Oh Brother: the Ontario health minister joins the Soggy Bottom Boys

... nearly blowed us into shivers and smithers. ~ Charles Dickens, Our Mutual Friend, Bk. 4, Chapt. 13

Ontario's health minister, George Smitherman, was singing his own version of Man of Constant Sorrow last month. He made a bad mess worse when he responded to criticism of the treatment of the elderly in the province's nursing homes by blurting out that he was prepared to don an adult diaper — and use it — to justify his government's policies. Not surprisingly, this singular outburst didn't sit well with an outraged public. Advocates for the improvement of personal care homes have complained for years that standards are poor, that homes are understaffed, and that private companies such as Extendicare endanger patients by pressuring their employees to cut costs.

The Ontario Association of Non-Profit Homes and Services for Seniors says seniors in nursing homes should be getting at least three hours of personal care; it says the average in the province is now about 2.5 hours a day. The Canadian Union of Public Employees (CUPE), which represents many nursing home workers, says the standard should be 3.5 hours. Many studies have shown that without proper staffing and adequate standards the quality of care plummets. Front-line nursing home staff in Ontario report that residents are sitting in deplorable conditions. Incontinence products are often kept under lock and key, and many homes are directing staff to change residents only when the product is 75% soiled.

On February 27, two long-term care workers used four bottles of water to fill an adult diaper at a CUPE press conference in Toronto. They wanted to show how much urine had to be in a diaper before care aides were allowed to change it under current legislation. With stunning insensitivity Smitherman said in response that he was ready to test out an adult diaper to show criticism was unfounded. “I’ve got one of these incontinence products — albeit a new one, not the ones that tend to appear at committee — on my desk and I’m really giving this matter very serious contemplation,” Smitherman said. It wasn't only critics of the Liberal government who were angry. There were loud calls for the minister's resignation, even within his own caucus.

Wags and cynics sharpened their quills. March 1st's National Post published an imaginary Smitherman diary entry, with entries like this:

TUESDAY
Major confession, diary. I tried out an incontinence diaper today. It was so ... freeing. I had three large coffees ... and then I sat through a three-hour meeting with a bunch of bureaucrats. No pee breaks! It was so much more efficient. Made a bit of a stumble at lunch, though, by having the side dish of asparagus. Won't make that mistake again! I think this will really help in my discussion with the nurses' union. Five hours seems to be the limit before things get a little soggy. I think I'll publicly float the idea tomorrow. Right after I shoot up an eight-ball of smack to get a better feel for drug addiction.

Of course, an apology followed immediately. "I wasn't trivializing the matter," Smitherman said. "I take it really, really seriously." Not surprisingly, the minister couldn't be reached for comment afterwards; but his "diary" entry gives us some insight into why:

FRIDAY
After I came in from my night on the streets yesterday morning, Dalton [Premier Dalton McGuinty] called and ordered me to apologize for the diaper "stunt." I explained that I only thought it would gain a better understanding of the issue, but he wouldn't listen. "Also, George," he said, "please tell me you weren't wearing one in my office the other day. Because I thought it smelled like asparagus, if you catch my drift." I told him my cellphone was cutting out and I hung up.

Sam Solomon, writing in his blog Canadian Medicine, adds that this isn't the first time that "Furious George" has run off at the mouth:

Speaking about new building plans suggested by some hospital boards in Ontario, Mr Smitherman dismissively referred to the expensive proposed upgraded facilities as "Taj Ma-hospitals."

His most famous outburst was featured on Stephen Colbert's American parody politics talk show in 2005. Talking to none other than an assemblage of the Ontario Association of Optometrists, Mr Smitherman called optometrists "a bunch of terrorists, and I don't negotiate with terrorists." "Bravo, sir," Mr Colbert said. "Optometrists are a menace. You have to be careful with a group that gets their kicks blowing air into our eyeballs."

Smitherman’s bizarre antics were dismissed by Sid Ryan, president of CUPE's Ontario chapter, who said the minister completely missed the point. The problem isn’t the products, but the cruel reality that residents in long-term care facilities are forced to wear soiled diapers through the night and sometimes up until noon the next day. “If the minister wants to play silly games, well then, let him put on a diaper and sleep in it all night long and come into the legislature and wear it up until 12 o’clock,” Ryan told the Canadian Press.

Could the problems so clumsily dealt with by Ontario's health minister be related to the fact that in Ontario 60% of all publicly funded long-term care beds are in for-profit institutions, as compared with 15% in Manitoba [1]? There is ample research to show that public investment in not-for-profit, rather than for-profit, delivery of long-term care results in more staffing and improved care outcomes for residents [1,2]. Instead of experimenting with adult diapers, perhaps Mr. Smitherman should try absorbing some of these important statistics. There are a lot of excellent health libraries within throwing distance of the Ontario legislature.


References:

1. McGrail KM, McGregor MJ, Cohen M, Tate RB, Ronald LA. For-profit versus not-for-profit delivery of long-term care. CMAJ. 2007 Jan 2;176(1):57-8.

2. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, Ronald L, Cvitkovich Y, Beck M. Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter? CMAJ. 2005 Mar 1;172(5):645-9.

The "Ah, Tennyson" moment and the postmodern professional

As a young man Alfred Tennyson was afflicted with a painful attack of piles. Accepting advice, he visited a youthful but well-known proctologist and was so successfully treated that for many years he had no further trouble. However, after he had become a famous poet and had been raised to the peerage, he suffered a further attack. Revisiting the proctologist, he expected to be recognized as the former patient who had become the Poet Laureate. The proctologist, however, gave no signs of recognition. It was only when the noble lord had bent over for examination that the proctologist exclaimed, "Ah, Tennyson."

I treasure this little anecdote, not only because it pokes wry fun at poets and proctologists alike, but because, parable-like, it illustrates a truth about the human condition. Part of its humour arises out of the absurdity that the clinician's concentration on his work should be so complete as to preclude his recognizing the great poet until the baronial drawers have been lowered. There is also, of course, the universal human delight in scatological jokes — the more irreverent the better, since everyone, even an aristocrat, has to sit on the throne.

