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Andre Picard's Second Opinion

Our two-tiered health system: a rural-urban split Add to ...

apicard@globeandmail.com

Running a health system in a country as vast and sparsely populated as Canada poses many challenges, big and small. But some of those seemingly small challenges have vast implications.

Take the case of Flower's Cove, Nfld. Located near the tip of the Great Northern Peninsula, the coastal community has a population of about 300 - and maybe double that number if you include the surrounding areas.

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Flower's Cove is home to the Strait of Belle Isle Health Centre. The clinic operates 24-hours-a-day, seven days a week.

There are basic emergency services, everyday family medicine (provided largely by nurse practitioners), an ambulance service (principally for transport to larger health-care facilities), home-care nurses, dental care and medical diagnostic services, including some laboratory testing and X-rays.

On Aug. 31, the provincial government decided to cut back the operating time of the clinic to 12 hours a day and shut down the lab.

A great hue and cry followed. There were protests in the streets. The health minister, Paul Oram, reversed the decision on the clinic hours so emergency services will be available around-the-clock.

Then he resigned, saying that the non-stop pressure and scrutiny of even the most mundane decisions was taking a toll on his personal health.

"There's no end to the stress and strain," Mr. Oram said in his words of farewell.

Flower's Cove is, in many ways, representative of the major challenge in our medicare system: Where do we draw the lines? And who draws them?

Canadians have developed an incredible sense of medicare entitlement: They want all care for all people, instantly and free of charge. (Hey, taxes don't count, right?)

While this may be possible - at least theoretically - in densely-populated, infrastructure-rich urban centres, distance poses a major challenge in health-care delivery in huge swaths of the country.

Canada's land mass is about 95 per cent rural/remote but less than 30 per cent of its population lives in rural/remote areas.

The reality is that there is two-tiered medicine, but it's not a private-public split, it's an urban-rural split.

The health outcomes of those who live in remote settings are poor compared to suburban dwellers: Life expectancy is lower; child mortality is higher; injury rates are astronomical; there is far more obesity and chronic illness such as heart disease. Much of this can be explained by the fact that residents of rural communities are more poor, and older (with the exception of aboriginal communities, which have their particular health challenges).

The reality, too, is these challenges predate the creation of medicare half a century ago, when the folkloric country doctor trudged miles on foot in a snow storm to save a patient's life. If anything, the factors that impede the availability of, and access to, good quality care for rural residents have been exacerbated by technological advances and social change.

The question though is: How do you improve the situation?

Do you build a 24-hour-a-day health clinic in every community, even those with a few hundred residents? A hospital in slightly-larger centres? If so, how do you staff them?

Modern medicine is heavily dependent on diagnostic testing. Do you build a lab in every outport? If so, how do you ensure quality and cost-efficiency?

What about surgery? Should that be done in small hospitals or only in larger institutions? After all, we know that outcomes are far better in high-volume centres.

We have this jingoistic love for hospitals and health clinics - communities that don't have one or two feel inadequate and neglected.

But are patients not better served by having high-quality diagnostic tests done at a central lab and getting the results by e-mail or FedEx than being dependent on a rinky-dink facility?

Should scarce health-care dollars not be invested wisely in improving transportation and family support so patients can be treated in well-equipped regional centres with a minimum of disruption instead of dotting the landscape with clinics that overreach their abilities?

More important still, can we not have these discussions without their being subsumed by political rhetoric? Can we not make rational, good-for-the-system decisions without them being substituted by politically-expedient ones?

The tragedy of Flower's Cove is not that the clinic has lost a lab or some operating hours. In the grand scheme of things that doesn't really matter.

What matters is that there are 10,000 Flower's Coves across Canada. There are tough decisions to be made - a balance to be found.

But decision makers can, seemingly, no longer make decisions. Politicians like Mr. Oram have become punching bags for those with vested interests.

Health administrators and government bureaucrats whose role should be to ensure the delivery of quality care in a cost-effective manner have been emasculated. Any time their policies make ripples, they get trashed. (And the media do a lot of aiding and abetting.)

Is that any way to run a health system?

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