because it leads us to treat others with consideration.

Second, social mammals live in hierarchies and follow rules of conduct enforced by others in the community, especially, but not only, by the dominant members. Depending on the species, there may be an alpha male, an alpha female, or both, as well as a ranked system of matrilines (in baboons) or patrilines (in humans). Whatever the social order, it is enforced, with measures ranging from gentle taps through vigorous hitting and biting to lethal violence.

De Waal tells the story of two juvenile chimpanzees in a zoo community who delayed the group’s evening feeding by refusing to enter the feeding station at the right time. Because the group always ate together, the others wouldn’t go in without everyone present. Then, the next day, when they were away from their keepers, the whole troop set upon the delinquent pair and gave them a sound beating. One can hardly miss the parallels with law, politics, government and justice.

A third universal aspect of social existence is reciprocity. In pursuit of dominance, chimpanzee males form coalitions that depend on mutual support during confrontations with rivals. Repeated failure to support a partner will break up the coalition. Monkeys and apes remember who has hit or bitten them and can exact revenge hours or even days later. In species that share food, the sharing is not random but related to other favors performed between individuals. Is it far-fetched to see in these exchanges the basis of such moral notions as respect for rights, keeping agreements, fulfilment of obligations and justice in the sense of proportionality between contribution and reward?

Finally, social animals ceaselessly fight and make up, often with other members of their community getting into the act. Although conflicts over food, mating opportunities, offspring and dominance can be severe, reconciliation follows through grooming, embracing or kissing. Third parties not involved in the original conflict often bring the combatants together, and all members of the community celebrate when reconciliation finally takes place. Human parallels involving forgiveness and mediation readily come to mind. We can indeed play the killer ape, but we can also respond to the words of the Sermon on the Mount: “Blessed are the peacemakers.”

The notion of a moral law ordained by a Supreme Being has weakened in the modern world; and without belief in a divine maker or designer, natural law theories of morality lose their force. The other main approach to moral philosophy is utilitarianism, which holds that true happiness can only arise from right conduct; but in practice, by identifying happiness with the fulfilment of individual desire, modern utilitarianism has foundered in a swamp of anything-goes morality.

Evolutionary biology offers a way out of this impasse by showing how the moral order of a social species arises from the competitive struggle of the selfish genes to replicate themselves. It explains morality not as the conscious design of a divine maker or as the intentional quest for happiness by individuals, but as behavior that has become genetically entrenched through differential reproductive success.

For example, an evolutionary biologist would argue that male chimpanzees like to groom each other not just because they enjoy it (though they seem to) nor because God willed it (though maybe He did), but because of its survival value: It lowers tensions between males who would otherwise compete for dominance and helps them cooperate in hunting and in defending the community against other chimpanzee bands. Unlike antisocial chimps, social chimps who groom each other help build a successful community, which in turn means greater success for their genes and thus for them as individual members of a social species. Transferred to our own species, this objective approach to explaining the existence of morality would help us understand, respect and enforce our own moral nature.

For anyone concerned about the moral vacuum of contemporary society, Good Natured is a profoundly hopeful book. Today’s fashionable ideologies – post-modernism, deconstructionism, critical theory, gender feminism, multiculturalism – teach that right and wrong are merely verbal expressions of power, that morality depends on race, class and gender. Children in school, if they get any moral instruction, are usually taught that everything depends on the individual’s choice of values – “Do what is right for you.”

Of course, at a deeper level, no one really believes all this relativism. We are still outraged if someone steals our car, breaks into our house or assaults a child in our neighborhood. We have not stopped being moral, but we have largely lost the capacity to understand and explain what good and evil are and why we should do good and avoid evil.

The ability to be moral depends on comprehending human nature and on an objective moral order. Our culture used to embody this understanding in religion, philosophy, history and literature; but those forms of expression have been seriously damaged, if not destroyed, by the malignant family of post-modern ideologies. Science, though under a similar attack, still survives as an objective inquiry into nature.

Under present circumstances, science may be the only intellectual force capable of rediscovering human nature and the moral order. Good Natured shows us that our intuitions of right and wrong are not just individual whims, but a natural aspect of being human, and that they exist in all societies, albeit with a unique cultural expression in each one.

Aristotle was the first philosopher to systematically articulate the moral tradition of the Western world. But he was also a great biologist. As the Greek philosophers understood, human nature is part of a larger cosmos or natural order. It is, therefore, quite in keeping that the modern recovery of moral understanding should arise from the discoveries of modern evolutionary biology.

The Good Society: The Humane Agenda

by John Kenneth Galbraith
(Houghton Mifflin, 1996. 152 pages) $29.95

AFTER READING THIS BOOK, I leafed through the front pages in search of copyright information. To my surprise I discovered it was written in 1996 by a John Kenneth Galbraith. I would have placed the book in 1949 and ventured Mao Tse-tung as the author. Every few pages have some reference to what the “good society” wants for its people and what it will not tolerate. Low on the list of items to tolerate is the present exploitation by the “favored, the affluent, and the corporate bureaucracy” of the “socially and economically deprived.”