But there is more to it than that. Implicit in this compelling but elusive narrative is a sense of how blind we can be to anything but the piles of work before and behind us, and how neglectful of the clamouring realities staring us in the face. We may laugh at the single-mindedness of Tennyson's doctor, but librarians are no exception. Squirrelling away at technology, too busy to think, obsessed with getting to the bottom of our own specialties, we suffer a sort of mental constipation, thinking that what we do is an end in itself while we miss the obvious. We are all guilty of this. Librarians can be as heedless as the most absent-minded of professionals.

The impending demise of Canada's leading consumer health information website gave me the opportunity to reflect again on professional short-sightedness and anal-retentiveness. What should librarians, particularly health librarians, think about the motivations and predilections behind the Conservative government's decision to cut funding for the Canadian Health Network? "Conservative" hardly seems to be the appropriate word for what is at work in Ottawa. Au contraire, axing CHN is just one part of a broader, quite radical set of imperatives, it seems to me. As Carol Goar puts it in the very first sentence of her Toronto Star article of November 16, "This is how a nation's social infrastructure is dismantled."

What should we do? Simply wring our hands, adjust our blinkers, and continue working on our promotion? Even the bureaucrats were fumbling for excuses. Shutting down the network was a "very difficult decision," said Alain Desroches of the Public Health Agency. "The agency will continue to look for effective and innovative ways to provide Canadians with high quality, credible information through other means." What, pray tell, might those other means be? Given a government whose primary affinity is with the catechisms of the market, I think we know what to expect.

In fact, Health Minister Tony Clement launched a new website, Healthy Canadians, in October, to provide users with "easy access to Government of Canada health-related promotional campaigns" — the government's children's fitness tax credit, its revised Canada Food Guide, its toy safety tips, its latest product recalls, and its healthy pregnancy guide — all designed to promote the government's vision of what constitutes an active, well-balanced lifestyle. Pregnancy OK, the kind of sex that doesn't result in pregnancy unmentionable. The website looks more like an election ad than a serious source of information for the general public, a feel-good exercise that has been hastily thrown together. What's being promoted is not health but the government itself. This reminds me of the ridiculously widespread use by television networks of the "coming up" promotional advertisement. In addition to being subjected to their incessant commercials, we now must endure frequent and detailed announcements of what they will be telling us later, to the point that a program like CNN news feels like one long advertisement for itself, punctuated regularly by lengthy advertisements for corporations which then finance CNN's own self-promotion. Lost in the midst of this tiresome cycle, this hollow, echoing Lotos-land, is any sense of what is actually occurring in the real world.

The centralization of health information in one place is a good thing. That was the vision behind the Canadian Health Network. Healthy Canadians is something different. As Carol Goar remarks, "What's missing from the new database is any reference to the links between health and the environment, disease and poverty, or violence and gun control. Nor does it touch sensitive topics such as abortion, genetically modified foods or sexual abuse. It completely overlooks mental illness. In contrast, the Canadian Health Network is all-encompassing. It looks at controversial questions from all sides. It is constantly updated as new knowledge becomes available."

What will happen after all the effort put into CHN? Inevitably we are drawn to rationalizing. Losing the program won't be the end of the world. Sad, but true. Canadians will make use, as they already do, of the rich resources of MedlinePlus from the United States and the multitudes of consumer health websites in many languages that have emerged on the web. The CHN contributors and sustainers will find other ways to reach their audiences. Somehow we'll cope. But here is the heart of the issue. Carol Goar again: "[T]he idea of a comprehensive, national database, built and maintained by the best people in their fields will wither. The belief that Canadians can work together, with the government providing a common forum, will wane. A promising experiment will die. And the government will look for another non-essential program to cut."

As information providers (and supposedly civilization's guardians), librarians are caught up willy-nilly in this ongoing ideological demolition job. Libraries, as a vital part of the civic commons, are not immune to the kind of calculation that is likely to erase the Canadian Health Network. It has been said, tongue lodged firmly in cheek, that nothing is so useless as a general maxim. But let me propose a new axiom that seems to me as firmly based as the laws of thermodynamics. Postmodernism is now driving politics as surely as the desert wind is dry. We are sliding into the postmodern, post-civil world; we're already there actually, but the process is so subtle that, like desertification in the Sahel, we see what's happening only with hindsight.

However, alternatives are still possible. Nothing is completely foreordained. Needless to say, there are many in this country who do not approve of this or other actions of the government that threaten the public good. The "Friends of CHN" have formed, one of their first initiatives being to start a petition, both in English and in French, demanding that the Canadian Health Network's funding cut be rescinded, and that full, stable funding be restored immediately to allow the program to become the kind of national resource it was meant to be. Letters are being addressed to the Prime Minister and the Minister of Health, people are organizing, bloggers are commenting. But librarians need to do more. So far both the Canadian Library Association and the Canadian Health Libraries Association have been silent. I hope to see some mention of this issue appearing on their websites soon.

To many, what is happening with the Canadian Health Network may seem of little consequence. "Let it go," they'll say. "The market will see to our needs. For that matter, let libraries go as well. Don't we have Web 2.0?" To such a glib proposal I would reply in this way. Once the foundations of the civic commons are removed, stone by stone, in a long process of disintegration of which the quiet removal of CHN is just one episode, there will be little left to remind us of the public polity that was. It will have been replaced by another, less polite, reality. Libraries are not exempt from this process. The new facts on the ground, the only essentials, will be commercial ones, such that culture will have become coextensive with the economy, and consumption will have successfully made itself into an immutable law. Civil society, in my apocalyptic vision, thus undergoes a slow dissolution into a wide-open commercial sphere, a jagged, desolate no-man's-land of receding equality, plutocratic machination, anonymous marauding, and deregulated violence — all garishly backlit by vacuous spectacle, the saturating ubiquity of wall-to-wall ideology. Think of the dystopian science fiction of William Gibson. In this new cultural logic, as Fredric Jameson has maintained, Utopia's deepest subject thus turns out to be precisely our inability to conceive it, our incapacity to produce it as a vision, our failure to imagine what could be. Alternatives become unthinkable. Life becomes, in Adorno's words, the ideology of its own absence.

