The Truth About Canada (2 page)

One editor asked me if I was not apprehensive about the strong criticism such a tough book will inevitably bring. The answer is simple. You cannot ever expect to accomplish anything important without bringing criticism from the entrenched forces this book describes, criticizes, and blames for what has gone wrong in our country.

I have been very fortunate in having some of the best minds in the country available to me for consultation as I wrote
The Truth About Canada
. You will find their names on the acknowledgements page. Many of the most important pages of original research in this book are the result of their help, for which I am very grateful.

Whether it’s our pathetically low number of doctors, our high comparative levels of both adult and child poverty, our truly awful record of educational funding, our shameful levels of foreign aid and peacekeeping, our abysmal voter turnout comparisons, our totally inadequate research and patent performances, our high infant and under-five mortality rates, the broad deterioration in our social programs, our increasing gaps in distribution of income and wealth in Canada, our treatment of our aboriginal peoples, the rapid decline of our manufacturing sectors, our serious post-secondary education problems, our continuing and very dangerous decentralization, our coming confrontation with the United States over water, our mind-bogglingly stupid NAFTA agreements regarding oil, natural gas, and water — in any or all of these topics, and in many more, you will frequently encounter vitally important and newly documented information that will make you cringe.

In researching this book, I found it truly dismaying to see how often the print media in Canada totally ignores or distorts information that doesn’t fit with their own philosophical/editorial positions. Quite often I pick up a morning paper and read about a new Statistics Canada, OECD, or other release, knowing that the newspaper story and the documented reality are vastly different from one another. The chapters in this book on poverty, social policy, wages, distribution of income and wealth, profit and investment, taxes, foreign ownership, the FTA and NAFTA, government in Canada, decentralization, and energy policy all contain information you likely never have seen before or information that
runs contrary to the conventional and widely accepted opinions in Canada found in much of our media and intentionally promoted by our far-right “think-tanks,” business leaders, and politicians.

I hope that when you read the following pages you will tell others about what you have read. If you need more information about sources, or if you want to be added to my e-mail list (I sometimes send out four or five items a month), you can contact me at [email protected]. If required, I will get back to you as soon as I can, but please understand that this will likely take quite some time.

Mel Hurtig

Vancouver

December 2007

PART ONE

1

HEALTH CARE IN CANADA AND OUR TRAGIC,
INEXCUSABLE SHORTAGE OF DOCTORS

AN ABSURD SITUATION NO ONE WANTS TO TAKE RESPONSIBILITY FOR

S
urely one of the most startling facts you will find in this book is this: during the years 1990 to 2004, in terms of the number of physicians per 100,000 people, Canada stood far, far down the list of all countries, in an appalling 54th place, according to the United Nations’s Human Development Report 2007/2008. With only 214 doctors per 100,000 during those years, we were down among some of the poorest and least developed countries in the world, and far below most other countries in the OECD (Organization for Economic Co-operation and Development).

Some comparisons in physicians per 100,000: Cuba 591, the United States 549, Belgium 449, Estonia 448, Greece 438, Russia 425, Italy 420, Turkmenistan 418, and Georgia 409. All the following countries have over 300 physicians per 100,000: Norway, Iceland, Sweden, Switzerland, the Netherlands, Finland, Austria, France, Spain, Germany, Israel, Portugal, the Czech Republic, Malta, Hungary, Argentina, Lithuania, Slovakia, Uruguay, Latvia, Bulgaria, Lebanon, Kazakhstan, Armenia, and Azerbaijan.
¹

How could this be? How could one of the world’s wealthiest developed countries have found itself in such an absurd position? And how is it that, in the millions of words in the press and from our politicians about the problems of the Canadian healthcare system, this preposterous shortage of physicians has received so little attention?

One very prominent and widely respected physician, who has to go unnamed in this book, told me that “the poor planning in health human resources is one of the most serious public policy failings that our governments have ever been involved in, yet no one wants to take responsibility.”
²

In the 1970s, Canada had the second highest physician-to-population ratio among developed countries. But subsequent ill-considered actions by provincial governments intentionally reduced the number of doctors in medical schools across the country.

Today, despite our acknowledged alarming shortage of doctors — and despite the large number of young men and women anxious for admission to our medical schools, even with high marks and excellent resumés — large numbers of our very best and brightest young people who want to be doctors are being forced out of the country. At the same time, some Canadian universities have raised annual medical-school tuition fees to astronomical levels. At the University of British Columbia they went up 375 percent in four years, to $14,280 in 2006, and only 16 percent of applicants were accepted.
³
At the University of Toronto, fees were just under $17,000.

While a recent federal budget committed to increasing medical-school enrolment by 15 percent, that will still leave Canada far short of the number of doctors needed, and the increased number of new graduates will not be available until 2011 at the earliest. Meanwhile, in a 2007 survey, over two million Canadians said they had tried but failed to find a family doctor during the previous year, and wait times in this country are far longer than in Germany, New Zealand, Australia, Britain, and a long list of other countries.

How did this happen? In the early part of the 1990s, a consensus developed that there was a surplus of doctors in Canada and that steps had to be taken to control the growth in the number of physicians. In 1991, the Barer-Stoddart Report suggested a 10 percent reduction in the number of Canadian medical students. The next year, a conference of provincial and territorial ministers of health agreed to reduce undergraduate medical enrolment by 10 percent, starting in 1993. They also agreed to reduce the reliance on international medical graduates, reduce postgraduate trainees, and maintain or reduce physician-to-population ratios.
In 1985, medical-school enrolment in Canada was 1,835. By 1999, it had dropped to 1,516. In 1995, there were 191 physicians per 100,000 population. By 2021, this is projected to drop to 130 per 100,000, ridiculously inadequate for patient requirements. By 2005, the average graduation rate for doctors in the OECD was 34 per 1,000 practising doctors, “too low to meet the expected increase in demand.” In Canada, it was closer to only 25 per 1,000 practising doctors.
⁴

Between 1993 and 2003, Canada’s population increased by 13 percent, but the number of doctors declined by 5 percent. On average, Canada now has about a third fewer doctors per population than other OECD countries and only slightly more than half as many per population as in France, Germany, or the United States. Despite the belated recognition of our serious problem, Canada is still well down the list, in 26th place, in the annual growth rate in the number of practising physicians during the period 1990 to 2003.