Who belongs to this good society, and how its members manage to think on one wavelength, is a mystery Galbraith does not care to uncover. He prefers to drag the reader through 152 pages of economic myth on the road to his revelation that the good society can only work if the poor start voting to grab more wealth from the rich. I, like many professional economists, do not believe the free market is perfect, but a book such as this one does not advance my understanding of how to fix what may be wrong. Instead, I was treated to comments about the economy that suggested Galbraith is highly selective in the economics journals he reads. He believes the corporate takeover wave of the 1980s destroyed wealth, ignoring studies by Harvard economist Andrei Shleifer and Chicago economist Robert Vishny that show just the opposite. Galbraith believes in a clear trade-off between unemployment and inflation – has he not heard the term “stagflation”? He claims that stock markets are myopically obsessed with short-term profits – perhaps he has never heard of the 3M corporation, or of the biotechnology industry, or of the ongoing explosion of research and development spending on high-risk, long-term ventures.

Still, Galbraith should not be dismissed. His economic proclamations may be off the mark, but he has his finger on the pulses of the many people who are bewildered by the changes in today’s world and who would invite a benevolent dictator to press on the brakes of progress.

Filip Palda

The Politics of Power: Ontario Hydro and Its Government, 1906-1995

by Neil B. Freeman
(University of Toronto Press, 1996. 252 pages) $18.95

FOR THOSE WHO NEED TO FOLLOW the comings and goings of cabinet ministers responsible for Ontario Hydro, or the appointments of the commissioners and board members in charge of the utility giant over the decades, The Politics of Power is the book for you. If, however, you are interested in the fundamental forces at play in the history of this giant monopoly – how various special interest groups sold the public on the power-at-cost concept, the utility’s underlying economics, or the decision to complete the Darlington nuclear station in 1986, which was Hydro’s ultimate undoing – you will have to look elsewhere. The book but dimly illuminates why political decision makers remained so ignorant for so many decades, and contributes little to the debate over how to solve the ongoing Hydro crisis.

Thomas Adams

Rebels Against the Future: The Luddites and Their War on the Industrial Revolution: Lessons for the Computer Age

by Kirkpatrick Sale
(Addison-Wesley, 1996. 320 pages) $18

WITH ALL THE RECENT ANGST over industrial restructuring, Kirkpatrick Sale’s study of insurgency and despair in England’s 19th-century textile industry promised timely insights. But Sale’s book about Ned Ludd’s rebellion slides off its mark into a much broader critique of industrialization, from the enclosure of common lands in the 15th century to the advent of computers in the 20th. Sale likens modern technology to Frankenstein’s monster: destructive, and beyond its inventor’s influence. Yet Sale tells only half the technology tale, scarcely mentioning the spinning jenny’s boon to weavers long before mechanized weaving incited the Luddite rebellion. Rebels Against the Future disavows the modern “technosphere”; but without analyzing its workings, Sale offers only moral support to those who do try to influence the shape of industrial society today through informed consumption, industrial and urban design, or political action.

Patrick Kennedy

The Quest for God: A Personal Pilgrimage

by Paul Johnson
(HarperCollins 1996. 216 pages) $29.95

PAUL JOHNSON INTRIGUINGLY TURNS THE TABLES on God’s detractors, showing how it is they, not the bible thumpers, who suffer from superstitious beliefs. But this noted historian’s argument that the atheists and other skeptics of religion are on the wrong side of history soon becomes lost in a sweeping, even ignorant, condemnation of all he sees as the 20th century’s organized alternatives to God, among them environmentalism, socialism, racial and sexual politics, and advocacy of animal rights. Johnson expects the 21st century, like the 19th, to be one for missionaries, whom he exhorts to evangelize and subdue Islamic territory in North Africa and the Middle East. Asia, with its Hindus, Shintoists, Confucians, Muslims and animalists, also needs converting. As for Jews, whom the Roman Catholic Johnson greatly admires, God may help them and Christians heal their schism prior to the Last Judgment. Johnson calls his book a meditation, denying The Quest for God proselytizes. In so denying, Johnson sins.

Lawrence Solomon

Lawrence Solomon
The Next City
September 21, 1996

Giving power to consumers will cure Canada’s ailing medicare system

 

Letters

1. Lorne Almack , Claremot, Ontario, responds: October 5th, 1996
2. James Clark Scarborough, Ontario, responds: Ocotber 14, 1996
3. Richard C. Millar Senneville, Quebec, responds: October 19 , 1996
4. Charles R. Neill , Edmonton, responds: November 8, 1996
5. Walter W. Rosser, M.D.  Professor and Chairman, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, responds: January 24, 1997

 

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Lorne Almack, Claremont, Ontario, responds: October 5, 1996

The article on Medicare is one of the best I have ever read.