As the Social Justice Librarian puts it:

When a pro-privatization government cuts national funding to social infrastructure and, at the same time, turns a blind (or at least feeble) eye to corporate challenges to public health and social policy regulations … well, I guess that’s where all that information literacy training we librarians are always pushing comes in. Because health information with a profit-motive is clearly not in the public interest. But without a not-for-profit health education, will we recognize it when we see it?

Speaking of the unthinkable, in her new book, The shock doctrine: the rise of disaster capitalism, Naomi Klein offers a revealing anecdote about her experience at a New Orleans hospital in the aftermath of Hurricane Katrina. A car accident leaves her with minor, but painful, injuries. Conveyed by ambulance to Ochsner Medical Center, "the most modern and calm hospital I have ever been in," Klein receives courteous and comprehensive care. She is amazed by the immaculateness of the wards and the quiet efficiency of the staff:

To a veteran of the Canadian public health care system, these were wholly unfamiliar experiences; I usually wait for forty minutes to see my general practitioner. And this was downtown New Orleans — ground zero of the largest public health emergency in recent U.S. history. A polite administrator came into my room and explained that "in America we pay for health care. I am so sorry, dear — it's really terrible. We wish we had your system. Just fill out this form." (p. 489)

Klein strikes up a conversation with an intern who has kindly slipped her some painkillers since the hospital pharmacy is locked up tight for fear of looters. From him she learns that the Charity Hospital, which serves the city's poor, has been heavily damaged. Then comes the "Ah, Tennyson" moment. "They'd better reopen it," the intern says. "We can't treat those people here." Klein comments:

It occurred to me that this affable young doctor, and the spa-like medical care I had just received, were the embodiment of the culture that had made the horrors of Hurricane Katrina possible, the culture that had left New Orleans' poorest residents to drown. As a graduate of a private medical school and then an intern at a private hospital, he had been trained simply not to see New Orleans turned into a giant emergency room: he had sympathy for the evacuees, but that didn't change the fact that he still could not see them as potential patients of his. (p. 490)

It is this inability to "see" something so obvious to others which, for me, characterizes the blinkered postmodern professional. We have here a terrible disconnect between practice and politics. Here is a promising young physician who cannot, or will not, allow himself to think through unacceptable social conditions, who is content, like Tennyson's proctologist, to focus on what he has been programmed to do while missing the obvious — and losing all the compassionate poetry of life. How many librarians, how many health librarians, are also without eyes to see? In what Lotos-land do we live and lie reclined, careless of mankind, attending only to our objects of professional interest? When shall we have our next "Ah, Tennyson" moment?

The Lotos blooms below the barren peak:
The Lotos blows by every winding creek:
All day the wind breathes low with mellower tone:
Thro' every hollow cave and alley lone
Round and round the spicy downs the yellow Lotos-dust is blown.
We have had enough of action, and of motion we,
Roll'd to starboard, roll'd to larboard, when the surge was seething free,
Where the wallowing monster spouted his foam-fountains in the sea.
Let us swear an oath, and keep it with an equal mind,
In the hollow Lotos-land to live and lie reclined
On the hills like Gods together, careless of mankind.

Alfred Lord Tennyson, from The Lotos-Eaters: Choric Song

Am I my bicuspid's keeper? Canadian opinions on publicly financed dental care

In the spirit of the National Medicare Week that wasn't, it seems fitting that an article should appear discussing the results of a survey of Canadians' opinions on publicly financed dental care (1). Not only do they overwhelmingly support universal health care coverage, the vast majority of Canadians also believe dental care should be a social right, are generous as to who should have this right, and expect the government to find the necessary funds to pay for it. In fact, according to this study, which has just been published in the Canadian Journal of Public Health, 83% of Canadians think dental care should be part of Medicare, and two thirds of those think "everyone" should be included.

Contrary to this energetic expression of the people's will, the stingily funded dental care that the less fortunate are able to get in hospitals has been declining steadily in Canada from roughly 20% in the early 1980s to the current 6% of total dental expenditures. As the authors state, these cuts are a mistake, especially with mounting evidence linking oral disease to diabetes, pneumonia, cardiovascular disease and adverse pregnancy outcomes.

Oral ill health is a significant burden to the impoverished, who suffer most of the disease and experience most of the barriers to access (2,3). And the Street Health Report 2007 has found that forty per cent of the homeless are driven to extraction with dental problems. Lack of access to dental care services is an important detriment to the oral and general health of many Canadians. Not that we are an isolated case. A Surgeon General's report, Oral Health in America, called the situation in the United States a "silent epidemic" (4). It seems a simple logical step to an acknowledgement that dental care should be fully integrated into a rational health care system.

The Atlas-Shrugged types will argue vociferously that it is wrong to use taxpayers' money to provide a safety net for gingivitic ne'er-do-wells who think floss is pink and consumed in great quantities at county fairs. Pundits from corporate-funded think tanks like the Fraser Institute and Manitoba’s Frontier Centre for Public Policy will gnash their teeth in horror at such a flagrant concession to human weakness. Obviously they've never had a twanging bicuspid or a suppurating abscess they couldn't spend their way out of. One need only consider the annual expenditure by the public purse on spavined hearts and riddled livers to see that this kind of supercilious cost-accounting is all that's left of decency after the nerve has been extracted.


I pray thee, peace. I will be flesh and blood;
For there was never yet philosopher
That could endure the toothache patiently,
However they have writ the style of gods
And made a push at chance and sufferance.

Shakespeare, Much Ado About Nothing 5.1


References

1. Quiñonez CR, Locker D. Canadian opinions on publicly financed dental care. Can J Public Health. 2007 Nov-Dec;98(6):495-9.

