The Gospel According to Roy
by John FitzGerald, publisher emeritus, NEW IMPROVED HEAD.
Much of the commentary about the recent Romanow report on the future of Canadian health care has been rather cavalier about what the report actually says. For example, Mr. Romanow has been criticized for ignoring the issue of long waits for service, although he makes two recommendations intended to reduce waiting time.
But this ignorance of the report's contents is as it should be, since the purpose of the report has never been to communicate ideas about reforming the health care system. Instead, its purpose has been to manipulate Canadians' imaginations.
If the government had truly been interested in obtaining worthwhile recommendations about the future of health care it wouldn't have assigned a project of this scope to a single commission. In his report Mr. Romanow gamely discusses funding, the performance of the health care system, regional differences in service, the effects of an aging population, the desirable characteristics of an electronic health information system, primary health care and prevention, access, ensuring quality of service, health care in rural and remote regions, home care, prescription drugs, aboriginal health care, the effects of globalization, and much, much more! Any one of those topics merits a royal commission – or two or three – of its own. You could make a glittering academic career out of a lifetime of work on a single aspect of any one of these issues, and Mr. Romanow covered all of them in just eighteen months!
A suspicious person might think the commission was struck so that the government could look as if it had an interest in health care that went beyond the parochial and the short term. The broad scope of the commission's terms of reference would ensure that any recommendations were so broad as to be dismissible on some grounds. An alternative explanation is that no one in government has a clue, but they seem a pretty astute bunch to me.
Anyway, from the government's point of view Mr. Romanow delivered the goods, a vast yet inevitably superficial report which, regardless of the soundness of its recommendations, is necessarily so sketchy that any of its recommendations or analyses is likely to arouse indignant objections and observations about their irrelevance or impracticality. Which they have, thus leaving the government with pretty well a free hand.
So the government gets to look serious while never intending to do anything other than what it feels like doing at the moment. Okay, some members of the government have been enthusiastic, but, as you know, cooler heads seem so often to prevail in the Liberal caucus. It's almost as if they were playing a game.
Some of Mr. Romanow's recommendations do seem sound, while others seem to be earnest exercises in the energetic throwing around of buzzwords. Largely they consist of the familiar governmental problem-solving techniques of throwing around money and dispensing cushy jobs to prominent white people. But the recommendations are not the issue.
The important point about Mr. Romanow's report is not, for reasons which we have already enumerated, what he recommends so much as how he recommends it. The true message of the report is revealed by its style.
When we examine the style of Mr. Romanow's report we find that it is a throwback to an era of political thinking which one had hoped we had left behind. It is a piece, a very long piece, of messianic scripture.
Mr. Romanow has drawn his inspiration from the forerunner of his political party; that forerunner was the Co-operative Commonwealth Federation. As you know, the CCF was heavily influenced by the social gospel, the idea that Christians' faith should issue in works of social reform intended to create an ethical society in which all worked together for the common good – a co-operative commonwealth.
Mr. Romanow sets the tone early with the following observation.
It has been suggested to me by some that if there is a growing tension between the principles of our health care system and what is happening on the ground, the answer is obvious. Dilute or ditch the principles. Scrap any notion of national standards and values. Forget about equal access. Let people buy their way openly to the front of the line. Make health care a business. Stop treating it as a public service, available equally to all. But the consensus view of Canadians on this is clear. No! Not now, not ever. Canadians view medicare as a moral enterprise, not a business venture. (p. xx)In other words, the health care system is threatened by unbelief and backsliding! Canadians' morality is threatened by "corrosive and divisive debates" which will lead to "the eventual unravelling of Canada's health care system" (p. 46)! To stop this threat to the health care system, Canadians must enter into a Covenant in which all of them pledge to work together for the good of the health care system! They must turn from their wickedness and live!! Ticonderoga winnebago!You know, debate and division constitute the essence of democracy. As Desmond Morton has observed, we don't talk about politics in barber shops because of all those razors lying around. But Mr. Romanow isn't after democracy, he's after the Kingdom of God. He wants spiritual rebirth:
A fundamentally new approach is needed, not only to foster trust but also to resolve disputes and conflicts in a productive and transparent manner. More importantly, Canadians want and expect to see their governments and those in the health care system working together to address many of the pressing issues outlined in subsequent chapters of this report. What is needed is a truly national approach to medicare in the 21st century – an approach that sets aside the differences of provinces, territories, and the federal government, and puts new and more effective governance approaches in place. (p. 47)And the lion shall lie down with the lamb! Canadians will forget their differences and work together for the good of all! Petty local interests will be cast aside and obstacles will be removed from the path toward a national revival! I think we can specify page 47 as the point at which Mr. Romanow enters cloud cuckooland, assumes the mantle of the Messiah who will lead us into the Kingdom of God, and starts meditating on the equitable slicing up of all that pie in the sky.And what is this covenant, which is so important that establishing it is the first recommendation in the report? Interestingly, Mr. Romanow's idea of a covenant is based on suggestions he received for a patient's bill of rights. Unlike a bill of rights, however, his covenant will not be embedded on the constitution. It won't even come to life in the form of a statute. It is to be a mere declaration, a mission statement (p. 49). Doing something legal would cause too many problems, he says, because it would establish "new rights that would be subject to legal interpretation and ultimately decided by the courts rather than by Canadians themselves" (p. 49).