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James Clark, Scarborough, Ontario, responds: October 14, 1996

One would think that everyone who pays road taxes is entitled to equal access to highways. Along comes ETR 407 (Express Toll Route 407), and we all think what a great idea and how it will take a lot of congestion off the 401. I don’t hear anyone whining about universality here (i.e., you can’t have anything I can’t have). So what’s the big deal about a two-tier health care system? What’s the big deal about boosting health care with private money, with some being able to pay?

You missed the most devastating and unique thing about health care in Canada: It is the only country in the world where it is forbidden to buy health insurance to cover what OHIP covers (at the time). So now we have a generation who basically will have less and less coverage as OHIP retracts and who were brought up to believe in a free lunch.

Disease insurance has been sold to us as health care just as death insurance is sold as life insurance! OHIP doesn’t cover healthful modalities.

There’s lots more I could add since I am one who sweats in the forced labour camps of OHIP.

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Richard C. Millar, Senneville, Quebec, responds: October 19, 1996

Building on Medicare to introduce choice and competition to our medical system with Medical Savings Accounts is a great idea.

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Charles R. Neill, Edmonton, responds: November 8, 1996

Your article “Patients, heal thyselves” in the Fall 1996 issue had many stimulating ideas. I would like to make some comments on the medical mall concept — I have in fact visited Addenbrooke’s Hospital in England to visit a sick relative.

My reservations arise not from Addenbrooke’s but from a Canadian hospital where I spent quite a lot of time as a visitor earlier this year. The atrium has been partially converted to the mall concept and the food facilities have been entirely contracted out — allegedly at the urgings of the staff. The result is that the offerings are heavily weighted toward enormous U.S. style servings of fat-laden food — I watched people ordering ice cream dishes that would have kept an African in calories for a week. The effect on the hospital staff is only too evident; I would guess that at least half of the nurses are suffering from obesity, to a degree that has been apparent in Canada only since the proliferation of American fast food chains. The sight of all those waddling caregivers in an institution supposedly devoted to health is most depressing — one can just see the future medical costs of all this overeating piling up.

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Walter W. Rosser, M.D., Professor and Chairman, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, responds: January 24, 1997

I recently read your excellent article “Patients, heal thyselves” with great interest. While it covers many of the important ideas being discussed on the reform of our health care system there is one statement that I believe is a misinterpretation of the situation in Canada and the U.S.

In regard to the number of family physicians compared to specialist physicians, the ratio in Canada is approximately 50/50 compared to only 17/83 in the U.S. You interpret this as an under-trained, unskilled workforce. The Americans have declared a 100,000 surplus of specialist physicians and a 60,000 shortfall of family physicians. Most Americans, and experts around the world, agree that the majority of physicians should be well-trained family physicians and that subspecialty physicians should be the minority. This balance provides the most effective and efficient delivery of health care to our populations.

Contrary to your remark, the Americans are currently striving to achieve the balance we currently enjoy in Canada.

Lawrence Solomon
The Next City
September 21, 1996

INSTEAD OF ADOPTING HMO-STYLE RATIONING, CANADIANS SHOULD turn to Medical Savings Accounts, another innovation in U.S. health care that over 2,000 large and small companies have been offering their employees.

With MSAs, as they’re known, employees generally receive a high-deductible insurance policy, plus the deductible in the form of cash, instead of a traditional low-deductible insurance policy. For example, the United Mine Workers Union successfully negotiated MSAs for 15,000 coal miners with the Bituminous Coal Operators Association. The zero deductible under the old health plan was replaced with a $1,000 deductible policy, and each employee was provided with a $1,000 cash bonus at the beginning of the year, to be used for health care expenses. If a miner has over $1,000 in expenses, the insurance policy kicks in. But if he doesn’t spend the full $1,000, he can keep the balance at the end of the year.

In most cases, employees end up with cash in their accounts: According to a study in the Journal of American Health Policy, one-third of Americans filed no claims in 1989, and 82 per cent, $1,000 or less. For this reason, MSAs have proved overwhelmingly popular with Americans, especially lower-income Americans who sometimes had difficulty paying the small deductibles common to traditional insurance policies. Because of their popularity, MSAs will soon be tried out in a demonstration project designed to let up to 1.5 million Americans keep their insurance if they lose their jobs.