2. Leake JL. Access and care: reports from Canadian dental education and care agencies. J Can Dent Assoc. 2005 Jul-Aug;71(7):469-71.

3. Main P, Leake J, Burman D. Oral health care in Canada--a view from the trenches. J Can Dent Assoc. 2006 May;72(4):319.

4. United States Surgeon General. Oral health in America: a report of the Surgeon General. Washington, DC: U.S. Department of Health & Human Services; 2000.

What happened to National Medicare Week?

This is National Medicare Week in Canada (November 18-24), but you would have to look very hard to find out much about the event. Ever true to their political convictions, the Canadian Health Coalition and the Canadian Centre for Policy Alternatives are celebrating the week with the publication of a new book entitled Medicare: Facts, Myths, Problems, Promise. (Duly added to my library acquisitions list for when I have a budget again.) No one else seems to have taken the trouble to mark the occasion, least of all the federal government that is charged with watching over our health. Except for the book launch, this so-called celebration week is eliciting scarcely a squeak from Canadians.

The new medicare book, of which only the preface can be previewed online, should be a worthy compilation of brave rhetoric from the usual stalwarts. It is based on contributions to a conference held last May in Regina: S.O.S. Medicare 2: Looking Forward. Among the many contributors are some imposing Canadian health care icons: Roy Romanow, Monique Begin, Tom Kent, Allan Blakeney, Stephen Lewis and Robert McMurtry. Summing up the book's raison d'être, Shirley Douglas comments: “I encourage Prime Minister Harper and CMA president Dr. Brian Day to read this book and commit to working together to fix problems rather than using the problems as an excuse to go back to the days before Medicare — when doctors could charge whatever they wanted and care was rationed on the basis of ability to pay not need.” (Douglas is the daughter of former Saskatchewan premier Tommy Douglas, who introduced universal public medicare in 1961.)

The blurb on the CCPA website does its preachy best to garner interest:

For anyone who cares about the future of Medicare, this book offers a unique source of reliable, independent information and analysis. At a time when ideologues and advocates of privatization capture much of the attention of the media and politicians, this collection is an invaluable source of information and ideas. Celebrate National Medicare Week by picking up a copy of this book today.

Frankly, the publicity could have been done better. Such drearily predictable boilerplate simply does not impress those for whom it is intended: "For anyone who cares about ... At a time when ... an invaluable source." This all may be true, but now that bringing eyes to progressive print is harder than selling sun block in Iqaluit, I am not hopeful that this latest defence of the just and the true will have much success.

Where is the web presence? I am a passionate supporter of universal health care, but I nearly missed hearing about National Medicare Week. It's sliding by with almost as little notice as the demise of the Canadian Health Network. A quick search in Google brings the abovementioned book launch to light, but precious little else, and much of it dated. Where are the media? We have been amply informed about the deaths of two more Canadian soldiers in Afghanistan, lead paint in children's umbrellas, and the fallout from the Vancouver Airport taser nightmare; but a week devoted to the celebration of medicare seems to have been overlooked across the country. There is no mention of it in the Mop and Pail, supposedly our "national newspaper," nor have there been any of the usual supportive statements from sympathetic organizations. Even the Canadian Health Coalition's own website is curiously reticent about this week devoted to medicare, providing only a link to a PDF of the book launch blurb — no separate web page, not even the week's dates on the calendar — in short, an abysmal lack of publicity.

Contrast this with last year. To mark the 2006 National Medicare Week the Canadian Nurses Association sent an open letter to the Minister of Health, Tony Clement, in which medicare receives warm praise: "Nurses are proud to be part of a system that assures Canadians' access to health services." (Unfortunately, CNA did not choose to send another one this year. Perhaps frustration has set in. Perhaps they found out the minister doesn't care.)

In a news release marking NMW in 2006 the College & Association Of Registered Nurses of Alberta positively yodelled: “The excellence of Canada’s health system is recognized internationally and registered nurses are proud of the vital contribution they make within it.” Perhaps such semi-socialist bedizenment was too much for Alberta, because that seems to have been the last of the College's news releases, period. Its website shows no further posts for 2007.

The Catholic Health Association of Canada and the Canadian Union of Public Employees also lent their voices — with their respective emphases — to the chorus, praising medicare as "a reflection of Canadians’ desire to build a caring and compassionate society" (CHAC) and "a social right in Canada, one that speaks to our best values of fairness, pragmatism, inclusion and hope" (CUPE).

Where are those voices now? They had better start making themselves heard, because we can be sure that in Ottawa something's cooking.

Health research disconnects

Thirsting for clean, clear knowledge

You know, medicine is not an exact science, but we're learning all the time. Why just fifty years ago they thought your daughter's illness was caused by demonic possession or witchcraft. But nowadays we know that Isabelle is suffering from an imbalance of bodily humors, perhaps caused by a toad or a small dwarf living in her stomach.

Steve Martin as Theodoric of York, Saturday Night Live, 1978

When it comes to health research, Canadian lawmakers have shown they don't really know their toads from their dwarfs. A study published last week in the CMAJ (1) identifies "significant knowledge gaps among Members of Parliament" regarding this important issue. The men and women who set government funding priorities and vote annually to determine the budget of the Canadian Institutes of Health Research (CIHR), "were poorly informed about health research activities, benefits and costs in Canada." In fact, only 22% of participants were aware that CIHR is Canada's leading federal funding agency for health research, supporting the work of more than 11,000 researchers and trainees in universities, teaching hospitals, and research institutes across the country — and 32% knew nothing about its role. Although they valued health research in the abstract, participants did not seem to appreciate fully the impact of health research on the economy, nor did they understand research's role in the promotion of healthier lifestyles and the improvement of health care delivery. The study concludes: "Many of these knowledge gaps will need to be addressed if health research is to become a priority."

