IN THE SPRING OF 1993, the United States prepared to spring into action on the most important debate of its collective life -- government-run medicine. At that time, another discussion was under way in Canada, one that involved Americans and their medical care. It was a quietly conceived Canadian plan that could have changed -- and still might change -- the face of American health care forever.
A plan was formulated by Canadian hospitals, in tandem with the Ontario government, to formally attract U.S. patients to Canada. The idea was not new: Over the course of 1990-91, $33 million had flowed into Ontario coffers from the treatment of U.S. patients. Now, the plan was to formalize this transfer of Americans into Canada. As one Canadian hospital administrator commented, Americans would soon be "rolling through the operating doors." The move appeared logical. For years, the Canadian government-run medical system sent (and continues to send) some of its citizens to the United States for treatment. The reasons are straightforward: Government-run medicine has created a crisis of funding in Canada. So, the rationale goes, why not turn that crisis into a solution by using government funding to undercut private enterprise in the United States?
Why would the United States, with its abundance of technology, be persuaded to such a scheme? Cost. Canada can provide medicine that falls below U.S. prices but above Canadian ones. Such a plan would appear to benefit everyone: An influx of U.S. cash would enable Canada to buy more technology and help prop up a flagging health care system. U.S. citizens would pay less for health care.
As a Canadian living in Canada, I invite you to consider the implications of such a plan for your country. Would such a "solution" prove to be a win/win scenario? Or is it a classic case of pouring the new wine of American free enterprise into the old and broken flask of socialized medicine?
While health care providers are still debating whether the U.S. and Canadian systems are compatible, maybe we all should be asking if they are comparable in the delivery of quality health care.
I realize that your country is grappling with huge medical costs and problems of accessibility. What inhibits the growth of medical accidents in your country, however, are market forces that encourage accountability and a justice system oriented toward carrying out the will of the individual rather than the collective.
Such forces are not a part of the Canadian system. If you traveled to Canada right now, you would read of the medical horror stories that dominate our newspapers: A woman enters the hospital for simple gall bladder surgery. She leaves the operation with a slit bile duct and blood vessel, half her liver dead and 9 surgical clamps left inside her body. Canadian patients wait months in line for medical treatment only to get to the head of the line and discover that the aging equipment has broken down. Canadian shortages now include doctors. Over the past several years, top-notch Canadian physicians exited in droves to the United States. Financial incentive? Maybe. Or maybe there are other reasons -- such as the anguish many fine physicians must feel when they read surveys that show a substantial number of their colleagues prescribing excessive narcotics to seniors, failing to monitor patients with diabetes, high blood pressure and thyroid disease and failing to follow up on abnormal lab results.
The trouble with blood
Arguably, with enough financial incentive, the Canadian system might improve. Unfortunately, what will not change are problems bred into the bones of a government collective. One such problem is the nation's blood supply.
In September of 1994, the U.S. government banned Canadian blood products. Specifically, it found 19 safety infractions at one Toronto blood plant. Several of Canada's 17 blood centers also failed U.S. safety regulations.
The ban was particularly unsettling because the United States granted a favor to Canada by allowing the blood to cross the border in the first place. Ten years ago, the United States suspended normal licensing requirements to allow Canadian blood to travel to a fractionation plant in North Carolina where blood products (such as clotting substances for hemophiliacs) are made. Having no plant of its own, Canada ran the risk of a blood shortage. The deal was struck on condition that Canada would ship only "recovered" plasma (whole blood which has been processed to remove the plasma) rather than "source" plasma (extracted directly from one donor). When the U.S. government examined the Canadian blood plants in the summer of 1994, it discovered that source plasma was being shipped along with recovered -- an act that contravened the original agreement. Canada was told it must cease shipment of all source plasma and meet safety requirements for the other.
Incensed at what it considered interference by the U.S. Food and Drug Administration, Canadian authorities denied there were problems at the blood plants and publicized their intention to create a Canadian fractionation plant in Halifax -- presumably one free from costly U.S. safety standards.
The news that there were difficulties within the Canadian blood supply was hardly a surprise. It was later learned that Canadian authorities knew about problems with blood processing safety as early as January 1994, but it was not until the FDA leaked information about the ban to the press that it became public knowledge and the necessity for an inquiry evident. Initially, authorities planned a secret inquest but, given public concern about the FDA accusations and growing evidence of critical problems in the blood supply, they decided to publicize the findings.