Medical Savings Accounts, like those in the U.S. demonstration, will allow account holders or their employers to make tax-deductible contributions, similar to our RRSPs. These funds can then be used to buy high-deductible catastrophic health insurance, to take care of any serious or expensive ailments, and to pay for routine medical expenses as they arise. Any unspent amounts can then be invested within the MSA. To discourage withdrawals from MSAs for non-medical purposes, withdrawals will not only be taxed, they’ll be penalized 15 per cent. (After age 65, the penalty will be removed, and the MSA will become identical to an RRSP.) Three dozen U.S. insurance companies are about to market a variety of MSA accounts. Some estimate that MSAs, if applied nationally, could save the U.S. health care budget $300 billion per year.

But while these private MSAs are a major advance in a country that has discouraged personal coverage, private MSAs also draw justifiable criticism: The rich will be able to contribute more than the less affluent, the rich will benefit from a tax-free shelter that they can use to accumulate funds while they retire; and private MSAs will create a two-tier system, in which the sicker, less affluent members of society who can’t afford the large deductibles will dominate the normal insurance pool, raising their premiums. (Private MSAs also draw less justifiable criticism from the HMOs and other corporate interests whose profits they threaten.)

But the drawbacks to private MSAs would disappear if implemented under a publicly funded medical system such as ours. Here’s how MSAs would work in Canada:

On average, Canadians spend about $2,500 per person per year on our health needs, less as young adults, more in our earliest and latest years. Almost 30 per cent of that amount comes out of our own pockets for drugs, dentistry and other uninsured services, and the balance, or roughly $1,800, comes from our taxes. Under a public MSA system, the tax money that governments have spent on our behalf by issuing cheques to our health care providers would instead be deposited into a medical savings account.

On average, close to half of that $1,800 (perhaps $700 or $800, depending on the policy), would pay the annual premium for mandatory, catastrophic insurance coverage, to cover surgery, hospitalizations and other major medical needs that might arise. The balance, roughly $1,000 per family member per year, would be available for any currently insurable medical purpose. As with private MSAs, once we spent that balance, the catastrophic policy would kick in. But if some or all of the balance remained, it would belong to us. As in the U.S., the less affluent would benefit: Money unspent in one year would be available in the next for their prescription drugs, dental work, chiropractic and other currently uninsured medical services. Any unspent money would be invested, as it would in an RRSP, letting it grow should extraordinary future needs arise. After age 65, people could transfer some or all of their balance to an RRSP and withdraw it (paying tax) as for any other registered retirement fund they might have.

Seniors, who use the medical system most, could be the biggest beneficiaries of a Medical Savings Account system. Each year, about 10 per cent of all Canadian seniors are admitted to hospital for drug-related illnesses, making them our hospitals’ most frequent clients. Of those admissions, an inordinate number stem from errors in taking medication: The Pharmaceutical Inquiry of Ontario puts the figure at about 50 per cent; the Canadian Grey Panthers, an advocacy organization for the elderly representing 50,000 Canadians, believes the actual figure could be 70 or 80 per cent, since falls and other accidents caused by overdoses or drug inter-reactions aren’t recognized as such. These entirely preventable errors aren’t entirely of the seniors’ making. Grey Panthers’ research director Penny Grey blames a tendency of physicians untrained in geriatric care to give the elderly doses suitable to the nervous system of younger patients, and a fixed-price-per-visit system that discourages doctors from taking the time to understand their patients’ needs. Because of the “patient mills” that some doctors run, Grey explains, seniors often go from doctor to doctor, seeking answers but receiving a tranquillizer or sleeping pill instead. “The result of this pill-for-every-ill approach is an older population that’s seriously over medicated, some taking a dozen or more drugs of questionable value, often the same drugs sold under different names.”

MSAs would eliminate most of the tragic and enormously costly hospitalizations that result by restoring the best aspects of the traditional doctor-patient relationship. With doctors able to provide patients with the time needed to fully understand their problems, and with the patients able to pay for the visits from their Medical Savings Accounts, drug use and misuse will drop dramatically, as will senseless hospitalizations.

Since we’ll all be in charge of our own spending decisions, we’ll make health purchases more prudently, because the size of our family’s future medical and retirement reserve will depend on careful shopping. Bargain hunting in medicine? A 1992 study by Chicago’s Heartland Institute, “Why We Spend So Much on Health Care,” found that hernia surgery in Illinois could cost as little as $404, or as much as $4,329, cataract surgery cost anywhere from $650 to $5,674, and mammograms ranged from $35 to $178. While no one will shop for bargains in an emergency, emergencies only account for one-seventh of health care expenses, and many of our minor medical needs — say, tending to a badly scraped knee — could be performed by seeing a trained nurse (registered nurses or nurse practitioners can perform 32 per cent of the procedures performed by GPs as well or better). In the U.S., telephone-based nurse counselling is booming, providing advice about treatment options and disease management, education and support. Staffed 24 hours a day by registered nurses, and paid for by HMOs to keep their clients healthy, phone counselling services have more than doubled in each of the past two years, with 13 million Americans enrolled to this toll-free service. Some nurse counselling services conduct personalized research, others follow up with phone calls to go over the issues, or mail or fax customers health care information. Six towns in rural Maine plan to funnel all primary care through nurses.

