Over the past 30 years, André Picard has become the most prominent Canadian commentator on the intersection between medicine and social values. His new book, Matters of Life and Death, a selection of some of his most powerful columns written for The Globe and Mail, further establishes his unique voice in discussions about Canadian health-care policy. Taken collectively, they represent a plea for a kinder and more just health-care system in this country.
The extent of Picard's influence has accrued because he stands outside medicine and the academy – he has no formal training in health care. This allows him a skepticism and clear-sightedness that has made him an indispensable medical writer. He is less interested in the shiny technologies that beguile television news producers than he is in the simple questions of fairness and compassion, which he writes about with fury and precision. He has led the advocacy – and continues it in this book – for improved mental-health care and argues powerfully for recognition of the terrible disparity in health-care outcomes among the Indigenous people compared with the country at large. His organizing idea, that inequity in wealth and power is the principle driver of pathology, was more controversial many years ago when he started declaring it, but with each year, the evidence grows stronger that this is exactly the case, that real advances in health and life expectancy turn far more on bread-and-butter issues of fairness and access than they do on anything existing at the molecular level. Which is a less exciting idea maybe – but this exactly is why a writer of Picard's talent is so valuable. He makes these issues seem as pivotal as they really are.
It isn't that Picard is unrivalled. This is a golden age of medical writing: Atul Gawande, Siddhartha Mukherjee and Abraham Verghese have achieved unprecedented prominence in their journalism and books, winning the most prominent literary prizes and topping the bestsellers lists, both. But the first of those is a surgeon, and the other two, physicians: For them, the wonder of their craft – their own skill – remains their principal interest.
But if medicine is to care for humans, then it must itself be human, and thus as likely to fail as it is to dazzle. Our medicine, Picard tells us, fails – rather a lot, and in ways that reflect our own personal failings: of bias, of greed and of fear. And just as in our own lives, our failings are only that, not catastrophes, not irredeemable evils, but things that can be improved. And should be, if our country is to aspire to something better than it is.
For instance: Canadians' health outcomes, Picard writes, are broadly better than Americans and achieved at far less expense. But the American comparator is the only one in the developed world that makes the Canadian model look good. Compared with the French and the Japanese or any of the Scandinavian health systems, we overtreat and overinvestigate, spending much more, and still have worse outcomes. Picard argues for a refashioning of the Canadian health-care system around patients, rather than care providers. This would go some distance to making the Canadian system as effective as the other developed countries.
Another important step would be the inclusion of marginalized people at the centre of our decision-making about the state's single most important and largest involvement in the lives of its individuals. Women, incarcerated people, the disabled, children, the elderly: The least politically powerful among us have the highest health-care needs, not coincidentally. And yet, their voices are the most muted in the discussions around the provision of that care. This is the case everywhere, of course, but in Canadians' penchant for self-congratulation about how it compares with the United States, we recognize too rarely how much we resemble the worst parts of our neighbours' (newly resurgent) habit of punishing the less privileged. We can do better, Picard argues throughout his book, and we should.
As a collection of columns that were written to stand alone, these cohere remarkably well. There remains a granular quality to them, however, and reading this book, one cannot help but wish Picard would attempt something still more ambitious, an Emperor of All Maladies with the Emperor cast as inequity rather than Mukherjee's cancer, perhaps. After all, he writes:
"People's income (or lack thereof) has about twice the impact on their health as cancer does. […] why is tackling poverty not a health priority? Patching and mending is all well and good, and our sickness-care system does a good job of it. But the data show us that the best tool we have in our health-care armamentarium is income redistribution. The most powerful drug we have – money – is pretty plentiful in Canada."
But this wish is no criticism of the book at hand, only testament to the potency of the writing and the ideas within it. Long may André Picard continue to argue his case and may he help draw our country away from the Gilded Age excesses we and our neighbours both sicken from, and die, in ours, the wealthiest of countries.
Kevin Patterson is a doctor and writer. His books include the novels Consumption and News from the Red Desert, and the memoir The Water in Between: A Journey at Sea.