Concern was heightened by the fact that the ban dovetailed with pressure from the Canadian Hemophiliac Society to investigate why more than 1,500 people became infected with the HIV virus in Canada in the early 1980s. While the problem had plagued many Western countries, the United States took quicker action to combat the possibility of tainted blood: High-risk groups were asked not to give blood by March 1983. Blood donor clinics were given information on what was still a relatively new disease: AIDS. Dr. Michelle Brill-Edwards of the U.S. equivalent of the Canadian Bureau of Biologics (a federal watchdog agency) urged colleagues to act swiftly. They did. Canada did not.
Canada issued information 13 months later. The crux of the current investigation focuses on why Canada chose to distribute contaminated blood products when safer, heat-treated blood was available.
One controversial 1984 memo indicates that the Canadian Blood Committee (a supervising agency) forced the Red Cross to use up existing blood supplies first, ignoring the safer supply. As late as 1985, documentation shows, 98 vials of potentially deadly blood were shipped to the Toronto Hospital for Sick Children -- all this when a ready supply of safe blood was sitting on the shelf. Evidence also showed that the Canadian Blood Committee ignored an offer from a U.S.-based laboratory that offered to supply Canadian hemophiliacs with heat-treated blood products "at any time." Instead, the U.S. lab, along with three other U.S. processors, was denied standing at a Canadian conference on the introduction of heat-treated blood products. The reason? Attendance was restricted to Canadian participants.
Members of the federal-provincial committee supervising the Canadian blood supply destroyed tapes and transcripts of discussions pertaining to the tainted blood supply. Despite this, Canadians still learned more than many wanted to hear: The Hepatitis C virus and other deadly contaminants infiltrated the Canadian system through the 1980s. While reliable screening procedures for Hepatitis C were being used in the United States, an estimated 12,000 Canadians were infected. Furthermore, because of a preoccupation with HIV contamination in Canadian hospitals, it was not until last spring that one Toronto hospital found time to write warning letters to the families of 8,000 youngsters informing them that their children might have contracted Hepatitis C.
The final results of the investigation are pending but the indicators are clear. U.S. experts involved in the investigation are unanimous in their complaints about indifference and a lack of accountability: Kenneth McClutcheon, chairman of the safety audit committee at the University of Michigan, admitted that it took him and his colleagues four months to figure out "who did what" in the tangled federal-provincial-volunteer bureaucracy. Dr. Donald Louria of the New Jersey Medical School suggested a timetable for change as one solution to the lack of accountability. Dr. Thomas Zuck, director of the blood center at the University of Cincinnati and vice chairman of the safety audit committee, concluded that Canada needs a whole new agency to administer change. The presiding Canadian judge, Horace Krever, recently expressed astonishment at the general ignorance about blood processing still prevalent among Canadian medical workers. The investigation continues, but the judge's statement to date is simply that "the [Canadian] blood system is still at risk from unknown contaminants."
The need for change
You may be asking yourself why a Canadian would speak out against a partnership that could prove of temporary advantage in the ongoing search for solutions to the health care challenge. Let me answer that I love my country, Canada. I stand in awe of ZTC its beauty and breadth and deep sense of dignity. I also know, however, that real change is necessary and will never occur if America, with the best of intentions, obscures the reality of the devastation that socialized medicine has created here.
The idea of moving U.S. patients north in large numbers is ripe to resurface again: Ontario has a new provincial government that is now being forced to look into every corner for unconventional solutions to a deepening medical crisis. To mask our problems with the American dollar, however, could prove the highest-risk move for your nation and mine: Imagine North America in three years' time. The tired old "bottle" of Canadian government-run medicine has been revitalized thanks to American support. With health care costs still a problem in the United States, the Canadian model looks better and better. Soon, all of North America enjoys the heady wine of the Canadian system -- one that you rejected thoroughly and completely in 1994.
Canada needs a strong and vital United States. To undercut your safety is, ultimately to undercut our own. No voice would be stronger than mine in support of a genuine partnership which would embody our finest qualities. This is not such a partnership.
It is you, my American friends, who have the choice in this matter. Please, just say no.
Susan Riggs is a free-lance writer who lives in Ontario.