A five-year study of 2,500 families completed in the late 1970s by the RAND Corporation shows just how careful consumers become when they have an incentive to control costs. Families with Canadian style coverage — those with insurance policies that had no deductible and no co-payments to make — spent 53 per cent more on hospital services and 63 per cent more on visits to doctors, drugs and other services. All told, these families spent 58 per cent more than families that paid part of the cost, in almost all cases without achieving any health benefits.

As in other consumer areas, health care choices often involve choosing between convenience and cost, a trade-off that will vary from consumer to consumer and even for the same consumer, depending on the circumstances. Laparoscopic, or “keyhole,” surgery, the minimally invasive technique that allows doctors to operate through small slits instead of large incisions, generally saves dollars as well as suffering through shorter recoveries for patients, and shorter hospital stays. But in the case of hysterectomies, traditional surgery can cost 20 per cent to 60 per cent less, depending on the hospital, saving as much as $2,500. If someone else is paying, we’ll always prefer laparoscopic surgery. But if the $2,500 comes out of our own account, the extra time in hospital may seem a reasonable price to pay.

With rationing systems, public or private, the patient wouldn’t get a choice — the less costly surgery would be chosen. Under an MSA system, the choice is ours. If the extra time in hospital means cancelling that vacation our family has booked, or failing to complete a contract for an important client, the $2,500 becomes well worth paying.

With MSAs, we’ll be cutting costs without cutting quality, and cutting quality only because doing so provides better value for our money. In a study earlier this year, the Canadian Institute of Actuaries warned that our medicare system could collapse as soon as the baby boomers start to retire, both because the boomers will start needing expensive medical services and because they won’t continue to contribute as much in taxes toward health care. The 10 per cent of GDP that Canada now spends on health care — the world’s highest next to the U.S., and 15 per cent more than Australia, New Zealand, Japan and most European countries — could balloon to an unsupportable 12 per cent. But the study also showed that Canada’s current spending level can be maintained if, on average, we keep our increases in health care spending to within one-half of one per cent of the increases in our GDP. If our nation’s earnings go up 3 per cent per year, in other words, health care spending can increase by 2.5 per cent without increasing our taxes. But the efficiencies to be had by converting to a government-funded MSA system — 10 to 15 per cent, according to one study of MSAs for U.S. Medicare — are at least 20 times as great as the Canadian actuaries need. With MSAs turning us into savvy health care consumers, health care costs will in all probability be slashed further from today’s high levels, leaving room in the system for either additional government spending or tax cuts.

Curing medicare’s side effects

ALTHOUGH MEDICARE PROVIDED A WORLD OF SOCIAL BENEFITS, because it disrupted a major sector of the economy, there was a price to pay as well. Among medicare’s losers are residents of small towns and rural areas, who often do not have ready access to medical services, and those choosing medical careers, who often find they cannot practise the medicine of their choice in Canada.

These failings spring from the way we regulate medicare, not from socialized medicine itself. To limit their health expenditures, governments set quotas for doctors, especially highly trained specialists, and then capped doctor fees to prevent prices of now-scarce doctor-provided services from rising. In effect, governments imposed wage and price controls on the medical sector, similar to the economy-wide wage and price controls that Canada and other countries tried in the 1970s. Because those controls, like most controls, caused serious side effects, they were eventually abandoned.

Medicare’s side effects saw the loss of many of our best doctors to the United States and a tendency of doctors to abandon rural areas and small towns for more prosperous city practices. By creating a shortage of doctors while still guaranteeing generous payments to doctors — the same payment, regardless of the doctor’s skill in providing the service — medicare provided doctors with a large and all-but risk-free, captive clientele in cities, tilting the economics of setting up a practice to cities. In so doing, medicare devalued the worth of rural and small-town customers — their business no longer counted for much in the new medicare economy.

MSAs do away with price and wage controls, and let the medical market function efficiently, virtually without economic distortion. Without governments controlling the supply of doctors, medical schools could graduate all qualified students, in all specialties, giving young adults more opportunities to pursue the career of their choice in Canada and giving Canada a more skilled medical system.

Once graduated, doctors would face the same job insecurities, and the same need to find their role in the workplace, as other professions. Urban practices would no longer be disproportionately lucrative, because competition would drive prices down. The distribution of doctors in Canada would spread to serve all communities whose size warranted them, just as lawyers and other professionals can be found to service small communities. Specializations such as geriatrics that promised a growing market in serving the specialized needs of our older population, would attract large numbers of young doctors. In this new buyers’ market, well-funded seniors would be able to pick and choose from a large pool of specialists eager to provide them with the time and the attention they demand, ending the doctor-caused epidemic of overmedication that leads to needless hospitalizations.