A Canadian Press article which appeared on the same day quotes one of the study authors, Patrick McGrath of Halifax's Dalhousie University (who chose his words carefully): "I feel that their knowledge of health research wasn't as good as I'd like it to be." The MPs ranked health care as the most important issue facing the country — topping security issues, economic growth and employment, the environment, and the war in Afghanistan. They also rated health research as the second most important funding priority, giving it an 8.2 rating on a scale of 10. However, they felt voters placed far less value on health research funding, and estimated voters would give it a 3.8 rating out of 10.

Christopher Paige, the Vice-President of Research at the University Health Network in Toronto and a professor in the Departments of Medical Biophysics and Immunology at the University of Toronto, wrote a commentary for the same issue of CMAJ (7). He perceives a "disconnect" between the MPs' acknowledgment that funding health research is important and their perception that Canadian voters don't care much about the issue. Paige told the media, "I think the voting public in fact does want health research to be well supported in Canada." He noted that a recent survey of the general public found 91% of respondents wanted more government investment in health and medical research.

Patrick McGrath told Canadian Press: "Here we have our members of Parliament thinking it's a wonderful idea to support health research. The voters think it's wonderful. And yet there's a disconnect there — the members of Parliament feel that the public doesn't think it's a good idea. Won't get them votes." According to Christopher Paige, the findings should be "a call to arms" for the scientific community. He sees policy-makers' lack of knowledge of health research funding as "a real barrier to progress" (7). As he told the media, "I think it just reinforces something that we do know in our community, that we have to be more effective at communicating how research is funded and what the key issues are. It's really as simple as that." He recommends a series of changes to funding regimes, including establishing a national system of credentialed research hospitals which would be eligible for federal and provincial funding to deliver health care innovations.

Health research in Canada is not yet sunk, but it is taking on water, according to a 1 Feb 2007 report in the Globe and Mail:

David Colman, director of the Montreal Neurological Institute, says huge investments are being made up front and then researchers are nickel-and-dimed on operating grants. If the best researchers can't get adequate funding, then the whole funding system is broken and the future of medical research is in peril, he warns. His exasperation is shared by many scientific and business leaders. After years of investment in health research (long overdue), the federal government has allowed budgets to stagnate, leaving not nearly enough money for operating grants. (And investments from provincial granting agencies and foundations are not making up for the shortfall.) ... [T]he situation recalls an old English proverb: "For want of a halfpenny of tar, the ship was lost."

In a situation in which there are more disconnects than even Ernestine on a roll could manage, health sciences librarians see yet another. On the one hand we have repeated pleas for increased research funding, including a national network of research hospitals to deliver health care innovations. On the other the glaring lack of a national network of libraries to support that research. The Canadian Health Libraries Association has long been championing a National Network of Libraries for Health, whose vision is to ensure that all health care providers in Canada will have equal access to the best information for patient care (2,4,6).

Part of the difficulty in achieving any kind of national solution is the way health issues often fall between the cracks in Canada's fragmented federal system, a situation in which achieving reform makes solving Rubik's Cube look easy. This is the subject of John Lavis's study of political elites and their influence on health care reform:

Who are these political elites, and how do they influence the prospects for change and for improved cooperation in bringing about change? The elites can include government officials at both the federal and provincial level who are engaged in constant finger pointing over health care, with federal government officials repeatedly saying to their provincial counterparts "administer the system better" and with provincial government officials responding "give us the money we need to run the system properly." Meaningful reform of any kind is difficult to achieve amidst such a dynamic, which some have called the "politics of blame avoidance." (3)

With such a dynamic holding sway, and with the now better understood knowledge gap in Ottawa, it may be some time before CHLA's vision can be realized. In a 2006 editorial in CMAJ, Sir J.A. Muir Gray, Director of the UK's National Electronic Library for Health, lent his support, calling for the provision of "clean, clear knowledge," centralized and made available through a national initiative:

I have watched with admiration and have benefited from Canadian developments, from the introduction of evidence-based medicine to the advances in knowledge translation and implementation. It has always seemed paradoxical that Canada, a country that is the fount of so much good work in these areas, does not have a national library. No new building is needed; simply a national network using the tools that are made available through the e-health revolution. Creation of the Canadian Health Libraries Association's proposed National Network of Libraries for Health would allow for coordinated, centralized access to evidence-based knowledge as well as support by librarians to all health care providers, researchers and policy-makers, regardless of their location or institutional affiliation. This network will capitalize on existing resources and networks. We look forward to learning from yet another Canadian initiative (5).

For this to happen Canadians must increase the importance of health research on the political agenda, and we health librarians must continue to work towards the goals set forth by our national association. At least we know our toads from our dwarfs.

Wait a minute. Perhaps she's right. Perhaps I've been wrong to blindly follow the medical traditions and superstitions of past centuries. Maybe we barbers should test these assumptions analytically, through experimentation and a "scientific method." Maybe this scientific method could be extended to other fields of learning: the natural sciences, art, architecture, navigation. Perhaps I could lead the way to a new age, an age of rebirth, a Renaissance! ... Naaaaaahhh!

References

1. Clark DR Bsc, McGrath PJ Phd, Macdonald N Md Msc. Members' of Parliament knowledge of and attitudes toward health research and funding. CMAJ. 2007 Oct 23;177(9):1045-1051.

2. McGowan J, Straus SE, Tugwell P. Canada urgently needs a national network of libraries to access evidence. Healthc Q 2006;9(1):72-4.

3. Lavis, John N. Political elites and their influence on health-care reform in Canada. Discussion paper no. 26. [Ottawa]: Commission on the Future of Health Care in Canada; 2002. Available: http://www.hc-sc.gc.ca/english/pdf/romanow/pdfs/26_Lavis_E.pdf (accessed 29 Oct 2007).

4. McGowan JL, Ellis P, Tugwell P. Access to the medical literature. CMAJ. 2007 Jul 17;177(2):176-7.

5. Muir Gray JA. Canadian clinicians and patients need clean, clear knowledge. CMAJ. 2006 Jul 18;175(2):129, 131.

6. National Network of Libraries for Health. Vision. Toronto: Canadian Health Libraries Association; 2007. Available: www.chla-absc.ca/nnlh/vision.html (accessed 29 Oct 2007).