Again, Mr. Romanow wants us to believe that spiritual rebirth will do the trick. And this time he also wants us to believe that the courts are run by foreigners.
At this point we can see that Mr. Romanow's vision of the co-operative commonwealth is remarkably like one the Roman Catholic church might come up with. We will all work together for the common good under the direction of a handful of powerful people. The role of the populace is to keep themselves from sin – their responsibilities in the covenant consist of losing weight, stopping smoking, and keeping fit.
The populace would have no role in the appointment of the new and powerful Health Council of Canada he wants to establish, and which is the subject of his second recommendation. Physicians would have no role, either, or nurses, or any other medical profession. The council would be appointed by "a consensus of federal, provincial, and territorial health ministers" (p. 59). The Kingdom of Heaven is a kingdom after all. It is definitely not a republic.
Perhaps my analysis seems extreme. The simple fact is, though, that it is not as extreme as the analysis of a man who wants to abolish disagreement from the discussion of public affairs and to eliminate diversity of thought ("fractious debate", p. 47) from public discourse. I could have said that he was acting in the propaganda tradition of the Soviet Union (he does propose a five-year plan), but the propaganda tradition of the Soviet Union was essentially religious. By Mr. Romanow's standards, my analysis is inherently cautious and jejune.
The really frightening thing is that this type of messianic exhortation is all too common these days. Need I mention the Boy President's Mission Against Evil, the idea that America is threatened by evil people and that to defeat them we all must act together (that is, let the government do whatever it wants without letting out so much as a peep), having rededicated ourselves to the American ideals?
We Canadians, of course, already have an example of this kind of thinking in our debates about the place of Quebec in Confederation. Needless to say, much of the argument for separatism/sovereigntism/whatever the hell it's called this week is based on the idea that the English are evil, that everything they touch turns to dross. The English language contaminates French, English culture contaminates French culture – man, the English are just plain evil! In English Canada, the approved opinion of the governing classes is that we all must work together to find a solution that will satisfy Quebec. Opposition to the legitimate aspirations of Quebec is evil. It's so evil that in the campaign before the 1993 referendum the mainstream press did its damndest to ignore opposition to the Charlottetown agreement (or Accord, the much more consensual-sounding term that its supporters dreamt up).
The religious approach is even found in local affairs. For example, the enactment of laws against squeegee people in Toronto was justified not by the need to maintain the public safety so much as by the characterization of squeegee people as evil.
Honestly, I don't view the health care system as a moral enterprise. I support single payer health care because I believe that the evidence shows it to be the most effective way to maintain the health of the population, thereby increasing productivity, reducing public expense, and giving citizens more control over their lives. Mr. Romanow does make this argument, sort of, but he obviously considers it secondary to his Great National Mission of committing the Canadian people to the correct health care ideals. For example, the phrases "cost effective" and "cost effectiveness" occur all of 14 times in the body of Mr. Romanow's text, or slightly more than once every 20 pages. The term "cost-benefit" appears once. Cost effectiveness is presented as a Good Thing, but it is not even defined. No standards for the assessment of cost effectiveness are discussed, nor are guidelines for making decisions based on these assessments, so of course none are recommended.
Cost-benefit analysis seems to me to be central to the public discussion of medicare. What, for example, is the benefit obtained from each dollar spent on MRIs? How does it compare to the benefit produced from a dollar invested in other health measures? It is not enough to be assured by Mr. Romanow that a practice is cost effective. We need to see how it has been determined to be cost effective, and just how much more cost effective it is than current practices, among other things. I guess this type of information is something Mr. Romanow considers appropriate only for the eyes of the fourteen (14) members of his proposed Health Council of Canada.
Mr. Romanow doesn't forget the final trick of the evangelist, though. First, he excoriates the works of the devil among us. Then he tells us we must commit ourselves to the One True Religion. Then – he tells us to send money.
Send lots of money. Send bags and bags of money. Don't worry, in disbursing all that money government will be advised by a Health Council appointed by – government!
So that's the deal. You turn your money over to those government appointees and in return you get a ringing declaration of principles, all the more ringing for being utterly hollow. Well, I don't need no stinking Covenant. I need to be able to get effective medical care. I need to get it from physicians and nurses and other trained medical people, not from a Health Council of Canada or from ideals I share with with my fellow citizens. You can set up all the Covenants and Health Councils you want, but in the absence of any real restraints on or requirements for government all that does is make jobs for the boys. Perhaps when the distribution of jobs to the boys is completed, someone can hire some investigators who know something about health care so we can finally get some problems solved.
The Gospel According to Roy © Coolth, 2002
Posted on December 5, 2002
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