In the same way that increasing the supply of doctors creates healthy competition, rather than arbitrarily closing hospitals, we should allow all viable hospitals to remain open to improve the options available to us. Because of the numerous niche markets that hospitals would quickly discover, most hospitals closings would be reversed.

By creating a functioning medical market, MSAs will help the Canada Health Act in doing its job of promoting universal access. But even more importantly, MSAs will promote health care by empowering consumers, putting purchasing power squarely in the hands of highly motivated consumers who will begin to direct the medical marketplace, and to be influenced by it. The same marketing know-how that understands how to package information for every demographic sliver of the marketplace — male, female, young, old, rich, poor, urban, suburban, educated, uneducated — will now set its sights on the consumer health market. With every company in the health industry knowing that every Canadian, from minimum wage earner to millionaire, is in the market for health-enhancing products and services, a burgeoning health market will succeed in conveying health information to those down the social ladder, who have not fully shared, despite Canada’s universal medical system, in the longevity gains of more affluent Canadians. Because the money in their accounts will be as good as anyone else’s, they’ll be courted, many for the first time. Motivated by messages from hucksters and humanitarians alike, advised and alerted by consumer protection agencies, excluded from the discourse of medical knowledge no longer, the longevity gap between the rich and the poor will narrow, while the longevity of all, rich and poor will rise.

Meet me at the medical mall

A CHANCE ENCOUNTER IN 1987 BETWEEN SENIOR EXECUTIVES OF the Cambridge Health Authority and BAA, the newly privatized British Airport Authority, began a revolution in the development of the hospital. BAA had set the airport world abuzz by discovering that more money could be made from shopping than from airplane take-offs and landings — the airport’s main business was in retail. The culture of the airport changed to become consumer friendly: Mall retailers at Heathrow and other British airports began to offer their merchandise at prices no higher than in the city, leading them to focus on the specialized products and services airport users most valued. The airport recognized that it had captive customers with specialized needs. Hospitals fit the same bill.

The experiment played out at Addenbrooke’s Hospital in Cambridge, which — amid concerns that it would lose its caring culture — opened a 650-square-metre mall the next year for its 925 patients, unknown numbers of visitors, and 4,000 hospital staff. The mall was a hit-and-miss learning experience for all. The florists, bank and bookstore (aisles wide enough to take a bed) raised a few eyebrows. The hairdresser proved a hit with patients, whose spirits perked up with a perm. The biggest surprise: Premier, the travel agent, who was popular with the hospital staff when booking holidays, but also with consultants on the medical conference circuit and the patients’ friends and relatives. The biggest failure: Imagination, a store selling frilly lingerie, which learned to its dismay that the hospital clientele wasn’t up to some kinds of entertaining. The proposal for an on-site undertaker didn’t survive the guffaws. The lawyers in the mall did, despite occasional jokes about ambulance chasers, with most patients grateful for help in the cases of accidents and in drawing up wills. The hospital’s staff use the lawyers for everything from relocation legalities to divorces (sometimes at the same time).

Just-in-time service is provided by the insurance agents, helpful in sorting through claims, and the baby shop, conveniently tucked in the maternity wing. There’s more, too. A supermarket, clothing store, dry cleaner, and food court (Pizza Hut and Burger King are among the tenants) draw customers from the outside world. All told, 30,000 shoppers visit the mall at Addenbrooke’s each week, providing the hospital with a pretty penny and a spirit money can’t buy. Nobody gets into the hospital without passing retailers strategically located to attract their attention.

Today, no one regrets the decision. “There’s a ‘buzz’ in the hospital because of the mall,” explains Julie Speck, a former airport employee who is now the Addenbrooke’s mall manager. “It gives patients a sense of normality to be able to get a cup of coffee and do a bit of shopping.” Addenbrooke’s has since expanded its own mall twice and advises hospitals in London, Leeds and elsewhere that are eager to develop malls of their own.

While Addenbrooke’s was the first hospital to capitalize on the glitz of the mall’s shopping environment, the first hospital mall opened more than a decade earlier, but for a more practical reason: Dallas’s Medical City was built on the town’s outskirts in 1974 as a convenience to patients. But the public demanded more from its hospital, and Medical City evolved into a kind of community centre that hosts car shows, health fairs, circuses and bridal fairs in its 8,000-square foot atrium, one of three elegant spaces of marble floors and water fountains. Other U.S. hospital malls also became public places: Lebanon, New Hampshire’s Dartmouth-Hitchcock Medical Center, which has 10,000 square feet for retail space, holds concerts in its public spaces. When it opened in 1991, it was the state’s leading tourist attraction; 20,000 people still tour the hospital each year. Residents of Kendall, Florida, find Baptist Hospital so beautiful they ask to hold wedding ceremonies there. The Sutter Maternity and Surgery Center in Santa Cruz, California “feels like a hotel,” says Iris Frank, its administrator. “We offer 24-hour room service, with food ordered at will and delivered on a hotel-like room service cart. The chef is a graduate of the California Culinary Academy.”