7. Paige CJ. The future of health research is hanging in the balance. CMAJ. 2007 Oct 23;177(9):1057-58.

Still scratching

I have received comments, one of them lengthy, from two individuals who appear to be involved in the creation of the video A Brief History of Medicine, which I lambasted in my post of 4 October, Scratching an itch. I replied rather tartly to "matthew" in the comments section, but this longer reply to Bungle M (who signs as "michael") deserves its own separate post. Besides, I haven't figured out whether it's possible to add illustrations to comments in this software. And I like illustrations.

Dear Michael (or is it Bungle M ?),

I seem to have caused a bit of a flap in the ScribeMedia pigeon loft with my blog post of 4 October. How else to account for the rush to reply to a satirical morsel of invective by an obscure, curmudgeonly hospital librarian in a remote Canadian outpost? Have you no sense of humour? Have you no sense of perspective? It's just a video after all; and I'm just a library guy who isn't always on top of every trend but who nevertheless has an axe to grind when the trend is rightwards. At least for my generation, short videos such as yours are at worst a vexing irritant and at best a trifling entertainment, not unlike radio jingles, urinal advertisements, movie trailers, and elevator music. I have observed with interest and some alarm the growing importance of videos as a means of communication for a new generation less interested in the printed word. YouTube up, library circulation down. It's not that I object to the short video on principle. Videos can be brilliant, inventive, disturbing, and informative. I enjoyed Web 2.0 … The Machine is Us/ing Us, whose style you so studiously copied. I just didn't think your video was all that good, in contrast to the fawning comments in praise of its awesomeness. And that infernal soundtrack! I'm still scratching. But, as you say, we won't get anywhere arguing about video and audio aesthetics.

I accept your claim that you did not intend to be partisan. I, on the other hand, freely admit to being one, although of the World War II variety — I take no prisoners. I didn't call anyone a Clintonite. I just thought it somewhat humorous that the Clintons got the good visuals in the video while nary a Republican was to be seen. Believe me: I am the last person to be making accusations about a "liberal agenda." The very term is foreign to Canadians, but I could fairly be labelled as having one. We actually like liberals up here, and frequently elect them to Parliament and to provincial legislatures. What I did appreciate about your video was its attempt at a statement of liberal values around health. Something goes terribly wrong at the end, however, when, as I have noted, the acme of health care is touted as a series of lavishly designed and highly remunerative websites.

To restate my point, what I chiefly object to about A Brief History of Medicine is how it allows itself to become a shill for a gathering of plutocrats and entrepreneurs who see the web as a means to make a killing in the health care biz. I would object to the use of the word "cabal" to describe such a group. This is not a conspiracy in the usual sense of the word. I'm sure they see themselves as good corporate citizens simply responding to consumer demand. They are only doing what any business would do when given the opportunity. That is the problem. It's all arranged; the market is targeted; the strategies for growth are being discussed in oak-lined boardrooms and on thousands of humming Blackberries. I would dearly love to be proven wrong in my suspicions. I would really like to be assured that Google's Product Marketing Manager, Kaiser Permanente's Senior Advisor [sic] & Medical Director, and Medstory/Microsoft's CEO have only the best interests of the public at heart, that they truly care about US. But I remain unconvinced. As George Eliot remarked in her novel Felix Holt, "the foxes have a sincere interest in prolonging the lives of the poultry."

For all its enfolding and rhapsodic idealism, your video actually does end up being partisan. Certainly, it seeks to avoid politics by emphasizing the personal; but the personal is political also. So, for example, the vacuous inclusiveness you praise in the video's self-congratulatory summing-up, "Health Is... Men. Women. Children. Mothers. Fathers. Brothers. Sisters. Doctors. Patients. Caregivers. You... Health is US," acknowledges despite itself the unmentionable yet clamorous need for all these atomized individuals to work together for a political solution to soaring health costs, the plight of the uninsured, unethical practices, and the general plunder and pelf of a corporatized health care system.

I recognize that when it comes to health care the United States has a particularly difficult set of circumstances. As you state yourself, American politicians and "thoughtleaders" have not been willing or able to offer solutions that would bring real change. But it is not my intention to launch a political critique of the American system. There is plenty to criticize in my own country. I simply maintain that universal, sustainable, not-for-profit health care, however infinitely debatable its successes and failures, is a workable solution with measurable outcomes. (For a good example of what I mean, see the much-praised but regrettably neglected Romanow Report of 2002, Building on values: the future of health care in Canada.) Yet such a notion — beyond liberal, even "socialist" in the view of many — is incompatible with and cannot even be easily articulated within the specific form of discourse around health that is dominant in the United States and growing in strength on this side of the border (see my discussion of the latest salvo from the Canadian Medical Association).

Would you not agree, my dear michael, that it is a sign of just how bad things are when even the modest proposal that everyone has a right to decent health care brings on howls of righteous indignation and mindless red-baiting? What is all the commotion about? Only extremists could argue against the equitable provision of health care to all, just as only extremists could endorse a global economic system that condemns billions to lives of poverty and desperation. Who are the real reds under the bed? Who are threatened with the loss of wads of money if universal health care is adopted? The peddlers of Health 2.0 and their ilk are counting on the continued survival of privatized medicine, gambling with some confidence that it's too good a show to shut down. They're itching for action.

Finally, in defence of my position I submit the agenda of the Health 2.0 Conference (San Francisco, 20 Sept. 2007), cut and pasted from the conference website itself. The presenters and panelists: almost exclusively company CEOs, COOs, VPs and Presidents. Their purpose: "to confront the decision of how to interact with ... new technologies and networks, and potentially adopt and integrate them into their strategies for growth." Translation: to figure out how to make money and then to make more money.