In 2005, there was a provincial high of 218 physicians per 100,000 population in Nova Scotia, 218 in Quebec, 205 in Yukon, and 199 in British Columbia. At the other end of the scale, there were only 46 in Nunavut, 103 in the Northwest Territories, 144 in Prince Edward Island, and 156 in Saskatchewan. In the middle, there were 193 per 100,000 in Newfoundland and Labrador, 188 in Alberta, 179 in Manitoba, 176 in Ontario, and 172 in New Brunswick. (Note how very low these numbers are compared to the numbers for the most developed countries that are listed in this chapter’s second paragraph.)

And supposing you don’t live in a big city? In 2004, over 21 percent of Canadians lived in rural areas. The same year, only about 9.4 percent of all physicians practised in rural areas.

One important positive: In 2004, for the first time in 40 years, more Canadian doctors returned to Canada than the number who left. In 2005, only 186 doctors left for the United States, but the number returning to Canada was up to between 200 and 300.
⁵
While it remains true that about one in nine trained-in-Canada doctors is now practising medicine in the United States (over 8,100 in 2006), the tide has definitely been turning, and there are signs that many more Canadian doctors in the
United States are unhappy and are considering returning to Canada. Is it any wonder that there is growing disenchantment among Canadian doctors in the United States, given the increasing dominance of the widely disliked Health Maintenance Organizations (HMOs) and the growing cost of malpractice insurance (up to as much as $30,000 a month)? More than a few doctors in the United States have been turning their backs on their own profession.

I find it difficult to understand why we give medical students such a quality, heavily subsidized, lengthy education without requiring them to practise for at least 10 years in Canada, or, if they wish to emigrate sooner, to return the large subsidies they have received to the universities or hospitals where they got their education.

Is the amount we pay our doctors part of the problem? In a list of 19 OECD countries, Canadian specialists are not as well paid as specialists in Belgium, the Netherlands, or the United States. But they receive better remuneration (as a ratio of GDP per capita) than specialists in all the other 15 countries. The comparative picture is somewhat similar for general practitioners, where Canadian GPs are at 3.45 percent of GDP, behind only the United States at 4.18 percent, the Netherlands at 3.73 percent, and Germany at 3.61 percent, and once again they are better paid than the GPs in the 15 other countries.
⁶

For those who think that the amount we pay doctors is the major reason for escalating healthcare costs, it’s interesting to note that from 1984 to 1992 physicians not directly employed by hospitals or public-sector health agencies accounted for between 15 and 15.7 percent of health expenditures in Canada, but by 2006 this had fallen to 13.1 percent.

Now, to see what we may well expect in the future, let’s turn our attention to the Canadian Medical Association (CMA). In two votes at their annual convention in Charlottetown in August 2006, Canadian doctors supported a two-tier healthcare system and rebuffed the efforts of their colleagues who wanted the CMA to curb private medical insurance and/or doctors moonlighting by offering their services both publicly and privately, the latter to patients willing and able to pay out of their own pockets. In the words of Dr. Danielle Martin, head of Canadian
Doctors for Medicare: “The CMA has now marginalized itself. It has shown that it’s out of touch with the majority of its members and certainly the majority of Canadians.… This is a real blow to the credibility of the profession.”

Then, in July 2007, the CMA, to the dismay of many in the profession, came out strongly in favour of a two-tier healthcare system that would allow doctors to work simultaneously in both the public and private systems, a proposal that would inevitably lead to queue-jumping and a deterioration of public health care. In most countries, doctors are prohibited from practising in both the public and private sectors. Stephen Harper had it right when he wrote to Alberta premier Ralph Klein, “Dual practice creates conflict of interest for physicians as there would be a financial incentive for them to stream patients into the private portion of their practice.” And federal health minister Tony Clement said, “How can you improve access if doctors are spending part of their time inside the system and part of their time outside the system? No one has shown how that can be done.”
⁷

Gordon Guyatt, professor of medicine at McMaster University, was direct and to the point in his response to the CMA’s proposal: “The CMA is acting on the basis of self-interest instead of the public interest. For-profit clinics would not lead to the training of a single additional doctor or nurse. Indeed, such clinics would suck desperately needed personnel from not-for-profit hospitals and clinics.”
⁸

Wendy Fucile, in the
Toronto Star
, wrote:

Nurses reject CMA’s recipe and say it is a privatization gimmick. In an open letter to Prime Minister Stephen Harper, the Registered Nurses’ Association of Ontario urged the PM to restate, in no uncertain terms, that physicians will not be allowed to practise simultaneously in both the private and public healthcare systems.

A wealth of evidence shows that allowing physicians to practise in both public and private systems decreases access
to health care, costs taxpayers more, and results in lower quality of care — including higher rates of complications and deaths. A parallel private system siphons healthcare professionals and drains resources out of the public system.

Countries with parallel private hospitals have larger and longer waiting lists in their public hospitals. A parallel private system allows for-profit clinics and the physicians who work in them to benefit from people’s vulnerability in times of illness. These clinics cherry-pick patients who are healthier, younger or have conditions that are cheaper to treat, leaving more complicated cases to a public system with fewer healthcare professionals.