Hospitals have come a long way since their origin in the last century. To shed their impersonal, inhospitable image in the emerging competitive health market for ambulatory care, hospitals are transforming themselves from being one of society’s most closed institutions into more welcoming and accessible places. Out are foul-smelling, green-tiled hospitals, in are medical malls designed to help ambulatory customers find their way. From the central atrium of the 220,000-square-foot Saint Joseph Health Center in Kansas City, Missouri, a visitor can locate all the mall’s services — among them the laboratory, physical therapy, medical offices, and surgery — by looking at the signs on the balconies of each level. Thanks in part to its better visibility in the marketplace, outpatient visits are up 16 per cent, 30 per cent for the pain clinic and ultrasound, since the centre opened in January 1995.

But most of the outpatients who visit the complex don’t enter the hospital itself. Instead of needing to navigate the hospitals’ intimidating maze of hallways, they now see the atrium’s glass backed elevators, a fountain and a player piano. And whether they’re entering or leaving, they must all pass through the mall, into the clutches of waiting retailers and service providers.

Education is the best inoculation

THE HOSPITAL — THE PLACE TO WHICH WE BRING OUR WORST MEDICAL problems and all the fears and insecurities that come with them — has in the past avoided both proselytizing and marketing its mission to its visitors. Yet we are never more open to changing our own unhealthy behavior than when circumstances take us to a hospital. For our health care system to treat the whole person, hospitals themselves need to capitalize on the educational opportunities in impressionable minds in the hospital traffic. Hospitals need to see their visitors as a pool of potentially motivated health care consumers, and their patients as more than about-to-be anaesthetized slabs on the hospital bed.

Fear of adverse consequences from unhealthy lifestyles — such as the fear of contracting lung cancer from smoking — only goes so far. People tend to adopt a new behavior when they feel their peers want them to. Nothing succeeds like a supportive environment.

Thousands of self help groups, for virtually all medical conditions, have sprung up to provide the peer support the human spirit craves. But because these groups are generally informal and difficult to find, they often don’t attract the membership they need to operate smoothly. They are often unfunded, poorly organized, and dependent upon a group leader whose illness may prevent him from carrying out his duties. By providing storefront space in an upbeat, empowering medical mall, hospitals would make it easy for self-help groups to find recruits in patients who are recuperating from a particular ailment, and in their friends and relatives, who might drop in to learn about the condition afflicting their loved ones. In meeting its members’ needs for support and information, self-help groups will be purchasing educational tools, providing tests, buying equipment and obtaining other paraphernalia. Each hospital specialty provides a ready market for a like-minded self-help group, a means to their empowerment.

Seniors, in particular, will gravitate to these self-help clubs, where, together with others with similar problems they’ll be able to share information about new discoveries (perhaps using their club’s Internet facilities) and benefit from lectures that they can solicit from members of the hospital’s professional staff on subjects of the seniors’ choosing. The membership fees required to pay for the club’s rent at the mall and otherwise maintain it should be eligible to come from the Medical Savings Account; these nonprofit, educational clubs will repay society many times over, and nowhere will the investment come back faster than in the case of seniors.

Seniors without a support structure — without helpful family or friends — are twice as likely to be in poorer health, according to Statistics Canada, and 50 per cent likelier to be taking three or more drugs. As well, for want of company and attention, seniors, often resort to visiting doctors’ offices, burdening the medical system without benefiting themselves.

Because group sessions aren’t for everyone, hospitals need to tap commercial retailers, who know how to appeal to the interests of almost everyone. Because the thousands of patients and their visitors that enter a hospital each day have health issues on their mind, they’ll be receptive to retailers able to capitalize on their needs, along the way providing them with the information that can turn a fear into an informed, empowering course of action. “Visiting someone with a heart condition? Shouldn’t you get your cholesterol tested while you’re here? Pick up your results in 30 minutes on your way out. Oh, while you’re at it, since it’s Tuesday, get a second test at half price — your choice from this menu of 21.

“Here, let me put you down on our mailing list for upcoming specials. Soon we’ll be able to check out your predisposition for Alzheimer and other inherited diseases.”