I submit that health for these "stakeholders" is a commodity like any other, to be packaged and sold for profit. My purpose in the blog post, aside from having a bit of fun at your expense, was to lift up a corner of the sequined curtain of Health 2.0 and expose what Ambrose Bierce described as the strife of interests masquerading as a contest of principles, and the conduct of public affairs for private advantage. I would be quite happy to see the Health 2.0 meme scratched off the parchment, now that it has been appropriated by the entrepreneurial seigneurs of the new feudalism.

Pruritically yours,

MR

---

Health 2.0 User Generated Healthcare Conference Agenda

8:00-8:30 INTRO Health2.0: User-Generated Healthcare
Matthew Holt/Indu Subaiya

8:30-9:30 OPENING PANEL:
The Role of the Consumer Aggregators
Missy Krasner, Product Marketing Manager, Google
Wayne T. Gattinella, CEO, WebMD
Peter Neupert, VP Health Solutions Group, Microsoft
Bonnie Becker, Director, Health Category, Yahoo!
Moderator: Jane Sarasohn-Kahn, THINK-Health

Special Perspective from: David J. Brailer
Former National Health IT Coordinator
& Founder, Health Evolution Partners

9.30-9.40 STRETCH BREAK, Bio Break & Coffee refill

9.40-10.40 DEMO PANEL & Discussion: Search in Healthcare
Alain Rappaport, CEO, Medstory/Microsoft
Venky Harinarayan, Co-Founder, Kosmix
Tom Eng, President & Founder, Healia/Meredith
Dean Stephens, President & COO,Healthline Networks
Moderator: Jack Barrette, CEO WeGoHealth (ex-Yahoo)

10.40-11.15 NETWORKING Break with Demonstrations

11.15- 12.15 DEMO PANEL & Discussion: Social Media for Patients
Ben Heywood, CEO, Patients Like Me
Doug Hirsch, CEO, Daily Strength
Steve Krein, CEO, OrganizedWisdom
Karen Herzog, Founder, Sophia's Garden
John de Souza, CEO, MedHelp International
Brian Loew, CEO, Inspire
Moderator: Amy Tenderich, Blogger/Journalist DiabetesMine

12:15-1:00 REACTOR PANEL Payers, Providers, & Pharma….and Health2.0
Paul Wallace, Senior Advisor & Medical Director, Kaiser Permanente
Joe Gifford, Chief Medical Officer, Regence BCBS
Jeff Rideout, Managing Partner, Ziegler HealthVest Fund
Bruce Grant, SVP, Digitas Health
Ted von Glahn, Director, Performance Information and Consumer Engagement, PBGH
Moderator: Doug Goldstein, eFuturist

1:00-2:00 LUNCH with "Unconference" issue tables
& more demonstrations

2:00-3:00 DEMO PANEL & Discussion: Tools for Consumer Health
Mike Battaglia, VP Healthcare Strategy, Intuit
Marlene Beggelman, CEO, Enhanced Medical Decisions
Dave Hall, VP of Innovations, HealthEquity
Joseph Villa, COO Employer Division, Revolution Health
Ryan Phelan, CEO, DNADirect
Moderator: Scott Shreeve, CrossOver Healthcare (founder Medsphere)

3:00-3:30 NETWORKING Break with Demonstrations

3:30-4:30 DEMO PANEL & Discussion: Providers and social networks
Daniel Palestrant, CEO, Sermo
Lance Hill, CEO, Within3
Chini Krishnan, CEO, Vimo
Gale Wilson Steele, Founder/CEO, Careseek
Patricia Ball, VP Product Development Consumer Aware/BCBS Minnesota
Doug Goldstein, eFuturist & President, Medical Alliances
Moderator - Enoch Choi MD, MedHelp/PAMF

4:30- 5:30 CLOSING REACTOR PANEL: Health2.0 - Looking Ahead
Lee Shapiro, President, Allscripts
David Kibbe, American Academy of Family Physicians
Bob Katter, Senior VP, Relay Health (McKesson subsidiary)
Jay Silverstein, Chief Imagineer, Revolution Health
Steve Brown, Founder Health Hero Network, Entrepreneur in Residence, Mohr Davidow Ventures
Esther Dyson, EDventure
Moderator: Marty Tenenbaum, Commercenet

5:30- 5:45 Wrap-up - Matthew Holt/Indu Subaiya

5:45- 6:45 Wine and Cheese Networking

Scratching an itch

In the new fashion of trying to explain our world to us with short, frenetic video clips, ScribeMedia.org has produced a typically upbeat piece called A Brief History of Medicine. As they say in their website puff: "We could/should add, 'American Style.'"

Heavily influenced by Michael Wesch’s Web 2.0 … The Machine is Us/ing Us and itching to get under our skin, this video was used to open the Health 2.0 Conference in San Francisco last month. It immediately demands eyeball attention and is hyperkinetically entertaining with its rapid cuts, fades, blends and dissolves. Our battered retinas barely have time to register the Gatling-gun spray of images as the jerky trail of the typescript cuts across the screen. The accompanying electronanotechbeat music, by the well named Luxxury, is aggressively irritating, like the soundtrack to a scabies infestation. If this were the 60s, someone with a head-band and dilated pupils would be emerging from the theatre waving a cigarette and exclaiming: "Far out, man."

Graphic hijinks aside, this is a tendentious, tauro-scatological and technologically obsessed treatment of the history of medicine. The video is divided into eight sections, each introduced with the caption, "Health is ... " The sections are engagingly entitled History, Education, Body, Global, Activists, Insurance, Information Technology, US — sounding better as a rundown of current fads and phobias than of medical history.

Is it petty to criticize what is so obviously a for-the-nonce throwaway? Well, watch out. I'm going for the throat. Nurses, not to mention the important contribution of religious orders in medieval Europe, are invisible in the onward march of male doctors with large scalpels. The discoveries of the smallpox vaccine, insulin and the x-ray are ignored, as is the introduction of asepsis, anesthesia and antibiotics. From the onset of AIDS we are rushed along to a 10-second liberal dig at the lack of proper health care insurance in the United States, with flattering photographs of Bill and Hillary Clinton. Some AIDS organizers and others working hard for reform may not be amused to find the Clintons featured so prominently in the Activists section. Finally, inevitably, and I suppose appropriately for this well-heeled California gathering, the acme of health care is touted as a series of lavishly designed and highly remunerative websites. We are peddling "Health 2.0" after all.