Want to do the testing in the privacy of your own home? Besides the pregnancy and HIV home tests now available, the University of Ottawa has just produced a $15 kit to help menopausal women decide if they want to take estrogen and progesterone. Medical hardware, such as blood pressure gauges, is also moving into the home. If you expect to be among the 100 Canadians that — on any day of the year — might suffer sudden cardiac arrest and die, Heartstream’s defibrillator, which weighs just four pounds, was designed to be operated by anyone, even in a state of panic. Users are guided through a one-minute setup by Peter Thomas, narrator of the PBS science program, Nova, after they turn on the machine. (“Apply pads to the patient’s bare chest . . .” he calmly intones.) The Heartstream devices, which start at $2,500, are priced for the super rich, or for a family with a history of heart disease with a medical savings account.

Medical software may prove to be a bigger market than heavy duty hardware. The American Medical Association’s Family Medical Guide, which sold five million copies in book form, is now available in a CD-ROM version. The guide does more than provide information on 650 diseases, disorders and general health concerns, it comes to life with over 60 animations and video clips providing information on self-care and medical tests, and guidance on wellness and prevention. Users answer a series of yes-or-no questions to evaluate their particular symptoms and help determine if medical attention is necessary.

Such reference manuals only begin to tap the market for medical material. CD-ROMs now let home-computer users view beating hearts or travel along the spine, all in 3-D. One of the first of dozens of such products, best-selling Visual Man, sells for $40. Another on retail shelves, 3-D Body Adventure, provides a full-body tour for $35. This software is based on an advanced academic research project, the Visible Human Project, that will revolutionize the understanding of medical professionals, allowing them to navigate the body the way airline pilots use flight simulators. But products based on this software will also be mass-marketed like Nintendo games to children and teens, providing Jules Verne-like adventures based on science fact instead of fiction. Medical education for the masses may not be far behind. With the help of mass marketers targeting different niches in the medical marketplace, the understanding of the body that has tended to be confined to society’s upper reaches may be distributed far more equitably. Punk rockers may develop an understanding of the workings of heart valves that rivals their interest in tattoos. Skate boarders may start caring about the mysteries of digestion as much as practising kick flips.

Once hospitals learn to treat their clients’ fears and insecurities as expertly as their tumors, they’ll take a giant stride toward their mission of promoting health in the population. By promoting an environment in which we can learn about our bodies, we will do so, eliminating many of our medical needs by becoming healthier.

A healthy conclusion

OF THE GROWING PORTION OF THE NATIONAL HEALTH CARE BUDGET THAT comes out of our own pockets — the $20 billion that medicare doesn’t cover — the fastest growing portion pays for treatments outside the medical mainstream. According to Statscan, at least 3.3 million Canadians paid more than $1 billion last year for chiropractic, homeopathic, naturopathic and Chinese therapies not covered by health plans. According to Canada Health Monitor, a polling organization, the number is closer to 5.5 million. In Canada, the market for natural remedies and nutritional supplements is growing at 20 per cent a year. In the U.S., the market for alternatives is even larger: one-third of Americans will use an alternative to mainstream medicine this year.

Ontario has 11 hospitals offering TT — therapeutic touch; at St. Joseph’s Hospital in Toronto, all nurses receive training in TT. In British Columbia, where the Vancouver Hospital is opening the Tzu Chi Institute for Complementary and Alternative Medicine, 75 per cent of doctors say they want to find out more about alternatives. The B.C. Medical Board has an alternative therapies committee. The faculty of medicine at the University of British Columbia and the B.C. Institute of Technology, which trains acupuncturists, will collaborate in research performed at the Tzu Chi Institute, which will treat patients using acupuncturists, shamans, aboriginal healers and specialists trained in ayurvedic techniques from the Indian sub-continent. The institute is responding to demand from Canadians who are frustrated by the failure of Western medicine to cope with chronic diseases such as cancer and AIDS, or mystery illnesses such as chronic fatigue syndrome. Once again, the public is leading, and the medical mainstream following.

Once again, the clamor for control over our lives is coming from those best off: Canadians in the top income bracket are 60 per cent likelier to use alternative medicine than those in the lowest income bracket. The affluent can better afford to pay for these unlicensed treatments, and they have the educational wherewithal to investigate alternatives. In all likelihood, this affluent group of medical activists will outlive its less affluent fellow citizens, who will have neither the medical budget nor the college degrees needed to access much of the literature now created by well-meaning, well-educated people for their peers.

The last century’s unprecedented lengthening of the human lifespan will carry on into the next one: With science’s daily unlocking of the mysteries of the genes and the citizenry’s march toward empowerment, that much seems certain. But if the human potential is to be realized for all of us, not just the affluent, medicare must offer more than the cradle-to-grave comfort of universal access; it must transform itself from a benevolent doctor/dictator to an agent of democratic change that puts power into the hands of the people. The Medical Savings Account, a great democratizer, promise to help span the longevity gap between rich and poor while moving us all toward our biblical 120 years and beyond.

Click here to continue to Part 2

Lawrence Solomon
The Next City
September 21, 1996

Discussion

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.

Patient power

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

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