ScribeMedia.org, which produced the video, hypes itself as travelling the U.S. to capture and deliver speeches, lectures, round tables and interviews of "thoughtleaders" across a broad range of subject areas that include current events, technology, media, business, health care and the arts. Its self-described goal is to be "a neutral forum for intelligent dialog and debate, uncluttered by soundbytes, instant punditry and shoutfests."

Hence their wacky video. Take five, hold on to your seat, and plunge into this gyrating, ululating manifesto. Not a soundbyte or pundit in sight. It's informative, in the way that a bungee jump is a lesson in Newton's law of universal gravitation. While the message is relentlessly positive and glitteringly Clintonesque — of course it's all about YOU and US — what it actually is all about is the manifold ways that WE are going to make a lot of money out of YOUR problems, and YOUR growing need to deal with every ailment by purchasing a costly commodity from US in the new web-based economy. The only noise not heard in this clever little propaganda Kunstwerk is the ringing of the cash register. The only itch not scratched is that for a just health care system.

If this is how our "thoughtleaders" are thinking about health care, then we'll just have to keep on scratching.

Health care vs. wealth care

Haply you shall not see me more; or if,
A mangled shadow: perchance to-morrow
You'll serve another master.

Antony and Cleopatra 4.2

The Canadian Medical Association unveiled its "new vision" in a policy document released on July 30. As reported by the CBC, the CMA wants provincial governments to hire private-sector firms to deliver publicly funded health care services to prevent delays for medically necessary treatment. Association president Colin McMillan said Canadians need timely access to medical services, and the private sector could act as a "safety valve" to ensure wait-time guarantees are met. "The CMA believes that we must now take that principle forward to meet the needs of a new generation."

Just as Dr. Michael Rachlis, a well-known critic of privatization, predicted last year (1), the operators of private clinics and their supporters -- encouraged by the Supreme Court’s ruling against a Quebec ban on private insurance for Medicare-covered treatments -- are aggressively shilling their wares, with the CMA’s explicit support.

Despite the CMA’s stance on the matter, polls consistently show that a large majority of Canadians endorse the recommendations of Health Commissioner Roy Romanow, whose 2002 Final Report strongly opposed privatization and outlined a system for updating and re-inventing health care (2). These popular instincts are strongly supported by reams of research, including a recent systematic review comparing health outcomes in Canada and the United States. It concluded that Canada’s single-payer system, which relies on not-for-profit delivery, achieves health outcomes that are at least equal to those in the United States at two-thirds the cost (3) -- while, it should be added, ensuring that no one is consigned to the special circle of hell reserved for the uninsured.

Many Canadian health librarians care deeply about this country’s successful single-provider system and see their work as an integral part of publicly funded health care delivery. Access to knowledge-based information and promoting health literacy were important issues in the Romanow Report (pp. 76-82), and were clearly reflected in Recommendations 10 and 12. There is even a pull-quote from the Canadian Health Libraries Association on page 79. Publicly funded and operated services, such as Alberta’s Health Knowledge Network or the UK’s National Library for Health, emphasize access and delivery through policy coordination, shared technology, and improved cooperation. Such resources are a fundamental part of a public health care system, and librarians should be concerned that any serious tampering with that system could eventually lead to their dissolution.

For a compelling alternative to the CMA’s vision for Canada’s health care system, see Mending Medicare, a collection of articles published by the Canadian Centre for Policy Alternatives. As the title of one of its contributions declares, health care and wealth care can’t viably co-exist (4). Tepid tolerators of Medicare, like the Canadian Medical Association, have taken advantage of legitimate public concern about delays in the system to push ill-advised policies such as for-profit delivery and private finance. But allowing private insurers to compete with the public system will increase wait times for treatment, not lower them. There is currently a shortage of doctors and nurses. Letting the private system draw already limited human resources out of the public system, and letting doctors bill on both sides of the fence, will only make this situation worse. As many astute observers have asserted time and again, solutions can be found and implemented within the public system.

If the Canadian Medical Association is successful in its efforts to disassemble public health care, then we shall have failed to heed Malcolm Gladwell’s warning. His disturbing meditation on the plight of uninsured Americans appeared in The New Yorker two years ago:

The United States has opted for a makeshift system of increasing complexity and dysfunction. Americans spend $5,267 per capita on health care every year, almost two and half times the industrialized world’s median of $2,193. … And, of course, every other country in the industrialized world insures all its citizens; despite those extra hundreds of billions of dollars we spend each year, we leave forty-five million people without any insurance. A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy -- a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper -- has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers (5).

References:

1. Rachlis M. Better public than private solutions to Medicare wait problem. The CCPA monitor. 2006 May:34.
2. Commission on the Future of Health Care in Canada. Building on values : the future of health care in Canada. Saskatoon : Commission on the Future of Health Care in Canada, 2002. Available from: http://www.hc-sc.gc.ca/english/care/romanow/index1.html.
3. Guyatt GH, Devereaux PJ, Lexchin J, Stone SB, Yalnizyan A, Himmelstein D, et al. A systematic review of studies comparing health outcomes in Canada and the United States. Open medicine 2007 1(1).
4. Flood CM, Sullivan T, Roos N, Lewis L, Noseworthy T. Health care and wealth care can’t viably co-exist under Medicare. The CCPA Monitor. 2006 May:16.
5. Malcolm Gladwell. The moral-hazard myth: the bad idea behind our failed health-care system. The New Yorker. 29 Aug 2005. Available from: http://www.newyorker.com/archive/2005/08/29/050829fa_fact (Gladwell is the author of The tipping point, and Blink: the power of thinking without thinking.)